By Aggarwal, Deepak Mohapatra, P R; Rekha, V V Banu; Balasubramanian, R; Swaminathan, S; Ramachandran, R; Rahman, F; Sundaram, V; Thyagarajan, K; Selvakumar, N; Adhilakshmi, A R; Iliayas, S; Narayanan, P R

Sir, Banu Rekha and colleagues’ in their study found that at the end of intensive phase of tuberculosis treatment among sputum positive cases, the smear conversion rates were 58, 61, 62 per cent and culture conversion 86, 88 and 92 per cent respectively. Also, the patients with HIV infection or diabetes had marginally better conversion rate than pulmonary tuberculosis patients without any co- morbidity. According to Revised National Tuberculosis Control Programme (RNTCP), the minimum duration of treatment to assess outcome of pulmonary tuberculosis patients is 6 months. However, the authors’ have discussed the smear conversion rate after two months (intensive phase) without mentioning treatment outcome at the completion of continuation phase (after 6 months of initiation of therapy).

This sputum conversion at the end of intensive phase can be attributed to fall and rise phenomenon2, where within weeks of starting anti-tubercular treatment there is a decrease in number of drug susceptible mycobacteria and sputum smear may turn negative. But, at the same time, resistant bacilli are not affected and they continue to multiply. As a result, after a certain time, bacillary content of the sputum rises again and sputum smear becomes positive for acid fast bacilli. Due to occurrence of this phenomenon, sputum conversion at 2 months is not an ideal parameter to predict and compare treatment outcomes among pulmonary tuberculosis patients with or without comorbid conditions.

It will be of immense help if the authors can provide the final outcome of the study after completion of treatment among the patients whose data are available. Sputum conversion at 6 months and after completion of therapy (not at 2 months) can substantially validate the current policy of RNTCP to treat all pulmonary tuberculosis patients, with or without co-morbidities, with category- I regimen.

Deepak Aggarwal & P.R. Mohapatra*

Department of Pulmonary Medicine

Government Medical College & Hospital

Sector 32

Chandigarh 160 030, India

* For correspondence:

[email protected]

References

1. Banu Rekha VV, Balasubramanian R, Swaminathan S, Ramachandran R, Rahman F, Sundaram V, et al. Sputum conversion at the end of intensive phase of category-1 regimen in the treatment of pulmonary tuberculosis patients with diabetes mellitus or HIV infection: An analysis of risk factors. Indian J Med Res 2007; 126 : 452-8.

2. Crofton J, Mitchison DA. Streptomycin resistance in pulmonary tuberculosis. Br Med J 1948; 2 : 1009-15.

Authors’ response

Sir,

This publication was an interim report on the first indicator of the efficacy of the regimen1. At the Tuberculosis Research Centre, Chennai, all patients are followed up with monthly smear and culture examination during treatment. The status of the pulmonary tuberculosis with associated diabetes mellitus or HIV infection at the end of treatment have shown that at the end of treatment smear conversion was 95 and 85 per cent for patients with diabetes mellitus or HIV infection, respectively23. Thus, the conversion observed at the end of intensive phase was a true indicator and the response was similar at the end of treatment in these groups. For patients receiving category-I regimen in the RNTCP, smear conversion at the end of intensive phase is emphasized as an important early predictor of treatment success. In this background, it is essential to evaluate associated co-morbid conditions like HIV infection and diabetes mellitus among TB patients that are likely to influence smear conversion. We agree that the sputum conversion at 6 months can substantially validate the current RNTCP policy of treatment all pulmonary tuberculosis patients with or without co-morbid conditions with category-I regimen. We are planning to publish the comparison of results of these groups of patients at the end of treatment and relapse up to 6-month of follow up.

V.V. Banu Rekha, R. Balasubramanian

S. Swaminathan, R. Ramachandran*, F. Rahman

V. Sundaram, K. Thyagarajan, N. Selvakumar

A.R. Adhilakshmi, S. Iliayas & P.R. Narayanan

Tuberculosis Research Centre (ICMR)

Mayor V.R. Ramanathan Road, Chetput

Chennai 600 031, India

* For correspondence:

[email protected]

References

1. Banu Rekha VV, Balasubramanian R, Swaminathan S, Ramachandran R, Rahman F, Sundaram V, et al. Sputum conversion at the end of intensive phase of category-1 regimen in the treatment of pulmonary tuberculosis patients with diabetes mellitus or HIV infection: an analysis of risk factors. Indian J Med Res 2007; 126 : 452-8.

2. Balasubramanian R, Ramanathan U, Thiagarajan K, Ramachandran R, Rajaram K, Bhaskar D, et al. Evaluation of an intermittent six- month regimen in new pulmonary tuberculosis patients with diabetes mellitus. Indian J Tuberc 2007; 54 : 168-76.

3. Swaminathan S, Sangeetha M, Arun Kumar N, Menon PA, Thomas B, Shibi K, et al. Pulmonary tuberculosis in HIV positive individuals: Preliminary report on clinical features and response to treatment. Indian J Tuberc 2002; 49 : 189-93.

Copyright Indian Council of Medical Research Apr 2008

(c) 2008 Indian Journal of Medical Research. Provided by ProQuest LLC. All rights Reserved.

By Leah Ward

Dr. Rosa Martinez is in trouble with state medical regulators again.

The Medical Quality Assurance Commission alleged in charges made public earlier this month that Martinez, a Yakima physician, has failed to comply with the terms of a 2007 order that found she practiced “below the standard of care” with patients taking prescription narcotics.

Martinez, a solo practitioner, was ordered to work in a group practice or alternatively hire a consulting physician to review her patient records weekly for three months.

The order also required her to complete an evaluation at the Center for Personalized Education for Physicians in Denver and complete six hours of continuing medical education in pain treatment and medication.

As a result, the Medical Quality Assurance Commission, which is part of the state Department of Health, alleges that Martinez has engaged in unprofessional conduct and is subject to sanction, including losing her license.

Martinez, a family practitioner who was licensed by the state of Washington in 1993, practices on West Spruce Street in downtown Yakima.

Martinez will contest the findings, according to her lawyer, J.J. Sandlin. He issued a statement by e-mail, saying the Department of Health has imposed dosage limitations on patients with chronic pain that “adversely impact our local residents who suffer from long- term pain.”

“Dr. Martinez is a dedicated, caring physician who believes her first loyalty is to her chronic pain patients, and she intends to fight the Department of Health with every resource she has,” Sandlin wrote.

In the 2007 order, the state said she created an unreasonable risk for five patients by not monitoring them with blood and urine tests while they were taking narcotics.

Separately, Martinez is awaiting a new trial on charges that she committed health care fraud by attempting to overcharge Medicaid, Medicare and the state workers’ compensation system.

A federal jury last spring found her guilty on eight counts of fraud and not guilty on four counts of practicing outside the scope of her degree by prescribing narcotics to patients with histories of addictions.

The jury couldn’t agree on two other charges of unlawful distribution of narcotics. A judge later formally dismissed those charges.

Leah Beth Ward can be reached at 577-7626 or [email protected].

Leah Beth Ward

Yakima Herald-Republic

(c) 2008 Yakima Herald-Republic. Provided by ProQuest LLC. All rights Reserved.

By JUDY SIEGEL-ITZKOVICH

They’re out there, and they’re after us – viruses, bacteria and other pathogens that ignore personal and national boundaries. They spread not only by direct contact but also by plane or migrating birds. Infections with these pathogens are usually diagnosed too late – when victims already have symptoms, can’t be treated effectively and have even infected others.

In recent years, the phenomenon has threatened many parts of the world with a series of diseases ranging from SARS (severe acute respiratory syndrome, which killed almost 800 people six years ago and then dissipated) and Legionnaire’s disease to influenza and West Nile virus (which killed 29 Israelis and infected 400 more in 2000). There is no known cure for either.

But a brilliant Israeli organic chemist who has set up a series of startup companies in Israel and the US to develop her patented technologies seems to have a solution. If Dr. Dorit Arad, who has dozens of patents or patents pending, is right, she could become very wealthy: The annual world market for quick diagnostic kits for such pathogens is estimated at around $40 billion.

She told The Jerusalem Post in a recent interview that the technology developed at her Ness Ziona company, Modules for Novel (MND) Diagnostics, has even wider applications in customized treatment for cancer patients.

She was working in the US developing antiviral drugs for a company named eXegenics when the SARS epidemic hit and got her so nervous about catching the contagious virus that killed almost 10% of its victims that she was “hysterical and even wore a face mask.”

THE THREAT also caused panic among health authorities here, who sent doctors to the airport to examine any passengers with pneumonia-like symptoms, put them through tests that took days and sent suspected SARS victims into quarantine for weeks or more. She decided to focus on the development of detection kits, not using the standard technique of finding antibodies, but focusing on enzymes present when live viruses multiply.

Using a small saliva or blood sample mixed with patented materials, the liquid in a test tube changes colors – like a pregnancy test kit – in a few minutes or becomes fluorescent when a specific virus is present. No specially trained personnel are necessary, said Arad. This makes mass screening possible in schools, airports, clinics, hospitals or other locations.

Born in Haifa to parents born in Poland – her father an Egged bus driver and her mother a kindergarten teacher – Arad had no role models for going into science. “I wasn’t very good in most subjects in high school, but I knew all the answers in chemistry. I had an excellent woman teacher in that subject.”

She didn’t mind the chore of washing test tubes, and today is also an excellent cook. “Chemistry involves mixing elements together, as if you are in the kitchen. I know many chemists who are also excellent cooks.”

AFTER SERVING as a trainer of medics in the Israel Defense Forces, Arad decide to forgo the study of medicine and went to Haifa’s Technion-Israel Institute of Technology to study organic chemistry, earning bachelor’s, master’s and doctoral degrees there. Prof. Yitzhak Apeloig, a leading chemist who is now Technion president, was then supervisor of her research. “I chose organic chemistry among all the fields because it was the best subject for understanding life mechanisms. I wanted to do practical things more likely to help people.”

By now, she has authored over 50 publications and received numerous awards, organized international meetings, created extensive global collaborations with world-class scientists (including 1998 Nobel laureate Dr. John Pople), and served as professional adviser for several pharmaceutical companies.

Fortunately, Apeloig pushed her to learn basic science, which more than ever leads to practical applications. “No one would have thought decades ago that nuclear magnetic resonance would lead to magnetic resonance imaging (MRI), the main tool for scanning patients,” she says. Basic scientific principles helped in her quest for rational drug design. Arad did her post-doctoral fellowship at the University of California at San Francisco and returned to become a biotechnology lecturer for nine years at Tel Aviv University. In her research in Israel, she “looked at structures of proteins and suit structures to inhibit them or speed them up,” she recalled. “I developed a new technique based on chemistry and the mechanism of reaction.”

THEN SHE moved to the US, starting with viruses and drug design at eXegenics in Dallas, Texas. The company bought her technology. After doing successful research for five years there, she bought back the rights from the company and returned to Israel, establishing MND Diagnostics four years ago and doing collaborative work with a company in France. Her first diagnostic kits for viral diseases, whose next hurdle will be US Food and Drug Administration approval, could go on the market next year. Clinical studies show they are very reliable and accurate.

“My target was an enzyme called 3C. The 3C enzyme has an important role in the maturation of viruses ranging from hepatitis A and enterovirus to polio and foot-and-mouth disease. We had inhibitors with a potential for drugs, used a substrate and found parts of virus with the enzyme. The technique,” she noted, works on many viruses, but one has to develop the suitable substrate for each. MND Diagnostics, she said, was established to provide timely responses against emerging diseases by utilizing novel routes of diagnosis and treatment.

MND Diagnostics is currently developing a quick test for cytomegalovirus (CMV), which is very risky for fetuses and people with weak immune systems, including cancer and HIV/AIDS patients. Most healthy people infected with CMV are symptomless. After infection, the virus remains latent for the rest of the individual’s life, though it can be found in bodily fluids. Fetuses infected by their mothers before birth are at high risk for complications such as low birth weight, smaller-than-normal brains, seizures and liver problems. Most babies with CMV disease will survive, but with a high risk of complications including mental retardation, hearing loss or vision impairment. These problems usually affect the fetuses of women who were newly infected during pregnancy and not those carrying the signs of an old infection, but it has been difficult to differentiate between the two. Thus a test to detect fresh CMV infections, when the virus is reproducing, would be crucial – and that is what Arad has done.

“We have a fast CMV kit that is not yet on market because it needs FDA approval. We have a number of clinical results already, and it will also be useful for testing potential transplant recipients. Today’s tests take much longer.” Also being targeted are SARS, the rhinovirus that causes the common cold, coronavirus, rotavirus, hepatitis C and even HIV-1.

But MND Diagnostic’s first product on the market will be a speedy kit to detect viral meningitis, and later, there will be one for bacterial meningitis. The need for this, said Arad, was pointed out by Prof. David Greenberg of the pediatric infectious disease unit at Beersheba’s Soroka University Medical Center, who is now medical director of MND Diagnostics, which currently has 15 employees. The company, of which she is chief technology officer, will be able to manufacture kits for the world from its rented Nes Ziona facility.

“Today,” said Arad, “it takes days to detect bacterial meningitis. Children have to go to hospital for tests and then are sent home until the results are ready. In the meantime, many are given strong antibiotics, causing resistance. With our test, it will take three minutes. Clinical trials were held this year. We will be prepared to market the tests after FDA approval in the second half or third quarter of 2009.” A kit for quick detection of bird flu in birds will be among the first products.

Arad’s technology can be applied as kits not only to detect well- known pathogens but also newly emerging viruses. Her enzyme-based method can also be applied to mutated viruses whose family can be identified.

There is also a potential for specific kits to detect any bacterial diseases or fungal infections that have enzyme activity. “Enzymes are also important in cancer markets. We are working on kits to detect enzyme markers for cancer. If a biopsy for prostate cancer is positive, for example, the patient has to undergo more tests like a biopsy. We believe we can develop a more accurate PSA test that will avoid unnecessary biopsies,” Arad suggested. “Another one of our ideas is to detect the cascade of coagulation profile in blood that would provide early detection of stroke.”

ARAD NEVER dreamed that applications of her theories would go so far.

“We have been so busy. Now is the time to start writing articles for publication. We have lots of advisers from Israeli hospitals.” In a decade, she predicted, “our kits will change the practice of medicine. Doctors in their clinics will test patients for diseases in minutes. There will also be home tests.” Eventually, Arad concluded, the kits could lead to prevention of disease, such as cutting down infection in hospitals caused by methycillin- resistant Staphylococcus aureus (MRSA) bacteria, which are resistant to a large group of antibiotics.

“I started working on the technology with the idea of simple detection kits to stop outbreaks in airports,” Arad stressed. “I never imagined it would turn into a broad breakthrough technology arousing world-wide interest. Indeed, only in the past few months we have begun to present it at international forums in the US, Italy, Japan and Britain, and at every convention it was highly praised and raised a lot of interest. As a result, new contacts with large pharmaceutical companies have been launched.”

There are thousands of potentially dangerous virus strains and bacteria that cause all kinds of mischief, but they can be assured that Dr. Dorit Arad is on their tail.

Originally published by JUDY SIEGEL-ITZKOVICH.

(c) 2008 The Jerusalem Post. Provided by ProQuest LLC. All rights Reserved.

Oversight Systems, the leading provider of automated continuous transaction monitoring software, announced today that The University of Texas M. D. Anderson Cancer Center has contracted to implement Oversight’s continuous monitoring solution for the procure-to-pay process. Oversight was awarded the contract after responding to a Request for Proposal (RFP) issued by M. D. Anderson.

“Our primary objective for continuous monitoring was to maximize the overall quality of our accounts payable processing, while minimizing the cost to support a 100 percent prepayment audit of all disbursements generated by the accounts payable process,” said Michael Keneker, M. D. Anderson associate vice president and controller.

Oversight’s software eliminates fraud, misuse and errors within transactions and streamlines financial processes through an integrated application that combines an audit data warehouse, advanced analytics and automated resolution workflow. Oversight’s Collaborative Reasoning Engine (CoRE)(TM) incorporates the tests and heuristics used by forensic accountants, auditors and fraud examiners to continuously inspect each transaction for errors, control-violations and fraud. The integrated Workbench, with its intelligent workflow system, makes it easy for customers to resolve any of the identified issues.

About M. D. Anderson Cancer Center

Celebrating more than six decades of Making Cancer History(R), The University of Texas M. D. Anderson Cancer Center is located in Houston on the sprawling campus of the Texas Medical Center. It is one of the world’s most respected centers devoted exclusively to cancer patient care, research, education and prevention. M. D. Anderson was created by the Texas Legislature in 1941 as a component of The University of Texas System. The institution is one of the nation’s original three Comprehensive Cancer Centers designated by the National Cancer Act of 1971, and is one of 39 National Cancer Institute-designated Comprehensive Cancer Centers today. For more information, visit www.mdanderson.org.

About Oversight Systems, Inc.

Oversight Systems takes continuous controls monitoring to the next level, with real-time transaction integrity inspection that provides companies with world-class assurance of the integrity of their financial information. Oversight’s software provides a platform for continuous monitoring with powerful analytics that excel at finding problems, then raises the bar with an investigator’s workbench for cost-effectively fixing the problem, and workflow-enabled audit trail and journaling for proving problem resolution and compliance. By inspecting each step of individual transactions across all financial systems, Oversight identifies all errors and fraud, drives defects out of the process, and sustains regulatory compliance. For more information, visit www.oversightsystems.com.

Today at the NACDS Pharmacy and Technology Conference, Varolii Corporation announced general availability of Varolii Adherence Outreach(TM), a fully managed, on-demand patient notification service that helps retail, mail-order and specialty pharmacies improve prescription medication adherence, a widespread health problem costing billions every year. By enabling delivery of automated, HIPAA-compliant communications to patients over the phone, through text messages or email, Adherence Outreach helps pharmacies reach more patients while avoiding the exorbitant time and money a traditional communications approach would require.

According to the World Health Organization, only half of patients worldwide take their medications as prescribed, leading to numerous health consequences, particularly among those with chronic conditions. In the United States, poor medication adherence is estimated to result in more than $100 billion in direct and $50 billion in indirect healthcare costs every year (Peterson, et. al, ASHP, 2003). And the problem is escalating due to the rising number of older patients, the number of prescriptions each of them take, a growing shortage of pharmacists, and increasing demands on their time–all of which make traditional care and contact strategies cost- and time-prohibitive.

Designed to overcome these operational barriers, Varolii Adherence Outreach not only benefits patients, but enables pharmacies to improve operational metrics, optimize pharmacist time, and even generate more revenue from non-pharmacy sales due to increased pharmacy customer visits.

Pharmacies that have already begun using Varolii Adherence Outreach have seen an overall 10-20 percent increase in refill efficiency for treated therapeutic classes (and more than 100 percent in some of them), an 18 percent enrollment lift into auto-fill programs, and a doubling of prescription refill rates among patients enrolled in the program versus those who were not.

By using Adherence Outreach, pharmacies can cost-effectively:

— Welcome new patients to pharmacy services

— Provide a variety of personalized reminders, including refills, tardy notifications, renewals, auto-fills and Rxs ready for pick-up

— Share significant news, such as changes to drug formularies or availability of generic substitutions

— Communicate time-sensitive information, such as medication recalls, dosage adjustments and changes in medication availability

— Survey non-adherent patients to understand why they aren’t taking their medication and then effectively triage to appropriate resources to get patients back on track

— Find missing contact information for patients and update pharmacy records

— Connect with patients who are identified as “lost to follow up” to re-engage and win them back

Varolii Adherence Outreach was developed with personalization, authentication and clarity in mind. Patients respond to relevant, accurate information–targeted directly to them–with the assurance no one else will receive this highly personal and protected information. Varolii Adherence Outreach incorporates patient authentication to ensure privacy and predictive analytics to identify the most appropriate patients, as well as the best timing, delivery and message for each one. In addition, Varolii’s digitally recorded real voices pronounce complex pharmaceutical names with crystal clarity so even hard-of-hearing patients can understand the message and respond.

“Low adherence rates are a major issue for everyone concerned,” said Dr. Michael Ross, Vice President of Healthcare at Varolii. “As healthcare consumers, we all pay for the associated costs of the resulting poor clinical outcomes. For affected patients, the impact is more personal, and for the pharmacies that serve them, low adherence drains their ability to profitably serve their clients. Varolii Adherence Outreach balances all of these needs by delivering personal communications that make a difference in a cost-effective, business-focused way.”

Varolii Adherence Outreach is generally available. For more information, please visit http://www.varolii.com/Industries/Healthcare.aspx.

About Varolii Corporation

Varolii Corporation provides the on-demand software and services that help organizations create intelligent, automated conversations with their customers and employees over whichever combination of communication channels will generate the best response. Each message is carefully designed and continually optimized to improve service, increase revenue or manage unplanned events, for example, flight cancellation notices, fraud detection alerts, outage notifications, customer surveys, medication adherence notifications, payment reminders, and emergency alerts. More than 350 organizations, including many of the largest U.S. banks, airlines, wireless carriers, utilities, and healthcare organizations, trust Varolii to send more than 3.5 million messages every business day. Varolii is headquartered in Seattle with offices in the Boston and Denver metropolitan areas. For more information, visit www.varolii.com.

Zynx Health, the leader in evidence-based healthcare, announced that its more than 1,400 clients nationwide have collectively built upwards of 50,000 unique order sets and interdisciplinary plans of care.

Zynx’s hospital clients use ZynxOrder(TM) to customize and maintain evidence-based order sets, and ZynxCare(TM) to customize and maintain interdisciplinary plans of care and bring evidence-based knowledge to clinical teams at the point of decision making. Zynx physicians, nurses, and allied health professionals develop and update more than 900 templates for order sets and plans of care according to a timely, rigorous analysis of the peer-reviewed literature, performance measures, and regulatory guidelines.

“Having the largest client base in the industry creates an ideal environment for collaboration,” said Scott Weingarten, MD, MPH, president and chief executive officer of Zynx. “With more than 50,000 order sets and interdisciplinary plans of care, our clients have created a vast repository of collective wisdom. We are dedicated to providing our clients with the opportunity to benefit from one another’s experience as they seek to improve the quality, safety, and efficiency of care.”

Guided in great part by client feedback, the Zynx content team is currently at work on several initiatives to facilitate integration with vendor systems and to support rapid customization of order sets and plans of care. Zynx clients use AuthorSpace(TM), an online content management tool, to streamline the development process and reach rapid consensus on best practices. Once customized, order sets and plans of care can be deployed into the clinical workflow in either a paper-based format or through export into a clinical information system.

About Zynx Health

Zynx Health was founded in 1996 by thought leaders in evidence-based healthcare and healthcare quality improvement and acquired by Hearst Corporation in 2004. Zynx has grown to become a recognized leader in evidence-based clinical decision support, and offers a suite of online solutions that help clinicians treat their patients based on the best available evidence from systematic research. The Zynx team of physicians, nurses, and allied health professionals rigorously reviews the latest peer-reviewed literature to develop clinically relevant summaries and distill evidence-based best practices.

More than 1,400 hospitals nationwide trust Zynx evidence-based decision support to address regulatory initiatives, optimize pay-for-performance reimbursement, and measurably improve the quality, safety, and efficiency of patient care. For more information about Zynx Health, visit www.zynxhealth.com or call 888.333.ZYNX (9969).

 Zynx Health Contact: Nichole Buswell Marketing Manager (310) 954-5676 Email Contact

SOURCE: Zynx Health

Endust(R), the makers of the successful dusting and cleaning spray, is launching a new product that’s nothing to sneeze at – literally. New Endust Free Dusting and Cleaning Spray is the first fragrance-free, hypo-allergenic dusting and cleaning product designed to reduce allergens on surfaces and in the air to help prevent allergic reactions. No other widely distributed furniture sprays address this issue.

“We know consumers are concerned about health and wellness, but the furniture-care market doesn’t offer any products for people with indoor respiratory issues,” said Stan Stoltzfus, director of marketing for Endust Free. “Endust Free is the only hypo-allergic cleaning and dusting spray available in stores that meets the needs of the allergy-sensitive consumer.”

Endust recently conducted a survey of 4,111 adults who purchase cleaning products nationwide to determine their level of understanding about allergy triggers in their cleaning products.(1) More than 30 percent of consumers surveyed said the act of dusting furniture causes themselves, family members or roommates to sneeze, cough and/or have watery eyes. However, more than 65 percent of those same consumers were either not sure or incorrectly believed that dust is the only factor responsible for their adverse reactions, while most experts agree fragrance and the lingering mist created from spraying cleaning products are often common allergy triggers.

Allergen expert Dr. Mark Sneller, director of Aero-Allergen Research, LLC in Tucson, Ariz., says it is important not to overlook the causes of fragrances and their effect on indoor air quality and recommends using products like Endust Free. “We’ve been conditioned over the years to associate sweet-smelling scents with a clean home,” explains Sneller, Ph.D. “The truth is these scents often contain chemical structures with a lot of irritant qualities that can cause allergic and asthmatic reactions for sufferers of allergies.”

Besides being free of any perfumes or fragrances, Endust Free Dusting and Cleaning Spray has a unique, hypo-allergenic formula that contains less-irritating ingredients and has an innovative dispensing system that features a narrow-directed spray to reduce bothersome lingering mist and overspray. The product also has a twist-and-lock cap to protect against accidental spraying. Many products that create a lingering mist after spraying can diminish good indoor air quality by introducing chemicals with high amounts of volatile organic compounds (VOCs), which may also trigger allergic reactions. The Federal Clean Air Act requires each state to submit standards for achieving good air quality and protecting against VOCs. California, a state known for being a pioneer in environmental health, has some of the strictest regulations in the country when it comes to VOC limits. The Endust Free Dusting and Cleaning Spray formula emits 60-percent less VOCs than the current California limit.

Besides its health benefits, Endust Free Dusting and Cleaning Spray retains all the cleaning power of the Endust brand to quickly dust and clean for a natural shine. The distinctive packaging has an ergonomic-shape for a better, more comfortable grip and its eco-friendly, smaller-sized can uses 14-percent less packaging for less waste. The suggested retail price is $3.99.

About Endust

Endust is solely focused on helping consumer’s quickly remove the unwanted dust in their lives. Endust products are sold nationwide and in Canada. For more information about the Endust brand, please visit www.endust.com.

About Sara Lee Corporation

Each and every day, Sara Lee (NYSE: SLE) delights millions of consumers and customers around the world. The company has one of the world’s best-loved and leading portfolios with its innovative and trusted food, beverage, household and body care brands, including Ambi Pur, Ball Park, Douwe Egberts, Hillshire Farm, Jimmy Dean, Kiwi, Sanex, Sara Lee, and Senseo. Collectively, these brands generate more than $13 billion in annual net sales covering approximately 200 countries. The Sara Lee community consists of 44,000 employees worldwide. Please visit www.saralee.com for the latest news and in-depth information about Sara Lee and its brands.

(1)Are You Allergic to Dusting? Online Survey conducted by Endust and Zogby International on July 18-20, 2008

FORT WORTH, Texas, Aug. 26 /PRNewswire/ — Healthpoint today announced that it has initiated a clinical trial to evaluate the effectiveness of a widely prescribed enzymatic debriding agent on healing cutaneous wounds and resulting scars. The pilot study was prompted, in part, by clinical reports of the reduced incidence of hypertrophic scars and beneficial healing properties associated with Collagenase SANTYL(R) Ointment.(1,2)

“Given the findings from the peer-reviewed literature, as well as anecdotal reports Healthpoint has received from clinicians, we determined that formal scientific exploration was an appropriate course of action to more fully characterize the therapeutic properties of collagenase,” commented Bert Slade, MD, FAAAAI, Chief Medical Officer at Healthpoint. “We hope the findings from this pilot study will inform future research as part of our ongoing collagenase development program.”

Collagenase SANTYL(R) Ointment is a selective enzymatic debriding agent that contains 250 collagenase units per gram of white petrolatum USP. It is indicated for debriding chronic dermal ulcers (e.g., pressure ulcers, vascular ulcers, and diabetic ulcers) and severely burned areas. The enzyme collagenase is derived from the fermentation by Clostridium histolyticum and possesses the ability to liquefy collagen in necrotic tissue. Collagenase SANTYL(R) Ointment is now the most widely used brand of enzymatic debrider in the United States.*

The study is double-blind, site randomized and placebo controlled involving 30 healthy adult volunteers between the ages of 18 and 50. Site randomized means that each subject receives both active (Collagenase SANTYL(R) Ointment) and placebo (white petrolatum ointment) with one test article applied to each of two dermatome-induced skin wounds according to the randomization scheme. The study objectives are to compare the rate of complete wound closure within 21 days, and quality of resulting scar at 3, 6, and 9 months, between the active and placebo treatments. The study is being conducted at the University of Texas Southwestern Medical Center in Dallas, with Shai M. Rozen, MD, serving as the principal investigator.

“This study is another example of Healthpoint’s ongoing commitment to scientific evaluation and clinical research designed to provide healthcare professionals with evidence-based therapies that contribute to improved clinical and quality of life outcomes,” said Robert Bancroft, General Manager of Healthpoint.

About HEALTHPOINT, Ltd.

HEALTHPOINT(R) is dedicated to bringing innovative technologies for the prevention and treatment of diseased and traumatized skin and related soft tissue to the wound care market. Since 1992, the company focus has been on research, development and marketing of branded biologics, pharmaceuticals, over the counter drugs, and medical devices. Current HEALTHPOINT(R) products include: Collagenase SANTYL(R) Ointment, OASIS(R) Wound Matrix, and HYRODFERA BLUE(TM) Bacteriostatic Wound Dressings. HEALTHPOINT(R) is also committed to advancing the care and treatment of wounds through support of industry leading continuing education from THE WOUND INSTITUTE(R). To learn more about this comprehensive and award winning educational resource, please visit http://www.thewoundinstitute.com/. HEALTHPOINT(R), with over 300 employees, is a DFB Pharmaceuticals, Inc. affiliate company, and is based in Fort Worth, Texas. For more information, visit HEALTHPOINT’s website at http://www.healthpoint.com/.

References

(1.) Zimmerman WE. The importance of collagenase for the local treatment of major burns. In: Mandl I, editor. Collagenase. New York: Gordone & Breach, Science Publishers, 1972: 131-141.

(2.) Frye KE, Luterman A. Decreased incidence of hyptertrophic burn scar formation with the use of collagenase, an enzymatic debriding agent. Wound, 2005; 17[12]: 332-336.

*Occasional slight transient erythema has been noted in surrounding tissue when applied outside the wound. One case of systemic hypersensitivity has been reported after 1 year of treatment with collagenase and cortisone. See complete prescribing information online at: http://www.healthpoint.com/divisions/tm/images/Santyl-PI-Update(Final-Client- 11Dec07).pdf

Healthpoint, Ltd.

CONTACT: Robert Bancroft, HEALTHPOINT, [email protected],+1-800-441-8227

Web site: http://www.healthpoint.com/http://www.thewoundinstitute.com/

By Lisa Ryckman

Ethan and Sheridan Snapp for president!

Ethan’s 7 and Sheridan just turned 10. Nevertheless, they’ve already got what it takes: abundant smarts, sunny dispositions, can- do attitudes, grace under pressure, a willingness to take risks and the faces of angels (all courtesy of parents Carma and Larry Snapp).

But the real topper: how they dove into the sometimes-grueling President’s Challenge Physical Fitness Test and came out the other end grinning.

“It was fun,” Sheridan said.

If you remember doing toe-touches to the Chicken Fat song, then you know just how long the nation has been fretting about pudgy kids. President Dwight Eisenhower, alarmed by a study that found that American kids were a bunch of slugs compared with children in other countries, created the President’s Council on Youth Fitness in the summer of ’56.

The Council and its fitness test have been through a lot of changes in the past half-century, but it’s still a doozy, with tests of muscular strength, flexibility, cardio endurance and agility.

And because so many kids who did the original President’s Challenge fitness test have grown up to be sloth-like adults, there’s a new President’s Challenge for adults.

Sheridan and Ethan’s mom, Carma – a 110-pound dynamo with energy to burn – kindly agreed to put herself through its tests of strength, flexibility and aerobic fitness.

Carma zipped around East High School’s track and kicked butt in the push-up test. But when it came to the half sit-ups, she learned a valuable lesson: Don’t do the President’s Challenge with abs that are still screaming from a week’s worth of boot camp workouts.

When all was said and done, Ethan’s favorite challenge was the shuttle run, a test of speed and agility; his sister preferred the flexed-arm strength test, which required her to keep her chin above a bar while her feet dangled in the air.

“At first, my abs really hurt, but my arms didn’t,” Sheridan said. “At the end, my arms felt like Jell-O.”

But she hung in there anyway. And that’s just the kind of moxie we need in a future president.

INFOBOX 1

The President’s Challenge

Adult fitness tests

AEROBIC FITNESS

* 1-mile walk or 1.5-mile run

MUSCULAR STRENGTH AND ENDURANCE

* Half sit-up: Lie on your back with knees bent and feet on the ground. Have your partner place a piece of tape under your finger tips, and another piece 3 1/2 inches in front of your fingertips.

Flatten your lower back to the mat or rug, and half sit-up so that your fingers move from the first piece of tape to the second. Then return your shoulders to the mat or rug and repeat the movement as described. Your head does not have to touch the surface.

Your partner counts the half sit-ups performed in one minute.

* Push-ups: Men start in the standard push-up position. Hands should be shoulder width apart, arms extended straight out under the shoulders, back and legs in a straight line, and toes curled under. Women do a modified push-up with knees bent and touching the floor. Lower until the chest is about 2 inches from the floor and rise up again. Perform the test until you cannot complete any more with proper form. If necessary, you can take a brief rest in the up position.

FLEXIBILITY

* Place a yardstick on the floor and put a long piece of masking tape over the 15-inch mark at a right angle to the yardstick. Remove your shoes and sit on the floor with the yardstick between the legs (0 mark close to your crotch), with your feet about 12 inches apart. Heels should be at the 14-inch mark at the start of the stretch. With the fingertips in contact with the yardstick, slowly stretch forward with both hands as far as possible, noting where the fingertips are to the closest inch. Exhaling when you stretch forward and dropping the head may allow you to stretch a bit further. Perform the stretch three times with a few seconds of rest between stretches. Record the best measurement.

Kids’ tests

MUSCULAR STRENGTH

* Flexed-arm hang: Using either an overhand grasp (palms facing away from body) or underhand grip (palms facing toward body), child assumes flexed-arm hang position with chin clearing the bar. Lift the child to this position. Child holds this position as long as possible. Chest should be held close to bar with legs hanging straight. Timing is stopped when child’s chin touches or falls below the bar.

* Partial curl-ups: Have child lie on cushioned, clean surface with knees bent and feet on the ground, about 12 inches from buttocks. Do not hold or anchor the feet. Arms are extended forward with fingers resting on the legs and pointing toward the knees. A partner is behind the head with hands cupped under the head.

The child curls up slowly sliding the fingers up the legs until the fingertips touch the knees, then back down until the head touches the partner’s hands. The curl-ups are done to a metronome (or audio tape, clapping, drums) with one complete curl-up every three seconds, and are continued until the child can do no more in rhythm.

SPEED AND AGILITY

* Shuttle Run: Mark two parallel lines 30 feet apart and place two blocks of wood or similar objects behind one of the lines. Child starts behind the opposite line. On the signal “Ready? Go!” the child runs to the blocks, picks one up, runs back to the starting line, places block behind the line, runs back and picks up the second block and runs back across starting line.

AEROBIC FITNESS

* Endurance run/walk: On a safe, one-mile distance, child begins running on the count “Ready? Go!” Walking may be interspersed with running, but child should be encouraged to cover the distance in as short a time as possible. Use a large-enough running area so that no more than eight laps are necessary to complete a mile. Alternative distances for younger kids are 1/4 mile for 6-7 years old, and 1/2 mile for 8-9 years old.

FLEXIBILITY

* V-sit: Mark a straight line 2 feet long on the floor as the baseline. Draw a measuring line perpendicular to the midpoint of the baseline extending 2 feet on each side and marked off in half- inches. The point where the baseline and measuring line intersect is the zero point. Child removes shoes and sits on floor with measuring line between legs and soles of feet placed immediately behind baseline, heels 8 to 12 inches apart. Child clasps thumbs so that hands are together, palms down, and places them on measuring line. With the legs held flat by a partner, child slowly reaches forward as far as possible, keeping fingers on baseline and feet flexed. After three practice tries, child holds the fourth reach for three seconds while that distance is recorded.

INFOBOX 2

Snapp family results

Carma Snapp, 43

* Aerobic fitness: 1-mile walk in 13:01, heart rate 150 at the end, 90th percentile*

* Muscular strength: 30 push-ups, 90th percentile; six half sit- ups, 5th percentile

* Flexibility: sit and reach, 17 inches, 55th percentile

* Body Mass Index: 20.1 (normal)

Sheridan Snapp, 10 (9 at the time of tests)

* Flexed arm hang: 37 seconds, 95th percentile

* Shuttle run: 10.4 seconds, 95th percentile

* V-sit reach: 5.5 inches, 85th percentile

* Endurance run (1/2 mile): 4:07, 80th percentile

* Partial curl-ups: 19, 45th percentile

Ethan Snapp, 7

* V-sit reach: 5 inches, 95th percentile

* Flexed arm hang: 22 seconds, 90th percentile

* Shuttle run: 12 seconds, 75th percentile

* Endurance run (1/4 mile): 2:16, 45th percentile

* Partial curl-ups: 12, 45th percentile

INFOBOX 3

Join the President’s Active Lifestyle Challenge

You don’t have to be an elite athlete to get healthier and earn an award from the President’s Council. Here are the steps to joining the challenge:

1. Choose an activity: Walking, basketball, tennis, aerobics, biking – almost any exercise will do. Just 30 minutes of moderate- intensity physical activity, done on most days of the week, has great benefits for adults. Sixty minutes is the minimum for youth.

2. Get active: Your goal is to meet your daily activity goal (30 minutes a day for adults/60 minutes a day for children under 18) at least five days a week for a total of six weeks. You can take up to eight weeks to complete the program.

3. Track your activity: Use the Council’s online personal activity log. You can log your time as often as you want, in amounts as short as 5 minutes (10 minutes is better).

4. Order your award: When you reach your goal, your activity log reminds you to order your award, either online or by mail. Then you may continue earning awards in the Active Lifestyle program or move on to the next challenge: the Presidential Champions program.

Here’s how to become a Presidential Champion:

1. Choose an activity: You’ll earn points for every activity you log. Points are based on the amount of energy each activity burns, so the more active you are, the more points you get. This program has a 750-point daily cap to encourage staying active every day. Earning a bronze award takes 20,000 points. For example, if you run 5 miles every day, you can reach that amount in about six weeks. More moderate activities will take a little longer.

2. Track your activity, using your online personal activity log.

3. Go for the goal: Reach it, and your activity log will remind you that you’ve earned an award that you can order online or by mail. Continue on in the President’s Champion program for a silver or gold award.

* Learn more at presidents challenge.org.

INFOBOX 4

History of the President’s Council on Physical Fitness and Sports

1956: President Dwight Eisenhower, alarmed by a report that finds American children are slugs compared with kids in other countries, creates the President’s Council on Youth Fitness. First chairman: Vice President Richard Nixon.

1960-63: President John F. Kennedy appoints University of Oklahoma football coach Charles “Bud” Wilkinson as the council’s executive and special consultant to the president. Nearly 250,000 school kids take part in a council-sponsored pilot program. At the end of the first year, 25 percent more students passed the physical fitness test than had before the program.

1966: President Lyndon B. Johnson broadens the Council’s mission to include sports and changes the name to the President’s Council on Physical Fitness and Sports. He creates an awards system to recognize active youth.

2002: President George W. Bush announces a reinvigorated Council under the leadership of former Pittsburgh Steeler Lynn Swann.

Originally published by Lisa Ryckman, Rocky Mountain News.

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

By Cooper, R G Magwere, T

Chloroquine (CHQ) is a cheap, relatively well tolerated drug initially developed for the treatment of malaria in the 1930s. CHQ has, however, since accrued a plethora of uses in the treatment and amelioration of several other diseases and conditions because of its lysosomotropic properties. It also has characteristic physiological and systemic effects. This review gives an overview of the history and pharmacology of CHQ, and progresses to consider some of the mechanisms that may underlie its biochemical and physiological effects. Additionally, an overview of some of the novel uses of CHQ in the treatment of viral infections and cancer are presented. The antimalarial mechanisms of CHQ were not discussed in this review. The message is that CHQ, despite its welldocumented toxicity and adverse side effects may have important future uses that are associated with its lysosomotropic and immunomodulatory mechanisms. The possibility exists therefore that CHQ might be re-introduced into regular malaria treatment. Key words Anti-inflammatory – antimalarial – chloroquine – malaria – pharmacology – toxicology

Introduction

The popularity of chloroquine [7-chloro-4-(4diethylamino-1- methylbutylamino) quinoline, CHQ] for malaria treatment in many Third World countries emanates from it being cheap, widely available, relatively well tolerated, and having a rapid onset of action15. CHQ is commonly sold as an over-the-counter medication and is also used as an anti-inflammatory drug in the treatment of rheumatoid arthritis6-8, discoid lupus erythematosus9-10 and amoebic hepatitis11. CHQ inhibits pro-inflammatory cytokine release into human whole blood and may be of therapeutic benefit not only during chronic inflammation, but also in diseases that are related to bacteria-induced inflammation12.

CHQ synthesis

CHQ was first synthesised in Germany by Bayer Corporation in 1934 as a cheaper alternative to the costly naturally occurring quinine, but was then considered toxic for any significant biological use13. However, as the demand for cheaper, readily available antimalarial drugs escalated during World War II, CHQ received a new lease of life and was subsequently discovered to be more effective than the costly quinine or quinidine against intra-erythrocytic malarial parasites13. For the following two decades thereafter (1946-1966), CHQ emerged as the drug of choice for treatment and prophylaxis of malaria in most disease-endemic tropical countries14. The disadvantages of quinine/quinidine are that they are really toxic and have a short half-life15.

Properties of CHQ and its usage

CHQ is a bitter, colourless, dimorphic crystalline powder soluble in water at pH 4.5, but less so at more neutral or alkaline pH. It therefore dissolves rapidly in the stomach (pH 2.0). CHQ’s bitter taste may be masked following administration in drug-loaded hydrogel beads enclosed in hard gelatin capsules16. CHQ has a quinoline ring like that of quinine and a side chain identical to that of quinacrine; and the chloride atom in the seventh position appears to be crucial to its antimalarial activity17. It specifically inhibits the malaria parasite’s digestive pathway for haemoglobin9. There are two enantiomers, the (-)-chloroquine being less active than (+)- chloroquine enantiomer against chloroquineresistant strains of Plasmodium falciparum9. Comparative antimalarial drug trials in humans revealed that CHQ was a more effective antimalarial than quinidine and quinine13. Subsequently, it was developed as the first choice drug for prophylaxis and treatment of all types of malaria due to susceptible strains of P. falciparum, P. ovale, P. vivax and P. malariae17.

The major vector of malaria in Africa is the Anopheles gambiae complexl8. Malaria remains a major cause of mortality and morbidity in Africa, and there is a need to utilize effective prevention and intervention methods to combat the spread of the infection1920.

From 1966 onwards an emergence of CHQ resistence in malaria parasites was seen worldwide20-24. Indeed, four countries in Africa (Malawi, Kenya, Botswana and South Africa) now deploy pyrimethamine- sulphadoxine as their first-line antimalarial25. It is believed that factors such as inadequate dosing, incomplete courses of therapy, indiscriminate and inappropriate use, and reliance on less effective medications, have contributed to the emergence and spread of resistant parasites26,27. Even in the presence of CHQ resistance the drug may still be quite useful especially in areas with high communal immunity28. In a study from Ghana, a significantly higher proportion of inappropriateness of CHQ use was a factor influencing the lower sensitivity of P. falciparum29.

To ensure its efficacy, and when alternative drug combinations are inaccessible, CHQ may be coadministered with calcium channel blockers, tricyclic anti-depressants and anti-histamines resulting in maintenance of CHQ levels30. Other studies using cyproheptadine have shown it to reverse resistance to CHQ in strains of P. falciparum both in vivo and in vitro31. Significant protection against CHQ-resistant malaria in mice has been shown using Menhades- fish oil32. Bio (benzyl) polyamine analogues have also been shown to inhibit both CHQ-resistant and CHQ-sensitive strains of P. falciparum in vitro33. Other studies report the effectiveness of gold-CHQ complexes against resistant strains34. Antimalarial drug combinations of CHQ and primaquine have been reported to reduce therapeutic failure in CHQ-resistant P. vivax infection21, as has pyrimethamine-suIphadoxine-CHQ combinations25. The judicious use of such drug combinations with CHQ may help to avoid development of resistance and combat resistant infections35,36. Indeed, if the combined treatment translates into a 3-5 yr extension in the useful lifespan of CHQ, the overall cost would be less than that of developing the next, more expensive alternatives (mefloquine and quinine). As a response to increasing levels of resistance to antimalarial medicines, the WHO recommended that all countries experiencing resistance to conventional monotherapies, such as chloroquine, amodiaquine or sulphadoxine-pyrimethamine, should use combination therapies, preferably those containing artemisinin derivatives (ACTs – artemisinin-based combination therapies) for falciparum malaria37. Although combination therapies can be effective in reducing/ reversing incidences of CHQ resistance in parasites38, the WHO recommends that combination therapies be limited to: (i) artemether/lumefantrine; (ii) artesunate plus amodiaquine (in areas where the cure rate of amodiaquine monotherapy is greater than 80%); (iii) artesunate plus mefloquine (insufficient safety data to recommend its use in Africa); and (iv) artesunate plus sulphadoxine/pyrimethamine (in areas where the cure rate of sulphadoxine/pyrimethamine is greater than 80%).

Amodiaquine plus sulphadoxine/pyrimethamine may be considered as an interim option where ACTs cannot be made available, provided that efficacy of both is high.

Absorption, metabolism and excretion of CHQ

When administered orally, CHQ is rapidly and almost completely absorbed from the gastrointestinal tract with a bioavailability of 75-80 per cent39,40. Other routes of CHQ administration include subcutaneous, intramuscular and rectal41. Maximum plasma concentrations are reached in 1-2 h3,8,42 and remain up to 3.6 hours40 after administration. CHQ has a large apparent volume of distribution in the body (160-800 1/kg)25. It has a half-life ranging from 2-3 days in rats39,43,44 and up to 3-6 days in humans11. The elimination half-life of CHQ however varies greatly between plasma and tissue in humans, ranging from 2-3 days in plasma to over 300 h in tissues where the drug is more avidly bound45. Up to 70 per cent of an ingested dose of CHQ is excreted unchanged in the urine and the parent drug can still be detected in the urine up to 120 days following a single 300 mg dose in humans46. The total plasma clearance of CHQ is approximately 600 ml/min47 and the renal clearance is about 400-450 ml/min40. The distribution of CHQ within human blood is also important because the malaria parasite is intraerythrocytic during schizogony48. CHQ-induced redistribution of a neutral aminopeptidase may be the cause of haemoglobin accumulation in endocytic vesicles of malaria parasites49.

CHQ is a weakly basic tertiary amine and is metabolized by oxidative deamination, elimination of the side chain, and N- oxidative pathways. It is oxidatively de-ethylated to give mono- desethylCHQ (30-40% of blood CHQ concentration) and then to bisdesethylCHQ (5-10% of blood CHQ concentration)50. Available data suggest that the enzymes responsible for CHQ metabolism in humans are the cytochrome P450 (CYP) isoforms CYP3A, CYP2C8, and CYP2D651- 53. The liver transforms approximately 30-50 per cent of the administered CHQ, although extrahepatic sites of microsomal metabolism could also be of clinical significance in view of the extensive tissue distribution of CHQ and the extrahepatic distribution of CYP3A isoenzymes51. Mono-desethylCHQ is the main metabolite of CHQ and it has been shown to have the same anti- malarial activity against CHQ-susceptible P. falciparum as the parent compound54. Bis-desethylCHQ is metabolized to a 4′-hydroxy- compound, which is further oxidised to its 4-carboxylic acid derivative. Further dealkylation of the CHQ side chain results in the production of 7-chloro-4-aminoquinoline55-56. In studies conducted on intravenous administration of CHQ at 2.5 mg/kg in rats, the excretion of monodesethylCHQ and bis-desethylCHQ was 25 and 64 per cent, respectively with maximum urinary excretion on the first day39. Renal clearance of mono-desethylCHQ accounts for 65 per cent of the apparent total clearance of CHQ57. Renal effects of CHQ

Current evidence suggests that CHQ may affect kidney function when taken either during treatment or prophylaxis of malaria or administered acutely or chronically in rats58-60 probably due to its accumulation in kidney cells56. The accumulation of CHQ in tissues may result from inhibition of anti-malarial microsomal metabolism in kidney cells and potentiate its uptake in lysosomes in the cytoplasm61. CHQ, which is also deposited in the adrenal glands62, may indirectly affect kidney function by modulating the secretory patterns of aldosterone to cause a reduction in tubular Na+ handling. The deposition of CHQ in the epithelial cells of the kidney may result in a possible interference with ion movements43,63. CHQ also causes vasodilatation and cardiac depression in rats64. This may alter perfusion pressure of the kidney and renal haemodynamics, and affect renal fluid and electrolyte handling. The lowering of Na+-K+-ATPase activity by CHQ is evidenced in the inhibition of renal brush border enzyme mediated carrier transport63. The influence of CHQ on renal fluid and electrolyte handling necessitates monitoring of kidney function in patients who consume the antimalarial in malaria endemic areas.

Chronic administration of CHQ has been reported to cause Na+ retention possibly via increase in plasma aldosterone concentrations59,66 and renal Na+-K+-ATPaSe activity67. It is not uncommon for people on CHQ prophylaxis to consume ethanol and/or analgesic drugs. The co-administration of CHQ with other drugs or substances that are substrates of the CYP enzymes (e.g., ethanol and paracetamol) can result in adverse effects to the kidney68-70. It was shown that concurrent administration of CHQ and ethanol induced extensive damage to the proximal tubules and collective duct cells of the kidney70. Recently it has also been proposed that the impairment of renal function by CHQ may be due to its modulatory effects on the renal tubular response to vasopressin, either directly by inhibiting cyclic AMP generation or indirectly via induction of nitric oxide (NO) production71. If NO is involved in the mediation of CHQ-improved insulin sensitivity, then the administration of inducible nitric oxide synthase (iNOS) blockers might halt or reverse glucose-induced insulin secretion in pancreatic beta-cells72. The critical role of nitric oxide in renal failure is underscored by findings that inhibition of iNOS in rats73 or iNOS knockout mice74 protects against acute renal failure.

Slow intravenous infusion of CHQ has been reported to alter kidney function by increasing urinary Na+ excretion58. Plasma arginine vasopressin (AVP) concentrations increase in rats following acute CHQ administration presumably to increase urinary Na+ excretion60,74-77. Natriuresis may also occur due to CHQ-induced synthesis of nitric oxide, which inhibits renal Na+-K+-ATPase activity78,79. Renal ion handling may be further potentiated by CHQ- induced, nitric oxide mediated inhibition of endothelial cell proliferation80.

Three consecutive days of oral CHQ administration has been reported to cause Na+ retention possibly via increases in plasma aldosterone concentrations59,66,69,70,76,81 and renal Na+-K+-ATPaSe activity67.

Pathomorphological influence of CHQ on the liver and kidney

CHQ is a potent autophagic drug that may lead to cellular degradation of hepatocytes in the liver with the concurrent production of vacuoles82-84. An initial decrease in the number and volume of mitochondria has also been reported83 due to their sequestration in autophagic vacuoles. Observed increases in the numbers of lysosomes suggest further cellular degradation. This is accompanied by fusion of lysosomes with autophagic vacuoles resulting in the biogenesis of new lysosomes84. CHQ accumulates especially in the Kupffer cells of the liver with resultant lysosomal damage including overloading of the liver lysosomes with non-digestible material, and an increase in their size and number85. The reported accumulation of CHQ in lysosomes86,87 has an apparent destabilising effect on lysosomal membranes88,89.

Colombo and Bertini90 argued that the biological and pharmacological actions of CHQ are directly related to its interaction with lysosomal membranes. CHQ, however, decreases the density of hepatocyte lysosomes, although it has no effect on sinusoidal cell lysosome density. Such a difference could result from the fact that sinusoidal cell lysosomes do not accumulate CHQ to the same extent as hepatocyte lysosomes, despite the former contributing to more than 40 per cent of the volume occupied by lysosomes in the liver91. The density decrease of lysosomes caused by CHQ has been reported to be due to their accumulation of the drug and their subsequent osmotic swelling92,93. Singh et al 94 reported additional effects of CHQ on organelles in rat hepatocytes as shown by increases in volume densities of mitochondria, lysosomes, rough and smooth endoplasmic reticula, and Golgi apparatus, and with a concomitant decrease in functional activity95.

Currently, there are only a few investigations on the effect of CHQ on kidney morphology70,96,97. CHQ may exert its renal effects indirectly via histopathological and ultrastructural cardiac damage98 through reductions in glomerular filtration rate (GFR). Given the importance of hepatic microsomal degradation of CHQ, an alteration in liver morphology by the antimalarial56 is likely to result in an impairment of its metabolism and an increase in its circulating levels. This is likely to result in an impairment of kidney function due to its reported accumulation in cells therein43,63. Investigating the effects of long-term oral CHQ administration on possible alterations of kidney structure may help to partially explain previously observed renal effects of CHQ on fluid and electrolyte balance58,59.

Effects of CHQ on cellular enzymes

The mechanisms underlying the physiological and systemic effects of CHQ are poorly understood. However, there is a growing body of literature to suggest that some of these effects may be exerted through interactions with cellular enzymes. Antimalarial drugs including CHQ were first documented to inhibit glucose 6-phosphate dehydrogenase activity in vitro99. Inhibition of drug metabolizing enzyme systems both in vivo and in vitro were described later67 and it was subsequently demonstrated that additional effects of CHQ included alterations in phospholipid compositions of microsomes100. Decreases in CYP-mediated microsomal aminopyrine-N-demethylase, aniline hydroxylase, and cytosolic glutathione S-transferase activities were also observed in rats following administration of CHQ. Other enzyme systems such as phospholipase A1 and A2 and lysophospholipase activities are also inhibited by CHQ and related drugs in vitro101. Mitochondrial NADH dehydrogenase, succinate dehydrogenase, and cytochrome C oxidase activities are reduced following CHQ treatment in rats95. Recent studies have shown that antimalarial drugs including CHQ decrease cytochrome aa3 and b content and adversely affect mitochondrial energy transduction in vivo by acting as uncouplers of oxidative phosphorylation102. The uncoupling effect of CHQ and other antimalarials was shown to be specific for sites II and III of phosphorylation but did not affect site I102. Modulation of drug metabolizing enzymes by CHQ can lead to significant drug-drug interactions in vivo that lead to the psychotic side effects of some antidepressants and neuroleptic drugs103.

Administration of CHQ to rats was shown to also cause alterations in several hepatic and renal antioxidant enzymes thereby inducing an oxidative stress in these organs104,105. When given to rats orally at 20 mg/kg once a week for 4 wk, CHQ caused an oxidative stress in rat liver as shown by elevated activity of superoxide dismutase and decreases in H^sub 2^O^sub 2^-decomposing enzymes such as catalase and glutathione peroxidase. Increased markers of lipid peroxidation were increased in these organs confirming the extent of oxidative damage following the CHQ administration104. CHQ thus increased the intracellular levels of H^sub 2^O^sub 2^, a condition that exacerbated the susceptibility of rat organs to lipoxidative damage from subsequent oxidative challenges with menadione (30 mg/kg) or CCl^sub 4^ (1.25 ml/kg)105. In recent studies, it has been proposed that the retinopathy106 and genotoxicity107 exhibited by CHQ is due to its ability to induce intracellular and intraorgan oxidative stress/damage; and it is plausible that CHQ-induced organ failure could be exerted through such mechanisms.

CHQ induces the expression of iNOS108, a property that is responsible for many of its physiological effects in organs such as the kidneys. It was shown that CHQ at non toxic concentrations (10- 100 [mu]M) could activate tyrosine kinase and protein kinase C to induce p38MAPK activation resulting in induction of iNOS expression and increased NO production in glioma C6 cells108. The stimulatory effects of CHQ on NO production were also demonstrated in mouse, pig, and human endothelial cells in vitro80 and are thought to be mediated via a CHQ-induced impairment of iron metabolism. In patients with rheumatoid arthritis, CHQ has hormone-like effects in that NO production stimulates glucose-induced insulin secretion as well as preventing degradation of insulin109. The effects of CHQ on NO production, however, seem to be cell type-dependent. In murine peritoneal macrophages that have been stimulated with either interferon-gamma (IFN-gamma) or bacterial lipopolysaccharide (LPS), CHQ inhibited iNOS activity and NO synthesis in a dose-dependent manner110. The inhibition of NO production by CHQ in macrophages occurred at both mRNA110 and protein111 levels where decreases in these cellular components were observed following exposure to the drug. Effects of CHQ on cytokines and the immune system

The lysosomotropic effects of CHQ are widely believed to be responsible for its anti-inflammatory properties and effectiveness in the treatment of some autoimmune diseases112. CHQ was shown to decrease the production of the pro-inflammatory cytokines IFN- gamma, tumour necrosis factor-alpha (TNF-alpha), and interleukin-6 (IL-6) in LPS- or phytohemagglutininstimulated peripheral blood mononuclear cells113, and also augmented LPS-induced expression of TNF-alpha, IL1alpha, IL-1beta and IL-6 in monocytic and microglial cells114. When administered alone however, CHQ induced, rather that inhibited, the production of pro-inflammatory cytokines in astroglial cells through activation of the transcription factor NF- kappaB114. Park and colleagues114 concluded that CHQ could induce either anti-inflammatory or pro-inflammatory responses in the CNS depending on the cellular context.

CHQ also exerts anti-inflammatory effects via non-lysosomotropic mechanisms115. CHQ was shown to inhibit TNF-alpha release in macrophages through inhibition of TNF-alpha mRNA synthesis, thereby showing it can also disrupt gene transcription115-117 but does so without interfering with posttranslational modification or release of the cytokine from macrophages118. Jang and colleagues showed that CHQ also interfered with macrophage function by blocking the conversion of cell-associated TNF-alpha to mature protein, and reduced the levels of IL1beta and IL-6 mRNA by altering their stability in a pH-dependent manner118. In human histiocytic U-937 cells, CHQ was shown to decrease cell surface expression of TNF- alpha receptors by retarding their transport to the cell surface119. The blocking of pro-inflammatory cytokines by CHQ was shown to be protective against LPS- and Escherichia coli DNA-induced inflammatory responses and/or sepsis in mice120. CHQ also inhibits cytokine release into human whole blood, an effect that could be beneficial in diseases that are related to bacterial-induced inflammation12. These anti-inflammatory properties of CHQ could have photoprotective effects in conditions such as lupus erythematosus121 and could be exploited in the amelioration of conditions such as post-transfusion graft-versus-host disease122.

The immunomodulatory effects of CHQ could theoretically have deleterious implications for diseases whose pathogenicity relies on suppression of the immune system. Seth and colleagues123 showed that CHQ administration exacerbated the severity of Semliki Forest virus infections in mice by upregulating the mRNA levels of pro- inflammatory cytokines such as IL-1, IL-6, and IFN-gamma -inducing factor, among others. However, this is the only incidence in the literature to date that has shown induction of pro-inflammatory cytokines by CHQ. As such, it is not known how CHQ treatment could affect the course of viral infections such as HIV in humans. However, the evolution of AIDS-causing HIV strains has recently been postulated to be related to CHQ use in humans124,126.

A new lease of life for CHQ

The forgone discussion has shown that the physiological, cellular, and biochemical effects of CHQ are exerted through pleiotropic mechanisms involving both lysosomotropic-dependent and independent effects. This cornucopia of mechanisms of action has seen CHQ persist on therapeutic regimens for several diseases and conditions despite its systemic toxicity and the emergence of drug resistance in malaria parasites.

CHQ for treatment of viral infections?

CHQ is currently under clinical trials as a potential, antiretroviral drug in humans. Malariotherapy is basically safe for HIV infection and it improves some immunological parameters of HIV positive patients127 resulting in an increased CD4 count128. Therapeutically induced acute vivax malaria was shown to be well tolerated in 20 HIV-positive subjects who represented a range of CD4 cell lines from 15-1868 per microlitre127. Paton et al129 argued that drug combinations of HCHQ and/or hydroxycarbamide and didanosine may be suitable for poorer countries. HCHQ has been shown to suppress HIV-1 replication in T cells and monocytes in vitro by inhibiting post-transcriptional modification of the virus130-132. Early in 1995, Sperber et al131 reported that administration of CHQ for 8 wk to HIV-1 positive patients resulted in decreases in copy number of HIV-1 mRNA as well as reductions in plasma levels of the pro-inflammatory cytokine IL-6 compared to placebo. In 1998, Pardridge et al132 reported that CHQ could inhibit replication of HIV-1 in human peripheral lymphocytes at concentrations similar to those achievable in humans in vivo, with minimal effects on host cell DNA replication. The mechanism of action of CHQ on HIV-1 and – 2 was later shown by Savarino and colleagues133,134 to include structural alterations in newly formed viral envelope glycoproteins (gp120) which led to impairment of the infectivity and ability to form syncytia by the newly formed viruses.

It is now believed that CHQ, through its lysosomotropic effects of increasing intra-organellar pH, could impair the catalytic function of the glucosyltransferases involved in processing of HIV glycoproteins135. Thus CHQ has potential for use as an adjunct in standard antiretroviral drug therapy. Some research groups have since demonstrated that CHQ has synergistic effects with zidovudine, didanosine, and hydroxyurea133,134,136 as well as with protease inhibitors such as indinavir, ritonavir, and saquinavir136. The presence of CHQ in breast milk137 and in blood138 has been postulated to be related to a reduction in the risk of vertical transmission of HIV in humans. CHQ is associated with low levels of HIV RNA in breast milk137. To date, CHQ is among several drugs that have been shown to have in vitro activity against the replication of SARS or coronavirus infections139.

CHQ – a part in anticancer strategies?

In 1992, Djordevic and colleagues140 reported that treatment of mouse melanoma cells with CHQ potentiated the effectiveness of radiation-induced cell killing. Human MDA-MB231 cancer cells were influenced by CHQ via radiosensitizing effects through a destabilisation of lysosomes and plasma membranes89. They showed that treatment of MDA-MB231 cells with CHQ resulted in the latter accumulating into lysosomes thereby causing their volume to increase; the swelling of the lysosomes was associated with translocation of ceramide to the lysosomal surface thus inducing massive necrotic cell death when the cells were exposed to radiation89. Other research groups have also demonstrated, using a wide range of concentrations (0.25-128 [mu]M) for 24-72 h, that low doses of CHQ inhibited growth of A549 human lung cancer cells in culture and that higher doses of CHQ induced A549 cell death by necrosis141.

CHQ also has potential for use as a chemosensitizer in cancer in conjunction with some conventional antineoplastic agents. CHQ has recently been shown to inhibit the function of membrane-associated proteins belonging to the p-glycoprotein and multi-drug resistance (MDR) protein families89,142,143. These proteins are at the forefront as mediators of chemotherapy resistance in a wide range of cancers because they pump drugs out of cells and are usually overexpressed in most chemoresistant cell phenotypes144. The inhibition of drug efflux from the cell by CHQ and related antimalarials could help in sensitizing resistant cells to the cytotoxic effects of anticancer drugs by maintaining high intracellular concentrations of the chemotherapeutic agent. Indeed, some research groups have shown that CHQ enhances the toxicity of doxorubicin in some resistant cancer cell lines143 as well as augment the antiviral effects of some agents136. However, the use of CHQ in vivo is not without its attendant problems. Radiotherapy given after a course of CHQ treatment led to unexpected skin reactions145, and this has prompted other workers to suggest a rigorous revaluation and delineation of all undesirable side effects before CHQ can be used safely in any new treatments146.

A comeback for the malaria miracle drug?

In 1993 Malawi, an African country, withdrew CHQ from use as a treatment for malaria in favour of the sulphadoxine-pyrimethamine combinations. A decade later, there was a return of CHQ-sensitive P. falciparum malaria in Malawi147. In Uganda, a study demonstrated that there were no pharmacokinetic interactions between CHQ, sulphadoxine and pyrimethamine when given together148.

In their study Kublin and colleagues147 measured the prevalence of the pfcrt 76T genotype (a molecular marker for CHQ-resistance) and observed that after 10 yr of CHQ withdrawal, the prevalence of this genotype decreased from a peak of 85 per cent in 1992 to only 13 per cent in 2000. A subsequent trial in 2001 showed that CHQ was able to clear 100 per cent of infections in a group of asymptomatic P. falciparum infections and no incidence of the pfcrt genotype was detected147. These findings were later corroborated by the another group who showed that CHQ cured 99 per cent of 80 malaria cases in Blantyre (Malawi) and the cure rate was even superior to that of the sulphadoxinepyrimethamine combination149. However, the authors urged a cautious return to the use of CHQ in malaria endemic areas and suggest that it be used in combination with other drugs to prevent the recurrence of drug resistance in parasites.

Conclusion

CHQ is one of the most successful and widely used medications and with obvious health precautions, saving countless lives from the scourge of malaria. Its relatively simple manufacturing methods mean that it is affordable in many countries of the world. It has numerous other uses that could prove significant as measures are sought desperately to combat the spread of some viral diseases and cancer. Indeed, there is the real potential for CHQ to be restored to the antimalarial armamentarium; and, efforts must focus on understanding the mode of action of antimalarial agents and on the mechanism by which the P. falciparum impedes the action of these drugs150. References

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137. Semrau K, Kuhn L, Kasonde P, Sinkala M, Kankasa C, Shutes E, et al. Impact of chloroquine on viral load in breast milk. Trop Med Int Health 2006; 11 ; 800-3.

138. Neely M, Kalyesubula I, Bagenda D, Myers C, Olness K. Effect of chloroquine on human immunodeficiency virus (HIV) vertical transmission. Afr Health Sci 2003; 3 : 61-7.

139. de Clercq E. Potential antivirals and antiviral strategies against SARS coronavirus infections. Expert Rev Anti Infect Ther 2006-4 : 291-302.

140. Djordevic B, Lange CS, Rotman M. Potentiation of radiation lethality in mouse melanoma cells by mild hyperthermia and chloroquine. Melanoma Res 1992; 2 : 321-6.

141. Fan C, Wang W, Zhao B, Zhang S, Miao J. Chloroquine inhibits cell growth and induces cell death in A549 lung cancer cells. Bioorg Med Chem 2006; 14 : 3218-22.

142. Vezmar M, Georges E. Direct binding of chloroquine to the multidrug resistance protein (MRP): possible role for MRP in chloroquine drug transport and resistance in tumor cells. Biochem Pharmacol 1998; 56 : 733-42.

143. Vezmar M, Georges E. Reversal of MRP-mediated doxorubicin resistance with quinoline-based drugs. Biochem Pharmacol 2000; 59 : 1245-52.

144. Kvackajova-Kisucka J, Barancik M, Breier A. Drug transporters and their role in multidrug resistance of neoplastic cells. Gen Physiol Biophys 2001; 20 : 215-37.

145. Rustogi A, Munshi A, Jalali R. Unexpected skin reaction induced by radiotherapy after chloroquine use. Lancet Oncol 2006; 7 : 608-9.

146. Savarino A, Lucia MB, Giordano F, Cauda R. Risks and benefits of chloroquine use in anticancer strategies. Lancet Oncol 2006; 7 : 792-3.

147. Kublin JG, Cortese JF, Njunju EM, Mukadam RA, Wirima JJ, Kazembe PN, et al. Re-emergence of chloroquine-sensitive Plasmodium falciparum malaria after cessation of chloroquine use in Malawi. J Infect Dis 2003; 187 : 1870-5.

148. Obua C, Ntale M, Lundblad MS, Mahindi M, Gustafsson LL, Ogwal-Okeng JW, et al. Pharmacokinetic interactions between chloroquine, sulfadoxine and pyrimethamine and their bioequivalence in a generic fixed-dose combination in healthy volunteers in Uganda. Afr Health Sci 2006; 6 : 86-92.

149. Laufer MK, Thesing PC, Eddington ND, Masonga R, Dzinjalamala FK, Takala SL, et al. Return of chloroquine antimalarial efficacy in Malawi. N Engl J Med 2006; 355 : 1959-66.

150. Lelievre J, Berry A, Benoit-Vical F. Artemisinin and chloroquine: do mode of action and mechanism of resistance involve the same protagonists? Curr Opin Investig Drugs 2007; 8: 117-24.

R.G. Cooper & T. Magwere*

Division of Physiology, Faculty of Health, Birmingham City University & * University of Leeds, Faculty of Medicine & Health, St. James University Hospital, Cancer Research Building, Leeds, UK

Received March 13, 2007

Reprint requests: Dr R.G. Cooper, Senior Lecturer, Division of Physiology, Faculty of Health, Birmingham City University,

704 Baker Building, Franchise Street, Perry Barr, Birmingham B42 2SU, UK

e-mail: [email protected]

Copyright Indian Council of Medical Research Apr 2008

(c) 2008 Indian Journal of Medical Research. Provided by ProQuest LLC. All rights Reserved.

By Varaiya, Ami Kulkarni, Nikhil; Kulkarni, Manasi; Bhalekar, Pallavi; Dogra, Jyotsana

Background & objectives: Metallo beta lactamase (MBL) producing Pseudomonas aeruginosa have been reported to be important cause of nosocomial infections. The appearance of MBL genes and their spread among bacterial pathogens is a matter of concern with regard to the future of antimicrobial therapy. The present study was undertaken to determine the incidence of MBL producing P. aeruginosa in patients with diabetes and cancer admitted to the intensive care unit of a tertiary care hospital in western India and to assess the clinical outcome after antimicrobial treatment. Methods: A total of 240 isolates of P. aeruginosa from various specimens between January and December 2005 were subjected to susceptibility testing against various antibiotics by disc diffusion test as per the Clinical and Laboratory Standards Institute (CLSI) guidelines. Imipenem and meropenem resistant isolates were selected for the detection of MBL production by disc potentiation test. Enhancement of inhibition zone around imipenem and meropenem discs impregnated with EDTA as compared to those without EDTA confirmed MBL production.

Results: Of the 240 P. aeruginosa isolates, 60 (25%) were found to be carbapenem resistant and 50 (20.8%) were found to be MBL producers. Of the 50 MBL producing isolates, 38 (76%) were from diabetes patients and 12 (24%) from cancer patients. Overall, 36 per cent patients responded to gatifloxacin, 42 per cent responded to piperacillin/tazobactam while 14 per cent responded to combination of gatifloxacin and piperacillin/tazobactum. Due to this nosocomial pathogen, the average hospital stay was 32 days and was associated with 20 per cent mortality due to septicaemia.

Interpretation & conclusions: Our findings showed that there is a need to do surveillance to detect MBL producers, judiciously use carbapenems to prevent their spread and use effective antibiotics, such as gatifloxacin and piperacillin-tazobactum, after sensitivity testing for treatment.

Key words Carbapenem resistance – metallo beta lactamase – Pseudomonas aeruginosa

The introduction of carbapenems into clinical practice represented a great advance for the treatment of serious bacterial infections caused by beta-lactam resistant bacteria. Due to their broad spectrum of activity and stability to hydrolysis by most beta lactamases, the carbapenems have been the drug of choice for treatment of infections caused by penicillin-or cephalosporin- resistant Gram-negative bacilli especially, extended spectrum beta- lactamase (ESBL) producing Gram-negative infections1. The carbapenems available for use in India are imipenem and meropenem2. However, carbapenem resistance has been observed frequently in non fermenting bacilli Pseudomonas aeruginosa and Acinetobacter spp. Resistance to carbapenem is due to decreased outer membrane permeability, increased efflux systems, alteration of penicillin binding proteins and carbapenem hydrolyzing enzymes-carbapenemase3. These carbapenemase are class B metallo beta-lactamases (IMP, VIM) or class D-oxacillinases (OXA 23 to OXA 27) or class A – clavulanic acid inhibitory enzymes (SME, NMC, IMI, KPC)3.

Metallo beta lactamase (MBL) belongs to a group beta-lactamase which requires divalent cations of zinc as cofactors for enzyme activity. These have potent hydrolyzing activity not only against carbapenem but also against other beta-lactam antibiotics4. The IMP and VIM genes responsible for MBL production are horizontally transferable via plasmids and can rapidly spread to other bacteria5. The genes responsible for MBL production may be chromosomally or plasmid mediated and hence pose a threat of spread of resistance by gene transfer among the Gram-negative bacteria3.

Thus, MBL-producing Pseudomonas aeruginosa isolates have been reported to be important causes of nosocomial infections associated with clonal spread6. These constitute 20-42 per cent of all nosocomial isolates7,8. The appearance of MBL genes and their spread among bacterial pathogens is a matter of concern with regard to the future of antimicrobial chemotherapy6.

We undertook this study to determine incidence of MBL producing P. aeruginosa in diabetes and cancer patients admitted to the intensive care unit of a tertiary care hospital in western India over a period of one year from January to December 2005 and to observe the clinical outcome in these patients after treatment.

Material & Methods

Two hundred and forty isolates of P.aeruginosa were obtained during a one year period from January to December 2005 in the Department of Microbiology, S.L. Raheja Hospital, Mumbai, Maharashtra. The specimens processed were: respiratory secretions (61), tissue (58), swabs pus/ wound (55), urine (52), blood culture (10) and bile (4). With Universal safety precautions, samples were collected from patients in ICU, transported and processed in the laboratory without delay. Blood cultures were processed using automated method with Versa Trek (Tri Vitron, India). Samples were cultured on brain heart infusion (BHI) blood agar and MacConkey’s agar. Identification of organisms was done by the standard laboratory technique9. Antimicrobial sensitivity testing was performed on Mueller – Hinton (MH) agar plates with commercially available discs (Hi-media, Mumbai) by Kirby Bauer disc diffusion method and interpreted as per CLSI recommendations10. P. aeruginosa ATCC 27853 (beta-lactamase negative) strain was used as control.

The routine antibiotic sensitivity tests were put up for aminoglycosides [amikacin (30 [mu]g), gentamicin (10 [mu]g), netilmicin (30 [mu]g), tobramicin (10 [mu]g)], cephalosporin’s [cefoperazone (75 [mu]g), cefepime (30 [mu]g), ceftazidime (30 [mu]g), ceftriaxone (30 [mu]g), ceftizoxime (30 [mu]g)], floroquinolones [ciprofloxacin (5 [mu]g), gatifloxacin (5 [mu]g), lomefloxacin (10 [mu]g)], carbapenems [imipenem (10 [mu]g), meropenem (10 [mu]g)], chloramphenicol (30 [mu]g) and piperacillin/ tazobactum (100/10 [mu]g).

MBL producing P. aeruginosa was suspected when the isolate was resistant to meropenem and imipenem.

Various methods have been recommended for screening MBL. These include the modified Hodge test, double disc synergy test using imipenem and EDTA discs or ceftazidime and EDTA discs, EDTA impregnated imipenem discs11 and EDTA impregnated meropenem discs7. For MIC detection of imipenem, the E -test strip7 and microdilution (microtitre) plate method12 is recommended.

We used disc potentiation test with EDTA impregnated imipenem and meropenem discs. However, MIC was not detected in this study as E- test strips were very expensive and a simple microdilution plate method is time consuming.

Disc potentiation test: A 0.5 M EDTA solution (pH 8.0) was prepared and was sterilized by autoclaving. Test organisms were inoculated onto plates of MH agar (Opacity adjusted to 0.5 McFarland opacity standards). Two 10 [mu]g imipenem discs and two 10 [mu]g meropenem discs were placed on inoculated plates and 5 [mu]l of EDTA solution was added to one imipenem and one meropenem disc. The zone of inhibition around imipenem and meropenem discs alone and those with EDTA was recorded and compared after 16-18 h incubation at 35[degrees]C. An increase in zone size of at least 7 mm around the imipenem-EDTA disc and meropenemEDTA discs was recorded as a positive result. The difference in the resistance pattern of MBL- positive and MBL-negative was considered to be statistically significant if the P value was

Results

Of the 240 isolates of P. aeruginosa, 60 (25%) were found resistant to carbapenems (both imipenem and meropenem) and 50 (20.8%) were found to be MBL producers confirmed by disc potentiation method. The ATCC 27853 P. aeruginosa did not exhibit any zone size enhancement with EDTA impregnated imipenem discs.

Of the 50 MBL producing isolates, 30 (60%) were from diabetes patients and 20 (40%) from cancer patients [acute lymphoblastic leukaemia (5), chronic myeloid leukaemia (4), carcinoma of gallbladder (3), carcinoma of oesophagus (3), prostatic adenocarcinoma (1), carcinoma of sigmoid colon (1), non-Hodgkin’s lymphoma (1), mesothelioma (1) and Hodgkin’s disease (1)]. Of the 50 patients, 38 (76%) were males and 12 (24%) were females; the average age being 63 yr (50-75 yr).

Patients were treated with gatifloxacin, piperacillin/ tazobactum, and combination of gatifloxacin and piperacillin/ tazobactum. Antibiotic sensitivity pattern of MBL positive and negative isolates is shown Table I. Antibiotic sensitivity pattern of MBL positive and negative isolates among cancer and diabetes patients is presented in Table II.

Statistically significant difference was found in the resistance pattern of MBL positive and negative isolates for amikacin, netilmicin, cefepime, ceftazidime, ceftriaxone, ciprofloxacin and lomefloxacin (P

The average hospital stay of patients with MBL producers was 32 days (range 4 days-2 months). Of the 50 patients, 10 had P. aeruginosa as the sole isolate from blood culture. All these patients died due to Pseudomonas septicaemia. Thus, the mortality was 20 per cent. Among the 40 patients with MBL producing P. aeruginosa who survived, 10 needed re-admissions to the hospital because of deterioration in their clinical condition due to progressive disease. All these patients were cancer patients.

Discussion

P. aeruginosa is a pathogen associated with numerous nosocomial infections in immunocompromised patients13. Carbapenems are the drugs of choice for multidrug resistant P. aeruginosa and ESBL producing organisms. However, resistance to carbapenems due to reduced uptake of drug leads to imipenem/meropenem resistant isolates14. In various studies across the world, varying resistance (4-60%) has been seen towards imipenem and meropenem15,16. We found 25 per cent resistance to imipenem and meropenem. P. aeruginosa producing MBL was first reported from Japan in 1991 “. In 2002 from India, Navneeth et al18 first reported MBL production in P. aeruginosa to be 12 per cent. Since then, the incidence of MBL production in P. aeruginosa has been reported to be 10-30 per cent from various clinical specimens across the country8. We found 20.8 per cent MBL production in P. aeruginosa of which 30 per cent were obtained from respiratory specimens in our study. Another study conducted by Shashikala et al14 reported 20.7 per cent carbopenem resistant P. aeruginosa isolates from endotracheal aspirates showing indwelling devices as major risk factors for the development of resistance.

Amongst the MBL positive isolates from diabetes and cancer patients admitted to ICU in this study, maximum sensitivity was observed for piperacillin/ tazobactum followed by gatifloxacin. Amongst the MBL negative isolates maximum sensitivity was observed for piperacillin/tazobactum followed by ciprofloxacin, ceftazidime, gatifloxacin, cefepime, netilmicin, ceftriaxone, amikacin, and lomefloxacin. In the study conducted by Taneja et al8, piperacillin and amikacin had the best in vitro susceptibility. In our study, 18 patients responded to gatifloxacin, 24 to piperacillin/tazobactum while 7 patients responded to combination of gatifloxacin and piperacillin/tazobactum. Amongst the 20 cancer patients in whom MBL producers were isolated, 9 showed sensitivity to gatifloxacin and 7 showed sensitivity to piperacillin/tazobactum. Amongst the 30 diabetes patients in whom MBL producers were isolated, 7 showed sensitivity to gatifloxacin and 14 showed sensitivity to piperacillin/tazobactum.

P. aeruginosa are responsible for 3-7 per cent bloodstream infections and high mortality rates (27-48%) in critically ill patients18. We observed 20 per cent mortality due to P. aeruginosa septicaemia in our patients.

In conclusion, our findings showed that there is a need to do surveillance to detect MBL producers, judiciously use carbapenems to prevent their spread and use effective antibiotics, such as gatifloxacin and piperacillin-tazobactum, after sensitivity testing for treatment.

References

1. Mendiratta DK, Deotale V, Narang P. Metallo beta lactamase producing Pseudomonas aeruginosa in a hospital from rural area. Indian J Med Res 2005; 121 : 701-3.

2. Gupta E, Mohanty S, Sood S, Dhawan B, Das BK, Kapil A. Emerging resistance to carbapenems in a tertiary care hospital in north India. Indian J Med Res 2006; 124 : 95-8.

3. Gladstone P, Rajendran P, Brahmadathan KN. Incidence of carbapenem resistant nonfermenting Gram negative bacilli from patients with respiratory -infections in the intensive care unit. Indian J Med Microbiol 2005; 23 : 189-91.

4. Bush K. Metallo beta-lactamase: a class apart. Clin infect Dis 1998; 27(Suppl 1): S48-53.

5. Bennett PM. Integrons and gene cassettes; A genetic construction kit for bacteria. Antimicrob Agents Chemother 1999; 43 : 1-4.

6. Bush K, Jacoby GA, Medeiros A. A functional classification scheme for beta lactamase and its correlation with molecular structure. Antimicrob Agents Chemother 1995; 39 : 1211-33.

7. Walsh TR, Toleman MA, Poirel L, Nordmann P. Metallo-beta- lactamase: the Quiet before the Storm? Clin Microbiol Rev 2005; 18 : 306-25.

8. Taneja N, Aharwal SM, Sharma M. Imipenem resistance in non fermenters causing nosocomial urinary tract infection. Indian J Med Sci 2003; 57 : 294.

9. Forbes BA, Sham DF, Weissfeld AS. Bailey and Scott’s diagnostic microbiology, 10th ed. New York: Mosby; 1998. p. 167-87.

10. Clinical and Laboratory Standards Institute. Performance standards for antimicrobial disk tests; Approved Standards, 9th ed. CLSI Document M2- A9, Vol. 26 No 1. Wayne PA 2006.

11. Hemalatha V, Sekar U, Kamat V. Detection of metallo betalactamase producing Pseudomonas aeruginosa in hospitalized patients. Indian J Med Res 2005; 122 : 148-52.

12. Migliavacca R, Docquire JD, Mugnaioli C, Amicosante G, Daturi R, Lee K, et al. Simple Microdilution test for detection of metallo- beta-lactamase production in Pseudomonas aeruginosa. J Clin Microbiol 2002; 40 : 4388-90.

13. Bonfiglio G, Laksai Y, Franchino L, Amicosante G, Nicoletti G. Mechanisms of beta-lactam resistance amongst Pseudomonas aeruginosa isolated in an Italian survey. J Antimicrob Chemother 1998; 42 : 697-702.

14. Shashikala, Kanungo R, Srinivasan S, Devi S. Emerging resistance to carbapenem in hospital acquired Pseudomonas infection: A cause of concern. Indian J Pharmacol 2006; 38 : 287-8.

15. Forster DH, Daschner FD. Acinetobacter species as nosocomial pathogens. Eur J Clin Microbial Infect Dis 1998; 17 : 73-7.

16. Gonlugur U, Bakiri MZ, Akkurt I, Efeoglu T. Antibiotic susceptibility patterns among respiratory isolates of Gram negative bacilli in a Turkish University Hospital. BMC Microbiol 2004; 4 : 32- 6.

17. Yano H, Kuga A, Okamota R, Kitasato H, Kobayashi T, Inon M. Plasmid coded metallo beta lactamase (imp 6) conferring resistance to carbapenems, especially meropenam. Antimicrob Agents Chemother 2001; 45 : 1343-8.

18. Navneeth BV, Sridaran D, Sahay D, Belwadi MR. A preliminary study on metallo betalactamse producing Pseudomonas aeruginosa in hospitalized patients. Indian J Med Res 2002; 116 : 264-7.

19. Endimiani A, Luzzaro F, Pini B, Amicosante G, Rossolini GM, Toniolo AQ. Pseudomonas aeruginosa bloodstream infections: risk factors and treatment outcome related to expression of the PER-1 extended-spectrum beta-lactamase. BMC Infect Dis 2006; 6 : 52; available from www.biomedcentral.com/1471-23 34/6/52.

Ami Varaiya, Nikhil Kulkarni, Manasi Kulkarni, Pallavi Bhalekar & Jyotsana Dogra

Department of Microbiology, S.L.Raheja Hospital, Mumbai, India

Received November 7, 2007

Reprint requests: Dr Ami Varaiya, Consulting Microbiologist, Department of Laboratory Medicine

S.L. Raheja Hospital, Mahim West, Mumbai 400 016, India

e-mail: [email protected]

Copyright Indian Council of Medical Research Apr 2008

(c) 2008 Indian Journal of Medical Research. Provided by ProQuest LLC. All rights Reserved.

By Chaudhry, Rama Joshy, Lovely; Kumar, Lalit; Dhawan, Benu

Background & objectives: Frequent use of broad spectrum antibiotics in hospitalized patients has increased the incidence of Clostridium difficile diarrhoea in recent years. In our tertiary care hospital in north India, C. difficile was responsible for 15 per cent of cases of nosocomial diarrhoea in 1999. A retrospective study was carried out to determine the frequency of C. difficile associated diarrhoea (CdAD) in our hospital, and to assess the effect of awareness among the hospital personnel and control measures taken to present C. difficile infection following the previous report. Methods: A retrospective chart review of all suspected cases of CdAD diagnosed at the hospital from January 2001 to December 2005 was done. Clinical specimens comprised 524 stool samples. All the samples were analyzed for C. difficile using culture and ELISA for toxin A and B. Attempts were made to type isolates using antibiogram, SDS-PAGE, gas liquid chromatography (GLC), PCR for toxin A and B gene fragments and restriction fragment length polymorphism (RFLP).

Results: A total of 37 (7.1%) specimens were positive for C. difficile toxin (11.2% in 2001, 9.4% in 2002, 8.6% in 2003, 5% in 2004 and 4% in 2005). The highest number of C. difficile toxin positive cases were from stool samples of patients hospitalized in the haematology/oncology ward (67.5% of all positive cases) followed by gastrointestinal surgery, neurology and nephrology wards. Of the C. difficile toxin positive samples, 15 (41%) were also positive for C. difficile culture. The isolates were grouped in to one, 3 and 5 groups using antibiogram, SDS-PAGE and PCR RFLP respectively. We observed an increase in the number of stool specimens tested for C. difficile infection but a decrease in C. difficile positives.

Interpretation & conclusions: A decrease in the number of C. difficile positive cases were noted during the 5 year study period though number of samples tested was increased. This may be due to stringent surveillance and an improved antibiotic policy followed in the hospital.

Key words C. difficile – culture – toxin A – toxin B – typing

(ProQuest: … denotes obscured text omitted.)

Diarrhoea is one of the most frequent side effects of antibiotic treatment. The symptoms may vary from slight abdominal discomfort to severe diarrhoea to colitis1. The aetiology of antibiotic associated diarrhoea (AAD) varies. The disruption of normal enteric flora caused by antibiotics may lead to overgrowth of pathogens and functional disturbances of the intestinal carbohydrate and bile acid metabolism, resulting in osmotic diarrhoea1. Allergic, toxic and pharmacological effects of antibiotics may also affect the intestinal mucosa and motility2. Cytotoxin producing Clostridium difficile has been reported to be the causative agent of approximately 20 per cent of AAD and of nearly all cases of pseudomembraneous colitis, the most severe manifestation of AAD1. Because of the frequent use of broad spectrum antibiotics, the incidence of C. difficile diarrhoea has risen dramatically in recent years3,4. Established guidelines should be followed to minimize exposure to the pathogen which include judicious use of antibiotics, rapid detection of C. difficile by immunoassays for toxin A and B, isolation of patients who had C. difficile associated diarrhoea (CdAD), proper disinfection of objects and education of staff members5. In our hospital which is a tertiary care hospital in north India, C. difficile was responsible for 15 per cent of cases of nosocomial diarrhoea in 1999(6). Standard control measures were implemented in our hospital to minimize the spread of this nosocomial pathogen after this report. This retrospective analysis was carried out in continuation of our earlier study6 to determine the effect of awareness and control measures taken to contain C. difficile infection in our hospital during the subsequent years.

Material & Methods

The study comprised retrospective analysis of faecal specimens from 524 patients suspected on clinical grounds to have CdAD2. The patients were hospitalized in All India Institute of Medical Sciences, New Delhi, India, over a period of 5 yr (January 1, 2001 – December 31, 2005). These included 80 patients in 2001, 96 in 2002, 92 in 2003, 106 in 2004 and 150 patients in 2005 respectively. Of these, 53 per cent were males and 82.4 per cent were in all age group > 12-60 yr (Table I).

Clinical information about the cause of diarrhoea underlying disease and antimicrobial therapy was obtained by reviewing the patient charts. A patient was considered to have CdAD if AAD was present and a stool specimen was positive in a toxin dependent C. difficile assay.

Sample collection and isolation of C. difficile: All the stool specimens were processed immediately for culture of C. difficile and stool aliquots were stored at -20[degrees]C for

The plates were incubated anaerobically at 37[degrees]C in an anaerobic jar for 48 h. After incubation, the plates were examined and colonies which resembled C. difficile were Gram stained and identified by biochemical reactions using standard methods7.

When culture plate were negative for C. difficile, subcultures were made from cooked meat broth onto CCFA and BHIA and incubated anaerobically at 37[degrees]C up to 5 days before being discarded as negative.

Enzyme immunoassay for toxin A and B: Detection of enterotoxin and cytotoxin (toxin A and toxin B) of C. difficile was performed on the stool specimens by a double sandwich enzyme-linked immunosorbent assay technique using a commercial kit (Premier toxins A & B; Meridian Diagnostics, Inc., Cincinnati, Ohio, USA). The assay was performed according to the manufacturer’s instructions.

Characterization of C. difficile isolates: All the C. difficile isolates were characterized phenotypically using antibiogram, SDS- PAGE6, gas liquid chromatography (GLC)7, and genotypically using PCR for toxin A gene and RFLP8,9.

Antibiogram typing – Antibiogram patterns were determined by disc diffusion method10. The antibiotics tested were chloramphenicol (30 [mu]g), penicillin G (10 units), clindamycin (2 [mu]g), vancomycin (5 [mu]g); metronidazole (5 [mu]g), tetracycline (30 [mu]g) and erythromycin (10 [mu]g). The results were expressed as susceptible or resistant.

Analysis of volatile fatty acids by gas liquid chromatography (GLC): All isolates were inoculated to cooked meat broth and incubated anaerobically for 48 h or more for GLC analysis to detect volatile fatty acids produced as metabolic end products. 1 ml of RCM broth was acidified with 0.2 ml of 50 per cent sulphuric acid and extracted with 1 ml of diethyl ether. The mixture was shaken vigorously and centrifuged at 176 g for 3 min; 1.5 [mu]l of the extracted ether layer was injected to the injection port of preconditioned GLC column with a 10 [mu]l Hamilton syringe. Chromatography was performed on a Nucon Series 5700, fitted with a flame ionization detector (FID)7. Operating conditions were as follows: carrier gas (oxygen free nitrogen): 60 ml/min oven temperature: detector 240[degrees]C, column 175[degrees]C, injector 240[degrees]C, attenuation 4X, sensitivity of the detector was set at 1000X. Fatty acids were identified by comparing the retention times of peaks in the test samples with those of known standard solutions which were examined each day7.

PCR assay for toxin gene fragments: The presence of toxin A gene in all isolates of C. difficile was determined by specific PCR using published primers8. PCR to detect the toxin B gene was performed in the C. difficile isolates using primers that had been developed and validated by Gumerlock et at9 to yield a 399-bp fragment for toxin B gene. PCR was performed in a 25 [mu]l reaction volume. Each reaction tube contained 1 X buffer (10 mm Tris HCl, pH 8.3, 50 mm KCl, 2.5 mm MgCl^sub 2^, 0.001% gelatin), each deoxynuclotide at a concentration of 100 mm (MBI, Fermentas, USA), each primer at a concentration of 20 pmol, 1.25 U Taq polymerase (MBI, Fermantas, USA) and 10 [mu]l of DNA. PCR was performed for 2 min at 95[degrees]C followed by 30 cycles of 1 min of denaturation at 95[degrees]C, 1 min of annealing at 52[degrees]C and 1 min of extension at 72[degrees]C. After the 30th cycle, extension was continued for an additional 10 min. 10 [mu]l of the amplified product was analyzed in 1 per cent agarose gel stained with ethidium bromide.

PCR-restriction fragment length polymorphism (RFLP) analysis: The amplified toxin A gene fragment was then digested with Alu I(10 units) restriction enzyme, under conditions recommended by the supplier (MBI-Fermentas). These digests were then subjected to electrophoresis on 2.5 per cent agarose gel at 60 V, along side a PCR size marker (100 bps, Sigma, USA).

Comparisons of patterns were performed visually. Strains with patterns differing alteast by one band were assigned to different types.

Results

A total of 524 stool specimens were analyzed for C. difficile from suspected cases of CdAD. The maximum number of C. difficile suspected cases were from oncology ward (378 cases, 72%), followed by other wards such as gastrointestinal surgery, neurology, nephrology and other medical wards. A total of 95 per cent of the analyzed group were on multiple antibiotics which included, 65 per cent on cephalosporins, 35 per cent on quinolones, 43 per cent on aminoglycosides, 12 per cent on macrolides, 69 per cent in vancomycin and metronidazole. Of the analyzed group, 37 (7.1%) patients were positive for C. difficile infection by the toxin dependent assay. Of these, 9 samples (11.2%) were positive in 2001, 9 (9.4%) in 2002, 8 (8.6%) in 2003, 5 (5%) in 2004 and 6 patients (4%) in 2005 (Fig. 1). Fifteen (41%) of the 37 toxin positive stool samples were also positive for C. difficile by culture. Eight of the 37 toxin positive cases expired, the cause of death was not directly related to C. difficile diarrhoea, although this might have been a contributory factor. Other pathogenic clostridia isolated from the patient group included C. perfringens (2.5%).

The highest number of C. difficile toxin positive cases were from stool samples of patients hospitalized in the haematology/oncology ward (25 samples, 67.5% of all positive cases), followed by gastrointestinal surgery, neurology and nephrology wards. Recovery rates of C. difficile in patient populations surveyed and summarized in Table II.

Of the 37 positive cases, 19 (51%) were males; 32 patients (86%) experienced diarrhoea during antibiotic treatment or within 15 days after the start of antibiotic treatment. The median time of occurrence of symptoms was 7 days (ranges 0-16 days) after start of antibiotic treatment and 8 days after admittance to hospital. All the patients were on multiple drugs and 50 per cent of the positive cases were on 3rd generation cephalosporins. None of the positive cases was on clindamycin. C. difficile positive cases were treated with metronidazole or vancomycin.

Antibiogram grouped all 15 isolates together as all were sensitive to erythromycin, chloramphenicol, penicillin, tetracyclin, clindamycin, vancomycin and metronidazole.

The identical fatty acid producers were grouped into 2 groups based on the production of isocaproic acid. Except one, all the isolates were producing isocaproic acid.

Based on the protein profiles observed on SDSPAGE, the isolates were placed into 3 groups; 12 isolates in group A, 2 in group B and 1 in group C.

PCR and RFLP analysis: All the …lates were positive for toxin A (1.2 kb fragment) … (399 bp) gene by PCR. Five different restriction profiles were obtained using Alu I endonucleases. The isolates were classified into five RFLP groups. The most frequent RFLP type was group I (6 isolates) group II, III, IV and V had 5, 2, 1 and 1 isolates respectively.

Discussion

C. difficile is considered as the most frequent aetiological agent of nosocomial diarrhoea occurring in hospitalized patients, spreading easily to the environment, the hands of health care workers and subsequently to other patients, particularly in large hospitals12. A trend of increasing prevalence of C. difficile has been reported in Europe and USA during the past 10 years13.

In our hospital C. difficile was found to be responsible for 15 per cent of the cases of nosocomial diarrhoea in our earlier study6. In this study, C. difficile was isolated mainly from patients in the haematology/ oncology wards. This points to the high risk areas for nosocomial spread of C. difficile isolates14. However, the percentage of infection showed a gradual decrease during the recent years.

Standard laboratory methods for diagnosing these infections include stool culture and identification of bacterial isolate, faecal toxin detection and C. difficile antigen detection. The culture lacks specificity due to the possible faecal carriage of non- toxigenic isolates, therefore many laboratories rely on toxin detection rather than culure for diagnosis of C. difficile infection15. A European survey of diagnostic methods for C. difficile, showed that culture of the organism is performed only in few countries. Mostly C. difficile toxin EIAs were used for diagnosis of CdAD16. In this study we used ELISA for toxin A, B and culture for diagnosing C. difficile infection. However, to the previous study6 we used C. difficile toxin A dependent ELISA for the analysis.

There was a gradual decrease in the percentage of … infection during 2001 and 2005. The fact … the 22 culture negative cases were on … or vancomycin at the time of sample … might be responsible for the decrease in isolation of organism as compared with the ELISA.

Older age, female gender and a prolonged hospital stay have been identified as risk factors in hospitalized CdAD patients17. In the current study, there was no gender prevalence among the positive cases and the median age of positive cases were 39 yr. However, highest percentage of culture positives was seen among patients >60 yr of age. Prolonged courses of antibiotic treatment have been related to an increased risk of AAD18,19. The median time for occurrence of symptoms was 7 days after the start of treatment in the present study, which was in accordance with other studies1,20. This suggests that disturbance of the normal colonic flora, eventually resulting in diarrhoea, takes place within about one week of antibiotic treatment. Prolonged duration of hospital stay has also been reported to be associated with AAD and CdAD19,21. In the present study, the median time of hospital stay was 8 days.

AAD was found to be frequently associated with cephalosporins, clindamycin and broad spectrum penicillins and quinolones22-25. In this study, about 50 per cent of our CdAD cases were on cephalosporins. However, since all the patients were on multiple antibiotics, the association with a particular group was not identified.

Discontinuation of antibiotic therapy withdraws the offending agents but is often not appropriate if the indication for such therapy was correct. An alternative is to change to antibiotics that do not belong to the high risk groups for induction of CdAD, such as quinolones, sulphonamides, parenteral aminoglycosides, cotrimoxazole, etc26. Metronidazole is suggested as the first line drug for the treatment of C. difficile infection2, and therefore the policy of the use of metronidazole in the treatment of suspected CdAD in our hospital is justified.

No nosocomial outbreak of C. difficile was reported during the study period. In this study we found antibiogram was least discriminatory of the typing strategies evaluated. The detection of short chain fatty acids by GLC is commonly utilized in bacteriological laboratories to identify anaerobes27. As all the isolates were positive for toxin A gene, we looked forward to analyze the variability of toxin A gene among C. difficile isolates by RFLP analysis. As the sequence analysis of the amplified 1.2 kbp toxin A gene fragment does not show any restriction sites for the previously reported restriction enzymes like Hinc II, Hind III, Ace I, EcoR I28, we decided to examine the amplified gene structure using restriction enzyme AIu I (5′ AG[arrow down]CT 3′, 3’TC[arrow up]GA 5′), which showed multiple restriction sites (8 sites) in the amplicon.

Although PCR-RFLP types 1 and II clustered some patient isolates, there was no epidemiological association between them. The locations where these patients were housed were different, and were admitted at different time periods. Better discriminatory methods such as pulsed field gel electrophoresis (PFGE) or ribotyping may be used to analyze the epidemiology of the pathogen.

In our recent prospective study, all the C. perfringens isolates were analyzed for the presence of enterotoxin by reverse passive later agglutination (RPLA), ELISA and by PCR assay for the presence of enterotoxin gene29. Of these, two were positive by PCR, RPLA and ELISA for C. perfringens enterotoxin. None of these samples had a co- infection with C. difficile.

Prevention of C. difficile infection is challenging. A change in antibiotic policy and implementation of standard infection control measures reduce the incidence of C. difficile symptomatic infections30,31. Combined approach, involving effective control measures, the use of rapid and sensitive techniques for laboratory diagnosis as well as prudent use of antibiotics, is necessary to reduce morbidity and mortality due to C. difficile associated infections in hospitalized patients.

In conclusion, we observed a decrease in the number of C. difficile toxin positive cases during the 5 yr of the study though there was an increase in the number of stool specimens tested per year for C. difficile. This possibly could be a result of stringent surveillance and antibiotic policy followed in our hospital especially in high risk areas such as haematology/oncology wards. Secondly, the use of clindamycin has been minimized in the hospital. Thirdly, antibiotics effective against C. difficile such as metronidazole have been included as the first line drugs in suspected CdAD cases. Isolation of the patients having C. difficile infection and regular awareness programmes conducted in the hospital might also have contributed.

Acknowledgment

Authors thank Ms. Sonam, Ms. Poornima and Shri Madho Prasad for technical assistance and acknowledge the Indian Council of Medical Research (ICMR), New Delhi, for financial suppport.

References

1. Wistrom J, Norrby SR, Myhre EB, Eriksson S, Granstron G, Legergrea, et al. Frequency of antibiotic-associated diarrhoea in 2462 antibiotic-treated hospitalized patients: a prospective study. J Antimicrob Chemother 2001; 47 : 43-50.

2. Hogenauer C, Hammer HF, Krejs GJ, Reisinger EC. Mechanisms and management of antibiotic-associated diarrhea. Clin Infect Dis 1998; 27 : 702-10.

3. Dallal RM, Harbrecht BG, Boujoukas AJ, Sirio CA, Farkas LM, Lee KK, et al. Fulminant Clostridium difficile: an underappreciated and increasing cause of death and complications. Ann Surg 2002; 235 : 363-72. 4. Kyne L, Hamel MB, Polavaram R, Kelly CP. Health care costs and mortality associated with nosocomial diarrhea due to Clostridium difficile. Clin Infect Dis 2002; 34 : 346-53.

5. Schroeder MS. Clostridium difficile-associated diarrhea. Am Fam Physician 2005; 71 : 921-8.

6. Dhawan B, Chaudhry R, Sharma N Incidence of Clostridium difficile infection: a prospective study in an Indian hospital. J Hosp Infect 1999; 43 : 275-80.

7. Sutter VL, Citron DM, Edelstein MAC, Finegold SM. Wadsworth Anaerobic Manual. Belmont, California: Star Publishers, 1985. p. 71- 5.

8. Kato N, Ou CY, Kato H, Bartley SL, Brown VK, Dowell VR Jr, et al. Identification of toxigenic Clostridium difficile by the polymerase chain reaction. J Clin Microbiol 1991; 29 : 33-7.

9. Gumerlock PH, Tang YJ, Weiss JB, Silva J Jr. Specific detection of toxigenic strains of Clostridium difficile in stool specimens. J Clin Microbiol 1993; 3 : 507-11.

10. Lambe DW Jr., Laslie WW. A standard disc diffusion method for antibiotic susceptability testing for anaerobes; four years antibiotic data. In: Lambe DW Jr, Gena RJ, Carson KJM, editors. Anaerobic bacteria-selected topics. New York: Plenum Press, 1980.

11. Laemmli UK. Cleavage of structural proteins during the assembly of the head of bacteriophage. Nature 1970; 227 : 680-5.

12. Wroblewska MM, Swoboda-Kopec E, Rokosz A, Nurzynska G, Bednarska A, Luczak M. Detection of Clostridium difficile and its toxin A (TcdA) in stool specimens from hospitalised patients. Pol J Microbiol 2005; 54 : 111-5.

13. Wongwanich S, Pongpech P, Dhiraputra C, Huttayananont S, Sawanpanyalert P. Characteristics of Clostridium difficile strains isolated from asymptomatic individuals and from diarrheal patients. Clin Microbiol Infect 2001; 7: 438-41.

14. Blot E, Escande MC, Besson D, Barbut F, Granpeix C, Asselain B, et al. Outbreak of C. difficile related diarrhea in an adult oncology unit: risk factors and microbiological characteristics. J Hosp Infect 1993; 53: 187-92.

15. Wilcox MH, Fawley WN, Settle CD, Davidson A. Recurrence of symptoms in Clostridium difficile infection-relapse or reinfection? J Hosp Infect 1998; 38 : 93-100.

16. Barbut F, Delmee M, Brazier JS, Petit JC, Poxton IR, Rupnik M, et al. ESCMID Study Group on Clostridium difficile (ESGCD). A European survey of diagnostic methods and testing protocols for Clostridium difficile. Clin Microbiol Infect 2003; 9 : 989-96.

17. Al-Eidan FA, McElnay JC, Scott MG, Kearney MP. Clostridium difficile-associated diarrhoea in hospitalised patients. J Clin Pharm Ther 2000; 25 : 101-9.

18. Spencer R. The role of antimicrobial agents in the aetiology of Clostridium difficile-associated disease. J Antimicrob Chemother 1998; 41 : 21-7.

19. Bignardi GE. Risk factors for Clostridium difficile infection. J Hosp Infect 1998; 40 : 1-15.

20. Thamilikitkul V, Danpakdi K, Chokloikaew S. Incidence of diarrhea and Clostridium difficile toxin in stools from hospitalized patients receiving Clindamycin, beta lactams, and nonantibiotic medications. J Clin Gastroenterol 1996; 22 : 161-3.

21. Clabots CR, Johnson S, Olson MM, Peterson LR, Gerding DN. Acquisition of Clostridium difficile by hospitalized patients: evidence for colonized new admissions as a source of infection. J Infect Dis 1992; 166 : 561-7.

22. Impallomeni M, Galletly NP, Wort SU, Starr JM, Rogers TR. Increased risk of diarrhea caused by Clostridium difficile in elderly patients receiving cefotaxime. BMJ 1995; 311 : 1345-6.

23. Pear SM, Williamson TH, Bettin KM, Gerding DN, Galgiani JN. Decrease in nosocomial Clostridium difficile-associated diarrhea by restricting clindamycin use. Ann Intern Med 1994; 720 : 272-7.

24. Pepin J, Saheb N, Coulombe MA, Alary ME, Carrivean MP, Authier S, et al. Emergence of fluoroquinolones as the predominant risk factor for Clostridium difficile-associated diarrhea: a cohort study during an epidemic in Quebec. Clin Infect Dis 2005; 41 : 1254- 60.

25. Muto CA, Pokrywka M, Shutt K, Mendelsohn AS, Nouri K, Posey K, et al. A large outbreak of Clostridium difficile-associated disease with an unexpected proportion of deaths and colectomies at a teaching hospital following increased fluoroquinolone use. Infect Control Hosp Epidemiol 2005; 26 : 273-80

26. Bartlett JG. Antibiotic associated diarrhea. Clin Infect Dis 1992; 15 : 573-81.

27. Pepersack F, Labbe M, Nonhoff C, Schoutens E. Use of gas- liquid chromatography as a screening test for toxigenic Clostridium difficile in diarrhoeal stools. J Clin Pathol 1983; 36 : 1233-6.

28. McFarland LV, Surawicz CM, Rubin M, Fekety R, Elmer GW, Greenberg RN. Recurrent Clostridium difficile disease: Epidemiology and clinical characteristics. Infect Control Hosp Epidemiol 1999; 20 : 43-50.

29. Joshy L, Chaudhry R, Dhawan B, Kumar L, Das BK. Incidence and characterization of Clostridium perfringens isolated from antibiotic- associated diarrhoeal patients: a prospective study in an Indian hospital. J Hosp Infect 2006; 63 : 323-9.

30. Khan R, Cheesbrough J. Impact of changes in antibiotic policy on Clostridium difficile-associated diarrhoea (CDAD) over a five- year period in a district general hospital. J Hosp infect 2003; 54 : 104-8.

31. Riley TV. Nosocomial diarrhoea due to Clostridium difficile. Curr Opin Infect Dis 2004; 17 : 323-7.

Rama Chaudhry, Lovely Joshy, Lalit Kumar* & Benu Dhawan

Departments of Microbiology, * Medical Oncology, Institute- Rotary Cancer Hospital

All India Institute of Medical Sciences, New Delhi, India

Received December 7, 2006

Reprint requests: Dr Rama Chaudhry, Professor, Department of Microbiology, All India Institute of Medical Sciences

New Delhi 110029, India

e-mail: [email protected], [email protected]

Copyright Indian Council of Medical Research Apr 2008

(c) 2008 Indian Journal of Medical Research. Provided by ProQuest LLC. All rights Reserved.

By Dangler, Jamie F

One university system’s union moves toward paid family leave. Faculty and professional staff at State University of New York campuses know all too well that balancing family life with the demands of an academic career is often a losing battle. Like their counterparts at other academic institutions across the country, they struggle to carve out a satisfying family life in the face of a system that rewards “ideal workers,” to borrow a term from legal scholar Joan Williams’s book Unbending Gender: Why Work and Family Conflict and What to Do About It. Williams characterizes ideal workers as those whose commitment to work is demonstrated by long hours and few, if any, visible distractions.

Over the past seven years, a growing movement within United University Professions (UUP), the union that represents 35,000 academics and professionals at thirty-three SUNY institutions, has put paid family leave on the collective bargaining agenda. A SUNY- wide paid family leave policy is one of several family-friendly policies that could take us a long way toward the elusive work-life balance we seek. Ratification of a new collective bargaining agreement in March 2008 took UUP a few steps forward on paid family leave, energizing the membership to press even harder and broaden its approach to securing a more comprehensive policy in the future.

While SUNY still does not offer guaranteed paid family leave for all academic and professional employees, the UUP contract provides a variety of possibilities for securing paid time off in the event of a birth or adoption, if elder care is needed, or if a sick relative requires care. Whether an individual’s family-care needs are accommodated depends on factors that include length of service and previous personal or family-care incidents (which affect the amount of accrued sick or vacation leave people can use for family leave purposes), as well as the “work environment” or “work culture” at the level of the department or office. (SUNY institutions have flexibility in accommodating family-care needs, but it is unevenly applied based on the level of support for meeting such needs at various points in the supervisory chain.)

UUP’s activists are aware of the obstacles that block the policy changes we seek: a tendency to focus on short-term costs rather than longer-term benefits and a cultural mindset that sees family care as an individual problem that should remain invisible in the workplace. I’ve been a full-time faculty member at SUNY for eighteen years and, while I’ve seen some changes that have increased support for workers who are caregivers, the changes have been uneven and remain incomplete.

Most of us continue to face family issues – childbirth, adoption, foster care, elder care, or care of sick relatives and domestic partners – without adequate structural support and often amid hostile work environments. This situation has severe implications for the career development, financial stability, and emotional and physical health of SUNY faculty and staff. Of equal import, as University of California, Berkeley, researchers Mary Ann Mason and Marc Goulden point out in “Do Babies Matter (Part II)? Closing the Baby Gap” (published in the November-December 2004 issue of Academe), we often let our careers dictate our family-formation patterns, leaving us to subordinate our need for family and our family’s needs to what we perceive as unyielding career obligations.

A Nationwide Problem

Still, there is growing optimism and excitement about the prospects for bringing our academic workplaces into the twenty- first century by compelling employers to accommodate workers’ need to balance work and family. Consistent with nationwide recognition of the need for change, as reflected in the AAUP’s Statement of Principles on Family Responsibilities and Academic Work, something new has taken hold at SUNY institutions and within UUR People who previously struggled in isolation have united in a collective effort to press for system-wide changes. The grassroots mobilization of women and men across SUNY campuses has crystallized into a statewide effort to resist what Pennsylvania State University researchers Robert Drago and Carol Colbeck call a “bias against caregiving.” Older cohorts of caregiving women who have spent decades working for change have united with younger cohorts of men and women who seem shocked that their institutions lag behind the economic and cultural realities of their lives. We are seeing a new energy and sense of urgency, born of lived experience and the empowerment made possible by strong unionism. The efforts of UUP leaders to provide the resources needed to sustain a serious campaign for paid family leave and other family-friendly policies have been indispensable to this progress.

In The Mapping Project: Exploring the Terrain of U.S. Colleges and Universities for Faculty and Families, published in 2003 by the Alfred R Sloan Foundation, Drago and Colbeck clarify the bias against caregiving that prevails at academic institutions. (They also wrote about the topic in the September- October 2005 issue of Academe.) Survey research conducted by UUP’s statewide Family Leave Committee in 2002 and more extensive research completed during the 2006-07 academic year verify that SUNY faculty are experiencing all the types of bias against caregiving identified by Drago and Colbeck. Situating our specific experiences at SUNY within the larger dialogue about work-family conflicts in academia has helped UUP develop a clear program of action to address its members’ needs.

First and foremost, we have begun to network across campuses within the SUNY system and to document our experiences, thereby challenging the long-standing notion that family-care “problems” are personal and should be resolved through individual negotiation with supervisors and administrators. Our research has confirmed the precarious position of untenured faculty members and, more generally, faculty members whose colleagues or supervisors perceive requests for flexible work arrangements as appeals for “special favors.”

The Situation at SUNY

SUNY’s patchwork of leave policies allows for tremendous variation in the way academics and professionals are treated when a family-care need occurs. (UUP professionals direct and administer support programs for students and staff, such as residence life, counseling, admissions, financial aid, and computer services.) Accumulated sick time is the primary vehicle for maternity leave for birth mothers. Neither fathers nor adoptive parents of either sex can use their personal sick leave to care for newborns or newly adopted children. Furthermore, recently appointed women who give birth typically do not have enough sick time accrued to take a full six-week leave, which requires about four years of sick leave accruals without depletion because of personal illness.

The recently settled UUP contract allows for thirty “family sick days” a year (up from fifteen in the previous contract), which men and women can use for family care. Adoptive parents, fathers, and those who must care for elderly parents or sick relatives can use these days to meet their family-care responsibilities. While UUP considers this increase in the number of “family sick days” to be a major contract victory, we recognize the need to monitor its impact over the next few years. Because these allowable days are not separate from regular sick leave accruals, newer employees or people who have used sick days for their own illnesses may not have enough sick time accrued to take up to thirty days off with pay when a family-care need arises.

UUP professionals are also entitled to compensatory and vacation time, which they may use for family-care situations. UUP teaching faculty generally do not have compensatory or vacation time. Although teaching faculty and some professionals have flexible schedules during the summer months, which allows them to meet family- care responsibilities without using accrued leave or getting approval from supervisors, this flexibility does not help when a birth, adoption, or family illness occurs during an academic semester. Such occurrences cannot always be “planned away.” Furthermore, some SUNY academics are twelve-month employees who teach a combination of classroom-based and online courses, leaving them little summer flexibility.

Many UUP members rely on unpaid leaves, guaranteed by the Family and Medical Leave Act and enhanced by New York state law, for family care. Our research shows, however, that most cannot afford to lose pay for an extended period. A faculty member who had been at her institution for only a few years and did not have enough accrued sick time for a six-week maternity leave told me that she had to borrow $5,000 “to have a baby” because her only option for time off was unpaid leave.

Many UUP members who responded to the Family Leave Committee’s 2002 survey or who were interviewed or participated in focus groups on family leave during the 2006-07 academic year reported losing considerable income during unpaid leaves and taking less time off than needed for economic reasons. Some said their health suffered when, for example, they returned to the classroom within a week or two of giving birth or trav- eled long distances between teaching days to deal with an elderly parent’s sudden illness. Others reported drop- ping down to a part-time schedule to manage what had become an im- possible situation. Although part- time work might be a positive solu- tion for some people, for others it reduces or eliminates the possibility of maintaining job security, needed income, and a desired career path. Respondents also revealed conflicts with supervisors and colleagues who did not support requests for time off because they worried about having to absorb the workload of those on leave without compensation or consideration of existing work demands. Grassroots Action

Created in 2001, UUP’s statewide Family Leave Committee complements the efforts of the union’s long-standing Women’s Rights and Concerns Committee by facilitating communication across campuses and providing a mechanism for connecting the campus-based work of union members to statewide research and policy initiatives. The fruits of our efforts were clearly visible at UUP’s September 2006 statewide Delegate Assembly. A plenary session keynote address by Vicki Lovell of the Washington-based Institute for Women’s Policy Research focused on family leave, members described their family- care needs and experiences at an open hearing, and a poster session couched UUP’s initiatives in the context of nationwide efforts to advance family leave policies and legislation. The delegate assembly’s focus on family leave at its first meeting of the 2006- 07 academic year set the stage for systematic collection of information and expansion of member support to make paid family leave a major item for the contract negotiations that took place through 2007.

In addition to gaining the use of fifteen additional accrued sick days for family-care purposes, UUP successfully negotiated a new program that allows members to spread the cost of taking unpaid leaves over a longer period of time. The program allows employees to take a pay reduction during a full-time work period in order to receive withheld pay during a later period that would ordinarily be unpaid leave time. This new program can be useful for family-care events that are planned (birth, adoption, scheduled medical treatments) and will avoid the loss of health insurance for what might have been an unpaid leave beyond the twelve weeks during which insurance coverage is protected by the federal Family and Medical Leave Act.

While these contract gains fall far short of guaranteed paid family leave for all employees, many family leave activists are encouraged by our success in filling in a few more policy gaps in the patchwork system SUNY offers. We clearly have begun to build momentum and are committed to pressing on. UUP members have become more active in the struggle to make New York the next state to pass legislation that would provide paid family and medical leave to all workers by expanding the state’s Temporary Disability Insurance program to cover time off for care of newborns, newly adopted children, or seriously ill family members. Similar legislation has been adopted in California, Washington, and New Jersey. The family leave movement within UUP has helped us connect with broader public efforts to meet the needs of all workers who struggle to balance work and family life.

We are determined to preclude the need for our members to engage in what Drago and Colbeck identify as “productive bias avoidance,” that is, foregoing marriage or partnering, delaying the birth of children, or deciding not to have a family at all. We are similarly disdainful of “unproductive bias avoidance,” hiding or minimizing family commitments to maintain the appearance of being ideal workers. (Examples of the latter include not asking for parental leave when it is needed or missing children’s important life events because we feel we must be visible at our workplaces so that others will note our dedication.) And we are certainly opposed to the prospect of being unable to respond when our spouses, domestic partners, or elderly relatives have emergencies. In other words, we do not want to encourage bias acceptance, and we cannot accept the possibility that we may have to settle for less in terms of family formation. We must be able to have children and be viable participants in the full range of family relationships that support stable, happy, and productive members of society.

By working though our union, SUNY academics and professionals are opting for “bias resistance.” We are determined to press for changes in policy and attitude that will maintain professional standards of excellence without forcing us to neglect or give up our desired family lives. Nevertheless, our project presents many challenges. We must, of course, demonstrate the benefits that paid family leave will bring to SUNY. These include long-term cost savings through the ability to recruit and retain talented personnel and improved productivity as a result of increased job stability and satisfaction. Rank-and-file members may also need to be convinced that a uniform paid family leave policy potentially benefits all. Since stay-at-home spouses or partners are rare these days, the need for family leave cuts across age groups and ranks in academia. Although women still bear the overwhelming burden of caregiving, cultural and economic changes are bringing more men into active caregiving roles. With increased longevity senior colleagues may well have elder-care demands equal in scope to the child-care obligations of their less senior colleagues.

UUP predicates its work in this area on the assumption that workers in academia need flexibility for family care over the course of our working lives. We need to balance our efforts to be productive teachers, scholars, and professionals with the planned and unplanned events that create and sustain our families. Allowing for this balance is good for us and good for our institutions. Providing paid leave for major familycare episodes – such as birth, adoption, an illness of a family member or domestic partner, or a change in the independent-living capacity of a parent – would take us a long way toward helping SUNY faculty achieve work-life balance. The ratification of UUP’s new contract in March 2008 marked the start of the next phase in our struggle to make SUNY an institution that maximizes its employees’ ability to balance their work and family needs for the benefit of all.

ALTHOUGH PART-TIME WORK MIGHT BE A POSITIVE SOLUTION FOR SOME PEOPLE, FOR OTHERS IT REDUCES OR ELIMINATES THE POSSIBILITY OF MAINTAINING JOB SECURITY, NEEDED INCOME, AND A DESIRED CAREER PATH.

THE FAMILY LEAVE MOVEMENT WITHIN UUP HAS HELPED US CONNECT WITH BROADER PUBLIC EFFORTS TO MEET THE NEEDS OF ALL WORKERS WHO STRUGGLE TO BALANCE WORK AND FAMILY LIFE.

JAMIE F. DANGLER

Bias Resistance at SUNY

Jamie F. Dangler is associate professor of sociology at the State University of New York at Cortland and chair of the statewide Family Leave Committee of United University Professions (UUP), the union that represents academics and professionals at SUNY institutions. She was a member of UUP’s recent contract-negotiations team. Her e- mail address is danglerj@ cortland.edu.

Copyright American Association of University Professors Jul/Aug 2008

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

By Magolda, Marcia B Baxter

This article describes three distinct yet interrelated elements of self-authorship: trusting the internal voice, building an internal foundation, and securing internal commitments. These elements, which emerged from longitudinal interviews with adults in their 30s, offer insights into the complexity and cyclical nature of self-authorship as well as provide guidance for how educators can assist college students in developing their internal voices to meet the challenges of adult life. Self-authorship, or the internal capacity to define one’s beliefs, identity, and social relations, has emerged in the past 15 years as a developmental capacity that helps meet the challenges of adult life. Robert Kegan (1994) articulated the developmental concept of self-authorship as a necessary foundation for adults to meet typical expectations they face at work, home, and school, such as the ability to be self- initiating, guided by their own visions, responsible for their experience, and able to develop interdependent relations with diverse others. My 21-year longitudinal study of young adults age 18 to 39 supports Kegan’s stance that complex epistemological, intrapersonal, and interpersonal development is necessary for adults to build complex belief systems, to form a coherent sense of identity, and to develop authentic, mature relations with diverse others (Baxter Magolda, 2001). In their work roles, my participants were required to analyze data, critique multiple perspectives, understand contexts, and negotiate competing interests to make wise decisions upon which to base their practice. These challenges required an internal belief system that allowed them to consider but not be overwhelmed by external influence, a coherent identity that yielded the confidence to act on wise choices, and mature relations to collaborate productively with colleagues. Similarly, personal life challenges of parenting, partnering, and managing daily life required obtaining and critiquing multiple perspectives, managing ambiguity, balancing competing interests, and making wise choices.

Today’s global society necessitates that adults engage in collaborative social relations with diverse others. These relations require intercultural maturity, which in turn requires epistemological, intrapersonal, and interpersonal complexity. For privileged adults, achieving intercultural maturity requires the ability to use multiple cultural frames (an epistemological capacity) and construct a nonracist, nonhomophobic, nonsexist identity (an intrapersonal capacity) to develop interdependent relations with diverse others (an interpersonal capacity; King & Baxter Magolda, 2005). For adults who experience oppression, the ability to deconstruct racist messages (an epistemological capacity) is crucial to denouncing those messages to create a positive racial or ethnic identity that in turn supports authentic relations with diverse others (Torres & Baxter Magolda, 2004; Torres & Hernandez, 2007). Similarly, the ability to deconstruct heterosexist messages and growth on all three developmental domains promotes sexual orientation identity development (Abes & Jones, 2004). These capacities are necessary for success in college and beyond.

Employers expect higher education to help college students achieve these capacities. In a 2006 national survey 76% of employers wanted colleges to place more emphasis on teamwork skills in diverse groups and intercultural competence and 64% advocated greater emphasis on complex problem solving (Association of American Colleges and Universities [AACU], 2007). Similarly, higher education reform reports emphasize personal and social responsibility, including intercultural competence, as essential college learning outcomes for 21st-century challenges (AACU). These learning outcomes are crucial for traditional 18-to-24 year-old students to be effective citizens on campus and to succeed in their future adult roles. These learning outcomes are equally crucial for nontraditional college students who already face many of these challenges. As the Spellings Commission noted (U.S. Department of Education, 2006), almost 40% of today’s college students are self- supporting adults 24 or older, more than a third of whom work full- time, and over a fourth of whom have children.

The pace of knowledge production in today’s society also requires forms of learning that in turn require self-authorship. Knowledge acquisition is no longer sufficient for adults to keep pace with rapid change. Educators, instead, call for transformational learning:

The process by which we transform our taken-for-granted frames of reference (meaning perspectives, habits of mind, mind-sets) to make them more inclusive, discriminating, open, emotionally capable of change, and reflective so that they may generate beliefs and opinions that will prove more true or justified to guide action. (Mezirow, 2000, pp. 7-8)

Transformational learning involves “learn[ing] to negotiate and act on our own purposes, values, feelings, and meanings rather than those we have uncritically assimilated from others” (p. 8). The learning outcomes called for in national higher education reform reports (e.g., critical thinking, integrative learning) support the need for transformational learning (Baxter Magolda, 2004; Meszaros, 2007).

The potential of self-authorship to help adults meet the challenges of adult life effectively warrants a better understanding of the nature of self-authorship, how it evolves, and how it can be fostered among the diverse array of students who currently attend college. This article offers a theory of self-authorship based on tracing its evolution from age 18 to age 39 among a group of 30 adults.

THE CONCEPT OF SELF-AUTHORSHIP

Although many lines of research historically address the components of self-authorship, Kegan coined the term in describing a shift of meaning-making capacity from outside the self to inside the self. He explained that a person takes values, beliefs, convictions, generalizations, ideals, abstractions, interpersonal loyalties, and intrapersonal states:

as objects or elements of its system, rather than the system itself; it does not identify with them but views them as parts of a new whole. This new whole is an ideology, an internal identity, a self-authorship that can coordinate, integrate, act upon, or invent values, beliefs, convictions, generalizations, ideals, abstractions, interpersonal loyalties, and intrapersonal states. It is no longer authored by them, it authors them and thereby achieves a personal authority. (1994, p. 185, italics in original)

The shift he described is from uncritically accepting values, beliefs, interpersonal loyalties and intrapersonal states from external authorities to forming those elements internally. The person becomes the coordinator of defining her/his beliefs, identity and social relations while critically considering the perspectives of external others. Self-authorship is sometimes confused with egocentrism and a focus on the self rather than on relations with others, which is of particular concern when exploring the utility of the concept of self-authorship for persons who belong to cultures that emphasize family and connection to the community. Yet Kegan emphasized that self-authorship involves each person determining for himself or herself how to construct mutually beneficial relationships. Thus, self-authoring individuals do not separate from others but rather reconstruct their relationships to be more authentic. Kegan’s (1982) most significant contribution to the evolution of self-authorship lay in his advancing the constructive- developmental tradition to integrate Piagetian cognitive psychology with psychoanalytic psychology. This constructive-developmental tradition surfaces the interconnectivity of how we view the world (the epistemological dimension), how we view ourselves (the intrapersonal dimension), and how we view social relations (the interpersonal dimension). Understanding the integration of these three dimensions provided a richer portrayal of adult development.

Self-authorship evolves when the challenge to become self- authoring is present and is accompanied by sufficient support to help an individual make the shift to internal meaning making (Baxter Magolda, 2001; Kegan, 1994). My longitudinal participants encountered the challenge to become self-authoring in their mid-20s in their work and personal contexts. Their stories of their 20s revealed a path out of following external formulas to a crossroads in which external influences and their initial internal voices conflicted. Most reported that negotiating this crossroads occupied their 20s (Baxter Magolda, 2001). The participants’ stories of their 30s are focused on how they came to trust their internal voices to effectively coordinate their beliefs, identities, and social relations. Increasing trust led them to build internal foundations based on their commitments and use these foundations to guide their lives. These commitments became increasingly secure and second nature as self-authorship evolved.

Research evidence suggests that adults who experience oppression and marginalization develop self-authorship prior to or during their 20s. Some Latino/a college students in Torres’s longitudinal study became self-authoring by trusting their internal voices to ground their negotiation of cultures and Latino/a identity; a few built internal foundations that enabled them to maintain their internalized identities across diverse contexts (Torres & Hernandez, 2007). A few lesbian college students in Abes’s longitudinal study also became self-authoring as they trusted their voices to mediate the heterosexist messages they received from their external environments (Abes & Jones, 2004). Pizzolato (2003) found evidence of selfauthorship among entering high-risk college students based primarily on the challenges they had encountered in striving to become college students. Their ability to maintain selfauthorship in the face of continued marginalization in college depended on their coping skills (Pizzolato, 2004). These studies suggest that self- authorship is possible in the late teens and early 20s if the challenge and appropriate support are available to enable it. Integrated developmental models are emerging to articulate the complexities of self-authorship development (Abes, Jones, & McEwen, 2007; Baxter Magolda, Abes & Torres, in press). A more comprehensive understanding of the elements of self-authorship can help educators provide the challenge and support for college students to shift to internal coordination of their beliefs, identities, and social relations. I have used the word elements to convey that there are certain components, or building blocks, that comprise what Kegan called the self-authored system; the term system stems from Kegan’s notion that self-authorship is “the mental making of an ideology or explicit system of belief” (1994, p. 91). This system does not emerge in a wholesale fashion but rather in an incremental, cyclical fashion. In this article I have offered one portrayal of three elements of self-authorship based on longitudinal interviews with adults in their 30s.

LONGITUDINAL STUDY METHODOLOGY AND METHOD

The self-authorship theory advanced here emerged from my 21-year longitudinal study of young adults from the age of 18 to 39 (Baxter Magolda, 1992; 2001). I originally designed this constructivist study to explore gender differences based on the work of Perry (1970) and Belenky, Clinchy, Goldberger, and Tarule (1986). Continuing the constructivist approach into the postcollege phase enabled the intrapersonal and interpersonal dimensions of development to emerge and thus shifted the nature of the study to a more holistic view of self-authorship in young adult life.

Participants

I interviewed 101 traditional-age students (51 women and 50 men) when they began college in 1986 at a Midwestern public university. Seventy percent of the entering class of which the participants were a part ranked in the top 20% of their high school class. Their majors included all six divisions within the institution (i.e., arts and sciences, education, fine arts, interdisciplinary studies, business, engineering and applied sciences), and cocurricular involvement in college was high. Of the 70 participants continuing in the postcollege phase of the study, 21 pursued additional academic preparation after college graduation, including law school, seminary, medical school, and various graduate degrees. Their occupations included business, education, social service, ministry, and government work. Attrition over the past 15 years resulted in 30 participants, all of whom are Caucasian, by Year 20. Of these 30, 2 were single, 1 was in a committed relationship, 26 were married, and 2 were divorced (one of whom remarried). Of these 18 women and 11 men, 22 had children. Seventeen had been or were pursuing advanced education: 12 had received master’s degrees in education, psychology, social work, business administration, and economics. One had completed seminary, 2 received law degrees, 1 completed medical school, and 1 completed a doctorate. The most prevalent occupations of these 30 participants were business (16) and education (9). Areas within business included sales in varied industries, financial work, public services, real estate, and marketing. Educators were primarily secondary school teachers and administrators; one was a college professor. The remaining participants were in social work, law, homemaking, and Christian ministry.

Procedure

The annual interview began with a summary of the focus of the project, which was to continue to explore how participants learn and come to know. The participant was then asked to think about important learning experiences that took place since the previous interview. The participant volunteered those experiences, described them, and described their impact on her or his thinking. I asked questions to pursue why these experiences were important, factors that influenced the experiences, and how the learner was affected. The interview became increasingly unstructured (Fontana & Frey, 2000) as the study progressed and addressed what life had been like for participants since we talked last. These conversations included discussion of the dimensions of life they felt were most relevant, the demands of adult life they were experiencing, how they made meaning of these dimensions and demands, their sense of themselves, and how they decided what to believe. Inherent in these dimensions was their sense of themselves in relation to others and their involvement in significant relationships. Interviews were conducted in person during college and by telephone after college; each interview ranged from 60 to 90 minutes.

My constructivist approach to this project and the partnership developed over the course of the study with participants both mediate data interpretation. My constructivist approach led to using grounded theory methodology (Charmaz, 2003, 2006) to analyze interview responses. Each year I reviewed transcriptions of the taped interviews and divided them into units. I then sorted the units into categories to allow themes and patterns to emerge from the data. I also reread data for each participant across years to develop successively evolving interpretations and further develop patterns. Credibility of the themes and patterns is enhanced through prolonged engagement to build trust and understanding and member checking to assure accuracy of interpretations. Two research partners joined me to reread and analyze a portion of the postcollege data. Each of us prepared summaries of themes individually followed by meetings in which we discussed and synthesized our perceptions. This use of multiple analysts helped mediate our subjectivities and increase the adequacy of our interpretations. I have negotiated interpretations with study participants as well. Full involvement with participants has yielded rapport and understanding. Yet Clandinin and Connelly emphasized that researchers “must also step back and see their own stories in the inquiry, the stories of the participants, as well as the larger landscape on which they all live” (2000, p. 81). Thus I bring my perspective to the interpretation yet simultaneously work to be true to participants’ narratives, and from the two, construct a theoretical perspective.

FINDINGS: AN IN-DEPTH SELF-AUTHORSHIP NARRATIVE

The theoretical perspective offered here is one possible portrait of the evolution of selfauthorship. Because it is based on constructivist interviews with one group of participants it cannot automatically be generalized to others. Clearly my participants encountered the demand for self-authorship at a different time in their lives than participants in Torres’s, Abes’s, and Pizzolato’s studies. Personal characteristics and environmental context both mediate the evolution of self-authorship. Thus the theoretical perspective offered here grows out of the particular personal characteristics and environmental contexts of the participants.

Longitudinal in-depth narratives of young adults’ meaning making enable constructing a nuanced theory of self-authorship that captures the complexities of personal characteristics, environmental contexts, and the interaction of the two in becoming selfauthoring. Tracing the evolution of meaning making in these narratives also reveals the varied role that dimensions of development play and how developmental cycles might occur. Because very few in-depth narratives of self-authoring persons appear in the literature, exploring such a narrative reveals the nuances of three elements of self-authorship. Understanding these nuances refines educators’ abilities to conceptualize how to support young adults in becoming self-authoring. I chose Dawn’s in-depth narrative here because Dawn’s ability to articulate her innermost thoughts offers a clear view of the process of self-authorship.

Dawn entered college with a proclivity for self-exploration. She found an outlet for exploring herself in theater, noting that, “To bring out the truth in a character, I think you have to have an immense understanding of all the little truths within yourself” (Baxter Magolda, 2001, p. 151). She also looked for these little truths by traveling solo to Australia for 3 months, climbing Mt. Kilimanjaro, and wrestling with career plans. Her explorations during her 20s were focused on finding and listening to her internal voice, gaining confidence in expressing it, and letting go of external noise in her life. Listening to her voice enabled her to self-identify as gay, explore her spiritual core, and gain clarity about what she wanted in life. She enjoyed the support of her parents, grandmother, friends, and theater colleagues in this exploration.

Dawn was challenged to further cultivate her internal voice when she was diagnosed with multiple sclerosis at age 33. The diagnosis accelerated her quest for self-discovery as she reported in our 16th interview just 2 weeks after her diagnosis:

There is so much processing going on, what I do on a daily basis, trying to fit all the pieces of the puzzle together. I think I’m definitely at a point where I am really defining a lot about my life. Not that it is discovering new things-I’m sure I am-but bringing everything that I’ve ever thought and believed into a much clearer focus for myself. I’m in very deep thought about evaluating what is important, what is not so important, what gives me comfort, emotionally, mentally, discovering these things. Specifying these things that accomplish these things for me. . . . If you are very specific in your frame of mind in how you approach and handle things, that makes it much simpler. The whole thought process of just taking stock of where you are in your life. It’s like putting your life through a sieve, getting the big awkward chunks out of your life, getting the nice finely sifted residue-it is kind of sorting it all out. What is the essence of you and what isn’t? What is important to the essence of you and what isn’t? . . . You have to decide what it is that you want and don’t want. Little by little, things take a much more specific shape. (Baxter Magolda, 2004c, pp. 18-19) Dawn’s processing reflected a shift from listening to her internal voice to cultivating it to make decisions about the essence of her identity. Using all that she previously thought and believed, she sorted and sifted to get to the essence of who she wanted to be.

Self-Authorship: Trusting the Internal Voice

Continual work on sorting out her essence increased Dawn’s confidence in her internal voice and led her to feel spiritually centered and “more malleable around obstacles.” She explained, “Obstacles are not a hard blockade, but rather you can shift and move with that energy around them, and they solve themselves.” She called this the “art of controlling without controlling”:

Finding the balance between [going with the flow] and me saying I have control over myself, not letting this condition get the best of me. Knowing how to make things happen and let things happen. When you find the balance between those things, life is spectacular. That is kind of a trust thing-trusting that you know yourself enough to dance that line. Know when to make something happen and when to let it happen. Trusting yourself that you know that space. I don’t quite know myself enough to trust that yet. I’m working on it. I’m getting close. That deepest self-knowledge to know you can stay there at that middle point and have that balance. That is a constant process for me. To be able to say this is my life and it’s on my terms; I love that. (Baxter Magolda, 2004b, pp. xx-xxi)

Trusting her internal voice meant knowing herself deeply enough to determine when to make things happen versus when to let them happen to live life on her own terms. She could not control having MS or the restrictions it placed on her physical capacity. Yet she viewed it as a gift and noted that learning you cannot do something opens another door to what you can do. Dawn actively searched for what she could do rather than framing MS as an obstacle. Developing this trust was an ongoing quest.

Dawn clarified, however, that the quest was not one of straightforward, steady progress. She noted that she was not always spiritually centered:

I went through this phase where I questioned everything. I questioned what I believed; I questioned every spiritual principle that I’d ever thought was true; I felt very lost. . . . I always felt like I was fighting to get back on track and I just couldn’t, and that lasted for a couple of months where I just felt like I was just tumbling around in space with no sense of direction or anything to cling to, and I was just out there lost. And I don’t know if I can pull it to one defining moment where everything came right back together for me. Now I feel like I’m at the complete opposite end of the spectrum because I know, I have such a clarity over what I think, what I believe, spiritual purpose, which is kind of an interesting journey. You don’t stay in the light all the time. There are times when you go to the shadow lands and I don’t know if that was teaching me something? I haven’t really sat down and put the pieces together, but it has led me to this point where I feel so grounded and so connected with myself and the world in which I live, and it has brought clarity to me about my health, about who I am, where I want to go.

This period of questioning suggests that coming to trust one’s internal voice requires cultivating it, questioning it, and refining it.

Three years later Dawn reported that she had lost sight of her internal voice in a relationship. Her frustration about this was compounded by the fact that the same thing had happened to her in her 20s. This time, focusing on the relationship drew her attention away from bringing her internal voice to it. The breakup of the relationship reminded Dawn of the need to be vigilant about keeping her internal voice in the foreground:

I wasn’t taking care of myself, my balance wasn’t good and I was running into stuff and falling down. And I noticed that that was happening, but I really wasn’t taking any steps to correct it. It was really frustrating me, making me angry, and some of that came out in our relationship. It wasn’t necessarily directed at her, but I would just be really frustrated, and I didn’t really know why. I stopped approaching myself as someone with a disease or condition [who needs] to take care of [herself]. Out of the breakup has just come a lot of self-awareness. It happened before, during, and after the break-up that this whole turnaround has happened. OK, I have this problem. Is that just because I have this problem with my health, or is it because of the MS and, it’s just kind of coming back to myself? That’s just been a huge thing. I totally lost it in this relationship and that was a big reason too why it didn’t work. You got to be yourself. You got to bring yourself to the relationship, and I just kind of stopped doing that, and I’m not really exactly sure why. I’m still working that one out.

Dawn was determined to figure out why she lost her internal voice in significant relationships. She continued to make use of every challenge she faced to analyze herself and move closer to trusting her internal voice in all dimensions of her life.

Self-Authorship: Building an Internal Foundation

Trusting her internal voice enabled Dawn to acknowledge and accept her personal talents as a building block for focusing on her purpose. She had always loved theater but was acknowledging her giftedness in cooking, a role she had assumed over the years to support herself financially. She began to think more long-term than she had in the past, and turned her focus toward creating both an internal and physical foundation for her life:

I started to look at what I’m good at and how to take those things, and particularly with the cooking, it’s like, “I am tired of working for somebody else’s vision.” I have my own ideas. I have my creativity. I have my own style in the kitchen. Why can’t I start working for my own vision and make that a success, and make a living off of that? In the past year is when I really focused in on the long term and settling down a little bit ’cause, we’ve talked since I was a freshman in college basically, [and] you’ve gotten a pretty good idea over the last, say, 5 to 10 years of what kind of a gypsy I’ve been. . . . Just kind of going and doing whatever, wherever, however. In the past year I’ve really started to bring the focus of my life into a more specific area and having a place to call my own. I love the flexibility that I have now because I don’t work every day and now I’m focusing in on getting my own place to call home, and building this whole network and infrastructure for myself. So then I use that to kind of launch myself into all these directions that I want to go and things I want to do, but when I come back, I know I have this framework in which to exist, and that’s made a big difference. And I don’t know if part of that is because of the MS or not. I think it is because of the precarious nature of my health, I think I need a framework or some stability there just so I know that I’ve got a solid place to be no matter what happens in my life.

Dawn’s focus on her internal identity had routinely overshadowed any concern about a physical infrastructure such as a home or stable job to support her life. Yet her deepening understanding of her MS and the connection between her health and internal identity provided her with the confidence necessary to structure her external environment in a way that best fits her needs and interests. Shifting from her gypsy past to a more stable future, she now used her own voice and vision to create a framework for her life. Whereas the structure others created for her had been confining, her own self-made structure is freeing. Beginning to feel both internally and physically grounded, Dawn moved closer to her core as she accepted and celebrated her talents and started to incorporate them into her identity:

I work magic in the kitchen, and my therapist would be so happy to hear me speaking in such really incredible terms about myself. Now I’m realizing too that what I’ve held onto all along is that it is very much a creative and artistic outlet for me, which is why I started cooking professionally in the first place, because my theater work wasn’t making me a lot of money and I had to support myself. I started cooking, and it’s just like a huge opening to all of the wonderful things in life that I am. Also, opening to myself, being a wonderful person, and enough of this downplaying it. Life is short. You’ve got to celebrate every moment that you have. Part of that also has been acceptance, even 3 years into it, of the whole MS thing. I’m sure I denied it a little bit, but just accepting that it is a part of me. It will not rule my life. I just feel such a complete sense of settling into myself and everything about me. This is the most peaceful I have felt in a very, very long time, if ever, you know? Accepting these parts of herself enabled Dawn to actively construct an internal foundation to use as a framework for her life. She described it as “opening the door” to using her talents in her professional and personal life. Her newfound ability to appreciate the full extent of her talents was a crucial part of this:

It had to be my willingness to change that, to stop the downplaying, to really embrace myself for all the amazing things that I can do. Even celebrating the little things that may not be necessarily categorized by some people as amazing, like the fact that I get up every morning and ride 15 miles on my bike. That’s pretty amazing in its own right. So there’s been a big shift in that approach to myself and my life.

Dawn’s construction of her internal foundation by embracing her talents, her MS, and the things she could do fueled her quest for her spiritual core. Dawn’s conscious quest for more meaning helped her continually build her internal foundation. By opening herself to that something more, by going to get it, she developed strength even through painful explorations. Each journey to the shadow lands made her stronger because she emerged each time with a stronger understanding of her spiritual core.

Self-Authorship: Securing Internal Commitments

As Dawn’s internal foundation strengthened, the commitments she made to how she saw the world, herself, and relationships became second nature to her. The multiple strands of Dawn’s previous introspection came together as she implemented decisions about her career, health and relationships to secure these internal commitments, as she explained in our 19th interview:

I feel like I’m in this situation where I’m learning a whole new side of me that I suspected might have existed before, but I never had the opportunity to get to know it or put it into practice: how resourceful, strong, resilient, and smart I am and just all these new facets of me that are starting to come to light. I’m very much enjoying the whole process of getting to know that. It’s almost another level. It’s not to say that I didn’t see those things before. It’s just maybe a deepening of all of that, a maturing of all of that.

Asked to elaborate, Dawn explained what she called a transformation from knowledge to wisdom:

It’s starting to feel-more like wisdom than knowledge. To me knowledge is an awareness of when you know things. You know them as facts; they are there in front of you. When you possess the wisdom, you’ve lived those facts, that information so fully that it takes on a whole different aspect than just knowing. It is like you absorbed that information into your entire being. Not just that you know things. It is something deeper. Knowledge is brain -wisdom comes from a different place, I feel like. Something deeper connecting with your brain so that you have something different to draw from. A point where knowing you are going to do something-the knowledge has a deeper level-internal, intuitive, centered in entire being, the essential part of you that just-makes the basic knowledge pale by comparison. (Baxter Magolda, 2007, p. 71)

Dawn’s description suggests that wisdom emerges when knowledge merges with sense of self as a result of living the facts. She offered two examples in which she relied on this internal, intuitive wisdom. She reported that her cooking was second-nature such that she often thought about other things while she cooked, rarely used recipes, and knew how ingredients would taste together even in dishes that she did not personally like. She explained, “There is just a sense there that these elements will all go together-I know it.” The second example was riding in the MS 150 in the summer heat. She knew instinctively that she was able to ride 150 miles despite the physical challenge it entailed. She never doubted her ability to finish the journey.

Dawn’s will, her wisdom and confidence in herself, and her feeling of completeness initiated a shift in her spiritual perspective:

I would say this is very spiritual but not necessarily in the ways that I thought it would have been, say, a year ago. Can I explain that? I don’t know. It’s just um . . . I guess because it feels much more freeform, not as concrete as I guess I would have maybe said some things were spiritually in the past. This feels much more amoeba-like and not as well defined, but yet comfortable and very much a part of me. I think that’s the best way I can say it. I mean . . . OK, so now do I get to the point in my life where like everything becomes undefined and not really vague, but indefinable? It just becomes something that you know, but you can’t really describe it? I mean what’s that about? You start to shift over into information or feelings or intuitions or senses that aren’t necessarily tangible, but you almost pick them up by osmosis. When it starts to become that sort of a thing, that to me is crossing over into wisdom.

Dawn seemed to be communicating that the deeper her knowledge of herself becomes (or as it becomes second nature), the more intangible, flexible and free her core sense herself becomes. She knows more firmly, yet in less concrete ways. This wisdom led simultaneously to a greater sense of freedom and a greater sense of certainty. She described feeling “much more grounded and much more solid and, in some ways much more powerful.” Asked to explain what “more powerful” meant, Dawn said:

Well, it kind of goes back to that whole superhero thing I was telling you about, . . . it’s in that confidence. Not that I wasn’t confident because I think you have to be confident to take off to Australia for 3 months by yourself. But it’s different. Where that might have been a little more powerful in a youthful, whimsical sort of way, this is just . . . there’s certainty. That was, “I am throwing myself into the great beyond and I don’t know what I’m going to come up against. I am just putting my faith in the fact that everything’s going to be fine because I’m not really entertaining any other ideas.” This is just a certainty . . . as certain as I was when I got on my bike to ride 150 miles. I absolutely know this to be true and while we don’t know what each day’s going to bring for us . . . and I think that’s where the spirituality ties in again . . . there’s a connectedness, and it’s just not so much casting yourself into the great beyond and whatever happens, happens. Now it’s more engaged and, “OK, now I’m going to do this, and I’m going to watch what happens.” That’s a very conscious way of expressing it, but it does become more unconscious when you’re actually proceeding through each day.

Dawn’s greater sense of certainty stems from the internal wisdom that prompts her to know she can do what she sets her mind to and adjust to unknowns that the next day brings. These external uncertainties do not shake her internal certainty. This grounded, more solid, and more powerful internal core yields a different form of freedom that is more substantive than the physical freedom to travel spontaneously. This well-developed internal foundation allows her the freedom to act, watch what happens, and be confident that she can make something positive take place. She is living the commitments she has developed. Dawn uses this internal foundation- what she calls wisdom-as a source of freedom.

Dawn worked to secure these internal commitments by making choices to acquire the kind of significant relationship she desired, manage her health, and launch her own cooking business. In doing so, she intentionally opened herself to emotional risks. She said, “Once you decide to move the boulder, it’s going to start rolling; that’s the choice you made. You took the risk, you pushed it, . . . everything that comes along with it, you just have to be there for.” Earlier she had uncovered her tendency to approach her MS as a “brave warrior” who would conquer all challenges. She was trying to let go of this default reaction to challenges in her life. At this point, her inner strength allowed her more flexibility to acknowledge the requirements of managing MS and also to accept help from others (e.g., her neurologist, therapist) in doing so. She described this as trying to be more human:

I’m on a mission to bring back the humanity to myself, [telling myself], “You know what? You are human. You don’t have to be Hercules about the issues that come up in your world and how well you can handle them and how much weight you can carry on your shoulders. You can be-” Huh. Interesting. I was just going to say, “You can be normal.” Well, because that’s an issue that’s come up. I think a lot of the things that I have done regarding myself physically is to prove to myself and everybody else that I am normal. I don’t have this thing that . . . or yes, I have it but it’s not-you know, it’s still normal; it’s still functioning. Rather . . . the normalcy in it all is that, there are going to be good days and there are going to be bad days, and you are a person with all of this going on, and it’s OK if you’re not having your A-game today.

Dawn was still trying to set aside the warrior, which masked or at least skewed certain parts of herself. Accepting a new normal for herself was all part of the ongoing quest to know herself more deeply. Her story reveals that evolution continues even after the internal voice is firmly established.

A NUANCED SELF-AUTHORSHIP THEORY

Dawn’s story conveys the complexities of the evolution of internal voice. Developing one’s internal voice requires moving the source of one’s beliefs, identity, and social relations “inside” oneself. Thus the internal voice must be built in all three dimensions to construct a self-authored system. This system becomes the mechanism through which individuals frame their experience and construct their reactions to the external world. Three elements of building a self-authored system emerged from participants’ stories: learning to trust their internal voices, building an internal foundation, and securing internal commitments. This article focuses on the three elements of selfauthorship; discussion of how participants moved from authority dependence to the threshold of self-authorship can be found in Making Their Own Way (Baxter Magolda, 2001). Three Elements of Building a Self-Authored System

Trusting the Internal Voice. Participants’ key insight in this phase was a distinction between reality and one’s reaction to it. They recognized that reality, or what happened in the world and their lives, was beyond their control, but their reactions to what happened was within their control. Trusting their internal voices heightened their ability to take ownership of how they made meaning of external events. They recognized that they could create their own emotions and happiness by choosing how to react to reality. This led to a better sense of when to make something happen versus when to let something happen. This way of making meaning enabled them to be more flexible and move around-rather than try to change-obstacles they encountered. Dawn called this the “art of controlling without controlling” and was using this approach to work with her MS. As participants developed confidence in their internal voices, they came to have faith in them and to trust them and the internal commitments they were making based on these voices.

Within the element of trusting the internal voice, participants moved from awareness of to confidence in their internal voices multiple times as they worked to trust their internal voices in each developmental dimension (i.e., epistemological, intrapersonal, and interpersonal) and in multiple contexts (e.g., work, personal relationships, parenting). Awareness often prompted exploration, which sometimes led to what Dawn called the shadow lands. These were times of confusion, ambiguity, fear, and even despair as individuals struggled to analyze and reconstruct some aspect of their beliefs, identity, or relationships in various contexts. As Dawn noted, it was not possible to be “in the light” all the time. By reflecting on these challenging experiences, participants emerged from the shadow lands with a clearer vision of themselves and greater confidence in their ability to internally author their lives. Their personal reflection skills and the extent to which they had good support systems mediated the intensity and duration of excursions into the shadow lands. Once they had sufficient confidence to trust their internal voices in multiple dimensions and contexts, participants were able to begin building an enduring internal foundation.

Building an Internal Foundation. Trusting their internal voices, participants consciously set about creating a philosophy or framework -an internal foundation-to guide their reactions to reality. They worked to refine their personal, internal authority in determining their beliefs, identity, and relationships. They reflected on how they had organized themselves and their lives and rearranged as necessary to align arenas of their lives with their internal voices. This often meant accepting personal components of themselves and incorporating these into their identities as Dawn did with her gift for cooking. They made additional choices using their internal voices as guides. Their ability to explain how and why they made particular choices gave individuals in this process assurance that they could use their personally created identity, decision, or relationship even amid uncertainty. Synthesizing their epistemological, intrapersonal, and interpersonal development into one internal foundation yielded what Dawn called the “core of one’s being.” This phrase reflects the enduring nature that the internal foundation acquires when all of the dimensions of one’s development become integrated into one cohesive entity.

Participants acted according to their internal foundations as they were building them. This often yielded feedback that they used in refining their internal foundations. As they constructed some parts of the internal foundation, they found that they needed to recycle through trusting their internal voices to gain additional confidence. Similar to a physical construction project, it is often necessary to return for additional materials or to revise a blueprint to address an unanticipated twist. Visits to the shadow lands occurred in this process as well, again mediated by participants’ reflection capacities and the quality of available support. Their increased confidence overall helped them process painful experiences and use the conclusions they reached to strengthen the internal foundation. However, participants pointed out that initially the beliefs and perspectives they were forming were in their heads rather than in their hearts. Some described this as admiring a set of convictions one has constructed versus living them. While they were building the internal foundation, they perceived that they were living their convictions. In retrospect, many could identify the transition from admiring to living their convictions that led them to securing internal commitments.

Securing Internal Commitments. Participants’ identified this third element of building a self-authored system as “crossing over” from understanding their internal commitments to living them. Dawn called it crossing over into wisdom. When the internal foundation became the enduring core of their being, participants felt that living their convictions was as natural and as necessary as breathing. This element was a time of living the internal foundation and securing internal commitments.

Many participants described inner wisdom as the blurring of their knowledge and their sense of self. Dawn described it as living the facts and absorbing that information into her entire being, which led her to “know” as second nature. This merger of knowledge and sense of self seems to reflect not only the bringing inside of personal authority but making personal authority one’s very core. In this element, participants integrated their internal foundations and infrastructure with their external personal realities. Dawn portrayed this as acting and watching what happens with the confidence that she could create something positive. Participants’ increased certainty that things would work out stemmed from knowing becoming second nature. This allowed them to move forward with faith and trust in their internal foundations even when on the surface it would be legitimate to question a course of action. Dawn’s riding in the MS 150 in the summer heat is a good example of participants moving forward with faith and trust.

The certainty that came with living their internal foundations also yielded a greater sense of freedom for participants. They were no longer constrained by fear of things they could not control and trusted that they could make the most of what they could control. They were open to learning about and developing new parts of their self-authored systems, often recognizing contexts in which they needed to refine or develop some aspect of themselves. In these instances, they returned to building that portion of the foundation or, in some cases, recycled back to gaining confidence in that area. In the securing internal commitments element, the internal foundation became increasingly open to being reconstructed because participants had an internal security to see reconstruction as positive and exciting. They accepted new versions of normal and enjoyed the dynamic process of living their internally authored systems. They were adept at rolling with whatever came their way.

Trusting the Internal Voice, Building an Internal Foundation, and Securing Internal Commitments appear to be three elements of the meaning-making structure of self-authorship. Each element reflects a distinct focus yet all three are based on the same underlying organizing principle-internally determining one’s beliefs, identity and social relations. The initial element involves developing the internal voice to use in these decisions. The intermediate element involves using the internal voice actively to build one’s internal belief system and solidifying that internal system. The advanced element involves refining and strengthening the internal system as it becomes the core of one’s existence. These constitute increments in increasing complexity within the same meaning-making structure. The solidification of this structure yields the security to explore more freely and continue personal evolution.

Clarification of Misconceptions of Self-Authorship

Participants’ stories clarify two common misconceptions about self-authorship. First, the cyclical nature of the evolution of self- authorship just described suggests that self-authorship is more complex and nuanced than a simple linear trajectory. Although all the participants moved toward increasing self-authorship, they took numerous paths in this journey based on their personal characteristics, experiences, challenges they encountered, and support available to them. Personal characteristics such as participants’ socialization based on their gender, sexual orientation, faith orientation, race, or ethnicity predisposed participants to seek particular experiences (e.g., jobs, relationships, travel). For example, Dawn’s sense of spirituality fueled the self-exploration she engaged in through theater and travel. Her coming out in her 20s was a salient experience that enabled her to cast off external expectations to listen to her own voice. Personal characteristics mediated how participants engaged experiences they sought and experiences that happened to them either at a personal level (e.g., relationship struggles, work challenges, health problems) or societal level (e.g., 9/11, the Iraq War). Their meaning making at any given point mediated how they approached experiences and how they interpreted those experiences, as did their particular combination of the epistemological, intrapersonal, and interpersonal dimensions of development. For Dawn, MS, relationship struggles, and trying to support herself via theater work versus finding another career presented major challenges in her 30s. Her capacity to self-reflect (an intrapersonal strength) and her appreciation of multiple perspectives (an epistemological strength) predisposed her to seek out experiences to explore herself and helped her process challenges she encountered. Participants’ work, family, and personal environments offered a range of challenges and support systems to face life’s challenges. The support of Dawn’s family, friends, and medical community combined to help her listen to and trust her internal voice. Trusting her own voice, her spirituality, her willingness to continue digging deeper, and her ongoing support from others enabled her to build her internal foundation and return from the shadow lands with greater strength. One participant referred to all these dynamics as a “personal set of realities.” Particular sets of personal realities yielded a complex set of dynamics that mediate developing self-authorship. Second, self-authorship enhances, rather than constrains, relationships. The longitudinal stories demonstrate that self-authorship refers to shifting the source of one’s beliefs, identity, and social relations from the external world to the internal voice and foundation. Doing so initiates a reframing of relationships that become more authentic because they honor one’s internal commitments. Connections based on these internal commitments result in interdependence in which parties to the relationship act authentically and support each other in doing so. Thus, self-authorship strengthens relationships and enduring ties with the external world. Dawn’s work on her internal foundation enabled her to enter an authentic relationship in her late 30s because she was finally able to bring her internal voice to the relationship.

USING A NUANCED SELF-AUTHORSHIP THEORY IN HIGHER EDUCATION

For Dawn and her peers, developing selfauthorship occurred after college as they also juggled adult commitments. Their stories offer insight into how educators might authentically engage young adults in developing their internal voices and foundations during their college experience. Because self-authorship can develop before (Pizzolato, 2003) or during (Abes & Jones, 2004; Torres & Hernandez, 2007) college, and because self-authorship is a capacity that allows young adults to better meet the challenges of adult life, enabling this capacity should be a key focus of a college education.

For those students who are struggling to listen to and cultivate their internal voices, educators can help reduce external noise, which can take such forms as peer, family, or social pressure, and draw out students’ internal voices. Once students move into building self-authored systems, educators can encourage acting on the internal voice to trust it and align beliefs with action. They can also help students process the building of their internal foundations through interactive reflection and discussion activities and assignments (see below). The same set of basic principles can be used to support students in both these circumstances.

Longitudinal participants were supported in cultivating and trusting their internal voices when others engaged them in learning partnerships. Their partners validated their capacity to use their internal voices, situated learning in their experience, and invited them to construct meaning of their experiences (Baxter Magolda, 2004a). Simultaneously, their participation in these partnerships, which occurred in academic, work, and personal arenas, challenged young adults to bring their internal voices to the complex challenges of adult life. When supervisors or mentors engaged young adults in complex experiences, guided them to intentionally reflect on and make sense of these experiences, and mutually constructed meaning of these experiences with them, young adults grew to trust their internal voices. Educators have used these principles effectively in both curricular (e.g., writing, core curriculum, diversity courses) and cocurricular (e.g., leadership, service- learning, residence life, cultural immersion) settings to draw out and cultivate students’ internal voices (Baxter Magolda & King, 2004; Meszaros, 2007; Pizzolato, 2006).

Reflective conversations in all arenas of the college experience can also draw out and support students’ internal voices. A Reflective Conversation Guide constructed from the Wabash National Study of Liberal Arts Education interview offers a structure to conduct these conversations (Baxter Magolda & King, 2008). The guide focuses on engaging students in talking about their most significant experiences; exploring how they have been affected by those experiences; and making sense of the effects for their view of the world, themselves, and their relationships. Reflective conversations with academic and career advisors about interests and strengths could help students frame academic and career choices. Reflective conversations with faculty could focus on making connections between new concepts and personal experiences or making meaning of how members of a group project interact. Student affairs professionals could use these conversations to engage students in bringing their internal voices to negotiating living arrangements with roommates and putting their beliefs into action. Supervisors of student leaders or employees could engage students in reflecting on how these roles relate to their goals and aspirations. Diversity educators could use these reflective conversations to help students deconstruct racism, heterosexism, sexism, classism, and White privilege. Intergroup dialogues that have been effective to help students gain intercultural maturity contain these same basic principles of cultivating students’ internal voices (e.g., Zuniga, 2003). All of these reflective conversations would help students making meaning of curricular and cocurricular experiences to refine their learning, professional, and personal goals.

Learning partnerships rely on the intersection of the voices of both partners. Thus they cultivate learners’ internal voices and allow educators to frame their participation in the context of the learner’s voice. This avoids using a standard practice that does not acknowledge difference among learners. Because practice is constructed with the learner, in the service of strengthening the learner’s internal voice, nuances of the learners development journey come to the foreground in the relationship. Giving learners responsibility for refining their internal voices using their own set of personal realities and supporting that process is our central challenge.

REFERENCES

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Baxter Magolda, M. B. (2004b). Preface. In M. B. Baxter Magolda & P. M. King (Eds.), Learning Partnerships: Theory and models of practice to educate for self-authorship (pp. xvii-xxvi). Sterling, VA: Stylus.

Baxter Magolda, M. B. (2004c). Self-authorship as the common goal of 21st century education. In M. B. Baxter Magolda & P. M. King (Eds.), Learning partnerships: Theory and models of practice to educate for self-authorship (pp. 1-35). Sterling, VA: Stylus.

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Baxter Magolda, M. B., Abes, E., & Torres, V. (in press). Epistemological, intrapersonal, and interpersonal development in the college years and young adulthood. In M. C. Smith & T. Reio (Eds.), Handbook of research on adult learning and development. Mahway, NJ: Lawrence Erlbaum.

Baxter Magolda, M. B., & King, P. M. (2008). Toward reflective conversations: An advising approach that promotes selfauthorship. Peer Review 10(1), 8-11.

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King, P. M., & Baxter Magolda, M. B. (2005). A developmental model of intercultural maturity. Journal of College Student Development, 46, 571-592.

Meszaros, P. S. (Ed.). (2007). Self-Authorship: Advancing students’ intellectual growth (New Directions for Teaching and Learning No. 109). San Francisco: Jossey-Bass.

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Pizzolato, J. E. (2003). Developing self-authorship: Exploring the experiences of high-risk college students. Journal of College Student Development, 44, 797-812.

Pizzolato, J. E. (2004). Coping with conflict: Self-authorship, coping, and adaptation to college in first-year, high-risk students. Journal of College Student Development, 45, 425-442.

Pizzolato, J. E. (2006). Complex partnerships: Self-authorship and provocative academic advising practices. NACADA Journal, 26(1), 32-45.

Torres, V., & Baxter Magolda, M. B. (2004). Reconstructing Latino identity: The influence of cognitive development on the ethnic identity process of Latino students. Journal of College Student Development, 45, 333-347.

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Marcia B. Baxter Magolda is Distinguished Professor of Educational Leadership at Miami University.

Correspondence concerning this article should be addressed to Marcia B. Baxter Magolda, 300D McGuffey Hall, Oxford, OH 45056; [email protected]

Copyright American College Personnel Association Jul/Aug 2008

(c) 2008 Journal of College Student Development. Provided by ProQuest LLC. All rights Reserved.

By Dhawan, B N

Turmeric: The salt of the orients is the spice of life, Kamala Krishnaswamy (Allied Publishers Private Limited, New Delhi) 2007. 248 pages. Price: Rs.350/-ISBN 81-8424-126-7 Spices have been used since times immemorial for culinary purposes but the discovery of their physiological properties and therapeutic potential is much more recent. Several spices had been used in traditional systems of medicine, mainly for preventive purposes. The most important among them undoubtedly is turmeric (rhizome of Curcuma longa Linn). About 30 species of Curcuma have been described and several of these are used for food colouring and flavouring but C. longa is most extensively used. Turmeric occupies an unique place among the spices since besides being used for culinary and medicinal use it is also employed extensively as a cosmetic, colouring agent and preservative.

The medicinal use of turmeric is mentioned even among the Vedas and elaborated in classical Ayurvedic texts like the Charaka Samhita. A systematic experimental and clinical evaluation of its medicinal properties, however, has been done largely from the middle of the last century. Major attention has centered round curcumin and related curcuminoids which constitute 2-5 per cent of the biomass of the rhizome and are responsible for its characteristic yellow colour. Curcumin free extracts also exhibit biological activity.

There have been several reviews on pharmacology and chemistry of C. longa including a monograph in WHO Monographs on Selected Medicinal Plants, Volume I (1999). The present book is perhaps the first book to comprehensively cover all aspects of the plant, including the historical development, botany, chemistry, pharmacology and uses in medical and other fields.

The opening chapter has reviewed the traditional uses vis-a-vis modern concepts of functional foods and nutraceuticals. It has highlighted the need to provide evidence information to support its traditional uses. It provides justification for turmeric being considered the world’s ‘most important herb’ today and lists about 20 medicinal uses in countries from all parts of the world even though the plant is a native of tropical and subtropical regions. The chapter also illustrates the wide variation in chemical composition of various varieties of turmeric. Thus, the curcumin content varies from 2.8 (Krishna) to 9.3 per cent (Roma, Suroma), oleoresins from 3.8 (Krishna) to 16.2 per cent (IISR Pratibha) and essential oil from 2 (Krishna) to 7 per cent (Suvarna, Sudarsana). These may be responsible partly for the varying results obtained with the crude extracts by different investigators.

The next chapter describes the chemical and nutritional composition of turmeric. The chemical description mainly covers curcumin and some other curcuminoids. An important omission is any mention of the pharmacologically active peptide turmerin. The yield of this 5-KDa water soluble cyclic peptide is 0.1 per cent and it contains 40 amino acid residues.

The remaining chapters of the book review the major pharmacological activities, mainly of curcuminoids, and related clinical and pharmacokinetic studies. The activities reviewed include antiinflammatory, anti-carcinogenic anti-mutagenic, antioxidant, anti-atherosclerotic and some other minor effects. The experimental data have been reviewed in chapters 3-11. The basic mechanisms underlying the pathological processes like inflammation, carcinogenesis, atherosclerosis, etc., have been reviewed in adequate detail thereby helping to locate the possible sites of action of curcumin, its analogues and metabolites.

Curcuminoids act on multiple sites in each of these conditions and some of these sites are common. These include kinins like PKC and tyrosine kinase, TNF, NFkappa B, cyclic D, protein API, STAT family agents, etc. They play important role in mutagenesis, tumour initiation, transformation, progression and metastasis. Pathogenic changes in vasculature are involved in different ways in growth and differentiation of tumours, wound healing, immune responses and thrombotic episodes. Curcumin suppresses proliferation of normal, transformed and malignant cells by modulating growth factors and induces apoptosis in a variety of tumour and other cells. The mechanisms include mitochondrial dependent and independent pathways. An important observation evident from the review is the potentiation of effects of anti-cancer drugs like cis-platinum by curcumin.

The prostaglandins are growth factors for inflammation and angiogenesis and perform a house keeping function. Curcumin modulates their activity by acting on the arachidonic acid metabolism. Other mechanisms involved in its anti-inflammatory activity include effect on lysosomal enzymes and membranes, inhibition of adhesion molecules and cytokine production by inhibition of NF-Kappa B target genes. The mechanism of other effects like hypolipidaemic, wound healing, anti-infective activity, etc., has also been similarly reviewed.

The author has reviewed the extensive data exhaustively but has not commented on the procedures used or the results obtained. Some of the studies have employed very high amounts of the test substances like 5 per cent in the diet and up to 5 mg/ml in some in vitro studies. Results of such studies must be interpreted with caution.

The clinical studies have been reviewed in a separate chapter and their inadequacies, and in many cases poor design of the trial, have been clearly brought out. It may have been better if the clinical studies had been given along with experimental studies on the condition and permitted better correlation. Still the clinical data provide enough evidence for chemopreventive and therapeutic potential of curcuminoids in malignancy and several chronic conditions.

Chronic disorders including degenerative (atherosclerosis, Alzheimer’s disease), proliferative (cancer) or inflammatory (rheumatoid arthritis, chronic infections) conditions share cellular/ subcellular biochemical, molecular regulatory and pathological events including abnormal redox sites, cytokines, apoptotic mechanisms, etc. The book elegantly brings out how the effect of curcuminoids on basic modulators of these processes is responsible for their beneficial effects in such diverse conditions. It helps to identify potential targets on which future work may help in developing novel chemical entities for the management of these chronic conditions. It also highlights the therapeutic potential of the polypeptide tumerin which has not received adequate attention. Similarly data on bioavailability studies suggest the possibility of improving it by combining with piperine.

The studies reviewed in the book also clearly demonstrate that the safety and excellent tolerance of even large doses of curcuminoids and turmeric extracts enhance their utility in preventive health programmes and as nutraceuticals. The author aptly points out (p 237) the paucity of in vivo bioefficacy data in terms of their concentration and synergistic or additive effects with other bioactive compounds. She has also emphasized (p 298) the impact food-based approach for enhancing the intake of such phytochemicals may have on the onset and progression of several chronic diseases. The approach may also provide means of improving and prolonging the success of standard therapies.

The book is extensively documented and covers references of papers published up to 2004. There are many patents on the curcuminoids and analogues, etc., but they have not been so well covered. The book has been profusely illustrated with black and white photographs, bar diagrams, etc. It would have been better to provide coloured photograph, for example, of the plant (Fig. 1) or the tissues (Fig. 6.1) The legends of some of the figures (e.g. Fig. 7.3, 14.4) could have been more explicit. Similarly the splitting of some of the figures (e.g., 4.3) and tables (e.g., 5.3) should have been avoided.

These minor aberrations, however, detract very little from the merits of a timely and authoritative document on biomedical aspects of turmeric. This well produced monograph will be a useful reference book not only for research workers and clinicians but also those involved in economic utilization of turmeric and its value added products in pharmaceuticals, cosmetics, etc.

B.N. Dhawan

3, Ramakrishan Marg

Faizabad Road

Lucknow 226 001, India

e-mail: [email protected]

Copyright Indian Council of Medical Research Apr 2008

(c) 2008 Indian Journal of Medical Research. Provided by ProQuest LLC. All rights Reserved.

By DAN SCANLAN

Bingo – that’s the action at the next River City Women’s Club meeting at 10:30 a.m. Wednesday, Sept. 17, at the Ramada Inn at 3130 Hartley Road.

The bingo event is one of the club’s annual major fundraisers, with proceeds donated to charity. It is open to friends and family as well as new and incoming members. Ticket prices are a $6 donation for a nine-game pack, and $1 for a grand-prize game sheet.

Reservations can be made through Friday, Sept. 12, at 262-8719.

The 23-year-old River City Women’s Club is also holding a membership drive: $10 for a Sept. 1 to Dec. 31 membership, and $20 for a full-year membership. Formed to provide social fellowship and promote philanthropy, the club meets at 10:30 a.m. the third Wednesday of each month for lunch and guest speakers as well as social outings, games and fundraising for local charities. The club also has smaller activity groups and a Social Committee, and regularly helps needy families with school supplies, holiday food baskets and clothing; donates food and other items to homeless shelters and food banks; and sends care packages to military troops.

For more information, call 268-9924.

JCA HOSTS CONVERSATIONS ABOUT COLLEGE ON SUNDAY

The Jewish Community Alliance presents Conversations About College at 1 p.m. Sunday at it campus at 8505 San Jose Blvd.

The afternoon workshop is set up to help high school students and their families make well-informed decisions about college, and includes discussions on college selection and admission, finance, college essays, students with special needs and other issues, ending with a 5:15 p.m. wrap-up.

The workshop will be led by Deborah Kaye, associate vice president for enrollment services at the University of North Florida. Students age 15-18 and their families may attend for $35 for JCA members and $55 for non-members.

For more information, call 730-2100, ext. 249.

The JCA is also offering art classes beginning in September in beginning and intermediate drawing, beginning and intermediate watercolors, reproduction, mixed media, pottery and creative painting and collage. The classes meet weekly for 10 weeks and supplies are not included. Classes are for adults and cost $170 for JCA members and $255 for non-members, while the pottery class is $180 for members and $270 for non-members.

For more information, call 730-2100, ext. 227.

YOGA ON THE RIVER

Yoga on the River will be held at 10 a.m. Sunday on the boardwalk at the city’s Walter Jones Historical Park at 11964 Mandarin Road. The yoga session is free and presented by trained yoga instructor Karen Roumillat.Participantsare asked to bring a blanket or pad to serve as a yoga mat. For more information, call 287-0452.

OPEN HOUSE AT BETH SHALOM

Mandarin’s Beth Shalom Congregation hosts an open house at 11 a.m. Sunday, Sept. 7, at 4072 Sunbeam Road, about half a mile east of San Jose Boulevard.

Visitors can meet Rabbi Martin I. Sandberg and members of the board, indulge in brunch and learn more about the congregation’s Sisterhood, Men’s Club, Friday Night Speakers and Adult Education programs, Rabbi’s Lunch-n-Learns and Hebrew School studies with bar and bat mitzvah lessons. The Beth Shalom Congregation, which celebrates its 36th anniversary this year, holds services at 7:30 p.m. Fridays and 9:30 a.m. Saturdays.

For more information, check www.bethshalomjax.org.

GRIEF COUNSELING SERVICES

Community Hospice of Northeast Florida is offering eight-week grief counseling services for those who have experienced the death of a loved one.

General group sessions are from 11 a.m.-12:30 p.m. Mondays, Sept. 29 through Nov. 17, at the McGraw Center for Caring of Community Hospice, 4715 Worrall Way (on the Mayo Clinic campus) off San Pablo Road. A series of sessions will also be held from 6:30-8 p.m. Thursdays, Oct. 2 through Nov. 20, at the Neviaser Educational Institute at Community Hospice at 4266 Sunbeam Road.

Participants must meet with a bereavement counselor before joining a group. Space is limited, so call Roxanne Clemens at 407- 6330 to schedule an appointment and reserve a place.

These bereavement services are free for community hospice families and $100 for others. Cost is adjustable based on ability to pay.

BONEFISH TO RAISE MONEY FOR MUSCULAR DYSTROPHY RESEARCH

Bonefish Grill is raising money for the Muscular Dystrophy Association in Jacksonville to fund research for Friedrich’s Ataxia, a rare form of the disease.

Customers can get donation cards at the restaurant at 10950 San Jose Blvd. MDA medical services are available at Nemours Children’s Clinic and Mayo Clinic. For more information, visit www.mda.org.Submit information for school and community events or awards in the 32217, 32223, 32256, 32257 and 32258 ZIP codes to Dan Scanlan at My Mandarin Sun, P.O. Box 1949, Jacksonville, FL 32231. Information can be faxed to (904) 359-4478 or e-mailed to dan.scanlan@jackson ville.com.

(c) 2008 Florida Times Union. Provided by ProQuest LLC. All rights Reserved.

Most Lush Garden Store

Winner: Stringer’s

For those with a green thumb, there’s no greater pleasure than walking among row upon row of plants and blooms; and for the brown thumb, there’s no greater comfort than knowing Stringer’s Garden Center is nearby.

“The employees, they all love to garden,” says Vador Vance, vice president of the company, when asked why the store won top honors as the most lush in town. “They’re always fluffing, creating and making it look like their own back yards.”

A combination of quality plants, employee attention and the right vendors have helped Stringer’s make the most of Memphis gardens for 65 years. The company has put the property of the Chickasaw Oaks location up for sale, and it is now an outlet center, while the Poplar Pointe store is now the focus of all that lushness.

“We just want people to succeed,” says Vance.

9495 Poplar, Germantown, 754-5700, 9 a.m.-6 p.m. Monday-Friday, 8 a.m.-6 p.m. Saturday, 1-5 p.m. Sunday. Stringer’s Discount Outlet, 2974 Poplar, 458-3109, 8 a.m.-6 p.m. Monday-Saturday; stringersgardencenters.com.

Finalist: Dan West Garden Center

The little shop along the railroad tracks at Poplar and Colonial is known for it’s year-round Christmas shop and huge selection of yard accessories. Gardeners looking for just the right plant, tree or shrub can get lost for hours wandering the grounds of the center’s newest location on Highway 64.

12061 Highway 64, Eads, Tenn., 867-2283; 4763 Poplar, 767-6743; 8 a.m.-5 p.m. Monday-Saturday, 11 a.m.-4:30 p.m. Sunday; danwestonline.com.

Finalist: Lowe’s Home Improvement

Mega-store, yes, but Lowe’s garden area is a cornucopia of outdoor wonders, from flowering plants to basic shrubs, yard dcor, ponds, borders, fencing and the all-important huge bags of fertilizer to keep everything lush.

Nine locations in the Memphis area; hours and directions are online at lowes.com.

Most Geared Bike Shop

Winner: Peddler Bike Shop

It is all about the bike when it comes to the readers’ choice of Most Geared Bike Shop in town, but don’t let the Lance Armstrong types who frequent Peddler intimidate you, says co-owner Hal Mabray.

“Being in an urban environment, we have a wide range of customers, from the typical college student to a family member to a serious rider. We say ‘hello’ to everyone that comes in the door even if we’re busy, and we give them our undivided attention.”

Mabray says the mechanics at all three locations – Germantown, Cordova and the University of Memphis area – have the education and training necessary to keep riders on the road, safely. “We know what we’re talking about when it comes to repairs,” says Mabray. “We’re not trying to up-sell something, just trying to make them safe.”

1140 Germantown Parkway, Cordova, 758-9770; 10 a.m.-7 p.m. Monday- Friday, 10 a.m.-5 p.m. Saturday, 1-5 p.m. Sunday. 575 S. Highland, Memphis, 327-4833; 9 a.m.-6 p.m Monday-Friday, 9 a.m.-5 p.m. Saturday, 1 p.m.-5 p.m. Sunday. 2095 Exeter Road, Germantown, 757- 8485; 10 a.m.-7 p.m. Monday-Friday, 10 a.m.-5 p.m. Saturday, 1 p.m.- 5 p.m. Sunday; peddlerbikeshop.com.

Finalist: Midtown Bike Company

Racer or cruiser? Either way – and even if you have no idea what that means – the folks at Midtown are all about fitting customers with the right bike for their lifestyle, from an old school Schwinn to a high-performance triathlon bike.

2091 Madison, 726-4511, 10 a.m.-6 p.m. Monday-Friday; 10 a.m.-5 p.m. Saturday; midtownbikeco.com/.

Finalist: Bikes Plus

The owners – a couple of retired Navy veterans – turned their love of biking into their after-the-service careers. The top-notch staff includes experts in BMX, cyclocross and mountain biking.

7780 Highway 64, Bartlett, 385-8788; 9445 Poplar, Germantown, 755- 7233. 10 a.m.-6:30 p.m. Monday-Friday, 10 a.m.-5 p.m. Saturday; bikesplus.net.

Most Cherished Gift Shop

Winner: Babcock Gifts

It’s noon on a Saturday, and a shopper rushes into Babcock’s, frantically searching for the perfect wedding gift. Oh, and the wedding’s at 12:30.

Panic at the shop? Hardly; the staff at the East Memphis shop have seen it – and can handle it – all.

“We have a very loyal clientele, an established, faithful clientele,” says manager Adrienne Oeding, who’s been on staff 22 of the 37 years Babcock has been in business. “But we have so many new customers who are just finding us, and realize our gifts, our gift wrapping, and our staff add up to the ultimate in service.”

Babcock offers familiar names in the china and crystal departments, from traditional china patterns from Haviland and Mottahedah to local and regional pottery from Agnes Stark and The Good Earth, among others.

4626 Poplar, 763-0700, 9 a.m.-5:30 p.m. Monday-Friday, 10 a.m.- 5:30 p.m. Saturday; babcockgifts.com.

Finalist: Gift & Art Shop

The 50-plus-year-old emporium of good taste offers great service and product lines, from the upscale, including Herend and Baccarat, to the casual, such as Jon Hart and Tervis Tumblers.

4704 Poplar, 682-1621, 9 a.m.-5 p.m., Monday-Saturday; giftandart.com.

Finalist: The Sanctuary for Mind, Body & Spirit

This little store in Bartlett offers alternative options for healing and holistic health. Visits from hypnotists and healers are the norm, while products tend toward essential oils, crystals and other natural elements .

6266 Stage Plaza, 377-6488; 11 a.m.-9 p.m. Monday, 11 a.m.-6 p.m. Tuesday-Thursday and 11 a.m.-7 p.m. Friday- Saturday; midsouthsanctuary.com/.

Most Browseable Bookstore

Winner: Davis-Kidd Booksellers

With more than 200,000 items in the store, Davis-Kidd is more than a place to lose oneself in the latest mystery or historic tome; it’s a destination for mothers with young children (for the reading groups), groupies hoping to meet their favorite author (for the book signings) and where more than a few business deals have been cut and charity auctions planned (in Bronte, the in-store bistro).

“It’s the atmosphere,” says general manager Eddie Burton, when asked what makes Davis-Kidd an enduring and endearing shop. “We try to make it customer-friendly and accommodating, and we listen to our customers. We will change our selection, or try new things because they ask for it.”

Burton, who has been with the store since it opened in 1995 and has been general manager for the last six years, says the mix of veteran staffers is what keeps the store both fresh and iconic; the average employee has been on staff nine years.

387 Perkins Ext., 683-9801; 8 a.m.-9 p.m. Monday-Thursday, 8 a.m.- 10 p.m. Friday-Saturday, 9 a.m.-8 p.m. Sunday; daviskidd.com.

Finalist: Barnes & Noble

The bookstore giant offers Starbucks, comfy chairs for reading and a giant children’s section; the Bookstar in Poplar Plaza, which is owned by Barnes & Noble, is located in a former movie theatre .

Four locations in the Memphis area; menu, hours and directions are online at bn.com.

Finalist: Borders

Although part of the Walden Books chain, Borders maintains a single Germantown location, including an extensive video collection of television series boxed sets, handcrafted cards, and a small caf.

6685 Poplar, 754-0770; 9 a.m.-10 p.m. Monday-Thursday, 9 a.m.-11 p.m. Friday-Saturday, 10 a.m.-9 p.m. Sunday; borders.com.

Most Outstanding Outdoor Store

Winner: Outdoors, Inc.

Never underestimate Memphians: That’s the mantra Joe Royer, co- owner of Outdoors, Inc., lives by.

“The Memphians I know are climbing the Matterhorn, running the Boston Marathon, kayaking confidently in the Mississippi River,” says Royer. “They have the skill and the fitness to do it.”

Royer, a member of the Yellowstone Foundation and a former chair of the Sierra Club who studied engineering at the University of Memphis, says he’s always been fascinated by and attracted to human- powered recreation and he loves sharing his knowledge with his customers.

“We test everything, like every kayak, every canoe we sell to the public, so we can talk about the way they paddle, the weight of the boat,” says Royer. “And the glass is more than half full in our area” he says of the natural resources for outdoor recreation. “Many people are getting strong and fit, and doing it here locally.”

Five locations in the Memphis area; locations, hours and directions are online at outdoorsinc.com.

Finalist: Bass Pro Shop

Need something in camouflage? Bass Pro Shop has it, from bed linens to coveralls, and all the things hunters, anglers and campers need.

6140 Macon, 213-5800, 9 a.m.-10 p.m. Monday-Saturday, 10 a.m.-7 p.m. Sunday; basspro.com.

Finalist: Sportsman’s Warehouse

You’ve gotta love a store that has a “gift bar” – a place to find all those little accessories for the sportsman, like night vision binoculars and that all-important filleting knife.

7951 Winchester, 753-5000; 9 a.m.-9 p.m. Monday-Saturday, 10 a.m.- 7 p.m. Sunday; 130 Marathon Way, Southaven, 662-349-5500; 10 a.m.-9 p.m. Monday-Friday, 9 a.m.-9 p.m. Saturday, 10 a.m. -6 p.m. Sunday; sportsmanswarehouse.com.

Most Fully Furnished Furniture Store

Winner: Ashley Furniture Homestore

What do women want? If a man could only answer that question, he could. … well, win the category of Most Fully Furnished Furniture Store.

According to Chad Spencer, owner and vice president of Ashley Furniture Homestore, knowing what women want is what makes the difference when it comes to helping them, as key decision makers, furnish their homes.

“Women love accessories, women love furniture,” says Spencer. “Typically, my customers are women 21 to 54 years old, and one thing she loves is for her home to look good.”

Spencer says that means offering not only a wide-range of furniture, from traditional to contemporary styles, but offering a full line of accessories to complete the look, from lighting and mirrors down to the comforter and sheet sets for bedrooms.

Four stores locations in the Memphis area; locations, hours and directions are online at ashleyfurniture.com.

Finalist: Samuels Furniture

It’s been a family affair since day one for the 92-year-old Memphis store, starting when carpenter Louis Samuels accepted an attic full of furniture in lieu of payment for his services. The store has staff designers and upscale lines, including Henredon, Bernhardt and Drexel Heritage.

5508 Poplar, 682-6681, 10 a.m.-5:30 p.m. Monday-Wednesday, Friday- Saturday, and until 8 p.m. Thursday. 1615 N. Germantown Parkway, 624- 7738; 10 a.m.-6 p.m. Tuesday, Wednesday, Friday, Saturday; 10 a.m.- 8 p.m. Monday and Thursday. 2449 Scaper Cove, 743-6707, 8:30 a.m.-5 p.m. Monday-Saturday; samuels-furniture.com.

Finalist: Great American Home Store

A relative new kid on the block, the store offers a huge showroom for browsing, two-day express delivery and dozens of brands to choose from, including Broyhill, Howard Miller and La-Z-Boy.

7171 Appling Farms, 260-5900; 5295 Pepper Chase Drive, Southaven, 662-996-1000; 10 a.m.-9 p.m. Monday-Saturday, 1 p.m.-6 p.m. Sunday; greatamericanhomestore.com.

Most Loaded Wine/Liquor Store

Winner: Buster’s Liquors & Wines

Choosing from 8,500 spirits and wines can be overwhelming, but Buster’s regulars know there’s always someone close at hand to guide them to the right bin or shelf.

“It never gets old,” says Josh Hammond, grandson of the founder, about serving customers. He notes the store’s regulars aren’t just from the surrounding area; many come from all across the city – and even farther away – to browse through the rows of wines from across the globe, the more than 100 tequila offerings and the vast selection of bourbon and whiskey.

“I had a customer come in the other day, who said ‘we’re from Cleveland,'” recalls Hammond. Turns out they weren’t from the Mississippi Cleveland, but the Ohio city of the same name. “They come to Memphis every two or three months, and they said they can’t wait to get in the store and see our selections.”

191 S. Highland, 458-0929, 8 a.m.-11 p.m., Monday-Saturday; bustersliquors.com.

Finalist: Kirby Wine & Liquors

The ultra-modern building on Kirby near Quince offers 8,000 square feet of fine wines and spirits. Tuesday is ladies’ day, where women are treated to a 10 percent discount on wine.

2865 Kirby Parkway, 756-1993; 9 a.m.-10 p.m., Monday-Wednesday, 9 a.m.-11 p.m. Thursday-Saturday; kirbywines.com.

Finalist: Joe’s Wine & Liquors

The dazzling, Sputnik-like neon sign might be the siren song luring customers to this Midtown must-stop, but once inside, it’s all about the pricing and front-of-store sale rack.

1681 Poplar, 725-4252, 8 a.m.-11 p.m Monday-Saturday.

Most Handy Hardware Store

Winner: Lowe’s Home Improvement

Although part of a huge national chain of hardware stores, Lowe’s district manager John Scherich says there’s plenty of local focus for every store in the Memphis area.

“One of the things we always focus is the store appearance, the store conditions and the appeal to local customers,” says Scherich. “We have the autonomy to make the right choices based on our customers at each location.”

That means wide-open aisles and friendly associates, says Scherich, along with getting most of the busywork – moving lumber and stocking shelves – out of the way before the store opens, so the customers never see the behind-the-scenes work.

Seven locations in the Memphis area; locations, hours and directions are online at lowes.com.

Finalist: Home Depot

The bright orange sign beckons the serious do-it-yourselfer, who rubs elbows with the construction pros in the unfussy, product- packed aisles.

Nine locations in the Memphis area; locations, hours and directions are online at homedepot.com.

Finalist: Germantown Hardware

The family-owned store caters to the community with personalized service, equipment rentals and small engine repair.

2083 S. Germantown Rd., 756-9522; 7 a.m.-8 p.m. Monday-Saturday, 10 a.m.-5 p.m. Sunday; germantownhardware.com.

Most Fabulous Flowers

Winner: Holliday Flowers Inc.

From what may be the city’s most grand floral arrangement – that huge affair in the fountain of the Peabody Hotel’s lobby bar – to a simple bouquet for a sweetheart, Holliday vice president Wayne Darling says they’ve got you covered.

“In the end, it’s the length we are willing to go to for our customers,” says Darling. “We’re willing to do anything.”

And he really means that. Darling himself regularly takes arrangements home overnight and pops them in the fridge so they’re fresh for an early delivery.

“If the Peabody wants an arrangement the size of a Volkswagen, we’re going to make it happen,” says Darling, who notes that Holliday’s floral workers spend four overnights a week creating arrangements for the hotel.

Four locations in the Memphis area; locations, hours and directions are online at hollidayflowers.com.

Finalist: Pugh’s

The store – and its cute little skunk mascot – has been around for 32 years, offering flowers flown in from around the world, as well as landscape and design services. Pugh’s is one of Teleflora’s top 100 providers – no easy feat for a little Memphis store.

1622 Union, 726-0738; 5645 Poplar, 682-2501; 2435 Whitten Road, 363-6744; 8 a.m. -5 p.m. Monday-Friday, 8 a.m.-2 p.m. Saturday, and Poplar store only, 10 a.m.-2 p.m. Sunday; pughs.com.

Finalist: Le Fleur

Tucked away in Laurelwood, the family-owned Le Fleur offers more than just masterful floral arrangements, with home dcor and accessories, garden accents and one of the city’s most creative Christmas shops.

4538 Poplar, 683-4313, 9 a.m.-5 p.m. Monday-Saturday; lefleur.org.

Most Uncommon Antiques

Winner: Palladio Antiques & Art

With dozens of dealers offering something for every taste, Palladio Antiques & Art is known as the go-to source for that finishing touch, eye-catching piece of art, or a little, must-have oddity.

“I think we have really encouraged our dealers to bring in the best quality and I think, by and large, the people who buy antiques are looking for quality things,” says Mindy Roberts, who has owned the store with husband Frank for 13 years. “And, I think our dealers have best quality in the city.”

Palladio serves up bistro-style meals in its lunch-only caf (open 11 a.m.-3 p.m. Monday-Saturday); the walls are decorated with works of local artists, which can be purchased .

In addition to Palladio, the Roberts own Market Central and Memphis Water Works, a trifecta of stores that adds up to quality and diversity, according to Mindy Roberts.

2169 Central, 276-3808, 10 a.m.-5 p.m. Monday-Saturday, thepalladiogroup.com.

Finalist: Sheffield Antiques Mall

Shopping Sheffield is a marathon, not a sprint: The massive antiques mall has a multitude of booths and takes hours to peruse, something dedicated antique lovers live for.

684 W. Poplar, Collierville; 853-7822; 10 a.m.-6 p.m. Monday- Saturday, noon-6 p.m. Sunday; sheffield-antiques.com .

Finalist: Toad Hall

The cheery, yellow building and cute-as-a-prince cartoon toad hypnotically lure customers inside, where two floors are filled with primitives, gifts, accessories and truly random finds, including single stained glass windows.

2129 Central, 726-0755, 10 a.m.-5 p.m. Monday-Saturday; toadhallmemphis.com.

Most Pedigreed Pet Goods

Winner: PETCO

Looking for a ball python to call your own? Or maybe a furry ferret is more your style. Either way, PETCO can help match potential owners with the perfect pet.

“We sell everything,” says Ronnie Dowty, general manager of the store at Highland and Poplar. “We probably have 50 different pets – and that’s not counting the fish.”

And then there’s the more than 6,000 items the store carries to help animal owners take care of their pets, from gerbil houses to dog carriers and all the food and toys imaginable; on-site grooming services are available as well.

There are pets PETCO doesn’t sell, namely cats and dogs. The company has an active adoption program, working with local shelters and pet adoption groups to help abandoned or unwanted dogs and cats find a good home.

Six locations in the Memphis area; locations, hours and directions are online at petco.com.

Finalist: PetsMart

Tails wag for the store’s doggie day camp and PetsHotel, which even has a real front desk for check-in and optional add-ons (think room service) that include special bones, playtime and other perks.

2805 Wolfcreek Parkway, 384-9823; 7941 Winchester, 756-2676; 9 a.m.-9 p.m. Monday-Saturday, 10 a.m.-6 p.m. Sunday; petsmart.com.

Finalist: Hollywood Pet Star

Smaller than the big chains, but fully stocked with food, grooming supplies and accessories for the pampered pet.

6765 Stage, 382-8002; 2648 Broad, 425-2474; 9 a.m.-9 p.m. Monday- Saturday, 10 a.m.-6 p.m. Sunday. Memphis-Shelby County Humane Society location, 935 Farm Road, 937-3900; 10 a.m.-6 p.m. Tuesday- Saturday, 1-5 p.m. Sunday.

Most Monster Motorcycle Shop

Winner: Bumpus Harley Davidson

In Memphis, it’s all about the pig, barbecue-wise, but to really go hog wild, our readers ride over to Bumpus Harley Davidson.

In this hog heaven with two wheels and no sauce in sight, hog equals American engineering at its most sleek and speedy -a Harley or a Buell.

From comfy touring bikes to a retro-style softail to the ultra- sporty and speedy Buells, Bumpus carries it all, plus accessories and gear so even novice riders can at least look the part.

2160 Whitten Road, 372-1121; 325 South Byhalia Road, Collierville, 316-1121; 9 a.m.-6 p.m. Monday-Friday, 9 a.m.-4 p.m. Saturday, 11 a.m.-3 p.m. Sunday; bumpusharleydavidson.com.

Finalist: Al’s Cycle Shop

The oldest Honda dealer in the Mid-South, Al’s sells motorcycles and so much more, including ATVs, Sea-Doos and utility vehicles.

3155 Summer, 324-3767, 9 a.m.-5:30 p.m. Monday-Friday, 9 a.m.-2 p.m. Saturday; alscycle.com

Finalist: Kawasaki of Memphis

Super-cool, super-sport bikes are the specialty at Kawasaki of Memphis, but the big selection also includes ATVs, utility vehicles and watercraft.

6412 Summer, 372-8210, 9 a.m.-6 p.m. Monday-Friday, 9 a.m.-5 p.m. Saturday.

Most Equipped Sporting Goods

Winner: Dick’s Sporting Goods

There’s a new sporting goods sheriff in town, and his name is Dick.

The store opened in November 2007 (there’s another opening in October on Hack’s Cross), and has established itself as the place to go for not just the goods, but the good advice, according to store manager Mark McCuiston.

“We have specialists in each department,” says McCuiston, noting that there are certified fitness trainers and bike technicians on staff, as well as an archery technician, a running specialist (a former U of M track athlete) and even a teaching PGA pro on staff in the golf department.

“Our customers feel comfortable talking with a teaching PGA professional about their games and their needs. Plus, we do a lot of service work; we fit clubs, clubs, lengthen them, bend them.”

2393 N. Germantown Pkwy, Cordova; 386-5302, 9 a.m.-9:30 p.m. Monday-Saturday, 10 a.m.-7 p.m. Sunday; dickssportinggoods.com.

Finalist: Sports Authority

Just about anything for any sport: Ski pants? Check. Tennis racquets? Check. Those all-important spandex shorts for whatever it is you might be doing? Yes, but remember to wear them under other shorts, please – unless you look like Lance Armstrong.

Four locations in the Memphis area; locations, hours and directions are online at sportsauthority.com.

Finalist: Bass Pro

The hunter’s paradise, with camo-colored everything, as well as all the fishing and camping supplies a Mid-South sportsman might need.

6140 Macon, 213-5800, 9 a.m.-10 p.m. Monday-Saturday, 10 a.m.-7 p.m. Sunday; basspro.com.

Most Grand Grocery Store

Winner: Kroger

It may be a national grocery giant, but the neighborhood feeling of most Kroger stores is what keeps customers loyal.

“Kroger’s overall philosophy of keeping our eye square on our consumer … the way we handle them, the products we carry, we do all of that with our customer in mind,” says the company’s Joe Bell.

Kroger’s Plus card – one of the first shopper ‘discount’ cards offered by a grocery chain – not only gives in-store discounts, but now can be loaded with coupons from the Kroger Web site, eliminating the need for some paper coupons.

With more than 25 stores scattered over the Memphis region, Kroger is one of the city’s largest employers, with 3,500 associates.

Twenty-five locations in the Memphis area; locations, hours and directions are online at kroger.com.

Finalist: Fresh Market

Gastronomic Nirvana for the gourmand – and the gourmand wannabe – Fresh Market offers the gifted chefs among us fresh (and sometimes difficult to find ) ingredients. Those of us who must fake culinary creativity can rely on the already-prepped foods in the chef’s case. … shhh.

835 S. White Station, 682-3434; 9375 Poplar, Germantown, 737- 5759; 9 a.m.-9 p.m. Monday-Saturday; 10 a.m.-8 p.m. Sunday; thefreshmarket.com.

Finalist: Schnucks

The full-service favorite is all over town with well-stocked and well-staffed meat, bakery and produce sections, plus a vast array of kosher delicacies.

Twenty-one locations in the Memphis area; locations, hours and directions are online at schnucks.com.

Most Appealing Produce

Winner: Easy Way Produce

Seventy-six years after Pate Carter, Sr., opened his first bright orange building on North Main Street – still in operation today – Easy Way Produce is still a family operation and a favorite of vegetable lovers across the Mid-South.

The Main Street location is the only full-service Easy Way, in fact, offering among other things a meat counter in addition to produce, but the other locations are primarily produce (they also carry some staples such as milk, cheese and bread), and offer fresh seasonal fruits and vegetables delivered daily, straight off local and regional farms. Depending on the season, look for a small selection of plants, and wreaths and garland during the Christmas season.

Oh, and why the color orange? It’s an easy way to attract attention, as well as supposedly being an appetite stimulant.

Nine locations in the Memphis area; locations, hours and directions are online at easywayproduce.com.

Finalist: Fresh Market

The produce selection at Fresh Market may be smaller than some stores, but it’s well-stocked and the freshness and quality are top- notch.

835 S. White Station, 682-3434; 9375 Poplar, Germantown, 737- 5759; 9 a.m.-9 p.m. Monday-Saturday; 10 a.m.-8 p.m. Sunday; thefreshmarket.com.

Finalist: Kroger

A wide range of produce for the picking, from organically-grown, ready-to-eat or just the most basic of fruits and vegetables.

Twenty-five locations in the Memphis area; locations, hours and directions are online at kroger.com

Most Service-Oriented Sales Staff

Winner: Sephora

They’re not just another pretty face, those sales folks at Sephora.

Cast members, as they are called, have taken over the top spot in customer service in this year’s Memphis Most survey – no mean feat, considering some of the ultra-service oriented staffs which have claimed the prize in years past.

Collierville store director Kelli Camurati says the stores – open just over a year in two locations – are simply completely different than anything Memphis has seen before; she calls it “AutoZone for women.”

“We put so much training into what we do, and the cast – myself included – is dedicated to giving good service,” says Camurati. “We don’t work on commission, and we don’t just give a spiel – we really care about and are invested in our clients, and everyone here gets that.”

Camurati notes that the tough economic times of late are even more reason to exceed customer expectations, and she says they’re fighting to keep their clients happy.

“I’ve never worked anywhere where even the vice presidents who visit the store come and help the clients. Without the client, we’re nothing.”

4630 Merchants Park Circle, Collierville, 861-3400; 2760 N. Germantown Parkway, 388-8466; 10 a.m.-9 p.m. Monday-Saturday, noon- 6 p.m. Sunday; sephora.com.

Finalist: Oak Hall

The venerable upscale clothing store, says owner Bill Levy, is dedicated to hiring the right people; as he puts it, “I’d rather make a friend than make a sale.”

6150 Poplar Avenue, 761-3580. Open 10 a.m.-6 p.m. Monday- Saturday and Thursday evenings until 7 p.m.; oakhall.com.

Finalist: James Davis

The “clothier for all occasions” offers anything – and any designer label – one could lust after, including Armani and Barry Bricken, made-to-measure custom shirts for gentlemen, and the designer jewelry boutique, Gregory’s.

400 Grove Park, 767-4640, open from 9:30 a.m. to 6 p.m. Monday- Saturday and Thursday evenings until 7 p.m.; jamesdavisstore.com.

Most Select Shopping Center/Mall

Winner: Wolfchase Galleria

Over a decade old, the mega-mall is still going strong, with 135 stores and almost 10 million shoppers a year.

“Store selection is certainly critical in that,” says general manager Keith Stewart of the continued success of the mall, which offers Macy’s, Dillard’s, JC Penney and Sears as its anchors. Other shopaholic faves include Hollister, Pottery Barn, Brooks Brothers and Banana Republic.

As Stewart points out, an open-air lifestyle center can’t compete with a roof when it comes to attracting shoppers. “They can come inside regardless of weather, and it is a nice, clean, and fun place to spend their time.”

2760 N. Germantown Parkway, 381-2769; open 10 a.m.-9 p.m. Monday- Saturday and Sunday noon-6 p.m.; simon.com/mall/ default.aspx?ID=840.

Finalist: Oak Court Mall

The easy-to-navigate, centrally located mall is a dream destination for the fast shopper, who can park, shop and grab a snack in record time.

530 Oak Court, 682-8928, 10 a.m.-9 p.m. Monday-Saturday, noon-6 p.m. Sunday; simon.com/mall/default.aspx?ID=197.

Finalist: The Avenue at Carriage Crossing

The Collierville lifestyle center is an appealing mix of retail favorites and restaurants, with public art, fountains and lush landscaping to soothe those who are just waiting for their loved ones to finish up, already!

4674 Merchants Park Circle, Collierville, 854-8240, 10 a.m.-9 p.m. Monday-Saturday, noon-6 p.m. Sunday; shoptheavenue.com.

Most Beautifying Beauty Salon

Winner: Gould’s

You look mah-ve-lous, darlings…. It’s what we all want to hear, and helping Mid-Southerners look spectacular is what Gould’s has been doing for over 75 years.

“We are only as good as our staff,” says Philip Gould, “and we provide our staff an outstanding continuing education program to learn the newest and latest trends. That keeps them motivated and excited – and they share that with their customers.”

With over 400 stylists and technicians on staff at the 14 area locations, Gould’s has become a Memphis institution; Philip Gould says a measure of their continued success is staying on top of the ever-changing salon industry.

“You can build beautiful salons and spas and provide the ambiance,” says Gould, “but if someone books an appointment, we’ve got to have qualified techs and stylists to perform the services, and we do – but we are very selective.”

Fourteen locations in the Memphis area; locations, hours and directions are online at gouldsalons.com.

Finalist: Master Design

The full-service salon offers the latest in color technology and cutting-edge style, and complements its hair services with a full range of wellness services including skin care and massage therapy.

5149 Wheelis Drive, 685-2351; open Monday by appointment only; 8:30 a.m.-7 p.m. Tuesday and Thursday, 8:30 a.m.-5 p.m. Wednesday and Friday, 8 a.m.-3 p.m. Saturday; masterdesign-spa.com.

Finalist: Capelli

The East Memphis “it” salon, the chairs at Capelli are arranged for easy, maximum chat and see-and-be-seen-ability; beauty services are offered along with some of the city’s best cut-and-color talent.

4615 Poplar, Suite 7, 767-5066, 8:30 a.m.-5:30 p.m. Tuesday- Wednesday, until 6 p.m. Thursday and 4 p.m. Friday and Saturday.

Most Fashion-Forward Clothes – Women

Winner: Macy’s

For a company that’s 150 years old, Macy’s is still a fashion- forward place for Mid-South women to shop, according to our readers.

“We certainly have apparel for all of customers,” says Macy’s Annette Askew. “From missy and contemporary clothes, to special sizes, to all of our designer and private labels, we have a great array of merchandise to choose from.”

The traditional department store features hot upscale brands including Hollywood favorite Ed Hardy, Lacoste, Michael Kors and local girl Dana Buchman, as well as shoes and bags from Coach and Kate Spade and more moderate lines, including Liz Claiborne and store brands INC and Charter Club.

Five locations in the Memphis area; locations, hours and directions are online at macys.com.

Finalist: Oak Hall

A must-shop for the must-have designers, Oak Hall features denim by David Kahn and AG, evening wear by Badgley Mischka and Vera Wang, and outwear from Burberry and Kooba.

6150 Poplar, 761-3580, 10 a.m.-6 p.m. Monday-Saturday and until 7 p.m. Thursday; oakhall.com.

Finalist: Joseph’s

The list of designers is an unpronounceable but loveable “Who’s Who” of clothing, accessories and shoes: Prada, Taryn Rose, Eskandar, Zac Posen and Vigal Azroul.

418 South Grove Park Road, 767-1609, 10 a.m. to 5:30 p.m. Monday- Saturday and until 7 p.m Thursday; josephstores.com.

Most Fashion-Forward Clothes – Men

Winner: Oak Hall

Can being fashion forward fuse with traditional Southern style, when it comes to men’s clothing?

Absolutely, says Bill Levy of the family run Oak Hall. Levy says the store is noted more for “updated traditional clothes and giving the most in customer service,” but also for helping the traditional business dresser find their right fit when donning a cutting-edge look.

“When a man is casual, that’s when he wants to dress a little more up to date,” says Levy. “We can dress someone from the boardroom to the playroom.” Designer labels at Oak Hall include Brioni and Ermenegildo Zegna, as well as Robert Graham and Tommy Bahama.

As for trends? Levy says denim is not dead by a long shot (he carries 15 brands) and seersucker is always fashionable in the South, but has enjoyed a more current look in terms of cut and fit.

6150 Poplar Avenue, 761-3580, 10 a.m.-6 p.m. Monday-Saturday and Thursday until 7 p.m.; oakhall.com.

Finalist: James Davis

The sharp-dressed man can find it all at James Davis , from furnishings (that’s shirts, ties and the like) to suits by Armani and outerwear by that favorite of the British country set, Barbour.

400 Grove Park, 767-4640,6 p.m. Monday-Saturday and until 7 p.m. Thursday; jamesdavisstore.com.

Finalist: Sammy’s Man of Fashion

The fashion-forward store just opened a second location in Southaven, spreading the trendy men’s wear featuring lines like Steve Harvey.

2703 S. Perkins, 366-0026; 5672 American Way, 523-2201; 6717 Airways Boulevard, Southaven, 662-536-0922; 10 a.m.-8 p.m. Monday- Thursday, 10 a.m.-9 p.m. Friday-Saturday, noon-6 p.m. Sunday.

Most Stylish Shoes – Women

Winner: Joseph’s

Not to go all ” Sex and the City” on you, but seriously, if Carrie and the girls lived in Memphis, they’d live at Joseph.

“We’ve been in the shoe business for 75 years,” says Barrie Wurtzburg, the lucky gal who gets to travel the world in search of the best flats, pumps, boots, slides, wedges, kitten heels and sandals.

“Our customers know our reputation and what we stand for,” says Wurtzburg, who notes that the most fabulous shoes in the world aren’t worth a darn if they don’t fit well. “And our people know how to fit women in shoes – that’s really important.”

Amen, sister.

418 South Grove Park Road, 767-1609, 10 a.m.-5:30 p.m. Monday- Saturday and until 7 p.m. on Thursday; josephstores.com.

Finalist: DSW

A veritable candy store for the well-heeled (as in stylish, not wealthy) bargain hunter, with aisles upon aisles of designer and name brand shoes for women – and you too, boys.

7712 Poplar, Germantown, 755-2204, 10 a.m.-9 p.m. Monday- Saturday, 11 a.m.-6 p.m. Sunday; dsw.com.

Finalist: Peria

Peria Gober put the fun into funky when it comes to her selection of shoes at the two-year-old Midtown boutique, with whimsical shoe, handbag and accessory collections sure to delight.

1680 Union, 274-8488, 10 a.m.-5:30 p.m Tuesday-Saturday and until 7 p.m. on Thursday; periashoes.com.

Most Treasured Jewelry Store

Winner: Mednikow

The oldest jeweler in the city is dear to the hearts of our readers – kind of like that special piece of jewelry that catches your eye as you walk by Mednikow’s glittering windows.

“About half the jewelry we sell, we make ourselves,” says Bob Mednikow, the fourth-generation owner who along with son Jay runs the business in what he calls “the old-fashioned, family way.”

“With age comes the certain continuity; what you’ve done in the past reflects on what you’ll do in the future,” says Mednikow, who notes that in addition to their own creations – many now designed by Jay – the store offers designers including David Yurman, Rolex and Patik Phillipe.

474 Perkins Ext., 767-2100, 10 a.m.- 5 p.m. Monday-Saturday, mednikow.com.

Finalist: Las Savell

The man with the poodles knows his jewels; the Midtown favorite (and featured in the movie “The Rainmaker”) has been selling fine jewelry since 1980.

61 S. McLean, 725-5200, 9 a.m.-5 p.m. Monday-Friday, 9 a.m.-4 p.m. on Saturday.

Finalist: Kay’s Jewelers

Every kiss begins with Kay, as the commercial says, and the selection at Kay ensures many kisses to come if you’re on the receiving end of a bauble; the brilliantly cut Leo diamond and watches from Movado and Bulova are a good place to start.

Four locations in the Memphis area; hours and directions are online at kay.com.

Most Charming Children’s Clothes

Winner: Little Lamb & Ivy

After 21 years in business, Arden and Jim Korn have closed their much-loved East Memphis store at 1227 Ridgeway, and are going out on a high note.

“We have had so many people express their sadness, and at the same time their joy for us,” says Jim Korn. The couple will be splitting their time between Memphis and South Carolina in order to spend a lot of time with their new granddaughter.

Korn says the weeks before closing were emotionally tough, as customers came in and shared their memories. “They bought their baptismal and christening outfits here, their first shoes for their children. They’ve given us so many wonderful years.”

Finalist: Chocolate Soup

Cute A-line dresses, appliqud with holiday and themed designs have long been a favorite of Memphis moms, as have the killer sales the yummy Germantown retailer holds with great frequency.

7730 Poplar, Suite 6, Germantown, 754-7157, 10 a.m.-8 p.m. Monday- Tuesday and Thursday-Friday, 10 a.m.-6 p.m. Wednesday and Saturday, 1-5 p.m. Sunday.

Finalist: The Children’s Place

Parents love it for the affordability factor and quality, while the under-teen set likes the fashionable (but age appropriate – don’t blow the secret) clothing selection.

Five locations in the Memphis area; locations, hours and directions are online at thechildrensplace.com.

Most Detailed Car Wash

Winner: Mr. Pride

Primp my ride, please! Between the weather, the dust, the mud and the pollen that settles on our precious automobiles any given day, there will always be a need for a car wash which goes the extra mile – and that’s just what Mr. Pride Car Wash is all about, according to its director of operations (who also cops to cleaning the toilets when the need arises).

“One thing that is important to know: In our society, service as a whole is going down,” says Kevin Nieminen, caught for an interview between toilet scrubbings. “We want to bring back the old-fashioned service that we used to get – that’s what we pride ourselves on.”

The company recently opened a lube center at its Poplar Avenue location; the four Mr. Pride locations employ about 80 people.

Nieminen says how the company treats its employees pays off for its customers. “We take care of our employees a lot better, with free insurance and higher pay than other jobs. We really try to focus in on that team-mate, so he’ll make our customer happy.”

Four locations in the Memphis area; locations, hours and directions are online at mrpride.com.

Finalist: Germantown Car Wash

It’s a bit tucked away, but Germantown Car Wash is worth hunting down if “Wash Me” can be read on your car.

7601 Poplar, Germantown, 753-9274, 8 a.m.-6 p.m. Monday- Saturday, 10 a.m.-5 p.m. on Sunday.

Finalist: Simoniz Car Wash

Express detailing – and one of those new-car-smell air fresheners – are just part of the package at Simoniz.

6800 Stage, Bartlett, 377-9693; 6040 Mount Moriah Rd. Ext., 375- 4848; 8 a.m.-6 p.m. Monday-Saturday, 10 a.m.-5 p.m. Sunday; simonizcarwash.net.

Most Conscientious Car-Repair Shop

Winner: Barton Car Care

It’s been 10 years since Ken Barton opened up his car repair shop, and he says it’s the loyal customers and his crackerjack technicians that keep the motor running at Barton Car Care.

“Its personal service – literally personal service,” says Barton. “We know them by name, they’re not just a number, they’re not just a car . We know their kids.”

Barton’s five techs work on 30 to 35 cars daily, doing general repairs on all makes and models; his customers come from all over the city.

“We have customers all the way from Collierville,” says Barton of his Midtown shop.

1553 Overton Park, 274-1881.

Finalist: Goodyear

Goodyear is more than just tires in Memphis; the company offers car care services as well as the right tires for your ride.

Multiple Goodyear tire center and auto service center locations in the Memphis area; locations, hours and directions are online at goodyear.com.

Finalist: Gateway Tire & Service Center

A one-stop shop for tires and auto services; Firestone and Bridgestone tires plus an array of car care services.

Six locations in the Memphis area; locations, hours and directions are online at gateway-tire.com.

Most Valued Bank

Winner: First Tennessee

When it comes to banking, some folks feel like it’s them against “The Man.”

But the man at our reader’s most valued bank – First Tennessee – says he and his 3,000 or so co-workers in the Memphis region are all about knowing their customers.

“It’s all about balance,” says David Popwell, president of the First Tennessee Bank of Memphis/Mid South market. “When you run a bank, you’re running it for four groups – your employees, your customers, your shareholders and the community. If you do a good job taking care of your employees, then your employees take care of your customers and so on; that’s a balanced formula for success.”

Popwell says First Tennessee’s employee retention rate is among the best in the industry, which is critical for the customer relationship; the bank is also big on giving employees autonomy to make decisions.

“They know how to do their job, know their authority and what decisions they can make,” says Popwell. “That’s a really big advantage.”

Fifty-eight locations in the Memphis area; locations, hours and directions are online at firsttennessee.com.

Finalist: Regions

The mega-bank – with 1,900 locations nationwide – still has that hometown feel from its old days as Union Planters; Morgan Keegan is a Regions partner, offering diverse financial services in concert with the bank itself.

Ninety-six locations in the Memphis area; locations, hours and directions are online at regions.com.

Finalist: Paragon

The average Paragon employee has 15 years in the banking business; the locally owned and operated bank has expanded to four locations since opening its doors in 2005.

Four locations in the Memphis area; locations hours and directions online at bankparagon.com.

Most Reliable Mobile Phone Service

Winner: AT&T

A 30-day bring-it-back policy , a $20-billion investment in nationwide network technology, and listening to their customers – that’s what sets AT&T Wireless apart when it comes to serving the Memphis area, according to Mike Bennett, executive director of consumer and government affairs for the company.

“We’ve rolled out the most consumer-friendly policies,” says Bennett, who points to an online coverage mapping tool, detailed cost analysis for new customers, and a pro-rated early termination fee and ability to change plans at any time without having to extend the contract.

“Here are the results of building the best network and doing all the things consumers wanted – we have the lowest complaints in the history of the company, and the cool thing i s Memphis and the Tennessee market have the lowest complaint rate in the entire company.”

We heard that with our bad ear.

Ten locations in the Memphis area; locations, hours and directions are online at wireless.att.com.

Finalist: Verizon

The V-Cast and other cool tools, including yummy Chocolate phones, are part of the offerings from Verizon. Can you hear me now?

Ten locations in the Memphis area; locations, hours and directions are online at verizonwireless.com.

Finalist: T-Mobile

The pink-hued T-Mobile has the Memphis metro area covered, with 40-plus locations in the area – and that figure includes stores like Target and Wal-Mart where you can buy pay-as-you-go phones.

Forty-one locations in the Memphis area, including inside some other retailers; locations, hours and directions are online at tmobile.com.

Most Fit Health Club

Winner: YMCA of Memphis & Mid-South

Developing the whole family – not just muscles – is what the YMCA is all about, and Keith Johnson, CEO of YMCA Memphis, says that philosophy is what is so appealing to so many Mid- Southerners.

“We try to focus not just on the individual coming in to lift weights or go to a class, but the whole family, to grow together and grow individually and develop,” says Johnson. “And people respond to that.”

Johnson notes that a big factor for YMCA members is that they are not intimidating to those who are just starting to work on a healthier lifestyle.

“Our goal is to make everyone feel comfy in the environment,” says Johnson. “My hope is that someone who is not fit would feel just as comfortable as the athlete.”

Eight locations in the Memphis area; locations, hours and directions are online at ymcamemphis.org.

Finalist: French Riviera Spa

Personal training, tanning, spin classes, even massage – the French Riviera Spas in the Memphis area offer a variety of services for today’s athletes.

Five locations in the Memphis area; locations, hours and directions are online at frenchrivieraspa.com.

Finalist: 24 Hour Fitness

Despite its name, the club is not open 24 hours, but in addition to the gym, yoga, tanning and a kids work-out club are all part of the package.

1285 Ridgeway Rd., 763-3265, 5 a.m.-11 p.m. Monday-Friday, 7 a.m.- 8 p.m. Saturday-Sunday; 24hourfitness.com.

Most Recommended Real Estate Agent

Winner: Lisa Cox, Coldwell Banker/John R. Thompson Co. Realtors

A bad real estate experience 13 years ago is what prompted agent Lisa Cox to get into the business.

“When I moved here, I had the worst agent in the world – and I knew I could do a better job,” says Cox. “I actually listen to my clients, and take care of them like they’re my mother or my children – I want the best for them.”

Cox has been the top agent for five years straight in her office, and is in the top 5 percent for Coldwell Banker agents in the nation.

6520 Stage Road, 872-4948; lisakcox.com.

Finalist: Jan Gordon, Crye-Leike

The East Memphis agent was the top vote getter in last year’s Memphis Most poll, and she continues to impress our readers with her service.

585 South Perkins, 766-9004; jangordon.crye-leike.com.

Finalist: Betty Carter, Crye-Leike

Carter’s a life member of the multimillionaire club, and offers 17 years of experience in the Memphis real estate market.

894 Germantown Parkway, Cordova, 756-8100; bettycarter.crye- leike.com.

Most Exemplary Employer

Winner: FedEx

The Memphis-based global distribution giant is the hometown favorite when it comes to being the best employer; 32,000 Memphis- based employees are what makes the company hum across every time zone.

“All of us take pride in the principles of our People First philosophy, which emphasizes the importance of treating each other with dignity, respect and fairness and of creating an environment that enables our employees to succeed,” says Judy Edge, corporate vice president, human resources for FedEx, in a statement.

But without the customer, Edge notes, the company could not exist; she says that earning the respect and confidence of those customers every day is critical. “It is this spirit of dedication to excellent service and the respect for each other that makes FedEx a great place to work.”

3610 Hacks Cross Rd., 434-8400; fedex.com.

Finalist: Paragon National Bank

The locally-owned bank offers a family-like atmosphere for employees, who average 15 years of experience in the business.

Four locations in the Memphis area; hours and directions online at bankparagon.com.

Finalist: Methodist Le Bonheur Healthcare

The 10,000-plus associates of Methodist, from Le Bonheur Children’s Hospital to each and every surgery and diagnostic center, know they’re part of the Mid-South’s healing and hope, and give their all to their employer and patients.

Twenty-three locations, including hospitals, surgery centers and diagnostic centers in the Mid-South; locations and more information online at methodisthealth.org.

Most Exceptional Hospital

Winner: Methodist Le Bonheur Healthcare

“Your readers are incredibly smart, intelligent people,” laughs Donna Abney, the executive vice president for Methodist Le Bonheur Health Care.

Kidding aside, Abney says the associates (employees) of the health care system – some 10,000 strong – are what makes Methodist exceptional.

“For us, it’s all of us holding hands and understanding our role as a health care ministry,” says Abney. “We’re taking care of each other’s moms and dads and neighbors and sisters – and that’s motivating to our associates. This award is going to resonate with them.”

Twenty-three locations, including hospitals, surgery centers and diagnostic centers in the Mid South; locations and more information online at methodisthealth.org.

Finalist: Baptist Memorial Health Care

It all started with one, 150-bed hospital; today Baptist is one of the Mid-South’s largest hospital systems.

Nineteen locations, including hospitals and minor medical centers, plus a variety of outpatient clinics and services in the three-state area; locations and information online at baptistonline.org.

Finalist: St. Jude Children’s Research Hospital

The hospital and research center that Danny Thomas built is forever in the hearts of Memphians; the huge complex near Downtown is fighting for children here and across the world every day.

262 Danny Thomas Place, 495-3300; stjude.org.

(c) 2008 Commercial Appeal, The. Provided by ProQuest LLC. All rights Reserved.

By DEBORAH LEGARE Staff Writer

For many teens, the path to their future isn’t as clear as they would like. However, Sarah Price, a soon-to-be 16-year-old, not only has her future planned but also has a fun detour scheduled along the way.

The detour is trying for the crown at the 2009 Miss Maryland Teen USA pageant.

“I heard that you didn’t need experience to win, so I decided I wanted to try,” Sarah said.

Being curious, she looked up the pageant, applied and was accepted.

“I saw how being a part of this contest could help others and that’s what I am all about,” she said.

She discovered through her research that many pageant winners speak on subjects about which they are passionate, such as environmental issues of the dangers of tanning.

While her interest in human science and her desire to become a registered nurse will allow her to help people in the future, she spends time helping those who can benefit from her attention now. Sarah volunteers at the American Society for the Prevention of Cruelty to Animals as much as she can.

With the support of her family and friends, the Glen Burnie High School junior will go on stage to compete during the weekend of Nov. 7 through 9 at the Bethesda North Marriott in Bethesda. The winner will advance to represent the state in the 2009 Miss Teen USA pageant. The pageant is still accepting applications until mid- September, so the number of contestants is still to be determined.

Although Sarah has never participated in a pageant before, she knows what competition is all about.

“I have competed with the Pom Squad three times and have done numerous field shows. It trains you to be in rhythm and consistent,” she said.

To compete for the crown, all contestants must be interviewed. They also are judged in a gown and swimsuit. The opening of the pageant includes a dance routine that Sarah is very confident in doing.

When the time came to raise the money for the pageant, her mother, Sandi Price of Glen Burnie, was right beside her daughter.

“My mom keeps the doors of opportunity open for me. I am very grateful for that,” Sarah said with pride in her voice.

Many local businesses have helped to raise the $995 needed to compete. Businesses like Cancun Cantina, JBA Mitsubishi and ZBest Limousines, as well as her doctors and councilman, Ed Middlebrooks, all took out their checkbooks to help this young newbie in the pageant arena, according to Ms. Price.

While dreaming of the crown, Sarah knows exactly what she wants for her life. She wants to help people.

Already in her third year at the Center of Applied Technology North training to be a medical assistant, she plans to one day be a registered nurse. She plans to study at Anne Arundel Community College, and another college yet to be determined, and hopes to work at the Maryland Shock Trauma Center in Baltimore.

“I have already talked to Shock Trauma nurses and know what I have to do to get there,” she said.

“She has a spirit that just wants to help,” her mother said.

Even when she was a little girl, she helped care for her mother when she was recovering from an illness.

Going for the crown can be a victory for many girls since there are five finalists and up to 15 semi-finalists. Each finalist will receive a trophy, cash scholarships as well as jewelry, clothes, photos, salon services and much more. Semi-finalists also will receive a trophy, salon services as well as scholarships. Scholarships awarded last year ranged from $250 to $1,500.

Everyone who tried to describe Sarah came to the same conclusion: She is outgoing, has a great attitude and is extremely funny.

“She is just naturally funny,” said longtime neighbor Tim Dash. “She will take this experience, win or lose, and grow from it.” {Corrections:} {Status:}

SARAH PRICE TO COMPETE FOR MARYLAND TEEN USA CROWN

(c) 2008 Maryland Gazette. Provided by ProQuest LLC. All rights Reserved.

NEW YORK, Aug. 25 /PRNewswire-USNewswire/ — ORBIS International’s flagship Flying Eye Hospital has arrived in Harbin, China with its global team of volunteer eye care specialists and global Alliance for Sight partner, Alcon, Inc. , the world’s leading eye care company. Invited by the Heilongjiang Provincial Government, Heilongjiang Provincial Health Bureau, and the Second Affiliated Hospital of Harbin Medical University, ORBIS is conducting an intensive two-week program (Aug. 25 – Sep. 5) focusing on training and equipping the next generation of Chinese eye care professionals and biomedical engineers. The ORBIS program in Harbin is being sponsored by Alcon.

At the request of the Second Affiliated Hospital of Harbin Medical University, the Flying Eye Hospital program will only train ophthalmic residency physicians, marking the first time in the plane’s history that it has been used as a venue for resident training. During the course of the program, the ORBIS medical team will transfer sight-saving skills to approximately 40 ophthalmology residents using hands-on surgical training, live surgical demonstrations, lectures and workshops. The program will concentrate on the treatment and management of pediatric strabismus, glaucoma and cataract – China’s leading cause of blindness. Residents will also benefit from clinics on retinal disease and neuro-ophthalmology and from wet lab and surgical simulator sessions.

“ORBIS’ approach is to tailor each of its programs to the educational needs of its hosts and the eye care needs of the local people,” said Dr. Hunter Cherwek, medical director, ORBIS International. “This residency- specific program is an exciting new venture that will allow ORBIS to train the next generation of sight-saving doctors and help China further grow its pool of human resources for fighting preventable blindness in the region.”

Fulfilling an Urgent Need

It is estimated that half of the medical equipment located throughout the world does not function properly, and the equipment in China is no exception. Compounding the problem is that few opportunities exist for biomedical engineers and technicians to pursue continuing education in ophthalmic equipment maintenance and repair. Most biomedical engineers must seek training in major cities like Beijing and Shanghai.

To this end, ORBIS and Alcon biomedical engineering staff will conduct a workshop to provide hands-on training to nine biomedical engineers and technicians in the management and maintenance of ophthalmic equipment. In the process, the Alcon biomedical technicians and workshop attendees will work together to repair many pieces of equipment critical to the delivery of proper eye care, such as microscopes, slit lamps, indirect ophthalmoscopes, phaco machines and ultrasound equipment.

“Having the knowledge and skill to maintain complex ophthalmic equipment is critical to the delivery of quality eye care, especially in underserved communities throughout the world,” said Michael Goh, general manager, Alcon China. “Through ORBIS’ skills-exchange program and partnerships with medical facilities worldwide, Alcon is proud to contribute our professional industry expertise to those on the front lines by helping train local biomedical engineers and supporting their critical role in the improvement of ophthalmic care.”

Blindness in China

China has a blind population estimated at 5 to 6 million, which accounts for 18 percent of the world’s blind. The major causes of blindness in China include cataract, childhood eye diseases, cornea diseases, glaucoma and diabetic retinopathy.

Of the roughly 24,000 eye doctors in China, 70 to 80 percent of them work in urban hospitals. Unfortunately, 70 to 80 percent of the country’s blind people live in rural areas. Coupled with resource constraints such as a lack of equipment, this disparity has resulted in people from remote rural areas having little or no access to quality eye care services.

ORBIS and Alcon – Leading the Way to a World Without Blindness

For more than 25 years, Alcon has supported ORBIS’ sight-saving programs and initiatives worldwide. In 2007, Alcon strengthened its commitment to ORBIS by renewing its global sponsor status for a further two-year period. This grant, of more than $2.7 million, provides cash and medical gifts-in- kind. It also increases Alcon’s support of training initiatives in developing countries through a combination of Flying Eye Hospital programs, hospital- based programs, fellowships and online Cyber-Sight telemedicine consultations.

Over the years, Alcon has donated state-of-the-art ophthalmic equipment, pharmaceuticals and supplies for the Flying Eye Hospital and its partner hospitals around the world, making it possible for ORBIS volunteer ophthalmologists to teach advanced surgical techniques to doctors in the developing world. Additionally the Alcon Volunteer Biomedical Corps, a dedicated group of Alcon biomedical technicians, participate in ORBIS training programs and share their skills with those in developing countries.

About Alcon, Inc.

Alcon, Inc. is the world’s leading eye care company, with sales of $5.6 billion in 2007. Alcon, which has been dedicated to the ophthalmic industry for more than 60 years, researches, develops, manufactures and markets pharmaceuticals, surgical equipment and devices, contact lens care solutions and other vision care products that treat diseases, disorders and other conditions of the eye. Alcon’s majority shareholder is Nestle, S.A., the world’s largest food company

About ORBIS International

ORBIS International is a nonprofit global development organization dedicated to saving sight worldwide. Since 1982, ORBIS programs have benefited people in 86 countries, enhancing the skills of more than 195,000 health care personnel and providing eye care treatment for more than 6.8 million people. To learn more about ORBIS, please visit http://www.orbis.org/.

ORBIS International

CONTACT: Brooke Johnson of ORBIS International, +1-646-361-0061,[email protected], or Hetao Yan of ORBIS China, +86-13608865921,[email protected]

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

By KATHLEEN SHATT for the Maryland Gazette

A quarter action will be held at 7 p.m. Thursday at the Ferndale Volunteer Fire Company hall, 4 S. Broadview Blvd., to benefit the Seleski family, who lost all of their belongings in a fire last month at the Ferndale home they were renting.

The doors will open at 6 p.m. for seating.

Admission is $12. Each ticket holder also will receive a $10 roll of quarters at the door.

Food items will be sold.

Prizes have been donated by businesses and members of the community and include gift baskets, jewelry, gift certificates and merchandise from Longaberger and Home Interiors.

Each participant will receive a bidding paddle with a number when they arrive. Participants can choose which prizes they want to bid on. After the bidding is closed, the auctioneer will then pull out winning numbers of the prizes from among those that paid their quarters to bid on the prizes.

Door prizes also will be awarded and there will be a 50-50 raffle. Each participant who takes a canned food donation to the fundraiser will receive a free raffle ticket.

For more information, call Kim Orzechowski at 410-859-1543 or e- mail [email protected].

Hymn singing

The Glen Burnie Church of Christ welcomes anyone who likes to sing hymns to its Wednesday evening singing practice.

The congregation will gather at 7:30 p.m. Wednesday at the church at 2 Eastern St. to practice singing new and old hymns.

The public is invited to attend the singing, which is free. No donations will be collected.

For more details, call 410-859-0511.

Garden club

The Ferndale Garden Club will host a potluck social at 6:30 p.m. Tuesday at the Ferndale Senior Center, 7205 Baltimore Annapolis Blvd.

The club’s program committee will unveil its plans for the upcoming year. Program books will be distributed to members.

New members are welcome to attend and learn more about the club. Membership dues cost $6.

For details, call president Kathy Shatt at 410-766-8547.

Weight loss seminar

The University of Maryland Center for Weight Management and Wellness will offer a free seminar on surgical weight loss from 6 to 8 p.m. Wednesday in the Courtney Conference Center, on the lower level of the Tate Cancer Center, 305 Hospital Drive.

Dr. Mark Kligman will be the speaker. Reservations are requested.

For more information, call 410-328-8940 or visit www.umm.edu/ weightloss.

Free massages

Certified massage therapist Bonnie Pavlak will offer free therapeutic massages at 9:30 a.m. Thursday at the Burwood Senior Nutrition program site, 6658 Shelly Road.

For details, call Latori Goldbourne at 410-222-6262.

Holy Trinity Seniors

The Holy Trinity Senior Citizens Club will meet at 1 p.m. Wednesday in the Holy Trinity Catholic Church hall, 7436 Baltimore Annapolis Blvd.

Naeemah Raqib from the University of Maryland Cooperative Extension Service will be the guest speaker.

For more information, call Marie Doyle at 410-766-3522 or the church at 410-766-5070.

Lions Club

The Glen Burnie Lions Club will meet at 7 p.m. Thursday at the Lutheran Church of Our Redeemer, 7606 Quarterfield Road.

Lions Club members raise funds for local charities and volunteer for community service projects. New members are welcome.

For more details, call 410-766-0859.

Roadrunners

The Ferndale Roadrunners will meet at 11 a.m. Thursday at the Ferndale Senior Center, 7205 Baltimore Annapolis Blvd.

For more information, call Melvia or Pete Scott at 410-761-0484.

Youth dance

The Ferndale Volunteer Fire Company will sponsor its monthly youth dance from 7 to 10 p.m. Friday at the fire hall, 4 S. Broadview Blvd.

The dance is for children ages 14 and younger. Admission is $5. Music will be provided by a disc jockey.

Parents must sign their children in and out of the dance. No child will be allowed to leave the hall unless their parent signs them out.

Refreshments will be sold.

For more information, call the fire hall at 410-766-2131.

Golf tournament

St. Paul’s Evangelical Lutheran Church will host its 11th annual golf tournament fundraiser on Sept. 18 at the Compass Pointe golf course in Pasadena.

Registration and breakfast will begin at 7:30 a.m., followed by a shotgun start at 8:30 a.m.

The cost is $125 and includes green fees, carts, contests, prizes, lunch, breakfast and beer and soda on the course. Tee sponsorships are available for $60.

An awards ceremony will immediately follow the luncheon.

Proceeds from the tournament will benefit the church’s office computers and automation fund, as well as missions. For more information, call the church at 410-766-2283 or Bill Critzman at 410- 991-5313.

Ravens Roost 18

Ravens Roost 18 will meet at 7 p.m. Monday at the Ferndale Volunteer Fire Company hall, 4 S. Broadview Blvd.

For more information, call Elaine Happel at 410-761-7790 or visit www.ravensroost18.org.

Bingo

The Ferndale Community Club, 15 N. Fifth Ave., offers bingo games on Tuesday afternoons and Thursday evenings.

The doors will open at noon for the Tuesday Sunshine bingo. The first games will begin at 1 p.m. Twenty-three bingo games will be offered. Cash prizes of $15 for regular games and $25 for special games will be offered.

The doors open at 6 p.m. for the Thursday evening bingo. Early bird games will begin at 7 p.m. Thirty-six games will be played. Cash prizes of $30 for regular games and $60 for special games will be offered. In addition, there is also a $500 jackpot game.

Food and refreshments will be sold.

The hall can also be rented for private parties, showers, wedding receptions and other special occasions.

For more information, call the club at 410-766-9727.

Marine Corps League

The Anne Arundel County Detachment 1049 of the Marine Corps League will meet at 7 p.m. Monday at the Veterans of Foreign Wars Post 160, 2597 Dorsey Road.

New members are welcome. Membership is open to all former Marines.

For more information, call Peter Pervi at 410-987-3811, e-mail [email protected] or visit www.mclaacdet1049.org.

Pascal Senior Center

The Severna Park Bums will present a Labor Day show at 12:30 p.m. Thursday at the Pascal Senior Center, 125 Dorsey Road.

The variety show will feature musicians and comics.

Admission is free and open to the public.

Other events taking place from the center:

The Pascal Book Club will meet at 10 a.m. Friday. Members will be discussing their current reads. New members are welcome.

The Stan Grant duo will perform at 12:30 p.m. Friday for listening and dancing.

For more information, call the center at 410-222-6680.

Clubs and organizations in the 21061 ZIP code area can call Maryland Gazette correspondent Kathleen Shatt at 410-766-8547 for publication of their news. They can also fax information to her at 410-766-1520 or send e-mail to [email protected].

(c) 2008 Maryland Gazette. Provided by ProQuest LLC. All rights Reserved.

By HELEN RAE

A ROYAL stamp of approval was given to health experts in the North East in honour of their devotion to patients.

Kathryn Kain, team leader for Sexual Health Advisers, and Ann Jones, a community matron, were named Queen’s Nurses, by the Queen’s Nursing Institute (QNI).

The pair, from Newcastle Primary Care Trust, were just two of nine nurses nationwide to receive the title during the first round of 2008, obtaining their award at a ceremony in London.

Kathryn works in the Genito-Urinary Medicine department at Newcastle General Hospital. She completed a rigorous application process for the award and feedback was also provided by her peers and patients.

She said: “I am delighted to have been awarded the title of Queen’s Nurse.

“I will continue working towards encouraging excellence in practice and innovation and improvements in community health care.”

In January last year, after a lapse of 40 years, the Queen’s Nursing Institute announced the reinstatement of the title of Queen’s Nurse.

Queen’s Nurse is awarded to individual nurses who have demonstrated a high level of commitment to patient-centred values and continually improving practice.

Ann, of Ponteland, Northumberland, was given the accolade for her work with Chronic Obstructive Pulmonary Disease (COPD).

In January 2006, the 54-year-old set up a community chest service, providing skilled help and support for those living with the condition which affects the airways.

Thanks to her scheme, those living with COPD can now have oxygen administered to them in their home and they can also take part in a rehabilitation scheme.

Ann, who has worked in the health service for 38 years, said: “I feel very honoured to be recognised for the work I do in the community.

“As there are not many people given the Queen’s Nurse award I am absolutely delighted to receive it.

“It’s really important nurses are recognised and appreciated for the work they do and I would recommend others to apply for the award.

“I always wanted to work in the community. I enjoy the job I do and it is lovely to be honoured in this way.

“This award recognises the expertise of nurses and it also acknowledges the level of support we give to people in the community.”

QNI director Rosemary Cook CBE said: “Congratulations are due to Kathryn and Ann for their success.

“Community nurses operate in an ever more challenging world and our role is to support them as effectively as we can.

“The Queen’s Nurse title is a key part of this and we would encourage other community nurses to apply.”

North of Tyne primary care organisations’ executive director of nursing, Lyn Dixon, said she was delighted the pair have been recognised for their hard work and commitment.

She added: “They both deserve the title as they continually deliver the very best nursing care and both work with such commitment and enthusiasm.

“The award also recognises their commitment to their patients.”

Last year, nurse Janice Lee, who worked for the North Tyneside Primary Care Trust, and health visitor Sue Spencer, from the Northumberland Care Trust, were named as Queen’s Nurses.

The pair were among the first NHS workers to receive the award.

Janice who worked in stoma care for 14 years, was honoured for helping patients cope with bowel or bladder surgery.

Sue, who had 20 years’ experience as a health visitor, was given the accolade for her expertise on postnatal depression.

(c) 2008 Evening Chronicle – Newcastle-upon-Tyne. Provided by ProQuest LLC. All rights Reserved.

Cytokinetics, Incorporated (NASDAQ: CYTK) announced today that additional interim results from an ongoing Phase IIa clinical trial of CK-1827452 are scheduled to be presented as a poster presentation at the European Society of Cardiology (ESC) Congress 2008, to be held August 30-September 3, 2008 at the Messe Muenchen GmbH in Munich, Germany. The trial is evaluating an intravenous formulation of CK-1827452, a novel cardiac myosin activator being developed for the potential treatment of patients with either acutely decompensated or chronic heart failure in stable heart failure patients.

In June, as part of the Late Breaking Trials Session at the 2008 Heart Failure Congress of the ESC in Milan, Italy, Cytokinetics announced results from an interim analysis of the first 22 patients in an ongoing Phase IIa clinical trial evaluating CK-1827452 administered intravenously to patients with stable heart failure. The safety data from this analysis suggest that CK-1827452 was well tolerated with no serious adverse events reported in patients exposed to the intended range of doses and plasma concentrations. A pharmacodynamic-pharmacokinetic analysis of data from these patients showed that when compared to placebo, CK-1827452 produced statistically significant and clinically relevant increases in Doppler-derived stroke volume and fractional shortening as a consequence of statistically significant prolongations of systolic ejection time. At the upcoming ESC Congress, Cytokinetics plans to present additional data from the first 22 patients who completed treatment in the ongoing Phase IIa clinical trial of CK-1827452.

Poster Presentation at ESC

Abstract #P1950: “First Clinical Trial of the Selective Cardiac Myosin Activator, CK-1827452, in Heart Failure: Effect of Dose and Plasma Concentration on Systolic Function” (Poster Presentation on Monday, September 1, 2008, during the Poster Session 3: Perspectives in Heart Failure Treatment, 8:30 am – 12:30 pm Munich Time). The poster will be found in Zone B4 of the poster session and presented by John Cleland, MD, FACC, FRCP, FESC, Professor of Cardiology, Castle Hill Hospital, University of Hull, United Kingdom.

About Cytokinetics

Cytokinetics is a biopharmaceutical company focused on the discovery, development and commercialization of novel small molecule drugs that may address areas of significant unmet clinical needs. Cytokinetics’ cardiovascular disease program is focused to cardiac myosin, a motor protein essential to cardiac muscle contraction. Cytokinetics’ lead compound from this program, CK-1827452, a novel small molecule cardiac myosin activator, entered Phase II clinical trials for the treatment of heart failure in 2007. Under a strategic alliance established in 2006, Cytokinetics and Amgen Inc. are performing joint research focused on identifying and characterizing activators of cardiac myosin as back-up and follow-on potential drug candidates to CK-1827452. Amgen has obtained an option for an exclusive license to develop and commercialize CK-1827452, subject to Cytokinetics’ development and commercial participation rights. Cytokinetics’ cancer program is focused on mitotic kinesins, a family of motor proteins essential to cell division. Under a strategic alliance established in 2001, Cytokinetics and GlaxoSmithKline (GSK) are conducting research and development activities focused on the potential treatment of cancer. Cytokinetics is developing two novel drug candidates that have arisen from this program, ispinesib and SB-743921, each a novel inhibitor of kinesin spindle protein (KSP), a mitotic kinesin. Cytokinetics is sponsoring a Phase I/II clinical trial of ispinesib as monotherapy as a first-line treatment in chemotherapy-naive patients with locally advanced or metastatic breast cancer. In addition, Cytokinetics is conducting a Phase I/II trial of SB-743921 in patients with non-Hodgkin and Hodgkin lymphomas. GSK has obtained an option for the joint development and commercialization of ispinesib and SB-743921. Cytokinetics and GSK are conducting collaborative research activities directed to the mitotic kinesin centromere-associated protein E (CENP-E). GSK-923295, a CENP-E inhibitor, is being developed under the strategic alliance by GSK; GSK began a Phase I clinical trial with GSK-923295 in 2007. In April 2008, Cytokinetics announced the selection of a potential drug candidate directed towards skeletal muscle contractility which may be developed as a potential treatment for skeletal muscle weakness associated with neuromuscular diseases or other conditions. All of these drug candidates and potential drug candidates have arisen from Cytokinetics’ research activities and are directed towards the cytoskeleton. The cytoskeleton is a complex biological infrastructure that plays a fundamental role within every human cell. Additional information about Cytokinetics can be obtained at www.cytokinetics.com.

This press release contains forward-looking statements for purposes of the Private Securities Litigation Reform Act of 1995 (the “Act”). Cytokinetics disclaims any intent or obligation to update these forward-looking statements, and claims the protection of the Safe Harbor for forward-looking statements contained in the Act. Examples of such statements include, but are not limited to, statements relating to Cytokinetics’ research and development programs, including planned presentations relating to clinical trial results, and the potential benefits of CK-1827452 and Cytokinetics’ other drug candidates and potential drug candidates. Such statements are based on management’s current expectations, but actual results may differ materially due to various risks and uncertainties, including, but not limited to, potential difficulties or delays in the development, testing, regulatory approval or production of CK-1827452 or Cytokinetics’ other drug candidates that could slow or prevent clinical development, product approval, including risks that current and past results of clinical trials or preclinical studies may not be indicative of future clinical trials results, patient enrollment for clinical trials may be difficult or delayed, Cytokinetics’ drug candidates may have adverse side effects or inadequate therapeutic efficacy, the U.S. Food and Drug Administration or foreign regulatory agencies may delay or limit Cytokinetics’ or its partners’ ability to conduct clinical trials, and Cytokinetics may be unable to obtain or maintain patent or trade secret protection for its intellectual property; GSK may decide to postpone or discontinue development activities for GSK-923295, Cytokinetics may incur unanticipated research and development and other costs or be unable to obtain additional financing necessary to conduct development of its products, standards of care may change, others may introduce products or alternative therapies for the treatment of indications Cytokinetics’ drug candidates and potential drug candidates may target, and risks and uncertainties relating to the timing and receipt of payments from our partners, including milestones and royalties on future potential product sales under Cytokinetics’ collaboration agreements with such partners. For further information regarding these and other risks related to Cytokinetics’ business, investors should consult Cytokinetics’ filings with the Securities and Exchange Commission.

 Contacts: Scott R. Jordan (Media) Director, Corporate Development (650) 624-3000  Christopher S. Keenan (Investors) Director, Investor Relations (650) 624-3000  

SOURCE: Cytokinetics, Inc.

HOUSTON, Aug. 25, 2008 (GLOBE NEWSWIRE) — Internationally recognized Greggy Girl(r) children’s wear label is taking center stage this season with marketing efforts unprecedented in the history of the label. Greggy Girl officially kicks off the Spring 2009 collection at MAGIC Marketplace, August 25-27, 2008, and a kick off it will be.

From the time of check-in at the Las Vegas Hilton(r), buyers will see the face of the Greggy Girl(r) model on every key card distributed to each Hilton(r) guest. The theme for Spring 2009 is appropriately named “Soak up the Fun.” The Greggy Girl booth located at K73000 will don a tropical beach getaway theme with the likes of miniature lounge chairs, a tiki bar and beach umbrellas. A vision any posh tot would love. On display will be the Spring/Summer 2009 Greggy Girl(r) collection that is fresh, tropical and vacation inspired, even lending to a touch of retro maritime.

The fun doesn’t stop there. The Greggy Girl staff will be on hand to personally work with new and old customers alike and only the most apropos swag for the season is in order as buyers exit the Greggy Girl booth. Sunglasses, lip balm and beach balls are just some of the goodies that buyers get to take home this season.

Greggy Girl(r) spring styles have been chosen by a juried committee to hit the catwalk for the MAGIC fashion show. The next Greggy Girl(r) tropical event will lead us to the Bahamas suite at the Las Vegas Hilton(r) from 7 to 9 p.m., Tuesday, August 26, where the Greggy Girl model, Arielle, a celebrity in her own right, will be the lead model showcasing the collection’s best looks of the season. Additionally, guests will dine on summer refreshments and enjoy the view of Las Vegas from the 29th floor. (Editor’s Note: This is an “invitation only” event, open to the press. Press attendees will be asked to provide credentials upon entrance.)

“While in June, the Greggy Girl(r) label was acquired by JMFA-Greggy Girl, Inc., our focus has remained the same since the beginning,” says Charlene May, Greggy Girl president and creative director. “It’s not about getting as many new customers as we can, it’s about servicing the great customers we have, and partnering with new and old alike to build a successful solid relationship. We are here to help the stores meet their profit goals, and today’s economy calls for creative thinking.”

“We are without a doubt the team for the job. We have an excellent group of analysts, marketing gurus and designers to work one on one with volume customers interested in taking their business to the next level. This is the time to strategize. From consulting to design, we will build a program to help businesses march with the parade,” May concluded.

Look for articles in Hudson’s Childrenswear Review, Kidsworld, and the Atlanta Apparel Guide in August 2008 showcasing interviews with Charlene May as she gives an inside look into the Greggy Girl culture as the team walks hand in hand with buyers proceeding down the road to something great!

About MAGIC

The MAGIC Marketplace is the preeminent trade event in the international fashion industry, hosting global buyers and sellers of men’s, women’s and children’s apparel, footwear, accessories and sourcing resources. As an incubator of fashion, MAGIC is where new trends surface and develop into what will be seen on the consumer. The show’s goal is to connect and inspire the fashion community, fuse diverse trends, while offering unbeatable service to its customers.

About Greggy Girl(r)

Tucked in the half moon curve of the lovely Texas shoreline overlooking Galveston Bay is the home of JMFA-Greggy Girl, Inc. The Greggy Girl(r) label was founded in 1999 by Creative Director, Charlene May, whose design experience includes handbags, jewelry, clothing, and interior design. Charlene’s designs focus on emerging trends in the fashion and entertainment industry. Tapping into looks that define a girl’s personality is one of the reasons the Greggy Girl(r) line was chosen by About.com as The Number One Line Every Cool Mom Should Know. The Greggy Girl(r) label is also known as the designer label of choice by some of the most popular child and young adult stars in Hollywood and is frequently called upon by television shows for wardrobe assistance. In 2007, the Greggy Girl(r) label was honored to be one of only three children’s brands nominated for a 2007 Earnie Award in Girls’ Sportswear 4-6X. The Earnie Award is an Earnshaw’s annual event honoring design excellence in children’s wear. The company maintains corporate showrooms in Houston, Dallas, Atlanta, and New York City. For more information on the Greggy Girl(r) label and its unique culture, please visit www.greggygirl.com.

“Every girl has a story, it’s not how she tells it, it’s how she wears it.”(tm)

Greggy Girl(r) is a registered trademark of JMFA-Greggy Girl, Inc.

This news release was distributed by GlobeNewswire, www.globenewswire.com

 CONTACT: Greggy Girl(r)          Media Inquiries          Charlene May          888-4-GREGGY          [email protected]                    Hagen and Partners          Media Inquiries          Shelley Bartkoski          913-642-3715          [email protected] 

Health Management Associates, Inc. (NYSE:HMA) announced today that Vicki Romero Briggs, FACHE, has joined HMA as Senior Vice President and Division CEO, responsible for leading HMA’s North and South Carolina hospitals and further enhancing the partnership in those hospitals between HMA and Winston Salem-based Novant Health.

Ms. Briggs has 27 years of hospital administration experience. She served most recently as the CEO of Birmingham, Alabama-based Affinity Health System, LLC, a joint venture partnership between Baptist Health System and Triad Hospitals, Inc. (now Community Health Systems, Inc. (NYSE:CYH)) which operates, among other things, Trinity Medical Center (formerly Montclair Baptist), a 560-bed tertiary medical center with 1,800 employees and a medical staff of 650 physicians. Ms. Brigg’s has previously served in other CEO roles with Triad and HCA, including President of HCA’s Baton Rouge, Louisiana, market.

“With a lifetime of healthcare experience, Vicki has demonstrated excellent leadership skills and generated a proven record of directing multifaceted, collaborative, quality-focused hospital operations,” said Kelly Curry, HMA’s Chief Operating Officer. “Vicki’s experience and expertise in leading successful whole-hospital joint ventures makes her a perfect fit to augment our existing partnership with Novant Health, and we are very pleased she has chosen to join HMA.”

HMA’s mission is the delivery of compassionate and high quality health care services that improve the quality of life for its patients, physicians, and the communities it serves. HMA owns and operates 57 hospitals, with approximately 8,100 licensed beds, in non-urban communities located throughout the United States. All references to “HMA” or the “Company” used in this release refer to Health Management Associates, Inc. or its affiliates.

Certain statements contained in this release, including, without limitation, statements containing the words “believes,””anticipates,””intends,””expects,””optimistic,” and words of similar import, constitute “forward-looking statements” within the meaning of the Private Securities Litigation Reform Act of 1995. These statements may include projections of revenue, income or loss, capital expenditures, debt structure, bad debt expense, capital structure, or other financial items, statements regarding the plans and objectives of management for future operations, statements of future economic performance, statements of the assumptions underlying or relating to any of the foregoing statements, and other statements which are other than statements of historical fact.

Statements made throughout this release are based on current estimates of future events, and HMA has no obligation to update or correct these estimates. Readers are cautioned that any such forward-looking statements are not guarantees of future performance and involve risks and uncertainties, and that actual results may differ materially as a result of these various factors.

NASHVILLE, Tenn., Aug. 25 /PRNewswire/ — HCA marked its 40th anniversary during a special program for employees today at the company’s corporate office.

The event featured HCA Co-Founder and Chairman Emeritus, Dr. Thomas Frist, Jr. and HCA Chairman and CEO, Jack O. Bovender, Jr., who spoke about HCA’s founding, mission and tradition of caring for patients, employees and the surrounding communities. The “Our History of Caring” program was a prelude to HCA’s annual Caring for the Community employee giving campaign, which begins this week.

“When we started HCA 40 years ago, we set out to provide communities in the Sun Belt with access to better quality healthcare,” said Frist. “My father, Jack Massey, Henry Hooker and I could have never conceived that HCA would grow into a company whose caregivers perform about 5% of many healthcare procedures in the U.S. and that Nashville would become a healthcare hub. I’m so proud of the impact our caregivers and employees have had over all these years as we’ve focused on treating our patients.”

A long-time cornerstone of Nashville’s healthcare industry, HCA was founded in 1968 by Frist, his father Dr. Thomas Frist, Sr., local businessman Henry Hooker and entrepreneur Jack Massey when Park View Hospital incorporated in May and became Hospital Corporation of America (HCA) in August of that year.

“I’ve spent almost my entire career with HCA because the principles Tommy, Dr. Frist. Sr. and our other founders believed in — putting patients first and treating people with dignity — are deeply ingrained in the bedrock of our company’s culture,” said Bovender. “It is because our employees and caregivers live these values everyday that HCA has prospered for 40 years.”

At its founding, HCA was one of the nation’s first hospital companies. HCA worked closely with local physicians and used innovative business practices and private capital to improve quality and efficiency. The company grew rapidly in its early years, focusing on a core group of market-leading hospitals using its financial resources, management capability and clinical expertise.

Today, HCA is a leading provider of healthcare services, with locally-managed facilities that include approximately 169 hospitals and approximately 113 freestanding surgery centers in 20 states and London, England. HCA affiliates employ approximately 180,000 people. The company has developed industry-leading patient safety initiatives to prevent healthcare-associated infections like MRSA and bar-code systems to help prevent medication errors.

The company has produced multiple generations of executives who have gone on to start or lead other healthcare companies in Nashville. Over the past several decades, three new health care industry segments were founded or fostered in Nashville — hospital management, freestanding outpatient surgery centers, and physician practice management groups. Today the Middle Tennessee area is home to nearly 300 healthcare companies operating on a multi-state, national, or international basis.

According to an economic study by the Nashville Health Care Council, Nashville’s healthcare industry has a total economic impact of $18.3 billion in the Nashville region. Additionally, it is the area’s largest non-governmental employer, with 95,000 people directly employed in the industry, and it accounts for more than 154,000 jobs related to healthcare.

All references to “Company” and “HCA” as used throughout this document refer to HCA Inc. and its affiliates.

HCA

CONTACT: Investors, Mark Kimbrough, +1-615-344-2688; or Media, EdFishbough, +1-615-344-2810, both for HCA

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

By Ask Dr. Ramo BARRY RAMO For the Journal

Q: I have been drinking energy drinks and have an energy bar before I exercise. What do you think of them? I think they make me stronger when I work out.

A: If they make you feel stronger, then they work for you even if they are a placebo. The idea that you can drink an energy drink or eat a bar right before you exercise and it is going to boost your exercise tolerance isn’t supported by science unless you are engaged in prolonged exercise.

They do pack a lot of calories in a small package so if you’re hiking or biking and can’t eat, they are fine. If you are on a diet and you are exercising for less than 90 minutes, they are empty and sugary calories that will keep you from losing weight.

The first of such concoctions were Power Bars and Gatorade, which were developed to give athletes easily digestible calories to reduce fatigue during prolonged exercise. Gatorade also has some potassium, sodium and magnesium. Some do contain caffeine and that is a bonus if you tend to fall asleep during a boring exercise. Caffeine makes those drinks unsuitable for kids, so read the labels and you will discover that there are ingredients in there you don’t really want in your body.

The allure of both the drinks and the bars has been too seductive for the average American to resist. Instead of eating breakfast, it’s a power bar. The sugary “power boosters” are useful for marathoners to soften the blow when they “hit the wall” and run out of glucose. That occurs at about 20 miles. Most power drinkers or snackers aren’t going to hit any walls.

You can build your sugar stores with a bagel and cream cheese before the race. Of course you need hydration but water works just fine. Some drinks contain vitamins and electrolytes and they won’t hurt you.

So my view, unless you’re out there for more than an hour or so, you won’t get much more than a lot of empty calories.

The additional downside is that when you drink sugary energy drinks your brain doesn’t process the information the same way it does if you have a bagel or a steak. So despite the fact that some energy drinks have fewer calories per ounce, you tend to drink a lot more and end up with the same or greater number of calories.

My advice is that the energy bar or drink won’t hurt the average weekend athlete but they won’t offer you a boost of energy. You just can’t pack all those vitamins, minerals and antioxidants into a bar to replace what you get from food.

Q: My 16-year-old daughter wants to start taking birth control pills. I am confused about the health benefits and the dangers because every study seems to show something different. What is the current thinking about the safety of birth control pills?

A: Medical research supports the idea that some cancers depend on naturally occurring sex hormones for their development, that there is a possible link between those hormones and the development of certain cancers.

An analysis of studies looking at what factors contribute to the development of breast cancer concluded that oral contraceptives produce a small increase in the risk for breast cancer. The younger a woman started taking them, the greater the risk. Ten or more years after women stopped taking birth control pills, their risk returns to the level of someone who had never taken them. Also, cancers that the women taking birth control pills developed were less aggressive than in women who had never taken the pill.

For a number of years researchers have known that the risk for ovarian and endometrial cancer is reduced when women take oral contraceptives. A recent study evaluating more than 50 reports asked the question, “Does longterm birth control pill use prevent ovarian cancer?”

The carefully performed study reported in the English journal Lancet in January 2008 found that compared to women who didn’t take birth control pills, those on birth control pills had a significantly lower risk for developing ovarian cancer. At five years, the risk was 20 percent less and by 15 years the risk of developing ovarian cancer was cut in half.

The study extended over the period during which birth control pills have been used and therefore the type of birth control pills changed significantly with the newer ones having far less estrogen than the original pills. Their conclusions were that the estrogen concentration didn’t seem to make any difference, but they couldn’t definitely prove that.

As for now, as always, your daughter needs to discuss the pros and cons with her physician and, based on what we know, take the birth control pill with the least amount of estrogen.

Dr. Barry Ramo is a cardiologist with the New Mexico Heart Institute and medical editor for KOAT-TV. Send questions for him to Albuquerque Journal Boomer, P.O. Drawer J, Albuquerque, NM 87103, or e-mail to htaylor@ abqjournal.com.

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

ATLANTA, Aug. 25 /PRNewswire/ — Saint Joseph’s Hospital of Atlanta, Inc. engaged in a systematic scheme to inappropriately admit and overcharge thousands of patients, according to Page Perry, LLC, which has filed a second class action lawsuit against the hospital.

Dorothy J. Rivard, a former nursing and pharmacy assistant who was hospitalized at Saint Joseph’s in October 2007, alleges in the new lawsuit that she was wrongly diagnosed as a stroke victim, injected over her objections with inappropriate medication, and then subjected to two days of unnecessary and expensive medical testing.

The lawsuit alleges that Ms. Rivard later learned that her medical records contained “a variety of serious mischaracterizations” that apparently were “used to justify the belated length of stay and the battery of medical testing.”

According to the Complaint, “In order to increase revenues, and thus profitability, [Saint Joseph’s] engaged in a widespread and systematic scheme to admit to inpatient status patients who did not otherwise meet inpatient admission criteria and then issue charges and bills for such inpatient services accordingly.” The scheme was “well known to [Saint Joseph’s] management, administration, staff and contractors, if not also its board of directors. Moreover, [Saint Joseph’s] management and administration actively concealed such practices,” the lawsuit claims.

In May, former Saint Joseph’s patient Steven M. Lamb, of Snellville, Georgia, alleged another class action lawsuit that a carotid artery stent procedure he underwent in 2005 kept him admitted on an “inpatient” basis for two days — about twice as long as was medically necessary and at a more costly rate than an “outpatient visit” which typically is accomplished in hours, not days.

Ms. Rivard and Mr. Lamb are represented by attorneys James M. Evangelista and David J. Worley, of Page Perry, LLC, of Atlanta, and James A. Dunlap Jr., of Atlanta. Counsel will seek to have Ms. Rivard’s lawsuit certified as class actions that includes all patients of the hospital system between Jan. 1, 2000 and Dec. 21, 2007 who were improperly admitted to Saint Joseph’s under inpatient status.

In December 2007, the United States Attorney for the Northern District of Georgia announced a “whistleblower” (qui tam) settlement in which Saint Joseph’s paid $26 million to settle federal false claims allegations related to thousands of patient stays between 2000 and 2005 that were billed to the federal Medicare program. The lawsuits filed on behalf of Ms. Rivard and Mr. Lamb seek to recover costs billed to individual patients, among other damages.

Attorney James M. Evangelista stated, “Patients came to Saint Joseph’s trusting that they would receive appropriate care, not expecting to be deliberately overbilled by Saint Joseph’s extending their hospital stay in a pretense of needed care. Ms. Rivard and Mr. Lamb and many people like him from throughout Georgia and elsewhere were inappropriately admitted and improperly billed.”

Both lawsuits — which allege breach of contract, breach of implied contractual duties of good faith and fair dealing, unjust enrichment, and breach of fiduciary duty — seek actual, exemplary, and punitive damages, and attorneys’ fees.

The new case is “Dorothy J. Rivard, et al., v. Saint Joseph’s Hospital of Atlanta, Inc., and Saint Joseph’s Health System, Inc.,” (Case No. 2008CV155034, in the Superior Court of Fulton County).

The previously filed case is “Steven M. Lamb, et al., v. Saint Joseph’s Hospital of Atlanta, Inc., and Saint Joseph’s Health System, Inc.,” (Case No. 08-CV-151075, in the Superior Court of Fulton County).

For more information, please contact Page Perry, LLC, (770) 673-0047, http://www.pageperry.com/.

Media Contact: Erin Powers, Powers MediaWorks LLC, for Page Perry, LLC, (281) 362-1411 or (281) 703-6000.

Page Perry, LLC

CONTACT: Erin Powers of Powers MediaWorks LLC, +1-281-362-1411 or \+1-281-703-6000, for Page Perry, LLC

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

By Mary Jo Balasco

Winthrop University Galleries will have the following exhibits:

* Faces: Works from the University Collection, until Sept. 18 in the Edmund D. Lewandowski Student Gallery.

* 20th Annual Undergraduate Juried Exhibition, through Sept. 4 at the Rutledge Gallery.

Gallery hours are 9 a.m. to 5 p.m. Monday through Friday. For details, call 323-2493 or visit www.winthrop.edu/vpa/galleries.

Art, computer classes offered in Fort Lawn

Registration is being accepted for the following classes at the Fort Lawn Community Center, 5554 Main St.:

* Healthy Habits Outreach, 11 a.m. to noon Mondays or 5:30 to 6:30 p.m. Thursdays.

* Yoga, 5:30 to 6:30 p.m. Tuesdays.

* Zumba, 6:30 to 7:30 p.m. Mondays and Thursdays.

* Belly dance, 6:30 to 7:30 p.m. Thursdays.

* Sewing, 6 to 8 p.m. Mondays or 12:30 to 2:30 p.m. Tuesdays.

* Crafts, 10 to 11 a.m. Mondays.

Cost is $20 membership fee.

The center offers these computer classes from 8:30 to 11:30 a.m.:

* Advanced Word, Aug. 27 and 28, $30.

* Excel ’03, Sept. 3 and 4, $30.

* Hallmark cards, Sept. 10, $20.

* Word 2007, Sept. 11 and 18, $30.

For details, call the center at (803) 872-4491 or visit www.fortlawncenter.com.

Ceramics, painting classes offered at Fewell Park

Fewell Park Recreation Center will offer the following art classes:

* Ceramics with Ann Pike, 10 a.m. to noon, Sept. 2 through Oct. 7, $2 plus supplies.

* Decorative painting with Jean Greco, 9:30 a.m. to 12:30 p.m. or 6 to 9 p.m., Sept. 18 through Oct. 23, $65.

* Watercolor painting with Johnny Wine, 9:30 to 11:30 a.m., Sept. 15 through Oct. 13; or 6:30 to 8:30 p.m. Sept. 18 through Oct. 16, $44.

* Creative photography with Rebecca McNeely, 6:30 to 8:30 p.m. Sept. 2 through 23, $44.

* Acrylic painting with Elizabeth Hawkins, 9 to 11:30 a.m. Sept 8 and 15, $39 plus supplies.

* Mosaic exploration with Mary Anna Richbourg, 6:15 to 8:15 p.m. Sept 9 through 30, $52 registration plus $20 materials.

* Children’s art and creativity with Mary Anna Richbourg, ages 7 to 12, 3:45 to 5 p.m. Sept. 9 through 30 or Oct 7 through 28 or Nov. 11 through Dec. 2, $42.

To register, visit the center from 8:30 to 5 p.m. Monday through Friday, 1204 Alexander Road, Rock Hill. For details, call 329-5645.

Wildlife Federation class is offered at MYCO

Habitat Stewards training, a National Wildlife Federation workshop to help make your backyard and community wildlife- friendly, will be 9 a.m. to 4 p.m. Sept. 12 and 13 at the Museum of York County, 4621 Mount Gallant Road, Rock Hill. Register by Sept. 5 by calling (803) 931-9182. Cost is $40 per person or $30 for CHM members. For details, visit www.chmuseums.org.

Clover theater needs actors, crew members

Clover Community Theatre is seeking actors, stage crew members, volunteers and sponsors. For details, call (704) 351-2300 or (704) 607-0673.

Youth pageant planned at Gold Hill school

The annual Little Miss-Teen Miss Fort Mill and Tega Cay pageant will be at 3 p.m Sept. 6 at Gold Hill Elementary School, 100 Dave Gibson Blvd., Fort Mill. For details, call Linda Hoverman O’Neal at (803) 547-3570 or (704) 904-0117 or visit picasaweb.google.com/ littlemissfortmillandtegacay.

Highway safety is topic of Sept. 6 class in Richburg

A free highway safety presentation for teens, including school- age and college-age students, will be at 11 a.m. Sept. 6 at the Lewisville Community Library, 3771 Lancaster Highway, Richburg. For details, call Diane Brown at (803) 789-3812.

Delta Sigma Theta presents reading program

The Rock Hill alumnae chapter of Delta Sigma Theta Sorority will kick off the 2008-09 School America reading program at 3 p.m. Sept. 7 at 229 Marion St., Rock Hill. School America is a free enrichment program for grades two through six. Students and parents are invited. For details, call Joyce Argo at 327-1405 or Joya Holmes at 517-2814.

City parks program has news to share

The following programs are offered through Rock Hill Parks, Recreation and Tourism:

* Discovery Station, an after-school program for children in kindergarten through fifth grade, is accepting applications for 2008- 09. The program is at Fewell Park Recreation Center, 1204 Alexander Road. Cost is $21 per week. For details, call the center at 329- 5645 or visit www.rockhillrocks.com.

* The Happy Travelers group is accepting registration for the Vermont Culinary Masterpiece trip Oct. 16 through 21. Cost is $845 per person. Registration has been extended to Sept. 1 at the PRT office at City Hall or mail to City of Rock Hill, Carolyn Snyder, P.O. Box 11706, Rock Hill, S.C. 29731. For details, call Carolyn at 329-5626 or 329-5620 or visit www.rockhillrocks.com.

* The Rock Hill Area Senior Sports Classic for ages 50 and older will be Sept. 22 through 26. Many events are at Boyd Hill Recreation Center. Events include golf, tennis, horseshoes, basketball, free throw badminton, disc golf, bowling and more. Register by Sept 5. For details, call Carolyn Snyder at 329-5626 or visit www.rockhillrocks.com.

Rock Hill civics course begins on Sept. 11

A free 10-week civics course for Rock Hill residents, “Inside Rock Hill,” will be from 6 to 8:30 p.m. Thursdays, beginning Sept. 11. To register, call the Neighborhood Empowerment office at 325- 2527 by Aug. 29.

Back to school is topic of local lunch program

The Clemson Extension Service will have a lunch and learn series from noon to 1 p.m. Tuesday at the Market Building, 116 Columbia St., Chester. Topic is “Successful Back to School.” Cost is $10 and includes lunch. To register or for details, call (803) 385-6181, Ext. 0 or visit www.clemson.edu/chester.

Tutoring available at Winthrop literacy clinic

The Literacy Clinic at Winthrop University’s Richard W. Riley College of Education is accepting applications for literacy tutoring for students in grades two through six. Tutoring will be provided by undergraduate students in elementary education or special education and will be supervised by Betty Lou Land, professor emertius. Applications are due by Sept. 4. For details, e-mail [email protected].

United Way, LIFT among local fundraisers

These area fundraisers are happening:

* The second annual United Men of York County fundraiser is seeking nominations of men to be featured in the 2009 United Men of York County Calendar. Nominations are $20 each, accepted until Thursday online at www.unitedwayofyc.org or by calling 324-2735 or 684-9847. Proceeds benefit the United Way of York County.

* Learning Institute For Tomorrow, LIFT, will have its fourth annual gala, “An Evening in Italy,” at 6 p.m. Sept. 6 at the University of South Carolina at Lancaster James A. Bradley building. Activities include a silent auction, Italian dinner and more. For details, tickets or donations, call (803) 285-8805.

* Thrift Store Ministries of Western York County, 31 N. Congress St., York, will have a sale on books, $1 per inch, this week. Record albums will be buy-one-get-one free. Donations of clothes and other items are needed. Thrift Store Ministries serves needy families in the York school district. For details, call 628-0808.

It’s time to sign upfor local 4-H clubs

The following 4-H clubs are seeking members:

* The Star, Strip and Snips 4-H horse club, environmental clubs, livestock clubs, pet care clubs, a shooting sports club and food classes are seeking new members. For details, call the York County Clemson Extension office at 684-9919, Ext. 114.

* A new 4-H horse club will meet at 6:30 p.m. Sept. 4 at the Clemson Extension office in York, 120 N. Congress St. The club will meet the first Thursday of each month. Register by calling Margie Sippel at 684-9919, Ext. 114, or Tori Campbell at (803) 222-7100.

Local groups have meeting news to share

The following groups/clubs will meet:

* The Rock Hill chapter of the National Federation of the Blind will meet at 7 p.m. Monday at the Red Cross building, 200 Piedmont Blvd., Rock Hill. The agenda includes guest speaker the Rev. White of Edgemoor, highlights of the state convention and Rocky Bottom Fun Day.

* Chester County First Steps will have a board meeting at 6 p.m. Tuesday at First Steps, 100 Center St., Chester. The meeting is open to the public.

* The York County Board of Disabilities and Special Needs will meet at 7 p.m. Thursday at 1657 Heatherhill Road, Rock Hill. The public is invited.

* The Tega Cay Vintage Club will meet Wednesday at the Tega Cay Golf Club in the Phil Glennon Community Center, 1 Molokai Drive. Cocktails begin at 6:30 p.m. with dinner at 7 p.m.

Local families have reunion news

The following families announce reunion information:

* The Good reunion will be at 1 p.m. Sunday in the Fellowship Hall at Woodlawn Presbyterian Church in Sharon. Bring tea and a picnic lunch.

* The Matthews family reunion will be from 1 to 3 p.m. Sept. 7 at Ebenezer Presbyterian Church, 2132 Ebenezer Road, Rock Hill. Bring a picnic lunch.

* The Bowers family reunion will be at 1 p.m. Sept. 27 at Beaver Creek Baptist Church, 4684 Stoneboro Road, Heath Springs, for descendants of Lewis Middleton and Martha (Mattie) Bowers. For details, call Alice Cairnes at (803) 285-3436 or Debbie Ballard at (803) 285-4803.

Leopold project available to homeschool families

The Leopold Education project is available to homeschooled students in the Rock Hill area. The curriculum uses “A Sand County Almanac” by Aldo Leopold to help ages 10 to 14 learn about the natural world. The project will begin Sept. 17. For details, call Jane Falkenstein at 329-5642 or e-mail her at [email protected] or Margie Sippel at 684-9919, Ext. 113 or e-mail her at [email protected].

Local preschools are accepting registration

The following preschools have openings:

* Ultimate Life Preschool Academy, a non-profit organization associated with Ultimate Life Church in Fort Mill, is accepting applications for 3- and 4-year-olds. For details, call (803) 802- 2641. The school is in the Rubin Center, 377 Carowinds Blvd. No. 124, Fort Mill.

* First Baptist Preschool of York has openings for 4-year-olds in its three-day class on Mondays, Wednesdays and Fridays. Children must be 4 by Sept. 1. For details, call Laura Nettles at 684-4297.

communitynews@

heraldonline.com

Deadline for Tuesday and Thursday columns is 5 p.m. two business days before publication. Deadline for Sunday is 5 p.m. Wednesday.

(c) 2008 Herald; Rock Hill, S.C.. Provided by ProQuest LLC. All rights Reserved.

NEW YORK, Aug. 25 /PRNewswire/ — Touchstone Health HMO, Inc. announced today that Dr. Roger London has recently joined the organization as Chief Medical Officer.

“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,” says Michael A. Muchnicki, President and Chief Executive Officer of Touchstone Health. “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.”

In his new role, Dr. London will be responsible for the corporate oversight of the medical management strategy and medical policies of Touchstone Health. “I look forward to working with the team at Touchstone Health to provide excellent service for our physician network and our members,” says Dr. London. “Touchstone Health has played a positive role in the New York market and I look forward to furthering the growth and development of the company.”

Dr. 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, Dr. 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 VP/Medical Director of the Lenox Hill Healthcare Network.

In recognition of his extensive consulting experience, Dr. London was recently named Executive of the Year (2008-2009) in healthcare consulting by Cambridge Who’s Who.

Before becoming a physician executive, Dr. London had extensive clinical and academic research experience. He graduated from Cornell University with a B.A. in History and he earned his M.D. from Mount Sinai School of Medicine. After completing his internship and residency at Columbia Presbyterian Medical Center, Dr. London did post doctoral research in renal physiology and a clinical nephrology fellowship at Yale University. Dr. London holds an M.B.A. from Columbia University and is board certified by the American Board of Internal Medicine.

About Touchstone Health

Touchstone Health, headquartered in New York City, is an HMO focused on the Medicare market. Touchstone Health currently has 11,000 Medicare beneficiaries in the Bronx, Kings, Queens, Richmond, Orange, Westchester, Broome, Chenango, Delaware & Onondaga counties. Benefits are available to anyone enrolled in both Medicare Part A and B and continue to pay their Medicare applicable premiums.

Touchstone Health is a privately held company owned and advised by, among other investors, Lehman Brothers Venture Capital, Essex Woodlands Health Ventures and Steven Wiggins. The company was founded in 1998 by a group of

neighborhood physicians to bring personalized health care to New York. Touchstone Health prides itself on its local focus and customer service.

For more information about Touchstone Health, please visit the company’s website at http://www.touchstone-health.com/ .

   Contacts:    Jill M. Tobin   Touchstone Health HMO, Inc.   14 Wall Street, 9th Floor   New York, NY 10005   212-294-6996   [email protected]    Rene Macapinlac   Touchstone Health HMO, Inc.   14 Wall Street, 9th Floor   New York, NY 10005   212-294-1647   [email protected]  

Touchstone Health HMO, Inc.

CONTACT: Jill M. Tobin, +1-212-294-6996, [email protected];or Rene Macapinlac, +1-212-294-1647, [email protected], bothof Touchstone Health HMO, Inc.

Web site: http://www.touchstone-health.com/

BioMarin Pharmaceutical has announced the roll-out of the national phenylketonuria demographics, outcomes and safety registry.

The registry is open to all phenylketonuria (PKU) clinics within the US, and all patients screened for Kuvan responsiveness are eligible for enrollment in the registry.

Also, from September 1, 2008 until December 31, 2008, to facilitate enrollment in the registry, new patients at clinics participating in the registry will be able to receive 45 days of free drug while individual insurance coverage is secured.

Jean-Jacques Bienaime, CEO of BioMarin, said: “We are excited to initiate the first PKU patient registry and believe that it will substantially strengthen the available data on a variety of PKU patient populations, including some less studied, such as children under four years of age and maternal PKU patients.”

LATHAM, N.Y., Aug. 25 /PRNewswire-FirstCall/ — Clinicians from the Image Guided Radiation Therapy program at Community Care Physicians in Latham have commenced treating cancer patients using RapidArc(TM) radiotherapy technology from Varian Medical Systems , an advancement that delivers a highly-precise image-guided, intensity-modulated radiotherapy (IMRT) treatment in two minutes or less.

RapidArc treatments spare healthy tissue and other vital organs in the body by adapting to the shape and size of a patient’s tumor. These treatments can be completed more quickly than conventional image guide IMRT because they are delivered with a single continuous rotation of the radiotherapy machine around the patient rather than treating the tumor from fixed positions.

Donald Shorkey, 71, an early-stage prostate cancer patient, was the first person to receive RapidArc treatments through this program. “I was immensely relieved when the doctors and nurses explained to me and my wife that RapidArc treatments focus just on the tumor.”

“Earlier technology for radiotherapy limited the number of angles we could use for striking at a tumor,” said Arun Puranik, MD, director of the Image Guided Radiation Therapy program. “With RapidArc technology, we are seeing excellent treatment plans that permit us to target the tumor from nearly every angle in a 360-degree circle around the patient. The impressive thing is that, when we use RapidArc to target the tumor from more angles, we can deliver a treatment using less radiation. And it only takes two minutes.”

The Image Guided Radiation Therapy program at Community Care Physicians was one of the earliest adopters of IGRT technology, and began offering image-guided IMRT treatments for prostate cancer back in August 2005. “The vast majority of our patients since then have had no complications, following treatment,” Puranik says. “I couldn’t imagine how we would improve on that. But with RapidArc, we have! We can get the same results two to eight times faster than was possible with our earlier technology.”

By completing highly-precise IMRT treatment so much faster, Puranik says, his clinical team members can spend more time with patients or completing administrative tasks. “Whereas we generally treated four patients each hour, RapidArc is making it possible for us to treat up to five patients an hour, with plenty of time in between appointments. Having extra time for administrative tasks will help us ensure that charges are captured correctly, and cut back on time-consuming billing errors.”

Shorkey is now finishing his third week of a nine-week course of radiotherapy, and reports that, to his surprise, he doesn’t feel anything during the treatments. “I’ve been pleased with the thoughtful and efficient care I’ve been getting at Image Guided Radiation Therapy,” he said. “I’m in the treatment room for only about five minutes per session. Because I live so close to the care center, I’m only away from home about an hour each day. The doctors told me that I was one of the very first patients in the Northeast to receive treatments using this technology. I think it’s wonderful that people are inventing these devices. It’s a miracle as far as I’m concerned.”

The American Cancer Society estimates that, in the state of New York this year, there will be 97,130 new cases of cancer, and 10,500 new cases of prostate cancer.

About Image Guided Radiation Therapy, Latham, NY.

Image Guided Radiation Therapy is a physician owned, physician governed multi-specialty medical group with more than 180 physicians and other clinical providers, located in 5 counties surrounding the Albany, New York greater Capital District. Community Care Physicians medical services include Internal Medicine, Pediatrics, Family Medicine, Obstetrics & Gynecology, Radiology, Radiation Oncology, Laboratory, General Surgery, Urology, Dermatology, Physical Therapy, Podiatry, Audiology, Occupational Medicine, Urgent Care, Diabetic Education and Travel Medicine. For more information about Community Care Physicians, PC contact Eileen Michaels, at 518-782-3743.

About Varian Medical Systems

Varian Medical Systems, Inc., of Palo Alto, California, is the world’s leading manufacturer of medical devices and software for treating cancer and other medical conditions with radiotherapy, radiosurgery, proton therapy, and brachytherapy. The company supplies informatics software for managing comprehensive cancer clinics, radiotherapy centers and medical oncology practices. Varian is a premier supplier of tubes and digital detectors for X-ray imaging in medical, scientific, and industrial applications and also supplies X-ray imaging products for cargo screening and industrial inspection. Varian Medical Systems employs approximately 4,600 people who are located at manufacturing sites in North America and Europe and in its 60 sales and support offices around the world. For more information, visit http://www.varian.com/.

    FOR INFORMATION CONTACT:    Robert Desjardins, RTT, MBA    Administrative Director, Image Guided Radiation Therapy    518-213-0302 or [email protected]     John Worlton, Varian Medical Systems    650-424-6438 or [email protected]  

Varian Medical Systems, Inc.

CONTACT: Robert Desjardins, RTT, MBA, Administrative Director of ImageGuided Radiation Therapy, +1-518-213-0302, [email protected]; orJohn Worlton of Varian Medical Systems, +1-650-424-6438,[email protected]

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

Noven Pharmaceuticals, Inc. (NASDAQ:NOVN) today provided an update on the status of Daytrana(R), the only transdermal patch indicated for the treatment of the symptoms of Attention Deficit Hyperactivity Disorder (ADHD).

Daytrana(R), developed and manufactured by Noven, is licensed globally to Shire Limited. Concurrently with this press release, Shire has announced that it is undertaking a voluntary recall of two lots of Daytrana(R) product (lots 2819811 and 2764211; NDC number 54092-553-30). Shire is taking this action because Daytrana(R) patches in these lots do not meet the product’s release liner removal specification and, as a result, patients and caregivers could have difficulties removing the release liner when they peel the patch open.

Shire has advised that, because the voluntary recall is not due to product safety issues, all Daytrana(R) patches, including those in the lots subject to the recall, can continue to be used unless the release liner cannot be removed, or the patches are damaged while being opened. The Daytrana(R) prescribing information and medication guide provide that, if a patch is damaged or the release liner is difficult to remove, the patch should be discarded. For additional information on this voluntary recall, see www.daytrana.com.

Peter Brandt, Noven’s President & Chief Executive Officer, commented: “Daytrana continues to bring important benefits to patients with ADHD and, together with Shire, we are committed to resolving the release liner issue. We have identified what we believe is the definitive root cause and are aggressively testing potential solutions that we expect will address the issue. As previously indicated, however, until testing is completed and solutions are implemented, voluntary actions like today’s two lot recall are possible, as we work to assure that patients and caregivers can use Daytrana(R) with the convenience they expect from this novel ADHD treatment.”

Shire has advised that current supply levels of Daytrana(R) are expected to be sufficient to ensure that patients can continue to have their Daytrana(R) prescriptions filled at their local pharmacies. Noven continues to manufacture the product and Shire continues to promote it in the United States.

Important Daytrana(R) Safety Information

Tell your doctor about any heart conditions, including structural abnormalities, your child or a family member may have. Inform your doctor immediately if the child develops symptoms that suggest heart problems, such as chest pain or fainting. Daytrana(R) should not be used if the child has: significant anxiety, tension, or agitation; allergies to methylphenidate or other ingredients of Daytrana(R); glaucoma; discontinued in the last 14 days or is taking a monoamine oxidase inhibitor (MAOI); tics, or family history or diagnosis of Tourette’s syndrome.

Tell your doctor before using Daytrana(R) if the child: is being treated for or has symptoms of depression (e.g. sadness, worthlessness, or hopelessness) or bipolar disorder; has family history of tics; has abnormal thoughts or visions, hears abnormal sounds, or has been diagnosed with psychosis; has had seizures or abnormal EEGs; has or has had high blood pressure; exhibits aggressive behavior or hostility. Tell your doctor immediately if the child develops any of these conditions/symptoms while using Daytrana(R).

In clinical studies, side effects were generally mild to moderate. The most common side effects reported with Daytrana(R) were decreased appetite, sleeplessness, sadness/crying, twitching, weight loss, nausea, vomiting, tics, and affect lability (mood swings). Aggression, new abnormal thoughts/behaviors, mania, and growth suppression have been associated with use of drugs of this type. Tell your doctor if the child has blurred vision while using Daytrana(R).

Note: Abuse of Daytrana(R) can lead to dependence. Daytrana(R) should be applied daily to clean, dry skin, which is free of any cuts or irritation. Skin redness or itching is common with Daytrana(R). Allergic skin rash may occur.

About Noven

Noven Pharmaceuticals, Inc. is a specialty pharmaceutical company engaged in the research, development, manufacture, marketing and sale of prescription pharmaceutical products. Noven’s business and operations are focused in three principal areas – transdermal drug delivery, the Novogyne joint venture, and Noven Therapeutics, Noven’s specialty pharmaceutical unit.

Safe Harbor Statement under the Private Litigation Reform Act of 1995

Except for historical information contained herein, the matters discussed in this press release contain forward-looking statements within the meaning of Section 27A of the Securities Act of 1933 and Section 21E of the Securities Exchange Act of 1934 that involve substantial risks and uncertainties. Statements that are not historical facts, including statements that are preceded by, followed by, or that include, the words “believes,””anticipates,””plans,””expects” or similar expressions and statements are forward-looking statements. Noven’s estimated or anticipated future results, product performance or other non-historical facts are forward-looking and reflect Noven’s current perspective on existing trends and information. Actual results, performance or achievements could differ materially from those contemplated, expressed or implied by the forward-looking statements contained herein. These forward-looking statements are based largely on the current expectations of Noven and are subject to a number of risks and uncertainties that are subject to change based on factors that are, in many instances, beyond Noven’s control.

These risks and uncertainties include: the risk that additional lots of Daytrana(R) may be recalled by Shire due to product failing to meet the release liner specification or otherwise; the risk that Noven may not be successful in identifying or implementing a solution to resolve the release liner issue; uncertainties related to the financial impact of the recall; the risk that Noven’s response to the FDA’s January 2008 warning letter, which remains under FDA review, may not be acceptable to the FDA or adequately address the FDA’s concerns, and in such case, the risk that the FDA may take regulatory action against Noven, which may include fines, product seizures or recalls, injunctions, suspension of production and/or the withdrawal of product approval; and the risk that any adverse effect to the market for Daytrana(R) due to the foregoing or other factors could adversely affect Noven’s reputation, results of operations and/or its financial position. For additional information regarding these and other risks associated with Noven’s business, readers should refer to Noven’s Annual Report on Form 10-K for the year ended December 31, 2007, as well as other reports filed from time to time with the Securities and Exchange Commission. Unless required by law, Noven undertakes no obligation to publicly update or revise any forward-looking statements, whether as a result of new information, future events, or otherwise.

BELLEVILLE, ON, Aug. 25 /PRNewswire-FirstCall/ — Bioniche Life Sciences Inc. (TSX: BNC), a research-based, technology-driven Canadian biopharmaceutical company, announced today that its U.S. Animal Health business, Bioniche Animal Health USA, Inc., has been granted full listing by the Organic Materials Review Institute (OMRI) for its premier immunostimulant technology for calves, Immunoboost. The addition of Immunoboost to the official OMRI list indicates that this biological product has met the national standard for use in organic dairy and beef operations in the United States.

Immunoboost is USDA-licensed for use in calves between the ages of one and five days, as a one-time immunotherapeutic treatment for reduction of the mortality and morbidities associated with calf scours caused by E. coli (K99) infections.

Immunoboost is a mycobacterial cell wall extract (MCWE) formulation. A distinct and more advanced Bioniche technology that also uses mycobacterial cell walls – Mycobacterial Cell Wall-DNA Complex (MCC) – is currently undergoing Phase III clinical testing in human patients with non-muscle-invasive bladder cancer in 31 North American urology centres.

Recognized experts in organic dairy and beef operations are pleased to have recourse to Immunoboost for the treatment of calf scours. Dr. Hubert Karreman, a Pennsylvania dairy veterinarian, has consulted on organic health care issues with veterinarians across the U.S. for over a decade and recently authored a book entitled, “Treating Dairy Cows Naturally: Thoughts and Strategies”.

“Enhancing the immune system is essential in helping animals to heal,” said Dr. Karreman. “With immunologic stimulation so critical to maintaining or enhancing health, I believe it is a wise choice to use Immunoboost as a therapeutic agent for all kinds of livestock production systems. Immunoboost is an effective, non-antibiotic treatment that has come of age and, being OMRI listed, it now provides the necessary assurance to organic producers and the veterinarians that service these specialized farms.”

Dr. Karreman works with over 85 certified and transitioning organic herds, and is a sought-after speaker on organic practices at both veterinary and producer conferences.

“Immunoboost has recently gained market interest in the organic sector,” said Mr. Jim Phillips, President, Bioniche Animal Health (global). “Its listing by OMRI comes at a time when antibiotic use is being carefully scrutinized by the industry and its customers, with alternatives to antibiotics being sought.”

Agriculture and Agri-Food Canada stated in a report that the natural beef market in the U.S. is one of the fastest growing segments of the beef market, driven by healthier eating choices, food scares and health-related issues. The U.S. natural beef sector is estimated to be worth US$500 to US$550 million annually, or 1% of the total U.S. beef market. Overall beef sales in the U.S. have been slowing since peaking in the 1970’s, and overall beef production figures continue to decline. However, the natural beef sector is growing by roughly 20% annually.

About OMRI

The Organic Materials Review Institute (OMRI) is a national non-profit organization that determines which input products are allowed for use in organic production and processing. Only OMRI Listed products may be used on operations that are certified organic under the USDA National Organic Program.

About Bioniche Life Sciences Inc.

Bioniche Life Sciences Inc. is a research-based, technology-driven Canadian biopharmaceutical company focused on the discovery, development, manufacturing, and marketing of proprietary products for human and animal health markets worldwide. The fully-integrated company employs approximately 200 skilled personnel and has three operating divisions: Human Health, Animal Health, and Food Safety. The Company’s primary goal is to develop proprietary cancer therapies supported by revenues from marketed products in human and animal health. Bioniche has been named one of Canada’s Top Ten Life Sciences Companies for 2008. For more information, please visit http://www.bioniche.com/.

Except for historical information, this news release may contain forward-looking statements that reflect the Company’s current expectation regarding future events. These forward-looking statements involve risk and uncertainties, which may cause, but are not limited to, changing market conditions, the successful and timely completion of clinical studies, the establishment of corporate alliances, the impact of competitive products and pricing, new product development, uncertainties related to the regulatory approval process, and other risks detailed from time to time in the Company’s ongoing quarterly and annual reporting.

Bioniche Life Sciences Inc.

CONTACT: Jennifer Shea, Vice-President, Communications, Investor &Government Relations, Bioniche Life Sciences Inc., Telephone: (613) 966-8058,Cell: (613) 391-2097, [email protected]

VANCOUVER, BRITISH COLUMBIA–(Marketwire – Aug. 25, 2008) – Urodynamix Technologies Ltd. (TSX VENTURE:URO) today announced that it has received a non-refundable financial contribution from the National Research Council Canada Industrial Research Assistance Program (NRC-IRAP) to help accelerate the development and commercialization of new NIRS technology for the detection of prostate cancer during the digital rectal examination, or DRE.

Urodynamix’s new technology, based on near infrared spectroscopy (NIRS), is designed to aid in the diagnosis and treatment of prostate cancer and related diseases in a physician office setting. During the DRE screening test for prostate cancer, a physician inserts a gloved finger into the rectum in order to be able to feel the size, shape, and texture of the prostate and other nearby organs. The sensitivity and specificity of DRE are highly subjective and dependent upon the skill of the physician, his or her ability to interpret what he or she feels, and the nature and progression of the disease. NIRS technology will allow physicians to detect and study abnormal prostate tissue and provide objective, clinically meaningful data to help doctors make better diagnostic decisions.

NRC-IRAP provides technology and business advisory services, coupled with shared financial support to innovative companies and organizations. NRC-IRAP will contribute approximately $60,000 over the next 8 months to support the development of NIRS technology used to detect, diagnose and monitor prostate cancer and related conditions.

“This financial support from the Government of Canada through the NRC-IRAP program will allow us to develop our next generation products more quickly and address a large market opportunity for improved prostate cancer diagnosis and monitoring using our NIRS technology platform,” said Barry Allen, President and CEO.

In North America, Europe and Japan, an estimated 40 million men have prostate cancer and 150 million men qualify for annual prostate cancer screening. Prostate cancer treatment and unnecessary biopsies cost $10 billion per year in the US alone. Urodynamix’s NIRS technology may help increase cancer detection rates by providing an objective measure of blood flow in the prostate gland. The device is also expected to be used in conjunction with transrectal ultrasound imaging to help improve the accuracy of targeted prostate biopsy and treatment.

About Urodynamix Technologies Ltd.

Urodynamix Technologies is a Canadian medical device company developing and commercializing non-invasive medical technology based on proprietary applications of near-infrared spectroscopy (NIRS). The Company is currently focused on products that aid in the diagnosis and treatment of urinary incontinence, lower urinary tract symptoms, prostate cancer, benign prostatic hyperplasia, and traumatic increases in intra-abdominal pressure that cause abdominal compartment syndrome. Urodynamix’s breakthrough medical technology has the potential to beneficially affect more than 200 million people worldwide.

Certain information contained in this press release may be forward-looking and is subject to unknown risks, which could cause actual results to differ materially from those set forth or implied herein. Although the Company believes that the expectations reflected in such forward-looking statements are reasonable, it can give no assurance that such expectations will prove correct.

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

CANNON BEACH, Ore., Aug. 25 /PRNewswire/ — A newly formed non-profit organization created to promote tourism in the Oregon oceanside community of Cannon Beach, has selected Leopold Ketel & Partners of Portland as its public relations firm.

Cannon Beach Business Associates (CBBA) said that Olga Haley, managing director of LKP’s public relations department, would oversee the year-long effort, beginning in September.

Haley and her team have extensive travel and tourism public relations experience, including several years representing the Oregon Coast Aquarium and other Oregon attractions and destinations. Previously, LKP produced travel campaigns for the city of Newport, Ore.

“The board considered several candidates and conducted a series of interviews with potential public relations firms before selecting Olga Haley and LKP,” said CBBA member Julie Walker.

Leopold Ketel & Partners is one of the Northwest’s leading agencies, providing advertising, design, public relations, interactive, media planning and buying for a diverse set of clients. LKP’s client roster includes Tillamook Cheese, Hood River Distillers, ODS Companies, Oregon Public Broadcasting, Springbrook Properties, The Allison Inn & Spa, Oregon Humane Society, Oregon Coast Aquarium, Houdini, Inc., Kells Irish Pub and The Old Mill District in Bend. For more information, call 503-295-1918 or http://www.leoketel.com/.

Leopold Ketel & Partners

CONTACT: Julie Walker of Cannon Beach Business Associates,+1-503-436-1966, [email protected]; or Olga Haley of Leopold Ketel & Partners,+1-971-244-0661, [email protected]

Web site: http://www.prnewswire.com/comp/133897.htmlhttp://www.leoketel.com/

Company News On-Call: http://www.prnewswire.com/comp/133897.html

By Annette Wells

By ANNETTE WELLS

REVIEW-JOURNAL

Dr. Richard Chudacoff has always had a high level of confidence in his abilities as a physician and teacher of medicine.

He didn’t look over his shoulder while teaching at Baylor College of Medicine in Houston, nor did he second guess his procedures at two of the nation’s top hospitals – St. Luke’s Episcopal Hospital and The Methodist Hospital.

That confidence took a hit, though, when Chudacoff received a letter from Dr. John Ellerton, chief of staff at University Medical Center, telling him his medical privileges had been suspended because of disruptive behavior and four surgery complications within a four-month time span.

The decision was made by the hospital’s Medical Executive Committee.

Chudacoff, who came to Nevada in 2007 to be closer to his mother in Palm Springs, Calif., has filed a complaint against UMC in federal court claiming defamation and a violation of his constitutional rights. The suspension and the reporting of it to the National Practitioner Data Bank are the cornerstone of the complaint.

The suspension came without warning, he said, and he was never given a chance to respond to the charges prior to the data bank’s receipt of the suspension.

Chudacoff claims UMC’s actions were in retaliation for a April 16 e-mail he sent to Dr. Paul G. Stumpf, chairman of the University of Nevada School of Medicine’s obstetrics and gynecology department.

In that e-mail, Chudacoff highlighted what he felt were “weaknesses in the training of residents at UMC,” and offered some suggestions on how to better train these new doctors. Instead of listening to his suggestions in the private e-mail, Chudacoff believes Stumpf forwarded that information to UMC’s obstetrics and gynecology department, which eventually led to his suspension.

“It was not only the fact that they reported but the blatant lies that were in the report that was the coup de grace that suggested to me a premeditated yet unwarranted action,” Chudacoff said about UMC submitting an adverse report to the national data bank. “Is it because I see a weakness in the training of the residents at UMC and I have offered to raise the bar of surgical skills and patient care, thus rocking the status quo? I don’t know.”

UMC officials would not comment about the complaint or Chudacoff’s accusations.

Tammy McMahan, a hospital spokeswoman, said UMC couldn’t comment on any action taken by the Medical Executive Committee because it is a separate entity. Ellerton signed Chudacoff’s suspension letter. He could not be reached for comment this week.

He is one of two physicians currently at odds with the county hospital. Dr. James Tate earlier this month was ordered not to perform trauma surgeries after an altercation with a family of a teen hurt in an auto accident. Tate says UMC officials also failed to talk to him before taking disciplinary action. He maintains he was defending himself from aggressive family members.

UMC officials have declined comment on the Tate matter.

According to Ellerton’s letter, dated May 28, Chudacoff was placed on a Focused Professional Practice evaluation and his obstetrical privileges were suspended. The two-page letter goes on to say that Chudacoff cannot perform any surgeries unless Dr. Nick Spirtos, director of gynecological and oncology services at UMC, is in the operating room with him.

Chudacoff was ordered to submit to drug testing and placed on a zero-tolerance policy for disruptive behavior, the suspension report said.

His suspension was reported to the National Practitioner Data Bank in June, according to the adverse report.

The data bank is an information clearinghouse that collects and releases information related to the professional competence and conduct of physicians, dentists and other health care practitioners.

David Bowman, a spokesman for the data bank, said health care providers routinely report to the data bank when a physician has lost clinical privileges. That information remains in the system unless the reporting entity asks that the information be amended or removed.

In its report to the data bank, UMC officials said Chudacoff’s clinical privileges were suspended because he provided substandard or inadequate care and displayed substandard or inadequate skills.

The report goes on to say that the obstetrician had “four serious operative complications during gynecologic surgery, in a four month period,” and that Chudacoff failed to respond to an obstetrical emergency when asked by a resident and nurse. It also noted disruptive behavior.

“They are basically saying this guy is horrible; this guy is dangerous without ever giving him an opportunity to respond,” said Jacob Hafter, Chudacoff’s attorney. “He was the attending physician. It wasn’t his hands that caused the problems. The harm was done by the residents.”

Hafter, a former paramedic, said UMC failed to notify Chudacoff of the alleged disruptive behavior and that Chudacoff has not had any medical malpractice complaints filed against him regarding those patients’ complications. The procedures took place between February and May.

“If they are so concerned about patient safety why are the residents still practicing?” the attorney asked.

Chudacoff, 49, who has privileges at Mountain View and Summerlin hospitals, admits he was responsible for the residents during those shifts. However, he said if UMC was “worried about my surgical skills after the index cases, then they should have, at the least, discussed that with me.”

As for the disruptive behavior charge, Hafter says UMC violated its own policy on handling such accusations. According to that policy, the hospital’s chief of staff should have notified Chudacoff of the allegation. Also, if the chief of staff identifies a pattern of disruptive behavior they “shall discuss the matter verbally and in writing” with the individual.

Chudacoff said that other than a conversation he had with Ellerton on May 28 – the day suspension letter was sent to him – he had never been told of being disruptive.

According to Ellerton’s letter, the Medical Executive Committee met on May 27.

Chudacoff said he wants the adverse action report removed from the data bank because it has left a black mark on his reputation. Already, he claims, other Las Vegas gynecologists don’t speak with him.

On July 2, Chudacoff’s insurance attorney, Anthony D. Lauria, filed a motion in federal court requesting that UMC return his hospital privileges and revoke the report submitted to the data bank.

Contact reporter Annette Wells at [email protected] or 702- 383-0283.

(c) 2008 Las Vegas Review – Journal. Provided by ProQuest LLC. All rights Reserved.

By Evelyn Barge

AZUSA – There was plenty of time for fun and games Thursday at Slauson Community Pool, where the girls from Daisy Girl Scouts Troops 279 and 264 staved off the heat with repeated trips down a two-story water slide.

The celebration was hard-earned for the troops from Walnut Unified School District, said Mona Soza, co-leader of Troop 279, as many of the girls prepared to become full-fledged Brownies after a year of community service and learning projects.

“A lot of them have gotten really interested in helping people,” said Tina Diaz, a Diamond Bar resident and co-leader of Daisy Troop 264.

Each project marked a petal – the Daisy equivalent of a Girl Scout badge – earned and proudly ironed on to the girls’ sky-blue tunics.

Between typical summer activities like camp and trips to the water park, Diaz said, the troops also put on a toy drive in July to benefit the children at Five Acres, The Boys’ and Girls’ Aid Society of Los Angeles County, based in Altadena.

It wasn’t the first time the Daisy troops teamed up to support Five Acres. In February, some of the troop members earned their “considerate and caring” petals by washing and donating unclaimed jackets and sweaters from Collegewood Elementary’s lost and found to Five Acres.

“Girl Scouts are known for selling cookies, and they have fun,” said Rene Alpi, placement coordinator for the Girl Scouts – Spanish Trails Council. “But they’re also taught to do something for somebody or something in the community.”

Susan Silverman, director of annual giving for Five Acres, said the donation of used clothing most likely went to benefit women and children at Grace Center, Five Acres’ domestic violence support program.

“We have a lot of little people helping the kids,” Silverman said. “Hopefully, as they grow up to become viable members of the community, they’ll remember us. The Girl Scouts are very important to us.”

With the support of their big sisters in Junior Girl Scouts Troop 225, the troops also plan to start collecting toys in October for Five Acres’ holiday drive.

“These girls will be growing up together,” Ruiz said. “That’s the main thing – that they will be a good influence to each other.”

With each outreach project, Soza said, the girls learn how to take action in identifying community needs – one of the three elements of Girl Scouts leadership.

“It’s the young people – the kids helping kids – that just really warms our hearts,” Silverman said.

For more information about donating to Five Acres, visit www.5acres.org

For more information about joining a local Girl Scout troop, visit www.gsspanishtrails.org

[email protected]

(626) 962-8811, Ext. 2472

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

By Anonymous

Ochsner Baptist Medical Center Wednesday said it plans to open a full-service emergency room on its Uptown campus at 2700 Napoleon Ave. by this winter.

Emergency services have not been available on the Baptist campus since Hurricane Katrina.

“We’re about halfway through construction, and upon completion, the ER will have 12 beds within approximately 6,000 square feet and will include state-of-the-art electronic computerized patient tracking to ensure that staff are always aware of patient waiting times, service delays, test results and all patient care activities,” said Baptist CEO Robert Wolterman.

CT scan and all other radiologic imaging will also be available, he said.

Credit: CityBusiness Staff Report

(Copyright 2008 Dolan Media Newswires)

(c) 2008 New Orleans CityBusiness. Provided by ProQuest LLC. All rights Reserved.

By Kandle, Kirk

Since the attacks of 9/11, law-enforcement agencies face real risks of terrorism, but Dr. Nathan Berger, 45, says the Louisville area is “blessed to have the resources we have.” Berger is specially trained to wear two hats – as a Special Weapons and Tactics (SWAT) team member and as a doctor who can help deal with unexpected medical concerns. He recently completed his second medical residency, this time in clinical forensics and tactical medicine at University Hospital.

Berger’s mentor is Dr. Bill Smock, an attending physician in the hospital’s emergency department. If the threat of a terrorist attack is a dark cloud, says Smock, “the silver lining is that we have the Dr. Bergers of the world who are committed to public safety.”

With 15 years experience as a firefighter and paramedic in suburban Washington, D.C., Burger had a keen interest in law enforcement before he went to medical school at the University of South Carolina. He sent a letter to Smock about six years ago, while he was a family-practice resident, to inquire about U of L’s program – the only one of its kind to combine clinical forensics and tactical medicine. The program equips doctors to work with law enforcement and to serve as a member of the Joint Emergency Services Unit (JESU), a local coalition of law enforcement, emergency, fire and rescue, public health, and medical agencies dedicated to keeping the community safe.

Berger’s job is to help JESU members remain healthy to do their jobs — and to be prepared for any man-made or natural disaster.

The group meets monthly to plan and train. “That’s why we’re the best-prepared in the country,” says Smock. “We’ve been doing this since 1997. The Louisville model, he says, has been taken up by the CDC and the FBI and transplanted around the country. “Attracting Nathan to Louisville to be part of this and to move to Floyd County is an example of why the Louisville model works,” says Smock.

Berger says it’s all about working as a team: “You leave your ego at the door.” He has been attached to the Floyd County’s SWAT team. He also completed the American College of Emergency Physicians’ special training for civilians to support tactical law enforcement operations.

Berger’s passion for scuba diving equips him to be a Louisville Metro Police dive team physician. “In that role, my job is to take care of the officers and make sure they stay safe from injury. You’d understand the challenge if you knew what’s at the bottom of the river,” he says. And, if necessary, Berger can take to the air, too. He holds a pilot’s license.

“The training we do covers anything that can happen in any location or tactical environment,” says Berger. “In a SWAT call- out, a hostage rescue, a high-risk warrant – these are all situations where, in case of injury to a civilian, hostage or officer, you need the highest level of medical care in the field. The public and our officers deserve nothing less.”

Copyright Louisville Magazine Inc. Aug 2008

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

By Kibbe, Cindy

New Hampshire’s health-care facilities are growing at a record pace. From Elliot Hospital’s $95 million redevelopment of the former Jac Par site in Manchester and a brand new Huggins Hospital in Wolfeboro, to the multimillion-dollar projects at New London Hospital in the lake Sunapee area to Portsmouth Regional Hospital on the Seacoast, projects are sprouting all across the Granite State. Here’s a look at how they shape up:

***

Frisbie Memorial Hospital, Rochester

Project: Expansion/Renovation

Estimated Cost: $42 million

Estimated Completion: December 2008

Frisbie Memorial Hospital in Rochester has just passed a major milestone on its 26-month-long, $42 million expansion/renovation project. In July, the hospital opened the doors to 88,000 square feet of new construction.

Situated within four floors, patients and visitors will find a new lobby and registration area, new endoscopy suite as well as a new 20-bed coronary care unit and a new 20-bed women and children’s unit.

“The hospital hadn’t had a major renovation in 25 years,” said Joseph Shields, vice president of planning. “In that time, there has been a change in emphasis from inpatient services to outpatient services.”

One of the important points of the project was to locate more of the outpatient services closer to the entrance

“Prior to the expansion, the hospital was really constructed for inpatients,” said Shields.

Workers are now focusing on the last stages of the project, joining the new building to the old as part of the 25,000-square- foot renovation.

“Prior to the start of the project, about 35 percent of our inpatient beds were private. When we’re done, we’ll be about 85 percent private,” said Shields.

Infection control and other standards have prompted many hospitals to convert their semi-private rooms to private.

The updated beds also will increase Frisbie’s bed count from 74 to 87 when the project is complete – expected in December.

Financing for the project will be partially covered by a $1.5 million, 18-month capital campaign.

“We started in November and have raised $1.2 million already,” said Bill Parkinson, executive director of fund development. “We expect to go over that ($1.5 million) goal.”

Project principals include Shepley Bulfinch Richardson & Abbott of Boston, architects; R.W. Sullivan of Boston, engineering and William A. Berry & Son Inc. of Danvers, Mass., construction manager.

***

Huggins Hospital, Wolfeboro

Project: Expansion/Renovation

Estimated Cost: $52 million

Estimated Completion: November 2010

One of the most ambitious hospital projects in New Hampshire Huggins Hospital in Wolfeboro is doing more than just renovating and expanding – it is essentially building an entirely new facility.

Many parts of the existing hospital had been built decades ago during a “different era of medicine,” said David Tower, president of Huggins. “Back then, inpatient stays were much longer. Today, more care is done in an outpatient setting.”

Although Huggins is licensed for 55 beds, it will remain a critical-care access hospital meeting the requirement for 25 licensed acute care beds. The other 30 beds are licensed for observation, obstetrics and skilled nursing. However, sections of the new 101,000-square-foot facility could easily be expanded for future needs and growth.

The new hospital will move inpatient rooms – to be all private instead of the current semi-private configuration – to the second floor, away from the outpatient and registration “hubbub,” said Tower. A new women’s health and obstetrics unit, intensive care unit and expanded emergency room and outpatient service areas are also planned.

With aesthetics an important part of today’s nurturing aspect of healing the new facility also will feature gardens for reflection and a greater use of natural light through the placement of windows, skylights, a central atrium and clerestory windows.

Tower said that reducing the hospital’s environmental footprint was a priority as well. “There are things that we can and should do such as water conservation and efficient utilities,” he said.

Financing for the $52 million price tag will come largely from the hospital itself with a capital campaign currently being designed. Other financing could come in the form of bonds.

With groundbreaking in July, the new facility is expected to admit its first patients in November 2010, with site work and parking completed in spring of 2011.

Project principals include DiGiorgio Associates Inc of Boston, architects and engineering and Gilbane Inc. of Manchester, construction managers.

***

Catholic Medical Center, Manchester

Project: First Noor and Fourth Floor renovations

Estimated Cost: $5.7 million

Estimated Completion: April 2009

After several years of renovations and expansions, Catholic Medical Center in Manchester is embarking on two other projects.

Renovations to the first floor will include a new endoscopy suite, an expanded cardiac catheterization lab, a new space for the medical laboratory and a new chapel.

These spaces will be housed in the same rooms previously occupied by operating rooms. Ten new surgical suites opened last October on the fourth floor.

Also on the fourth floor will be renovated medical/surgical inpatient rooms.

“That project is less than $200,000, and just requires some minor equipment changes,” said Gail Winslow-Pine, marketing director for the 330-bed hospital.

Project principals include Dignard Architectural Services of New Boston, architect and Harvey Construction of Bedford, construction managers.

***

Southern New Hampshire Medical Center, Nashua

Projects: Medical office building, Merrimack; Expansion/ Renovation of medical center, Nashua

Estimated Cost: $2.2 million (medical office); $35 million (medical center expansion)

Estimated Completion: Medical office building, early 2009; Medical Center project, Summer 2009

Southern New Hampshire Medical Center has not one, but two major capital improvement projects under way – a new medical office building and the second phase of an expansion/renovation project at the medical center itself.

Construction teams have begun working on the high-profile conversion of the former Newick’s restaurant in Merrimack to a medical office building.

Turning a seafood restaurant into a physician’s office is not as challenging as some other projects, said Scott Cote, vice president of facilities for the Nashua-based for-profit hospital.

“The 14,000-square-foot building sits on one floor, and the way it was constructed has an open floor plan,” said Cote. “The openness will make a nice entrance to the building.”

The building sits on five acres, and will become home to seven physicians – four family practitioners, two pediatric practitioners and an OB/GYN practice.

In addition to the physicians, ambulatory care services – such as a laboratory, radiology and physical therapy – will be a part of the new facility.

Project principals for the medical office include Dennis B. Mires P.A., The Architects, Manchester; site engineer Hayner/Swanson Inc., Nashua; and construction manager Fulcrum Associates, Amherst.

The construction going on at the medical center itself is the second phase of a large expansion/renovation project.

The first phase entailed the creation of a new emergency room and surgery unit, and was completed in 2006.

The second phase will involve the creation of a new labor, delivery and recovery unit reflecting today’s standards for caring for new mothers during the entire stay in the same room.

The biggest challenge, said Cote, to the project is the confined site on which the medical renter is located.

“We are in an urban area, with businesses and some residential properties boarding us,” he said.

Making construction at the 188-bed hospital more complicated is that several non-clinical departments had to be moved off-campus to other locations in Nashua. A few will remain off-campus after the project is complete in summer of 2009, giving more space over to patient care areas.

Lavallee/Brensinger of Manchester is the architect for this project with construction managers Engelberth Construction Inc. of Keene, N.H., and Colchester, Vt., and site engineers Hayner-Swanson of Nashua.

***

Concord Hospital, Concord

Project: Langley Parkway

Estimated Cost: $2 million

Completion: Opened June 25, 2008

It is said that good things come to those who wait. As far as Concord Hospital is concerned, its patients and the surrounding community had waited long enough.

Langley Parkway, a controversial road extension between Pleasant and Clinton Streets in Concord, with parts running adjacent to the hospital, had been discussed by city planners as far back as 1956.

The parkway which finally opened in June, allows drivers from Interstate 89 to reach the hospital without driving east on Clinton Street to South Fruit Street. Opponents had argued that sensitive wetlands and open space that the road would cut through needed to be preserved. They also questioned whether the bypass would mitigate the city’s traffic problems.

Concord Hospital, along with nearby St. Paul’s School, partnered to help the $6 million, 4,300-foot parkway become a reality. Concord’s tab for the construction was $2 million.

A new road is just one of the projects the 295-bed Concord Hospital has embarked on.

Well along on its $60 million North and East Wing expansions, the projects entail some 160,000 square feet of new construction with 25,000 square feet of renovations, which include an expanded emergency room, intensive care unit, progressive care unit for patients recovering from cardiac surgery, and new operating suites. Also part of the project is an expanded visitor’s entrance and cafeteria.

The current renovation phase is expected to be completed at the end of year.

The hospital also is planning a $1.75 million renovation of its pediatric unit.

And the hospital is planning on a permanent home for its high- tech simulation lab, which provides a sophisticated training environment for physicians and nurses on a variety of procedures.

***

Portsmouth Regional Hospital, Portsmouth

Project: Expansion/Renovation

Estimated Cost: $83 million

Estimated Completion: 2012

Portsmouth Regional Hospital has just begun the initial phase of its $63 million renovation and expansion project.

A total of 156,000 square feet will be built – 88,000 square feet of renovation and 68,000 square feet of new construction.

One of the first phases of the project will be to build an entirely new third floor with 40 more private hospital rooms. Not only will this allow continued use of the facility, the move will add 19 additional medical/surgical beds, raising the hospital’s bed count to 224.

Seacoast area mothers-to-be will find a new maternity unit when the construction is completed.

The hospital will be reconfiguring space to create 20 more rooms in the cardiac unit as well as moving the cardiac operating room near with the intensive care unit, cardiac catheter laboratory and the cardiovascular ICU to create a continuous, cohesive space.

To make it easier for patients and visitors alike to find their way around the hospital, the three entrances it currently has will be reconfigured to just a single entrance which will open into a new lobby with a two-story atrium.

The new lobby’s design will also feature display cases with artifacts reflecting the Seacoast’s nautical and maritime heritage.

Ground-breaking is scheduled for September.

JSA Architects of Portsmouth is the architect for the project.

***

Valley Regional Hospital, Claremont

Project: Expansion/Renovation

Estimated Cost: $22.5 million

Estimated Completion: Summer 2010

Valley Regional Hospital in Claremont held a groundbreaking in July to celebrate the beginning of construction of its $22.5 million renovation project.

The two-year project will include 54,000 square feet of new construction and renovation. This is the hospital’s largest renovation project in history, reported the Claremont Eagle Times.

The project calls for a new entranceway and the emergency department will be moved to a lower floor.

The 25-bed critical access hospital, a member of the Dartmouth- Hitchcock Alliance of hospitals, will convert its inpatient rooms to a private configuration. There also will be designated family areas with refrigerators throughout the hospital for families visiting loved ones, the Eagle Times said.

The central plant, which houses the hospital’s boiler room, will be moved to the rear of the building, and the helipad will be moved closer to the emergency room entrance. Administration offices will be torn down and moved to the east side of the hospital, and significant changes are also planned for the same-day surgery unit.

Project principals are Lavallee/Brensinger Architects, Manchester and construction manages Harvey Construction, Bedford.

***

Elliot Health System, Mancaster

Project: Elliot at Rivers Edge

Estimated Cost: Ambulatory Care Center, $95 million

Estimated Completion: Summer 2010

Elliot Hospital in Manchester is planning the state’s largest health-care project – Elliot at River’s Edge. The massive $95 million project includes a 236,000-square-foot ambulatory care center and a medical office building as well as an apartment building and a retail complex.

“When we created a new master plan about 2-1/2 years ago, we needed to address the access of the delivery of care. The parking at the [hospital] campus was becoming congested, more patients were seeking outpatient services and we needed to address the growing inpatient population,” said Doug Dean, CEO of Elliot Health Services.

Expansion of the Manchester hospital campus was first studied, but found to he inadequate, said CEO Rick Elwell.

“We looked at available property a quarter-mile and a half-mile out, but found negotiations with neighbors would be too costly and time-consuming.”

When the former Jac Par site along the Merrimack River in Manchester became available, Elliot found the property “perfect” for its needs, said Dean.

Most outpatient services currently housed on the 296-bed hospital campus – such as urgent care, physical rehabilitation and ambulatory surgery – will be moved to River’s Edge when it opens. Those spaces will be filled with possible additional operating room suites and more private inpatient rooms.

The residential and retail projects are a little less developed, said Elwell, but will probably have shorter construction times. Also, those projects may or may not be owned by Elliot, he added.

The ambulatory care project is also expected to bring in between 200 to 300 jobs. Some positions will betaken by existing employees as they relocate from the main campus to the new site.

Groundbreaking for the ambulatory care building is expected to take place this fall with construction anticipated to be finished summer of 2010. It will be owned by Elliot, with financing through a combination of tax credits, fund-raising and other vehicles.

Project principals include developer Anagnost Companies, Manchester and architect Cube 3 Studio of Lawrence, Mass.

***

Alice Peck Day Memorial Hospital/Harvest Hill, Lebanon

Project: The Woodlands at Harvest Hill

Estimated Cost: $28 million

Estimated Completion: Spring 2010

Alice Peck Day Memorial Hospital’s independent and assisted living community Harvest Hill in Lebanon is nearing ground-breaking for its new $26 million community – The Woodlands at Harvest Hill.

The project consists of 66 apartments, ranging in size from 790 square feet to nearly 2,200 square feet, with prices ranging from $260,000 to $622,000.

The four-story facility will include such amenities as weekly housekeeping services, a theater room, a salon, a daily meal and a swimming pool. Some apartments will even have terrace views.

Independent living retirement communities have become a popular choice for seniors who wish to remain independent but have the safety and security of home care when necessary.

Three years in the planning, when the final approvals were made in December 2007, it proved to be a popular one.

“We’ve already sold more than half of the apartments,” said Ron Andrews, adnministrator of Harvest Hill.

The groundbreaking ceremony is scheduled for Aug. 20, with an estimated completion date of spring 2010.

The Woodlands was designed by UK Architects of Hanover. Construction management is being provided by Trumbull-Nelson of Hanover.

When the situation calls for a higher level of care, she said, residents can transition easily to Alice Peck Day’s Elizabeth S. Hughes Care Unit at Harvest Hill, which also is undergoing renovations.

Five apartments will be reconfigured into seven private rooms with baths. Two nurses will be dedicated to the unit 24 hours a day.

Project costs for the unit renovations are estimated at under $1 million. Much of it has been financed by donations, including at $500,000 donation by Jim Hughes in memory of his wife Elizabeth.

***

New London Hospital, New London

ProjeW: New medical office building; Expansion/Renovation

Estimated Cost: $21 million

Estimated Completion: Phase I – November 2008; full project May 2009

New London Hospital is nearing completion of the first phase of an expansion/renovation project encompassing some 60,000 square feet.

This first portion of the project consists of 46,000 square feet of new construction and is expected to be complete in November. Renovation of some 14,000 square feet of existing space will take place in the following months, with a project completion date of May 2009.

Bruce King, president of the hospital, said the project has four main goals: converting semi-private inpatient rooms to private rooms; tearing down an adjacent free-standing medical office building and constructing a new, attached medical office facility; expanding areas for specialty services; and reuniting departments currently located in leased spaces back to the campus.

A new chapel, an interior connection for a mobile MRI unit, a new patient entrance, and additional parking will also be added.

Despite one of the worst winters on record and hitting granite ledge, King credits the project’s construction team, especially Engelberth Construction of Keene, N.H., and Colchester, Vt., for keeping the project on budget and on track.

Other principals on the project include architect Lavallee/ Brensinger, Manchester, and engineers Clough, Harbour & Associates, Keene.

The $21 million project is being financed through a $15 million bond from the New Hampshire Health & Educational Facilities Authority, and a $7.2 million capital campaign, through which $6.3 million has been raised to date.

Copyright Business Publications Inc. Aug 1, 2008

(c) 2008 New Hampshire Business Review. Provided by ProQuest LLC. All rights Reserved.

By Jennifer Gomez

WAS it a coincidence that a teacher who verbally abused her students and a doctor who slapped a patient were of a different race from their victims? Or is race the fundamental issue here? A third possibility could be that the `rat race’ has led

anger levels to go out of control. JENNIFER GOMEZ examines the issue.

BLAME it on stress.

That’s what two mental health experts feel caused the incidents, involving a doctor and a teacher.

Clinical psychologist Urmilah Dass said stress and personal problems could have led to the teacher verbally abusing the students in Klang and the University Malaya Medical Centre doctor slapping her patient.

“We are (however) reacting to racial connotations, which we shouldn’t.

“For the students who were verbally abused, telling them the reason the teacher acted that way towards them was because they are Indians will leave a negative impression.

“They will grow up thinking this way and the racial issue will be carried on into the future.”

She said a child’s support system, which included teachers, parents and relatives, should play down the issue of racism.

Dass added that it was impossible to say for sure what prompted the teacher to hurl the abuses but stress and personal problems might have been factors.

She said it was important for teachers to have a certain level of psychological fitness. This had to be inculcated during their training in college.

“Children and adolescents are going through many developmental changes in their lives. As such, there can be behavioural issues.

“If stressful situations with youngsters occur, a teacher should be able to address them with a clear mind.”

Dass added that if a teacher was short-tempered and picky by nature, maybe he or she should re-evaluate his career decision or seek help to counter these traits.

As for the doctor who slapped the patient, Dass said that stress, lack of sleep and improper nutrition could be possible reasons for a professional to lose her cool like that.

“In government hospitals, doctors work long hours and they often lack sleep.

“This is why it is important for government servants to attend retreats and training sessions every now and then, to revive themselves so they are psychologically healthier and do not do something they may regret when they get angry,” she added.

Damansara Specialist Hospital consultant child and family psychiatrist Dr Kasmini Kassim said the rat race was prompting people to lose their temper.

She also felt that the situations quoted above had nothing to do with race.

“Getting angry is human nature. A person’s level of patience and tolerance is eroding given the rat race climate now.

“People are just working too hard and it’s getting to them.”

She said parents often went home and took out the anger they felt towards their bosses on their children.

Kasmini’s solution therefore has to do with a big pile of newspapers.

“Walk away from trouble, go find a big heap of newspapers and tear it all up. I advise a lot of my patients to do this.

“And when you come back to the person who was annoying you, you will be calmer and able to discuss matters.”

She said taking a break did not include going for a drive or kicking a door.

“These actions could hurt you. So, the soft pile of newspapers is the best option.”

Consultant psychologist Valerie Jaques said the question was what gave the teacher the confidence to speak in a derogatory manner to her students.

“This teacher obviously felt she had some power to do this.”

Jaques said a possible reason for this feeling of power could be derived from the fact that political parties in Malaysia were race- based.

She said a possible solution included putting in place proper disciplinary procedures for government servants and for punishment to be meted out in a transparent manner.

“In this teacher’s case, instead of just being slapped on the wrist with a transfer, she should be investigated and evaluated.

“But here, there is no disciplinary action because although she is transferred, she still gets her salary, her bonuses and so on.

“And she could go on to do the same thing at the next school.”

(c) 2008 New Straits Times. Provided by ProQuest LLC. All rights Reserved.

Manufacturing

Ferro Glass Systems named senior scientist Sean Weir product manager of SpecTruLite heavy-metal-free organic inks and coatings, a newly-created position.

Somerset Welding & Steel Inc. appointed Jeff Reeping industrial sales representative.

Accounting

McClintock & Associates added Michael Musilli as a senior tax accountant in its tax practice and Clif Chioda and Rachel Calvin as staff accountants in its audit practice.

Legal

Matthew D. Haydo joined the Pittsburgh office of Hull McGuire PC as a corporate associate.

The Pittsburgh office of K&L Gates LLP welcomed David A. Grubman as a partner in the firm’s corporate, mergers & acquisitions and securities practice. Grubman advises public and private clients in a range of industries.

Advertising and PR

The Pittsburgh office of Mullen welcomed Lauren Fulcher as a senior account executive and Jessica Zachar as a public relations assistant account executive in the consumer engagement department. Hallie Ban was promoted to assistant media planner/buyer.

Health care

The Washington Hospital appointed Dr. Wenhui Cao medical director of its acute rehabilitation unit. She is board certified in physical medicine and rehabilitation.

Weirton Medical Center appointed Kevin D. Brown director of communications and public relations.

Barbara VanKirk, president and owner of IQ Inc., was named to the board of directors of Forbes Health Foundation, The Western Pennsylvania Hospital, Forbes Regional Campus.

Dr. Jamil C. Mohsin joined Butler Health System’s Cardiovascular Consultants practice at BHS Whole Health, Rose E. Schneider Family YMCA, Cranberry. He is board certified in internal medicine, cardiovascular medicine and nuclear cardiology.

Nonprofits

Leslie Osche, executive director, United Way of Butler County, was elected vice chair of the board of directors for United Way of Pennsylvania.

Gerard Pompa, vice president and general manager of Compunetix Inc., communications systems division, was selected as a member of the board of directors of Interactive Multimedia Collaborative Communications Alliance.

James L. Aiello is now chief operating officer of the Institute for Research, Education and Training in Addictions and director of the Northeast Addiction Technology Transfer Center, an institute affiliate.

Other

Brad Knapik, project engineer with Landau Building Co., passed the LEED Professional Accreditation Exam.

Carl T. “Ted” Sonnie joined Dave Smith Chevrolet in Penn Hills as a sales and leasing consultant.

Space Florida appointed Bernie McShea vice president of business development.

Erdman Anthony hired Scott Crone as a structural designer in its Harrisburg-based transportation group.

At Verizon’s Wireless Zone of Ross Township, Caitlin McKernan was promoted to sales representative and Nicky Ruperto was hired as a sales representative.

Joseph Curtin was named vice chairman of Tube City IMS LLC. He will continue as chief operating officer of the raw material, scrap processing and optimization group.

Officers named for Pennsylvania Association of Credit Management: chairperson, Kevin R. Cook, Centimark Corp.; president, Harold D. Booth, Pennsylvania Association of Credit Management; first vice chairperson, Corrie J. Zettle, Sports Essentials; second vice chairperson, William Clinefelter, IA Construction Corp.; and treasurer, Frank B. Buckstein, Del Monte Foods.

Awards

Schnader Harrison Segal & Lewis LLP recognized attorney Judith F. Olson with its first Earl G. Harrison Community Service Award.

John Weir, board certified hypnotist and president of The Hypnosis Center for Motivation and Habit Management, won the Charles Tebbetts award at the National Guild of Hypnotists Annual Convention.

New business

Kathryn’s Country Gift Shoppe, owner, Suzie Mattey. Located just beyond Bill’s Golf Land on Route 51 South in Rostraver. Open 11 a.m. to 5 p.m. Tuesdays through Saturdays. 724-929-9700.

Personnel Moves is a listing of promotions, hirings and other personnel actions at area companies. Submitted items should include contact names and telephone numbers. Photographs should bear the names of the individuals. Items may be mailed to: Personnel Moves, Pittsburgh Tribune-Review, D.L. Clark Building, 503 Martindale St., Pittsburgh, PA 15212, faxed to 412-320-7921 or e-mailed to [email protected].

Originally published by The Tribune-Review.

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