Einstein Was an Image Streamer

By Rajen M.

THERE are basically two types of meditation and they are diametrically opposed to each other.

One is passive and the other dynamic. One attempts to still the mind while the other follows the vagaries of the mind and the thoughts that go with it.

Most people are familiar with passive meditation. However, the concept of dynamic meditation – called “image streaming” by researcher and educator, Win Wenger, is less well known.

As discussed last week, this is a type of medication that Einstein may have used. Except that he described it as “vague play” with “signs”, “images”, and other elements, both “visual” and “muscular”.

“This combinatory play,” he wrote, “seems to be the essential feature in productive thought”.

Win Wenger’s project of the last 25 years has been to develop techniques and mental exercises, based in part on Einstein’s methods. These work in the short term and seem to develop the mind’s permanent powers.

The Image Streaming technique that Win Wenger developed opens the mind to a flow of symbolic imagery as potent as that of any dream.

However, unlike dreaming, you can practise image streaming while wide awake. Best of all, you can do it virtually any time, anywhere.

Ten minutes of image streaming per day will suffice to induce profound, positive change in your life.

Here are some simple rules and then you and your loved ones can get started.

The first “commandment” of image streaming is to describe the images that come to you aloud. For better effects, have someone listen or use a tape recorder.

The second “commandment” is to use all five senses. Be as descriptive as you can. This seems to increase intelligence. This works very well with kids.

The third “commandment” is surely to “use the present tense”. Describe as it happens. The faster you do it the better. It is a “live telecast”.

The impact on the brain and consciousness is phenomenal.

Even if the image has already vanished from sight, you should never say, “I saw such-and-such,” in your description. Always phrase it, “I see such-and-such”, or “I am looking now at such-and-such”.

The idea here is to “connect” all the different parts of your brain at once.

Through speech and imagination, an image streamer talks, listens, sees, smells, tastes, feels, analyses, reflects, wonders, creates and generates mental imagery all at the same time.

This unusual combination of activities spans harmonises many opposing “poles” of the brain. After all, intelligence is all about increasing the usage of the many and diverse parts of the brain.

Over the past 15 years, the quest to achieve balance between the brain’s analytical left hemisphere and its creative, pattern- sensing right hemisphere has become a fad.

Describing the brain as divided merely between left and right has been overplayed and unduly simplified. Important functions are just as likely to be separated between top and bottom or front and back.

But any activity that links opposite sides, or “poles”, of the brain contributes toward the brain’s balance and increases its resources. Image streaming is one of many possible “Pole-Bridging” exercises.

The value of image streaming was given some unexpected confirmation in a preliminary experiment at Southwest State University in Marshall, Minn, in 1988.

Physics professor Dr Charles P. Reinert asked 79 of his first year students to compare the effect of two mental exercises on IQ. Half the students used the Whimbey Method, a standard programme that uses word problems to build analytical skills.

For each hour of study, these students’ IQ scores gained .4 of a point. The other group used image streaming – they gained more than twice that, or .9 points.

Some people – about 30 per cent of the population – have difficulty with visualising with their eyes closed.

Imagery comes more easily in a relaxed, but alert, state. A simple method for attaining this state is “Velvety-Smooth Breathing”.

Close your eyes and keep them closed for the next 10 minutes. Don’t look for any images. You’ll just aggravate yourself if you can’t find them.

Focus instead on your breathing. Breathe in and out so smoothly that there is no pause between the “in” breath and the “out” breath. It is just one, long continuous, flowing b-r-e-a-t-h, like a slow, sensuous sigh.

Let it stroke you, as you might stroke a smooth piece of velvet. Then, with your eyes closed, try describing a familiar person or object in great detail: your mother, your child, or your spouse. Then describe the Taj Mahal or another interesting building.

Now, having read the instructions for Velvety-Smooth Breathing, please actually try the technique before moving on.

Like passive meditation, image streaming is also very relaxing.

It also improves the mood and state of mind. It also seems to improve sleep and state of health.

* Datuk Dr Rajen M. is a pharmacist with a doctorate in holistic medicine. Email him at [email protected]

(c) 2008 New Straits Times. Provided by ProQuest LLC. All rights Reserved.

What to Juice and Why

By Denice Moffat

DURING a juice fast, select juicing materials and teas specific to your health conditions, choose the fruits on the highly beneficial and neutral foods lists specific to your blood type.

Organic vegetables are the best type to use, but if you can’t find or afford those, wash whatever you can find thoroughly before juicing them. And, if you don’t know your blood type, here is a short list of vegetables juices with the maladies they are good for:

Vegetable Juices:

* Asparagus – Kidneys, diuretic, blood purifier, bowel health, soothes nervous system (Note: urine will turn dark and have a different odor to it when you eat or drink a lot of asparagus. This is normal and harmless and will pass.)

* Beet greens – Gallbladder, liver, osteoporosis.

* Beets – Blood cleanser, liver cleanser, menstrual problems, arthritis, lymph glands, flushes the kidney and bladder, and is good for low blood pressure. (Note: never drink it straight as it can temporarily paralyze your vocal cords, cause hives, increase the heart rate and give you alternating chills and fever. Hmm – sounds like a good reason to stay away from beets altogether! They sure do taste “earthy.”)

* Brussels sprouts – Good for diabetics and hypoglycemia, makes for healthy skin, increased male potency and stomach ulcers.

* Cabbage – Colitis, ulcers, and it curbs alcohol cravings. (Note: Do not store cabbage juice because its Vitamin U content can be quickly lost.)

* Carrots – Eyes, liver problems, high cholesterol, protects skin from UV rays, nervous problems (like Multiple Sclerosis), arthritis, osteoporosis, and low blood pressure.

* Cauliflower – Breast cancer

* Celery – Kidneys, diabetes, osteoporosis, good for people who sweat in excess, muscle cramps, fatigue, anxiety, stress, insomnia, headaches, air pollution, sweet cravings, low blood pressure, and obesity.

* Comfrey – Intestines, hypertension, osteoporosis.

* Cucumber – Edema, diabetes, tendonitis, skin tone, muscle tone, complexion problems, poor nail growth.

* Dandelion Greens – Spring tonic, strengthens blood and bones, increases stamina and energy. (Note: eat them early in the summer as they get bitter as they age.)

* Fennel – Night blindness, eye disorders, flatulence, blood strengthener, migraines, nausea.

* Garlic – Allergies, colds, hypertension, cardiovascular disease, high fats, diabetes, immune booster, anticarcinogen, antibacterial, antifungal, rids body of toxins through the skin, low blood pressure.

* Ginger root – Circulation, motion sickness, nausea, laryngitis, clears mucous in the throat, sinuses and lungs.

* Greens (Collard, Mustard, Turnip, Kale, Parsley, Spinach, Turnip, Chard) – Cardiovascular disease, skin, eczema, digestive problems, obesity, breath. (Note: Greens contain more than 100% of the RDA for Vitamin C and Vitamin A)

* Jerusalem artichokes – Diabetes.

* Jicama – Sooths upset stomachs, osteoporosis/osteopenia, and hemorrhoids.

* Kale – Constipation, bladder problems, arthritis, also see Greens.

* Lettuce – Lung cancer prevention, hair and nail strength, skin problems.

* Onion – Normalizes nervous system for sympathetic dominance, stimulates beneficial bacteria, breaks up mucous, low blood pressure.

(Note: If you juice onions, put them in the juicer first THEN the other vegetables so the odor does not stay on the juicer parts.)

* Parsley – Kidneys, edema, arthritis, tendon and ligament problems, osteoporosis (has lots of natural calcium), one of the most nutritious foods in the world, boils and cysts, increases oxygenation of the blood, bad breath, stimulates normal peristalsis of the gut, vision problems, adrenal exhaustion, thyroid disease, obesity.

* Potatoes – Intestines, ulcer.

* Radish – Liver, high cholesterol, obesity, sinus problems, clears excess mucous, soothes sore throats.

* Spinach – Anemia, eczema, regenerates damaged intestinal tracts, constipation, circulation problems, cleans liver and glands.

* Sprouts – Baldness, morning sickness.

* String beans – Bruising.

* Sweet potatoes – Any kind of skin problems.

* Tomatoes – Use them alone or leave them alone, but adding celery and cucumber to it works fine.

* Watercress – Anemia, colds.

* Wheat grass – Anemia, liver, intestines, breath, excellent antioxidant, Parkinson’s disease.

* Zucchini – internal cleanser, fantastic as a mineral supplement.

Which vegetables are you most drawn to eating? Now I hope you know why. Happy juicing!

Dr. Denice Moffat is a practicing naturopath, medical intuitive, and veterinarian working on the family unit (which includes humans and animals) through her phone consultation practice established in 1995.

Check out her website at http://www.NaturalHealthTechniques.com with a free internationally distributed monthly newsletter. To read more articles about juicing, fasting, dry brushing and enemas, go to: http:// www.naturalhealthtechniques.com/HealingTechniques/ healing_techniques1.htm

(c) 2008 New Straits Times. Provided by ProQuest LLC. All rights Reserved.

10 Killed As Plane Crashes After Takeoff in Utah

By PAUL FOY

By Paul Foy

The Associated Press

MOAB, Utah

A small plane crashed and burned shortly after takeoff, killing everyone on board, including the pilot and nine people who had spent the day working at a skin cancer clinic in a remote community.

The twin-engine Beech King Air A-100 crashed shortly after takeoff Friday evening from Canyonlands Field airport, 18 miles northwest of Moab. It hit the ground in nearby hills, flattened and exploded on impact, authorities said.

Emergency responders rushed to the site to search for possible survivors and fight a brush fire that was apparently sparked by the crash.

On board were employees of a Southwest Skin and Cancer/Red Canyon Aesthetics & Medical Spa, a dermatology company based in Cedar City, 200 miles to the west, that traveled to remote areas to provide treatment for skin cancer and other ailments where it might otherwise be unavailable.

They had flown into Moab earlier Friday. The tourist town was among nine regular stops the team made throughout Utah, northern Arizona and Nevada.

Crews on Saturday sifted through the wreckage on a small rise about 2 miles from the runway. Bodies were placed in body bags and carted away.

Grand County Sheriff James Nyland identified those killed as pilot David White; the company’s director, Dr. Lansing Ellsworth, 50, and his son Dallin Ellsworth, 23; David Goddard, 60, and his daughter Cecilee Goddard, 31; Mandy Johnson; Marcie Tillery, 29; Valerie Imlay, 52; Keith Shumway, 29; and Camie Vigil, 25.

“It is with disbelief that we struggle to comprehend the events of yesterday,” the Ellsworth family said in a statement issued Saturday afternoon. Those from the company “provided much needed dermatology care to patients who might otherwise go without.”

Linda Snow, the company’s office manager in Cedar City, said: “We are just deeply saddened. These are individuals that were highly skilled and very professional in what they do, and they will be missed.”

The airplane is owned by Leavitt Group Wings, part of the Cedar City-based Leavitt Group, an insurance brokerage. The dermatology group had a time-share agreement for use of the plane, said CEO Dane Leavitt.

the crash

The Beech King Air A-100, carrying a pilot and nine people, crashed after takeoff Friday night from an airport near Moab, Utah. There were no survivors.

Originally published by BY PAUL FOY.

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

Russian Steelmaker to Buy PBS Coals in Somerset

Russia’s biggest steelmaker plans to buy fast-growing PBS Coals, which counts the Quecreek Mine among its operations in Somerset County.

OAO Severstal of Cherepovets, Russia, said Friday it will acquire PBS for $1.3 billion to supply its U.S. operations with coking coal.

Severstal, led by billionaire Alexei Mordashov, follows steelmakers including ArcelorMittal and Posco in acquiring coal mines after a year in which steel and coal have doubled to record prices. Steelmakers have boosted production to satisfy greater usage in China and India.

“The big steel companies are getting concerned about getting the raw materials — the coal and iron ore — that they need,” said Robert Scott, CEO of Somerset-based PBS. “They are starting to buy up the resource companies.”

The 45-year-old company runs six surface and six underground mines, all within about a 15-mile radius in Somerset County.

One operation is new this year, and another two underground “drift” mines are to open by year’s end, Scott said. Drift mines tunnel into a coal seam from a hillside and don’t need shafts.

So far this year, 110 new employees have been hired, and 55 are to be added by the end of 2008, he said. PBS has a total 630 employees.

The company has an annual capacity of more than 4 million metric tons of coking coal, and produces thermal coal. Severstal said it plans to complete the purchase in mid-October, which involves buying a combination of PBS and Penfold Capital Acquisition Corp. for $7.93 a share.

PBS’s best-known mine is Quecreek, which flooded in 2002 and nearly killed nine miners. Millions watched on live TV as the men were rescued one by one, after being trapped for 76 hours underground.

Quecreek — reviewed, rehabilitated and improved after the accident — remains the company’s top-producing mine, and likely is one of the country’s safest, said Scott, who has been with the company for 23 years. “Most of the guys who were there and some of the ones who were trapped are back working,” he said.

Still, lawsuits against PBS over the Quecreek accidents, blamed largely on faulty underground maps submitted to regulators before the excavation, could go to trial later this year in Allegheny County Common Pleas Court.

Gregory Mason, Severstal’s chief operating officer and head of its international division, said yesterday the PBS acquisition will help ensure the steelmaker controls costs “by providing a guaranteed supply of metallurgical coal.”

Severstal is expanding in the United States to take advantage of a weaker dollar, which has made the nation’s steel exports more competitive.

The company, ranked fourth among steelmakers in the United States, spent $950 million this year on an ArcelorMittal plant near Baltimore and WCI Steel Inc., based in Warren, Ohio, and this month acquired Wheeling-Pittsburgh Steel parent Esmark Inc. for $1.25 billion. The steelmaker runs a mill in Dearborn, Mich., that supplies Ford Motor Co., and the SeverCorr factory in Columbus, Miss.

The PBS transaction comes amid quickening consolidation in the U.S. coal industry. ArcelorMittal, the world’s largest steelmaker, agreed to buy West Virginia-based Mid Vol Coal Group on June 23 to add more than 85 million tons of reserves, for example.

Scott said PBS is due to go public in about three weeks on the Toronto Stock Exchange. There was concern, before the acquisition agreement, that “if our shares were out there, that we could be bought by anybody,” he said.

The Severstal relationship ensures PBS will have an outlet for its coal, even in future down times for the industry, Scott said. “It is going to create stability, and with their desire to grow the company this is a great opportunity,” he said.

Originally published by Staff and wire reports.

(c) 2008 Tribune-Review/Pittsburgh Tribune-Review. Provided by ProQuest LLC. All rights Reserved.

Factors Predictive of Signed Consent for Posthumous Organ Donation

By Godin, Gaston Belanger-Gravel, Ariane; Gagne, Camille; Blondeau, Danielle

Context-The shortage of organs for transplantation has led public health authorities to invest significant efforts in the promotion of organ donation. Objective-To identify factors predictive of signed consent for posthumous organ donation by using the theory of planned behavior.

Participants and Design-A random sample of 602 adults completed a questionnaire at baseline, and behavior was self-reported 15 months later.

Results-Logistic regression indicated that intention, perceived behavioral control, moral norm, and past behavior were factors predictive of consent for posthumous organ donation. Participants’ perceived behavioral control, past behavior, and moral norm were also predictive of intention to sign, but attitude and perceived barriers were 2 additional determinants. Finally, anticipated regret and knowledge of persons who had made an organ donation were 2 moderators of the intention-behavior relationship.

Conclusion-Overall, the results showed that intention is an important determinant of signing the organ donor’s consent sticker and also highlighted that moral consideration and perceived difficulties could be 2 potential avenues for designing interventions. (Progress in Transplantation. 2008;18:109-117)

In Canada, as in many other countries, the gap between the number of organs needed for transplants and the number of organs available is increasing.1 For those waiting for an organ, this shortage has dramatic consequences on quality of life and life expectancy.2 Among the strategies used to increase organ donation, offering financial incentives and applying presumed consent3,4 have been suggested. From an ethical point of view, however, these financial and juridical strategies are questionable, and they are not allowed in Canada.57 Thus, public health practitioners must rely on educational interventions or promotional campaigns to promote organ donation. In Quebec, a province of Canada, there are 2 major ways to consent to posthumous organ donation: (1) signing the organ donors register of the Chambre des Notaires du Quebec [Notary Chamber of Quebec] and (2) signing the organ donor’s consent sticker when renewing the health insurance card.

Much of the scientific literature on organ donation has focused on the study of willingness/intention to register as organ donors. In general, willingness to donate is linked to a set of salient beliefs (eg, religious, cultural, altruistic, and normative) mediated by attitude toward becoming a donor.8 However, according to these authors, longitudinal studies based on strong theoretical foundations are needed. Likewise, many authors argue that the lack of theory-based studies may provide a potential explanation for the limited success of interventions aimed at promoting health-related behavior.9

More recent studies based on Bandura’s social cognitive theory10 suggest that past behavior, as well as the perception of positive and social outcomes and selfefficacy, should be considered to increase willingness to sign as an organ donor.11,12 Along the same line of thought, attitude, subjective norm, and perceived behavioral control, 3 variables of the Ajzen theory of planned behavior (TPB),13 as well as moral norm, were additional determinants of intentions related to organ donation in adults.14 Notwithstanding these findings, in a recent prospective study, researchers documented that a gap may exist between psychological predispositions toward organ donation and action.15 Indeed, they observed that many individuals who were willing to donate organs did not obtain their organ donor cards.

This lack of consistency between intention and subsequent behavior has been observed for several healthrelated behaviors.16 One explanation for this phenomenon could be the moderating effect of certain variables on this relationship. Previous studies on the moderating effect suggest that the intention-behavior relationship could be modulated by variables such as past behavior, anticipated regret, moral norm, and age.16-19 In the context of organ donation, however, only the moderating effect of religious beliefs has been documented.15

Thus, the aims of this study were (1) to identify the factors predicting the signing of the organ donor’s consent sticker among the general population in Quebec in reference to the TPB and (2) to test potential moderators of the intention-behavior relationship.

Theoretical Framework

In the present study, an extended version of the TPB was adopted (see Figure). According to the TPB, the immediate determinant of behavior is the intention to act. This intention is influenced by 3 main factors: attitude, subjective norm, and perceived behavioral control. Perceived behavioral control is defined as the degree of ease or difficulty with which a behavior can be adopted and can also directly predict behavior in parallel to intention when the behavior under study is not under volitional control (ie, when the adoption of the behavior requires skills, abilities, and resources). Attitude designates the individual’s favorable or unfavorable position toward adopting a specific behavior. Subjective norm corresponds to the subject’s perception of the level of approval or disapproval of important people or groups of people with respect to adoption of the behavior.

In the present study, additional variables known to contribute to either the prediction of behavior or intention also were considered. For instance, perceived barriers, anticipated regret, and moral norm were included in the theoretical framework (see Figure).20-22 Anticipated regret refers to an individual’s beliefs regarding the degree of regret, tension, or preoccupation one would feel if the targeted behavior were not adopted. Moral norm measures the sense of personal obligation toward adopting the behavior. It may be viewed as an expression of the core self, that is, individuals referring to their personal values and principles of conduct when deliberating the adoption of the behavior. Related to this latter variable, and based on previous research on ethics-related behaviors, constructs of autonomy, beneficence, and justice have been identified as subdimensions explaining moral norm.23 Beneficence is defined as “an action done to benefit others.”24(p166) More precisely, the “principle of beneficence refers to a moral obligation to act for the benefit of others.”24(p166) In other words, beneficence is associated with promoting the well-being of others. It is also related to the concept of nonmaleficence, which refers to the principle of not hampering others, of not causing them any harm or distress, of avoiding hurting them. Autonomy is the capacity of individuals to govern their lives and make their own choices. Finally, justice comprises 2 principles: commutative and distributive justice. These concepts are based on the recognition that all humans are equal and that social and natural imbalances must be corrected.

Finally, past behavior (eg, to have signed one’s card in the past), sociodemographic characteristics (eg, age, sex, education level, and marital status), and personal experience with organ donation such as knowing someone waiting for organ donation, knowing someone who received an organ, knowing someone who had made an organ donation, and knowing how to manifest consent to organ donation were considered, although their effect should be mediated through one or more of the main psychological factors explaining intention and predicting behavior.25

Materials and Methods

Population and Sample

The population targeted by this study was made up of individuals aged 18 years or older, living in Quebec, and likely to renew their health insurance cards in the coming year. A total of 2018 individuals were reached by phone by using a random digit number technique for the recruitment. Interviews were conducted by a firm specializing in telephone surveys. Before the questionnaire was completed, the purpose of the study, the right to refuse participation without consequence, and the confidentiality of responses were discussed. Among individuals reached, 918 (45.5% of participation rate) agreed to complete the questionnaire at baseline, but 30 did not agree to be contacted again for a follow- up on their behavior. Thus, among the 888 respondents who consented to be phoned again, a total of 625 respondents were successfully interviewed at follow-up. The others could not be reached or refused to participate. Also, 23 respondents were excluded because too much data was missing. Compared with the respondents included in the analysis (N = 602), those who were excluded were mainly male. No other significant differences were observed with respect to sociodemographic and psychosocial variables. This study was approved by the local university ethics committee.

Data Collection Procedure

At baseline, the interviews were conducted by a firm specializing in telephone surveys. The questionnaire was completed for those who agreed to participate. On average, this procedure lasted 12 minutes. At the end of the interview, respondents were invited to consent to be contacted by telephone 15 months later. At follow-up, respondents were asked if they had signed and applied their organ donor’s consent stickers on the back of their health insurance cards upon renewal (yes/no).

Questionnaire The questionnaire was developed following the guidelines specified by Ajzen and Fishbein26 and Godin and Kok,27 that is, the formulation of theoretical constructs (etic dimension) based on the beliefs and perceptions of the population under study (emic dimension). Behavior was defined as signing the organ donor’s consent sticker when renewing the health insurance card. The quality of the questionnaire was first verified among 10 individuals in the general population. They were asked to provide feedback and comments on item wording and clarity of questions; some modifications were made to the initial version of the questionnaire. Then, a 2-week test-retest reliability study was conducted among 53 respondents representative of the target population to determine internal consistency (Cronbach alpha coefficient) and temporal stability (intraclass coefficient). Items of the psychosocial variables, as well as their psychometric values, are presented in Table 1. Items of the subdimensions of moral norm that is autonomy (4 items, alpha= .81), beneficence (7 items, alpha = .96) and justice (4 items, alpha = .90) are described elsewhere.23

Statistical Analysis

A hierarchical logistic regression was performed to identify determinants of behavior (signing or not signing the organ donor’s consent sticker). Because the distribution of data was skewed, each variable was dichotomized at the median value. For the prediction of behavior, intention and perceived behavioral control were first entered into the model. Then, moral norm, anticipated regret, perceived barriers, and past behavior were included. Because the distribution of the dependent variable was skewed, a similar approach was used for the prediction of intention.

First, attitude, subjective norm, and perceived behavioral control were entered into the model. Next, moral norm, anticipated regret, and perceived barriers were added, followed by the sociodemographic variables and past behavior. For the preceding analyses, all potential predictors related at P

The moderating effect of some variables on the intention- behavior relationship was tested by using a 3-step hierarchical regression analysis.29-10 To test the independent contribution of each potential moderator (ie, moral norm, anticipated regret, the 3 ethical subdimensions of moral norm, past behavior, sociodemographic variables, and variables related to personal experience with organ donation), a model including the significant predictors of behavior identified in the previous steps was tested for each moderator and their interaction term. A moderating effect was detected if the interaction term reached statistical significance (P= .10) and if the log likelihood ratio indicated that the model was significantly improved (P

Results

Description of the Sample

The mean (SD) age of the sample (N = 602) was 41.6 (14.2) years. Most respondents were married (59.7%), were women (60.1%), and had completed at least some college education (70.1%). In this sample, 71.1 % of the respondents had signed a card to consent to organ donation. Results also showed that 90.0% of the respondents knew that they could consent to organ donation by signing the organ donor’s consent sticker. Finally, the majority of the respondents reported having very good or excellent health (69.3%).

Determinants of Behavior

Among the respondents, 391 (65.0%) had signed their organ donor’s consent sticker at the followup. For the prediction of behavior, 4 variables made a significant contribution: past behavior (P

Determinants of Intention

The median score of intention was 3.67. The logistic regression model showed that the following factors, in order of decreasing importance, were predictive of intention to consent to organ donation: past behavior of signing the organ donor’s consent sticker (P

Moderation Effects

Tests for moderating effect of the intentionbehavior relationship revealed that anticipated regret (P= .05) and knowing someone who had made an organ donation (P= .05) were 2 independent significant moderators of this relation (see Table 2, Models 3a and 3b). None of the other interaction terms were significant (data not shown). The intention-behavior relationship was verified separately for those who differed in their level of anticipated regret and for those who reported knowing or not knowing someone who had donated their organs. The results of these analyses are presented in Table 4. Contrary to expectation, the intentionbehavior relationship was weaker among those who had a higher level of anticipated regret. Deeper analysis of the relationship indicated that this was mainly due to the behavior of low intenders (chi^sup 2^= 13.08; P

A final model of behavior that included the 2 interaction terms was tested. All variables previously found to be significant predictors of behavior remained significant (see Table 2, Model 4), although moral norm (P = .05) was not significant but remained near significance.

Discussion

This prospective study provides useful information on the factors predicting behavior (not only intention) and potential moderators of the intention-behavior relationship. More specifically, the results showed that signing the organ donor’s card is predicted by intention, perceived behavioral control, moral norm, and past behavior, whereas the intention-behavior relationship is moderated by anticipated regret and knowing someone who has made an organ donation.

The contribution of intention and perceived behavioral control in the prediction of signed consent to organ donation is congruent with Ajzen’s TPB, and the importance of those factors as determinants of health-related behaviors has been confirmed in several meta- analyses.27,31 Past research, essentially based on cross-sectional studies, has placed much emphasis on the study of intention (eg, willingness) to consent to register for posthumous organ donation, but has not given much attention to its predictive power. The present longitudinal study confirms the important role of intention in predicting signed consent for posthumous organ donation, and our findings are well aligned on a quantitative summary of a number of meta-analyses showing that a significant portion of the variance in behavior is accounted for by intention.16 Thus, our results highlight the relevance of understanding determinants of intention, as this information can guide the development of interventions and promotional strategies to increase the motivation of potential organ donors.

To our knowledge, this study is the first to report that perceived behavioral control is a determinant of signed consent for posthumous organ donation. Recent research indicates that perceived behavioral control is actually an amalgamation of 2 constructs: perceived difficulty and perceived control.32,33 In the present study, the concept of perception of control referred to the perceived difficulty dimension. Thus, individuals who evaluated providing consent for posthumous organ donation as a simple act were more likely to sign the sticker of their health insurance cards at renewal.

Moral norm was also identified as a direct predictor of behavior. Within social cognitive theories, it has been documented that moral norm adds to the understanding of intention31,34 and certain healthrelated behaviors.35,36 However, the vast majority of studies that showed an impact of moral norm on intention did not show a similar impact on behavior, at least when intention was included in the analysis. Although the current study does not provide explanations for this direct effect, an attempt to conceptualize the way in which moral norm impacts on behavior can be found in the norm- activation theory (NAT).37 Schwartz and Berkowitz37(p231) argue that it is likely that many individuals adopt specific behaviors by conviction; that is, because they feel a moral obligation to adopt them: “Individuals sometimes act in response to their own self- expectations, their own personal norms.” According to NAT, a given behavior is adopted not because of the expected outcomes of performance, but for more internalized feelings that can be captured by the concept of moral norm. Schwartz and Berkowitz proposed that these personal norms are not experienced as intentions, but as feelings of moral obligation, and so can directly influence behavior. Obviously, signed consent for posthumous donation also involves dimensions other than a more rational statement of intention and perceived behavioral control. Similar to what has been observed for other altruistic behaviors,38,39 past behavior was an important determinant of signed consent for posthumous organ donation. Although past behavior is not a modifiable target for intervention, it is likely that those who signed their cards in the past will sign them again in the future. To date, the mechanism by which past behavior influences future behavior is not well understood. One possible explanation is the development of a habit; that is, as the past behavior increases, the influence of this variable on future behavior also increases.40 However, since the frequency of renewal is relatively modest in the present context (ie, about every 4 years), it would be difficult to accept that the frequency of past behavior exerted such an effect. The present study does not provide specific explanations for this effect. Results support the relevance of offering specific interventions aimed at promoting willingness to register as a potential posthumous organ donor in adolescence to develop lifetime habit in youth. Examples of such successful interventions can be found in scientific literature.41-43

Because intention is a significant predictor of behavior, the examination of the determinants of this variable helped to identify promotional strategies to increase the motivation of potential organ donors. As was the case for the prediction of behavior, perceived behavioral control and past behavior were determinants of intention; these 2 factors were discussed earlier. Additional factors explaining intention were attitude, perceived barriers, and moral norm (or beneficence).

Most scientific reviews of willingness to consent to become a potential organ donor have reported that attitude is one of the main factors explaining this decision.8,44 The present findings are no exception to this conclusion and confirm its contribution to explaining intention. This suggests that persuasive messages about the positive consequences of organ donation still represent an interesting approach to promoting this behavior. Nonetheless, attitude is not alone, and other variables share the same weight in the explanation of intention. According to Ajzen,13 perceived behavioral control should mediate the effects of perceived barriers on intention. However, a recent meta-analysis found significant relationships between perceived barriers and intention after perceived behavioral control had been taken into account.20 The results of this study support this hypothesis. Consequently, perceived barriers enhance the level of explained variance in intention and should be considered in future studies aimed at predicting the intention of individuals toward organ donation. Among the barriers identified was the fear of one’s body being mutilated and the fear of not having done everything possible to save one’s life. These 2 items are quite similar to the perceived negative outcomes of registering as an organ donor reported among Dutch adolescents.11,12 Obviously, such barriers should be considered in future promotional strategies. In particular, special attention should be given to explaining legal procedures that must be followed for the determination of death before organs are taken from the dead body.

Interestingly, the present study showed that beneficence, a subdimension of moral norm, was predictive of intention beyond the global assessment of moral norm or other psychosocial determinants. Hence, it seems important to assign importance to ethical variables in future research to study behavior that has a moral connotation. The contribution of beneficence to the explanation of intention confirms the view of Radecki and Jaccard8 that the person who agrees to sign his/her organ donor card is actively involved in an altruistic act. In the context of organ donations, a person could sign a donor card with the altruistic goal of doing a good deed for another person with the intention of improving that person’s quality of life. From a practical point of view, this suggests that more interventions should promote the idea of personal commitment to donate by signing the donor card. In this regard, persuasive messages encouraging individuals to make a decision regarding posthumous donation are effective.45 It might be suggested that focusing on the potential positive effects of organ donation on others’ lives (eg, saving a mother of 3 children or saving a child’s life) could stimulate individuals to consent to organ donation.

In the present study, anticipated regret and knowing someone who donated 1 or more organs were identified as moderators of the intention-behavior relationship. We observed a surprising effect for the moderating effect of anticipated regret: the intention-behavior relation was weaker among those who anticipated regret if they did not sign their organ donor’s consent stickers than among those who did not anticipate regret. The analysis of this relationship showed that this effect was attributable to the low intender group. Indeed, low intenders who did not anticipate regret did not provide consent for posthumous organ donation. On the other hand, low intenders who anticipated regret presented more variation in behavior at follow- up; that is, a significant proportion signed their cards at follow- up in spite of their negative intention to do so. In a recent study46 of adolescent smoking initiation, researchers also observed a similar moderating effect of anticipated regret. They found that participants who anticipated regret about starting smoking, although they had the intention to start smoking, were not consistent with their initial intention and were more likely not to smoke at follow- up. In the context of the present study, this result suggests that the absence of anticipated regret supports the decision not to sign, whereas the presence of anticipated regret creates ambiguity in the decision. As a consequence, someone who anticipates regret is more likely to sign a consent for posthumous organ donation. This result should, however, be confirmed in future studies. For intervention purposes, it might be suggested that a specific message such as: “Don’t regret not doing it, just sign it to give life!” could be used to invite individuals to sign their organ donor’s consent stickers on the back of their health insurance cards.

Knowing someone who has donated 1 or more organs was the other moderator identified in the present study. Thus, knowing someone who has donated organs is likely to make the need for organ donations more salient. This finding offers an avenue for intervention, as suggested by recent findings.43,47 For instance, Smits et al43 showed that an intervention provided by kidney transplantation patients was successful in encouraging adolescents to make a well- considered choice with regard to registering as potential posthumous organ donors.

A few limitations of this study must be noted: the response rate, social desirability bias, and cultural factors. The response rate does not allow the results to be generalized to the general population, and it is possible that respondents were more positive toward the topic of the study than one would expect from the general population. Those who refused to participate might have responded differently and most likely more negatively than the cohort of this study. For instance, 65% reported having signed to provide consent for posthumous organ donation, a proportion much higher than the known proportion in the population (at about 28%).48 All possible precautions were taken to avoid social desirability bias, but this bias still might have affected some participants’ answers. Finally, diverse cultural factors such as religious beliefs44 or race49 can affect organ donations. The present study was conducted among a predominantly white and Catholic population. In other words, a cultural context different from the study setting might have revealed a different interplay of factors.

To conclude, this prospective study provides a better understanding of the factors predicting behavior. In particular, it shows that intention is an important determinant of signing to provide consent for organ donation, whereas moral considerations influence both behavior and intention to provide consent for posthumous organ donation. Overall, the present study provides interesting avenues for designing interventions aimed at promoting signed consent for posthumous organ donation.

Acknowledgments

We thank Leo-Daniel Lambert for his technical assistance in the statistical analysis and Isabelle Martineau for project coordination.

Financial Disclosures

Gaston Godin holds a Tier 1 Canada Research Chair in Health Related Behaviour, Laval University. This work was supported by a grant from the Canadian Institutes of Health Research (grant no. 43932).

References

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2. Sim KH, Marinov A, Levy GA. Xenotransplantation: a potential solution to the critical organ donor shortage. Can J Gastroenterol. 1999;13(4):311-318. 3. Rosner F, Henry JB, Wolpaw JR, et al. Ethical and social issues in organ procurement for transplantation. N Y State J Med. 1993;93(1):30-34.

4. Kittur DS, Hogan MM, Thukral VK, McGaw LJ, Alexander JW. Incentives for organ donation? The United Network for Organ Sharing Ad Hoc Donations Committee. Lancet. 1991;338(8780):1441-1443.

5. Council on Ethical and Judicial Affairs; American Medical Association. Ethical issues in managed care. JAMA. 1995; 273(4):330- 335.

6. Dossetor JB, Manickavel V. Ethics in organ donation: contrasts in two cultures. Transplant Proc. 1991;23(5):2508-2511.

7. Keyserlingk EW. Human dignity and donor altruism-are they compatible with efficiency in cadaveric human organ procurement? Transplant Proc. 1990;22(3): 1005-1006.

8. Radecki CM, Jaccard J. Psychological aspects of organ donation: a critical review and synthesis of individual and next- ofkin donation decisions. Health Psychol. 1997;16(2):183-195.

9. Bartholemew L, Parcel G, Kok G, Gottlieb N. Planning Health Promotion Programs: An Intervention Mapping Approach. 2nd ed. Etobicoke, Ontario: John Wiley & Sons Canada Ltd; 2006.

10. Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977;84(2): 191-215.

11. Brug J, Van Vugt M, Van Den Borne B, Brouwers A, Van Hooff H. Predictors of willingness to register as an organ donor among Dutch adolescents. Psychol Health. 2000; 15(3):357-368.

12. Reubsaet A, Brug J, van den Borne B, van Hooff H. Predictors of organ donation registration among Dutch adolescents. Transplantation. 2001;72(1):51-56.

13. Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process. 1991;50:179-211.

14. Hubner G, Kaiser F. The Moderating Role of the AttitudeSubjective Norms Conflict on the Link Between Moral Norms and Intention. Eur Psychol. 2006; 11(2):99-109.

15. Ashkenazi T, Miniero G, Hornik J. Exploring the intentional gap between signing an organ donor card and actual behavior: comparing the Jewish State and Christian Italy. J Int Consum Mark. 2006;18(4):101-121.

16. Sheeran P. Intention-behavior relations: a conceptual and empirical review. Eur Rev Soc Psychol. 2002;12:1-36.

17. Ferguson E, Bibby PA. Predicting future blood donor returns: past behavior, intentions, and observer effects. Health Psychol. 2002;21(5):5130 -518.

18. Godin G, Conner M, Sheeran P. Bridging the intentionbehaviour ‘gap’: The role of moral norm. Br J Soc Psychol. 2005;44(4):497- 512.

19. Sheeran P, Orbell S. Do intentions predict condom use ? Meta- analysis and examination of six moderator variables. Br J Soc Psychol. 1998;37:231-250.

20. Godin G, Gagne C, Sheeran P. Does perceived behavioural control mediate the relationship between power beliefs and intention? Br J Health Psychol. 2004;9(4):557-568.

21. Triandis HC. Values, attitudes and interpersonal behavior. In: Page MM, ed. Nebraska Symposium on Motivation. Beliefs, Attitudes and Values. Lincoln, NE: University of Nebraska Press; 1980:195-259.

22. Van der Pligt J, De Vries Nk. Expectancy-value models of health behaviour: the role of salience and anticipated affect. Psychol Health. 1998;13:289-305.

23. Blondeau D, Godin G, Gagne C, Martineau I. Do ethical principles explain moral norm? a test for consent to organ donation. J Appl Biobeh Res. 2004;9(4):230-243.

24. Beauchamp T, Childress J. Principles of Biomedical Ethics. 5th ed. NY: Oxford University Press; 2001.

25. Fishbein M, Ajzen I. Belief, Altitude, Intention and Behavior: An Introduction to Theory of Research. Reading, MA: Addison-Wesley; 1975.

26. Ajzen I, Fishbein M. Understanding Attitudes and Predicting Social Behavior. 1st ed. Englewood Cliffs, NJ: Prentice Hall; 1980.

27. Godin G, Kok G. The theory of planned behavior: a review of its applications to health-related behaviors. Am J Health Promot. 1996;11(2):87-98.

28. Hosmer D, Lemeshow S. Applied Logistic Regression. 2nd ed. New-York, NY: John Wiley & Sons, Inc; 2000.

29. Aiken L, West S. Multiple Regression: Testing and Interpreting Interactions. Thousand Oaks, CA: Sage Publications Inc; 1991.

30. Baron RM, Kenny DA. The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol. 1986; 51(6):1173- 1182.

31. Armitage CJ, Conner M. Efficacy of the theory of planned behaviour: a meta-analytic review. Br J Soc Psychol. 2001; 40(4):471- 479.

32. Trafimow D, Sheeran P, Conner M, Finlay K. Evidence that perceived behavioural control is a multidimensional construct: perceived control and perceived difficulty. Br J Soc Psychol. 2002;41(1):101-121.

33. Ajzen I. Perceived behavioral control, self-efficacy, locus of control, and the theory of planned behavior. J Appl Soc Psychol. 2002;32(4):665-684.

34. Manstead ASR, Terry DJ, Hogg MA. The Role of Moral Norm in the Attitude-Behavior Relation. Mahwah, NJ: Lawrence Erlbaum Associates; 2000:11-30.

35. Beck L, Ajzen I. Predicting dishonest actions using the theory of planned behavior. J Res Pers. 1991;25:285-301.

36. Godin G, Gagnon H, Lambert LD. Factors associated with maintenance of regular condom use among single heterosexual adults: a longitudinal study. Can J Pub Health. 2003; 94(4):287-291.

37. Schwartz SH, Berkowitz L. Normative Influences on Altruism. New York, NY: Academic Press; 1977:221-279.

38. Charng H-W, Piliavin JA, Callero P. Role identity and reasoned action in the prediction of repeated behavior. Soc Psychol Q. 1988;51(4):303-317.

39. Armitage CJ, Conner M. Social cognitive determinants of blood donation. J Appl Soc Psychol. 2001;31(7):1431-1457.

40. Ouellette JA, Wood W. Habit and intention in everyday life: the multiple processes by which past behavior predicts future behavior. Psychol Bull. 1998;124(1):54-74.

41. Reubsaet A, Brug J, Kitslaar J, van Hooff JP, van den Borne HW. The impact and evaluation of two school-based interventions on intention to register an organ donation preference. Health Educ Res. 2004;19(4):447-456.

42. Reubsaet A, Brug J, Nijkamp MD, Candel MJ, van Hooff JP, van den Borne HW. The impact of an organ donation registration information program for high school students in the Netherlands. Soc Sci Med. 2005;60(7): 1479-1486.

43. Smits M, van den Borne B, Dijker AJ, Ryckman RM. Increasing Dutch adolescents’ willingness to register their organ donation preference: the effectiveness of an education programme delivered by kidney transplantation patients. Eur J Public Health. 2006;16(1):106- 110.

44. Horton RL, Horton PJ. A model of willingness to become a potential organ donor. Soc Sci Med. 1991;33(9):1037-1051.

45. Birkimer JC, Barbee AP, Francis ML, Berry MM, Deuser PS, Pope JR. Effects of refutational messages, thought provocation, and decision deadlines on signing to donate organs. J Appl Soc Psychol. 1994;24(19):1735-1761.

46. Conner M, Sandberg T, McMillan B, Higgins A. Role of anticipated regret, intentions and intention stability in adolescent smoking initiation. Br J Health Psychol. 2006;11(pt 1):85-101.

47. Quinn MT, Alexander GC, Hollingsworth D, O’Connor KG, Meltzer D. Design and evaluation of a workplace intervention to promote organ donation. Prog Transplant. 2006;16 (3):253-259.

48. The Partnership for Organ Donation, The American Public’s Attitudes Toward Organ Donation and Transplantation. http:// www.transweb.org/reference/articles/gallup_survey / gallup_chap3.html. Accessed March 2, 2008.

49. Davidson MN, Devney P. Attitudinal barriers to organ donation among black Americans. Transplant Proc. 1991;23(5): 2531-2532.

Gaston Godin, PhD, Ariane Belanger-Gravel, MSc, Camille Gagne, PhD, Danielle Blondeau, PhD

Laval University, Quebec, Canada

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Psychiatric Differences Between Liver Transplant Candidates With Familial Amyloid Polyneuropathy and Those With Alcoholic Liver Disease

By Telles-Correia, Diogo Barbosa, A; Mega, Ines; Direitinho, M; Morbey, A; Monteiro, E

Background-Psychiatric diagnoses are very common in liver transplant candidates, and such diagnoses are predictive of a poor clinical evolution and quality of life after transplantation. Also, nonadherence before the transplant is predictive of nonadherence after the transplant. Methods-We studied the psychiatric and psychosocial profiles of 85 liver transplant candidates, comprising consecutive patients attending outpatient clinics of a liver transplantation unit at a public hospital. Interviews and questionnaires were used to measure personality traits, symptoms of anxiety and depression, social support, and adherence. These patients were broken into 3 groups: patients with familial amyloid polyneuropathy (n=20), patients with alcoholic liver disease (n=33), and patients with other liver diseases (n=32).

Results-About 58% of patients had a current psychiatric diagnosis (24.8%, major depressive disorder, 22.3% generalized anxiety disorder, 8.3% adaptive disorder, 2.3% abuse of or dependence on substances other than alcohol). Current psychiatric diagnosis did not differ between patients with familial amyloid polyneuropathy and patients with alcoholic liver disease. Patients with alcoholic liver disease showed lower scores for 2 protective personality traits, social support and adherence to medication, than other patients. Patients with familial amyloid polyneuropathy showed higher scores for those traits.

Conclusions-All patients waiting for a liver transplant should undergo psychiatric and psychological assessment. Some psychological characteristics such as personality traits and social support differ between clinical groups, so it may be useful to design different approaches for each group. Patients with alcoholic liver disease may require a special approach to improve adherence to medication. (Progress in Transplantation. 2008;18:134-139)

Psychiatric disorders are common in candidates for transplantation: the prevalence of depression is 33%1-6; anxiety, 34%2-6; and personality disorders, 27%.7,8 Depression and anxiety can be associated with a poor clinical evolution and a reduction in quality of life after transplantation.2,9-11 Alcohol use can also be associated with a poor clinical evolution in some cases.12-14 Some personality traits also can be associated with a poor clinical evolution, including more frequent hospitalizations and rejection episodes and alcoholism recidivisms.7,8

Nonadherence has important implications in morbidity and mortality, reduction in quality of life, and elevation of medical costs. According to Cooper et al,15 nonadherence can be a direct cause of 21% of all transplantation failures and 26% of posttransplantation mortality.

Other authors1,16-18 report that nonadherence before transplantation is predictive of nonadherence after transplantation.

We compared psychiatric features, psychosocial characteristics, and adherence of transplantation candidates among 3 specific groups of patients: candidates with alcoholic liver disease, candidates with familial amyloid polyneuropathy (FAP), and candidates with other chronic liver diseases. FAP is an autosomal dominant, multisystemic fatal disorder characterized by a progressive peripheral and autonomic neuropathy with neural and systemic amyloid deposits. The disease is caused by a mutant gene in chromosome pair 18. The amyloid protein in type 1 familial amyloid polyneuropathy of Portuguese, Swedish, and Japanese origin is the variant of transthyretin (TTR), in which methionine is a substitute for valine at position 30 (TTR Met 30). More than 90% of this TTR Met 30 is produced by the liver and the rest by the choroid plexuses. The most consensual way to treat FAP is liver transplantation in the initial stage of the disease. Patients with FAP are almost asymptomatic when they receive a transplant, unlike other liver transplant candidates, who generally have chronic liver disease.19

Methods

Participants

We studied 85 transplant candidates on the waiting list for transplantation who were attending the weekly outpatient clinics of 2 hepatologists at Curry Cabrai Hospital’s Liver Transplantation Center in Lisbon, between March 1, 2006 and March 1, 2007. All patients agreed to participate in our study and provided informed consent. These patients were divided into 3 groups: FAP group (n = 20), an alcoholic liver disease group (n = 33), and an other liver diseases group (n = 32).

Data were collected in the transplantation center by a psychiatrist and a psychologist after medical appointments with the hepatologists.

The study protocol was approved by the institutional review committee (according to ethical guidelines of the 1975 Declaration of Helsinki).

Medical Evaluation

The diagnosis of FAP was established by a neurologist and confirmed by a hepatologist. Diagnoses of alcoholic liver disease and other liver diseases were made by a hepatologist.

Psychiatric and Psychological Evaluation

Current psychiatric diagnosis and lifetime psychiatric disorders were assessed on the basis of the classification in the Diagnostic and Statistical Manual of Mental Disorders (revised 4th edition),20 using the Mini International Neuropsychiatrie Interview,21 validated for the Portuguese population by Amorim et al.22

Personality was assessed by means of the NEO Five-Factor Inventory (NEO-FFI). The NEO-FFI is a shortened version of the NEO PI-R23 (Portuguese version by Bertoquini24), a questionnaire designed to give quick, reliable, and valid measures of the 5 domains of adult personality (openness to experience: appreciation for art, emotion, adventure, unusual ideas, imagination, and curiosity; conscientiousness: a tendency to show self-discipline, act dutifully, and aim for achievement [spontaneousness vs planned behavior]; extroversion: energy, and the tendency to seek stimulation and the company of others; agreeableness: a tendency to be compassionate and cooperative rather than suspicious and antagonistic toward others [individualism vs cooperative solutions]; and neuroticism: a tendency to easily experience unpleasant emotions such as anger, anxiety, depression, or vulnerability [emotional stability to stimuli]). The 60 items are rated on a 5-point scale from 1 (“I completely disagree”) to 5 (“I completely agree”).

Social Support Evaluation

No instruments were available to assess social support in this special population, so the first 2 items of the Psychological Assessment of Candidates for Transplantation,25 which access only social support and no psychological variables (family/social support systems stability, Family/social support systems availability), were used to evaluate the social support. This questionnaire, designed to assess social support and psychological issues in transplant candidates, was adapted to Portuguese population by Telles-Correia et al,” with the author’s permission.

Measurement of Adherence

To measure adherence, we used the Multidimensional Adherence Questionnaire (MAQ), developed and validated (reliability, construct validity, and criterion validity) by Telles-Correia et al.18 The MAQ explores 3 dimensions of adherence: adherence to medication, presence at medical appointments and treatments, and alcohol consumption. Responses are rated on a 6-point scale ranging from 1 (never) to 6 (always). Dimensions’ scores can be used independently or, if summed, correspond to the MAQ’s final score.18

Statistical Methods

Statistical analysis were carried with the SPSS 13.0 for Windows software package (SPSS, Chicago, Illinois). Descriptive data were presented as absolute frequencies, percentages, and mean values.

Mean values from continuous variables with a normal distribution were compared between 2 populations by using a Student t test for independent samples. Mean values of continuous variables without a normal distribution were compared between more than 2 populations by using a Kruskal-Wallis test. A chi^sup 2^ test was used to compare percentages of noncontinuous variables between different populations.

Results

Demographic and Medical Data

Men accounted for 69.4% of the participants, compared with 30.6% for women. We found that 50.6% of the patients were less than 50 years old (mean age, 48.5 years old); 34.3% were either single, divorced, or widowed; and 87.1% had less than a high school education (Table 1).

The patients’ medical diagnoses were FAP in 23.5% (n=20), alcoholic liver disease in 38.8% (n = 33), and other liver diseases in 37.6% (n = 32; see Figure). Other liver diseases included such diagnoses as chronic viral hepatitis, liver cancer, hemochromatosis, primary biliary cirrhosis, and familial progressive cholestasis. Some patients had more than 1 liver disease diagnosed.

Psychiatric and Psychological Characteristics

In this population, only 28.2% did not have any previous psychiatric disorder, and 17.6% had had at least an episode of major depression. General anxiety disorder was diagnosed in 3.5% of the patients and 22.3% had a history of alcohol dependence or abuse disorder, 3.5% had dependence on or abuse of other substances, and 24.7% mixed alcohol/other drugs abuse/dependence (Table 2).

Only 42.4% of the patients did not have any current psychiatric diagnosis. The current diagnosis was major depressive disorder in 24.7%, generalized anxiety disorder in 22.3%, adjustment disorder in 8.2%, and dependence on or abuse of substances other than alcohol in 2.3% (Table 2). Differences Among Groups

Demographic. We found demographic differences among clinical groups in age (FAP patients were younger than other patients, P= .001), and sex (fewer female patients in the FAP and alcoholic liver disease groups than in the other liver diseases group, P= .042; Table 3).

Psychiatric and Psychological Profile. Patients from the 3 groups differed significantly in lifetime psychiatric history: compared with the other 2 groups, fewer patients with FAP had a history of psychiatric disorders, P= .001; Table 4).

The main disorders in the psychiatric history of patients in the alcoholic liver disease group were alcohol abuse/dependence and other substance abuse/ dependence; in the FAP group, the main disorder was major depressive disorder; and in the other diseases group, the main disorders were other substance abuse/ dependence and major depressive disorder (Table 5).

Analysis of the test results and of the percentages shows that the presence of a current psychiatric diagnosis did not differ significantly among the different groups (Table 4).

We found significant differences between the groups in the personality traits “agreeableness” and “conscientiousness.” Analyzing the mean ranks obtained by Kruskal-Wallis test, it is easy to conclude that the group with lowest scores for agreeableness and conscientiousness was the alcoholic liver disease group, and the group with the highest scores for these personality traits was the FAP group (P= .031; Table 6).

Social Support. Using the Kruskal-Wallis test, we found that the group with lowest scores for social support was the alcoholic liver disease group (mean rank, 23.69) and the group with the highest scores for this factor was the FAP group (mean rank, 36.30; P= .03).

Adherence. Even though we did not find any significant differences among the 3 groups in 2 of the MAQ adherence dimensions (presence at medical appointments and abstinence from alcohol), nor in the MAQ total score, we found significant differences in adherence to medication (patients in the alcoholic liver disease group had lower scores for adherence, P= .020; Table 7).

Discussion

The prevalence of psychiatric disorders in liver transplant candidates has been reported by several authors.2,4-6

According to rates obtained by means of questionnaires or scales, between 28%5 and 64%4 of liver transplant candidates have clinically significant levels of depression. In a meta-analysis, Telles- Correia et al’ reported a mean value of 33% of liver transplant candidates to have clinically significant levels of depression. This variance might be due to the different kind of populations that were assessed in each of these studies, in terms of kind of medical disease, demographic characteristics, and psychiatric comorbility.1,6 Signs and symptoms of depression are more common in patients with alcoholic liver disease, paramyloidosis, and liver cancer.4-6

Clinical significant levels of anxiety, assessed by means of questionnaires or scales, were found in between 37%5 and 31.1%2 of liver transplant candidates, with Telles-Correia et al’ reporting a mean value of 34%.

The rates of current diagnosis or lifetime alcohol dependence/ abuse differ among authors, depending on the type of liver diseases that were assessed. Rates of alcohol use can reach almost 100% in studies of patients with alcoholic liver disease.26 In studies that include different kinds of patients, rates of alcohol use can vary between 39.5%10 and 79%.9

We were unable to find any study in which a psychiatric international classification such as DSM (Diagnostic and Statistical Manual of Mental Disorders) was used to assess current or previous psychiatric disorders in liver transplant candidates, as was done in the present study.

Nevertheless, the percentages we found for current diagnosis of major depression (24.7%) and for general anxiety disorder (22.3%) were not far from the mean value for clinical significant levels of depression and anxiety showed in the studies reviewed.

All of the patients we assessed who had a previous history of alcohol dependence/abuse had been abstinent for some time. Their abstinence explains why, even though 47.1% of patients had a psychiatric history of alcohol abuse/dependence and mixed abuse/ dependence, none of the patients had this actual current psychiatric diagnosis.

The 3 clinical groups differed somewhat with respect to lifetime history of psychiatric disorders. The main psychiatric disorders in the alcoholic liver dis ease group were alcohol dependence/abuse and other substance abuse/dependence. This association is easy to understand, because the comorbidity between alcohol use and other substance use (mainly cannabis) is very common. Among patients in the FAP group, the main lifetime psychiatric disorder was major depression, which is also easy to understand because of the high incidence of depression in patients with genetic chronic diseases such as FAP. In the other liver diseases group, the main lifetime psychiatric disorders were other substance abuse/dependence and major depression. The presence of substance abuse/dependence in this group is probably due to the fact that the group includes patients with chronic viral hepatitis (mainly intravenous drug users). Current psychiatric diagnoses did not differ significantly among the 3 groups.

Some differences were apparent in personality profiles: patients with alcoholic liver disease had lower scores for agreeableness (tendency to be compassionate and cooperative rather than suspicious), conscientiousness (self-discipline, tendency to act dutifully), social support, and adherence compared with the other groups.

We also found that patients with alcoholic liver disease had significant lower social support and adherence to medication than did patients in the other 2 groups. These findings are interesting, because results of some studies indicate that social support27,28 and personality traits28,29 are essential determinants of adherence in transplant candidates and transplant recipients. Psychiatric syndromes were equally present in all clinical groups, indicating that psychiatric and psychological evaluation must be available in all clinical groups. Nevertheless, some psychological characteristics such as personality traits and social support differed among clinical groups, which might indicate that it would be useful to design different approaches for each group. Patients with alcoholic liver disease might need an approach tailored to improve adherence do medication.

Although patients with FAP presented a favorable personality profile (higher scores for openness and conscientiousness), and had the best social support and best adherence to medication, they did not differ from the other patients with respect to psychiatric diagnosis. This finding is interesting because very little has been published about the psychiatric profile of these patients.

Many studies1,12,14 have shown some psychiatric differences between patients with alcoholic liver disease and other transplant candidates. Nevertheless, we did not find any study in which patients with FAP (a rare genetic liver disease found almost only in Portugal) were compared with other liver transplant candidates.30

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17. Bush B. Psychosocial, emotional, and neuropsychological factors influencing compliance and liver transplantation outcomes. Curr Opin Organ Transplant. 2004;9:104-109.

18. Telles-Correia D, Barbosa A, Mega I, Barroso E, Monteiro E. Adherence in transplantation. Acta Med Port. 2007;20:73-85.

19. Monteiro E, Freire A, Barroso E. Familial amyloid polyneuropathy and liver transplantation. J Hepatol. 2004;41 (2): 188-194.

20. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: Revised Fourth Edition (DSM-IV-TK). Washington (DC): American Psychiatric Publishing; 1994.

21. Sheehan BV, Lecrubier Y, Sheehan KH, et al. The Mini International Neuropsychiatrie Interview (MINI): the development and validation of structured diagnostic psychiatric interview for DSMIV and ICD-IO. J Clin Psychiatr. 1998;59(suppl 20):22-33.

22. Amorim P, Guterres T, Sheehan BV, Lecrubier Y. MINIEntrevista Neuropsiquiatrica Internacional. Versao, Portugal: 2000.

23. Costa PT, McCrae R. NEO PI-R Professional Manual. Odessa, FL: Psychological Assessment Resources, Inc; 1992.

24. Bertoquini V, Pais-Ribeiro JL. Estudo de Formas reduzidas do NEO-PI-R. Psicologia: Teoria, Investigacao e Pratica 2006; 85:102- 111.

25. Olbrisch ME, Levenson JL, Hammer R. The PACT: a rating scale for the study of clinical decision making in psychosocial screening of organ transplant candidates. Clin Transpl. 1989; 3:164-169.

26. Tringali RA, Trzepacz PT. Assessment and follow up of alcohol- dependent liver transplantation patients. Gen Hasp Psychiatry. 1996;18:70-77.

27. Matas M, Staley D, Griffin W. A profile of the noncompliant patient: a thirty-month review of outpatient psychiatry referrals. Gen Hasp Psychiatry. 1992;14(2):124.

28. Dew MA, Roth LH, Thompson ME, Kormos RL, Griffith BP. Medical compliance and its predictors in the first year after heart transplantation. J Heart Lung Transplant. 1996;15(6):631-645.

29. Shapiro PA, Williams DL, Foray AT, et al. Psychosocial evaluation and prediction of compliance problems and morbidity after heart transplantation. Transplantation. 1995; 60(12):1462-1466.

30. Luis M. Paramyloidosis. Acta Med Port . 1995;8:333-334.

Diogo Telles-Correia, MD, A. Barbosa, MD, PhD, Ines Mega, M. Direitinho, A. Morbey, MD, E. Monteiro, MD, PhD

University of Lisbon (DTC, AB) and Curry Cabral Hospital, Lisbon, Portugal

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Infection, Rejection, and Hospitalizations in Transplant Recipients Using Telehealth

By Leimig, Renata Gower, Gayle; Thompson, Denise A; Winsett, Rebecca P

Context-Telehealth technology serves individuals who live in geographical areas that prohibit easy access to specialized health care and can provide transplant recipients with access to transplant center personnel for adjunctive follow-up care. Objective-To compare infection, rejection, and hospitalization events in subjects randomized to telehealth or to standard posttransplant care.

Study Design, Study Participants, Setting and Research Procedure- This longitudinal prospective study compared transplant outcomes (infections, rejections, and hospitalizations) of 106 subjects who were randomized to either the telehealth (n = 53) or standard care (n = 53) group and met the 6-month study end point. Sex, race, and transplant type were evenly distributed within the 2 groups. Subjects received primary follow-up care from nurse practitioners. The telehealth visits were conducted via live interactive sessions with digitized equipment used to perform physical examinations.

Main Outcomes-Infections, rejections, and hospitalizations were summarized for each of the groups. Subgroup analyses were performed by sex, transplant type, and time since transplant.

Results-No differences were found between the telehealth and standard care groups for infections, rejections, or hospitalizations at the 6-month data end point. Overall, females had twice as many infections as males (P = .01). In this analysis, group assignment did not affect study outcomes.

Conclusions-The rates of infection, rejection, and hospitalization in a sample of primarily long-term transplant patients did not differ between patients who received telehealth follow-up and patients who received standard care, indicating that this delivery system can be used to provide follow-up care after transplant. (Progress in Transplantation. 2008;18:97-102)

Surveillance of organ dysfunction and detection of infection and rejection in transplant recipients is crucial for long-term survival of grafts and patients.1 Although the usual standard for visiting a health care provider is for treatment of an acute problem, in transplant recipients, the ongoing clinical follow-up is for prevention of acute complications. It is important for the recipient to return to a normal life; however, it is just as important for recipients to receive close followup care at their transplant center and from their local health-care provider. In a study of heart transplant recipients, attendance at clinic appointments was associated with better medication adherence,2 supporting the importance of ongoing clinical follow-up.

Appointments for transplant recipients are intended to help detect complications, monitor other comorbid diseases, and detect 2 major problems after solid-organ transplantation: the often subtle signs of infection and rejection.3 The down side to the increased number of visits to the health care provider or to the transplant center is that many transplant recipients travel outside of their home city to attend clinic. Ongoing long-term follow-up can be a double-edged sword. Although the transplant recipient needs and wants the appointment, the travel and the time waiting at the clinic office may serve as deterrents to attendance. Concurrently the transplant center continues to expand the number of patients it must follow, creating an overloaded clinic schedule. Given this situation, telehealth seems a reasonable delivery system to use; however, to date there have been no systematic investigations of the use of telehealth in transplant recipients.

Telehealth, defined as live, interactive, audio communications between health care provider and patient,4 is the focus of this study. Transplant recipients who live in areas distant from the study transplant center were randomized to either receive health care via telehealth or continue current standard care practices via in-person clinic attendance. The purpose of this analysis was to determine if infection, rejection, and hospitalization events were altered by using telehealth as compared with patients who received standard care. Thus, this study effectively tested the hypothesis that quality posttransplant care can be provided by using telehealth without additional risk of organ loss, hospitalization, or infection, while enabling the recipient to avoid undue travel for follow-up care. A brief overview of telehealth is provided, followed by a discussion of provider concerns regarding its reliability, patient and provider satisfaction with telehealth, and a review of studies focused on the outcomes of telehealth.

Literature Review

Overview of Telehealth

Technology in health care has been used since the telephone became universally available.5 With current advances in television, cable security, video streaming, and the Internet, use of technology in health care has advanced beyond simple follow-up phone contact with patients.5 Initial uses of advanced technology processes first emerged with professionals evaluating test results remotely from where the test was performed.6 This approach is known as store and forward technology; today it is used routinely in radiology,6,7 pathology,6,7 cardiology,7 and ultrasound.7 Access to health information (store and forward) and educational telehealth are the most useful forms of telehealth.7 Videoconferencing is rapidly replacing teleconsulting, which connected the health care professional and the patient in different locations via telephone.6 Patient visits via live videoconferencing are used in dermatology and psychiatry.7 Most published studies are limited to pilot projects and studies of short-term outcomes.8

Home health nurses use telehealth to monitor blood glucose values, with the ability to download data from blood glucose monitors as well as obtain blood pressure readings directly from home blood pressure monitors.9 Equipment is now available in the patient’s home to monitor physiological parameters of patients with chronic obstructive pulmonary disease and congestive heart failure.10 Home health agencies now use telehealth to follow up patients with mental illnesses,11 persons with acute infections,12 elderly patients with coronary artery bypass grafts,13 lung transplant patients,14 and hemodialysis patients.15

Reliability of Telehealth As a Delivery System

A significant concern for providers is the ability to recognize and treat illness appropriately, particularly when the provider and the patient are not in the same room. A study to evaluate the ability to diagnose and treat common acute illnesses was performed in a pediatric primary care center.16 Interrater reliability in diagnosis was tested with duplicate examinations performed on patients by both a telehealth physician and a regular treating physician. No significant differences were found in diagnosis between the 2 groups for all acute illnesses except for the discordance for acute otitis media. Poststudy evaluation of all study physicians indicated that the diagnosis of otitis media from the telehealth visit was more likely to be the correct one because the equipment provided in telehealth allowed the physician to make the diagnosis on the basis of evaluation of high-quality images of the tympanic membrane rather than on the basis of a glance as practiced in an in-person examination.16 Another study evaluated the feasibility and accuracy of cardiopulmonary examinations in 50 patients with heart failure by 2 cardiologists: one using an electronic stethoscope transmitting through a digital network line and the other using a conventional stethoscope. Investigators found that the remote examination was a feasible and reliable method of assessing patients.17 Other interrater agreement studies have been done with evaluation of cervical smears in telecytology,18 store- and-forward images in teledermatology,19 histologie specimens in telepathology,20 diagnostic reliability in telepsychiatry,21 and forensic evaluations22 with all results indicating that telehealth produces outcomes similar to outcomes achieved with conventional methods.

Satisfaction With Telehealth

Studies suggest that patients’ satisfaction with telehealth tends to be high. A focus group study12 to evaluate satisfaction and experiences of individuals transitioning from hospital to home telehealth showed that patients had an overall positive experience with telehealth. In another home telehealth study10 of patients with chronic obstructive pulmonary disease and congestive heart failure, researchers also found good satisfaction with telehealth among patients, although telehealth care was not a significant predictor of health and well-being. Patients’ satisfaction with teledermatology was significantly related to quality of life; patients reporting lower quality of life tended to prefer face-to- face rather than telehealth contact with their dermatologist.23 In a study24 conducted in the rural regions of northern Ontario, Canada, where patients experience unfavorable weather, geographic isolation, and significant costs to ensure delivery of care, home parenteral nutrition patients were generally satisfied with this alternative method of care. Satisfaction was also high in a school-based telehealth program where healthcare providers, children, and parents found telehealth in the school system an acceptable alternative to traditional health care.25 However, in a study26 that compared views on telehealth among health care professionals and patients, patients consistently demonstrated more positive perceptions of telehealth visits than did their health care providers, who demonstrated more discomfort with the telehealth system. Health Outcomes Studies

Few outcome studies have been focused on telehealth. A recent study27 compared outcomes in patients who were enrolled in the Cancer Care Coordination/ Home-Telehealth program from the Veterans Affairs with outcomes in veterans receiving standard care. Results indicated that patients in the telehealth program used fewer preventable services and had fewer noncancer clinic visits than did patients who received standard care.27 In another study” in Australia, researchers found that mental health patients enrolled in a telehealth program reported greater treatment adherence and compliance than did patients in the control group. In the Canadian parenteral nutrition study24 mentioned earlier, patients who were followed up via telehealth had catheter sepsis rates similar to rates reported in the literature. The infection rate, however, was not compared with the rate in a group followed within the traditional health care system, limiting the generalizability of the study results.24 To date, no telehealth studies exploring infection, rejection, or hospitalizations as outcomes in a transplant population have been reported.

Study Significance

Telehealth is emerging as an important delivery system with documented satisfaction among patients and diagnostic reliability. To facilitate widespread use of this technology, additional studies are needed to show that the health outcomes of patients followed up with telehealth and patients who receive standard care are equivalent. As we move toward patient-centered care, telehealth can provide alternative methods to help patients achieve their goals to remain healthy. Although the University Health Network of Toronto has not published their outcomes, telehealth has been successfully used in Canada with pretransplant evaluations, donor consultations, education, group support, and some posttransplant follow-up care (personal communication, Sharon McGonigle, MSN, August 29 and 31, 2007). No health outcome studies have been done in patients followed up with telehealth after transplant, which highlights the importance of this study, particularly for patients who live long distances from a transplant center. This study is a preliminary report of health outcomes of transplant recipients who received care via telehealth.

Methods

Study Design

This study was part of an ongoing longitudinal randomized control trial that examined the impact of care delivery via telehealth on health-related quality of life, adherence, and satisfaction between the 2 delivery systems (telehealth vs standard care) and transplant outcomes (infections, rejections, and hospitalizations). The university’s institutional review board approved this study.

Study Participants

To be included in the study, subjects were required to have received a transplant at the host center, be older than age 18, understand English, and be followed up primarily by a nurse practitioner at the time of recruitment. Subjects in this analysis were enrolled in the study between August 1, 2005, and October 31, 2006.

Setting

Within the transplant clinic, an examination room was set up to be the receiving site where 1 of the 3 posttransplant nurse practitioners visited with patients located in 1 of 3 available remote locations. Each site was equipped with a television monitor, a Polycom H.323 video-conference camera, an analog stethoscope with headphones for confidential auscultation, a hand-held close examination camera, and an otoscope. The telehealth infrastructure used dedicated point-topoint T-1 lines capable of transmission speeds of 1.544 Mbps. The equipment was connected to the University’s telehealth network via dedicated Cisco network switches and router for remote real-time diagnostic and preventive maintenance upgrades.

Research Procedure

Subjects were randomly assigned to either telehealth or standard care by a computer-generated concealed allocation sequence, after the informed consent process was completed and the signed written informed consent document was obtained. Telehealth subjects self- selected 1 of the 3 telehealth remote sites that were developed for this study. Telehealth subjects were expected to choose the site located geographically closest to their residence, although doing so was not required. Sites were located 19, 90, and 120 miles from the standard care clinic.

Patients assigned to standard health care were seen through the usual procedures in the transplant clinic. Laboratory results, review of medication, and physical assessment were performed by the nurse practitioner according to current transplant clinic policies. Telehealth visits were conducted in the same pattern as the standard care visit, but via a live interactive session. Transplant outcomes were collected from subjects’ medical records at study entry and at 6 and 12 months after entry. Infection was defined as any documented bacterial, viral, or fungal infection that necessitated treatment with antibiotic, antiviral, or antifungal medications. Rejection episodes were defined as health care provider documentation of rejection with biopsy verification. Hospitalizations were defined as inpatient admission for greater than 24 hours for any reason.

Telehealth Clinical Procedure

At the beginning of each visit, the trained telehealth nurse at the remote site obtained blood pressure, pulse, and weight and reviewed the patient’s medication list by intake, dose, and schedule. The nurse also took notes on any physical symptoms that needed to be addressed during the telehealth session. Medical record forms were faxed between sites before the nurse practitioner entered the room in the transplant clinic. Once the intake information was obtained, connection with the transplant clinic’s receiving unit was initiated. The telehealth system was operated by a telehealth coordinator present at the nurse practitioner’s receiving unit. The camera focused on the patient so that behavior, facial expressions, and body language were easily seen by the nurse practitioner. With picture-in-picture capability, the patient saw the nurse practitioner as well as himself in the TV monitor. Because adherence to antirejection medication is crucial for the survival of the transplanted graft, the nurse practitioner would also double-check the medication intake before reviewing laboratory results and completing the physical examination with the available digitized equipment. At the end of the visit, all orders (laboratory or otherwise) were faxed to the patient and a follow-up visit was scheduled. The telehealth nurse at the remote site would also review discharge instructions with the patient. In the event the patient had signs or symptoms that required urgent measures, arrangements for overnight hospital izations or same-day testing could be made. If deemed necessary by the nurse practitioner, patients with nonurgent problems could be scheduled to be seen in the standard care clinic.

All statistical analyses were conducted by using SAS version 9.1 statistical software (SAS Inc, Cary, NC). Chi-squared tests were used for univariate analysis between categorical variables. Poisson regression models were used for multivariate analysis to investigate associations between number of events (dependent variable) and race, sex, transplant type, and time since transplant (independent variables). The maximum likelihood method was used to estimate the odds ratio. Probability values were set at .05.

Results

Of the 121 subjects who entered the trial, 106 have met the 6- month data point and were included in this analysis. The telehealth group and the standard care group each had 53 subjects. The distribution of the 106 recipients by organ transplanted was as follows: 82 kidney transplants, 11 kidney-pancreas transplants, 2 pancreas alone, and 11 liver transplants. Patients were a mean of 5.6 years after transplant. Race, sex, and transplant type were evenly distributed between the 2 groups (Table 1).

During the first 6 months, the telehealth group (n=53) had 116 clinic visits. Of these visits, 59 (50.9%) were via the telehealth equipment and 57 (49.1%) were conducted in the regular clinic rather than via telehealth. The telehealth group had 32 documented infection events, 3 rejection episodes, and 10 hospitalizations. The standard care group (n = 53) had 139 visits during the 6-month period. A total of 31 documented infection events, 3 rejection episodes, and 10 hospitalizations occurred in the standard care group. No significant differences were found in the numbers of infections, rejections, or hospitalizations between the 2 groups (Table 2).

No differences between groups were found for subgroup analysis by sex, transplant type, or time from transplant. As the 2 groups did not differ in outcome, group assignment was subtracted from the model. When outcomes were evaluated without group assignment, sex of the patient was associated with infections. Females had significantly higher risk for infections than did males (P = .01), which was expected, because the incidence of infections females is twice as high in female than in male renal transplant recipients.28 No significant associations were found between the study outcomes and transplant type or time from transplant.

Discussion

In the analysis evaluating health outcomes (infection, rejection, and hospitalization events) between patients assigned to the telehealth group or the standard care group, no significant differences were found (Table 2). A significant association was found, however, between sex of the patient and infection episodes, with the odds for women higher than men.

Patients assigned to the telehealth group had a number of standard care visits in the transplant clinic. Healthcare delivery was not dictated by the study protocol, but the unusual number of standard care visits in the telehealth group was surprising and was considered a confounding variable. Review of the medical records did not show any new documented comorbid diseases, so that the number of standard care visits of patients in the telehealth group was most likely due to several factors such as hesitancy of the clinic personnel to use the telehealth equipment, patients’ hesitancy to lose face-to-face contact with the nurse practitioner, or patients wanting to see the practitioner or a physician in person. Further evaluation of the use of standard care in the telehealth group is ongoing. We were concerned that the transplant nurse practitioners were worried about both the loss of face-toface evaluation and the uncertainty of the ability to catch new diagnoses with telehealth. Hesitancy with new technology is common, and incorporating novel diagnostic equipment requires adequate time, orientation, and resources to adapt the new technology into practice. Findings from a study examining the adaptation of nurses to computer access from their workplace, a rural nursing home with a distant medical center,29 identified 3 major concerns for the staff. Two of the 3 major concerns identified were on-site staff knowledgeable and willing to provide immediate assistance and mentoring of individuals to build confidence with the new equipment. Acceptance of the computers was more likely if exposure to technology had occurred outside the facility so that encouragement of the staff to use the equipment for other purposes facilitated adaptation.29 Using these 3 identified outcomes guided our orientation and ongoing support for the nurse practitioners. The preliminary findings of our study indicated that we still need to focus on adaptation of nurse practitioners to the specialized diagnostic equipment.

Implications for Clinical Practice

Our initial findings are quite promising, but must be viewed as preliminary because of the study’s small sample size. Subjects had received their transplanted organs a mean of 5 years earlier. Thus, major concerns during health-care visits focused on review of chronic comorbid conditions rather than on the transplanted organ. As a result, the relevance of these findings in recent transplant recipients is unclear. Continued evaluation of the diagnostic capabilities of telehealth equipment as well as continued focus on adaptation of nurse practitioners to the technology is required. These adjustments will allow telehealth to be used during all phases of posttransplant follow-up.

Conclusion

Preliminary data show that it is possible to maintain the same level of adequate surveillance to prevent infections and organ dysfunction in long-term organ transplant recipients. Implementation of a telehealth program in the transplant clinic may include a combination of telehealth and standard care visits depending on time from transplant or the complexity of the posttransplant course. Diagnostic confidence is key to incorporating telehealth into the transplant clinic. Further evaluation will help clarify the issues surrounding adaptation to telehealth in the transplant setting.

Acknowledgment

The authors thank Dr Mona Wicks for content review and Ms Gail Spake for editorial revisions made in this manuscript.

Financial Disclosures

This study was supported by a grant from the National Institutes of Nursing Research, R01 NR-008917.

References

1. Kasiske BL, Vazquez MA, Harmon WE, et al. Recommendations for the outpatient surveillance of renal transplant recipients. American Society of Transplantation. J Am Soc Nephrol. 2000;11(suppl 15):S1- S86.

2. De Geest S, Dobbels F, Fluri C, Paris W, Troosters T. Adherence to the therapeutic regimen in heart, lung, and heart-lung transplant recipients. J Cardiovasc Nurs. 2005;20(5 suppl): S88- S98.

3. Cupples SA, Ohler L. Transplantation Nursing Secrets. Philadelphia, PA: Hanley & Belfus; 2003.

4. Thede LQ. Telehealth: promise or peril? Online J Issues Nurs. 2001;6(3):1.

5. Jenkins RL, White P. Telehealth advancing nursing practice. Nurs Outlook. 2001;49(2):100-105.

6. Wootton R. Telemedicine: a cautious welcome. BMJ. 1996;313(7069):1375-1377.

7. Gagnon MP, Duplantie J, Fortin JP, Jennett P, Scott R. A survey in Alberta and Quebec of the telehealth applications that physicians need. J Telemed Telecare. 2007;13(7):352-356.

8. Hailey D, Roine R, Ohinmaa A. Systematic review of evidence for the benefits of telemedicine. J Telemed Telecare. 2002;8(suppl 1):1-30.

9. Hjelm NM. Benefits and drawbacks of telemedicine. J Telemed Telecare. 2005;11(2):60-70.

10. Whitten P, Mickus M. Home telecare for COPD/CHF patients: outcomes and perceptions. J Telemed Telecare. 2007;13(2): 69-73.

11. D’Souza R. Improving treatment adherence and longitudinal outcomes in patients with a serious mental illness by using telemedicine. J Telemed Telecare. 2002;8(suppl 2):113-115.

12. Marineau ML. Special populations: telehealth advance practice nursing: the lived experiences of individuals with acute infections transitioning in the home. Nurs Forum. 2007;42(4): 196-208.

13. Barnason S, Zimmerman L, Nieveen J, Hertzog M. Impact of a telehealth intervention to augment home health care on functional and recovery outcomes of elderly patients undergoing coronary artery bypass grafting. Heart Lung. 2006;35(4):225-233.

14. Karl BC, Finkelstein SM, Robiner WN. The design of an Internet-based system to maintain home monitoring adherence by lung transplant recipients. IEEE Trans Inf Technol Biomed. 2006;10(1):66- 76.

15. Skiadas M, Agroyiannis B, Carson E, et al. Design, implementation and preliminary evaluation of a telemedicine system for home haemodialysis. J Telemed Telecare. 2002;8(3):157-164.

16. McConnochie KM, Conners GP, Brayer AF, et al. Differences in diagnosis and treatment using telemedicine versus in-person evaluation of acute illness. Ambul Pediatr. 2006;6(4):187195; discussion 196-197.

17. Fragasso G, Cuko A, Spoladore R, et al. Validation of remote cardiopulmonary examination in patients with heart failure with a videophone-based system. J Card Fail. 2007;13(4): 281-286.

18. Lee ES, Kim IS, Choi JS, et al. Accuracy and reproducibility of telecytology diagnosis of cervical smears. A tool for quality assurance programs. Am J Clin Pathol. 2003;119(3):356-360.

19. Pak H, Triplett CA, Lindquist JH, Grambow SC, Whited JD. Store-and-forward teledermatology results in similar clinical outcomes to conventional clinic-based care. J Telemed Telecare.2007;13(1):26-30.

20. Nordrum I, Johansen M, Amin A, Isaksen V, Ludvigsen JA. Diagnostic accuracy of second-opinion diagnoses based on still images. Hum Pathol. 2004;35(1):129-135.

21. Shore JH, Savin D, Orton H, Beals J, Manson SM. Diagnostic reliability of telepsychiatry in American Indian veterans. Am J Psychiatry. 2007;164(1):115-118.

22. Lexcen FJ, Hawk GL, Herrick S, Blank MB. Use of video conferencing for psychiatric and forensic evaluations. Psychiatr Serv. 2006;57(5):713-715.

23. Williams TL, Esmail A, May CR, et al. Patient satisfaction with teledermatology is related to perceived quality of life. Br J Dermatol. 2001;145(6):911-917.

24. Saqui O, Chang A, McGonigle S, et al. Telehealth videoconferencing: improving home parenteral nutrition patient care to rural areas of Ontario, Canada. JPEN J Parenter Enteral Nutr. 2007;31(3):234-239.

25. Young TL, Ireson C. Effectiveness of school-based telehealth care in urban and rural elementary schools. Pediatrics. 2003; 112(5):1088-1094.

26. Mair FS, Goldstein P, May C, et al. Patient and provider perspectives on home telecare: preliminary results from a randomized controlled trial. J Telemed Telecare. 2005;11(suppl 1): 95-97.

27. Chumbler NR, Kobb R, Harris L, et al. Healthcare utilization among veterans undergoing chemotherapy: the impact of a cancer care coordination/home-telehealth program. J Ambul Care Manage. 2007;30(4):308-317.

28. Munoz P. Management of urinary tract infections and lymphocele in renal transplant recipients. Clin Infect Dis. 2001; 33(suppl 1):S53-S57.

29. Armer JM, Harris K, Dusold JM. Application of the Concerns- Based Adoption Model to the installation of telemedicine in a rural Missouri nursing home. J Nurses Staff Dev. 2004;20(1):42-49.

Renata Leimig, BA, Gayle Gower, RN, BSN, Denise A. Thompson, PhD, Rebecca P. Winsett, PhD

University of Tennessee Health Science Center

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African American Slave Medicine: Herbal and Non-Herbal Treatments

By Medina, Katherine Bankole

African American Slave Medicine: Herbal and Non-Herbal Treatments. By Herbert C. Covey. (Lanham, Md., and other cities: Lexington Books, c. 2007. Pp. [viii], 207. $85.00, ISBN 978-0-7391- 1644-9.) Herbert C. Covey’s book African American Slave Medicine: Herbal and Non-Herbal Treatments is evidence of the growing scholarly interest in slavery and medicine as a distinct field in the history of science in the United States. Covey’s purpose is to outline how enslaved blacks used medicines in the art and vocation of folk healing during the antebellum period. The study’s data has been largely extracted from the Works Progress Administration (WPA) narratives. Covey trusts these vital documents and considers them to be “major sources of untapped medical information” about slavery (p. 11).

Chapter 1 supplies a concise overview of the field, including a review of the literature. Chapter 2 describes the medical care that whites provided to slaves, and chapter 3 explains the work of enslaved folk-medicine practitioners. The spiritual aspects of “African-based healing practices” are reviewed in chapter 4 (p. 56). Chapter 5 examines the use of specific botanical treatments; chapter 6 keenly depicts nonplant and nonherbal contributions to African Americans’ materia medica. Finally, the last chapter offers a succinct analysis of the subject, along with a note on the persistence of these practices today. In addition, Covey presents three important appendixes: “Plant and Herb Treatments,””Unknown Plant/Herbal Treatments,” and “Non-Plant or Herbal Treatments.”

Covey’s approach is straightforward and impartial. He offers a comprehensive analysis of the literature, judiciously recognizing the work of other historians in this field. At the same time, his contribution stems from an insightful monographic focus and his effort to use the evidence to demonstrate the empowerment of enslaved African Americans in their own medical care. He has also expanded the compendium of plant and herbal treatments known from earlier scholarship. It is clear that Covey has great respect for the complexities of the subject matter and the wide-ranging scholarly precedents. His well-written work does not obsessively challenge the emerging contours of the scholarship in the field of slavery and medicine. Instead, the merits of this work rest in Covey’s revised articulation of established ideas about what the WPA data reveals about African American medicine in the antebellum period. “The scarcity of White formal medical care and its ineffectiveness,” Covey asserts, “fuelled the development of alternative medical systems. These systems included plantation- based care (physicking) and informal slave medicine” (p. 40).

This volume is worthy of a wide readership across disciplines. Covey’s concise work should prove valuable to Americanists specializing in African cultural history. The book would add depth to courses on American slavery because of Covey’s specific attention to critical questions in the African American historical experience. The book’s scholarly frame of social history would undeniably benefit instruction in introductory African American history and other courses. Deficiencies in this work are minor. African American Slave Medicine: Herbal and Non-Herbal Treatments is a precise and substantial work that serves as a functional primer for slavery and medicine in the United States.

KATHERINE BANKOLE MEDINA

West Virginia University

Copyright Southern Historical Association Aug 2008

(c) 2008 Journal of Southern History, The. Provided by ProQuest LLC. All rights Reserved.

Redlands Community Hospital Appoints Vice President of Patient Care Services

REDLANDS – Redlands Community Hospital has appointed Lauren A. Spilsbury as president of patient care services.

Before joining Redlands Community Hospital, Spilsbury served as interim chief nursing officer and vice president of patient care services at Anaheim Memorial Medical Center where she was responsible for directing patient care services.

“We are pleased to welcome a veteran nursing professional such as Lauren to our leadership team,” said James Holmes, president and CEO of Redlands Community Hospital.

“Her experience and dedication to quality care will prove to be great assets in carrying out our mission of providing compassionate and quality care to each and every member of the community.”

Spilsbury received a bachelor of science degree in nursing and a master of science degree in nursing administration from California State University, Dominguez Hills. She has received many awards and recognitions including Saddleback Memorial Medical Center Critical Care Nurse of the Year and Memorial Health Service Special Achievement Award. She is a member of the Association of California Nurse Leaders.

“I can’t think of a more special hospital to work at than Redlands,” Spilsbury said. “The small-town feel of the community is reflected in the very personal yet highly clinical nature of the hospital’s caring staff.”

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

PharMEDium to Be Provider of HealthTrust Hospitals’ Outsourced Compounded Pharmacy Preparations

BRENTWOOD, Tenn., and LAKE FOREST, Ill., Aug. 22 /PRNewswire/ — HealthTrust Purchasing Group, LP (HealthTrust) and PharMEDium Services, LLC, today announced an agreement under which PharMEDium will serve as a supplier of outsourced compounded pharmacy preparations for HealthTrust’s acute-care hospitals.

(Logo: http://www.newscom.com/cgi-bin/prnh/20051202/PHARMEDIUMLOGO)

The agreement applies to the full line of outsourced compounded drug preparations supporting more than 1,300 acute-care hospitals within HealthTrust, including HCA, Triad, HMA, Community Health Systems, Consorta and Lifepoint. PharMEDium, the leading provider of outsourced hospital pharmacy I.V. compounded solutions, currently services thousands of hospitals across the United States.

“We are excited to add PharMEDium’s outstanding record of quality, customer service and experience to our organization and its hospitals,” said John Romano, AVP Pharmacy National Agreements, [HealthTrust]. “PharMEDium is the leader in its field, and its expertise aligns with our commitment to superior patient care that is supported by market-leading suppliers.”

“This partnership marks a significant milestone for PharMEDium,” said David Jonas, PharMEDium Chairman and CEO. “To work at this level with an organization of HealthTrust’s reputation, one that shares our values around quality, safety, and leadership, is tremendous.”

About HealthTrust Purchasing Group, LP HealthTrust Purchasing Group, headquartered in Brentwood, Tennessee, is a group purchasing organization that supports over 1300 not-for-profit and for-profit acute care facilities, as well as ambulatory surgery centers, physician practices, and alternate care sites. With an annual purchasing volume by its members of more than $13 billion, HealthTrust is committed to obtaining the best price for clinically- recommended products, ensuring their timely delivery and continuously evaluating and improving its services to the patients, physicians and clinicians it serves.

About PharMEDium Services, LLC

PharMEDium is the leading provider of pharmacy outsourced sterile IV compounding services. PharMEDium is a nationwide network of state licensed and federally registered compounding centers providing trusted and innovative solutions to thousands of hospitals throughout the United States. State-of- the-Art admixture services are supported by the industry leading online purchasing system including an electronic 222 controlled substance ordering system. PharMEDium is managed by licensed pharmacists and staffed by certified technicians; the company complies with all applicable state laws and FDA regulations, including USP Chapter 797, and DEA requirements.

Photo: http://www.newscom.com/cgi-bin/prnh/20051202/PHARMEDIUMLOGOAP Archive: http://photoarchive.ap.org/PRN Photo Desk, [email protected]

PharMEDium Services, LLC

CONTACT: Amy Langan, Director of Marketing, of PharMEDium,+1-847-457-2327, [email protected]

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

Monsters, Ghosts and Gods: Why We Believe

Monsters are everywhere these days, and belief in them is as strong
as ever. What’s harder to believe is why so many people buy into hazy
evidence, shady schemes and downright false reports that perpetuate
myths that often have just one ultimate truth: They put money in the
pockets of their purveyors.

The bottom line, according to several interviews with people who study these things: People want to believe, and most simply can’t help it.

“Many people quite simply just want to believe,” said Brian Cronk, a
professor of psychology at Missouri Western State University. “The
human brain is always trying to determine why things happen, and when
the reason is not clear, we tend to make up some pretty bizarre
explanations.”

A related question: Does belief in the paranormal have anything to do with religious belief?

The answer to that question is decidedly nuanced, but studies point
to an interesting conclusion: People who practice religion are
typically encouraged not to believe in the paranormal, but rather to
put their faith in one deity, whereas those who aren’t particularly
active in religion are more free to believe in Bigfoot or consult a
psychic.

“Christians and New Agers, paranormalists, etc. all have one thing
in common: a spiritual orientation to the world,” said sociology
Professor Carson Mencken of Baylor University.

Tall tales

A tale last week by three men who said they have remains of Bigfoot in a freezer
was reported by many Web sites as anywhere from final proof of the
creature to at least a very compelling case to keep the fantasy ball
rolling and cash registers ringing for Bigfoot trinkets and tourism
(all three men involved make money off the belief in this creature).
Even mainstream media treated a Friday press conference about the
“finding” as news.

Reactions by the public ranged from skeptical curiosity to blind faith.

“I believe they do exist but I’m not sure about this,” said one reader reacting to a story on LiveScience
that cast doubt the claim. “I guess we will find out … if this is on
the up and up,” wrote another. “However, that said, I know they exist.”

A subsequent test on the supposed Bigfoot found nothing but the DNA of humans and an opossum, a small, cat-like creature.

Also last week, in Texas there was yet another sensational yet
debunkable sighting of chupacabra, a beast of Latin-American folklore.
The name means “goat sucker.” In this case, law enforcement bought into
the hooey with an apparent wink and nod.

Ellie Carter, a patrol trainee with the DeWitt County sheriff’s
office, saw the beast and was, of course, widely quoted. “It was this –
thing, looking right at us,” she said. “I think that’s a chupacabra!”
After watching a video of the beast taken by a sheriff’s deputy,
biologist Scott Henke of Texas A&M University said, “It’s a dog for
sure,” according to a story on Scientific American’s Web site.

Meanwhile, the sheriff did nothing to tamp down rampant speculation,
expressing delight that he might have a monster on his hands. “I love
this for DeWitt County,” said Sheriff Jode Zavesky, who would
presumably be just as thrilled to let Dracula or a werewolf run free.

With that kind of endorsement and the human propensity to believe in
just about anything, it’s clear that Bigfoot and chupacabra are just
two members in a cast of mythical characters and dubious legends and
ideas will likely never go away.

In a 2006 study, researchers found a surprising number of college students believe
in psychics, witches, telepathy, channeling and a host of other
questionable ideas. A full 40 percent said they believe houses can be
haunted.

Why are people so eager to accept flimsy and fabricated evidence in
support of unlikely and even outlandish creatures and ideas? Why is the
paranormal realm, from psychic predictions to UFO sightings, so
alluring to so many?

The gods must be crazy

Since people have been people, experts figure, they have believed in the supernatural, from gods to ghosts and now every sort of monster in between.

“While it is difficult to know for certain, the tendency to believe
in the paranormal appears to be there from the beginning,” explained
Christopher Bader, a Baylor sociologist and colleague of Mencken. “What
changes is the content of the paranormal. For example, very few people
believe in faeries and elves these days. But as belief in faeries
faded, other beliefs, such as belief in UFOs, emerged to take their
place.”

Figuring out why people are this way is a little trickier.

“It is an artifact of our brain’s desire to find cause and effect,”
Cronk, the psychology professor, said in an email interview. “That
ability to predict the future is what makes humans ‘smart’ but it also
has side effects like superstitions [and] belief in the paranormal.”

“Humans first started believing in the supernatural because they
were trying to understand things they couldn’t explain,” says Benjamin
Radford, a book author, paranormal investigator and managing editor of Skeptical Inquirer magazine. “It’s basically the same process as mythology:
At one point people didn’t understand why the sun rose and set each
day, so they suggested that a chariot pulled the sun across the
heavens.”

Before modern scientific explanations of germ theory, explained Radford, who writes the “Bad Science” column for LiveScience,
people didn’t understand how diseases could travel from one person to
another. “They didn’t understand why a child was stillborn, or why a
drought occurred, so they came to believe that such events had
supernatural causes,” he said.

“All societies have invoked the supernatural to explain things
beyond their control and understanding, especially good and bad
events,” Radford said. “In many places – even today – people believe
that disasters or bad luck is caused by witches or curses.”

Which raises the bigger question: With science having answered so many questions in the past couple centuries, why do paranormal beliefs remain so strong?

Related to religion?

Sometimes the belief in curses crosses paths with religion, as was
the case in 2005 when televangelist John Hagee (whose endorsement was
solicited and received by presidential hopeful John McCain) blamed
Hurricane Katrina on God’s wrath for a gay parade that had been
scheduled for the Monday of the storm’s arrival.

“I believe that New Orleans had a level of sin that was offensive to
God, and they are – were recipients of the judgment of God for that,”
Hagee said at the time, reiterating the belief in 2006.

That might lead one to assume religion and paranormal beliefs are intertwined.

But in a 2004 survey, at the researchers at Baylor found just the opposite.

“Paranormal beliefs are very strongly negatively related to religious belief,” study team member Rod Stark said this week.

Another study, of 391 U.S. college students done in 2000, found that
participants who did not believe in Protestant doctrine were most
likely to believe in reincarnation, contact with the dead, UFOs,
telepathy, prophecy, psychokinesis, or healing. Believers were the
least likely to buy into the paranormal. “This may partly reflect
opinions of Christians in the samples who take biblical sanctions
against many ‘paranormal’ activities seriously,” the Wheaton College
researchers wrote.

Cronk, the psychologist, did a small survey of 80 college students
and found no connection between religiosity and paranormal belief.

But a 2002 study in Canada did find a correlation between religious
beliefs and paranormal beliefs, Cronk notes. He figures that among
other explanations, Canadians may not have the same belief systems as
U.S. residents.

“My guess is that religiosity has a lot to do with how you were
raised, and less to do with genetics,” Cronk said. “Those people who
may have a high genetic susceptibility to ‘faith-based knowledge’ may
end up being highly religious or may end up having belief in the
paranormal depending on how they were raised. Those people less
susceptible to that method of forming beliefs may still end up being
highly religious if they were raised in a religious family.”

Religion vs. paranormal

Mencken, the Baylor sociologist, says sacrifice and stigma (for
holding ideas outside the group norm) keep the paranormal at bay among
the highly religious. He has two papers forthcoming that are based on a national survey of 1,700 people.

The first, to be published in the journal Sociology of Religion in 2009, reveals this:

“Among Christians, those who attend church very often (and are
exposed to stigma and sacrifice within their congregations) are least
likely to believe in the paranormal,” Mencken told LiveScience. “Conversely,
those Christians who do not attend church very often (maybe once or
twice a year) are the most likely to hold paranormal beliefs.”

A third group, which he calls naturalists, do not hold supernatural views, Christian or paranormal.

Another study to published in December in the Review of Religious Research,
shows that those who go to church “are much less likely to consult
horoscopes, visit psychics, purchase New Age items,” and so on, Mencken
said. “However, among those Christians who do not attend church, there
is a much higher level of participation in these phenomena.”

Educated to believe

Profiling the typical Bigfoot believer turns out to be as
challenging as determining the scientific methodology of a psychic,
however.

“Perhaps amazingly, [paranormal beliefs] are not related at all to
education,” Stark said. “Ph.D.s are as likely as high school dropouts
to believe in Bigfoot, Loch Ness Monster, ghosts, etc.”

The 2006 study of college students, done by Bryan Farha at Oklahoma
City University and Gary Steward Jr. of the University of Central
Oklahoma, reached a similar conclusion. Belief in the paranormal – from
astrology to communicating with the dead – increases during college,
rising from 23 percent among freshmen to 31 percent in seniors and 34
percent among graduate students.

Bader, the sociologist at Baylor, and his colleagues teamed up with
the Gallup organization to conduct a national survey of 1,721 people in
2005 and found nearly 30 percent think it is possible to influence the
physical world through the mind alone (another 30 percent were
undecided on that point). More than 20 percent figure it’s possible to
communicate with the dead. Nearly 40 percent believe in haunted houses.

Asked if “creatures such as Bigfoot and the Loch Ness Monster will one day be discovered by science,” 18.8 percent agreed while 25.9 percent were undecided.

In a remote Himalayan village, on the other hand, belief in Bigfoot’s cousin, the yeti, is seen by some as a sign of ignorance.

Media madness

Today’s ubiquitous and often one-sided, promotional coverage of the
paranormal, both on the Internet and TV, perpetuate myths and folklore
as well or better than any ancient storyteller. Fiction and belief
masquerade as fact and news, feeding the 24/7 appetite of the easily
swayed.

Scientists are left with an impossible task: proving something does
not exist. You can prove a rock is there. You can’t prove that Bigfoot
or a ghost or the god of thunder is not there. Bigfoot paraphernalia
purveyors and cash-cow psychics know this well.

“Many paranormalists claim that their powers only work sometimes, or
that they don’t work if there is a ‘non-believer’ in the room,” Cronk
points out.

Or, in the case of the unsupportive DNA testing on Bigfoot last
week, the top proponent, Tom Biscardi (who recently produced a film
about Bigfoot and might be said to have an interest in garnering press
coverage), simply dodged the mythbusting bullet by claiming the DNA
samples might have been contaminated.

Money motivates even the law to look the other way.

Regarding the chupacabra “sighting” last week in Cuero, Texas: “It’s
amazing,” said Zavesky, DeWitt County sheriff. “We still don’t know
what it is.”

Of course his county, specifically the town of Cuero, has been dubbed the Chupacabra Capital of the World and benefits by monster tourism.

So while a sheriff might well be concerned if he thinks there’s a
goat-sucking, menace in town, Zavesky is in no hurry to catch the beast
and debunk the myth. “It has brought a lot of attention to us,” he
said. “We’re not near ready to put this one to bed yet.”

Trio of Teen Deaths Sparks School Help

By HOWE, Jonathon

Crisis teams, counsellors are put in place for distressed students. ——————– The sudden deaths of three teenagers in the past week in the region has seen school principals set up guidance and counselling services for distressed classmates.

None of the deaths is being treated as suspicious.

The body of a 14-year-old girl, from Awatapu College, was found in a playground area of Palmerston North’s Victoria Esplanade on Tuesday morning.

This incident followed the deaths of an 18-year-old Marton girl on Saturday and a 16-year-old boy, who attended Palmerston North Boys’ High School, on Sunday.

Awatapu College principal Tina Sims said the death of the 14- year- old girl was a tragedy.

“We have got a place set up for students to receive support. We have been in touch with mental health services and crisis teams have been put in place for all students.”

Parents of students who knew the girl had been contacted by school staff, she said.

Boys’ High rector Tim O’Connor said the school was working with the student’s family and individuals affected by his death.

“Counsellors are spending time with boys and we have set up an area (this week).

“We have about 70 to 80 boys going to the funeral.”

Funerals were to be held for this teen and the 18-year-old Marton girl today.

Suicide Prevention Information NZ director Merryn Statham said it was not unusual to see clusters of deaths among young people.

“Suicide is still an incredibly rare event. When you get a little cluster, sometimes it’s just out of the blue.”

Reports about increasing teen suicides were often misguided because the statistical age group described as youth was under 24, she said.

“Most of these deaths sit at 21-to- 24 (year-olds).”

Although most suicides in New Zealand occurred among people aged 25 and over, youth suicides were still disproportionately high.,

“One of the key messages is that you can seek help,” Ms Statham said.

She said Palmerston North’s Youth One Stop Shop was a great example of one of the organisations young people could reach out to.

(c) 2008 Evening Standard; Palmerston North, New Zealand. Provided by ProQuest LLC. All rights Reserved.

Cruces Hospital Exceeds Average ; Memorial’s Heart Failure Rate High

By Journal Staff Report

Hospital death rates published Thursday in USA Today show that Memorial Medical Center in Las Cruces exceeded the national average for heart failure in 2007, based on newly released Medicare data.

San Juan Regional Medical Center in Farmington reported fewer pneumonia deaths and Heart Hospital of New Mexico in Albuquerque had fewer heart attack deaths than average for Medicare patients nationally, according to the data.

Memorial Medical Center experienced a mortality rate of 15.9 percent from July 1, 2006, to June 30, 2007, exceeding the national rate of 11 percent, according to data collected by the U.S. Centers for Medicare and Medicaid Services, better known as CMS.

Dr. Bruce San Filippo, Memorial’s chief medical officer, said Memorial treats a large patient population with late-stage illnesses such as renal disease and metastatic cancer.

“End-of-life issues are prominent in the population here,” San Filippo said Thursday. Many patients facing terminal illnesses make choices “that might have precluded the kind of care that normal heart failure patients might undergo.”

San Felippo said Memorial plans to use the data to improve care and applauded CMS’ decision to release the data. CMS has never before released mortality data for hospitals.

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

Leading Neurologist Opens Missouri Baptist Medical Center’s First MS Center

ST. LOUIS, Aug. 22 /PRNewswire/ — Barry Singer, M.D., leading neurologist and adjunct assistant professor of clinical neurology at Washington University School of Medicine, will open The MS Center for Innovations in Care on the campus of Missouri Baptist Medical Center on August 18th.

(Photo: http://www.newscom.com/cgi-bin/prnh/20080822/AQF023)

Multiple Sclerosis (or MS) is a chronic, often disabling disease that attacks the central nervous system, which is made up of the brain, spinal cord, and optic nerves. Symptoms may be mild, such as numbness in the limbs, or severe, such as paralysis or loss of vision. The progress, severity, and specific symptoms of MS are unpredictable and vary from one person to another.

“Dr. Singer’s new MS Center will bring innovations in treating this disease as well as cutting-edge care for MS patients in region,” said Joan Magruder, president, Missouri Baptist Medical Center. “As a principal investigator, Dr. Singer has been involved in major clinical trials for multiple sclerosis, including potential new treatments. He is a leader in bringing advancements in research and early treatment to individuals with MS, and we are thrilled to have him coming on-staff.”

Concurrently with his move to Missouri Baptist, Dr. Singer has launched a new website, http://www.mslivingwell.org/, where he offers information to empower patients so they can maximize their potential to live well with multiple sclerosis. “Learning more about MS, including treatment options, allows people living with MS to make better decisions that can affect them now and in the future,” said Dr. Singer.

Dr. Singer, a native of St. Louis, is board-certified in neurology. He earned his undergraduate degree from Duke University and his medical degree from Columbia University College of Physicians and Surgeons. He completed his residency training in neurology at New York Hospital-Cornell University. In addition, Dr. Singer completed a neuroimmunology fellowship focusing on clinical and laboratory research in multiple sclerosis at the National Institutes of Health. He is an active member of the American Academy of Neurology and serves as a member of the clinical advisory committee of the Gateway Chapter of the National Multiple Sclerosis Society.

In January 2008, he received the Pathlighter Award from the National Multiple Sclerosis Society. In March 2008, Dr. Singer was a recipient of a Congressional Proclamation from Congressman Russ Carnahan, who co-chairs the Congressional MS Caucus, for accomplishments in research in MS.

The MS Center for Innovations in Care will be located in Physicians’ Office Building B, Suite 207, Missouri Baptist Medical Center, 3015 North Ballas Rd., St. Louis, Mo, 63131.

Photo: NewsCom: http://www.newscom.com/cgi-bin/prnh/20080822/AQF023PRN Photo Desk, [email protected]

The MS Center for Innovations in Care at the Missouri Baptist Medical

CONTACT: Mary T. Beck, +1-314-996-7575, cell, +1-314-707-6944,[email protected], for The MS Center for Innovations in Care at the MissouriBaptist Medical Center

Web site: http://www.bjc.org/http://www.missouribaptist.org/http://www.mslivingwell.org/

Study: Cancer Risk Decreases After Age 80

While old age has been linked with heightened cancer risk, research suggests most cancer rates decrease in octogenarians, U.S. researchers said.

Senior author Richard Wilson of Harvard University said that in general, it seems that centenarians are asymptomatic or untargeted by cancers and that almost all cancers peak at age 80 and drop to toward zero near the end of the human life span.

Age-specific cancer rates traditionally come from mortality data, which are termed more reliable, because they are more frequently collected than incidence records. Yet, more than 25 years ago, rates were observed to flatten above the age of 75. Pathology studies in autopsy lends support to the idea that cancer prevalence increases more slowly at old age, and these cancers tend to be less virulent in older patients.

Wilson said that among the reasons for a possible decrease in the probability of getting cancer at a more advanced age are:

— Change their diets, giving a possible reduction in dietary carcinogens.

— Lose weight, which may have an effect on several cancers.

— Decrease use of substances such as alcohol and tobacco.

— Have fewer exposures from occupational carcinogens.

The findings are published in the American Association for Cancer Research Journal.

DC Brands’ Controversial Decision Vindicated

Today, DC Brands International, Inc. (PINKSHEETS: DCBR) states that in numerous previous communications, the company announced that they had made the decision to transition away from traditional energy drinks into a much healthier line of beverages with their H.A.R.D. Nutrition Functional Water Systems. The company’s CEO Richard Pearce has said many times that over the past year, they have met with many professionals from the field of health and heard over and over again the negative opinions of traditional energy drinks and dire predictions for the industry at large.

Today, on the front page of the industry’s online information leader BevNet is the headline “Researchers Find Red Bull May Raise Stroke Risk.” Go to www.bevnet.com for more information. Mr. Pearce said, “We took a lot of flak from many of our shareholders who just could not understand the decision to walk away from such a sizable investment; such as the one we had made over the years with our Dickens Cider and Turn Left energy drinks. I have said in the past that over the next decade, we believe the traditional energy drink industry will start to closely resemble that of fast food and tobacco.”

Pearce continues, “We are just as shocked as everyone else reading about potential stroke risks. We have been much more concerned about the obesity rates, diabetes rates, heart palpitations, etc. associated with energy drinks. Nonetheless, I truly believe this is only the first of many negative articles to come with respect to those drinks. This news comes on the heels of Men’s Health naming Vitamin Water as the world’s most unhealthy, healthy beverage. It is true that timing is everything and I believe it will bode well for anyone with a truly healthy alternative in the years to come.”

About DC Brands International:

DC Brands International, a publicly traded company under the ticker symbol (PINKSHEETS: DCBR), presently specializes in and manufactures health products. Established in 1998, DC Brands went public in 2005 producing the company’s first products, Dickens Energy Cider then eventually Turn Left Energy Drink. In 2007, DC Brands purchased the assets of H.A.R.D. Nutrition and began its quest to produce a new health line of products. DC Brands is now proud to announce the release of their new H.A.R.D. Nutrition Functional Water Systems, which is set to revolutionize the functional beverage category.

For more information on DC Brands International, visit their website at www.HardNutrition.com.

Note: Except for the historical information contained herein, this news release contains forward-looking statements that involve substantial risks and uncertainties. Among the factors that could cause actual results or timelines to differ materially are risks associated with research and clinical development, regulatory approvals, supply capabilities and reliance on third-party manufacturers, product commercialization, competition, litigation, and the other risk factors listed from time to time in reports filed by DC Brands International with the Securities and Exchange Commission, including but not limited to risks described under the caption “Important Factors That May Affect Our Business, Our Results of Operation and Our Stock Price.” The forward-looking statements contained in this news release represent judgments of the management of DC Brands International as of the date of this release. DC Brands International and its managers and agents undertake no obligation to publicly update any forward-looking statements.

 Contact: Keith Howard [email protected]

SOURCE: DC Brands International, Inc.

CityCentre Life Time Athletic Set to Open on Friday, September 12 in Houston

Life Time Fitness, Inc. (NYSE: LTM) today announced that the Grand Opening of its newest exclusive and luxurious Life Time Athletic club in Houston’s CityCentre development, will occur Friday, September 12, 2008, at 5:00 a.m. This is the Company’s first three-story center to open in the country and the fourth Life Time Fitness location in the Houston area, joining the Willowbrook, Cinco Ranch and Sugarland locations.

CityCentre Life Time Athletic members, area residents and special guests are invited to take part in a VIP preview celebration and ribbon cutting ceremony on Wednesday, September 10, 2008, beginning at 6:45 p.m. The event will offer tours of the distinctive, large new three-story facility and feature opportunities to experience program demonstrations and activities.

In keeping with the Company’s commitment to help members achieve and lead a healthy and active way of life, CityCentre Life Time Athletic offer a comprehensive array of family sports and recreation, health and fitness and resort-spa amenities, programming and services, supported by a team of certified fitness and nutrition specialists.

Life Time Fitness officials commented on its latest opening in Houston. “We are proud to be a part of the CityCentre community and to serve consumers with this incredible facility and associated healthy-way-of-life, spa and recreational programs and services which are enveloped in a luxurious, resort-like environment,” said Mike Gerend, President and Chief Operating Officer, Life Time Fitness. “Because we limit the number of available memberships at each Life Time Athletic club, members are provided an added level of personalized services and benefits in a relaxing and rejuvenating atmosphere.”

Among the multitude of CityCentre Life Time Athletic amenities are over 400 pieces of state-of-the-art cardiovascular and resistance equipment, multiple group exercise, Pilates and yoga studios with free and fee-based programs, a cycle theatre, team of certified personal trainers and programming, wide selection of adult and youth programs and activities, indoor rock climbing cavern, two full-size basketball courts, and dry saunas. The facility also features indoor and outdoor aquatics areas with multiple pools.

Families will appreciate Life Time Fitness’ large, interactive child center, featuring a play maze, junior basketball court, computer lab, children’s activity areas, and a separate infant playroom. Dedicated family dressing rooms also are available.

Furthermore, members can take advantage of LifeSpa, which delivers a full range of hair, nail and skin care services, and therapeutic massage, and LifeCafe, which offers the best in healthy food and beverage services.

Life Time Fitness provides 24 hour access, complimentary towel and locker service and an initial 30-day money-back guarantee with no long-term membership contracts.

For more information about CityCentre Life Time Athletic, please visit

lifetimefitness.com/city-centre.

About Life Time Fitness, Inc.

Life Time Fitness, Inc. (NYSE: LTM) operates distinctive and large, multi-use sports and athletic, professional fitness, family recreation and resort and spa centers. The company also provides consumers with personal training consultation, full-service spas and cafes, corporate wellness programs, health and nutrition education, the healthy lifestyle magazine, Experience Life, athletic events, and nutritional products. As of August 22, 2008, Life Time Fitness operated 74 centers in 17 states, including Arizona, Colorado, Florida, Georgia, Illinois, Indiana, Kansas, Maryland, Michigan, Minnesota, Missouri, Nebraska, North Carolina, Ohio, Texas, Utah and Virginia. Life Time Fitness is headquartered in Chanhassen, Minnesota, and can be located on the Web at lifetimefitness.com. LIFE TIME FITNESS, EXPERIENCE LIFE, and the LIFE TIME FITNESS TRIATHLON SERIES are registered trademarks of Life Time Fitness, Inc. All other trademarks or registered trademarks are the property of their respective owners.

Note To Editors:

CityCentre Life Time Athletic is located at 12888 1/2 Queensbury Lane, Houston, TX 77024

The center’s telephone number is 713-464-1200.

Please contact Kent Wipf at 952-229-7211 or [email protected] for all Life Time Fitness preview, interview, photography or video requests.

AltaMed Opens First-of-Its-Kind Health Care Center in the Nation

LOS ANGELES, Aug. 22 /PRNewswire/ — AltaMed Health Services along with community and political leaders, celebrated today the grand opening of the Family Health and Wellness Center located in the heart of El Monte. With a population in critical need of health care services, the Family Health and Wellness Center represents a new model for how medical services will be provided to underserved communities in the future.

The center co-locates quality senior programs with conventional clinic services such as prenatal, internal medicine, dental health, pediatrics and even HIV specialty care. The first-of-its-kind in the nation to be operated by an independent community-based non-profit, the center will allow seniors who come in for clinical care to access an array of supportive services (such as social work services, counseling and meals) and will allow seniors enrolled in support programs to have direct access to primary medical care.

The center’s comprehensive and specialized services for the whole family, from birth to the golden years, will be a significant addition to a community with a patient-to-doctor ratio of 10,000 to 1. This is startling when one considers that communities in Los Angeles’ Westside have a patient-to-doctor ratio of 250 to 1 and that the country of Iraq has a ratio of 1,500 to 1.

“AltaMed’s Family Health and Wellness Center in El Monte is the culmination of years of work to develop a model of service that meets the health needs of every family member at every age,” said Castulo de la Rocha, President and CEO of AltaMed Health Services Corporation. “This unique model will serve as a vehicle to address the health crisis in this medically underserved area and can be duplicated in communities across the nation.”

El Monte is one of the poorest and most underserved areas in Los Angeles County. A total of 41% of the population lives at less than 200% of the Federal Poverty Level. AltaMed built the new Family Health and Wellness Center from the ground up and expanded its services to address the tremendous need for medical care in El Monte and surrounding communities. The center can eventually accommodate up to 58,000 patient visits a year.

“The opening of the AltaMed Family Health and Wellness Center serves as a powerful example of what dedicated advocates can do to minimize the effects of our health care crisis on our most vulnerable populations. For more than 39 years, AltaMed has served as a passionate champion on this issue,” said Congresswoman Hilda Solis, 32nd District. “I am proud to stand here with them today to celebrate what will be a treasured resource in our community.”

The state-of-the-art center, financed with a combination of government resources, private foundations and individual donors, features a full service clinic, completely digital dental technology, electronic medical records, a new x-ray room, general surgery services (outpatient and non-invasive procedures) and smart chip equipment for physical therapy. To ensure patients are seen in an efficient and effective manner, a lighting system will monitor visits from the moment they enter the treatment rooms to the moment they leave. The system allows AltaMed professionals to know the exact stage of a patient’s visit and eliminates the need to rely on public address systems or walkie-talkies.

The senior services offered at the El Monte Family Health and Wellness Center are administered at the adjoining AltaMed Adult Day Health Care (ADHC) Center. The ADHC is designed to offer adults 18 years and older a wide array of programs and services that include transportation to and from the ADHC, nursing care, individual counseling, physical, occupational and speech therapy, recreational activities, emotional support for caregivers, health education classes and other community resources. The ADHC is focused on promoting independence for its participants; a factor important to the well being of the adult and his/her family caregivers.

“I am very grateful for AltaMed’s ADHC at the Family Health and Wellness Center because it allows me to look forward to something during the day and provides me and my family with the medical and emotional support we need,” said Martha Gutierrez, ADHC participant.

“Being at AltaMed is like being with your second family; they truly make sure you receive the care you need.” AltaMed has recently opened ADHC facilities in Pico Rivera and Downey to address the growing need for culturally relevant senior services in the Latino and other ethnic communities.

The new AltaMed Family Health and Wellness Center is located at 10418 Valley Blvd., El Monte, CA 91731. The medical and dental clinic services are available from 8 a.m. to 7 p.m., Monday and Wednesday; 9 a.m. to 7 p.m., Tuesday and Thursday; 8 a.m. to 5 p.m. on Friday; and 8 a.m. to 1 p.m. on Saturday. The Adult Day Health Care center operates from 7:30 a.m. to 4:30 p.m., Monday thru Friday.

The services offered at AltaMed’s ADHC facilities are available free of cost to individuals enrolled in Medi-Cal or private pay for non-Medi-Cal beneficiaries. For more information on AltaMed Services please call (877) 462-2582.

ABOUT ALTAMED HEALTH SERVICES CORPORATION

AltaMed Health Services, a private nonprofit organization, is a major provider of health and human services in the Greater Los Angeles area and the largest Federally Qualified Health Centers (FQHC) in the State of California. AltaMed’s mission is to provide high quality, coordinated, comprehensive health and human services to the underserved in Southern California, with particular attention to Latino and multi-ethnic populations. AltaMed began as the East Los Angeles Barrio Free Clinic in 1969, a volunteer-staff storefront providing basic medical services. Today AltaMed’s service area extends beyond East Los Angeles, to the Greater Los Angeles area and Orange County.

AltaMed Health Services

CONTACT: Barbara Hodgson of Arevalo Sanchez, Inc., +1-310-625-7394, forAltaMed Health Services

Brush Off Your Talent, Take a Shot at Local Auditions

By Mary Jo Balasco

These auditions are planned:

* The York County Choral Society will have fall auditions at 7 p.m. today and Aug. 28 at Oakland Baptist Church, 1067 Oakland Ave., Rock Hill. For details, call Jane Hudson at 547-0962 or 327-2967.

* Palmetto Youth Dance Company, a non-profit organization, will have “Nutcracker Twist” auditions from 2 to 7 p.m. Sunday at Fort Mill High School auditorium, 225 Munn Road. For details, visit www.pydc.net or call 547-7414.

Vintage celebration is Saturday at MYCO

The 2008 Vintage Celebration 15th anniversary wine tasting will be from 7:30 to 11 p.m. Saturday at the Museum of York County, 4621 Mount Gallant Road, Rock Hill. Tickets are $50 CHM members, $60 nonmembers and $90 per couple for members. For details and tickets, call Michelle DiEduardo at 329-2121, Ext. 113, or e-mail her at [email protected].

Local groups have meeting news

The following groups/clubs will meet:

* The Rock Hill branch of the NAACP will have its general and youth division meetings at 6 p.m Sunday at the Freedom Center, 215 E. Main St., Rock Hill. The executive meeting will be at 5 p.m. The meetings include an update of the election process and review of master calendar of events. For details, call Susie B. Hinton at 366- 2184.

* The Lewisville Preservation Society will meet at 7 p.m. today at the Front Porch Restaurant, 3072 Lancaster Highway, Richburg. Guest speakers will be Bob Harlee and Ray Douglas of Alpha Serendipity, who proposes to rehabilitate the historic No. 2 Republic Mill in Great Falls.

Fort Mill YMCA has buddy challenge

The Fort Mill branch of the Upper Palmetto YMCA will have a SurvYvor Buddy Challenge Saturday at the YMCA gym, 857 Promenade Walk, Fort Mill.

Sign-ups begin at 7:30 a.m. Teams compete in a series of challenges. For details, call Beth Klipa at 548-8020.

Retirement center hosting dog show

Chandler Place Retirement Living will have a small dog show at 10:30 a.m. Friday at the center, 745 Dilworth Lane, Rock Hill. Dogs must be 40 pounds and under and owner must be at least 55 years old. For details, call 325-1008.

Orientation offered by local sorority

The Rock Hill alumnae chapter of Delta Sigma Theta Sorority will host a Jabberwock 2009 orientation at 4 p.m. Sunday at Dutchman Creek Middle School, 4757 Mount Gallant Road, Rock Hill. The meeting is for girls ages 6 to 18 and their parents.

For details, call Millicent Whitener Dickey at (704) 408-8434 or Joya Holmes at 517-2814.

Summerfest breakfast is planned in York

Trinity United Methodist Church will have a Summerfest breakfast from 7 to 9 a.m. Saturday at the church, 22 E. Liberty St., York. Cost is $6 adults; $3 children, ages 4 to 10; and free for children younger than 3. Proceeds benefit the Bible study class and Christmas needy families.

For details, call Mary Jane Shuler at 684-4539 or Bill Fischer at 628-1744.

[email protected]

(c) 2008 Herald; Rock Hill, S.C.. Provided by ProQuest LLC. All rights Reserved.

Amy Street, Certified Prosthetist and Orthotist, Joins BridgePoint Medical Partner, Charlotte Orthotic and Prosthetic Center (COPC)

CHARLOTTE, N.C., Aug. 22 /PRNewswire/ — BridgePoint Medical, LLC’s partner, Charlotte Orthotic and Prosthetic Center (COPC), announced today that Amy Street, CP has joined COPC’s practitioner care team as Staff Prosthetist and will assume the responsibility for prosthetic care at the Charlotte facility.

Amy is an ABC certified Prosthetist and Orthotist with 11 years of O&P experience, most recently as a Staff Prosthetist / Orthotist with OrPro in Maryland. She received a Bachelor of Science in Rehabilitation Services, East Carolina University, in 2000 and her Prosthetic and Orthotic certificates from University of Connecticut in 2003 and 2006, respectively. Amy has worked closely with physicians at Children’s National Medical Center and at the Hospital for Special Care in the Washington, D.C. area where she has been exposed to a wide variety of challenging clinical situations.

“We are pleased to have someone of Amy’s caliber join our partner team,” commented BridgePoint Chief Clinical Officer, Brian Gustin, CP. “Amy’s background in rehabilitation services and her previous experience centered on patient issues, rather than on fabrication issues, will allow her to achieve a level of service that is unique in the Charlotte area.” Mr. Gustin further commented, “Amy embodies what we think are critical skills and perspectives for the practitioner of the future — she is forward facing, professional and is eager to solve patient issues.”

“The COPC team is very excited to have someone of Amy’s background and caliber joining us here in Charlotte,” stated Mr. Hagler, CO and practitioner in COPC’s Charlotte facility. “Her experience with children’s clinics is a perfect fit for our practice here in Charlotte. She will be a solid addition to our team as we pursue continued excellence in this market.”

About BridgePoint Medical

BridgePoint Medical, an independently owned prosthetic and orthotic company based in Lexington, Kentucky, was formed in 2004 and operates prosthetic and orthotic healthcare facilities in Kentucky and North Carolina. BridgePoint Medical partners with prosthetic and orthotic practices providing administrative support and marketing programs that dramatically reduce non-patient-related functions for the facility, while growing top-line revenues through operational improvement. For more information see their web site at http://www.bp-medical.com/.

About Charlotte Orthotic and Prosthetic Center, Inc.

COPC is part of Asheville Orthotic and Prosthetic Center, Inc. (AOPC), which operates three facilities, Charlotte, Hendersonville and Charlotte, NC. AOPC has been serving its patients since 1995.

   Contact:    Jim Clifton   BridgePoint Medical, LLC   354 Waller Avenue, Ste 150   Lexington, KY 40504   800.694.9820   [email protected]   http://www.bp-medical.com/    

This release was issued through eReleases(TM). For more information, visit http://www.ereleases.com/.

BridgePoint Medical, LLC

CONTACT: Jim Clifton of BridgePoint Medical, LLC, +1-800-694-9820,[email protected]

Web site: http://www.bp-medical.com/

Human Genome Sciences Completes Enrollment in Randomized Phase 2 Trial of HGS-ETR1 in Non-Small Cell Lung Cancer

ROCKVILLE, Md., Aug. 22 /PRNewswire-FirstCall/ — Human Genome Sciences, Inc. today announced that it has completed the enrollment and initial dosing of patients in a randomized Phase 2 trial of HGS-ETR1 (mapatumumab) in combination with the chemotherapy agents paclitaxel and carboplatin as first-line therapy in advanced non-small cell lung cancer (NSCLC).

(Logo: http://www.newscom.com/cgi-bin/prnh/20080416/HGSLOGO )

“There is an urgent medical need for effective treatment options for non- small cell lung cancer because current treatment strategies have only a minimal impact on survival,” said Joachim von Pawel, M.D., a principal investigator in the study from the Asklepios Fachkliniken Munchen-Gauting, Germany. “The majority of patients who are newly diagnosed with non-small cell lung cancer have locally advanced or metastatic disease that is currently incurable. We look forward to evaluating the potential of mapatumumab plus chemotherapy to offer a new approach to the first-line treatment of this deadly disease.”

The NSCLC trial is a randomized, multi-center, open-label Phase 2 study to evaluate the efficacy and safety of HGS-ETR1 in combination with carboplatin and paclitaxel as first-line therapy in the treatment of advanced non-small cell lung cancer (Stage IIIB or IV). 111 patients have been randomly assigned to one of three treatment groups and treated with either the two-agent combination of carboplatin and paclitaxel or the three-agent combination of carboplatin, paclitaxel, and HGS-ETR1 at either 10 mg/kg or 30 mg/kg. HGS announced the initiation of the NSCLC trial In December 2007.

“A growing body of preclinical data suggests that combining HGS-ETR1 with chemotherapy agents could be an effective approach to the treatment of a number of malignancies, including non-small cell lung cancer,” said Gilles Gallant, B. Pharm., Ph.D., Vice President, Clinical Research – Oncology, HGS. “HGS-ETR1 is the most advanced of any product in development that targets the TRAIL apoptotic pathway. The NSCLC study is one of three ongoing HGS trials designed to evaluate combinations of HGS-ETR1 with chemotherapeutic agents for the treatment of specific cancers.”

About the HGS-ETR1 Proof-of-Concept Trials

The HGS-ETR1 proof-of-concept phase includes three randomized trials to evaluate its potential in combination with chemotherapy for the treatment of specific cancers:

— Randomization and initial dosing of patients in the NSCLC study have now been completed.

— In July 2008, HGS initiated dosing in the safety lead-in to a randomized Phase 2 trial of HGS-ETR1 in combination with Nexavar (sorafenib) in patients with advanced hepatocellular cancer, which accounts for 80-90% of all liver cancers.

— The Company expects to have initial data available in the third quarter of 2008 from a randomized Phase 2 trial of HGS-ETR1 in combination with Velcade (bortezomib) in advanced multiple myeloma. Patients in the multiple myeloma study will continue on treatment until the progression of disease.

These three trials, taken together, will support a decision on whether to advance HGS-ETR1 to Phase 3 development. It also is possible that a sufficiently positive result from any one of the trials could lead to a Phase 3 decision for that specific indication.

About Non-Small Cell Lung Cancer

Non-small cell lung cancer accounts for approximately 75-80% of all lung cancers. It is estimated that more than 170,000 new cases and more than 160,000 deaths occur annually in the United States alone. It is currently the leading cause of cancer death in the U.S. in both men and women.

About HGS-ETR1

HGS-ETR1 (mapatumumab) is an agonistic human monoclonal antibody that directly induces cancer-cell death by specifically binding to and activating the protein known as TRAIL receptor 1. Using genomic techniques, HGS originally identified the TRAIL receptor 1 protein. The HGS-ETR1 antibody was generated by HGS through collaboration with Cambridge Antibody Technology. HGS is developing HGS-ETR1 as a potential treatment for a broad range of cancers.

About Human Genome Sciences

The mission of HGS is to apply great science and great medicine to bring innovative drugs to patients with unmet medical needs.

The HGS clinical development pipeline includes novel drugs to treat hepatitis C, lupus, inhalation anthrax, cancer and other immune-mediated diseases. The Company’s primary focus is rapid progress toward the commercialization of its two key lead drugs, Albuferon(R) (albinterferon alfa- 2b) for hepatitis C and LymphoStat-B(R) (belimumab) for lupus. Phase 3 clinical trials of both drugs are ongoing.

ABthrax(TM) (raxibacumab) is in late-stage development for the treatment of inhalation anthrax, and the Company is on track to begin the delivery in fall 2008 of 20,000 doses of ABthrax to the Strategic National Stockpile under a contract entered into with the U.S. Government in June 2006. HGS also has three drugs in clinical development for the treatment of cancer, including two TRAIL receptor antibodies and a small-molecule antagonist of IAP (inhibitor of apoptosis) proteins. In addition, HGS has substantial financial rights to certain products in the GSK clinical development pipeline.

For more information about HGS, please visit the Company’s web site at http://www.hgsi.com/. Health professionals and patients interested in clinical trials of HGS products may inquire via e-mail to [email protected] or by calling HGS at (301) 610-5790, extension 3550.

HGS, Human Genome Sciences, ABthrax, Albuferon and LymphoStat-B are trademarks of Human Genome Sciences, Inc.

SAFE HARBOR STATEMENT

This announcement contains forward-looking statements within the meaning of Section 27A of the Securities Act of 1933, as amended, and Section 21E of the Securities Exchange Act of 1934, as amended. The forward-looking statements are based on Human Genome Sciences’ current intent, belief and expectations. These statements are not guarantees of future performance and are subject to certain risks and uncertainties that are difficult to predict. Actual results may differ materially from these forward-looking statements because of the Company’s unproven business model, its dependence on new technologies, the uncertainty and timing of clinical trials, the Company’s ability to develop and commercialize products, its dependence on collaborators for services and revenue, its substantial indebtedness and lease obligations, its changing requirements and costs associated with facilities, intense competition, the uncertainty of patent and intellectual property protection, the Company’s dependence on key management and key suppliers, the uncertainty of regulation of products, the impact of future alliances or transactions and other risks described in the Company’s filings with the Securities and Exchange Commission. In addition, the Company will continue to face risks related to animal and human testing, to the manufacture of ABthrax and to FDA concurrence that ABthrax meets the requirements of the ABthrax contract. If the Company is unable to meet the product requirements associated with the ABthrax contract, the U.S. government will not be required to reimburse the Company for the costs incurred or to purchase any ABthrax doses, and we will not receive any of the expected revenues relative to ABthrax. Existing and prospective investors are cautioned not to place undue reliance on these forward-looking statements, which speak only as of today’s date. Human Genome Sciences undertakes no obligation to update or revise the information contained in this announcement whether as a result of new information, future events or circumstances or otherwise.

Photo: NewsCom: http://www.newscom.com/cgi-bin/prnh/20080416/HGSLOGOAP Archive: http://photoarchive.ap.org/PRN Photo Desk, [email protected]

Human Genome Sciences, Inc.

CONTACT: Media, Jerry Parrott, Vice President, Corporate Communications,+1-301-315-2777; Investors, Tim Barabe, Senior Vice President and ChiefFinancial Officer, +1-301-315-1780

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

Company News On-Call: http://www.prnewswire.com/comp/121115.html

Terminally Ill Care Vow

TERMINALLY ill patients were yesterday promised better care.

Scottish health secretary Nicola Sturgeon’s pledge came after a report found “inconsistencies” in services for different illnesses.

Audit Scotland’s study revealed 90 per cent of specialist care was delivered to cancer patients. But the disease accounted for fewer than 30 per cent of deaths.

The report also found communities outside the Central Belt didn’t have access to as many services for the terminally ill.

Around pounds 59million was spent on this type of care in 2006- 7, half of which came from the voluntary sector.

Sturgeon said a government action plan in October would improve treatment for patients outside the Central Belt.

She added: “This is a process already under way.

“But there’s no doubt we have to accelerate that progress.”

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

Family Physician’s Loss Mourned

By Sean Smith

Loma Linda University Medical Center will now be without one of its most respected family physicians.

Dr. Robert Avina died of a heart attack Aug. 14 in Redlands. He was 58.

Avina came to Loma Linda University in 2001. He taught family medicine to resident physicians in addition to his practice.

Students, colleagues and patients alike held Avina in high regard because of his caring attitude and excellence as a physician and a teacher, both of which he has won numerous awards for.

“(Avina) was never too busy to spend time talking to someone in need,” said Avina’s wife of 33 years, Dr. Lony Castro. “He always had a smile on his face and tried to share his happiness with everyone.”

Avina was born in East Los Angeles on Sept. 4, 1949. He always took pride in his accomplishments coming from such humble beginnings, Castro said.

After receiving a bachelor’s degree in biology from UC Riverside in 1972, Avina served in the National Guard as a medical corpsman.

In 1975, Avina married Castro upon his return from the National Guard.

Avina went on to receive his medical doctorate from UC San Diego in 1977. He then completed his residency in family medicine at the San Jose Hospital and Medicine Center in 1980.

Dr. John Testerman said Avina’s absence will felt by all at the Loma Linda hospital.

“He’s been an important figure in our department since he came here,” said Testerman, who has knew Avina since 2001. “He was well liked by students, patients, colleagues and staff.”

Avina practiced and taught family medicine in several locations before his time in Loma Linda.

He has held positions at Harbor-UCLA Medical Center, San Pedro Peninsula Hospital and San Bernardino County Medical Center (now Arrowhead Regional Medical Center), among other hospitals and medical centers.

A man of many interests, Avina’s hobbies included traveling, playing the guitar, golf, reading and swimming.

In addition to his wife, Avina is survived by his sons, Jason, Jeffrey and Daniel; his parents, Robert Avina Sr. and Nellie Avina; one brother and two sisters.

Memorial services will be held at 4 p.m. today at Monteceito Memorial Park and Mortuary, 3520 E. Washington St., Colton.

Donations will be accepted for the Robert Avina MD Memorial Fund, which will support an endowed lectureship for family medicine residents at Loma Linda University.

For more information about the memorial fund, contact Julie Tudor at (909) 558 6511.

(c) 2008 Inland Valley Daily Bulletin. Provided by ProQuest LLC. All rights Reserved.

Benefits of Repeated Reading Intervention for Low-Achieving Fourth- and Fifth-Grade Students

By Vadasy, Patricia F Sanders, Elizabeth A

Many students have difficulty achieving reading fluency, and nearly half of fourth graders are not fluent readers in grade-level texts. Intensive and focused reading practice is recommended to help close the gap between students with poor fluency and their average reading peers. In this study, the Quick Reads fluency program was used as a supplemental fluency intervention for fourth and fifth graders with below-grade-level reading skills. Quick Reads prescribes a repeated reading procedure with short nonfiction texts written on grade-appropriate science and social science topics. Text characteristics are designed to promote word recognition skills. Students were randomly assigned to Quick Reads instruction that was implemented by trained paraeducator tutors with pairs of students for 30 minutes per day, 4 days per week, for 18 weeks. At posttest, Quick Reads students significantly outperformed classroom controls in vocabulary, word comprehension, and passage comprehension. Fluency rates for both treatment and control groups remained below grade level at posttest. Keywords: fluency; repeated reading; paraeducator tutors

Skilled reading appears deceptively effortless but is coming to be better appreciated as the balanced coordination and timing of subskills involved in word recognition and comprehension (Perfetti, 1992; Stanovich, 1980). The effortless and fluent reading of text, or reading fluency, is often summarized as “the ability to read connected text rapidly, smoothly, effortlessly, and automatically with little conscious attention to the mechanics of reading such as decoding” (Meyer & Felton, 1999, p. 284). This definition guides the most common procedure for describing fluency in terms of rate and accuracy on an oral reading measure, such as a curriculum-based assessment. More comprehensive fluency assessment may include standardized procedures that capture prosody and comprehension (Pikulski & Chard, 2005). This definition also guides the most widely used instructional approaches to improve reading fluency, including repeated reading (Dahl, 1979; Samuels, 1979).

Our understanding of reading fluency continues to be deepened by research that underscores the developmental nature of fluency (Bowers, 1995; Kame’enui, Simmons, Good, & Harn, 2001; Manis & Freedman, 2001; Pikulski, 2006), the underlying lexical and sublexical processes that support fluency (Ehri, 1995; Wolf & Bowers, 1999), and the coordination of both cognitive and attentional resources (Berninger, Abbott, Billingsley, & Nagy, 2001; Breznitz, 2001) that supports this illusion of effortless fluent reading. As it is most commonly described (National Reading Panel, 2000), fluency has three components: accuracy, rate, and prosody, the latter of which is more difficult to objectively measure and quantify and has been less well studied than accuracy and rate.

The accuracy component of fluency most often refers to decoding accuracy (Meyer & Felton, 1999). Research has informed our understanding of the coordination of subprocesses that underlie decoding accuracy (Berninger, 1994; Berninger & Abbott, 1994; Berninger et al., 2001; Breznitz, 2001). This coordination includes making connections at the one- and two-letter spelling-pattern level (the orthographic layer) as well as connections at the morphological level (affixes and inflections). Torgesen, Rashotte, and Alexander (2001) reviewed variables most correlated with text reading rate across five intervention cohorts, ranging from second to seventh grade. Across studies, word reading accuracy and efficiency consistently explained the most variance in reading rate. As others (Berninger et al., 2001; Bowers & Wolf, 1993; Torgesen, Alexander, et al., 2001; Wolf, 2001) have shown, fluency is influenced by the level of word reading accuracy, but this process has both lexical and sublexical layers that become more well coordinated over time and are influenced by attentional resources.

Rate of processing and retrieving lexical information also influences reading fluency, and deficits in rapid automatized naming, or the very complex processes involved in perceiving, representing, and retrieving verbal labels for visual stimuli (Wolf, 1991; Wolf & Bowers, 1999), explain variance in reading skills from kindergarten through adult age (Meyer, Wood, Hart, & Felton, 1998; Wolf et al., 2002). Naming speed is strongly related to word reading fluency (Bowers, Golden, Kennedy, & Young, 1994; Wolf & Bowers, 1999) and is predictive of reading performance across both regular and less regular orthographies (Breznitz, 2001; Ho, Chan, Tsang, & Lee, 2002; Wimmer & Hummer, 1990). Naming speed may more strongly predict word reading accuracy for older than for younger students (Manis & Freedman, 2001). Students’ general cognitive speed of processing exerts a powerful influence on reading fluency. In the regression analyses Torgesen, Rashotte, et al. (2001) conducted on five cohorts, rapid naming speed for letters consistently explained additional variance in reading rate beyond that accounted for by the word reading accuracy and efficiency measures.

Remedial interventions have been designed to address limited fluency component skills, with a focus on making the word reading process effortless and automatic (LaBerge & Samuels, 1974) so that resources can be allocated to comprehension. Repeated reading is the most widely applied and studied remedial method to develop fluency (Dahl, 1974, 1979; Samuels, 1979, 1988). Repeated reading was found by the National Reading Panel (2000) to be the only well-supported approach for improving reading fluency (see reviews by Chard, Vaughn, & Tyler, 2002; Kuhn & Stahl, 2003; Meyer & Felton, 1999; Wolf & Katzir-Cohen, 2001). Quite simply, the repeated reading procedure involves reading a short passage aloud several times. The instructor often models and provides scaffolding and corrections. Students may read a passage a prescribed number of times until the student reaches a certain reading rate goal (in terms of words per minute; Samuels, 1979) or until he or she demonstrates a set number of rate improvements (Weinstein & Cooke, 1992). Fluency norms (Hasbrouck & Tindal, 2006) and benchmarks (Good & Kaminski, 2002) have become available to identify students who are not developing fluency and to monitor their progress. Students placed in a repeated reading intervention usually read from short passages that are selected to be at a certain level of difficulty or that feature repeated words across passages (Rashotte & Torgesen, 1985). Kuhn and Stahl (2003) concluded that passages read at a more difficult level contributed to larger reading gains than easier passages. Repeated reading may be assisted or unassisted. In their review, Chard et al. (2002) found that reading with a model was more effective for low- skilled students than reading without a model, and having the teacher model reading seemed to promote comprehension. These researchers found benefits for gradually increasing the difficulty of the texts and for providing feedback and correction for word reading errors. Most repeated reading interventions have been relatively short: Those reviewed by Wolf and Katzir-Cohen (2001) ranged from 1 to 15 days, and the median length of interventions reviewed by Meyer and Felton (1999) was four sessions. The number of rereadings varies from seven times (O’Shea, Sindelar, & O’Shea, 1985) to three to four times, which appears most common. Most studies have not addressed the level of training needed to provide repeated reading practice, and although most interventions have been provided by teachers, repeated reading has also been implemented by teaching assistants (Mercer, Campbell, Miller, Mercer, & Lane, 2000), by peer tutors (Mathes & Fuchs, 1993), or in a computer- based instructional situation (Carver & Huffman, 1981). As both the Meyer and Felton (1999) and Wolf and Katzir-Cohen (2001) reviews concluded, the effects of repeated reading on comprehension are unresolved. Other unresolved questions about repeated reading include the subtypes of students who most benefit from fluency interventions, the particular method and intensity of repeated reading, and the impact of these interventions on fluency components and subcomponents (e.g., word identification and decoding fluency).

The Quick Reads Program

In this article, we report on the 1st year of a 3-year evaluation of a published fluency program, Quick Reads (Hiebert, 2003), designed for use with students in Grades 2 through 6. In this study, the program was implemented with fourth and fifth graders. Schools often seek effective reading interventions for the nearly 4 in 10 fourth graders who read below basic level (U.S. Department of Education, 2004). The well-known reciprocal relationship between fluency and comprehension (Pinnell et al., 1995; Shinn, Good, Knutson, Tilly, & Collins, 1992; Tan & Nicholson, 1997) further supports providing students with reading practice to develop the skilled word reading and fluency skills that allow students to allocate attention to comprehension. In Kuhn and Stahl’s (2003) review of fluency interventions, gains in fluency were associated with gains in comprehension, although less so when more general standardized comprehension measures were used that draw from background knowledge or inferencing skills (see Francis et al., 2006). Preliminary Research on Quick Reads

Hiebert (2005) conducted a quasi-experimental study of the fluency intervention for second graders. Three schools were randomly assigned to one of three groups: a literature-based intervention, using the district’s literaturebased basal reading program; a content intervention, using Quick Reads texts; and a control classroom, using its regular basal reading instruction. The first two fluency groups used the procedures outlined for fluency- oriented reading instruction (FORI; Stahl, Heubach, & Cramond, 1997): The teacher modeled fluent reading of basal text, the students worked with a partner to reread text, the teacher led choral or echo reading, and the teacher conducted comprehension extension activities. The fluency intervention extended across a 20- week period. Students were assessed before and after the intervention on two passages, which were scored for fluency, phrasing, and comprehension. The Quick Reads fluency group significantly outperformed the control group on fluency at posttest despite having less opportunity to engage in repeated reading (as revealed by four indices that measured opportunity for reading in the seven intervention classrooms that were required to follow different school policies on reading time allocation). The present study extends the work of Hiebert with a more rigorous research design and a focus on students using the upper grade levels of the program.

The purpose of our research was to determine the effectiveness of the Quick Reads program used as a supplemental remedial fluency intervention for low-skilled fourth and fifth graders. We specifically considered the use of Quick Reads implemented by paraeducator tutors with student dyads in a pull-out tutoring intervention. The simplicity of the repeated reading procedure and the engaging nature of the Quick Reads passages make the program well suited for use by nonteachers with minimal background and training in reading and in student management.

Method

Students

Referral and screening. In the fall of the academic year, 40 fourth- and fifth-grade teachers in 12 public elementary schools in a large northwestern city were asked to refer students who (a) had never been retained, (b) had low rates of reading fluency or comprehension, and (c) would particularly benefit from a fluency- oriented intervention (i.e., teachers were asked to recommend students with adequate word reading skills who would benefit most from fluency instruction and who could be pulled out for instruction). Once active parent consents were obtained, referred students were screened for eligibility. Students were considered eligible for participation if they demonstrated at-risk performance on the average of three gradelevel reading passages from the Oral Reading Fluency (ORF) subtest of the Dynamic Indicators of Basic Early Literacy Skills (DIBELS; Good & Kaminski, 2002); fourth-grade at-risk performance was defined as scoring below 93 words correct per minute (WCPM) on fourthgrade passages, and fifth-grade at-risk performance was defined as scoring below 104 WCPM on fifth-grade passages. Of those screened, one fifth grader was recommended for an alternative intervention, as the student was able to read only 11 WCPM (far lower than bottom 10th percentile performance of 61 WCPM for fifth graders; see Hasbrouck & Tindal, 2006). Students eligible for participation were administered the full pretest battery.

Group assignment. Group assignment was a two-stage process. First, eligible students were randomly assigned within schools to dyads (pairs of students). Next, dyads were randomly assigned to one of two conditions: treatment (supplemental Quick Reads tutoring) or control (no tutoring; classroom instruction only). A few schools had uneven numbers of eligible students, and three eligible students were not assigned to either condition (through a random selection process) and were subsequently removed from study participation. Although it would have been preferable to randomly assign students within classrooms to dyads and conditions, there were too few eligible students within each classroom. Thus, dyads were cross- classroom, cross-grade pairs, and controls were typically dyads in name only-control pairs seldom had the same teacher.

Attrition. After group assignment, the sample comprised 70 students in each condition. By the end of the year, 16 (23%) treatment and 5 (7%) control students were lost to attrition. The treatment group attrition was greater due to study design: If 1 treatment student left, the student’s dyad partner was also removed from the study (although in three treatment dyads, both students moved), because tutoring instruction was designed for pairs. Controls, however, were dyads in name only, and thus the attrition of 1 control student did not affect another student. Treatment group attrition included 6 students who moved from their schools, 3 who were removed due to scheduling conflicts, 1 who had severe behavior problems during tutoring, 1 whose parent requested study removal, and 5 whose dyad was no longer intact. All control group attrition was due to students’ moving from their schools. Final sample sizes were thus 54 treatment students (27 dyads) and 65 control students. As reported in Table 1, there were no significant differences between groups on grade or status variable frequencies (all ps > .05).

Tutors

Twenty tutors were recruited from their school communities. Tutors’ educational levels, general tutoring experience, and experience working with fourth and fifth graders varied. Two tutors were employees of the district and served regularly as instructional assistants (IAs), and 3 were hourly employees. Prior to the study, tutors ranged from O to 11 years of tutoring experience and averaged 15 years of education: Two had master’s degrees, 11 had bachelor’s degrees (3 with teaching certificates), 2 had associate’s degrees, and 5 had attended some college. The average educational attainment of tutors in this study matches the paraeducator competency requirements under the No Child Left Behind Act of 2001.

Intervention

The Quick Reads program includes short, nonfiction passages written for Grade Levels 2 through 6. Each grade level includes nine science topics and nine social studies topics chosen on the basis of national and state grade-level curriculum standards for science and social science. Each topic is developed in five reading passages. For example, for Level D (fourth grade), science topics include “The Human Body,””Volcanoes,” and “Wind and Solar Energy.” Level D social studies topics include “The Constitution of the United States,” Natural Resources and the Economy,” and “The History of Sports.” An important feature of the Quick Reads program is its attention to text features that are expected to influence fluency rate. Texts that include a large number of unknown and difficult words can be discouraging for the struggling reader and difficult to process and comprehend. Therefore words chosen for inclusion in Quick Reads texts reflect expected grade-level decodability. The number of unique or rare words in Quick Reads texts is minimized, as students are unlikely to acquire these words as sight words from single exposures and from unlikely subsequent practice encounters in classroom reading texts. The vocabulary features many high- frequency words: Ninety-eight percent of the words used in the texts are high-frequency words or words that reflect grade-level phonics and syllable patterns. Texts emphasize words that students most need to learn to recognize automatically, and words are repeated to build opportunities for sight word learning. In previous studies of repeated reading (Faulkner & Levy, 1994; Rashotte & Torgesen, 1985), students’ reading fluency increased when they read texts that had a high overlap of words. Quick Reads text characteristics are hypothesized to develop underlying lexical accuracy and automaticity, prerequisite skills often overlooked in traditional conceptions of repeated reading as a remedial intervention.

Quick Reads is designed for classroom or small-group use either as part of the regular reading program or as a supplemental intervention. The number of passages students cover daily and the length of the intervention depend on how it is used. If a teacher follows the recommended classroom instructional routine, students use Quick Reads for 15 minutes a day for one semester, or 18 weeks. Each passage is read three times:

First read: The teacher activates background knowledge about the topic and asks students to find two words that are challenging. Students read the passage aloud or silently and then write notes or phrases of key ideas.

Second read: The teacher reads aloud with the students, setting a model for fluent reading, all reading aloud at the target rate of 1 minute. The teacher asks students to “tell the one thing the author wants you to remember.”

Third read: The teacher tells the students that their goal is to read as much of the passage as they can read in 1 minute. The students then read silently for 1 minute, and when the time is up, each student records the number of words read. The teacher and student review the comprehension questions together.

The teacher’s manual suggests many classroom extension activities to develop vocabulary skills and comprehension, including suggestions for supporting English language learner students. For example, activities suggested to build prior knowledge include discussing the student’s experience with the topic and creating a word web related to the topic. Activities suggested to build vocabulary include listing difficult words on the board and asking students to generate definitions and to find the vocabulary words in their readings. Activities suggested to identify key ideas include asking students to retell what they recall from the passage. Extension activities are recommended for each of the three readings, and additional reading is suggested for each topic. Treatment students received supplemental Quick Reads tutoring in dyads for 30 minutes per day, 4 days per week, for 20 weeks (November to June). Students assigned to the control group received regular classroom instruction while treatment students received tutoring. Students were pulled out for tutoring on the basis of teachers’ scheduling preferences. Classroom activities missed by treatment students during tutoring sessions (as reported by their classroom teachers) included reading or language arts, social studies, science, music, library, and physical education. More than half (55%) of treatment students were pulled out of literacy instruction at least some of the time during the intervention.

Tutoring sessions. The Quick Reads instruction for this evaluation was scripted to ensure that all tutors used the same procedures (as noted above, the teacher manual is written for classroom or small-group instruction and assumes that the teacher chooses the enrichment activities, coordinated with student need and other reading instruction). Each session began and ended with vocabulary instruction that had been designed by the research staff to match the vocabulary introduced in the Quick Reads passages.

Vocabulary extension activity. To incorporate the type of teacher support that would be provided if the program were used by the classroom teacher, we scripted a layer of brief vocabulary instruction, one of the extension activities suggested in the program. For each passage, one or two challenging words were identified. Criteria for selecting words for vocabulary instruction were that (a) the word was difficult to decode (e.g., symbol, engineer), (b) the word was important for understanding the topic being developed in the passages, and (c) the word was repeated in the passage at least twice and was also repeated across passages. We selected high-frequency, Tier 2 words (Beck & McKeown, 1985) that would be useful in middle school reading and that might not be familiar to students who are English language learners. We identified about 60 words per level and wrote clear, accessible definitions for the tutors to use to introduce and review. Tutors were provided with suggestions for several vocabulary review activities (e.g., student asked to provide examples or related words or to make a discrimination between two words) based on principles for effective vocabulary instruction (Baumann & Kame’enui, 2004; Beck, McKeown, & Kucan, 2002; Biemiller, 2001). Penno, Wilkinson, and Moore (2002) reported that students learn vocabulary from listening to stories being reread, with enhanced vocabulary acquisition when the teacher provided explanations of the words as they occurred in context.

Each tutoring session had seven steps, as follows.

1. New vocabulary: Tutor introduces new vocabulary word.

2. First read: Tutor introduces the passage and its main idea. Students take turns reading the passage.

3. second and third read: Tutor and students read the passage aloud together twice, with the tutor modeling smooth and fluent reading.

4. Fourth read: Each student completes a 1-minute timed reading.

5. Comprehension: Tutor and students read aloud the two comprehension questions that accompany each passage.

6. Vocabulary review: Tutor reviews vocabulary word from previous passage.

7. Read new passage: Students complete Steps 1 through 5 for a second passage (such that students read a minimum of two passages per session).

Quick Reads placement and coverage. Quick Reads passages are organized by grade levels (A = first grade, B = second grade, C = third grade, D = fourth grade, and E = fifth grade). We placed dyads into levels based on the grade level for which their averaged pretest reading fluency most closely matched 50th percentile (Hasbrouck & Tindal, 2006). Our sample, after attrition, included 1 dyad placed into Level B, 7 dyads placed into Level C, 18 dyads placed into Level D, and 1 dyad placed into Level E. Each Quick Reads level has three books, and each book contains six content areas with 5 passages per content area, for a total of 90 passages per level.

Each session, tutors recorded attendance, including the Quick Reads passage(s) covered. By the end of intervention, treatment students covered an average of 90 passages (SD = 22) and attended an average of 57 tutoring sessions (SD = 7), or 28.5 hours of intervention. After computing students’ individual passage coverage per session, we found that our treatment group averaged 1.6 passages per session (SD = 0.25; range = 1.1 to 1.9).

Tutor training. Tutors participated in one initial 4-hour training by project staff. Training included an overview of reading fluency development and the repeated reading method. Research staff then modeled the use of Quick Reads materials and vocabulary instruction. The tutors practiced and received feedback before they began work with students. Following initial training, coaches visited tutors weekly to provide coaching and modeling and to collect observation data on tutor instruction and management. Midyear, tutors attended a 3-hour workshop provided by research staff to reinforce tutoring strategies and effective student management. The workshop addressed specific tutor skills for successful Quick Reads lessons and included a demonstration of a Quick Reads lesson with students in study.

Tutor coaching. Throughout the 20-week intervention, research staff supported and conducted observations of the tutors. Specific researcher coaches were assigned to a set of tutors, and for each tutor, a minimum of eight observations were conducted (of which there were at least two observations per dyad). Coaches met monthly to discuss tutoring implementation progress.

Tutor observations (fidelity). To monitor treatment implementation fidelity, data were collected via observation forms, including (a) tutors’ adherence to scripted Quick Reads protocols, (b) tutor behavior in terms of both organization and responsiveness to students’ needs, and (c) student progress in terms of the amount of time spent actively engaged in reading passages. Tutors’ fidelity to scripted protocols was measured using a dichotomous (yes-no) implementation checklist that included two to five criteria for each of the Quick Reads instructional steps (the percentage of observed correct criteria across all steps was calculated per observation). Tutors’ behavior was measured using a 5-point rating scale of 0 (never) to 4 (always) on eight criteria, including “organizational materials,””tutoring time spent on instruction,””full tutoring time used,””smooth transitions,””corrections match error and skill,””use of specific praise,””quick pace,” and “keeps students engaged.” Student progress was measured by recording the amount of time (in seconds) students were actively reading text. Across all three measurements (protocols, behaviors, and student progress), only components actually observed were recorded (i.e., if the beginning of the tutoring session was the only component observed, then tutor behavior and student progress were not recorded). A total of 54 paired observations from five pairs of raters (one researcher- rater was used as a baseline for comparison with the other five) were used to obtain interobserver reliability. Adherence to scripted Quick Reads protocols reliability ranged from r = .53 to r = .91 and averaged r = .76. Reliabilities averaged r = .81 for tutor behavior ratings and r = .92 for the amount of time students spent on passage reading.

Across 254 observations (approximately 13 per tutor), adherence to protocols averaged M = 90% (SD = 11.5%); across 248 observations (approximately 12 per tutor), tutor behaviors averaged M = 3.7 (SD = 0.55), and across 206 observations, each student (within the dyad) spent an average of M = 7.8 minutes per session (SD = 4.42) actively engaged in orally reading Quick Reads text.

Student Assessments

Students were individually pretested and posttested by trained testers unaware of group assignment on skills hypothesized to be affected by intervention, including word reading accuracy, word reading efficiency, word comprehension, vocabulary, fluency rate, and passage comprehension. Attention and rapid automatized naming were measured only as a way to better describe the sample. Except for attention, vocabulary, and fluency rate, standard scores were used in analyses (population mean of 100 and standard deviation of 15). Measure descriptions are as follows.

1. Attention was measured midyear using the Attention scale from the Multigrade Inventory for Teachers (MIT; Shaywitz, 1987). To calculate the score, we averaged four items from the MIT together (those with reliable item-factor loadings; Agronin, Holahan, Shaywitz, & Shaywitz, 1992, pp. 98-99). Scores range from 0 to 4, with higher scores indicative of worse attention. Internal consistencies reported by the authors for Grades 4 and 5 are .91 and .92, respectively. For our sample, internal consistency is .90.

2. Rapid automatized naming was measured at pretest using the Rapid Letter Naming subtest of the Comprehensive Test of Phonological Processing (Wagner, Torgesen, & Rashotte, 1999). Students are presented with a card containing five letters repeated in random order, which they must name as fast as possible. The raw score is the number of seconds required to name all of the letters on two 36-item stimulus cards. Test-retest reliability reported in the test manual is .72 for 8- to 17-year-olds. For our sample, alternate form reliability is .75 (Form A and Form B letters correct per second).

3. Word reading accuracy was measured using the Word Identification subtest from the normreferenced, standardized Woodcock Reading Mastery Test-Revised/Normative Update, Form H (WRMTR/NU; Woodcock, 1998). This assessment requires students to read increasingly difficult words, and testing is discontinued after six consecutive incorrect responses. Split-half reliability (alternating items) reported in the test manual averages .99 for third graders and .91 for fifth graders. Internal consistencies for our sample of fourth and fifth graders are .93 at pretest and .94 at posttest. 4. Word reading efficiency was measured using the Sight Word subtest from the norm-referenced, standardized Test of Word Reading Efficiency, Form B (Torgesen, Wagner, & Rashotte, 1999). The Sight Word subtest requires students to read as many words as possible in 45 seconds from a list of increasingly difficult words. Test-retest reliability reported in the test manual for 6- to 9- year-olds is .96. For our sample, internal consistencies are .94 at pretest and .95 at posttest.

5. Vocabulary was assessed with a multiple-choice, curriculum- based measure of vocabulary developed by research staff in consultation with Dr. Judith Scott. Eighty initial items were constructed using 20 words sampled from each of four levels (B, C, D, and E) of the Quick Reads passages (no students were expected be placed in Quick Reads Level A). Criteria used for constructing the initial item pool included (a) words that appeared in at least three of the passages within the Quick Reads level and (b) words that were high-utility, content words (e.g., symbol, sense, native). Three distractors were written for each word and were constructed to have matching syntactic form to the correct definition and to have adequate semantic separation (the position of the correct definition among the four choices was randomly sorted). Students were asked to read each item and the four choices silently. All items were administered consecutively in the order of the Quick Reads levels, with 1 point awarded for each correct response. From the highest item-total (point-biserial) correlations at pretest, we selected half (10 of the original 20 items per level) of the items as our final measure. Thus, students’ scores reflect their raw number of items correct out of 40 items. Internal consistencies for our sample are .83 and .84 at pretest and posttest, respectively.

6. Word comprehension was assessed using the WRMT-R/NU Word Comprehension subtest. The WRMT-R/NU Word Comprehension subtest, measured at each test period, includes three increasingly complex subsections: Antonyms, Synonyms, and Analogies. For each section, items are arranged in increasing difficulty, and testing is discontinued after six consecutive incorrect responses. The Antonyms section requires students to read a word and supply a word opposite in meaning, and the Synonyms section requires students to read a word and supply a word similar in meaning. The third section, Analogies, requires students to read a pair of related words aloud, then read a single word aloud, and then supply a word related to the single word (using the relationship of the pair). For example, the student would read the word pair on-off followed by the single word in, and the correct response would be out. The raw score for the Word Comprehension test is the total number correct across all three sections. The test manual reports split-half reliability (alternating items) as .90 for fifth graders. For our sample, internal consistency is .92 at both pretest and posttest.

7. Fluency rate was assessed using students’ mean WCPM on three grade-level passages drawn from DIBELS ORF benchmarks. Specifically, fourth graders read the following DIBELS ORF Grade 4 passages at pretest: “Water Cycle,””Land at the Top of the World,” and “Georgia O’Keefe”; and at posttest: “The Youngest Rider,””Maid of the Mist,” and “She Reached for the Stars.” Fifth graders read the following DIBELS ORF Grade 5 passages at pretest: “Something’s Missing,””A New Habitat,” and “Mount Rainier”; and at posttest: “Help Is on the Way,””Whale Song,” and “Mount Everest.” Students read each passage aloud while the tester recorded errors; testing was discontinued after 1 minute. Words omitted, substituted, and hesitations of more than 3 seconds are scored as errors (words self-corrected within 3 seconds are scored as accurate). Test-retest reliabilities for elementary students are reported by Tindal, Marston, and Deno (1983) and range from .92 to .97. For our sample, Grade 4 passage fluency rate intercorrelations are .84 to .91 at pretest and .79 to .82 at posttest (all ps

8. Passage comprehension was measured using the WRMT-R/NU Passage Comprehension subtest, which requires students to supply a missing word that would be appropriate in the context of each sentence or passage read (silently). A series of acceptable responses are listed on the easel page for the tester. Items are increasingly difficult, and testing is discontinued after six consecutive incorrect responses. The test manual reports split-half reliability (alternating items) as averaging .97 for first and third graders and .73 for fifth graders. For our sample, internal consistencies are .89 at both pretest and posttest.

Data Analysis Strategy

Because pretest occurred prior to group assignment, pretest data were analyzed in one-way analyses of variance (SPSS 13.0 used for these analyses). However, two issues inherent in the research design we employed required a more complex analysis strategy for posttest data. First, students in the treatment condition received instruction in pairs (dyads) during most tutoring sessions, which suggests that students within a dyad cannot be expected to have outcomes independent from one another. As such, the assumption of independence required for typical analyses of variance and covariance (ANOVAs and ANCOVAs) is not tenable.

One strategy to handle this problem would be to collapse dyads into their means (cf. Graham, Harris, & Chorzempa, 2002); this is not a preferable option, because use of dyad means would lead to loss of individual student information as well as difficulty in drawing meaningful conclusions from analysis results. In addition, students in the control condition were dyads by label only (thus, it is reasonable to assume that students within a control dyad will have outcomes independent of one another). Another strategy, then, would be use of hierarchical linear modeling (also known as multilevel modeling, mixed modeling, and random effects modeling) to account for the nonindependence of students within treatment dyads while simultaneously allowing each control student to serve as his or her own dyad. However, this leads to a secondary but no less important issue: By posttest, we did not expect that treatment and control groups to have within-group variances similar enough to pool, which is the assumption in typical hierarchical linear model specifications (the treatment group, composed of dyads, was expected to be more homogeneous in their reading skills as a function of paired instruction, whereas controls’ variance was hypothesized to be stable at both pretest and posttest). Given these issues, our data analysis strategy was to specify ANCOVA-like hierarchical linear models that allow for heterogeneous group variances as well as random variation between dyads (cf. Raudenbush, Bryk, Cheong, & Congdon, 2004, pp. 52-54). Respective pretests were group-mean centered for use as covariates, and group was dummy coded for ease of interpretation (1 = treatment; 0 = control). HLM 6.0 (Raudenbush, Bryk, & Congdon, 2004) was used for all hierarchical analyses. The general equation used for all posttest analyses is provided below.

Interpretation of the general model is as follows: Each outcome estimated for student i in dyad j (controls were coded as one dyad) is equal to (a) the fixed effect of intercept gamma^sub 00^ (posttest mean for all students, holding group and pretest constant), plus (b) the fixed effect of slope gamma^sub 01^ (effect of treatment group membership, holding pretest constant), plus (c) the fixed effect of slope gamma^sub 10^ (effect of individual’s pretest ability relative to their group mean), plus (d) the random effect of variance between dyads u^sub 0j^, and plus (e) the random effect of within-group variance r^sub ij^.

Results

Pretests

Group means and standard deviations at pretest and posttest are shown in Table 2. We used a series of one-way ANOVAs to test for possible group differences at pretest, because students had yet to receive any treatment in dyads. The results of these analyses showed no evidence of group differences for any measure (all Fs = 1.2, all ps > .05), which was expected because students within dyads were randomly assigned to condition within schools. Pretests, shown in Table 2, reveal that the combined sample averaged approximately in the lower 20th to 25th percentile on all norm-referenced measures (as per the average standard scores) as well as fluency rate (see Hasbrouck & Tindal, 2006).

Posttests

To determine whether schools should be considered in our nesting structure for hierarchical posttest analyses, we tested for pretest differences between schools using oneway ANOVAs followed up with Tukey’s HSD pairwise comparisons. Because we found no significant differences between schools on any measure (Fs = 1.7, ps > .05), schools were not incorporated into posttest analyses.

Results from our hierarchical linear models (fixed effects shown in Table 3) revealed that there were significant treatment effects for vocabulary, word comprehension, and passage comprehension but not for word-level reading or fluency rate. The model estimates show that students in the treatment group had a 3-point advantage over controls on the curriculum-based vocabulary measure (d = .42); for word comprehension, the treatment group is estimated as having an advantage of 3 standard score points (d = .27); and finally, for passage comprehension, treatment students are estimated as having an advantage of 4 standard score points (d = .50). For our norm- referenced measures, these results imply that the treatment group averaged in the 30th percentile at posttest on both word comprehension and passage comprehension, whereas the control group averaged in the 25th and 10th percentiles, respectively. (Although we report Cohen’s d for significant treatment effects, calculated as the difference between groups divided by pooled standard deviation [Cohen, 1988], we wish to note that the computation assumes the variances of the two groups can be pooled, which is unreasonable given our research design. As such, we encourage readers to use caution in interpreting this kind of effect size, and to focus more on the estimated differences between groups in terms of standard score points and percentile ranks.) In all analyses, pretest accounted for significant variation in posttest (all ps .05 in chi-square tests), with the exception of fluency rate (between-dyad variation was greater than chance, p

Exploration of Fluency Rate Relationships

We hypothesized that the lack of treatment effects for fluency rate might be related either to the generally low word-level reading skills (accuracy and efficiency) of our sample or to treatment- related variables. Intercorrelations were computed and are provided in Tables 4 and 5 for treatment and control groups, respectively. For the treatment group, we added three treatment-related variables: (a) Quick Reads total passage coverage (number of unique passages read), (b) rate of coverage (average unique Quick Reads passages per session covered), and (c) dichotomously coded classroom reading instruction missed during tutoring (1 = missed some literacy instruction; 0 = otherwise). (Although not shown in the table, tutor protocol fidelity is not related to any pretest or posttest; all rs .05.)

Examination of the treatment group’s intercorrelations shows that although pretest word reading accuracy and efficiency have a low to moderate relationship with posttest fluency rate (r = .28, p .05, whereas passage coverage rate uniquely accounted for 10.6% of posttest variance; after pretest fluency rate and word reading efficiency were taken into account, F^sub change^ (1, 50) = 12.707, p

Attention and rapid automatized naming were not strong predictors of posttest outcomes for either group. For treatment students, attention accounted for 11% of the variance in fluency rate, and rapid automatized naming accounted for approximately 11% of the variance in word reading accuracy and 14% in passage comprehension. For the control group, attention accounted for approximately 7% of the variance in vocabulary, and rapid automatized naming accounted for approximately 9% of the variance in word reading efficiency and 11 % in fluency rate.

Discussion

The aim of our study was to evaluate the use of the Quick Reads fluency program for fourth- and fifth-grade students whose fluency rate was below grade level in the fall of the academic year. Students were referred by classroom teachers for supplemental fluency instruction, screened, and randomly assigned to dyads within schools. Dyads were then randomly assigned to either Quick Reads tutoring or no tutoring (regular classroom reading instruction only). Quick Reads instruction was provided by paraeducator tutors to pairs of students who worked on passages estimated at their average reading level for approximately 20 weeks. At posttest in the spring of the academic year, the treatment group significantly outperformed the control group on measures of vocabulary, word comprehension, and passage comprehension; however, we found no treatment effects for word-level reading or oral reading fluency. At posttest, both treatment and control students’ average fluency rate performance was in the lowest quartile, according to Hasbrouck and Tindal’s (2006) grade-level norms.

As noted by others (LaBerge & Samuels, 1974; Perfetti, 1985; Wolf & Katzir-Cohen, 2001), the complexity and developmental nature of reading fluency suggests that intervention efforts begin with attention to sublexical and word-level skills. In this study, we asked teachers to refer students who had poor reading fluency and basic wordreading skills. We further attempted to impose a minimum level of word reading skill for eligibility to ensure that students would be able to participate in and benefit from dyadic oral reading practice. We should note that teachers were not willing to refer students with higher reading skills for this pull-out intervention. Yet at pretest, treatment students averaged nearly one standard deviation below the population mean in word reading accuracy and efficiency, which may have been too low to allow them to develop reading rate and therefore reduced the fluency effects of the intervention.

If we take the developmental perspective outlined by Kame’enui et al. (2001), a more effective fluency approach for this low-skilled cohort of fourth and fifth graders might first target word-level reading efficiency. Our findings support the recommendations of others (Kame’enui et al., 2001; Torgesen, Rashotte, et al., 2001; Wolf & Katzir-Cohen, 2001) that effective fluency intervention must attend to all components of fluency, including explicit instruction to address gaps in sublexical and word-level skills as well as semantic, orthographic, and morphological processes. In choosing the vocabulary extension activity for this field test, we had hoped to address what we expected would be the most developmentally appropriate word-level instruction that would fit into the 30- minute instructional block without reducing the intensity of repeated reading time required to test its effects. In retrospect, we would replace the vocabulary extension activity with added explicit instruction in alphabetics and decoding efficiency. Many students in the treatment group struggled to recognize single- as well as multiletter spelling patterns. We were surprised and dismayed to find that many students had word-reading miscues due to confusion about single vowel sounds. In the 2nd year of our evaluation of Quick Reads, we will consider its use in a more preventive than remedial application for second- and third-grade students. In that evaluation, we will incorporate explicit instruction in the alphabetic principle as the short extension activity to accompany repeated reading procedures. One limitation of the current study is the lack of data on classroom reading instruction. In our future research with younger students, we will conduct observations to account for the influence of classroom reading instruction on student outcomes.

Because this study was designed to evaluate the effectiveness of the Quick Reads program, which is a repeated reading approach, the final stage of passage-level fluency was the developmental fluency target. And in spite of students’ lexical-level deficiencies, treatment students derived benefits from the Quick Reads intervention in the areas of vocabulary and comprehension. The Quick Reads text characteristics may have enabled these lowskilled readers to develop vocabulary and comprehension skills in spite of the fact that they continued to struggle at the lexical and sublexical levels in word reading and decoding (i.e., perhaps through the text characteristics: high-frequency words, word repetitions, and connections with grade-level concepts being taught in the classroom). One implication of this evaluation is that the effectiveness of Quick Reads might be increased if the extension activities for low-skilled students target explicit instruction to develop word reading efficiency. The intentional word choice and word repetitions that characterize the Quick Reads passages would allow a skilled teacher to readily add this instruction to the repeated oral reading practice. We expect it may be even more important to attend to students’ lexical level of fluency in earlier grades, the stage in development when many students are consolidating these underlying component skills. Authors’ Note: Grant R305G040103 from the Institute of Education Sciences, U.S. Department of Education, supported this research. We especially acknowledge Sueanne Sluis for coordinating the intervention, and we thank Julia Peyton and Sarah Tudor for coordinating student assessments. We also thank coaches, testers, tutors, and data entry staff, especially Kathryn Compton, Katy Compton, Eleanor Garner, Rayma Haas, Robin Horton, Ruth McPhaden, Siobhain Mogensen, Steven Pearson, Nancy Rerucha-Borges, Katia Roberts, Linda Romanelli, Laura Root, Tyler Rothnie, Yu Linda Song, Jason Vincion, and Lynn Youngblood. Finally, we are most grateful to the teachers, staff, and children of the schools for their support and participation in this study.

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Patricia F. Vadasy

Washington Research Institute

Elizabeth A. Sanders

University of Washington

Patricia F. Vadasy, PhD, is a senior researcher at Washington Research Institute. Her research interests include reading acquisition and reading intervention.

Elizabeth A. Sanders, MEd, is a doctoral student in measurement, statistics, and research design in the College of Education at the University of Washington. Her academic interests are in quantitative methods in educational research.

Copyright PRO-ED Journals Jul/Aug 2008

(c) 2008 Remedial and Special Education; RASE. Provided by ProQuest LLC. All rights Reserved.

Linguistic Capital and Academic Achievement of Canadian- and Foreign- Born University Students

By Grayson, J Paul

Au Canada, plusieurs universites prennent des mesures pour recruter des immigrants ou leurs enfants et satisfaire leurs besoins- et parmi eux plusieurs ont l’anglais comme langue seconde. Il n’y a pas de recherches au Canada qui comparent la progression potentielle du capital linguistique des etudiants ayant l’anglais comme langue seconde et celui des autres etudiants au fil de leur parcours universitaire, avec les relations entre les progressions du capital linguistique et de l’acquisition des connaissances. L’auteur montre dans cette etude que, contrairement aux etudiants canadiens et ceux nes a l’etranger pour lesquels l’anglais est la premiere langue, le capital linguistique des etudiants nes a l’etranger dont l’anglais est une langue seconde s’accroit au cours des quatre annees d’etudes universitaires. Cependant, cette augmentation du capital linguistique ne correspond pas a une augmentation de l’acquisition des connaissances. In Canada, many universities are taking steps to recruit and meet the needs of immigrants and/or their sons and daughters, many of whom have English as a second language (ESL). There is, however, no research in Canada comparing potential increases in the linguistic capital of ESL and other students over the course of their university careers and the connection between increases in linguistic capital and academic achievement. In this study, it is shown that in contrast to Canadian- and foreign-born students for whom English is a first language, and Canadian-born ESL students, the linguistic capital of foreign-born ESL students increases over 4 years of university study; however, this increase in linguistic capital is not paralleled by an increase in academic achievement.

ALMOST 2 MILLION IMMIGRANTS ARRIVED IN Canada in the 1990s. Seventeen percent of this number were children aged 5-16. As a result of this migration pattern, the foreign born now make up 18.4 percent of the Canadian population (Canada 2003). Many newcomers have taken up residence in Canadian cities. In Toronto, Montreal, and Vancouver, Canada’s largest cities, immigrants comprise 44 percent, 18 percent, and 38, percent, respectively, of the population (Justus 2004). In earlier decades, most immigrants to Canada in general, and Toronto in particular, were of European descent. At the turn of the current century, however, most immigrants to Toronto were from China, India, Pakistan, the Philippines, Sri Lanka, Hong Kong, Iran, Russia, South Korea, and Jamaica (p. 43). In 2003, only 10 percent of immigrants had either English or French as a first language (Canada 2004).

Immigration patterns such as these result in well-documented economic (Samuel and Bassavarajappa 2006), social (Laguian, Laguian, and McGee 1997), and psychological (Beiser and Fang 2006) problems for immigrants. Moreover, the well-educated share in the difficulties. For example, national data indicate that in the 1990s, as many as one in four new immigrants with university degrees held jobs that required no more than secondary school education. This was twice the proportion of those born in Canada. In addition, the unemployment rate for new immigrants in the 25-54 age group was three times that of the Canadian born (Galaraneau and Morissette 2004).

Although large numbers of immigrants have postsecondary education (PSE), the results of the International Adult Literacy and Skills survey indicate that many well-educated immigrants have English language deficiencies. For example, whereas 37 percent of native- born university-educated Canadians scored in the highest literary category, the figure for similarly educated recent immigrants was only 11 percent. Even well-educated immigrants with English as a first language scored lower than the Canadian born. Importantly, length of residence in Canada was of no consequence for the literacy performance of immigrants. Evidence such as this suggests that any programs in place designed to facilitate literacy improvements among immigrants may be having less-than-optimal impacts. Understandably, immigrants with high levels of English literacy were most likely to be employed (HRDC 2005).

While it is difficult to say with certainty that they were inspired by findings such as the foregoing, it is nonetheless clear that procedures have been put in place in many Canadian postsecondary institutions designed to facilitate the adaptation of non-English-speaking new comers, or their sons and daughters, to Canadian society. For example, postsecondary educational institutions increasingly recognize that it is necessary to put in place processes that will ensure the recruitment of students from diverse backgrounds and the development of programs to meet the needs of such students. In Toronto, the city that hosts a plurality of Canada’s new immigrants, all three universities have policies designed to meet the needs of students from a diversity of backgrounds. As shown by Grayson (2007), the University of Toronto recognizes that, “our recruitment process [must] … be sensitive to the needs and interests of those whom we are attempting to recruit” (Neuman 2003). Potential recruits include those for whom English is a second language. York University has a similar commitment. As a result, its academic plan has, as one of its goals, “improving support for students in need of additional support, and students for whom English and French are second languages” (Anonymous 2005). Because of its similar commitment to diversity, the academic plan at Ryerson University recognizes that, “there may be many implications for program design and delivery, particularly related to factors such as learning styles and English language familiarity” (Anonymous 2003).

How well are such policies working? Although some research shows that immigrants are less likely than others to find employment equal to their level of education, and that students for whom English is a second language do not graduate from high school in numbers comparable to those of English speakers (Radwanski 1987; Derwing et al. 1999; Roessingh and Watt 2001), a national study indicates that after imposing controls for variables such as income, gender, visible minority, and immigrant statuses, those with a mother tongue other than English or French are 12 percent more likely to be enrolled in universities (Frenette 2005). Mother tongue is of no consequence for college registration.

While these findings may appear to be discrepant, they can be interpreted as follows: As a group, highly educated English as a second language (ESL) immigrants are less likely than others to find employment consistent with their education. In addition, ESL students, whether immigrants themselves or sons and daughters of immigrants, may have lower high school graduation rates than others. This said, ESL students are a diverse group. Members of some groups, such as those of Chinese origin, may be inclined to graduate from high school, and proceed to higher education, in great numbers. Indeed, the proportion of such individuals who proceed in this fashion may be sufficiently high to result in the finding that ESL students in general are more likely than others to enroll in universities. This interpretation is consistent with analyses of the educational levels of members of different groups of young people based on census materials. For example, in Toronto, within the 25- 34 age group, 33.2 percent and 28.3 percent of European origin males and females, respectively, have a university degree. The comparable figures for those of Chinese origin are 48.5 percent and 54.3 percent (Ornstein 2006, table 3.a).

Although they may enter PSE in greater-than-average numbers, it does not mean that postsecondary experiences of ESL immigrants or their sons and daughters are similar to those of other groups. For example, it was found in one study of a Canadian university that ESL students with 3-5 years of experience in Canadian high schools performed worse academically than either non-ESL students or ESL students who were required to pass an English language proficiency test before being admitted. The reason for the relative success of the latter group is in part attributed to the fact that they were eligible for English language support programs. By comparison, such programs were not available to ESL students coming from Canadian high schools (Fox 2005).

Other research indicates that when they enter postsecondary institutions, the dropout rates for ESL students may be no higher than for other students; however, consistent with Fox (2005), the grades of the former are relatively low (Roessingh et al. 2004). Importantly, in a study in which the grades of ESL students were compared with those of students who spoke English while growing up, it was also found that after controls had been applied for high school grades, in addition to home language, university grades were also affected by ethno-racial origin (Grayson 2008). Additional research on international and domestic ESL and English-speaking students at the University of British Columbia, York University, McGiIl University, and Dalhousie University found that international ESL, domestic ESL, international English speakers, and domestic English speakers, in that order, experienced difficulties communicating in English. Again, after controls had been applied for high school grades, the first-year grades of students for whom English was a second language were lower than those of students with English as a first language (Grayson and Stowe 2005). Although there is mounting evidence that independent of high school grades ESL students, both domestic and international, face English problems at the postsecondary level that are concomitant with relatively low levels of achievement, little is known about the extent to which the university experience contributes to the development of linguistic capital of ESL and non-ESL students from different social backgrounds, and the connection of linguistic capital to academic achievement. This article will fill in some of these lacunae.

ORIENTATION

The examination of the issues noted above can be viewed in the more general context of cultural reproduction (Grayson 2008). For Bourdieu and Passeron (1990), “linguistic capital” is a component of “cultural capital” that predisposes the sons and daughters of the privileged classes to academic success; however, a clear definition of the concept is not provided. Other writings of Bourdieu do not deal with this limitation. Using Bourdieu’s concepts as a point of departure, however, Sullivan (2001:893) defines linguistic capital as, “the ability to understand and use ‘educated’ language.” Morrison and Lui (2000:473), in an examination of colonial Hong Kong, define linguistic capital as, “fluency in, and comfort with, a high-status world-wide language which is used by groups who possess economic, social, cultural and political power and status in local and global society.” As in the former colony of Hong Kong, in English Canada, the dominant language is English.

Despite Bourdieu’s inattention to a precise definition of linguistic capital, he makes four things very clear. First, linguistic capital, as a component of a broader cultural capital, is acquired in large part from parents. Second, the uneducated lower classes in capitalist societies lack the kind of linguistic capital valued by the powerful. Third, academic success is contingent upon the acquisition of linguistic capital. Fourth, deficiencies in linguistic capital contribute to the winnowing out of the sons and daughters of the less advantaged from successive levels of education. This means that relatively few students from disadvantaged backgrounds are found at the university level.

Bourdieu and Passeron argue that in elementary schools teachers constantly evaluate students’ use and understanding of language. These evaluations find lower-class students deficient. Not only teachers’ evaluations but also tools of assessment themselves (e.g., IQ and other standardized tests) have been found to embody ways of viewing the world foreign to economically disadvantaged students. Because of such biases, the performance of linguistically disadvantaged students on many tests is such that the educational credentials necessary for success in capitalist societies elude them (Gipps 1999).

At postsecondary levels of education, Bourdieu and Passeron argue that it is difficult for students with relatively limited linguistic capital to understand the “convoluted” language of their professors (e.g., the use of “big” words and compound-complex sentences). This difficulty would be compounded for ESL students in English Canada. Overall, the effect of processes such as these is that “the educational mortality rate … increase[s] as one moves towards the classes most distant from scholarly language” (Bourdieu and Passeron 1990:73).

Bourdieu’s argument that linguistic capital is a function of class, and is used to marginalize the lower classes at all levels of education, is not without its critics. It has been argued, for example, that in France language and high culture are more a vehicle of social distinction than in other countries such as Britain and the United States (Dumais 2002). Consequently, a lack of linguistic capital may be of more consequence in France than elsewhere. Also, it may be naive to assume that in Britain, teachers, many of whom have lower-class roots, are gatekeepers for the upper classes (Sullivan 2001; Dumais 2002; Robson 2003). Despite these and other criticisms, it is clear that language development varies by class and that disadvantage accrues to the relatively underprivileged (Ensminger and Slusarcik 1992; Bayder, Brooks-Gunn, and Furstenberg 1993; Parcel and Menaghan 1994; Hart and Risley 1995; Brooks-Gunn, Klebanov, and Duncan 1996; Alexander, Entwisle, and Horsey 1997; Farkas and Beron 2001).

In Canada, there is some research indicating that the cultural capital (which includes its constituent linguistic capital) available to students has implications for progression to higher education and for income upon graduation from university. As yet, however, the extent to which cultural capital affects postsecondary performance has received little attention.

As an example of the first point, research conducted in Canada has shown that the cultural capital of parents is of consequence for the completion of postsecondary studies by their children. For example, a longitudinal examination conducted in British Columbia revealed that 5 and 10 years after high school graduation individuals whose parents could be seen as being rich in cultural capital were far more likely than others to have completed postsecondary studies (Andres and Grayson 2003). It is worth noting that in this study 5 years after high school graduation the effect of the cultural capital of parents on the occupational status of children took an indirect route via the educational attainment of their children. There was no direct connection between parents’ cultural capital and the occupational status of their children. An example of the second point is provided by research in which the impact of cultural capital, human capital, and social capital on incomes 2 years after graduation was analyzed. The results of the study indicate that the cultural capital of parents was passed on to university graduates in the form of income levels after graduation (Grayson 2004). In short, all else being equal, the incomes of graduates from families high in cultural capital were higher than those of students from low cultural capital families.

Within the university, a manifestation of the operation of cultural and linguistic capital has been demonstrated in a Canadian study focusing on the grades of different language groups after adjustments had been made for fathers’ educational background, age, ethno-racial origin, high school grades (from administrative records), self-assessed communication skills, and faculty of enrollment. By and large, the university grades (from administrative records) of the sons and daughters of the Canadian born with English as a first language were higher than those of the children of immigrants, most of whom spoke a language other than English while growing up (Grayson 2008).

While the foregoing study indicated a disadvantage on the part of nonEnglish linguistic groups, it could not examine possible changes within and between groups of different students once they enter university. More concretely, does the linguistic capital of various linguistic groups increase over the course of university studies? University professors might hope so. Also, does the academic performance of initially disadvantaged linguistic groups improve over time? As indicated earlier, answers to these questions are the focus of the current inquiry.

SAMPLE

York University, the institution on which the current study is based, is a racially diverse comprehensive commuter university of approximately 45,000 students located in Toronto, Canada. At the end of their first year of study in 1995, a mail-out questionnaire was returned by a random sample of 1,865 students who had entered York University directly from high school in 1994. These 1,865 students represented a response rate of 64 percent. Exactly the same questionnaire was mailed to this original group of respondents at the end of 1996,1997, and 1998. By the final year, 513 students (or 28 percent of the original sample) had responded to each wave of the study. When adjustments are made for the fact that in the intervening years students had left the university either before or after degree completion, the 513 students who completed the final questionnaire represent 55 percent of those who had responded to the original survey and who were still enrolled in the university and eligible to participate (Grayson 1999). In a longitudinal study of this nature, this is an excellent retention rate (Dey 1997).

Given that in all faculties with the exception of Arts for each wave of the study questionnaires were sent to all students who originally enrolled in the faculty in 1994, it was not possible to compare all ongoing survey participants with a broader base of students. In view of the large size of Arts, however, it was possible to compare Arts students who had remained in the study to a sample of Arts students in general. When this was done, it was found that ongoing participants were similar to Arts students in general in terms of ethno-racial origin, sex, family income, number of completed credits, and grade point average (GPA) (Grayson 1999:48).

MEASURES

In view of the potential importance of English linguistic capital to academic success, survey respondents were asked to self-assess a number of different English communication skills. As noted by Portes and Schauffler (1994), unlike self-assessments of other skills, those of language ability have been found to be both reliable and valid. Consistent with this conclusion, an examination of data derived from The International Adult Literacy Survey (IALS) (Anonymous 1995) jointly undertaken by Statistics Canada and The Educational Testing Service sheds important light on the relationship between self-reported and other measures of skills. As noted elsewhere (Grayson 2008), this study obtained self- assessments of reading, writing, and quantitative skills, and required participants to complete a number of performance tasks of varying levels of difficulty related to prose literacy, document literacy, and quantitative literacy. For Canadians aged 16-25 who had completed PSE (the group most comparable to the subjects of the current study), the correlations between self-assessed reading and testmeasured prose and document literacy were .45 and .36, respectively (analysis of data by author). The correlations between self-reported writing skill and test-measured prose and document literacy were .29 and .22; however, the last mentioned was not statistically significant. Finally, there was a correlation of .29 between self-assessed quantitative skills and quantitative literacy as measured in tests. This study, based on Canadian data, shows that there are small-tomoderate statistically significant correlations between self-assessments of communications skills and skills measured in other ways. While the magnitude of these correlations is insufficient for making academic decisions about, for example, the linguistic capital of individual university students, they suggest that in comparisons between groups self-reports may be used as a cautious proxy for more “objective” measures. This assumption is supported by the results of a great deal of other research (Berdie 1971; McMorris and Ambrosino 1973; Pohlmann and Beggs 1974; Baird 1976; Dumont and Troelstrup 1980; Pascarella and Terenzini 1991; Evers et al. 1993; Pike 1994, 1995a, 1995b; Kuh et al. 1997). The National Survey of Student Engagement, which is now used widely to measure experiences and outcomes in Canadian universities, relies exclusively on self-assessments of linguistic and other skills.1

In the current study, English linguistic capital was assessed by four questions in which students were asked whether they agreed or disagreed that it was easy for them to engage in different English language activities. The areas identified were: speaking English; reading English; writing in English; and following a conversation in English. Response options ranged from 1, meaning that it was very hard to complete the activity in the statement, to 5, indicating that it was very easy.

Cronbach’s a2 for the four questions combined was .71, .71, .77, and .71 for each of the 4 years. By removing the results of the question pertaining to ease of writing in English, however, alpha increased to .87, .87, .90, and .89. As a result, although the alpha for all four items was sufficient, it was decided to combine speaking, reading, and conversing into one index (nonwritten skills) and treat the item dealing with ease of writing in English (written skills) separately from the other three items. The average nonwritten score in the first year was 4.7 with a standard deviation of .59. The respective figures for written scores were 4.3 and 1.3.

Given the fact that it has been shown in many studies that the cultural and linguistic capital of children is directly related to the class and education of their parents (Laureau and Weininger 2003; Robbins 2005), students were asked to provide information on parental education. For the current study, students were classified in terms of having a minimum of one parent who had at least some postsecondary experience. Overall, 57 percent of students reported that at least one parent had at least some postsecondary experience.

Country of birth was determined by a question in which students were simply asked to identify the country in which they were born. In total, 75 percent of students were born in Canada. For students born overseas, the average number of years in Canada was 3.0 with a standard deviation of 5.9. These figures indicate that a large portion of foreign-born students were relatively recent immigrants.

Language background was assessed by asking students to identify the language they spoke in the home while growing up and still understood. Sixty-seven percent of students reported English as their first language. In the analyses, those who specified English were categorized as Englishspeaking students. Students who identified a language other than English were categorized as ESL.

Of the 513 students who completed all four surveys, 59 percent were born in Canada and spoke English while growing up. Eight percent of respondents were born outside of Canada and also spoke English while growing up. Large numbers of these were immigrants from Caribbean countries. A further 16 percent were born in Canada but spoke a language other than English in their childhood homes. The remaining 17 percent were born outside of Canada and spoke a language other than English while growing up. With the exception of Canadian-born English speakers (303 cases), the absolute number of cases in some groups is relatively low. Overall, 41 English speakers were born outside of Canada. Eighty-seven ESL students were born outside of Canada and 82 ESL students were born in Canada. As a consequence of these relatively small group sizes, for some statistical analyses, false-negative findings are possible.3 Discussions of results will take this possibility into consideration.

Information on high school grades (Ontario Academic Credits [OAC]), university GPA, and faculty of enrollment was obtained from administrative records and linked to survey data. The average high school grade was 80.3 percent with a standard deviation of 6.3 percent. In the first year, the average GPA was 5.9 (low of O and high of 9) with a standard deviation of 1.5.

At the time of the study, York had several faculties, the largest of which was the Faculty of Arts. Medium-sized faculties included Science and Engineering, Fine Arts, and Glendon College (a small bilingual college located 19km away from the main campus). Environmental Studies and the Schulich School of Business were relatively small faculties, at least at the undergraduate level.

ANALYSIS

Analysis will proceed in three steps. First, as other studies have shown that grades in Science tend to be lower than in other faculties (Astin 1993; Pascarella and Terenzini 2005), we will focus on the enrollment patterns of different language groups. This is a necessary step as otherwise we might attribute low grades to particular language groups when in fact such grades reflect the fact that such language groups enroll in particular faculties in large numbers. second, through repeated analysis of variance, a method that allows us to assess changes between individuals and groups over time, potential changes in English linguistic capital and academic achievement will be examined over the 4 years of the study. Third, regression analyses will be carried out to determine, in each year, the effects of variables described above on academic achievement (GPA).

FACULTY DISTRIBUTIONS

The distribution of language groups across faculties can be found in Table 1. For current purposes, it is sufficient to make four observations. First, the largest percentage of English Canadian students (34 percent) are enrolled in the Faculty of Arts. The second largest group of these students (21 percent) is enrolled in Fine Arts.

A large percentage of Canadian ESL students (43 percent) is also enrolled in the Faculty of Arts. By comparison, the largest single group of foreign English students (30 percent) is enrolled in Science and Engineering. This faculty is also home to the largest group of foreign ESL students (36 percent). Given the bilingual nature of Glendon College, it is not surprising that a substantial number of Canadian ESL students (20 percent) are found there. While differences among groups are not always large, they are statistically significant and indicate that different language groups are not randomly distributed across all faculties.

Repeated Analyses of Variance

Because of some small cell sizes noted earlier, it is not practical in the repeated analyses of variance to control for a wide variety of variables. (This task will be left for the regression analyses.) Despite this limitation, repeated analyses of variance allow us to examine the possibility of change in nonwritten and written linguistic capital and academic achievement over 4 years of study.

Table 1

Faculty of Enrollment by Language Group

Figure 1. Nonwritten English Linguistic Capital Score by Birthplace and First Language

The average scores (maximum of 5) for nonwritten and written linguistic capital of each language group are plotted in Figures 1 and 2. The first point of interest in Figure 1 is that with the exception of students born outside Canada who did not speak English while growing up (foreign ESL), for each group, the absolute scores for nonwritten English linguistic capital are reasonably high. For example, in year 1, students who were born in Canada and who spoke English while growing up (Canadian English) scored 4.91; students who were born overseas but spoke English in their families (foreign English) self-rated at 4.79. For Canadian-born students who spoke a language other than English while growing up (Canadian ESL), the score is 4.80. The score for students born overseas who did not speak English in their households (foreign ESL) is 4.10.

The second point of interest is that with the partial exception of foreign ESL students, the scores of different language groups remain basically the same over the 4 years of study. For example, Canadian English students score 4.91 in year 1 and 4.94 in year 4. By comparison, the year 1 score for foreign ESL students is 4.10 and modestly increases to 4.25 in year 4.

As might be expected, given the magnitude of change over 4 years, and the relatively small numbers in some groups, the results of repeated analyses of variance on these and other variables reported in Table 2 indicate that, overall, wii/im-subject variance (changes within individuals from one survey to the next) over the 4 years of the study is not statistically significant, nor are changes for individual groups of students. Information in Table 2 also shows that over the 4-year time span, the between-subject differences (differences between the groups averaged over the entire 4 years) among groups are statistically significant in nonwritten English scores. In addition, the scores for Canadian ESL and foreign ESL students are statistically significant from those of Canadian English students, the reference group. By comparison, and as might be expected, differences between the scores of the reference group and foreign English speakers are not statistically significant. Recall, however, that the absolute numbers in the latter group are small, and false negatives are possible. Figure 2. Written English Linguistic Capital Score by Birthplace and First Language

The results for English linguistic capital as measured by the single question are summarized in Figure 2. On this dimension, scores for all groups are lower than for nonwritten English. Most noticeable differences for the first 3 years are between foreign ESL students and all other groups. For example, in year 1, the respective scores for Canadian English, foreign English, Canadian ESL, and foreign ESL students are 4.52, 4.00, 4.26, and 3.61, respectively. In year 4, there is some convergence. As was the case in the examination of nonwritten English, the greatest gains in written English capital are made by foreign ESL students who increase from a score of 3.61 in year 1 to 4.00 in year 4.

Table 2

Significance of Repeated Analyses of Variance

The results of the repeated analyses of variance reported in Table 2 indicate that the overall changes from 1 year to the next (within-subject changes) for written English linguistic capital are not statistically significant nor are the gains made by Canadian and foreign speakers of English and Canadian ESL students. By contrast, improvements in the written English of foreign ESL students are statistically significant. Put differently, there is an improvement in this aspect of the linguistic capital of foreign ESL students over the study period. In addition, the overall differences among groups averaged over 4 years (between-subject differences) are statistically significant. Also, differences between Canadian English students and those in each of the other three groups are statistically significant.

Keeping in mind the potential limitations imposed by small numbers in some groups, taken together, these two sets of findings indicate that over time there are no changes in the nonwritten English linguistic capital of students. By comparison, the written English capital of foreign ESL students does improve. In addition, with the exception of nonwritten English linguistic capital scores of foreign English students (which again may be a reflection of low numbers), between-subject differences between Canadian English and other groups in nonwritten and written English averaged over 4 years are statistically significant.

Figures. Grade Point Average (GPA) by Birthplace and First Language (Adjusted for Ontario Academic Credits)

As in Canada the best predictor of academic achievement in first- year university is high school grades (Grayson 1996), it is important in analyses of university achievement to control for high school achievement. If this step is not taken, we may wrongly attribute university achievement to ascriptive factors, such as language, when in fact achievement is not a product of language but of the fact that different language groups enter university with different levels of previous achievement.

In the current study, Canadian English and foreign ESL students enter university with comparable high school averages (roughly 81 percent). By comparison, the high school grades of foreign English and Canadian ESL students are slightly lower. Differences, however, are not statistically significant: high school grades do not vary by language group.

The annual grades achieved by different groups of students with adjustments for high school grades (OAC or the equivalent) are summarized in Figure 3. As can be seen, there are considerable differences in the grades of different language groups. In year 1, the highest grades, 6.04 (the scheme goes from O to 9 at York), are achieved by Canadian English students, and the lowest, 4.35, by Canadian ESL students. The GPAs of foreign English and foreign ESL students are 5.43 and 5.66, respectively.

The within-subject analyses of variance reported in Table 2 indicate that overall increases in grades between years 1 and 4 from one year to the next are statistically significant; however, when groups are examined individually, only changes for Canadian English students are statistically significant. Their grades go from 6.04 to 6.41. Once again, however, the absence of a statistically significant change in other groups must be seen through the lens of small numbers for some groups. We can see from Table 2 that differences among groups averaged over 4 years are statistically significant; however, while differences between the reference group and foreign ESL students are statistically significant, other comparisons are not.

It was noted earlier that in analyses of variance, the small size of some groups may have resulted in some false-negative findings. As a result, a conservative approach will be adopted for the overall interpretation of results discussed in this section. More specifically, it will be assumed that statistically significant results reflect real differences in the population while results that are not statistically significant, because of some small group sizes, will be viewed as inconclusive. Bearing in mind these caveats, there are four overall conclusions that can be derived from the analyses of variance. First, averaged over the entire study period, Canadian-born speakers of English enjoyed a higher level of nonwritten linguistic capital than Canadian- and foreign-born ESL students. second, averaged over the entire 4 years, Canadian English students displayed an advantage over all other groups in written linguistic capital. Nonetheless, foreign ESL students experienced an increase in written linguistic capital from one year to the next. Third, averaged over the total study period, the academic achievement of foreign ESL students was lower than for the Canadian English group. Fourth, Canadian-born English-speaking students experienced an increase in academic achievement from one year to the next.

Regressions

The foregoing repeated analyses of variance are appropriate in examining change in linguistic capital and achievement over time; however, they do not allow us to examine the degree to which cultural capital and language group have independent effects on academic achievement, controlling for other theoretically relevant variables. This objective is realized through regression analyses. In these, sample size does not present the same potential problems as it did for analyses of variance: with 12 independent variables, the sample size of 513 meets the minimal requirements for this type of analysis (Brace, Kemp, and Snelgan 2003).

The results of the regression analyses are given in Table 3. Note that “foreign English,””Canadian ESL,” and “foreign ESL” are dummy variables, with 1 indicating group membership and 0 indicating nonmembership. Canadian-born English-speaking students are the reference group. Dummy variables have also been created for various faculties at York with Arts as the reference category. For these variables, 1 was recorded for enrollment in the faculty and a value of 0 was given for nonenrollment. All of the other variables have been explained in a previous section. In the analysis, variables were entered in blocks in order to identify changes in explained variance attributable to different groups of variables. The cumulative amount of explained variance is given after the introduction of parental education, OAC grades, language group variables, faculty variables, and for nonwritten and written English linguistic capital.

Table 3

Regression Coefficients (beta) for GPA

In analyzing data, it is best to consider beta weights for the same variable across all four surveys. When doing this, it is evident that beta’s associated with having at least one parent with a PSE (a likely indication of a relatively high cultural capital) are small, have positive signs in some years and negative in others, and are not statistically significant. Not surprisingly, this variable explains a negligible amount of variance in GPA. In essence, the indicator of cultural capital used here reveals no independent effect of this variable on academic achievement in any year.

When the effect of OAC (high school) grades is examined, as expected, it has a relatively large, positive, and statistically significant impact on grades in each year. Indeed, the impact of OAC grades on GPA is the largest of any variable. In year 1, OAC grades account for 29 percent of the explained variance (R^sup 2^). The effect of high school achievement is still felt in year 4 in which it explains 16 percent of the variance.

As was anticipated, the signs of the beta’s for the variable foreign English are negative, indicating that the GPAs of this group of students are slightly lower than those of the reference group. This said, for no years are the coefficients statistically significant, and for all years they are low.

In every year, with the exception of year 4, the coefficients for Canadian ESL status are negative and small. This finding suggests a slight disadvantage to this group of students compared with Canadian English students; however, none of the beta’s is statistically significant. Similarly, as anticipated, all of the coefficients for foreign ESL status are negative. Once again, however, with the exception of year 3, the coefficients are not statistically significant. For all years they are low. Collectively, the amount of variance attributable to language group ranges from a high of approximately 2 percent ((.307-.291) x 100) in year 1 to a low of .2 percent in year 4. In contrast to the negligible effect of language group on GPA, many of the effects of faculty of enrollment on grades are statistically significant. In year 1, students enrolled in Environmental Studies (beta = .084) received slightly higher grades than those in Arts. Also, in the Schulich School of Business, in year 1 (beta = .092), grades were higher than those in Arts. Most evident, however, is that students in Science (beta = – .219) received grades that were lower than those in Arts. Students enrolled in Glendon received slightly higher grades (beta = .082) than their counterparts in Arts in year 1.

In year 2, the grades of Fine Arts Students exceeded those of their peers in Arts (beta = .128), while once again the grades of Science students were relatively low (beta = – .128). In year 3, students in all faculties received grades similar to those of Arts students. In year 4, however, once again, the grades of Science students were relatively low (beta = – .120).

The amount of variance in grades explained by faculty of enrollment ranges from a high of 8 percent in year 1 to a low of 2 percent in year 4. Overall, faculty of enrollment explains far more of the variance in grades than language group.

For nonwritten linguistic capital, only coefficients for years 3 (beta = .096) and 4 (beta = .195) are statistically significant. These figures indicate a small positive impact of nonwritten linguistic capital on achievement in these years. While in year 4 nonwritten linguistic capital increases total explained variance by 2 percent, the increase in variance in other years approaches zero.

An examination of the final variable in the regressions, written linguistic capital, indicates small negative coefficients for all years; however, none is statistically significant, indicating that high levels of written linguistic capital do not translate into high levels of achievement.

The table R^sup 2^’s indicate that the total explained variance for the regression models ranges from a high of 39 percent in year 1 to a low of 22 percent in year 4. R^sup 2^’s of these magnitudes are typical for analyses of academic achievement in which controls for high school grades are imposed (Pascarella and Terenzini 2005).

The overall impression left by the data in Table 3 most relevant to the current undertaking is as follows: As seen earlier, while family cultural capital in Canada may predispose students to higher education, and has implications for earnings after graduation, it is of no discernable consequence for academic achievement, at least at this university. This finding may be explained by the possibility that independent of parental education, all families of students had a level of cultural capital sufficient to inspire their children to enroll in university.

Second, while, as expected, belonging to a group other than Canadian English results in depressed levels of academic achievement, the effect is confirmed only for foreign students in year 3, in which this group earns slightly lower grades than the reference group.

Third, in contrast to language group, faculty of enrollment has considerable consequences for academic achievement. Most noticeable is that students enrolled in Science receive lower grades than those in Arts for 3 of the 4 years. Where statistically significant, the data show that students in other faculties receive higher grades than their peers in Arts.

While nonwritten linguistic capital, as expected, results in slightly higher grades in years 3 and 4, written linguistic capital is of no consequence for grades. There are a number of possible explanations for this finding.

First, despite the fact that, as shown in the repeated analyses of variance, all language groups have lower written linguistic capital than Canadian English students, their levels may be sufficient to meet the academic challenges of university life. Moreover, excluding exams, students have time to think about, and modify, their written work before submission. As a result, deficiencies in written linguistic capital may have relatively muted effects on achievement.

A second explanation involves the possibility that in their attempts to accommodate, professors, to a degree, overlook deficiencies in the written work of students for whom they know English is a second language. This explanation is consistent with research at the secondary school level in which it was found that teachers frequently award what are called “goodwill” grades to ESL students, in the belief that in doing so they are providing needed support (Roessingh and Kover 2003).

A third possible explanation is that students who have written linguistic difficulties stay away from courses in which they would be required to write essays and reports. Instead, they might seek out courses in which considerable weight is given to performance on multiple-choice tests.

A fourth possibility is that the measure of written linguistic capital used in this study underestimates the real capital possessed particularly by ESL students. At this point, further research is needed to determine which of the above possible explanations is most probable.

CONCLUSIONS

Most recent immigrants to Canada have limited English linguistic capital. While such deficiencies are associated with un- and underemployment of immigrants with higher education, a disproportionate number of immigrants, or their sons and daughters, proceed to university. We know from previous research that such students receive relatively low grades once they enter university; however, we do not know whether the university experience results in an increase in their linguistic capital, or the complete nature of the relationship between linguistic capital and academic achievement.

The results of the current research suggest several conclusions with regard to these matters. First, over 4 years of study, by and large, Canadian English students maintain an advantage in linguistic capital over other groups of students. second, bearing in mind possible limitations imposed by some small numbers, with the exception of written linguistic capital for Foreign ESL students, there is in general no increase in the linguistic capital of students over 4 years of study. In other words, despite the probability of an increase in subject matter expertise and other forms of human capital over the course of a university education, there is no improvement in linguistic capital. Third, nonwritten linguistic capital is of little consequence for academic achievement in university. Written linguistic capital is also of no consequence for academic achievement. When considering the implications of this finding, however, it is important to remember that despite differences among different language groups, students may nonetheless enter university with sufficient linguistic capital to meet academic demands. If they get low grades, it is because of other factors. Alternately, students with low levels of linguistic capital may manage their course selections in ways that minimize any linguistic deficiencies that they might have. Fourth, while family cultural capital has been shown to affect whether or not young adults attend postsecondary institutions, and is of consequence for earnings of university graduates, it is of no consequence for achievement in university. This finding may be explained by the possibility that students acquire sufficient cultural capital to meet the challenges of university life in ways other than through parental transmission. Fourth, in contrast to cultural capital and linguistic capital, academic achievement in high school is the best predictor of achievement in university. This finding may indicate that along with subject matter expertise, in high school students acquire sufficient cultural capital to offset any potentially negative effects of capital deficits in the family. Fifth, the second best predictor of academic achievement is faculty of enrollment. In other words, all else being equal, students who enroll in, for example, Science, receive relatively low grades.

As seen in the introduction, universities are taking steps to recruit minority and ESL students and to meet their needs. On the basis of the findings of this study it is difficult to be conclusive as to the results of their efforts, at least in the university under study. On the one hand, it seems that, with one exception (written English of foreign ESL students), there is no increase in the linguistic capital of students over the course of their studies. From an educational point of view, this is regrettable, and steps should be taken to remedy the situation. Moreover, while there are anecdotal explanations for this state of affairs, there appears to have been no systematic inquiry into the matter in Canada. On the other hand, it appears that membership in particular language groups does not affect students’ academic achievement. The grades that they get are more related to their level of ability and to the faculty in which they enroll. Unfortunately, this lack of connection between language group membership and linguistic capital on grades may indicate that within the university certain linguistic deficiencies are overlooked. While further research is needed to confirm this possibility, it is supported by anecdotal evidence.

LIMITATIONS

There are several limitations of the current study. First, the number of individuals in some linguistic groups is relatively small. As a result, there is a possibility of false-negative findings in some of the analyses of variances. Additional research with larger samples is needed to confirm the findings of the current study. Second, although many other studies have used education of parents as an indicator of cultural capital, education, and cultural capital are not synonymous. It is possible for individuals with low levels of education to have relatively high levels of cultural capital. The reverse is also true.

Third, self-assessments of linguistic capital have been used to good effect in numerous other studies, and, with some qualifications, studies using self-reports yield the same general results as those using “objective” measures. Nonetheless, studies utilizing objective as well as subjective measures of linguistic capital are desirable, albeit very expensive. As a result, Canadian studies utilizing more objective measures of cultural capital, and objective measures of linguistic capital, are needed.

Fourth, the current study was carried out in a university in which relatively large numbers of students have English as a second language and most come from families with relatively modest incomes. Also, large numbers are the first in their families to attend university. Under circumstances such as these, it might be that a cultural context develops that is more supportive of the needs of ESL and first-generation students than would be the case in universities in which such students were a small minority. Under circumstances such as these, the experiences and outcomes of different language groups may be different from that discovered in this study. As a result, research is needed to determine whether the results of the current study can be generalized to other circumstances. It should be noted that unless they involve very large samples so that individual institutions can be compared, national studies cannot achieve this objective.

1 This is not an endorsement of the use of the survey in Canada. While it is a valid and useful survey, its results are being used in many unjustifiable ways.

2 Cronbach’e alpha is a measure of the internal consistency of a scale, based on correlations among different items. Generally, an alpha of .6 to . 7 indicates an acceptable level of consistency.

3 Assuming a similar alpha and effect size, a targe sample is more likely to result in a statistically significant finding than a small sample.

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J. PAUL GRAYSON York University

J. Paul Grayson, School of Social Science, Atkinson Faculty, York University, 3700 Keele St, Toronto, Canada M3J 1P3. E-mail: [email protected].

Copyright Canadian Sociology and Anthropology Association, c/o Concordia University Department of Sociology and Anthropology May 2008

(c) 2008 Canadian Review of Sociology and Anthropology, The. Provided by ProQuest LLC. All rights Reserved.

Can the Diameter of Endoluminal Shunt Influence the Risk of Hyperperfusion Syndrome After Carotid Endarterectomy?

By Bakoyiannis, C N Tsekouras, N; Georgopoulos, S; Tsigris, C; Filis, K; Skrapari, I; Bastounis, E

Aim. The aim of this study was to evaluate if there is a possible relation between the size of endoluminal shunt, in carotid endarterectomy (CEA), and the risk of postoperative hyperperfusion syndrome. Methods. We retrospectively studied prospectively collected data from 156 patients, who were subjected to CEA using shunting and vein patch angioplasty. One hundred and thirty-eight of the patients had bilateral, high grade (>90%) internal carotid lesions and the remaining 18 had a highgrade stenosis (>90%) and a contralateral internal carotid artery (ICA) occlusion. In 81 patients varying diameters of shunts were used (8-14 Fr) according to the diameter of ICA (group A) and in the other 75 patients (group B) only the smallest shunt was used (8 Fr). Development of hyperperfusion syndrome was evaluated both clinically and radiologically with magnetic resonance imaging.

Results. Fifteen patients developed hyperperfusion syndrome (9.6%), between 0 to 6 days postoperatively. Thirteen belonged to group A (86.6%), and 2 (13.3%) belonged to group B (P

Conclusions. During CEA in patients with high-grade bilateral lesions, we recommend the use of a shunt with small diameter: this aims at reducing the risk of hyperperfusion syndrome.

[Int Angiol 2008;27:260-5]

Key words: Endarterectomy, carotid – Postoperative complications – Carotid stenosis.

Hyperperfusion syndrome is a rare, but potentially lethal, complication after carotid endarterectomy (CEA). The classic triad of the syndrome includes: unilateral severe migraine symptoms (head, face and eye pain), focal deficits and focal seizures, due to cerebral edema or intracerebral hemorrhage (ICH).1,2 This triad is not always complete. Migraine symptoms and seizures are more common 3 and ICH is reported to occur in only 0.4% to 2% 4, 5 of the patients. The pathogenesis of the syndrome is still obscure: paralysis of normal vascular autoregulatory mechanisms, in a chronically hypoperfused hemisphere of a patient with high-grade carotid stenosis, combined with an acute and pronounced increase in cerebral blood flow (CBF), after endarterectomy, is the main hypothesis.1, 2, 6

We suggest that using a smaller size of endoluminal shunt during endarterectomy, as opposed to the size that could normally be fitted to the internal carotid artery (ICA), we can achieve lower risk of hyperperfusion syndrome, since the increase in blood flow of ICA, till its maximum value just after declamping, is more gradual.

Materials and methods

We retrospectively reviewed prospectively collected data from the Vascular Department of our clinic of 169 consecutive patients that were subjected to CEA because of bilateral high-grade (?90%) carotid stenoses or a high-grade lesion (?90%) and a contralateral ICA occlusion, during the period 1998 to 2004. Complete data were available for 156 of these patients (138 with bilateral high-grade stenoses and 18 with a high-grade lesion and a contralateral ICA occlusion). Stenoses were measured using cerebral digital subtraction angiography according to the North American Symptomatic Carotid Endarterectomy Trial (NASCET) study.7 Symptomatic lesions were first treated. In asymptomatic patients, with an equal degree of stenosis, characteristics of angiography (plaque ulcers, kinks, coils) were taken into account to decide which lesion to treat first. Preoperative neurological staging was done by the same consultant neurologist.

All CEA procedures were performed under general anesthesia by the same surgical team according to the standard technique: gentle dissection of the carotid bifurcation, systemic use of heparin (100 U/kg), careful insertion of an endoluminal shunt (Argyle, Sherwood Med., St. Louis, MO, USA), in all cases, and tacking sutures at the distal and proximal end of the endarterectomized internal/common carotid arteries, when needed. The arteriotomy was closed using a patch angioplasty (vein patch) in all cases. In 81 initial patients (group A), we decided who got which kind of shunt according to the diameter of ICA. So, the diameter of shunt in these patients was analogous to the diameter of ICA and shunts with varying diameters were used (from 8 Fr to 14 Fr). In a later group of 75 patients (group B), the smallest diameter of shunt was used (8Fr), even if a bigger one could be normally fitted to the ICA (Table I). All shunts of our study were of equal length (15 cm).

We studied the postoperative course of the patients only after the initial operations (in cases of bilateral stenoses). After CEA, all patients were clinically examined for neurological symptoms by the same certified neurologist who did the preoperative neurological staging. Clinical suspicion for hyperperfusion syndrome was set from the presence of the following symptoms: focal seizures (contralateral to the side of CEA), deterioration of consciousness levels at least 8 h postoperatively or focal neurological signs such as motor weakness (also contralateral to the side of CEA). Depending on the particular patient, duplex scanning or arteriography were performed to evaluate the patency of the endarterectomy site in all patients with the above clinical presentation.

All symptomatic patients were subjected to magnetic resonance imaging (MRI) examination with diffusion-weighted imaging (DWI) and perfusionweighted imaging (PWI), within 24 h after the onset of symptoms. The diagnosis of hyperperfusion syndrome required: any one of the above clinical symptoms, the absence of findings of ischemic lesions on MRI study with DWI, and finally the presence of a relative interhemisphere difference (RID) of CBF on MRI study with PWI.8

Statistical analysis

Immediate intensive control of arterial systolic blood pressure between 100 and 140 mmHg was instituted after establishment of diagnosis of hyperperfusion syndrome with intravenous administration of antihypertensive drugs. The chi2 test was used to evaluate the correlation between the diameter of shunt and the risk for hyperperfusion syndrome. A P value of

Results

Mean ages and other demographic data, such as symptomatic lesions, did not differ significantly between the two study groups (Table II). Overall, there were significantly more males than females, but their distribution was similar between the two groups.

All patients were awakened, noted to have no new gross neurological deficits. There was no 30-day mortality and new neurological symptoms or signs were observed 0 to 6 days postoperatively in 21 patients. Six of them had only transient deterioration of consciousness of a duration

Postoperative arteriography in 4 patients and duplex scanning in the remaining 11 patients did not show thrombosis or any technical deficit that could cause embolization from the site of endarterectomy. Furthermore, MRI did not demonstrate any additional ischemic cerebral infract ipsilateral to CEA. In one patient (0.6% of the study group) a 4 cm in diameter ICH was demonstrated in MRI on the 3rd postoperative day. His clinical presentation was with focal seizures and focal deficits contralateral to the side of operation. The patient belonged to group A and a 14 Fr shunt was used. In all 15 patients (including the patient with the ICH), MRI study with DWI demonstrated absence of acute ischemia or cytotoxic edema and MRI study with PWI demonstrated presence of RID of CBF. So, all 15 patients met the clinical and imaging criteria that were mentioned before and thus they were considered to have hyperperfusion syndrome (9.6% of the study group). Thirteen of them (85%) had a symptomatic carotid stenosis and all of them had a history of hypertension. Elevated blood pressure during symptoms of hyperperfusion was observed in 11 of the 15 patients (73.3%) and was managed immediately in all cases.

Thirteen of the patients with hyperperfusion syndrome belonged to group A (86.6%), where shunts with various diameters were applied. In group B, where the smallest shunt (8 Fr) was applied in all cases, 2 patients presented the syndrome (13.3%). The chi2 test demonstrated that the patients, where the smallest shunt was used, were protected against the risk of postoperative hyperperfusion syndrome. The value of chi2 was 6.55 after Yates’ correction (significant at P

Discussion

Post-CEA neurological deficits may rarely be related to a major increase in ipsilateral CBF after removal of a tight carotid stenosis1, 2 (hyperperfusion syndrome). A high-grade stenosis and a contralateral carotid occlusion are considered to be important risk factors of this syndrome.9 Other risk factors include long-standing hypertension and poor collateral blood flow to the brain.9 The patients of our study had bilateral high-grade stenoses or a high- grade stenosis and an occluded contralateral ICA. We chose a subgroup of patients that underwent CEA with a high risk of developing hyperperfusion syndrome, in order to collect cases and study the syndrome. Pre-existing cerebral hypoperfusion can be evaluated by measuring the degree of cerebrovascular reserve capacity (CRC), which is termed as the ability of further vasodilation of cerebral vessels after a sudden rising of CBF. We did not perform preoperatively any test of this kind. Nevertheless, existence of cerebral hypoperfusion is established in symptomatic stenoses and in asymptomatic occlusions10 as it happens in patients of our two groups. Many studies have concluded to the point that the impaired CRC is a significant risk factor of hyperperfusion syndrome.10,13

Moreover, 13 out of the 15 patients with hyperperfusion syndrome had a symptomatic carotid stenosis (85%). This result is in accordance with the greater hemodynamic impairment in symptomatic patients with a significant carotid stenosis or occlusion.14, 15 Yonas et al.16 claim that an impaired cerebrovascular reactivity, which is used to evaluate the collateral capacity of cerebral circulation, has a predictive value for post-CEA stroke only in symptomatic patients.

Postoperatively, we studied the syndrome using MRI images. All 15 patients with the clinical syndrome were subjected to MRI studies with DWI and PWI, which proved to be very useful in establishing the diagnosis. Absence of abnormal DWI hyperintensity in the hemisphere ipsilateral to the site of endarterectomy suggested absence of acute cerebral infraction.8 Furthermore, PWI demonstrated a moderate relative hyperperfusion in the hemisphere ipsilateral to the operated side.8 According to Karapanayiotides et al.8 hyperperfusion syndrome can occur even in the presence of relative hyperperfusion of the ipsilateral hemisphere.

Hemodynamic complications of ICA stenoses that can lead to hyperperfusion syndrome have not yet clearly been defined. Nevertheless, it is claimed that the drop of pressure ipsilateral to the lesion is compensated by collateral arteries, such as arteries of the circle of Willis (anterior and posterior communicating arteries) and ophthalmic or leptomeningeal arteries.17, 18 Thus, high-grade stenoses and poor collateral blood flow, because of a high degree of contralateral stenosis or a contralateral carotid occlusion, are considered to be risk factors of hyperfusion syndrome. The suggestion for collateral compensation is consistent with the clinical observations of Ouriel et al.19 about the predictive factors of the syndrome and with hemodynamic studies in patients with severe carotid stenoses with or without contralateral carotid occlusion.14, 15. 20-22

If collateral capacities are not sufficient, a second step of compensation mechanism is the increase of oxygen extraction from the circulating blood.17, 18 Cerebral tissue tries this way to satisfy its metabolic demands.

Moreover, if all above compensation capacities become insufficient, vasodilation of the cerebral arterioles occurs to improve cerebral perfusion10 (third step of compensation). This autoregulatory vasodilation lessens the ability of the arterioles for a further vasodilation and for this reason they are more prone to damage if rapid restoration of blood flow is achieved through them, after removal of tight ICA stenosis. Rupture of the hyperperfused vessels leads to ICH;19 nevertheless, the most common consequence of hyperperfusion syndrome is not rupture of arterioles, but a mildly leaky capillary bed that leads to brain edema.23 The ability of further vasodilation, as we mentioned above, is known as the CRC, which is an important risk factor for hyperperfusion syndrome.

Hyperperfusion syndrome usually presents in its mild form, with relatively slight symptoms, such as headaches, temporary seizures, temporary deteriorations in consciousness levels, or temporary focal deficits. In these cases, a mild cerebral edema is the cause for the characteristic clinical presentation.23. In our study, the incidence of the syndrome was 9.6%. The incidence that is referred to literature is 8-12%.2, 11, 24, 25 Florid symptoms and ICH are much rarer conditions as mentioned in the introduction. In our study only 1 patient out of 156 (0.6%) suffered from a major ICH, which fortunately proved not to be fatal. Mortality of patients with post- CEA ICH has been estimated to be approximately 36%.26

We were very cautious with the management of postoperative blood pressure, using intravenous antihypertensive drugs in all occasions of hyperperfusion syndrome. Long-standing hypertension is considered to be another independent risk factor for the syndrome, because of the possible damage in cerebral arterioles.27 It is known that hyperperfusion syndrome can occur even in normotensive patients,2, 25, 27, 28 after CEA, but elevation of blood pressure is a more common occurrence. In our study all patients with hyperperfusion syndrome had a history of hypertension and 11 of them (73.3%) had elevated blood pressure during onset of symptoms. Meticulous and continuous control of postoperative blood pressure is considered extremely important in preventing the syndrome.2, 11. 12, 24

The significant result of our study was the relation between the diameter of shunt and the incidence of hyperperfusion syndrome. It is known that liquid flow through a linear tube can be estimated from Poiseuilles law: Q=piDeltaPr^sup 4^ (Delta=3.14; DeltaP: P2- P1; P2: pressure at the distal end of the tube; Pl : pressure at the proximal end of the tube; r: diameter of the tube; n: viscosity of liquid; 1: length of tube). The characteristic of Poiseuille’s law is that the diameter of the tube is much more important for liquid flow, compared with the other mentioned factors that affect it. Flow is analogous with the fourth force of the tube s diameter. For instance, if we double the diameter of a tube the flow through it increases 16 times.

In our study, if we suggest that the only significant variable is the diameter of the shunt and all the others (DeltaP, n, 1) are approximately stable, we can see the great differences in blood flow between certain shunts (Table V). Using a small shunt during endarterectomy, means that we avoid an abrupt increase of blood flow through cerebral arteries after declamping. This “preconditioning” is useful for a more gradual rise in blood flow after removal of significant stenosis which seems to be a protective factor for a possible postoperative hyperperfusion syndrome.

Conclusions

Patients with high-grade bilateral ICA stenoses or a unilateral high-grade stenosis and a contralateral ICA occlusion are a high- risk group for post-CEA hyperperfusion syndrome. We suggest that CEA using routine shunting is a safe method and the use of a smaller shunt than the shunt that could be otherwise fitted to the ICA is surgical practice that can reduce the incidence of this syndrome.

Received on June 7, 2007; accepted for publication on October 10, 2007.

References

1. Sundt TM Jr, Sharbrough FW, Piepgras DG, Kearns TP, Messick JM Jr, O’Fallon WM. Correlation of cerebral blood flow and electroencephalographic changes during carotid endarterectomy: with results of surgery and hemodynamics of cerebral ischemia. Mayo Clin Proc 1981;56: 533-43.

2. Piepgras DG, Morgan MK, Sundt TM Jr, Yanagihara T, Mussman LM. Intracerebral hemorrhage after carotid endarterectomy. J Neurosurg 1988;68:532-6.

3. Powers AD, Smith RR. Hyperperfusion syndrome after carotid endarterectomy: a transcranial Doppler evaluation. Neurosurgery 1990;26:56-9.

4. Jansen C, Sprengers AM, Moll FL, Vermeulen FE, Hamerlijnck RP, van Gijn J et al. Prediction of intracerebral haemorrhage after carotid endarterectomy by clinical criteria and intraoperative transcranial Doppler monitoring: results of 233 operations. Eur J Vase Surg 1994;8: 220-5.

5. Riles TS, Imparato AM, Jacobowitz GR, Lamparello PJ, Giangola G, Adelman MA et al. The cause of perioperative stroke after carotid endarterectomy. J Vasc Surg 1994;19:206-14.

6. Schaafsma A, Veen L, Vos JP. Three cases of hyperperfusion syndrome identified by daily transcranial Doppler investigation after carotid surgery. Eur J Vasc Endovasc Surg 2002;23:17-22.

7. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991;325:445-53.

8. Karapanayiotides T, Meuli R, Devuyst G, PiechowskiJozwiak B, Dewarrat A, Ruchat P. Postcarotid endarterectomy hyperperfusion or reperfusion syndrome. Stroke 2005;36:21-6.

9. Reigel MM, Hollier LH, Sundt TM Jr, Piepgras DG, Sharbrough FW, Cherry KJ. Cerebral hyperperfusion syndrome: a cause of neurologic dysfunction after carotid endarterectomy. J Vase Surg 1987;5:628-34.

10. Orosz L, Fulesdi B, Hoksbergen A, Settakis G, Kollar J, Limburg M et al. Assessment of cerebrovascular reserve capacity in asymptomatic and symptomatic hemodynamically significant carotid stenoses and occlusions. Surg Neurol 2002;57:333-9.

11. Hosoda K, Kawaguchi T, Shibata Y, Kamei M, Kidoguchi K, Koyama J et al. Cerebral vasoreactivity and internal carotid artery flow help to identify patients at risk for hyperperfusion after carotid endarterectomy. Stroke 2001;32:1567-73.

12. Yoshimoto T, Houkin K, Kuroda S, Abe H, Kashiwaba T. Low cerebral blood flow and perfusion reserve induce hyperperfusion after surgical revascularization: case reports and analysis of cerebral hemodynamics. Surg Neurol 1997;48:132-8.

13. Fujimoto S, Toyoda K, Inoue T, Hirai Y, Uwatoko T, Kishikawa K et al. Diagnostic impact of transcranial colorcoded real-time sonography with echo contrast agents for hyperperfusion syndrome after carotid endarterectomy. Stroke. 2004;35:1852-6.

14. Rutgers DR, Klijn CJ, Rappelle LJ, Eikelboom BC, van Huffelen AC, van der Grond J. Sustained bilateral hemodynamic benefit of contralateral carotid endarterectomy in patients with symptomatic internal carotid artery occlusion. Stroke 2001;32:728-34. 15. Soinne L, Helenius J, Tatlisumak T, Saimanen E, Salonen O, Lindsberg PJ et al. Cerebral hemodynamics in asymptomatic and symptomatic patients with high-grade carotid stenosis undergoing carotid endarterectomy. Stroke 2003;34:1655-61.

16. Yonas H, Smith HA, Durham SR, Pentheny SL, Johnson DW. Increased stroke risk predicted by compromised cerebral blood flow reactivity. J Neurosurg 1993;79:483-9.

17. Derdeyn CP, Grubb RL Jr, Powers WJ. Cerebral hemodynamic impairment: methods of measurement and association with stroke risk. Neurology 1999;53:251-9.

18. Powers WJ, Press GA, Grubb RL Jr, Gado M, Raichle ME. The effect of hemodynamically significant carotid artery disease on the hemodynamic status of the cerebral circulation. Ann Intern Med 1987;106:27-34.

19. Ouriel K, Shortell CK, Illig KA, Greenberg RK, Green RM. Intracerebral hemorrhage after carotid endarterectomy: incidence, contribution to neurologic morbidity, and predictive factors. J Vasc Surg 1999;29:82-7.

20. Markus H, Cullinane M. Severely impaired cerebrovascular reactivity predicts stroke and TTA risk in patients with carotid artery stenosis and occlusion. Brain 2001;124:457-67.

21. Vanninen R, Koivisto K, Tulla H, Manninen H, Partanen K. Hemodynamic effects of carotid endarterectomy by magnetic resonance flow quantification. Stroke 1995;26:84-9.

22. Wiart M, Berthezene Y, Adeleine P, Feugier P, Trouillas P, Froment JC et al. Vasodilatory response of border zones to acetazolamide before and after endarterectomy: an echo planar imaging-dynamic susceptibility contrastenhanced MRI study in patients with high-grade unilateral internal carotid artery stenosis. Stroke 2000;31: 1561-5.

23. Breen JC, Caplan LR, DeWitt LD, Belkin M, Mackey WC, O’Donnell TP. Brain edema after carotid surgery. Neurology 1996;46:175-81.

24. Dalman JE, Beenakkers IC, Moll FL, Leusink JA, Ackerstaff RG. Transcranial Doppler monitoring during carotid endarterectomy helps to identify patients at risk of postoperative hyperperfusion. Eur J Vasc Endovasc Surg 1999;18:222-7.

25. Ogasawara K, Konno H, Yukawa H, Endo H, Inoue T, Ogawa A. Transcranial regional cerebral oxygen saturation monitoring during carotid endarterectomy as a predictor of postoperative hyperperfusion. Neurosurgery 2003;53:309-14.

26. Pomposelli FB, Lampareilo PJ, Riles TS, Craighead CC, Giangola G, Imparato AM. Intracranial hemorrhage after carotid endarterectomy. J Vase Surg 1988;7:248-55.

27. Ascher E, Markevich N, Schutzer RW, Kallakuri S, Jacob T, Hingorani AP. Cerebral hyperperfusion syndrome after carotid endarterectomy: predictive factors and hemodynamic changes. J Vasc Surg 2003;37:769-77.

28. McCabe DJ, Brown MM, Clifton A. Fatal cerebral reperfusion hemorrhage after carotid stenting. Stroke 1999;30: 2483-6.

C. N. BAKOYIANNIS, N. TSEKOURAS, S. GEORGOPOULOS, C. TSIGRIS, K. FILIS

I. SKRAPARI, E. BASTOUNIS

First Department of Surgery, Vascular Department

University of Athens Medical School, Laiko General Hospital, Athens, Greece

Address reprint requests to: C. N. Bakoyiannis, MD, 17, Agiou Thoma 11527 Goudi, Laiko Hospital, First Department of Surgery, Athens, Greece. E-mail: [email protected]

Copyright Edizioni Minerva Medica Jun 2008

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

Osteoporosis in Older Men: Feelings of Masculinity and a ‘Women’s Disease’

By Solimeo, Samantha

Osteoporosis is a metabolic bone disorder characterized by low bone density and associated with atraumatic fractures, pain, disability, long-term-care placement, and premature mortality. The condition is an important public health issue for all older adults, but the construction of osteoporosis as a “women’s disease,” and men’s behavior in response, may limit the efficacy of current screening and treatment options for men. Though men are indeed at risk for osteoporosis, it does occur primarily among postmenopausal women, with the therapeutic interventions, educational outreach, and screening programs thus aimed primarily at women. The positive trends seen among at-risk womenimproved healthcare utilization and health outcomes for osteoporosis-are not evident among at-risk men. Men themselves rarely recognize their risk of osteoporosis, and behaviors associated with masculine gender identity may constrain them when it comes to preventive behavior to avoid osteoporosis and to recognize the disease if it does appear. Attention to men as a risk group and to the behaviors associated with masculine gender identity must inform research and practice related to osteoporosis.

EFFECTS ON QUALITY OF LIFE

We know that osteoporosis has negative consequences for interpersonal relationships and overall quality of life among older female sufferers (Gold, 1996, 2001, 2003). Women with the disease have difficulty performing recreational and home-keeping activities from which they derive identity, and they often experience feelings of role loss and of premature aging, as well as shame or embarrassment, stress, anxiety, and depression (Gold, 1996,1999; Gold and Roberto, 2000; Penrod, 2000; Roberto and Gold, 1997,2002; Roberto, Gold, and Yorgasen, 2004; Roberto and Reynolds, 2001). But we do not know the ways and extent to which osteoporosis similarly affects the quality of life for men.

The gendered nature of social roles and activities in later life would suggest a qualitative difference in how men feel about and adapt to osteoporosis. Although literature on the epidemiology and treatment of male osteoporosis is thin, recent study of men’s knowledge about osteoporosis and feelings of self-efficacy in relation to it, as well as studies of the relationship between gender performance and health behavior, illustrate how men’s experience of osteoporosis most likely will differ from that of women and identify areas for future qualitative and intervention research.

MEN’S VULNERABILITY TO A WOMEN’S DISEASE’

Several studies have demonstrated that men have little knowledge of risk factors for osteoporosis, have inadequate calcium consumption, and engage in alow levd of weight-bearing exercise (Ailinger et al., 2005; Sedlak, 2000; Tung and Lee, 2006). In addition, the incidence of osteoporosis and related fractures in men is increasing because more men now live past the seventh decade of life, and the prevalence may continue to grow with the proportion of our population that is over the age of 70 (Nguyen et al., 1996, p. 259; Fande and Francis, 2001). But men’s own health and illness behavior is not the only reason that men are vulnerable to osteoporosis. Even in the presence of fractures, osteoporosis in men is underdiagnosed and infrequently treated. In a study of male HMO members over 65 years of age, treatment for osteoporosis was infrequent (Feldstein et al., 2005). Among those who were treated for fractures, less than 2 percent had their bone density measured, and almost 70 percent of men with vertebral fractures received no osteoporosis-relatcd treatment (Feldstein et al., 2005).

These data reveal a missed opportunity to decrease the vulnerability of men to subsequent fractures, disability, and premature death. In comparison to women, men with osteoporosis experience vertebral body and hip fractures more often; have higher post-fracture mortality, higher rates of disability and institutionalization; and are diagnosed later in the disease, after a fracture has occurred (Campion and Mariac, 2003; Pande and Francis, 2001; Vondracek and Hansen, 2004).

MASCULINITY AND SYMPTOMS OF OSTEOPOROSIS

Osteoporosis is commonly referred to as a “silent disease” because the disease process is unapparent until a painful fracture or measure of bone density brings it to the fore. Despite public perception of osteoporosis as a disease that affects only postmenopausal women, men have the potential to exhibit a majority of risk factors for the disease. Of the nineteen risk factors identified by the National Osteoporosis Foundation (NOF) (2007), only three are specific to women, and of the twelve risk factors identified by the National Institutes of Health Consensus Panel (cited in Stone and Lyles, 2006, p. 67), only two are specific to women.

Risk factors for men include the following: history of smoking or alcohol use, low bone mineral density, family history of fracture, low body mass index, smaller stature, older age, low dietary calcium, vitamin D insufficiency, lack of weight-bearing exercise, low testosterone, history of prior fracture, and the use of corticosteroids and certain cancer-related medications (Anderson and Cooper, 1999; Bilezikian, 1999; NOF, 2007; Kirk and Fish, 2004; Nguyen et al., 1996; seeman et al., 2004; Skmenda et al., 1992; Vondracek and Hansen, 2004).

Men are physiologically less vulnerable to osteoporosis than are women, but prevention among older men is precluded by their lack of awareness of their susceptibility to this condition. A survey-based study of knowledge about osteoporosis across gender and age found that older adults perceived greater susceptibility than did younger people and that women in general felt more susceptible than did men (Johnson et al., 2007).

However, an educational intervention targeting men demonstrated that men’s knowledge of osteoporosis could be improved, but that this improvement did not translate into engagement in prevention behaviors (lung and Lee, 2006). Such research reveals the relevance of gender and the necessity that it be taken into account when planning osteoporosis prevention and intervention.

The rules for gender performance-how individuals express masculinity or femininity-differ by age, race, social class, and other axes of social stratification, and while the consequences of behavior that does not follow these rules are less severe for older people than for younger people, gender performance does influence the health and well-being of older adults.

Men may actively avoid what might be construed as “healthy” behavior and purposely engage in risky behavior (Courtenay, 2000). Some forms of male gender performance pose special challenges for practitioners working in osteoporosis prevention. Back pain, a potential indicator of vertebral fractures, may be construed by men as something they ought to withstand rather than treat, as expressed ability to tolerate pain without complaint is seen as a masculine trait (Courtenay, 2000; O’Brien, Hunt, and Hart, 2005). Efforts to raise awareness among men about their risk of osteoporosis may be stymied by a reluctance to utilize preventive services that is common among men. Men may equate use of Healthcare services with weakness and thus actively avoid physicians (O’Brien, Hunt, and Hart, 2005; Mahalik, Burns, and Syzdek, 2007).

Similarly, the stigma many older men experience in being labeled as men with a “women’s disease” can deter some from seeking treatment and from recognizing the risk factors they may possess (Feldstein et al., 2005; Resnick, Wehren, and Orwig, 2003).

It is also important to consider the ways in which age intersects with gender performance, as older men negotiate a set of cultural expectations that differ from those of their younger counterparts (Courtenay, 2000; Gough, 2006). In a study by O’Brien and colleagues, older men were more likely to seek medical care than were younger men, and the comments of older men articulated a tension between the genderdriven pressure to “wait things out” and their age-related concern that they may put themselves at risk of injury by waiting. Men who had lived through a serious disorder such as prostate cancer represent exceptions to the gender norm of healthcare avoidance, and both groups-older men and men who had survived a serious disorder-acknowledged the need for and sought preventive care (O’Brien, Hunt, and Hart, 2005).

Thus, men do not uniformly avoid care, but they utilize services via a “hierarchy of threats to masculinity” (O’Brien, Hunt, and Hart, 2005, p. 514). Unfortunately, osteoporosis is most likely positioned at the very bottom of this hierarchy: The condition is commonly symptomfree, it is construed as something of concern to postmenopausal women, and men do not consider it to be life threatening.

A RESEARCH AGENDA

Seeman and colleagues’ (2004) essay provided a road map for building the scientific basis for understanding osteoporosis in men. Many of the gaps they identified are emerging as major lines of research, but others remain unaddressed. As the literature on osteoporosis in men becomes deeper, broader, and more sophisticated, we have a unique opportunity to integrate gender performance into our understanding. The following questions should be included in a research agenda:

* In what ways do age, race, ethnicity, and sodoeconomic status combine to differentially influence the incidence of osteoporosis in men? * How do men interpret the symptoms of osteoporosis, and how do these interpretations influence their health behavior?

* In what ways does the condition affect men’s identity? Do specific problems related to osteoporosis, such as back pain, affect identity differently for men than for women? Do socioeconomic and cultural factors contribute to the poorer osteoporosis-related outcomes seen among men as compared to women?

* Does adherence to osteoporosis medications differ by gender?

* Given the relationships between testosterone and osteoporosis and between testosterone and gender identity, how do testosterone medications and androgen-deprivation therapy affect men’s identity?

* Where do men with osteoporosis locate the disorder among their “hierarchy of threats”?

* Does osteoporosis-related quality of life differ by gender?

* What are the beliefs of healthcare professionals concerning osteoporosis screening and treatment in men?

Recent scholarship emphasizes the importance of measurement of bone density and pharmacotherapy to the health and survival of men at risk for osteoporosis (Schousboe et al., 2007). The issues surrounding osteoporosis among men may be an analog to the history of cardiovascular disease among women.

An analogous situation can be seen in consideration of cardiovascular disease, long considered a “men’s disease,” for which research and practice historically focused on middle-aged and older men. The extent to which women were at risk of the disease was long underrecognized, contributing to poorer outcomes for women. More recently, more attention has been paid to the incidence of the disease in women.

Recent calls for a men’s health movement, the development of new journals dedicated to the study of men’s experiences, and feminist scholarship exploring the intersection of masculinity and age have moved gender into the forefront of gerontological research. These developments have produced exciting new work exploring how gender performance relates to health behavior. In the case of osteoporosis in men, gender and health scholarship have yet to be fully integrated.

Men are indeed at risk.

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Roberto, K. A., Gold, D. T., and Yorgasen, J. B. 2004. “The Influence of Osteoporosis on the Marital Relationship of Older Couples.” The Journal of Applied Gcrantology 23(4): 443-56.

Roberto, K. A., and Reynolds, S. G. 2001. The Meaning of Osteoporosis in the Lives of Rural Older Women.” Health Care for Women International 22: 595-611.

Schousboe, J. T., et al. 2007. “Cost-EfFectiveness of Bone Densitometry Followed by Treatment of Osteoporosis in Older Men? Journal of the American Medical Association 298(6): 629-37.

Sedlak, C. A, 2000. “Osteoporosis in Older Men: Knowledge and Health Beliefs.” Orthopaedic Nursing 19(3): 38-46.

Seeman, E., et al. 2004. “Osteoporosis in Men: Consensus Is Premature.” Calcified Tissue International 75: 120-2.

Slemenda, C. W., et al. 1992. “Long-Term Bone Loss in Men: Effects of Genetic and Environmental Factors.” Annals of Internal Mediane 117:286-91.

Stone, L. M., and Lyles, K. W. 2006. “Osteoporosis in Later Life.” Generations 30(3): 65-70.

Tung, W. C., and Lee, I. F. K. 2006. “Effects of an Osteoporosis Educational Programme for Men.” Journal of Advanced Nursing 56(1): 26-34.

Vondracek, S., and Hansen, L. B. 2004. “Current Approaches to the Management of Osteoporosis in Men? American Journal of Health- System Pharmacists 61: 1801-11.

Samantha Solimeo, Ph.D., M.P.H., is a postdoctoral fellow, Aging Center, Duke University Medical Center, Durham, N.C.

Copyright American Society on Aging Spring 2008

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

Top 10 Myths About Vitamin D

By Skowron, Jared M

Myth 1: Vitamin D is a vitamin. The Truth: Vitamin D is a hormone. It’s derived from cholesterol. It activates cellular processes and does not do so as a co-factor. Vitamin D receptors nave direct effects on the following cells: adipose, adrenal, bone, brain, breast, cancer, cartilage, colon, endothelium, epididymis, ganglion, hair follicle, intestine, kidney, liver, lung, muscle, osteoblasts, ovary, pancreatic B, parathyroid, parotid, pituitary, placenta, prostate, skin, stomach, testis, thymus, thyroid and uterus.

Myth 2: Normal activity provides us enough vitamin D from sun exposure.

The truth: Most people do not get enough sunshine to maintain adequate vitamin D levels. Our ancestors spent most of the day in the sun, farming, fishing and hunting. Our bodies physiologically developed to need that much vitamin D. Today’s indoor society of office workers, television watchers and hermits gets much less sun exposure and vitamin D production. Add on clothing and sunscreen, which also inhibit vitamin D production, and you understand the problem.

Myth 3: Supplemented vitamin D in foods is adequate.

The truth: Vitamin D^sub 2^ is one-third as effective in the body as naturally occurring vitamin D^sub 3^. Most foods have D^sub 2^ added. A study that analyzed vitamin D^sub 2^ levels in milk off supermarket shelves showed almost 50 percent had less than the label claim of 400 IU of D^sub 2^. A support scientist from the USDA believes no food-label claims are accurate and these labels cannot be trusted.

Myth 4:1,25(OH)D3 is the best analysis for vitamin D levels.

The truth: Vitamin D is mostly stored in adipose and should not be routinely measured. It then converts to 25(OH) D3, which has a long half-life and is the best analysis of vitamin D levels. It then converts to bi-hydroxy forms such as 1,25(OH)D3, 24,25(OH) D3 and other forms, which have the actual action of the cell receptors. However, this form has a short half-life and is not a good measurement.

Myth 5: The reference range for vitamin D levels is accurate.

The truth: The reference range for 25(OH)D3 is horribly inaccurate and is maintaining our vitamin D deficiency in this country. The current reference range of 20-100 is too low. Levels

Myth 6: Vitamin D supplementation is nontoxic.

The truth: The major consequence of vitamin D toxicity is hypercalcemia, which should be monitored periodically while under therapy. Changes in cardiac rhythms or lithiasis are common concerns. Urine calcium monitoring is not accurate. Serum calcium .should be monitored monthly to check vitamin D toxicity, which normally occurs at 40,000 IU/day. Right now, 10,000 IU/day is being proposed as the safe upper limit.

Myth 7: The RDA for vitamin D is accurate.

The truth: People taking only the RDA of vitamin D will lower their 25(OH) D3 levels. The RDA is too low. When treating with vitamin D supplementation, three months of daily dosing is sufficient to max out 25(OH)D3 levels. Five thousand IU/day for three months should elevate 25(OH) D3 by 80 nmol/L, and 10,000 IU/ day for three months should elevate 25(OH) D3 by 120 nmol/L. People on 1,000 IU/day will elevate their levels by only 10 nmol/L.

Myth 8: Different forms of vitamin D are all the same.

The truth: Vitamin D^sub 3^ is the preferred form. Avoid D^sub 2^ at all costs. D^sub 3^ is derived either from plant sources or from lanolin. Lanolin-derived D^sub 3^ is more active and absorbable. I take the 10,000 IU capsules of D^su 3^.

Myth 9: Vitamin D only treats osteoporosis and rickets.

The truth: The therapeutic benefits of vitamin D are still being discovered. Benefits relative to cancer, cardiac, immune-boosting, diabetes and neurological (such as multiple sclerosis) therapies, as well as low bone density, are just the tip of the iceberg. I test all of my patients for vitamin D deficiency and supplement regularly up to the 75-200 reference range of 25(OH)D3.

Myth 10: Vitamin D should be avoided in pregnancy and breastfeeding.

The truth: Pregnant women should receive 4,000 IU of daily vitamin D supplementation. Breast-feeding women should receive 6,000 IU of daily vitamin D supplementation. Vitamin D, not 25(OH)D3, crosses into the breast milk, and daily doses are preferred over weekly doses. Avoid supplementing the infant and instead supplement the breast-feeding mother directly. If the infant is bottle-fed, supplement with 400-800 IU/day.

By Jared M. Skowron, ND

Bio

Dr. Jared M. Skowron is in private practice in Hamden, Conn., where he specializes in pediatrics and treating autistic spectrum disorders in children. He is the senior naturopathic physician with Metabolic Maintenance and an adjunct professor at the University of Bridgeport, teaching pediatrics, CPD and EENT.

Copyright Dynamic Chiropractic Aug 12, 2008

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

Restructuring Municipal Government

By McDonough, Peggy Worts, Diana; Fox, Bonnie; Dmitrienko, Klaudia

Cette etude presente une enquete selon la methode mixte sur l’association qui existe entre les relations travail-gestion et la sante mentale d’employes d’un secteur municipal subissant une restructuration de style nouvelle gestion publique. L’analyse des donnees du sondage (N = 902) demontre qu’il existe une relation relativement forte et constante entre les pratiques de gestion et la sante psychologique des employes. Des interviews realisees aupres d’un sous-echantillon de 54 travailleurs revelent que le controle excessif, l’incompetence et l’indifference des gestionnaires combines avec un minimum de recompenses soulignant les efforts consentis par les travailleurs ont pour consequence que le personnel se sent devalorise. Nos resultats demontrent que la sante mentale des travailleurs a ete ebranlee, en sapant leur estime de soi et en leur faisant perdre des possibilites d’ameliorer leurs conditions de travail. This study is a mixed-method investigation of the association between labor-management relations and employees’ mental health in a municipal sector undergoing New Public Management-style restructuring. Analysis of the survey data (N = 902) demonstrates a relatively strong and persistent relationship between management practices and employee psychological health. Interviews with a subsample of 54 workers reveal that management’s excessive control, incompetence, and unresponsiveness, combined with minimal rewards for workers’ efforts, left staff feeling devalued. Our findings suggest that workers’ mental health was harmed by the undermining of their sense of self-worth and the loss of avenues to improve their working conditions.

MAJOR STRUCTURAL SHIFTS IN THE GLOBAL economy have led to dramatic restructuring of paid workplaces and, as might be expected, researchers are finding that this is harming employee health and quality of life (Vahtera et al. 2000; Anderson-Connolly et al. 2002; Brenner, Fairris, and Ruser 2004; Bourbonnais et al. 2005). The state has not remained untouched by economic globalization, as neoliberal calls to reduce public expenditures spawn retrenchment, restructuring, and privatization at all levels (Barry, Osborne, and Rose 1996; Shields and Evans 1998; Campbell and Pedersen 2001; Jessop 2002; Hay 2004). In some jurisdictions, municipal governments have eliminated work units, amalgamated remaining units, and contracted out work to produce a smaller, more compact organizational hierarchy with compressed job ladders (Young 1996; Doogan 1997; Bach 2000; Jorgensen and Bozeman 2002; Korunka et al. 2003). Through the deployment of managerialist practices from the private sector, New Public Management (NPM) promises to make service delivery more efficient and cost effective, but its detractors suggest that NPM is yet another mode of regulating public-sector workers (Poynter 2000).

Empirical studies of health and workplace restructuring in the public sector have focused on “downsizing.” Cutting the labor force has increased workloads and fostered job insecurity among the remaining employees (Ferrie et al. 2002; Ladipo and Wilkinson 2002). These working conditions are, in turn, linked to poor health (McHugh 1998; Kivimaki et al. 2001). Although fewer studies examine labor- management relations in the public service, one of the most striking findings of our own pilot interviews with municipal employees experiencing workplace restructuring was the consistency of complaints about an uncaring, unresponsive, and uncommunicative management, and a sense that this harmed workers and workplace relations. In this paper, we report the results of a mixed-method follow-up study of employees from the same municipal site, where restructuring was (and is) ongoing. We begin by outlining the context of public-sector reform, as well as the research that tells us something about the effects of these changes on working conditions and employee health. We then turn to our own study, which uses survey data to examine the association between management practices and workers’ health, and interviews to better understand the nature of this relationship.

PUBLIC-SECTOR REFORM

Reform has long been a feature of the public-sector landscape in Organisation for Economic Co-operation and Development (OECD) countries. In the context of economic globalization and neoliberalism, its contemporary manifestation involves a fundamental rethinking of the nature of government. This rethinking means a growing reluctance of, and sometimes refusal by, the state to provide public services. While differences in contexts may create variation in the type of public-sector responses to these pressures (Tuohy 1999; Pollitt and Bouckaert 2000; Lian 2003), current changes aim to make government smaller, leaner, and more efficient.

If neoliberalism rationalizes state reform (Osborne and Gaebler 1992), NPM concretizes it by offering a management solution to the problems of globalizing capitalism (Pollitt 1993; Walsh 1995). Although it has dominated the bureaucratic reform agenda in many OECD countries since the late 1970s, NPM is a rather loose concept. Nevertheless, seven overlapping elements appear in most discussions of it: (i) greater hands-on professional management or “freedom” to manage; (ii) emphasis on explicit and measurable standards of performance in terms of services; (iii) greater emphasis on output controls by stressing results; (iv) greater disaggregation of publicsector organizations into separately managed units; (v) enhanced competition within the public sector and between the public and private sectors; (vi) use of private-sector management styles; and (vii) an emphasis on greater labor discipline and parsimony in resource use (Hood 1995).

Proponents of NPM argue that injecting market discipline into the management of public services will overcome problems with motivating, monitoring, and controlling the performance of public- sector workers, and thereby improve the quality of service to the public. But NPM’s critics argue that restructuring the public sector to “get more for less” involves developing new, more sophisticated forms of organizational control aimed at intensifying the public- sector labor process (Hoggett 1996; McElligott 2001). Some critics contend that the reforms have fundamentally altered public-sector employment relations, creating a division between managers who are oriented toward budget concerns and front-line staff who remain focused on service provision (Pollitt 1993; Sinclair, Ironside, and Siefert 1996). Indeed, while the extent to which NPM’s goals of cutting costs and improving the quality of services have been achieved is contested, it is undeniable that recent changes have altered the terms and conditions of work within the public sector. Five consequences affecting employees are evident: job loss, increased job insecurity, work intensification, increased surveillance, and an erosion of the strength of organized labor (Sinclair et al. 1996; Burchell 2001).

Job loss and the subsequent reduction of the public-sector workforce are the most apparent consequences of public-sector restructuring. Canadian federal public-sector employment decreased annually from 1992 through 1999, so that even a recent upswing leaves current numbers below those of 1992 (Statistics Canada 2006). Much of the decline is due to the shifting of jobs out of the public sector via privatization and contracting out. However, the decrease in public-sector employees is also attributable to redundancies and forced retirement, both relatively new phenomena in the public sector with its tradition of guaranteeing lifelong employment (Lloyd and Seifert 1995). Along with job loss, restructuring has led to the spread of nonstandard, part-time, and contingent employment, and thus growing job insecurity for public-sector workers. Job insecurity also reduces, or places at risk, employees’ hours, benefits, and salaries (Morgan, Allington, and Heery 2000).

Work intensification is another consequence of the increasingly flexible public-sector workforce. Staff reductions and a shift toward replacing fulltime positions with part-time positions mean increased work responsibilities for those who remain (Ladipo and Wilkinson 2002). Such work intensification is a fundamental component of the drive to increase public-sector workers’ productivity. Moreover, it is often accompanied by increased managerial supervision (Colling 1999). Under NPM, the role of public- sector managers is one of enforcing cost-saving and efficiency measures that necessitate greater surveillance of employees. This may involve direct monitoring and inspection of work (Mclntosh and Broderick 1996), and/or regular performance measurement via reviews and staff-appraisal systems (Hoggett 1996).

Deteriorating working conditions are related to a decline in trade unionism and collective bargaining in the public sector (Morgan et al. 2000). For example, contracting out leads to an increase in part-time and contingent employees, who are less likely to be unionized than full-time workers. Unions must play catch-up, to reorganize or reunionize workers and to negotiate a new collective agreement with a potentially more hostile employer. Whether unionized or not, however, public-sector workers are not all similarly affected by restructuring. Job insecurity, work intensification, and increased surveillance are more often borne by front-line service providers than senior managers, and by support staff rather than professionals (Cohn 1997; Bach 2000). The combined evidence also suggests that male-dominated positions have been subject to all-out cuts, while female-dominated positions have mostly experienced cutbacks in hours or benefits (Farnham and Horton 1997; Bach 2000; Geddes 2001). These changes have caused further feminization of the public-sector workforce and subsequent worsening of conditions of work for these female employees.

It seems reasonable to expect that the effects of public-sector restructuring would be reflected in deteriorating health. Downsizing, the change most often investigated, has been associated with more sick leave among Finnish local government workers (Vahtera, Kivimaki, and Pentti 1997; Kivimaki et al. 2000); more depression, anxiety, and burnout among Swedish social-service employees (McHugh 1998); more psychosomatic illness and burnout for a sample of Ontario nurses (Burke 2003); lower morale among Australian nurses (Moore and Mellor 2003); and declines in general health and increases in back pain and neck pain among personnel in a Canadian teaching hospital (Shannon et al. 2001). Allan’s (1998) findings of higher staff counseling rates, quit rates, and workplace injury and illness during reforms at an Australian hospital echo the results of these studies. In fact, a growing body of evidence indicates that public-sector restructuring damages employee health by increasing work stress (Siegrist 2001; Denton et al. 2002).

In sum, transferring public services to the private sector or exposing them to competition and managerialism has had a significant impact on the terms and conditions of work. Research indicates that NPM practices are associated with changes in the employment relationship (i.e., increased job insecurity, declining remuneration, and altered work hours), the nature of work (via work intensification, surveillance, and performance reviews), and labor relations (primarily, the declining strength of labor). A handful of studies raises concerns about the consequences of such change for health, but their emphasis on downsizing means that the health effects of labormanagement relations under the new managerialism have been largely overlooked. In our examination of the relationship between management practices and employee health, we are guided by the heuristic model depicted in Figure 1. The model suggests that NPM affects the labor process and labor relations in ways that generate work stress, which, in turn, affects employee mental health.

RESEARCH CONTEXT

The local government in Toronto has been undergoing extensive restructuring over the past decade. Fiscal restraint throughout the 1990s was followed by a provincially mandated amalgamation of seven municipalities in 1998 that brought about massive and ongoing workplace change. Practically, this meant a decade or more of downsizing; departmental reorganization; work intensification; reductions in, and the privatization of, some services; and the introduction of new technologies, a “new corporate culture,” and employee performance indicators. Within 3 years, nearly 10 percent of the municipal labor force was laid off (Garrett 2001), and staff that remained faced a period of dramatic upheaval. Frequently, workers were relocated or reassigned to new jobs as the City moved to reorganize office space and integrate hundreds of services, programs, and operations that had been both geographically and operationally separate. Also, new computer systems were installed with the aim of homogenizing and expediting service delivery, and new reporting systems were introduced to increase accountability. Amidst all of this, union representation shifted, as the former municipalities’ separate unions were collapsed into much larger bodies.

Figure 1 Heuristic Model of Workplace Relations, Working Conditions, and Employee Mental Health in the Context of Municipal Sector Restructuring.

A pilot study, conducted in 2000 to 2001 and consisting of in- depth interviews with 45 unionized City of Toronto workers, suggested that these changes were taking a toll on the people who retained their jobs. A majority of these front-line employees reported negative experiences. Noting the considerable increase in workload and responsibilities, participants described increased management surveillance of their activities that heightened workplace tensions and left people feeling undervalued. Deteriorating relationships with management constituted a pervasive concern. The pilot study also suggested links between restructuring and workers’ physical health and psychological well-being.

This paper reports findings from our subsequent study aimed at determining the prevalence of workers’ negative experiences and better understanding their concerns. Before undertaking this research, we tried to secure the support of the employer, but were unsuccessful. One reason given by senior management was that their endorsement would raise employee expectations for change, expectations that they would be unable (or unwilling) to meet. In stark contrast, labor groups representing front-line staff were very supportive of the study. Thus, we were able to collect data from front-line staff with the cooperation of the unions, but we could not obtain detailed information about the employer’s strategies for workplace change. Nevertheless, public documents outlining the postamalgamation orientation to local government and providing progress reports (Garrett 1999, 2001) suggest that several key elements of NPM were part of their plan (see Verma and Lonti 2001 for the federal and provincial context). These included more formal performance evaluation, greater labor discipline and parsimony in resource use, an emphasis on private-sector management styles, and a shift to greater competition. Indeed, these general themes were evident in workers’ accounts of their experiences in a changing workplace. Following an outline of our methods, we discuss the findings from our survey that demonstrate a negative association between poor labor-management relations and employee well-being, then draw on our interviews to show how City of Toronto front-line staff experienced these relations and why they may be detrimental to their well-being.

METHODS

Survey Data and Analysis

The two unions from which the survey sample was drawn represent “inside” employees (i.e., majority white collar, female) and “outside” employees (i.e., majority blue collar, male) working fall- time for local government in Toronto.1 Because the union membership lists are confidential, union officials agreed to handle sample selection and data collection, following our instructions. A questionnaire was mailed to 2,100 people randomly selected from the lists. A thank-you/reminder card was sent 1 week later to all selected respondents, and 3 weeks after that another questionnaire was mailed to those who had not yet responded (Dillman 2000). We received 902 completed surveys (78 addresses were incorrect and 60 people refused to participate) for a response rate of 45 percent- well within the range of similar research (Swanson and Power 2001; Korunka et al. 2003; Jimmieson, Terry, and Gallon 2004). Fortyfour percent of respondents were from the “inside” worker union.

Survey questions covered health; job characteristics; working conditions; relations with coworkers, supervisors, and management; demographics; and work-life balance. Two measures of psychological health are used in this analysis. The first is the mental health component of the SF12 (Ware, Kosinski, and Keller 1995), where questions assess fatigue and energy levels, ability to carry out activities as usual, role limitations due to emotional problems, and general feelings of well-being or distress. The second measure of mental health is personal burnout (range 0-100), defined as a state of prolonged physical and emotional exhaustion and taken from the Copenhagen Burnout Inventory (Borritz et al. 2006).

Our measures of workplace relationships and working conditions are drawn from well-known conceptual models in the work stress literature (Karasek and Theorell 1990). They include management practices, as well as working conditions previously found to be associated with health: workgroup relations, relations with supervisor, workload, control,2 skill underutilization, and job security. The items, assessed on a 5-point Likert scale, are adaptations of items that appear in the Job Content Questionnaire (Karasek et al. 1998), the National Institute for Occupation Safety and Health (NIOSH) Generic Job Stress Questionnaire (Hurrell and McLaney 1988), and (for one item) a survey of Canadian auto workers. Percentage distributions of the items constituting each working condition variable are given in Table 1. Because we used the average of the summed items constituting each work variable in our multivariate analyses, Table 1 also presents Cronbach’s alpha reliability coefficients for variables consisting of two or more items, along with means and standard deviations.

Finally, our models also adjust for age (X = 46 years, SD = 9) and gender (coded female = 1; male = 0), variables that may be related to our predictors and health outcomes but are not of central interest to this analysis. The control for gender also addresses a bias in the composition of the two unions. Although the total sample was roughly equally split along gender lines (45 percent were women), the union representing mainly “outside” (mostly manual) workers is three-quarters male; the other union, comprising mainly “inside” workers doing nonmanual work, is three-quarters female. While a control for gender addresses some of the differences in the two unions, earlier in-depth interviews suggested that the dominant “culture” within the two unions might be different. For example, we noted a more conflictuel representation of working conditions and relationships among the outside workers, compared with their counterparts inside. To capture the effect of this culture that may not be subsumed through a gender control, we also include a union membership variable in our models: female-majority union (coded yes = 1; no = 0). Table 1

Percentage Distribution of Working Condition Items; and Reliability, Means, and Standard Deviations of Working Condition Variables (N=809)

Table 1

Percentage Distribution of Working Condition Items; and Reliability, Means, and Standard Deviations of Working Condition Variables (N=809)

Our analytical strategy involves running ordinary least squares (OLS) regression models that assess the relationships between management practices and our two continuous outcomes, burnout and mental health, while controlling for workers’ sociodemographic characteristics and other working conditions and relationships. On the basis of prior research suggesting that the consequences of workplace restructuring may vary according to gender (Bach 2000; Geddes 2001), we tested for, but did not find, statistically significant interactions between gender and working conditions. Hence, data for women and men are pooled in the analyses.

Interview Data and Analysis

After collecting the survey data, we conducted 54 in-depth interviews with respondents who indicated their willingness to be contacted for this purpose. The choice of participants at this stage was guided by a preliminary analysis that identified areas calling for in-depth exploration. Based on this initial analysis, we selected volunteers who indicated that they were worn out, burned out, or emotionally exhausted (N = 26), or who were experiencing problems with management and/or job uncertainty (N = 19); in addition, we selected respondents who stood out for their positive feelings about their working conditions and relations, as well as their general wellbeing (N = 9). Our aim in choosing respondents who fit these profiles was to gain greater insight into employees’ experiences of the aforementioned problems, which the survey indicated were widespread in the sample.

The interviews lasted from 40 minutes to more than 2 hours and averaged approximately 90 minutes in length. The interview guide consisted of a set of semistructured questions probing their responses to the survey items on labor-management relations, working conditions, morale, commitment, coping strategies, relationships with coworkers, health and well-being, and life outside work. All interviews were digitally recorded and fully transcribed before analysis.

Because our inquiry into workers’ experience of change was fairly openended, the interview data were analyzed using grounded-theory methods (Glaser and Strauss 1967; Creswell 1998). The transcribed materials were reviewed several times to identify themes and then open-coded. Themes pertaining to labor-management relations and psychological well-being provided the basis of the analysis here. Four themes captured employees’ experiences of postamalgamation working conditions and relations: excessive control, incompetent supervision, unrewarded labor, and unresponsive management.

RESULTS

Management Orientations and Worker Psychological Health

Table 1 gives distributions for the measures of management practices and working conditions and relations used in the analysis. Most striking here is worker dissatisfaction with management practices. Only about a quarter of respondents agreed that management was concerned about employees’ well-being, paid attention to employee’s concerns, and had fair policies. Although a slightly higher proportion (39 percent) believed that management valued the work they did, many (31 percent) disagreed with this statement.

Other workplace relations were much more positive (Table 1). Just under half of the sample said that they received much or very much support from their coworkers, 44 percent believed that there was team spirit in their work group, and only 26 percent thought that there was conflict in their work group. Almost three-quarters said that there was no conflict between themselves and their supervisor.

The organization of the work itself, in the form of too-heavy workloads and minimal control over how they did their work (Table 1), also was problematic. Two-thirds of respondents believed that they had too much work to do, 43 percent had little control over the amount of work they did, and 21 percent had little control over the pace of their work tasks. Even higher proportions said they had little control over proposed changes to the way they did their work, or policies and procedures that affected their work unit (51 percent and 67 percent, respectively).

Making matters worse, front-line staff did not always have the support they needed to do their jobs well. While almost half felt that they received the feedback they needed from their supervisor, only 36 percent agreed that they could count on his/her support when things got tough. A substantial proportion of workers felt that they lacked the help, supplies, and equipment to do their work.

Many of these employees also lacked the kinds of workplace opportunities that might foster well-being. One-third of respondents said that they were rarely or never given the chance to do the things they were good at, and fully 45 percent reported rarely or never having the opportunity to develop their skills and abilities. Even more striking, especially given the long-term service record of these front-line staff (X = 15.5 years, SD = 7.2), is the extent to which they did not know what the future held for them at work. Anywhere from nearly one-half to two-thirds of the sample reported some degree of uncertainty about future job responsibilities, opportunities for promotion, value of their skills, or security of their jobs.

In sum, while this is a workplace characterized by reasonably good relations among workers and between workers and immediate supervisors, it is also one in which employees face problems involving the organization of work, inadequate support, and a scarcity of future opportunities. Accompanying all of this is considerable evidence of poor labor-management relations, with employee perceptions of management’s uncaring attitudes and unfair policies dominating more benign characterizations.

These workers may be suffering psychologically. The sample mean for general mental health was 45.6 (SD = 11.4), compared with an average mental health score of 50 in a random sample of Americans aged 18-75 years (Ware, Kosinski, and Keller 1995). Similarly, the average burnout score for City workers was 44.9 (SD = 23.4), well above an average of 38.5 reported for a sample of Danish human- services employees (Borritz et al. 2006). Although we do not have comparable Canadian data for general mental health and burnout (the SF12 and Copenhagen Burnout Inventory were developed and tested outside of the Canadian context), evidence from several representative surveys suggests that City of Toronto workers are in worse overall health than other working-age Ontarians in full-time employment. Fully 22 percent of our sample rated their health as fair or poor, while estimates for the general population are consistently much lower than this. For example, using data from the Canadian Community Health Survey (CCHS), we found that only 9 percent of full-time employees aged 25-64 and living in Ontario were in fair or poor health in 2004 (the year of our study). Estimates from the 2005 CCHS and earlier waves (2001, 2002, and 2003) ranged from 6 to 7 percent. Clearly, there is cause for concern about the health status of City front-line staff.

To what extent are the poor labor-management relations linked to employee well-being? We examine the impact of management practices on worker psychological health, controlling for sociodemographic characteristics and other working conditions that might be associated with both health and management practices. The results, shown in Table 2 (Model 1), demonstrate that having a fair, supportive, and caring management lowered burnout scores. The standardized estimates also indicate that, while many of the other variables influenced burnout, the relationship between management practices and employee burnout was among the strongest of those considered.3 A similar pattern is seen for general mental health (Table 2, Model 2).

Table 2

OLS Regression of Burnout and Mental Health on Workplace Relations, Working Conditions, and Sociodemographic Characteristics of City of Toronto Front-Line Staff

Overall, we find a robust relationship between management practices and worker psychological health. Yet, this finding leaves at least one important question unanswered: What about their working conditions lead a majority of front-line staff to characterize management as unconcerned, unappreciative, and unfair. To better understand workers’ experiences of these management practices, we draw on data from in-depth interviews with survey respondents.

Employees’ Experiences of Workplace Change

Four themes emerged as prominent features of workplace relations in the interviews with front-line staff: excessive control by management, incompetent supervision, unrewarded labor, and unresponsive management. Among these, excessive control by management was the most recurrent and obviously distressing. A few respondents described management directives in especially harsh terms. Helen4 likened her current experience of work to being in the military. “You’re just told [what to do]… it’s like being in the army.” Neil characterized the new style as dictatorial: “If you question anything [our manager] says about any policy he wants to impose, he just says, ‘if you don’t like it, you know what you can do.'” And Elizabeth compared the current state of affairs with schoolyard bullying, arguing that restructuring had brought in “people who were bullies and more used to working in a ‘power over’ position.” Some front-line staff were bothered by what they described as a general increase in monitoring. Closer scrutiny of how they spent their time on the job meant they had little breathing room. But perhaps more important, tighter direction conveyed the message that they could not be trusted to do their jobs in a competent and responsible manner. Many found this demeaning or anxiety-provoking, sometimes intolerably so. One widely disliked manifestation of tightened control was a recently established Attendance Management Program, designed to restrict employees’ use of sick days. Marie, who viewed “harassment [over] absenteeism” as “the biggest problem” at work, found the scrutiny so disturbing that she was considering leaving her job altogether. In general, these workers expressed the view that tighter control by management eroded their sense of themselves as responsible adults and valued workers.

Management’s excessive control was all the more galling in light of the second major theme in the interviews: incompetent supervision. This problem was often attributed to direct supervisors, but also applied to mid-level managers, with whom many of these workers had regular contact. Although the complaint was not always directly about management, incompetent supervision was generally understood to reflect management strategies. Some City staff believed that hiring practices during restructuring had bloated upper-level ranks with unqualified individuals. Elizabeth’s assessment of what had taken place was typical:

[It was] ’98, ’99 that they decided, “well, we’re gonna have a full-time supervisor position.” And they did that right across the City. They recruited all these supervisor positions and manager positions, and basically put people-the majority of whom are underqualified-into these positions.

In a time of fiscal restraint, too many supervisors and managers meant too few people to do what respondents saw as the “real” work of their units-the front-line work. Cheryl put it succinctly: “There’s too many power heads and not enough staff.” Beyond that, workers described being directed by individuals who had no previous experience with the work being done in the unit. The result, they said, was a series of inadequate, inappropriate, or contradictory directives, which often left workers “holding the bag.” Mike recalled being told, in response to a query about how he should prioritize his time, “it’s not my job to find you work; you have to find your own work.” His conclusion, like that of many others we spoke with, was: “quite literally speaking, she’s not qualified to do the job she does.” Although others were slightly more forgiving, the end result was that not only the work, but much of the responsibility as well, fell to front-line staff. Their anger was palpable at times. As John told us, “They are getting paid big bucks and they don’t do zero. We are the front-line workers. We’re the ones that make [the supervisors] look good.”

Ultimately, incompetent supervision was demoralizing. Marie, a longterm City employee with a strong commitment to her work, struggled to convey her exasperation: “It doesn’t matter that I know the legislation better [than the supervisor], that what they’re doing is breaking the law. It doesn’t matter. How [would] you feel?” In a similar vein, Helen lamented, “I’ve lost respect for the management. … They don’t even know what it is we’re trying to do half the time. So, that’s really discouraging.” Clearly, poor- quality direction left many front-line staff feeling disheartened.

The sense that many superiors were superfluous or underqualified was linked to a third theme that ran through the interviews: unrewarded labor. Two aspects of the postamalgamation reward system, frozen pay and declining opportunities for advancement, were particularly problematic. Both were keenly felt as losses by City workers. Interviewed shortly after the completion of a lengthy wage harmonization, Tina’s dismay was over the settlement’s failure to acknowledge the value of her work: “We’re so disappointed. … We’re rated at the same scale as people I know that don’t do a quarter of what I do.” For others, the issue was a belief that restructuring (including the hiring practices that had brought in “underqualified” managers) had closed off opportunities to most front-line staff. As Joseph, a disillusioned long-term City employee, explained,

[In the past] you had small expectations that when your boss retired, you would move up the ladder. Now … they can hire whoever they want from wherever they want-inside, outside, parachute this, that, and everything else. The opportunities are decreasing. They told us that if you made it to a foreman, congratulations, you will never get any higher.

While some were disturbed by the loss of concrete work-related rewards, others mourned the disappearance of less tangible returns- what Suzanne referred to as “the pat on the back.” Tina, although unhappy with her pay, also stressed the importance of intangibles. “It’s hard not to compare myself to other people that are in my field … and not to see what they’re doing and how they’re compensated for it. And just the fact… not so much the compensation, but the fact that it’s not acknowledged.”

Key to these employees’ distress was the perception that dedication and quality no longer mattered at work. Helen-so committed to her job that she spent personal time and money on professional development and thought of her work as “my contribution to the world”-noted wearily that her devotion was lost on management: “If you mentioned to the powers-that-be here that I spend a lot of my own time just getting the job done, they’d say, ‘Well don’t’. … You know, the quality doesn’t matter to them.” In the eyes of these employees, then, there was no longer any payoff at work for dedication. Those who valued their job precisely because they felt it allowed them to make a real contribution in the world found this especially troubling.

While dedication and quality seemed not to matter in the new City of Toronto, the same cannot be said about “connections.” Indeed, a number of respondents directly linked unrewarded labor to the favoritism they believed was rampant in the organization. In keeping with the survey finding that respondents were more likely to see management policies as unfair than fair, Linda commented that, “even if you’ve been an absolutely horrible [front-line] worker… if you have pleased somebody in management and you have a powerful advocate, you can still get ahead.” Several workers who felt that connections mattered more for promotion than dedication and quality had abandoned efforts to improve their situation.

On several levels, then, poor management-labor relations played out in the lives of these workers as a low sense of their worth as employees and low expectations of being rewarded. But they also found themselves with little power to change their situation. Indeed, the fourth major theme in the interviews involved these workers’ encounters with an unresponsive management. Several respondents tried to raise concerns with their superiors following amalgamation, but were simply ignored or dismissed. Rick described his manager’s response to a request for two-way communication between front-line staff and management: “[He said] ‘we don’t have to talk to you; we’re management.'” Julia painted a similar picture of a workplace in which communication traveled in one direction only, leaving workers’ concerns ignored or dismissed: “If you question, ‘why do we do this?’ [you’re told], ‘well, here’s the policy. You got a problem with it? Here it is again-it’s in large print now.'” As Elizabeth noted with exasperation, “it doesn’t matter what we say or who we say it to … it has no effect.” The result was that many gave up trying to change things for the better.

Taken as a whole, front-line worker narratives give us a window on the meaning behind the widespread negative views about management expressed in the survey. They also suggest why management practices may be detrimental to mental health. The new top-down, top-heavy approach and the lack of rewards signified disregard for workers’ knowledge, integrity, and value to the organization. Front-line staff experienced these practices as assaults on their identities as valuable workers worthy of dignity and respect. They also expressed a keen sense of powerlessness to change, for the better, the ways in which they did their work. Indeed, threats to identity, and the corresponding helplessness that emerges from the belief that one’s actions are ineffectual, are widely known in the health literature to harm mental health (Helgeson 1994; Thoits 1999; Rosenfield, Vertefuille, and McAlpine 2000). For the municipal workers in our survey, this meant feeling tired, worn out, and compromised in their daily activities.

CONCLUSION

In this paper, we utilized data on municipal workers to examine labor-management relations and employee mental health in the context of public sector restructuring. We found compelling evidence that problems with management, documented 3 years earlier in a pilot study conducted just aftter amalgamation, continued to plague this work site. The survey data suggested that these problems affected workers’ psychological well-being, regardless of the nature of other working conditions. Although we cannot infer causality here, the interview data allowed us to “look beneath” these findings, to explore what workers found most problematic about their relationships with management. Our findings make three contributions to the literature on work, public-sector restructuring, and health. First, by directly linking labormanagement relations with psychological health, we expand existing knowledge about possible health consequences of public-sector restructuring for workers. As noted, most studies focus on the fallout from downsizing-increased job insecurity and work load-and the resulting intensification of the labor process. However, the relative strength of the associations between health and management practices suggests that more research attention should be devoted to this neglected area in health research on work.

Second, our multimethod approach enables us to develop a deeper understanding of workers’ experiences of restructuring in this workplace. Because we supplement our survey findings with qualitative data, we are able to identify some possible dynamics of labor-management relations and worker mental health. Existing research suggests that the link between reorganization and health is through work stress, but does not elaborate on the meaning of this relationship (Huuhtanen et al. 1997; Swanson and Power 2001; Korunka et al. 2003; Jimmieson, Terry, and Callan 2004). We find that for many City of Toronto front-line staff, the pathway is one in which management’s single-minded focus on the bottom line found expression in several concrete managerial practices-excessive control, supervisory incompetence, failure to reward, and unresponsiveness. These practices, in turn, may have harmed psychological well-being by undermining workers’ sense of themselves as valued employees, and ultimately, as individuals worthy of dignity and respect. Importantly, these workers also felt powerless to change things. Marie aptly summarized the damage done by restructuring as she reflected on what had been sacrificed in the reorganization of her workplace: “You know,” she said, “what it’s about is dignity.”

Third, we shed new light on labor-management relations by bringing together insights from bodies of work that are seldom in direct communication-the separate literatures on the social relations of work and on restructuring and health. Management’s violation of worker dignity, whether deliberate or unwitting, is not a new theme in studies of the social relations of paid work. For example, Hodson (2001) places lost dignity at the core of poor labor- management relations, and Marxist discussions of worker alienation and the degradation of paid work are implicitly about assaults on worker dignity (Braverman 1974). The dynamics in labor-management relations that Hodson identifies as most problematic to workers’ dignity closely align with what we found for City of Toronto employees, suggesting that our findings may have relevance for workplace reorganization more generally. However, those who study the social relations of work focus on the strategies that workers develop to contend with lost dignity, rather than on health per se, and its consequences (Westwood 1984; Burawoy 1985; Harris 1987; Hodson 2001). We extend this work, and thus our understanding of restructuring more generally, to show that the problems that have been identified may also affect mental health. Importantly, our interview material shows that these consequences may actually interfere with workers’ abilities to resist or transform workplace changes that run counter to their best interests.

Despite these contributions, the study is not without limitations. An important one is that we know very little about the employer’s formal plans and implementation of NPM: management refused to participate in the study. Nevertheless, unlike most other research on public-sector restructuring that focuses on management practices of NPM and managers’ or professionals’ responses (Connor 1997; Armstrong-Stassen 1998; Ferrie et al. 2002; Jorgensen and Bozeman 2002; Roper, James, and Higgins 2005), our study provides information on how unionized workers experience such practices. A second limitation concerns our lack of direct access to employee lists. Had we been able to telephone nonresponders in an additional contact attempt, we may have been able to raise our response rate by roughly 10 percent (Dillman 2000). Whether this would have drawn in people whose views diverged from those we report remains an open question. A third possible concern is that our in-depth interviews were conducted largely, although not exclusively, with those who expressed negative views of their working conditions and labor- management relations. This was a deliberate strategy based on the survey results; we were interested in learning more about the meaning of adverse experiences so clear in the survey data. Nevertheless, by privileging this strategy over a “constant comparative” approach that would have included front-line staff with a wider range of views, we may have missed important information about workers’ experiences. Related to this, the negative relationships in the survey data between mental health and work might reflect a negative affectivity bias-the tendency to respond negatively to all questions. However, the high proportion of workers who said on the survey that they were committed to their work and loyal to their employer provides some evidence against a charge of bias (McDonough 2005).

What broader conclusions about the overall effectiveness of public-sector restructuring programs can be drawn from our findings? Hodson (2001) argues that management practices that undermine dignity also, in the process, erode employee commitment and productivity. This presents a special challenge to the public sector where workers typically carry out their duties on the basis of a high level of commitment to public service (Pratchett and Wingfield 1996; Hanlon 1998; Richards and Smith 2000; Hebson, Grimshaw, and Marchington 2003). Our earlier work found this to be true of City of Toronto front-line staff-although many were struggling over how to stay committed following amalgamation (Worts, Fox, and McDonough 2005; McDonough 2006). If the loss of dignity goes hand in hand with declining commitment, the present study suggests that NPM-style strategies may make it difficult, if not impossible, to accomplish the stated goal of “doing more with less.” In the end, the costs of restructuring may be borne not only by front-line staff but also by the public they serve.

1. Although one of the study inclusion criteria was being a full- time employee, two respondents were working part-time when interviewed some months after the survey.

2. Following work by Carayon and Zijletra (1999) that highlighted the multidimensional nature of control at work, we assess this construct in three ways: task control, resource control, and decision control.

3 Interestingly (while only marginally significant), control over the resources needed to do one’s work raised burnout scores, an association that may reflect position in the organizational hierarchy. Although all survey respondents were nonmanagement, it may be that those with greater resource control had jobs with more responsibility and, thus, experienced more burnout. We were not able to examine this contention with these data; however, an earlier analysis of the pilot study interviews identified this as a problem among those front-line staff (often women) for whom new opportunities had opened up during reorganization.

4 All employees’ names are pseudonyms.

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PEGGY MCDONOUGH, DIANA WORTS, BONNIE FOX, AND KLAUDIA DMITRIENKO University of Toronto

Peggy McDonough, Department of Public Health Sciences, University of Toronto, 155 College Street, 6th Floor, Toronto, ON, Canada M5T 3M7. E-mail: [email protected]. We thank Linn Clark for her editorial assistance. This research was support by an SSHRC Standard Grant 502-202-106.

Copyright Canadian Sociology and Anthropology Association, c/o Concordia University Department of Sociology and Anthropology May 2008

(c) 2008 Canadian Review of Sociology and Anthropology, The. Provided by ProQuest LLC. All rights Reserved.

Neptune Technologies Further Advances Its Cardiovascular Pharmaceutical Development Through Its New Operating Subsidiary Acasti Pharma

Neptune Technologies & Bioressources Inc. (“Neptune”) (NASDAQ:NEPT) (TSX VENTURE:NTB) announces the formation of an operating pharmaceutical subsidiary named Acasti Pharma Inc. Neptune structured part of its pharmaceutical operations into its subsidiary Acasti Pharma to carry out the research, development and commercialization of active pharmaceutical ingredients (“API”) for chronic cardiovascular disease. According to its business strategy, Acasti Pharma will pursue negotiations with the objective to enter strategic pharmaceutical alliances.

During the last fiscal year, Neptune has advanced its internal pharmaceutical operations to a point requiring important structural decisions within the organization. In order to further advance the cardiovascular pharmaceutical program, Neptune has now granted to Acasti Pharma a license to rights of its intellectual property portfolio related to cardiovascular applications. The transfer of this license allows Acasti Pharma to exploit intellectual property rights in order to develop novel active pharmaceutical ingredients into commercial products for three pharmaceutical markets, namely the over-the-counter (OTC), the medical food (MF) and the prescription drug (Rx) market.

The license was transferred to the pharmaceutical subsidiary in the exchange of 25 million category C shares, 5 million multi-voting category B shares, and 8 million warrants expiring on July 31, 2010 for an aggregate value of $9 million. Acasti Pharma will pay royalties to Neptune from licensed product sales in the cardiovascular field with a minimum annual royalty payment for each of the three pharmaceutical markets. Neptune ascribed a fraction of its warrants held in its subsidiary to employees, officers and administrators. Acasti Pharma is responsible for carrying out the research and development of the APIs, as well as required regulatory submissions and approvals and intellectual property filings with regards to cardiovascular applications. Acasti Pharma is preparing an investigational new drug application (IND) with the Food and Drug Administration (FDA) in the United States and a clinical trial application (CTA) with Health Canada.

Acasti Pharma is leveraging the intellectual property, clinical data and know how gained by Neptune during the last ten years by advancing a portfolio of proprietary novel omega-3 phospholipids through the pharmaceutical development pathway for prescription medical food, over-the-counter and prescription drug applications. Neptune has already demonstrated through clinical trials that Neptune Krill Oil (NKO(R)), a patented composition containing proprietary novel omega-3 phospholipids, can reduce LDL -bad cholesterol- levels and can raise HDL -good cholesterol- levels. These clinical results with pilot precursors offer a great degree of comfort and reassurance of the effectiveness and proof of concept of Acasti Pharma API’s. Neptune is continuing the development of all its other pharmaceutical applications, including cognitive diseases development.

About Acasti Pharma

Acasti Pharma is currently wholly owned by Neptune and is governed by the Board of Directors of Neptune. Its head office is located at the same address as Neptune at 225 Promenade du Centropolis, Suite 200, Laval, Quebec, Canada H7T 3B3.

Acasti Pharma will be managed by the present Chief Scientific Officer of Neptune, Tina Sampalis B.Sc., M.D., Ph.D. as President, supported by Bruno Battistini B.Sc., M.Sc., Ph.D. as Senior Director of Pharmaceutical R&D and Wael Massrieh B.Sc., Ph.D. as, Director of R&D. Dr. Battistini conducted his postdoctoral studies at William Harvey Research Institute, London, UK with Sir J. Vane, FRS, Nobel Laureate; UBC-St.Paul’s Hospital, Vancouver and Sherbrooke University. He has led as VP, R&D and CSO IND-enabling preclinical studies successfully reaching phase I trial in less then three years. Dr. Wael Massrieh joined Neptune in October 2007 after working as Director of R&D at Biomechanics. He completed his studies at McGill University in Montreal. The President and CEO of Neptune, Mr. Henri Harland B.Sc., M.B.A., will lead the Acasti Pharma management team as Chief Executive Officer. The business, finance and administration teams of Neptune along with its technical and laboratory facilities and personnel will support Acasti Pharma’s operations and technological requirements.

Acasti Pharma’s Scientific Advisory Board is comprised of Steven E. Nissen M.D. MACC, Chairman, Cleveland Clinic, Cardiovascular Medicine, & Past President, American College of Cardiology, Magdy M. Abdel-Malik Ph.D., Former Global External Opportunities, Pfizer Consumer Healthcare, NJ and Thomas G. Hartman Ph.D., Mass Spectrometry Lab Manager at Rutgers University Center for Advanced Food Technology. Two additional Scientific Advisory Board members will be appointed in the future.

Acasti Pharma’s product portfolio of proprietary novel long-chain omega-3 phospholipids are sourced from sustainable abundant marine biomass including Antarctic krill (Euphausia superba). Phospholipids are the major component of cell membranes and are essential for all vital cell processes. They are one of the principal constituents of High Density Lipoprotein (good cholesterol) and play, as such, an important role in modulating cholesterol efflux. Acasti Pharma’s proprietary novel phospholipids carry and functionalize the polyunsaturated omega-3 fatty acids EPA and DHA, which have been shown to have substantial health benefits, and which are stabilized by potent antioxidants. Acasti is focusing initially on treatments for chronic cardiovascular conditions.

About Neptune

Neptune researches and develops proprietary bioactive ingredients and products for nutraceutical and pharmaceutical applications and is carrying out clinical research to show the therapeutic benefits in various medical indications. The Company patents and protects its innovations and continuously expands its intellectual property portfolio. Neptune has already obtained many regulatory approvals allowing commercialization of its products in various geographic markets and has filed for and is expecting additional approvals. Neptune continues to strongly support its strategic development plan to form partnerships with worldwide leaders in the nutraceutical industries. Neptune signed agreements with Nestle and Yoplait, worldwide leading food manufacturers, and paved its entrance into the global functional food market.

Neither NASDAQ nor TSX venture exchange accepts responsibility for the adequacy or accuracy of this press release.

Statements in this press release that are not statements of historical or current fact constitute “forward-looking statements” within the meaning of the U.S. Private Securities Litigation Reform Act of 1995 and Canadian securities laws. Such forward-looking statements involve known and unknown risks, uncertainties, and other unknown factors that could cause the actual results of the Company to be materially different from historical results or from any future results expressed or implied by such forward-looking statements. In addition to statements which explicitly describe such risks and uncertainties, readers are urged to consider statements labeled with the terms “believes,””belief,””expects,””intends,””anticipates,””will,” or “plans” to be uncertain and forward-looking. The forward-looking statements contained herein are also subject generally to other risks and uncertainties that are described from time to time in the Company’s reports filed with the Securities and Exchange Commission and the Canadian securities commissions.

Bulletin Board

By Chad Warfield

Alzheimer’s support

The DeSoto County Alzheimer’s Support Group will meet at 7 tonight at Hernando United Methodist Church. Call (662) 449-5720.

Republican women

The Republican Women-DeSoto Area will meet at 10 a.m. today at the Hernando library. Retired U.S. Secret Service agent Ralph Kennedy is the speaker. Call (901) 335-1441.

Sound of Music

Horn Lake High School will hold open community auditions for its production of Sound Of Music 5:30-8:30 p.m. today. Three roles are available for girls appearing to be ages 7, 9 and 13. One role is available for a boy appearing to be age 11. Those auditioning must be able to sing and be a resident of DeSoto County.

Glenn’s Chapel

Glenn’s Chapel, 8235 Miss. 301 in Lake Cormorant, will have its revival at 7 p.m. through Friday . Rev. Santiago Shol is the featured speaker.

Gospel singing

Abundant Grace Ministries, 9239 E. Holmes, will have gospel singing at 7 p.m. Friday featuring The Almost Famous Crains and The Bluff City Quartet. Call (901) 299-8831 or (662) 349-3822.

Jackson Chapel Church, 2231 Grays Creek in Hernando, will have gospel singing at 7 p.m. Saturday featuring The Servants Heart Quartet.

Guitar Hero

The Hernando High Theatre Department will host a Guitar Hero III Tournament on a big screen 11 a.m.-6 p.m. Saturday at the Hernando Performing Arts Center on the Hernando High School campus. Arrive at 10 a.m. to sign up for your time slot with a chance to win a $100 Game Stop gift card. Everyone is eligible. There will also be a teacher division. No entry fee for teachers. The cost is $15. You can get registration forms at the Hernando Game Stop or register at the door. Email ashley.hawkins@desoto countyschools.org.

DARS pet adoption

The DeSoto Animal Rescue Society will have a pet adoption 11 a.m.- 4 p.m. Saturday at Petco, 205 Goodman in Southaven. Dogs are $90 and cats are $75. Call (662) 342-9448 or visit desotopetlovers.org.

Garden of Grace

Garden of Grace Church, 2220 Cresthill in Southaven, will have its revival Sunday-Wednesday featuring Evangelist E. Kidd. Times are 10:45 and 6 p.m. Sunday and 7 p.m. Monday-Wednesday . Call (662) 393- 6349.

Wicker for Senate

Senator Roger Wicker and his campaign team are seeking persons wishing to volunteer and help in his re-election. There will be an informational meeting at the B.J. Chain Public Library in Olive Branch at 6:30 p.m. Monday . Call (901) 488-3882 or e-mail [email protected].

Preschool classes

The Getwell Road United Methodist Church Day School has openings for its 3- and 4-year-old preschool classes in the new children’s building. Call (901) 283-7090 or visit getwellroad.org.

Bible study

The Olive Branch Community Bible Study meets at 9:30 a.m. every Thursday beginning Aug. 28 at Hope Baptist Church, 6400 Center Hill. The study is Amos/Isaiah. Call (662) 893-6620, visit olivebranchcbs.org or e-mail [email protected].

Bible Community Life Study, an evening Bible study class for men and women of all denominations, begins at 7 p.m. Sept. 4 at First Baptist Church in Olive Branch. The Book of Mark will be studied during the first semester, which runs September through mid- December. Call (662) 838-3132 or (662) 393-6952.

GROW Bible study

Colonial Hills Church, 7701 U.S. 51 in Southaven, will present Girls Raised On the Word weekly Bible study and fellowship for women 9-11 a.m. every Tuesday through Oct. 30. Child care is provided and homeschool classes are available. Call (662) 393-2445, visit colonialhillschurch.com or e-mail [email protected].

Free hunter education

A free hunter education course will be held at Goodman Oaks Church of Christ, 1700 Goodman in Southaven. The times are 6-8:30 p.m. Monday-Tuesday, Aug. 28 and 8-10:30 a.m. Aug. 30. You must be at least 10 years of age, attend all four classes, pass a written exam and show that you can handle a firearm safely. Bring your Social Security number to class. Call (662) 349-3600.

Southaven Girl Scouts

Southaven Girl Scouts will have open registration 6:30-8 p.m. Aug. 29 at the Southaven Public Library and 10 a.m.-noon Aug. 30 at Southaven City Hall. Call (901) 767-1440 or (662) 536-3952.

Steak dinner

Cornerstone Church, 5998 Elmore in Southaven, will have A Night Out On The Ranch steak dinner at 7 p.m. Aug. 29. The cost is $15. Childcare is available on request. Proceeds benefit a missions project team to Thailand. Call (662) 349-0216.

Playwrite competition

The Tallahatchie River Players have extended the deadline of the one-act playwriting competition of the Tallahatchie RiverFest to Aug. 31. Prizes for first is $100, second is $50 and third is $25. The Tallahatchie River Players will produce the winning entry Sept. 27 during the annual RiverFest. The play is free to the public in the Magnolia Civic Center in New Albany. The competition is open to all ages. Entry fee is $10. Visit tallahatchieriverfest.com or call (662) 534-4354.

English classes

First Baptist Church, 3505 Goodman in Horn Lake, will offer English classes for internationals. Registration for new students is 7-8 p.m. Sept. 2. No new students will be accepted after Sept. 30. Classes are 7-8:30 p.m. Tuesdays Sept. 9-Nov. 18. Textbooks are $15 or $20. Instruction is free. Students should use the east entrance from the parking lot behind the building. Call (662) 393-7760.

Broadway Bound

Broadway Bound is taking registrations for musical theater training classes for children ages 6-14. Classes are Thursdays at St. Timothy’s Episcopal Church and begin Sept. 4. The first semester’s performance is Jan. 23. Space is limited and available on a first-come, first-served basis. Call (901) 212-6865 or e-mail [email protected].

Safe driving class

There will be an AARP safe driving class 8:30 a.m.-12:30 p.m. Sept. 6 and Sept. 13 at the University of Mississippi, DeSoto campus, 5197 W.E. Ross Parkway in Southaven. Students 55 and older who complete the course are eligible for a discount on car insurance. AARP membership is not required. You must attend both sessions to receive your certificate. The fee is $10. Register before Sept. 6. Call (662) 342-4765.

Another AARP safe driving class will be held 10 a.m.-2 p.m. Sept. 9-10 at the B.J. Chain Library in Olive Branch. Call (662) 895- 5900.

Also, an AARP safe driving class is scheduled for 8:30 a.m.- 12:30 p.m. Sept. 9-10 at the Southaven Tennis Center, 3750 Freeman Lane. Register before Sept. 8. Call (662) 349-6833.

Finally, an AARP safe driving class will be held 9 a.m.-1 p.m. Sept. 16-17 at the Olive Branch YMCA, 8555 Goodman. Register before Sept. 15. Call (662) 890-9622.

Golf tournament

The Special Olympics Area 16 four-person scramble Golf Tournament is Sept. 15 at Wedgewood Golfers Club in Olive Branch. Entry fee is $100 per person. Hole sponsorship available. Lunch will be provided. Call (662) 393-8358 or e-mail [email protected].

Graceview Visitors Day

Graceview Presbyterian Church, 7660 Swinnea in Southaven, will have Visitors Day Sept. 17 for anyone looking for a Church. Worship service will start at 11 a.m. There will be a church cookout at noon followed by lawn games and fellowship. Call (662) 349-0133.

SHS Class of 1988

The 1988 Southaven High School class reunion is 6 p.m. Sept. 27 at Hollywood Casino in Tunica. Visit shsclass88.blogspot.com for more information or e-mail Terry Stanford ([email protected]), Clay Collins ([email protected]) or Carrie Cook (carriecookrealtor@ yahoo.com).

Glenn’s Chapel bazaar

Glenn’s Chapel Church, 8235 Miss. 301 N. in Lake Cormorant, will hold its annual bazaar 8 a.m.-3 p.m. Sept 27. There will be breakfast, white elephant sale, cake walk, arts and crafts, moon walk for kids, barbeque plates or sandwiches for lunch and more. They we will have Boston Butts for $30 each, order in advance. Booth rental is $15. Call (662) 429-4510 or (662) 781-3636.

Soles 4 Souls

Holy Cross Episcopal Church, 8230 Highway 178 in Olive Branch, has joined with the SOLES 4 SOULS charity to collect gently used shoes for men, women, boys, girls and infants ending Sept. 28. There will be a collection box located in the church. Soles 4 Souls suggest a $1 donation per pair to assist with shipping cost. Call (662) 895-5029 or e-mail [email protected]

Baseball tryouts

The 10-year-old Mississippi Royals competitive baseball team is holding tryouts for the 2009 season. Players must be age 10 or younger as of May 1, 2009. Call (901) 674-4733.

The North Mississippi Razors 12-year-old AA competitive baseball team is now holding tryouts. Call (901) 270-4166.

The Mississippi Wolf Pac 9-under competitive baseball team is holding tryouts. Experienced 8-year-olds are also welcome to call. Call (901) 277-9776 or (662) 781-8417.

14-year-old Team DeSoto competitive baseball team is holding tryouts. Call (901) 351-6931 or (901) 487-8086.

A 13-year-old competitive baseball team is looking for players for the fall. Call (901) 461-6807.

The D.C. Wolf Pack 10-year-old competitive baseball team is now holding tryouts for the upcoming season. Call (662) 404-0608.

The DeSoto Cardinals 9-under player pitch baseball tryouts are ongoing. To schedule a tryout, call (901) 870-0961.

Southaven VFW

Southaven VFW Post 10567, 1884 Veterans Drive, meets at 7 p.m. the second Tuesday of the month. Call (662) 393-4488.

O.B. Senior Center

The Olive Branch Senior Center, 8800 College Street, has canasta at 10 a.m. and scrabble at 1 p.m. Mondays, and other card games during the week. Call (662) 890-7182.

Line dancing

Lline dancing is held at 7 p.m. every Tuesday at Graceland Christian Church on State Line in Southaven. The fee is $3 per class. Call (662) 429-1701.

Samaritans Ministry

The Samaritans Ministry, 2600 Goodman in Horn Lake, has extended its hours to accommodate clients who work during the day. New hours are 10 a.m.-3 p.m. Monday and Wednesday and 6:30-8:30 p.m. the first Thursday of every month. Monetary and food donations and volunteers are always welcome. Call (662) 393-6439.

All About Adoption

The All About Adoption support group meets at 6:30 p.m. every first Monday of the month in the meeting room at Atmos Energy, 5249 Pepperchase in Southaven. Call (662) 342-9401.

AA and Al-Anon

The Greenbrook Group meets at 8 p.m. Wednesdays at Graceland Christian Church, 2126 State Line in Southaven.

The Love and Tolerance Group of Alcoholics Anonymous meets at noon every Monday, Wednesday and Friday at Hernando Church of Christ, 2110 U.S. 51. Monday and Friday are discussions and Wednesday is Big Book Study. Al-Anon also meets at noon Monday and Friday. Call (662) 470-4701.

The Hernando Group Alcoholics Anonymous and Al-Anon meet at 8 p.m. Thursdays at Holy Spirit Catholic Church, 575 E. Commerce in Hernando.

DeSoto Group AA and Al-Anon meet at 8 p.m. Thursdays and Saturdays at Maples Memorial Methodist Church, 8745 Goodman in Olive Branch. Call (901) 604-0929 or (901) 604-0930.

Olive Branch Trusted Servants Group AA and Al-Anon meet at 7:30- 8:30 p.m. Wednesday and Friday every week at the Olive Branch library. For AA call (901) 283-7673; for Al-Anon call (901) 605- 5021.

The Southaven OA

The Southaven OA, a fellowship of individuals who want to stop eating compulsively, meets at 2 p.m. Wednesdays and 6 p.m. Thursdays at Getwell Road United Methodist Church, 7875 Getwell. Call (901) 356-1237.

Tai-Chi/Pilates

A Tai-Chi/Pilates class meets at 8:30 a.m. every Thursday at the Snowden Grove Sports Complex in Southaven.

Cruise-In

A Cruise-In will be held 5-8 p.m. the second and fourth Tuesdays of the month at Lenny’s Sub Shop, 3019 Goodman West in Horn Lake. Call (662) 393-5558.

Line dance class

Longstreet Methodist Church presents easy-level line dance classes, open to beginners, at 7 p.m. Tuesdays. Call (901) 753-0562 or (662) 393-2156.

Tri-County Adoptions

Tri-County Animal Rescue will have Adoption Days the first and third Saturday of the month at Petco on Goodman in Southaven. Fees range from $75-$150. Call (662) 393-7529.

Marine Corps League

The DeSoto County Chapter of the Marine Corps League, Anderson- Jordan Det. meets at 7 p.m. the first Tuesday of each month at the American Legion Post 134, 2520 Goodman in Horn Lake. Call (901) 229- 0001 or (662) 429-2567.

Horn Lake reunion

The Class of 1984 is looking for anyone who graduated from Horn Lake High School and is interested in attending the 25-year reunion. The reunion is tentatively set for July 24-25, 2009. Contact Renay Hunt Goodwin at (901) 255-0643 or e-mail at [email protected].

Klingon Assault Group

The Klingon Assault Group, a not-for-profit Star Trek fan organization, meets twice a month on Tuesdays and Saturdays in Horn Lake. Call (662) 543-0036.

Aerobics classes

Graceland Christian Church, 2126 State Line, has aerobics classes 5:30-6:30 p.m. every Tuesday, Wednesday and Thursday. Call (901) 603- 9038.

Wonderful Wednesday

Graceview Presbyterian Church, 7660 Swinnea in Southaven, presents Wonderful Wednesday children’s ministry for children grades 1-6 from 4:30 to 6 p.m. Wednesdays. There will be games, refreshments and Bible study. Call (662) 349-0133.

Pet adoptions

Olive Branch Humane Society has pet adoptions 4:30-6:30 p.m. Tuesday, Thursday and Friday and 1-4 p.m. Saturday at 7140 Miss. 178. Dogs, $100; cats, $90. Includes shots, spay or neuter and microchip. Visit obpets.petfinder.com or call (662) 895-5328.

– Compiled by Chad Warfield: [email protected] (662) 996- 1413

Originally published by Compiled by Chad Warfield .

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

State Investigating Deaths at Pasadena Psychiatric Hospital

PASADENA – The state is investigating three deaths and a rape that occurred this year at a Pasadena psychiatric hospital featured on the VH1 show “Celebrity Rehab With Dr. Drew,” records show.

The state’s report charges that Aurora Las Encinas hospital, at 2900 E. Del Mar Blvd., did not properly conduct routine checks on a patient who overdosed on drugs in the facility in April. A hospital employee was fired as a result of the incident.

Another patient who died from a drug overdose the same month has spurred a Pasadena police investigation into whether another patient gave him drugs that he smuggled into the hospital, according to Sgt. Cheryl Moody of the Pasadena police department.

A third patient hung himself on the hospital’s grounds earlier this month, and a 16-year-old male at the facility was arrested for allegedly sexually assaulting a female patient this month as well.

A spokesperson for UnitedHealth Group, the nation’s second largest health insurer, told the Los Angeles Times that it has suspended referrals to the hospital while it conducts an investigation of the hospital. The Times originally broke the story on Thursday morning.

Dr. Drew Pinsky, the doctor who treated celebrities at the facility as part of VH1’s show released a statement to the Times indicating that he was not personally involved in the care of any of the patients. In addition to appearing on “Celebrity Rehab With Dr. Drew,” Pinsky co-hosts the syndicated radio show “Loveline”

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

Dopamine Increased By Sleepless Nights

Findings may help explain how sleep-deprived people stay alert

Just one night without sleep can increase the amount of the chemical dopamine in the human brain, according to new imaging research in the August 20 issue of The Journal of Neuroscience. Because drugs that increase dopamine, like amphetamines, promote wakefulness, the findings offer a potential mechanism explaining how the brain helps people stay awake despite the urge to sleep. However, the study also shows that the increase in dopamine cannot compensate for the cognitive deficits caused by sleep deprivation.

“This is the first time that a study provides evidence that in the human brain, dopamine is involved in the adaptations that result from sleep deprivation,” said Nora Volkow, MD, director of the National Institute on Drug Abuse, who led the study.

Volkow and colleagues found that in healthy participants, sleep deprivation increased dopamine in two brain structures: the striatum, which is involved in motivation and reward, and the thalamus, which is involved in alertness. The researchers also found that the amount of dopamine in the brain correlated with feelings of fatigue and impaired performance on cognitive tasks.

“These findings suggest dopamine may increase after sleep deprivation as a compensatory response to the effects of increased sleep drive in the brain,” said David Dinges, PhD, at the University of Pennsylvania School of Medicine, an expert unaffiliated with the study. “The extent to which this occurs may differentiate how vulnerable people are to the neurobehavioral effects of sleep loss,” Dinges said.

The researchers studied 15 healthy participants who were either kept awake all night or allowed a good night’s sleep. Researchers tested the same participants in both conditions. On the morning of the study, participants rated how tired they were and did cognitive tasks testing visual attention and working memory.

The researchers used the imaging technique positron emission tomography to study the changes in the dopamine system that occur with sleep deprivation. Compared to well-rested participants, sleep-deprived participants showed reduced binding of a radiolabeled compound ([11C]raclopride) that binds to dopamine receptors in the striatum and thalamus. Because raclopride competes with dopamine for the same receptors, decreased raclopride binding indicates increased levels of dopamine, according to the study authors.

Although decreases in raclopride binding could also indicate a reduction in the number of dopamine receptors, these findings are consistent with prior research implicating increased dopamine levels in wakefulness. For example, some stimulants that prevent sleep, like amphetamines, increase dopamine in the brain, and sleepiness is common in people with Parkinson’s disease, which kills dopamine neurons.

The rise in dopamine following sleep deprivation may promote wakefulness to compensate for sleep loss. “However, the concurrent decline in cognitive performance, which is associated with the dopamine increases, suggests that the adaptation is not sufficient to overcome the cognitive deterioration induced by sleep deprivation and may even contribute to it,” said study author Volkow.

Future research will examine the long-term effects of chronic sleep disturbances on dopamine brain circuits.

The study was supported by the National Institute of Health Intramural Research Program and the U.S. Department of Energy.

The Journal of Neuroscience is published by the Society for Neuroscience, an organization of more than 38,000 basic scientists and clinicians who study the brain and nervous system.

On the Net:

Administrators Start Shutting Cains Pubs ; Brothers Still Own Brewery

By ALEX TURNER

THE administrators of Liverpool brewer Cains have begun shutting the loss-making pubs in the group.

It also emerged yesterday that brothers Sudarghara and Ajmail Dusanj, who bought Cains in 2002, still own the brewery and a number of pubs.

The administrators, PricewaterhouseCoopers, refused to confirm the number or location of the closures until all the affected staff had been informed, which might not be completed until next week.

Cains Beer Company, which operates the Toxteth brewery and around 100 pubs, has been trading as a going concern since entering administration on August 7.

The company added 92 pubs to its portfolio in 2007 when it bought Honeycombe Leisure in a reverse takeover for pounds 37m.

However, this deal, which left the company with heavy borrowings and increased Cains’ exposure to the slowdown in the pub sector, was at the root of the company’s recent financial problems. Former Cains chief executive Sudarghara Dusanj confirmed to the Daily Post that the troubled company does not own the brewery or about 10 Cains- branded pubs, including Doctor Duncans, the Dispensary and the Brewery Tap.

They are instead owned by a Dusanj family company and leased to Cains.

It is understood the rent was about pounds 500,000 a year.

Sudarghara Dusanj said: “The family does own the brewery, including the plant, fixtures and fittings, and some pubs. The family trust bought the brewery freehold in 2002.”

He remained tightlipped about whether he intended to try and buy the company from the administrators, but confirmed they had been in discussions.

“We are not quite sure yet if we are going to put a package together.

We have just been talking to the administrators,” he said. “We think its a superb business and a great opportunity to build a great brand.

We have always said that.”

More than 50 companies have lodged expressions of interest with the administrators and companies are continuing to come forward.

The administrators expect to identify the serious bidders next week.

In a statement, the administrators confirmed the programme of closures, which will take place in the coming days.

It said: “The challenges faced by the pub sector are well-known and, consequently, it is not surprising that, within the Cains Group portfolio, there are loss-making pubs which are not likely to realise any value for the creditors in the administration.

“We regret that staff at the loss making pubs are being made redundant.

“We continue to trade the remainder of the business and are dealing with numerous parties who have contacted us expressing interest in the group.”

[email protected]

(c) 2008 Daily Post; Liverpool. Provided by ProQuest LLC. All rights Reserved.

Fish Melanoma Mimics Pigment Pattern That Attracts Mates

Swordtails can inherit melanoma that drives sexual selection

Though skin cancer is deadly to male fish, it also has one perk: The black melanoma splotches arise from attractive natural markings that lure female mates. A new study published in the Proceedings of the National Academy of Sciences this week shows that the melanoma gene can be conserved in swordtail fish because of its beneficial role in sexual selection.

Ohio University scientists Andr© Fernandez and Molly Morris studied three populations of female swordtails, tiny freshwater fish native to North and Central America, and found that two of them preferred males whose tails were painted to resemble the skin cancer spots. The researchers also examined specimens of swordtail fish with real melanomas, which confirmed that the cancer gene is switched on only in the tissue with the dark pigment. The study marks the first time scientists have found a cancer gene linked to a pigment pattern that functions to increase mating success in animals.

In the current study, the researchers placed a female swordtail in the middle of a tank with two partitions. They positioned a male with the faux pattern from which melanomas form on one side, and a male without the pattern on the other. After releasing the female from an opaque tube into the tank’s center chamber, the scientists observed how much time she spent looking at each male during an eight-minute period. The project builds on previous studies in the Morris lab, which used the same tests to show that female swordtails are strongly attracted to males with dark vertical bars.

To avoid any bias the female might have for a particular side of the tank, Fernandez then switched the males. Two days later, he conducted the trials again, this time changing which male received the painted skin cancer spot. The female consistently chose the male with the dark pigmented marking in two of the three populations, he said.

But the research suggests that the swordtail fish population also keeps the prevalence of the cancer gene in check. A third population of females in the study rejected the males painted with the pattern that can form melanomas. The scientists suspect that’s because the third group had a higher ratio of both males and females with the gene for skin cancer, which increases the likelihood of too many offspring inheriting the gene and dying off.

Swordtail fish usually live for 1.5 to 2 years in the wild and sexually mature at 4.5 months. The ones with the skin cancer gene can develop melanomas at about 7 months and die a few months later.

“Melanoma formation cuts the reproductive life cycle in half,” Fernandez said. “It has a huge cost for males.”

But during the few months when the male is sexually mature and healthy, he also can produce a lot of offspring, he noted.

The swordtail melanoma has been studied since the 1920s, and scientists previously believed that fish developed the cancer only in captivity. But in the recent study, 10 percent of the swordtails collected from the third population in Mexico also exhibited the disease, said Fernandez, who joins the University of Texas M.D. Anderson Cancer Center this fall as a postdoctoral fellow. He hopes to conduct further studies on the habitat, such as whether stronger exposure to the sun’s UV rays might be driving more instances of skin cancer in the wild.

The study was funded by a National Institutes of Health Research Service Award predoctoral fellowship to Fernandez and a National Science Foundation grant to Morris. Morris is a member of Ohio University’s Ohio Center for Ecology and Evolutionary Studies.

Image Caption: Swordtail fish can develop a dark, pigmented melanoma on their tails. Photos by: Andre Fernandez, Ohio University

On the Net:

Cleveland Clinic Launches Fully Dedicated International Comprehensive Critical Care Program

CLEVELAND, Aug. 21 /PRNewswire/ — Cleveland Clinic has launched a comprehensive critical care program that provides specialized care by Cleveland Clinic physicians, nurse practitioners and critical care nurses to domestic and international patients through means of mobile intensive care unit, helicopter and fixed-wing jets.

With the launch of this program, Cleveland Clinic can now provide specialized critical care services to an expanded population, allowing patients access to superior medical care from bedside to bedside, no matter their location. Each mission is staffed with tremendous flexibility, dictated by the special needs of each patient.

“Cleveland Clinic continues to put patients first. This expansion allows the initiation of Cleveland Clinic care upon the arrival of our teams and ensures the highest quality of service world wide,” said Marc Harrison, M.D., Director of Medical Operations and Associate Chief of Staff, Cleveland Clinic. “While in the air, our team has the full complement of Cleveland Clinic expertise at its disposal via direct communication with the Clinic or back to the referring physician. We provide a seamless transition of care and on-scene initiation of Cleveland Clinic treatment.”

The program will offer uninterrupted service for patients via a diverse fleet of vehicles including ground ambulance, helicopter, and two fixed-winged jets. The jets are outfitted to provide comprehensive intensive care during intercontinental transports.

The jets are configurable for virtually every critical care scenario including mechanical ventilation, balloon pump and ECMO. This provides Cleveland Clinic the flexibility of transporting a wide variety of cases from a premature infant to an adult on a heart lung machine. The clinical expertise of the team, coupled with the technology, makes it possible to transport patients who normally would not have the opportunity to travel due to the extreme severity of their condition.

“As one of the leading healthcare institutions in the world it is our responsibility to share our resources with others,” said Christopher Manacci, MSN, ACNP, Emergency Services Institute. “This expansion brings Cleveland Clinic care to a patient’s bedside worldwide. It is an advanced practice model that is designed to meet the needs of the patient, not one in which the patient must meet the needs of the system. Furthermore, the addition will broaden the resources that will be available for a global response.”

The fleet will be stored at Cleveland Clinic with the exception of the two Beechjet 400 medical aircrafts, which will be based at Cleveland’s Burke Lakefront Airport. Cleveland Clinic has partnered with AirMed internationally for aviation and logistical support. AirMed will provide the fixed-wing aircraft, as well as the flight and maintenance personnel for the Cleveland Clinic program.

About Cleveland Clinic

Cleveland Clinic, located in Cleveland, Ohio, is a not-for-profit multispecialty academic medical center that integrates clinical and hospital care with research and education. Cleveland Clinic was founded in 1921 by four renowned physicians with a vision of providing outstanding patient care based upon the principles of cooperation, compassion and innovation. U.S. News & World Report consistently names Cleveland Clinic as one of the nation’s best hospitals in its annual “America’s Best Hospitals” survey. Approximately 1,500 full-time salaried physicians at Cleveland Clinic and Cleveland Clinic Florida represent more than 100 medical specialties and subspecialties. In 2005, there were 2.9 million outpatient visits to Cleveland Clinic. Patients came for treatment from every state and from more than 80 countries. There were nearly 54,000 hospital admissions to Cleveland Clinic in 2005. For more information, visit http://www.clevelandclinic.org/.

About AirMed International

AirMed International is the country’s leading air ambulance service, offering unparalleled medical care and bedside-to-bedside transportation on a worldwide basis. AirMed flies more than 2,000 transport missions each year and manages the fixed-wing operations for two of the nation’s top hospitals. With company-wide CAMTS accreditation, AirMed is a preferred carrier for the U.S. Department of Defense and operates a fleet of medically dedicated fixed-wing aircraft from its headquarters in Birmingham, Alabama. AirMed has additional bases in Honolulu, Hawaii, Rochester, Minnesota, and an international base in Hong Kong. AirMed is the 2007 recipient of the prestigious “Air Ambulance Provider of the Year,” an international award recognizing industry excellence on a global scale. For more information, visit http://www.airmed.com/.

Cleveland Clinic

CONTACT: Eileen Sheil, +1-216-444-8927, [email protected], or Erinne Dyer,+1-216-444-8168, [email protected], both of Cleveland Clinic

Web site: http://www.clevelandclinic.org/http://www.airmed.com/

Taos Campus Looks to Sun for Power

By STACI MATLOCK

State’s largest photovoltaic project a ‘community effort’

By Staci Matlock

The New Mexican

The University of New Mexico campus in Taos is going solar with the largest photovoltaic system in the state.

Kit Carson Electric Cooperative, UNM officials and others held a groundbreaking Wednesday afternoon for the 500-kilowatt solar panel system. It is part of a planned 1.1-megawatt photovoltaic ground- mounted system distributed among several sites and all tied into the conventional electric grid. “Kit Carson will act as the battery for when the sun doesn’t shine,” said Luis Reyes, Kit Carson’s chief executive officer.

Of the project’s remaining 600 kilowatts, 150 kilowatts will be installed at Kit Carson Corp. facilities, 100 at KTAO, the Taos solar radio station, and the balance, 350 kilowatts, will be built at Northern New Mexico College’s El Rito Campus. Any excess power generated will be fed back into the grid and available to other customers.

One megawatt can power between 500 and 600 homes a year.

The project requires

7,040 solar panels, each measuring 2 feet by 4 feet, Reyes said. Engineering for the UNM portion will be finished next week, and construction will take about eight weeks, he said. He said the engineering, design and construction contract with California-based American Capital Energy calls for 75 percent of the entire photovoltaic project to be completed by the end of the year and the rest in January.

Kit Carson Electric serves more than 25,000 customers in Colfax, Rio Arriba and Taos counties.

Reyes said the solar project has been a “real community effort.” Kit Carson’s members wanted more renewable energy, but they wanted production close to home, he said. “Buying wind power from Kansas didn’t make sense,” Reyes said. “Solar seemed like the best option.”

Los Alamos National Laboratory and Sandia National Laboratories helped the cooperative identify the best kind of photovoltaic system.

Kit Carson was the only New Mexico cooperative to apply for and receive a $5 million Clean and Renewable Energy bond issued by the federal Internal Revenue Service. The money helped purchase the solar panels and will pay other construction costs upfront, which will reduce the cost of the solar electricity.

Reyes said Kit Carson customers pay about 11.5 cents per kilowatt- hour of power. But he said that amount will continue going up as the costs of fossil fuels rise. Under the 20-year agreement Kit Carson signed with American Capital Energy, the cost of the solar power will stay at 16 cents to 18 cents per kilowatt-hour.

“We think by 2015 that conventional power will be more expensive than solar,” Reyes said. “We have in essence fixed our costs at 16 cents per kilowatt-hour for 20 years.”

Kit Carson hopes the project will be a model for how other rural electric cooperatives can switch to renewable energy economically.

As not-for-profits, cooperatives don’t benefit from any solar- tax incentives and must look for other ways to pay upfront costs.

Kit Carson Electric Cooperative is one of 13 member-owned electric cooperatives serving rural New Mexico communities. It receives power from Tri-State Generation and Transmission based in Denver.

Contact Staci Matlock at 470-9843 or [email protected].

(c) 2008 The Santa Fe New Mexican. Provided by ProQuest LLC. All rights Reserved.

It Was Mistake: Skydiver Who Cheated Death

By VICTORIA O’HARA

A NORTHERN Ireland man who cheated death after plummeting to earth when a skydive in America went wrong has revealed how messages of support have given him strength to recover.

Paul McMahon suffered multiple injuries after hitting the ground from over 100 feet during a jump in California two weeks ago. He smashed both legs, crushed his pelvis and lost six pints of blood.

Paul, from Castlederg in Co Tyrone, lay unconscious in hospital for three days on a life support machine after the accident.

Towards the end of the skydive the parachute twisted and turned.

“All I remember was once I hit the ground people were running around me,” he said.

“I knew then that I must have been seriously injured as they had phoned for the ambulance. I knew I had a lot of pain in my legs.

“My memories are a bit sketchy after that. I remember feeling a lot of pain while in hospital in America.”

Paul, an experienced skydiver, said he had been looking forward to the jump.

“I was heading towards my 100th jump, that was my 97th,” he said.

“I was looking forward to it, and had spent a lot getting over to America to do it.

“I wouldn’t say it was a miracle (I survived), it was more of a mistake, but I don’t think I will ever get back in a plane to skydive.”

Paul is now in the Royal Victoria Hospital and has so far undergone three operations.

He faces at least another four weeks in the RVH and months of rehabilitation.

“I would like to be transferred to Altnagelvin soon. It would be closer to family and friends, it is hard for them to come and visit as much as they would like.”

He said the many messages of support from across the world has helped him stay positive.

“I just want to thank everyone for their letters, cards, prayers and messages of support. And all the people who visit, they have given me strength.”

Father Victor (60), who makes the 90-mile journey to his son’s bedside, said he’s hopeful for his full recovery.

“We are just thankful he is with us. We would like to have Paul transferred to Altnagelvin as all the travelling to Belfast is hard. There are nights when I have just stayed overnight, rather than travel the 90 miles.

“It has been tough, Paul’s mum has recently been diagnosed with cancer and is currently undergoing chemotherapy, but we are all just trying to stay positive and looking to the future.”

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

“It’s About How You LIVE – In Faith” – New Resources Enhance Hospice Community’s Support for Spiritual Care

“It’s About How You LIVE – In Faith,” materials are now available free of charge from Caring Connections, an initiative of the National Hospice and Palliative Care Organization. These resources help hospices and faith communities support people living with a serious illness and their family caregivers.

New research released this week affirms the hospice approach of recognizing faith as an important issue for people faced with serious illness or impending death. The importance of well informed healthcare professionals and clear understandings about care at the end of life must also be available to patients and families notes the National Hospice and Palliative Care Organization.

“Hospice has always placed importance on the spiritual needs of the patients and families they serve and spiritual care is an integral component of the hospice philosophy of care,” said J. Donald Schumacher, NHPCO president and CEO.

Newly available materials include the “It’s About How You LIVE – In Faith Outreach Guide” and the consumer brochure, “Offering Spiritual Support for Family or Friends.”

The Outreach Guide offers key strategies to help hospice and palliative care providers and coalitions with:

— Building partnerships with faith communities in their area,

— Examples of successful model programs,

— Practical resources to help develop faith community outreach and initiatives.

Created in collaboration with the Duke Institute on Care at the End of Life and Project Compassion, the guide is non-denominational and is intended to help hospices and coalitions reach out across traditional religious and cultural lines.

A recent survey of professional clergy and lay leaders by the Duke Institute on Care at the End of Life indicates that many faith community leaders do not have the knowledge, resources and support they need to care for people during this important time of life. For example:

— Though 90 percent of clergy report visiting with people at the end of life, only 60 percent describe themselves as “very comfortable” making these visits;

— Fewer than 40 percent of leaders surveyed feel comfortable training lay people to offer support for others;

— Fewer than 20 percent of respondents offer any education related to serious illness, caregiving, end of life, or grief.

Questions about meaning, purpose, guilt, forgiveness, healing and hope are common to those struggling with illness and end-of-life care. Many people turn to their faith community or reestablish contact with religious traditions when faced with a serious or life-limiting illness. For more than 30 years, hospices have helped the dying and their family caregivers with such issues. Working collaboratively with neighboring faith communities can be a valuable source of support for families.

“A shared concern for spiritual care creates a natural connection among hospices, coalitions and faith communities and a common ground for education, dialogue and partnership,” Schumacher added. “These resources from Caring Connections will help providers respond more effectively to patients and families coping with the serious illness or death of a loved one.”

Materials may be downloaded free of charge at Caring Connection’s Web site, www.caringinfo.org/faith. Questions may be directed to the HelpLine at 1-800-658-8898.

Caring Connections, program of the National Hospice and Palliative Care Organization, is a national consumer and community engagement initiative to improve care at the end of life, supported by a grant from The Robert Wood Johnson Foundation, Princeton, NJ. Caring Connections provides free resources and information that address end-of-life issues such as advance care planning, serious illness, caregiving, grief and more. www.caringinfo.org.

Duke Institute for Care at the End of Life is a catalyst for growth and transformation, a global resource to improve care for those at life’s end. The mission of the Institute is to create and promote the growth of knowledge and to encourage the application of that knowledge in caring for the whole person at life’s end. www.iceol.duke.edu.

Project Compassion provides support for people living with serious illness, care giving, end of life and grief. Project Compassion helps people have the resources, support, and hope they need to live life to the fullest every day. www.project-compassion.org.

Atlanta-Based North Star Health, Inc. Signs Partnership Deal With Jack Hughston Memorial Hospital

ATLANTA, Aug. 21 /PRNewswire/ — North Star Health, a health care data analytics company, recently signed Jack Hughston Memorial Hospital and The Hughston Clinic as implementation and development partners.

“We are excited about our partnership with North Star Health and look forward to providing our employees with the ability to control their own healthcare costs by their active participation in Lumina(TM). Jack Hughston Memorial Hospital is quality and customer service driven and we believe that healthier and happier employees will help us provide the kind of care that we want to be known for,” said James L. Matney, Chief Executive Officer, Jack Hughston Memorial Hospital.

Lumina(TM), the cost and care management program developed by North Star Health, integrates wellness, preventive health, disease management and predictive health functionalities into one platform. Designed for both employer and employee use by separate online portals, the program identifies risk factors associated with some of the most costly chronic disease states such as diabetes and heart disease. It then tracks and alerts the individual to seek medical attention based on nationally recognized preventive health guidelines.

“In order for Jack Hughston Memorial Hospital and The Hughston Clinic to operate at maximum profitability, we needed a system to provide us with management level visibility into our health plan expenditures. Lumina(TM) gives us the ability to analyze, predict and manage our healthcare spending while encouraging the employee to participate in their own personal wellness,” said Mark Baker, Chief Operating Officer of The Hughston Clinic. Based on a dual-option plan design, members who comply with preventive care guidelines throughout the year are rewarded with enrollment in the lower-cost plan option, Healthy Choice.

According to Dr. Paul Davis, CEO of North Star Health, “We are very excited about our partnership with Jack Hughston Memorial Hospital and The Hughston Clinic. Both Entities understand the importance of early intervention as it relates to chronic diseases. Lumina(TM) will empower the hospital and clinic to identify, manage, and in some cases actually prevent the occurrence of a chronic illness. According to Ken Thorpe, PhD – National Healthcare Policy Expert / Economist and Advisory Board Member for North Star Health, the top 15 chronic diseases in America account for 75% of the overall health care dollar. Using the North Star Health Lumina(TM) system, I believe, can impact this number greatly.”

ABOUT JACK HUGHSTON MEMORIAL HOSPITAL

Located in Phenix City, Ala., the Jack Hughston Memorial Hospital (http://www.jackhughstonmemorialhospital.com/) is an 110,000-square-foot facility with 62 private patient rooms. Opened in August 2006, the facility is a general hospital providing a wide array of services such as a Surgery Department with outpatient, endoscopy and orthopaedics; and a Diagnostic Imaging Department with ultrasound, MRI and 64-Slice CT Scanner, one of the few scanners of its kind in the region. The hospital features wireless Internet access, 27-inch flat screen televisions in each patient room, a dining hall with outdoor terrace, and floor-to-ceiling windows providing natural light. The hospital received a National Pyramid Award in 2006 from the Associated Builders & Contractors for excellence in design and construction of a healthcare facility.

ABOUT THE HUGHSTON CLINIC

Based in Columbus, Ga., The Hughston Clinic (http://www.hughston.com/) is a full-service orthopaedic practice with nine offices in Georgia and Alabama. Founded in 1949 by Dr. Jack C. Hughston, The Hughston Clinic is a nationally and internationally recognized center of excellence for research, education, training, and the quality treatment of musculoskeletal injury and disease. Other facilities and services located on the campus of The Hughston Clinic in Columbus include The Hughston Foundation Inc., the Hughston Health Center, Hughston Rehabilitation, and Hughston Diagnostics.

ABOUT NORTH STAR HEALTH

Based in Atlanta, Georgia, North Star Health (http://www.northstarhealth.com/) is a health care data analytics company providing risk, cost, and care-management solutions for health plans, TPAs, brokers, self-insured companies, wellness companies, disease management companies, provider networks, and benefits consulting groups. Lumina(TM) from North Star Health integrates wellness, preventive health, disease management and predictive health functionalities into one platform. It was developed in conjunction with a nationally recognized health care policy expert and economist, Dr. Ken E. Thorpe.

North Star Health

CONTACT: Sherry Farrugia, North Star Health, Inc., +1-404-419-2102,Fax: +1-404-419-2101, [email protected]

Web site: http://www.northstarhealth.com/http://www.hughston.com/http://www.jackhughstonmemorialhospital.com/

Shingles Pain Treatment Will Benefit More Patients

LONDON, August 21 /PRNewswire/ — The medicated pain relief plaster, (Versatis) is now approved by the Scottish Medicines Consortium (SMC) for restricted use within NHS Scotland for patients suffering pain following shingles(1) http://www.scottishmedicines.org.uk/smc/5850.html. This reversal of the previous SMC decision (issued in February 2007) for Versatis (5% lidocaine medicated plaster) is based on significant new clinical and cost-effectiveness comparative data and brings prescribing availability of the treatment in line with England and Wales. These new data on Versatis will be presented for the first time at the International Association for the Study of Pain (IASP) Congress in Glasgow (17-22 August 2008).

The pain that persists for more than three months after the onset of the shingles rash is called Post-herpetic Neuralgia (PHN) (2). PHN affects approximately 200,000 people in the UK(3). PHN can be described as an incessant burning, stabbing or shooting pain. The pain can start several weeks or even months after the shingles rash has gone and can continue for weeks, months or years(4).

Licensed in the UK in 2007, Versatis offers sustained pain relief associated with PHN(5). Versatis is an innovative combination of local analgesic lidocaine and a soft hydrogel plaster. Application of the plaster to the skin releases an appropriate level of lidocaine into the skin to impair the transfer of signals which would be associated with the perception of pain.

Based on clinical trial data, Versatis is used as a continuous once-daily 12 hours on/12 hours off application schedule for 2-4 weeks and provides rapid and continuous pain relief from 30 minutes after application(6).

Dr Michael Serpell, Consultant and Senior Lecturer in Anaesthesia, Glasgow says: “The new recommendation from the SMC is to be welcomed. New data supporting the role of Versatis in post-herpetic neuralgia will further establish that such a novel, non-systemic treatment approach offers significant benefits in the older patient group who suffer co-morbidities and consequential polypharmacy”.

Heather Wallace, Chairman of Pain Concern commented: “The SMC is to be congratulated on its revised decision for Versatis. They’ve taken a huge step forward in extending options for pain relief for people living with neuropathic pain. This decision will alleviate a lot of suffering”.

The risk of developing PHN increases with age – it is most common in people aged over 50. About half of shingles cases affecting people of the age of 65 will cause PHN(7,8).

Prescribing Information

Versatis 5% medicated plaster. Refer to the Summary of Product Characteristics (SPC) for full details on side effects, warnings and contra-indications before prescribing. Presentation: Versatis is a medicated plaster (10cm x 14cm) containing 700 mg (5% w/w) of lidocaine in an aqueous adhesive base. Indication: Treatment of neuropathic pain associated with previous herpes zoster infection (post-herpetic neuralgia, PHN). Dosage and method of administration: Adults and elderly patients: Use up to three plasters for up to 12 hours, followed by at least a 12 hour plaster-free interval. Cover painful area once daily. Apply the plaster to intact, dry, non-irritated skin (after healing of the shingles). Remove hairs in affected area with scissors (do not shave). Remove the plaster from sachet and its surface liner before applying immediately to the skin. Plasters may be cut to size. Patients under 18 years: Not recommended. Contra-indications: Hypersensitivity to active substance, any excipients, or local anaesthetics of amide type (e.g. bupivacaine, etidocaine, mepivacaine and prilocaine). Warnings and precautions: Do not apply to inflamed or injured skin (e.g. active herpes zoster lesions, atopic dermatitis or wounds), mucous membranes or the eyes. Plasters contain propylene glycol which may cause skin irritation, methyl parahydroxybenzoate and propyl parahydroxybenzoate which may cause allergic reactions. Use with caution in patients with severe cardiac impairment, severe renal impairment or severe hepatic impairment. Interactions: No clinically relevant interactions have been observed in clinical studies. Absorption of lidocaine from the skin is low. Use with caution in patients receiving Class I antiarrhythmic drugs (e.g. tocainide, mexiletine) or other local anaesthetics. Pregnancy and lactation: Do not use during pregnancy or breast-feeding. Undesirable effects: Very common (greater than or equal to 10%): administration site reactions (e.g. erythema, rash, pruritus, burning). Uncommon (>0.1%-less than or equal to 1%): skin injury, skin lesion. Very rare (less than or equal to 0.01%) but potentially serious: anaphylaxis, hypersensitivity. Adverse reactions were predominantly of mild and moderate intensity. Systemic adverse reactions are unlikely. See SPC for full details. Overdose: Unlikely. If suspected, remove plasters, provide supportive treatment (see SPC). Legal classification: POM. Marketing Authorisation number, pack sizes and basic NHS cost: PL 21727/0016, 30 plasters (GBP 72.40). Marketing Authorisation Holder: Grunenthal Ltd, Regus Lakeside House, 1 Furzeground Way, Stockley Park East, Uxbridge, Middlesex, UB11 1BD, UK. Date of text: June 2008. V0138

Information about adverse event reporting can be found at: http://www.yellowcard.gov.uk/

           Adverse events should also be reported to Grunenthal Ltd                         (telephone +44(0)870-351-8960)     References:    1) Scottish Medicines Consortium, NHS Scotland, website:   http://www.scottishmedicines.org.uk/smc/5850.html    2) Cunningham, A. and Dworkin, R. (2000) The Management of   post-herpetic neuralgia. BMJ 321, 778-779    3) Shingles Support Society. Bowsher D. Treatment of post-herpetic   neuralgia in the elderly. Available at:   http://www.herpes.org.uk/shingles/index.html    4) Herpes Viruses Association. Available at: http://www.herpes.org.uk/    5) Versatis Summary of Product Characteristics    6) Baron R et al. Abstract presented at the Congress of the   European Federation of IASP Chapter, Istanbul 2006    7) Shingles Support Society. Bowsher D. Treatment of post-herpetic   neuralgia in the elderly. Available at:   http://www.herpes.org.uk/shingles/index.html    8) http://cks.library.nhs.uk/patient_information_leaflet/neuralgia     For further information, please contact:  

Janis Troup/Debra Lord at Right Angle Communications: Tel: +44(0)20-8846-3170 or [email protected] or [email protected]

Grunenthal medical information department: Tel: +44(0)870-351-8960 (follow options).

Grunenthal Ltd

CONTACT: For further information, please contact: Janis Troup/DebraLord at Right Angle Communications: Tel: +44(0)20-8846-3170 [email protected] or [email protected]; Grunenthalmedical information department: Tel: +44(0)870-351-8960 (follow options).

Discharge of First U.S. DuraHeart(TM) Patient

ANN ARBOR, Mich., Aug. 21 /PRNewswire/ Terumo Heart, Inc. today announced the discharge of the first U.S. patient implanted with the DuraHeart(TM) Left Ventricular Assist System (LVAS). The patient was discharged home on August 14th, from the University of Michigan Health System, 15 days after receiving the device.

The patient is a 62-year-old man from Livonia, Michigan, who has been suffering from heart failure for nearly 20 years. He is the first U.S. patient to receive a ventricular assist system that utilizes advanced magnetic levitation (Mag-Lev), a new, innovative type of technology.

Dr Pagani, National Co-Principal Investigator for the U.S. pivotal trial of the DuraHeart LVAS commented on the recent discharge. “We are extremely pleased with the performance of the DuraHeart and the recovery of our patient to an excellent functional state to permit discharge. We look forward to expanding upon our early experience with the DuraHeart in the near future.”

The goal of these devices is to return the patient back to a relatively normal lifestyle and to provide improved “quality of life.””We are delighted that the FDA has allowed us to begin this trial with no restriction on patient discharge, which has not been true of some of the other devices currently conducting Trials in the United States,” said Chisato Nojiri, M.D., PhD, Chief Executive Officer for Terumo Heart, Inc.

Earlier generation Left Ventricular Assist devices are prone to hemolysis, blood clots and mechanical failure. Significant advances have been made in the DuraHeart LVAS to potentially overcome these problems. Dr. Nojiri explained: “We have a unique pump design that combines advanced “Mag-Lev” technology and a centrifugal pump. The “Mag-Lev” allows for the complete elimination of mechanical contact within the blood flow path, minimizing the chance of mechanical failure. This is expected to significantly improve the clinical performance and long-term potential of this type of therapy.” It has been used in more than 70 patients in Europe with the longest ongoing support over 3 years.

The DuraHeart Bridge-to-Transplant Pivotal Trial is a multi-center, prospective, non-randomized study of 140 patients and will include up to 40 centers. The device is intended to provide cardiac support for patients awaiting transplant who are at risk of death due to end-stage left ventricular failure. The National Co-Principal Investigators are Francis Pagani, M.D., Ph.D., from the University of Michigan and Yoshifumi Naka, M.D., Ph.D., from Columbia Presbyterian Hospital in New York.

Terumo Heart, Inc. is a US subsidiary of Terumo Corporation with headquarters and manufacturing facilities in Ann Arbor, Michigan. The company’s focus is the innovation and introduction of products to improve the quality of healthcare for heart failure patients. Terumo Corporation, located in Tokyo, Japan, is a leading developer, manufacturer and global marketer of a wide array of medical products.

For more information, please contact Carmen Fox, Senior Marketing Communications Specialist, Terumo Heart, Inc. at (734) 741-6345 or [email protected].

Terumo Heart, Inc.

CONTACT: Carmen Fox, Senior Marketing Communications Specialist, TerumoHeart, Inc., +1-734-741-6345, [email protected]

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

Concord Community News

AMBER WITHAM, daughter of Mel and Barb Witham, graduated from Empire Beauty School in Hooksett.

MARISSA SPLENDORE won a semifinalist spot in the Discovery Channel’s Young Scientist Challenge. Splendore, 11, is a student of Kimball School.

Christopher Dustin,

son of Darrin and Heidi Dustin, will attend St. Michael’s College, where he will major in chemistry. Dustin is a member of the Bishop Brady High School Class of 2008, where he was a member of the National Honor Society and the varsity soccer and varsity lacrosse teams.

RYLEIGH O’KEEFE, 7, won the Junior National Photogenic award at the Dancer’s Inc. National Dance Competition in Portland, Maine. O’Keefe is a second-grader of Conant School.

ANNA BARNWELL, daughter of Julia Emly and Ed Barnwell, was named to the dean’s list for the spring semester at Vanderbilt University in Nashville, Tenn.

ALLISON MORRIS, daughter of J. Morris and D. dePeyster, was named to the dean’s list for the spring semester at Vanderbilt University in Nashville, Tenn.

ANDREW NILES, son of Darwin and Lucinda Niles, was named to the dean’s list for the spring semester at the University of Rochester in New York, where he is a senior majoring in mathematics. Niles is a graduate of Concord High School.

KAYLA SHIRLEY, daughter of Cheryl and Hoke Shirley, was named to the dean’s list for the spring semester at the University of Rochester in New York, where she is a freshman majoring in molecular genetics. Shirley is a graduate of Concord High School.

THOMAS AKEY, son of Marian and D. Thomas Akey, will attend the Rochester (N.Y.) Institute of Technology, where he will major in film and animation. Akey is a member of the Class of 2008 at Concord High School, where he received the Boy’s Lacrosse Boosters Club Scholarship.

REBECCA BAROODY, daughter of Philip and Lia Baroody, will attend Sacred Heart University in Fairfield, Conn. Baroody is a member of the Concord High School Class of 2008.

SARA CROSBY, daughter of Robert and Sally Crosby, earned a bachelor’s degree in political science and international affairs, with a minor in French, magna cum laude, from the University of New Hampshire. Crosby is a 2004 graduate of Concord High School.

DANIEL MASTERS earned a bachelor’s degree in electrical engineering, cum laude, from Drexel University in Philadelphia. Masters is a 2003 graduate of Concord High School.

ELIZA COOLEY will attend American University in Washington, D.C. Cooley is a graduate of the Holderness School.

SENIOR HEALTH CLINICS: The Concord Regional Visiting Nurse Association will offer senior health clinics today from 9 a.m. to 3 p.m. at St. Paul’s Church Outreach Center and from 9 a.m. to 3 p.m. at Horseshoe Pond. The cost is $10. For more information, call 224- 4093.

THE CHRISTA MCAULIFFE PLANETARIUM will offer “Earth Attacks! A History of Martian Exploration,” tomorrow from 7 to 8 p.m. The cost is $8, $5 for children 12 and younger; $7 for students older than 12 and seniors, free for members. For information, call 271-7831.

STUDENT PACKETS: Concord High School 2008-09 student packets will be available for pick up today from 7 a.m. to 7 p.m. and tomorrow from 7 a.m. to 3 p.m. at the main office.

NEW AND RETURNING STUDENTS of Rundlett Middle School may pick up their packets today from noon to 5 p.m. and tomorrow from 7 to 11 a.m.

THE COMMUNITY PLAYERS OF CONCORD will hold their third annual Kick-off-the-Season potluck pool party Saturday at 2 p.m. at 260 River Road in Epsom. Grills will be provided. For more information or directions, call Betty and David Lents at 736-4716.

HOSPICE VOLUNTEER TRAINING: Concord Regional Visiting Nurse Association will offer a 10-week hospice volunteer training Tuesdays from Sept. 9 through Dec. 2 from 6 to 8 p.m. at Harris Hill Center, 20 Maitland St. The volunteer application deadline is Wednesday. For information, call 224-4093.

AFTER SCHOOL PROGRAM OPENINGS: The Concord Boys & Girls Club is accepting children ages 6 through 12 in its after school program. Fees range from $5 to $50. For more information, call Christine at 224-1061.

Originally published by Monitor staff.

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

Ardea Biosciences Advances Lead Product Candidate for the Treatment of Gout, RDEA594, Into Phase 1 Clinical Trial

SAN DIEGO, Aug. 21 /PRNewswire-FirstCall/ — Ardea Biosciences, Inc. today announced that the Medicines and Healthcare products Regulatory Agency (MHRA) in the United Kingdom has authorized a Phase 1 study evaluating RDEA594 in normal healthy volunteers. RDEA594 is the Company’s lead product candidate for the treatment of gout.

“Regulatory clearance for us to proceed with our Phase 1 study of RDEA594, within six months from designation as a clinical candidate is a testament to the efficiency of our development organization, and the importance we place on our gout program — a program we intend to expand with second-generation compounds from our exciting ongoing research in this area,” said Barry D. Quart, PharmD, Ardea Biosciences’ President and CEO. “Earlier this quarter, we initiated a Phase 2a proof-of-concept study of RDEA806, a prodrug of RDEA594, which should allow us to provide an early confirmation of RDEA594’s activity in the target population of patients with gout.”

This Phase 1, randomized, double-blind, placebo-controlled trial will evaluate the safety, tolerability, pharmacokinetics and uric acid lowering effects of single ascending oral doses of RDEA594 in healthy adult male volunteers.

About Gout

An estimated 3-5 million people in the United States, and approximately 5 million people in the European Union, suffer from gout, which is the most common form of inflammatory arthritis in men over 40. Gout, also known as metabolic arthritis, is a painful and debilitating disease caused by abnormally elevated levels of uric acid in the blood stream. These abnormally elevated levels lead to the deposition of uric acid crystals in and around the connective tissue of the joints and in the kidneys, leading to inflammation, the formation of disfiguring nodules (tophi), intermittent attacks of severe pain (acute flares), and kidney damage (nephropathy). While gout is a treatable condition, there are limited treatment options and a number of adverse effects are associated with current therapies. No new therapies have been approved by the FDA for the treatment of hyperuricemia associated with gout in the past 40 years

About RDEA594

RDEA594, our lead product candidate for the treatment of gout, is a major metabolite of RDEA806, our lead non-nucleoside reverse transcriptase inhibitor (NNRTI) in clinical development for the treatment of HIV. RDEA594 does not have antiviral activity and is believed to be responsible for the uric acid-lowering effects observed following administration of RDEA806 to over 100 subjects in Phase 1 and Phase 2 clinical trials. In Phase 1 studies of RDEA806 in normal healthy volunteers, increased urinary excretion of uric acid was observed in the first 24 hours after dosing, with statistically significant, exposure-dependent, decreases in serum uric acid of 35% to 50% observed during multiple dosing out to 14 days.

About RDEA806

RDEA806 is a novel NNRTI for the potential treatment of HIV infection. Based on preclinical and clinical studies to date, we believe that RDEA806 may have important competitive advantages compared to currently available NNRTIs. These include the potential for potent antiviral activity against a wide range of HIV viral isolates, including those that are resistant to efavirenz (Sustiva(R)) and other currently available NNRTIs; a high genetic barrier to resistance; limited pharmacokinetic interactions with other drugs; no reproductive toxicity based on animal studies; and the potential to be readily co-formulated in a single pill with other HIV antiviral drugs, such as Truvada(R) (emtricitabine and tenofovir) from Gilead Sciences, Inc, which is important for patient compliance.

About Ardea Biosciences, Inc.

Ardea Biosciences, Inc., of San Diego, California, is a biotechnology company focused on the discovery and development of small-molecule therapeutics for the treatment of HIV, gout, cancer and inflammatory diseases. We have five product candidates in clinical trials and others in preclinical development and discovery. Our most advanced product candidate is RDEA806, an NNRTI, which has successfully completed a Phase 2a study for the treatment of patients with HIV. We have evaluated our second-generation NNRTI for the treatment of HIV, RDEA427, in a human micro-dose pharmacokinetic study and have selected it for clinical development. RDEA594, our lead product candidate for the treatment of gout, is being evaluated in a Phase 1 study. We are currently evaluating our lead MEK inhibitor, RDEA119, in a Phase 1 study in advanced cancer patients, and have completed a Phase 1 study in normal healthy volunteers as a precursor to trials in patients with inflammatory diseases. Lastly, we have evaluated our second-generation MEK inhibitor for the treatment of cancer and inflammatory diseases, RDEA436, in a human micro-dose pharmacokinetic study and have selected it for clinical development.

Statements contained in this press release regarding matters that are not historical facts are “forward-looking statements” within the meaning of the Private Securities Litigation Reform Act of 1995. Because such statements are subject to risks and uncertainties, actual results may differ materially from those expressed or implied by such forward-looking statements. Such statements include, but are not limited to, statements regarding our goals, including the expected properties and benefits of RDEA806, RDEA427, RDEA594, RDEA119, RDEA436 and our other compounds and the results of preclinical, clinical and other studies. Risks that contribute to the uncertain nature of the forward-looking statements include: risks related to the outcome of preclinical and clinical studies, risks related to regulatory approvals, delays in commencement of preclinical and clinical studies, and costs associated with our drug discovery and development programs and business development activities. These and other risks and uncertainties are described more fully in our most recently filed SEC documents, including our Annual Report on Form 10-K and our Quarterly Reports on Form 10-Q, under the headings “Risk Factors.” All forward-looking statements contained in this press release speak only as of the date on which they were made. We undertake no obligation to update such statements to reflect events that occur or circumstances that exist after the date on which they were made.

Ardea Biosciences, Inc.

CONTACT: Investors, John Beck of Ardea Biosciences, Inc.,+1-858-652-6523, [email protected]; or Media, Edie DeVine of WeissCommPartners, +1-415-946-1081, [email protected], for Ardea Biosciences, Inc.

Telemedicine Expanding in Rural Wyo. Areas

By Michelle Dynes

At least 36 places in the state are connected to video conferencing so that patients can communicate with physicians.

By Michelle Dynes

[email protected]

CHEYENNE – Technology is changing the way patients interact with their doctors.

The congressional interest in telemedicine is at an all-time high, said Jonathan Linkous, CEO of the American Telemedicine Association. He updated state health-care leaders on the progress of telehealth from his office in Washington, D.C. during a statewide video conference Thursday.

The teleconference connected 14 Wyoming hospitals, including Cheyenne Regional Medical Center, as experts used the equipment to discuss the expansion of telemedicine services. The equipment allows patients and physicians to interact as if they were in the same medical room even though they might be hundreds of miles apart.

Linkous said Congress approved a Medicare bill to expand telecommunications in rural areas like Wyoming, where health-care services are scattered.

Local experts say the move makes sense.

Rex Gantenbein, director of the Center for Rural Health Research and Education at the University of Wyoming, said he first encountered telemedicine in the mid-1990s. He worked with a health monitoring program connected with astronauts on the Mir Space Station and thought if the technology could provide health care to patients orbiting the planet, there was no reason it couldn’t work in Wyoming.

Today 16 sites are connected with live interactive video conferencing, said Dana Barnett, director of Outreach Services at CRMC. Another 20 sites have computers connected to streaming video.

“At least 36 sites are connected,” he added. “(Because of) the rural and frontier nature of our state, video conferencing made a lot of sense.”

Hospital staff first used the equipment to host administrative meetings and educational sessions. But earlier this year, CRMC provided a video conference link to the Shriners Hospital for Children in Salt Lake City. Next month, a local urologist will use the technology to follow up with surgery patients.

Telemedicine saves patients from making an extra trip to a distant hospital. It also saves money for the hospitals. Lessons are completed on site instead of losing a staff member for several days because of training. For example, the equipment was used to connect state nurses to a program through the University of Washington without spending any money for travel expenses, Barnett said.

Gantenbein said bandwidth is the main barrier to expanding the network. But last year, the Federal Communications Commission selected Wyoming as one of 69 nationwide projects to improving health telecommunications. The state collected about $850,000 to install telecommunications services throughout Wyoming.

He added that UW will act as a contractor for the project, selecting a vendor in January. The statewide network is scheduled for completion in June 2010.

(c) 2008 Wyoming Tribune-Eagle. Provided by ProQuest LLC. All rights Reserved.

Former Weight Watchers Group Leader Suing Company, Alleging Food It Sells May Be Killing You

WHITE PLAINS, N.Y., Aug. 21 /PRNewswire/ — Weight Watchers, the leader in the multi-billion dollar weight loss industry, may in fact assist in weight loss but at what cost? Regina Nathe, in an unprecedented lawsuit commenced in the United States District Court for the Southern District of New York (Regina Nathe v. Weight Watchers International, Inc., Docket No.: 06-CV-0415 LTS/DFE), has sued Weight Watchers alleging that the food it sells as a part of its overall healthy lifestyle may in fact being killing you; she should know because she was employed by Weight Watchers as a group leader for nineteen years and is an expert in nutrition. Weight Watchers immediately moved to dismiss the lawsuit but the motion was denied and the Judge allowed the case to proceed. Weight Watchers, Ms. Nathe alleges, has misled its customers through promotions, brochures, press releases and on its website into believing that its snack foods are healthy and will result in weight loss when in fact the food contains trans fats, partially hydrogenated oils and high fructose corn syrup all of which are confirmed to cause health problems including cancer, high blood pressure and death. Trans fats are so harmful to humans that the State of California has recently banned them; other states are sure to follow. In fact, as a result of the lawsuit, Weight Watchers itself has stopped using Trans fats in its products. The lawsuit is scheduled to go to trial early next year.

Danzig Fishman & Decea

CONTACT: Thomas Decea, Danzig Fishman & Decea, Attorneys at Law,+1-914-285-1400

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

VIDAZA(R) Receives Expanded FDA Approval to Include Overall Survival in Higher-Risk MDS

Celgene Corporation (Nasdaq:CELG) today announced VIDAZA (azacitidine) received expanded U.S. Food and Drug Administration (FDA) approval to reflect new overall survival achieved in the AZA-001 survival study of patients with higher-risk myelodysplastic syndromes (MDS). This expanded indication supplements the 2004 FDA authorization of VIDAZA as the first therapy approved in the U.S. for the treatment of patients with all five French American British (FAB) subtypes of MDS. VIDAZA is also the first and only drug to show a statistically significant and clinically meaningful extension of survival in higher-risk MDS patients.

“The overall survival detailed in the expanded FDA approval of VIDAZA is extremely important for patients with higher-risk MDS, a group with limited options and median survival of about 15 months with classical treatments,” said Pierre Fenaux, M.D., Ph.D. of the Universite of Paris and lead investigator of the AZA-011 survival trial. “VIDAZA, however, is also effective across a broad range of MDS subgroups, including WHO-classified AML patients, the largest subgroup in our study.”

The approval is based upon the significant improvement in overall survival achieved in the VIDAZA survival trial (AZA-001), the largest, international randomized Phase III controlled study ever conducted in higher-risk MDS. The median overall survival for patients treated with VIDAZA in the study was 24.5 months compared to 15 months for conventional care regimens (CCR), demonstrating a survival benefit of over 9 additional months with a stratified log-rank p-value of 0.0001. The hazard ratio describing this treatment effect was 0.58 (95 percent confidence interval of 0.43 to 0.77). The extension of survival was seen across the relevant patient subgroups including those greater than 65 years, as well as poorer prognostic groups such as those with World Health Organization (WHO) classified acute myelogenous leukemia (AML), which formed 31 percent of the enrolled patients, and patients with poor risk cytogenics. In the trial, the two-year survival rate for patients with higher-risk MDS treated with VIDAZA was almost doubled with 50.8 percent compared to 26.2 percent for CCR. Patients treated with VIDAZA received treatment for a median of nine cycles.

“The clinical data from this randomized Phase III controlled study demonstrated that patients with higher-risk MDS treated with VIDAZA benefit from a significant survival advantage, a critical measure of a drug’s effectiveness,” said Lewis Silverman, M.D., of the Mount Sinai Medical Center in New York City. Dr. Silverman was the lead author and Principal Investigator for the original VIDAZA approval study (CALGB 9221) and an author and investigator of the international AZA-001 survival trial. “Additionally, the efficacy and safety profile of VIDAZA allows for long-term therapy in patients with higher-risk MDS, underscoring the ability to treat until disease progression for optimal survival benefit.”

In the AZA-001 study, the most commonly occurring adverse reactions for patients with higher-risk MDS receiving VIDAZA were thrombocytopenia (69.7%), neutropenia (65.7%) and anemia (51.4%).

“This decision by the FDA reflects the unprecedented survival advantage demonstrated by VIDAZA in patients with higher risk MDS,” said Mohamad A. Hussein, M.D., Global Head, Medical Affairs, Hematology of Celgene, formerly of the H. Lee Moffitt Cancer Center and Research Institute. “VIDAZA is another example of Celgene developing novel therapies for critical blood diseases that are enabling patients to live for years, rather than weeks and months. Today’s decision strengthens our Company’s ability to deliver VIDAZA and our other therapies to patients in need around the world.”

IMPORTANT SAFETY INFORMATION

— VIDAZA is contraindicated in patients with a known hypersensitivity to azacitidine or mannitol and in patients with advanced malignant hepatic tumors.

— In Study 1 (a randomized, open-label, controlled trial carried out in 53 U.S. sites compared the safety and efficacy of subcutaneous VIDAZA plus supportive care with supportive care alone (“observation”) in patients with any of the five FAB subtypes of myelodysplastic syndromes (MDS)) and Study 2 (a multi-center, open-label, single-arm study of 72 patients with RAEB, RAEB-T, CMMoL, or AML), the most commonly occurring adverse reactions by SC route were nausea (70.5%), anemia (69.5%), thrombocytopenia (65.5%), vomiting (54.1%), pyrexia (51.8%), leukopenia (48.2%), diarrhea (36.4%), injection site erythema (35.0%), constipation (33.6%), neutropenia (32.3%), and ecchymosis (30.5%) Other adverse reactions included dizziness (18.6%), chest pain (16.4%), febrile neutropenia (16.4%), myalgia (15.9%), injection site reaction (13.6%), and malaise (10.9%). In Study 3, the most common adverse reactions by IV route also included petechiae (45.8%), weakness (35.4%), rigors (35.4%), and hypokalemia (31.3%).

— In Study 4 (the AZA-001 survival trial), the most commonly occurring adverse reactions were thrombocytopenia (69.7%), neutropenia (65.7%), anemia (51.4%), constipation (50.3%), nausea (48.0%), injection site erythema (42.9%), and pyrexia (30.3%). The most commonly occurring Grade 3/4 adverse reactions were neutropenia (61.1%), thrombocytopenia (58.3%), leukopenia (14.9%), anemia (13.7%) and febrile neutropenia (12.6%).

— Because treatment with VIDAZA is associated with anemia, neutropenia and thrombocytopenia, complete blood counts should be performed as needed to monitor response and toxicity, but at a minimum, prior to each dosing cycle.

— Because azacitidine is potentially hepatotoxic in patients with severe preexisting hepatic impairment, caution is needed in patients with liver disease. In addition, azacitidine and its metabolites are substantially excreted by the kidneys and the risk of toxic reactions to this drug may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, it may be useful to monitor renal function.

— VIDAZA may cause fetal harm when administered to a pregnant woman. Women of childbearing potential should be apprised of the potential hazard to the fetus. Men should be advised not to father a child while receiving VIDAZA.

— Nursing mothers discontinue nursing or the drug, taking into consideration the importance of the drug to the mother.

About VIDAZA

In May 2004, VIDAZA became the first drug approved by the FDA for the treatment of patients with Myelodysplastic Syndromes (MDS). The FDA approved VIDAZA, the first in a new class of drugs called demethylation agents, for treatment of all five MDS subtypes, which include both low-risk and high-risk patients. These MDS FAB subtypes include according to the French American British (FAB classification: refractory anemia (RA) or refractory anemia with ringed sideroblasts (RARS) if accompanied by neutropenia or thrombocytopenia or requiring transfusions; refractory anemia with excess blasts (RAEB), refractory anemia with excess blasts in transformation (RAEB-T), and chronic myelomonocytic leukemia (CMMoL).

About Epigenetics

VIDAZA is an epigenetic compound believed to exert antineoplastic effects by causing hypomethylation of DNA and direct cytotoxicity on abnormal hematopoietic cells in the bone marrow. The concentration of VIDAZA required for maximum inhibition of DNA methylation in-vitro does not cause major suppression of DNA synthesis. Hypomethylation may restore normal function to genes that are critical for differentiation and proliferation. The cytotoxic effects of VIDAZA cause the death of rapidly dividing cells, including cancer cells that are no longer responsive to normal growth control mechanisms. Non- proliferating cells are relatively insensitive to VIDAZA. VIDAZA was approved for IV administration in January 2007.

About Myelodysplastic Syndromes

Myelodysplastic syndromes (MDS) are a group of hematologic malignancies that affect approximately 300,000 people worldwide. Myelodysplastic syndromes occur when blood cells remain in an immature or “blast” stage within the bone marrow and never develop into mature cells capable of performing their necessary functions. Eventually, the bone marrow may be filled with blast cells suppressing normal cell development. According to the American Cancer Society, 10,000 to 20,000 new cases of MDS are diagnosed each year in the United States. Patients with higher risk MDS have a median survival of only approximately 6-12 months. MDS patients must often rely on blood transfusions to manage symptoms of anemia and fatigue and may develop life-threatening iron overload and/or toxicity from frequent transfusions, thus underscoring the critical need for new therapies targeting the cause of the condition rather than simply managing its symptoms.

About Celgene

Celgene Corporation, based in Summit, New Jersey, is an integrated global biopharmaceutical company engaged primarily in the discovery, development and commercialization of novel therapies for the treatment of cancer and inflammatory diseases through gene and protein regulation. For more information, please visit the Company’s website at www.celgene.com.

This release contains certain forward-looking statements which involve known and unknown risks, delays, uncertainties and other factors not under the Company’s control, which may cause actual results, performance or achievements of the Company to be materially different from the results, performance or other expectations implied by these forward-looking statements. These factors include results of current or pending research and development activities, actions by the FDA and other regulatory authorities, and those factors detailed in the Company’s filings with the Securities and Exchange Commission such as Form 10-K, 10-Q and 8-K reports.

Self Hypnosis and the Healing Process

By Marriott, Judith A

Abstract The concept of self-hypnosis as an attitude of mind rather than a state to be induced is discussed with reference to healing; and the role of self-hypnosis in so-called psychic healing is briefly explored. A case history is presented to illustrate the use of self-hypnosis with resulting accelerated healing in a burns case.

The Bible says, “In the beginning God created the heaven and the earth…” In one of the systems of Hindu philosophy it is propounded that in the beginning there were only two principles: briefly translated as the observer and that which is observed. These may be referred to as the Soul and Primordial Matter. The latter possesses no quality of its own but has the potential to take on any kind of form. The Soul on the other hand can only be conscious through matter. The observer gazes upon that which is observed and certain processes are set in motion… consciousness occurs, and then, necessarily ego-awareness and other-awareness…the “I” becomes manifest…and from there layers of illusion to protest the ego. In other words, through a process of involution the subtler principals descend to more gross levels of manifestation, which they both form and support.

However, all is not lost: awareness of the reality of truth still exists on a level of the mind or psyche. For the whole person, the potentiality for perfection and all-knowing exists – it may never manifest in the persons lifetime because of various beliefs, illusions, and delusions about life ranging from mere disinterestedness and closed-mindedness through neuroses and psychoses. All therapy, then, is geared to break through these outer layers in order that the person may see or contact this knowledge, i.e. to bring that which is obscured by the layers of defence or self-suggestion into the light. The basic concept of psychotherapy is, then, to lift that which is unconscious to the conscious, to deal with it, and then, that which was unconscious having been brought to the conscious and dealt with makes way for bringing that which is unconscious to the conscious – through layer after layer after layer, or level upon level. This involves long and tedious work for those who are prepared to attempt it, with no hope of being completed in a person’s lifetime in some cases; or painful but relatively quick if a person is determined and there’s no other way to go, or a revelation that inspires change overnight – like Saul on the road to Damascus.

All levels of a person, if one considers the whole, relate, so by the same token the perfect form exists on the physical level. Kirlian photography (Hagen, 1981) may picture an amputee with the limb still intact i.e. it is gone but not gone – the hypothesis then in phantom limb pain could be not that the limb is not there, but that it is there. Physically of course it is not, it has been removed. But on some level it remains for a while, just as by the same token a broken off part of a living leaf remains. Now presuming there indeed exists on some level a perfect limb, it obviously can’t be re-installed in the flesh – or if it can such a thing is beyond our range of comprehension and would not be a goal to aim for in healing. On the other hand, if the photography is correct, it then should follow that a damaged limb, or organ, or what have you, also exists in its perfect form on that level. And damage can be repaired.

It could be said then, that the real power in healing does not come from a false indoctrination of health – an illusion, but from the ability to actually contact that level and to normalise the problem to see how it works and reverse it. What are we doing in treating a person with hypnosis? It seems a temporary illusion is created. For example, the illusion of being a confident speaker at a Rotary meeting may last long enough to show a person he or she can be a confident speaker at such a meeting, and so generalises – they can be confident speaker at any gathering. That is, a learned habit is unlearned, or a dehypnotising takes place (Brice, 1985). An old belief about the self is shown to be wrong i.e. “speaking at Rotary meetings would cause my mind to go totally blank and my knees to shake…and worse”. Simultaneously the life decision that, “I would rather die than get up to speak at a Rotary meeting”, becomes obsolete and change takes place. Using another example, the hypnotist may create the illusion that you, a smoker, are a non- smoker, its good to be non-smoker, you feel better, you are more healthy, you will be ill if you smoke… whatever… and this created illusion may last long enough to break a habit or belief, which is an acquired illusion that you must smoke if you are to exist as “I”. In effect, an illusion is created to break an illusion and if the created illusion fits observer’ truth it becomes a reality as opposed to illusion. But if other illusions pertaining to “I am not me unless I have cigarette in my hand/mouth, and therefore cannot exist without smoking” and in some cases. “I would rather die than change”, are too solid and real to you, to admit the created one, the hypnotists created illusion collapses. Treatment is a ‘failure’. The above serves to illustrate that mind and body are inextricably interwoven…changes don’t occur in one area with out influencing the other, and without change in one area, it may not be possible to make changes in the other, even though the latter is the primary concern.

As I mentioned above, no therapist in his right mind would work with a client to re-instate an amputated limb. But there is a fallacy in the teaching of self-hypnosis or mind-expanding techniques today – that of “beating” a problem before “owing” it. Self-hypnosis becomes self-delusional – a kind of indoctrination of joy if you like – “Everyone can rule the world – if you come and learn the right techniques from me”. This joyous positivism may be referred to as trance logic. A good example of trance logic is the negative hallucination produced in the hypnotised subject. In order not to see something, the hypnotised subject must see it to know it is not there. Subjective reports from clients indicate they experience either the presence in the room of something ‘peculiar’ with a ‘not-to-be-inquired-into’ aspect, or the existence of a white space where the thing is. There is no incongruity in the situation from the subject, though it might seem quite peculiar to the viewer. Now if the hallucination denies the presence of a seated person, the client will find some reason for avoiding the chair. The hallucinating person will not unintentionally sit in the invisible man’s lap. Trance logic is quite simply illogical. Things, which are manifestly illogical to an impartial observer, are seen as quite logical to a hypnotised person if that is what he must believe to maintain the integrity of his belief system. Therefore, if he believes that the person has left the room, even though that person is obviously present, he will accept whatever illogical notions he must accept to continue denying the person’s presence (Shaw 1977). In a way then, the personality splits into two parts, similar to the hidden observer idea as described by Hilgard (1977) – the conscious part or aspect which is unable to see that the person is in the room, and the second ego, or unconscious that was quite aware of the person’s existence, but which has been forbidden by the hypnotist to inform the conscious part. One would expect that these two parts of the person’s mind could ‘get together’ at a later date and produce a dream-like memory of the experience, but by then the purpose of the exercise – whatever it might have been – would have been achieved.

Trance logic is quite common. It is seen everywhere in the followers of certain religions and religious cults, for instance, where illusion becomes conviction. Only the followers ofthat cult will get to heaven and/or reach enlightenment, and all manner of illogical statements and beliefs will be used to support and maintain the belief. Indeed, all that seems to be good or beneficial, but is not of the particular cult, is considered by the believers as trickery and the work of the devil. (The leaders of these organisations are often somewhat worldlier and tend to do rather well by earthly standards.)

Almost anyone who holds a strong conviction about something will show signs of trance logic if he is confronted with evidence that belies his beliefs.

There are many other examples, but one of the most tragic examples I have come across in my own practice was that of a client, a woman with cancer of the liver and extensive metastases, who requested hypnosis. She had opted out of chemotherapy with approval of the hospital because of the far advancement of her condition. Her husband accompanied her. Both were keen for her to have hypnosis to learn self-hypnosis to make her enjoy a special diet which was to cure her. This diet consisted of liver juice, vegetable and fruit juices, nuts etc., no animal protein whatsoever, no animal fats because animals “eat indiscriminately and all sources of food must be pure and organically grown”. Another essential aspect of this magical treatment was a coffee enema twice daily. Her problem was that she could not retain the enemas – not surprisingly – nor could she stomach the juices. Consequently she was surviving on a lettuce leaf and a slice of tomato at meal times and had lost nearly 2 stone in weight in the last 2 weeks. Her husband, who obviously cared deeply for her, was barely concealing his anger with her for not sticking to the diet, accusing her of not trying to live. But the light of conviction was in their eyes. A dynamic and authoritative man had done his work well in talking so eloquently of the inevitability of “complete cure” so long as his Organic diet’ is adhered to rigidly. His literature included many examples of such cures, not only of cancer, but apparently every scourge known to man from leprosy to multiple sclerosis, from arthritis to old age. So here she was, under pressure from this promise of cure, anxiety and pressure from her family members, who were so anxious for life that they were wasting what time she had left. It took four weeks before they were prepared to face this for themselves. This had to be handled indirectly because, as we’ve seen, trance logic does not lend itself easily to direct assault. It was felt that knocking the perpetrator of their indoctrination would only serve to produce animosity. Therefore during this time she became so weak she had to be carried up the stairs by her husband and it wasn’t until then that they really faced the facts. But at least she enjoyed what she ate during those four weeks – her diet was supplemented by some fish and cooked vegetables (previously a no-no because cooked vegetables “contained no nourishment” and fish was “filled with pollutants” according to their indoctrinator). This was after the obvious was pointed out, i.e. if the cancer didn’t get her, starvation would. In that time she and her husband were assisted to sort out a great deal in regard to how they felt about one another and themselves, and their quality of life. They consequently discovered that rather than waste time struggling to survive, both could give more to each other in the little time left than they had ever done in some 15 years of marriage. And who knows, without the dreadful burden of guilt and “fault” and with her new found acceptance, she may well live a few days, weeks, or even months longer. “As you think, so you are”, we are told. Too true, and what are we if what we are exhorted to think we are by these propounders of the good life is based on trance logic? To summarise and to look at the above somewhat obliquely in psychological terms, we might consider the individual development of human personality through three levels:

1. Existential – the highest level – separation of the individual from the environmental

2. Physical – separation of mind (mental function) from body

3. Mental/psychological separation of ego/persona (the personal conscious, or that part of personality socially displayed) from the personal unconscious (or repressed aspect of consciousness). (Wilbur 1977).

One problem of the human personality is that dissociation can occur, producing aspects of personality that are unrelated to each other. This can be distinguished from differentiation in which the separated parts remain related to each other. Anxiety and despair at level three are often confused with anxiety and despair at level one. In summary there is a danger of denying and repressing the environment, body, and unconscious elements of the psyche. These splits are reflected both within the individual and within society (the collective level). During therapy, both the whole person and the dissociated level must be considered. In a way the problem must, at some stage, be given back’ to the person – who is asked what they want to do with it. In healing or treating the self, then, it seems important to:

1. Acknowledge that something is wrong

2. Find out what it is and own it

3. Find out how it is wrong compare it with perfection or the closest thing to it

4. Drop all anxiety, and move towards health in the fullest sense of the word.

The following case history illustrates these four steps in the use of self-hypnosis by a teenaged girl to accelerate healing of 3rd degree burns. This is not presented as a blueprint of how self- hypnosis should be used to heal but rather an account of the way one individual chose to use it with remarkable results.

Case History

The patient, a 17 year-old girl, was admitted to hospital after sustaining 3rd degree burns to her left foot and left hand, and 2nd and 3rd degree burns to areas of the left leg, when the contents of a pan of cooking oil which had caught fire, and which she had attempted to carry outside, spilled over her.

Three days after admission the hand and foot were grafted, the donor areas being the front and back of the left thigh. A course of antibiotics was prescribed as a prophylactic measure. Eight days later she was discharged from hospital, the bandages having been removed the day before. The grafts were sound and healing progressed rapidly. Twice daily for the next three to four weeks’ the grafts were rolled, trimmed, and tulle gras applied. Tulle gras and vitamin E oil was applied to the non-grafted areas. Eight weeks after sustaining the injury healing was complete. There was no tendon contraction or restriction of movement in either the hand or fingers or the foot and toes. Apart from one small area on the leg (non- grafted), which had to be scraped down, there was no build-up of scar tissue.

Some significant aspects of this case were:

1. The patient in question was known to be an excellent subject for hypnosis, capable of active somnambulistic trance, wherein she displayed superior abilities including that of pain control.

2. She used self-hypnosis regularly to enhance her memory and concentration in her studies.

However, from the moment she was injured, she not only vehemently rejected any attempt made to hypnotise her but refused to use self- hypnosis to control or block the obviously excruciating pain. Instead, she demanded injections and consequently received LM. Pethidine at three to six hourly intervals throughout the first few days. This experience seems to refute some claims that persons in shock are always easily hypnotisable (Furst, 1969, and others). In addition, while hospitalised and for a week or so after discharge, she lost all appetite for food, and ate very little. Weight loss was therefore considerable over six kilos in three weeks.

The following explanation for the above anomalies was given in her own words several weeks later. “I was, I think, very shocked after the accident. But my mind was very clear. I could see my foot and my hand and they were things they didn’t belong to me. The pain was terrible. I couldn’t think past it. I couldn’t tell myself it wasn’t there because that would take up too much energy. The injections stopped the pain so I could think straight. Then I could look at that thing on the end of my leg and that other thing on the end of my arm and admit that they were mine and part of me… that was so hard to do, you wouldn’t believe; but I did it. Then I had to compare them to my right hand and foot so I could remember how they should look I had to keep concentrating on the feeling of the blood pulsing and circulating, too, especially after the grafts were done, so that they would grow onto me just like the real skin that used to be there. Even eating wasn’t important to me I needed all my energy for healing. In my mind I would see my fingers and toes moving easily while I flexed and relaxed the muscles to stop them from getting stiff. It was better when the bandages were off and I could move them easily. I couldn’t let you hypnotise me because it would have interfered with what I knew I had to do on my own.”

Conclusion

In short, this patient acknowledged her limitations – the pain which she could not ‘pretend’ wasn’t there. She accepted the problem (the injuries) as her own, saw what was wrong and compared it to how it should be, and moved toward health using all the energy at her disposal. This girl was given no instructions. She was aware of her priorities, saw what had to be done, and did it. In this case, we see self-hypnosis perhaps as it should be – an attitude of mind, not a process; reality rather than delusion; a knowledge, not merely a belief.

References

Brice, G. (1985).To hypnotise or dehypnotise? The Australian Journal of Clinical Hypnotherapy and Hypnosis, 6 (1), 15-21.

Furst, A. (1969). Post hypnotic instructions. California: Wilshire Book Co.

Hagen, Z. (1981 ). Kirlian photography. Nature and Health, (2) 4.

Hilgard, E.R., (1977). Divided consciousness: Multiple controls in human thought and action. New York: John Wiley & Sons.

Kapila, in Richards, S. (1982). Invisibility. England: Aquarian Press.

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Wilbur, K. (1977). The spectrum of consciousness. Wheaton, Illinois: Quest.

Copyright Australian Society of Clinical Hypnotherapists Autumn 2008

(c) 2008 Australian Journal of Clinical Hypnotherapy and Hypnosis. Provided by ProQuest LLC. All rights Reserved.

Trigeminal Neuralgia

By Shirley, Barry

Hypnotherapy for Pain Reduction: Two Case Studies Abstract

Trigeminal Neuralgia (tic douloureux) has been referred to as the ‘suicide disease ‘by many of those afflicted. It is a disorder of the fifth cranial (trigeminal) nerve and can produce intense, stabbing, electric shock-like pain sensations. A less common form called Atypical Trigeminal Neuralgia may cause less intense pain sensations, ranging from a constant burning or dull ache to occasional electric shock-like stabs. This paper presents two case studies where the objective was to initially use hypnosis in a clinical situation for possible pain level reduction, and then to teach self-hypnosis for the client’s own ongoing pain management.

The incidence of trigeminal neuralgia in the general population is quite small, cited as 155 per 100,000 (Troost, 2007). It is a condition that very few hypnotherapists will be presented with and the available evidence of treating this condition by hypnosis is very limited. The generally accepted methods of treatment range from medical pain management (pain reduction drugs) to various surgical procedures. There has been some acknowledgement given to the use of complementary and alternative medicine, including hypnosis, by organisations such as the Trigeminal Neuralgia Association (Lawhern, 2006).

It is hard for us to imagine the extreme pain levels felt by people afflicted with trigeminal neuralgia. The pain has been described as so intense that it could be compared to that of biting on a needle or fracturing a tooth (Troost, 2007). Common descriptions range from lance like jabs, stabbing pains and electric shock-like sensations. The pain can last from just a few seconds to almost one minute.

The client is usually incapacitated during this time and generally attempts to immobilise the pain in the face by pressing on trigger points for pain relief. In severe cases, clients may not be able to eat, drink, or clean their teeth without experiencing some degree of pain. Due to the inconsistent pattern of pain attacks (sometimes several per day, extending to months apart), the client is understandably anxious and is unable to enjoy life without some apprehension, waiting for the next pain episode.

Trigeminal neuralgia can occur across all age groups, having even been recorded in a child as young as 16 months. It occurs predominantly in middle and old age. Around 70% of sufferers are over the age of 40, with many in this age category having hypertension or ateriosclerosis. Generally the ratio of females to males afflicted with trigeminal neuralgia is 2:1 and the right side of the face is involved more than the left in a ratio of 3:2, with the condition being bilateral in only around 2% of cases (Troost, 2007). It is not generally considered to be an inherited condition although around 5% of cases occur in same families, which may suggest a possible genetic link in these cases (Mayo Clinic, 2006).

Aetiology and Pathology

The trigeminal nerve originates deep inside the brain and its function is to carry sensations from the face to the brain. There are three branches of the nerve. The first branch controls sensations in the eye, upper eyelid, and forehead. The second branch covers the sensations from the lower eyelid, cheek, nostril, upper lid, and upper gum, while the third branch is concerned with the sensations from the jaw, lower lip and gum.

Pain generally results when there is a disturbance in the function of the trigeminal nerve (usually due to contact of the nerve by a normal artery or vein). When pressure is placed on the nerve the nerve misfires. Physical nerve damage or stress may be the initial trigger. Trauma and dental problems can also cause trigeminal neuralgia (Mayo Clinic, 2006). Other less frequent sources of trigeminal neuralgia pain are intracranial tumours (usually in the posterior fossa), multiple sclerosis, stroke (affecting the lower part of the brain), changes in myelin sheaths, and, in rare cases, drug intoxication (Troost, 2007).

There are a variety of triggers which may set off the pain. These include smiling, feeling a breeze on the face, washing, shaving, brushing teeth, applying makeup, eating and/or drinking, and stroking the face (Mayo Clinic, 2006).

Medical Treatments

Once trigeminal neuralgia is diagnosed, the first treatment option is usually through medication. Analgesics such as aspirin and paracetamol are not considered due to the rapid intensity of the attack and the usual severity of the pain level. The primary drug used to treat trigeminal neuralgia is carbamazepine (available as Tegretol) which is administered slowly at first and gradually increased to a level that allows the client to be pain free. The initial relief achieved by this drug is very effective and many physicians use it to confirm the diagnosis of trigeminal neuralgia. A newer medication is oxcarbazepine (available as Trileptal) which is now considered preferable due to a more favourable side effect profile (Lawhern, 2006). There are other medications available, increasing in numbers with further research.

In cases where medications are not effective in pain reduction pain blocking procedures may be used.

* Glycerol Injection

A needle is inserted through the face into the base of the skull and guided into the trigeminal cistern (a small sac of spinal fluid around the trigeminal nerve ganglion). Glycerol is injected to damage the trigeminal nerve and render it insensitive.

* Balloon Compression

In this procedure a hollow needle is inserted near the nerve and a balloon inflated, exerting enough pressure to damage the nerve.

* Microvascular decompression

Blood vessels are surgically removed or relocated and separated from the nerve by a small pad. This is one of the more successful surgical procedures for this condition.

Other surgical procedures involve severing the nerve (partial sensory rhizotomy) and radiation (gamma-knife radiosurgery) to damage the nerve. Each procedure has risks and these can range through muscle damage, ongoing pain and numbness, stroke, and even death (Mayo Clinic, 2006).

Complementary and Alternate Medicine

Alternative medical therapy has been acknowledged as increasingly popular with an estimate of one person in three at some time using these therapies for pain problems, anxiety, and mind-body interactions (Sadock & Sadock, 2003). The American TNA (Trigeminal Neuralgia Association) has been accumulating anecdotal data on non- traditional remedies found helpful by patients to treat their pain relief. They are in the process of assembling a task force to establish guidelines for patients to follow when seeking alternate help and to share the data collected. Hypnosis has been included in their list of therapies where some success in pain reduction has been achieved (Lawhern, 2006). Due to the sudden and extreme nature of the pain from trigeminal neuralgia, hypnotherapy requires reinforcement to maintain the pain reduction, and teaching self- hypnosis can provide some ongoing support for the patient (Marriott, 1981).

In my own particular practice, there are two case studies that present different aspects in the use of hypnosis when applied to trigeminal neuralgia.

Case Study One – September 2006

Female, aged 60 years, single, retired ex-school teacher, experiencing acute trigeminal neuralgia pain. The initial onset of the condition was subtle and probably resulted from facial trauma injuries received in a car accident some 10 years earlier. 12 months prior to her first consultation with me she had a microvascular decompression medical procedure relocating blood vessels away from the trigeminal nerve in the third area (jaw), right hand side of the face and the insertion of pads to separate the nerve from surrounding muscle. Subsequent to the operation, the pain level and the incidence of attacks increased. On some days she could experience several attacks and then not have any for some time, but all attacks were accompanied by hysterical screaming over which she had no control. Most of the attacks lasted from approximately 20 seconds up to one minute, but her worst attack went for 30 minutes. She described each attack as an electric shock producing excruciating pain. The pain attacks were increasing in both quantity and intensity. In addition to the anxiety of anticipating an attack, she was under severe stress resulting from her brother’s terminal cancer condition.

In the first session an extensive history was taken It was noted that she was medicating with Tegretol which was having less effect on the pain intensity. Her face was noticeably contorted on the right hand side, and she reported experiencing insomnia and anxiety which were impacting on her enjoyment of life. Hypnosis 30 years previously to overcome exam stress had worked well. We discussed a possible three-part strategy to help reduce her pain levels

* To use glove anaesthesia to help numb the painful area along her jaw line

* To use suggestions that her level of pain intensity during an attack would be reduced to a more acceptable level

* To teach her self-hypnosis to achieve better relaxation levels to enable her to sleep.

She responded well to a visualisation/induction test (Alien, 2005) to gauge her level of suggestibility. I then used the Elman- Banyan Rapid Hypnotic Induction (Banyan & Kein, 2001) but with a modification involving more widespread muscle relaxing than just the eyes. Once somnambulism was achieved, I further deepened the level of trance following the Elman-Banyan method of counting from one to five. During the induction I suggested that the back of her right hand was extremely numb, and that she could transfer this numb feeling to the painful areas of her face. She moved her hand to her face and began stroking her right jaw from mouth to ear. I also suggested that the level of pain she would feel from now on would be more of a tingling sensation than a sharp pain, and that the number of pain attacks would reduce. She was to use the back of her right hand to induce numbness to her face whenever she had another attack, to limit the pain level. It was further suggested that she would be able to induce herself to this deep level of relaxation using self- hypnosis when at home. I then proceeded to awaken her with a count from one to five, with five allowing her to return to the room, completely awake, pain-free and looking forward to the rest of her day. It was surprising that she admonished me for awakening her too soon as she found it difficult to return in a relaxed state. I immediately reintroduced her to a deep level of hypnosis and slowly used a count often. This time she responded well to wakening. (Note: a count of ten was used for each of the subsequent sessions with good results.) At the conclusion of the first session, she was experiencing a pleasant numbness in her face and she was pain-free. The contorted right side of her face appeared far more relaxed.

The second session was conducted 15 days later due to a full schedule of medical tests including an MRI scan. She had had a stressful week with several pain attacks so rapid and unexpected that there was no time to even think about the glove anaesthesia. We concluded that using this method would not be successful due to the rapidity of the attacks and that further work would be directed toward lessening the intensity of the pain. She had increased her Tegretol medication and was experiencing blurred vision and noticing weight gain. It was difficult to assess whether any level in pain reduction was attributable to the hypnosis or to the increase of Tegretol. This session was used to suggest that her trigeminal nerve would stop firing abnormal signals to cause a pain attack (Waxman, 1993). She was able to visualise the trigeminal nerve functioning normally and her pain levels reducing. Further teaching of self- hypnosis continued as she reported having had a better sleep pattern and being able to relax during the day. There was no pain attack during these self-hypnosis periods and her level of anxiety had reduced markedly, with more relaxed facial muscles on her right hand side. It is interesting to note that she was using the visualization of a rose garden for relaxation (which we had used in the first session) which seemed to deepen her level of self-hypnosis.

The third and final session took place 15 days later. She had experienced only two minor attacks of pain. The intensity of pain had diminished and she was far more relaxed. It appeared that the suggestions of pain level reduction and the continuing use of self- hypnosis were showing some promise. Further work on using this same strategy was conducted. In a telephone conversation approximately two months later, she was quite happy with the results achieved by the hypnosis but had decided to follow her medical practitioners advice and have another medical procedure, this time a partial sensory rhizotomy to sever the nerve. There was no further contact from this time.

Case Study Two – December 2006

Male aged 61 years, retired engineer and toolmaker. In 1980, he was involved in a serious car accident and suffered severe injuries to his face and cervical spine, becoming a paraplegic. He was unable to stop his head from falling forward which led to further surgery to the neck and spine, requiring the insertion of metal plates. After this operation, he experienced acute trigeminal neuralgia pain to the left side of his head in the jaw region. This remarkable man then taught himself to walk again with the aid of walking sticks and to drive a car with his own specially made mechanical device. Over the years he had microvascular decompression surgery with pad insertion around the trigeminal nerve without much reduction in pain level. A second surgical procedure involved severing the trigeminal nerve in a partial sensory rhizotomy surgical procedure, following which he had a stroke. He had to teach himself to walk again.

The pain level resulting from the second operation and the stroke was described as a constant ache, as if several teeth had been extracted. His pattern of sleep was extremely poor. The stroke caused optical nerve damage requiring special glasses to correct blurred vision. Extensive dental work had been ongoing since the car accident. During the first session and the history taking, he kept referring back to his many dental sessions and the effect of the Novocaine giving him some relief from the pain until it wore off. This provided a good foundation for a hypnosis strategy and once it was established that he could achieve a somnambulism level of trance using the Elman-Banyan Rapid Hypnotic Induction (Banyan & Kein, 2001) he was asked to visualise the word “calm” and to feel the effects of Novocaine spreading through his jaw. Instructions for self-hypnosis were also given while he was under trance, using the word “calm” as a trigger to induce relaxation and a pain deadening effect.

The second session was conducted 12 days later, due to the Christmas break He reported some initial pain relief but a serious head cold had confined him to bed and his pain had returned to the previous intensity level. His left facial muscles (zygomaticus, masseter, and orbicularis oculi) were noticeably tight. A somnambulism level of trance was achieved and he was asked to relax his facial muscles and to think of the word calm’ and the Novocaine effect of pain reduction. He was awakened and asked how he felt. There was no pain and his facial muscles appeared quite relaxed. He was asked to return to his previous level of trance and the Elman- Banyan method of counting from one to five for deepening was applied (Banyan & Kein, 2001). Further suggestions were made to increase the association of the word cairn with the pain lowering effect of Novocaine and self-hypnosis instructions reinforced.

The third and final session took place five days later with some surprising results. His pain level was now quite manageable even though the week had been stressful following a very expensive car repair problem. His sleep pattern had improved markedly. He lived in a two storey house and it usually took him 15 minutes to climb the stairs to his bedroom. He had started using self-hypnosis (initially following my self-hypnosis CD specially recorded for him) after this exhaustive stair climb each night just before sleeping. He was so relaxed that he allowed himself to drift oft” to sleep at the end of the self-hypnosis. Whenever he started to experience pain increasing, he consciously thought of the word “calm” and the pain level reduced to what he described as a tolerable level (Meares, 1979). The session was spent reinforcing the same strategy and allowing him to achieve his own trance state with self-hypnosis. A follow-up telephone call approximately three months later confirmed that he was still happy with the results, especially the self- hypnosis and its application to help him sleep.

Conclusion

My previous experience of using hypnosis for pain management problems had been mainly confined to helping clients with headache, neuralgia, and relief from chronic pain. When I was asked via a referral to help my female client with trigeminal neuralgia, I set out to research the condition and the application of hypnosis to help relieve the pain. There was very little literature available and a request for information from colleagues on an online forum produced only a limited amount of information. Even information on other alternate forms of therapy in the treatment for trigeminal neuralgia such as chiropractic, acupuncture, and others was very limited. It appeared that self-hypnosis was probably the best application of hypnosis for these unfortunate people suffering from this dreadful affliction. It is encouraging to note that the Trigeminal Neuralgia Association and its various branches are collecting data and appear to have an open mind toward the use of what they term ‘CAM’ (complementary and alternative medicine).

In my own limited experience with trigeminal neuralgia clients I have made some observations that could be helpful to other practitioners. The debilitating effect of the pain attacks reduces sufferers to an almost helpless state where they are unable to think of anything other than the pain itself. Due to the rapid and completely unexpected onset of the severe pain attacks, the use of conventional analgesic hypnotic methods, such as glove anaesthesia, would be unsuitable.

However, teaching self-hypnosis is of benefit to these clients. They can practice it whenever they wish and it does appear to have beneficiai results in reducing anxiety and helping them achieve a better sleep pattern. Reduced anxiety levels can help clients relax during the periods in between the attacks, and to help reframe their pain levels to a more acceptable state. This can only aid in helping them to strengthen themselves between pain attacks, and to allow some comfort beyond just waiting to face the uncertainty of the next attack.

References

Allen, R.P. (2005). Scripts, strategies in hypnotherapy: The complete works. Bancyfelin, Wales: Crown House.

Banyan, C.D. & Kein, G.F. (2001). Hypnosis and hypnotherapy: Basic to advanced techniques and procedures for the professional. Minnesota: Abbot Publishing House.

Lawhern, R.A. (2002). Choosing between treatments for trigeminal neuralgia. http://www.tna-support.org/newlook/ Articles/Choose.htm Marriott, J.A. (1981). Hypnosis and the relief of pain. The Australian Journal of Clinical Hypnotherapy & Hypnosis, 2(2).

Mayo Clinic http://www.mayoclinic.com/ health/trigeminal- neuralgia/DS00446

Meares, A. (1979). Relief without drugs. Melbourne: Fontana Collins.

Sadock. B.J. & Sadock, V.A. (2003). Synopsis of psychiatry. Philadelphia: Lippincott, Williams & Wilkins.

Troost, T. (2007). Web Master for http://www. imigraine.net/ other/mtic.html

Waxman, D. (1993). Hartland’s medical and dental hypnosis. London: Balliere Tindall.

Barry Shirley

Hypnotherapist, West Ryde NSW Australia

Barry Shirley is a qualified and practicing Clinical Hypnotherapist and a registered Counsellor with a private practice in West Ryde, Sydney. He is a qualified and registered remedial masseur with the ATMS, specialising in pain management.

Copyright Australian Society of Clinical Hypnotherapists Autumn 2008

(c) 2008 Australian Journal of Clinical Hypnotherapy and Hypnosis. Provided by ProQuest LLC. All rights Reserved.

A Column for Your Questions About Aging

By Dr. Michael Camardi

Q: I just don’t know what to do anymore. Me and my husband are at our wits end with my parents. Now, we love them dearly and all, but we just need a rest — we need to get away — but we don’t know if we can.

They both are in their 80s and have what the doctors called “mild dementia,” but it sure isn’t mild to us. The problem is that they live across town and both get a little fidgety and don’t finish what they start, and we’re afraid that if we do go away for a few days something will happen.

We wind up going over there two or three times a day to see if they’re all right and to get them things because we’re afraid we’ll find them on the floor one day. They own their own house and will not leave to go anyplace else. What do you suggest?

— Roanoke

A: There is a way that I have counseled people over the years to do this without feeling guilty or overly responsible and get away to recharge your batteries and come back refreshed and ready to be caregivers again.

Having a respite is key to survival in this difficult time, and I have seen so many marriages crack under the strain of an overwrought sense of responsibility for their parents. It just doesn’t have to be that way.

Anybody in the medical field will tell you that caring for another person to the best of your ability can be an exceedingly draining experience if you do it day after day, night after night, without enough rest. For families of parents with dementia, this is a 24-hour-a-day burden, seven-days-a-week marathon that few finish without profound emotional strain. Frankly I admire you and your husband for making such a commitment.

Practically speaking, I would ask you to consider the use of the following four methods in combination to gain control of this difficult situation not only for a daily routine, but also as a means of taking some time away.

First, set up a call schedule where your parents will know that you’ll be calling in to see how things are going. I like the every three hour approach until bedtime. This works well anytime, anyplace, anywhere, and people tell me their parents enjoy the contact and the attention.

Second, enlist neighbors or friends to help. Maybe as they walk by your parents’ house, would they either pick up the mail or the newspaper and give it to one of your parents? This gives a sense of friendly outside contact to your parents, and so many times this type of intervention has saved lives. Please make sure you give these good Samaritans your phone numbers so they can get in touch with you quickly if needed.

Third, invest in a MedicAlert-type notification system so that if an emergency situation were to occur, your parents would have a fast means of easily getting help. Families and patients rank this as a godsend to their peace of mind.

Finally, if your situation allows it, hire a companion to come in two or three days a week. In my experience, this can be a delicate situation if the respite caregiver is looked upon as an intrusion (often quoted as “somebody they got to snoop around my house”).

Also these folks must be vetted thoroughly before you entrust them with your parents. However, this resource can represent a good degree of peace of mind.

Once your plan is set, make sure you have a family meeting so your parents know that all of these changes are for their benefit as well as yours. Make sure the plan is understood not to be a rejection but as a means to nurture the family as a whole.

And one final word: It’s never quite as bad as it seems, and don’t underestimate your folks: They know a lot about caregiving — they were taking care of you before you were born!

Today, I’m happy to introduce Dr. Michael Camardi, a geriatrician at Carilion’s Center for Healthy Aging, and his new monthly column: Age Matters.

Camardi has been with Carilion for about three years and was one of the experts that reporter Beth Macy spoke to for her series, “Age of Uncertainty.” He wanted to start this column to help answer questions he’s often heard as part of his job.

Camardi’s credentials include being the founder and past medical director of the geriatric liaison program for Jacobi Medical Center (Albert Einstein College of Medicine) in Bronx, N.Y. The geriatric liaison program was the cornerstone service that united the inpatient management of the geriatric patient with their outpatient care.

Following his military service, Camardi trained at Winthrop University Hospital (Stony Brook University Medical School), Mineola, N.Y., where he was chief medical resident. He has received numerous awards and commendations for his contributions in education, patient advocacy, community relations and hospital administration, including Carilion’s 2007-08 “Outstanding Attending” Award from the Department of Internal Medicine residency program.

His columns will run on the third Tuesday of each month.

If you have questions for Camardi, please mail them to him at Center for Healthy Aging, 2118 Rosalind Ave., Roanoke, VA 24014, or e-mail them to [email protected] with “Age Matters” in the subject line.

— Kathy Lu, features editor

(c) 2008 Roanoke Times & World News. Provided by ProQuest LLC. All rights Reserved.