A Diamond Makes You Feel Special – and Amahl is Our Diamond IN GOOD HANDS The Unsung Heroes and Heroines of the NHS Who Always Go Above and Beyond the Call of Duty

IT IS time to say happy birthday and thanks . . . the NHS will be 60 years old on Saturday.

West Scotland is celebrating with an anniversary show at Glasgow Royal Concert Hall, hosted by Clyde 1 DJ Gina McKie.

It will be an afternoon to remember, with entertainment and amazing stories to be told.

And the winners of the NHS Greater Glasgow and Clyde Diamond Awards, sponsored by the Evening Times and Radio Clyde, will also be announced.

The awards will honour the unsung heroes and heroines of the NHS, whose dedication, commitment and willingness to work above and beyond the call of duty set them apart.

They will be presented with their prizes by Deputy First Minister and Health Secretary Nicola Sturgeon;

Andrew Robertson, chairman of NHS Greater Glasgow and Clyde; Evening Times editor Donald Martin;

and Susie McGuire, George Bowie, Paul Cooney and Norman Ross, of Radio Clyde.

If you missed out on tickets for the event, you can still view a special exhibition at the Concert Hall’s exhibition suite.

It features archive fi lm and photos and is open from noon. The images are from the files of the Evening Times and The Herald and Glasgow’s NHS archive.

H E WAS once the life and soul of every party. Everyone in Glasgow’s East End knew Burdie.

“Burdie, give us Lily the Pink”, they’d shout in the pub and Burdie would be only too happy to oblige with his signature tune.

But Carntyne man James Conner will never sing again.

He’ll never speak in that loud, booming voice again. He’ll never again taste his favourite food or savour his favourite drink.

James has had a major operation for throat cancer and complications with the treatment have meant he has been in and out of hospital over the past few months.

“You can see in people’s faces that he is only a shadow of what he was, ” says his daughter, Janie, “and he gets frustrated that he can’t speak.”

Give him his due, though – James, who will be 70 on Friday, may be down but he’s not out.

He pours himself a wee Guinness into a syringe and feeds it into the peg in his stomach.

There’s a mix of defiance and mischief in the action.

“You can’t keep a good man down, ” the retired roofer writes on his notepad, grinning widely as he holds the message up.

Sister Amahl Mathie, head and neck cancer nurse specialist based at Gartnavel, shakes her head at him. “You’re a terrible rascal, ” she remonstrates and they laugh together.

Illness has robbed James of many of the things he enjoyed and took for granted, as we all do, and Amahl doesn’t see the point of nagging or judging.

It’s part of why James and his whole family love Amahl so much.

She is a life saver, they say.

They have nominated her for the NHS Diamond anniversary awards and are thrilled that she is a finalist in the Extra Mile Award category.

“A diamond makes people feel special and she is our diamond, ” says Janie, 40, a mother of two and a grandmother. “She has defintely made our family feel special and we have no doubt that without the help, advice and comfort shown by her, my father would not be with us today.”

Over the past few months, James has been so ill that he has often wanted to throw in the towel.

“Most of his strength to fight on has been encouraged by this wonderful nurse, ” says Janie. “So many people feel lost and worried and anxious at a time like this. We felt all those things when my mother, Agnes, was ill with kidney problems and we couldn’t get any straight answers.

“Whereas with Amahl, if we have a question, she will answer it and if she doesn’t know the answer, she will find it for you and make sure that you understand it. You are never left wondering.”

It’s pretty obvious from the start that Amahl is everything the family say she is.

T HE minute she comes into the room James’ eyes light up. They hug and for the next few minutes Amahl is absorbed in trying to sort out a problem he has with the tracheostomy in his throat.

And then she takes time to advise him about his medication and sort out a solution.

The family know by now that when she promises to do something, it’s as good as done.

Amahl is trying to make sure James has as good a quality of life as possible. “It’s important to James that he gets out and sees some of his pals, goes to the shops and to the bookies. People thrive on that. It’s an awful lonely day if you can’t get out.”

She also recognises the strain on the whole family has been massive. They are a close and caring family.

Janie has three older brothers; Eddie, 46, James ,45, and Thomas ,44, and they have all mucked in to help their parents.

Having Amahl at the end of a phone or ready to visit has made all the difference to what they are going through.

“It’s the caring, the touching, the empathy, ” says Janie.

“It’s the way she comes across and reassures you and it really calms you.

“She was obviously born to be a nurse and loves not only her job, but also her patients.

From her toes to the last hair on her head, she oozes sincerity, compassion, care and consideration for her patients and their families.

“No matter when you need advice, she is there for you.

“She will always call us if she has anything new to pass on or if she has not heard from us for a few days.

“Nothing is any trouble to her. She really is a saint.”

James has had a tough time since his cancer was diagnosed last autumn. For such a sociable man, someone who loved to talk, having to communicate by writing is always going to be a barrier.

“Because he was an alcoholic, he would miss hospital appointments and by the time they found the cancer it was quite aggressive, ” explains Janie.

Her father, she says, started drinking heavily about 13 years ago after her brother, Paul, was murdered. “He took it really badly. He could never understand how it happened and how he never got to say goodbye.

“Some people think he has done this to himself and we as a family say ‘you’ve only got yourself to blame, dad’.

“Amahl isn’t like that. He is an individual to her. There is no prejudice because of his drinking.”

“All we can do is give support and advice to our patients, ” Amahl says. “We can’t tell them what to do.”

Amahl has been trying to shut her ears to the praise Janie is heaping on her. “I am hugely embarrassed and touched, ” she says. “But a nomination like this has to go to the whole department.

“The only reason I can do my job is because I am so well supported by my colleagues.

“The list is endless. There are so many people making sure that everything is as calm and easy flowing for our patients and their families as it possibly can be.”

Amahl, 42, of Elderlsie, who is married with a stepson, works closely with her fellow specialist nurse, Trish McDonnell.

Their base is Ward 5A of the Ear, Nose and Throat department at Gartnavel and together they cover north Glasgow, responding to patients’ individual needs.

Since they started in the post five years ago, they have had several hundred patients between them.

A MAHL says: “I was working on the wards as a staff nurse and we recognised then that when people were discharged they didn’t have anyone to contact if they had a problem.

“We as a unit worked for many years to get these posts up and running and I feel very privileged to be involved. Every day you feel you are trying to make a difference.

“Patients don’t come on their own – they come with families. Every family has a very difficult time and they cope with it differently and we need to make sure they are supported.”

Originally published by Newsquest Media Group.

(c) 2008 Evening Times; Glasgow (UK). Provided by ProQuest Information and Learning. All rights Reserved.

Hokkaido-Sakhalin Cable System Starts Commercial Operations

TransTeleCom, a Russian backbone telecommunications operator, and NTT Communications, a provider of IP solutions, has announced that the Hokkaido-Sakhalin Cable System, which directly links the two companies’ telecom networks via an undersea cable between Nevelsk, Sakhalin in Russia and Ishikari, Hokkaido, Japan, began commercial operation on July 3, 2008.

The two companies jointly started to construct the fiber-optic submarine cable Hokkaido-Sakhalin Cable System (HSCS) in 2007 and the work was completed in December 2007.

The HSCS measures 570 km in length and has a capacity of 640 Gbps. Its startup gives NTT Com the shortest route between Japan and Europe, compared with existing cable routes through southern Asia and the United States, by connecting the cable to the TransTeleCom’s (TTK’s) extensive backbone network in Russia, which exceeds 55,000 km.

The HSCS route will enable NTT Com to provide additional offering in Arcstar Global Leased Line Service utilizing the new route and taking orders starting on July 3, 2008. It is estimated to shorten the latency within the company’s backbone by 20 to 30% compared to the existing routes.

The HSCS route will be added to the backbone of NTT Com’s secure, scalable Arcstar Global IP-VPN Service (MPLS) beginning August 2008. The HSCS route will be added to NTT Com’s global IP Tier 1 network covering Asia-Pacific Europe and North America, with connection to major ISPs worldwide, beginning on July 3, 2008.

Saint Agnes Infection Control Plan is Released: Hospital to Hire More Staff, Monitor Surgeries in Effort to Get Cardiac Unit Reopened.

By Barbara Anderson, The Fresno Bee, Calif.

Jul. 4–Saint Agnes Medical Center will hire more infection-control staff and aggressively monitor surgeries to convince state health officials that an outbreak of infections among cardiac-surgery patients won’t happen again.

The plan, released Thursday, is part of the hospital’s attempt to get its beleaguered cardiac surgery unit reopened. But it remains unclear when surgeries will resume.

Saint Agnes will not be able to do cardiac surgeries until the hospital is back “in compliance with state and federal regulations and the Department of Public Health reinstates the hospital’s special permit for cardiac surgeries,” said Ken August, a department spokesman.

In a written statement, hospital officials said they are “working constructively with the state to reinstate our cardiac program as soon as possible.”

The eight-page plan, approved by the state June 27, addresses only how Saint Agnes will prevent and monitor leg-incision infections related to cardiac surgery. Leg veins often are used to replace blocked coronary arteries.

An investigation of leg-incision infections led the state to shut down the cardiac surgery unit for six days in May.

Saint Agnes voluntarily suspended all cardiac surgeries last month, saying it wanted to do an audit of the program to ensure public safety.

The leg infections, however, were only a part of the state’s concerns about the hospital’s cardiac surgery unit.

A 54-page report issued last month outlined public-health and safety concerns of state investigators, including a lack of monitoring of new doctors.

The state has yet to review or accept the hospital’s plan of correction that addresses those issues, August said.

The correction plan for leg infections, however, lists several things the hospital said it will do to prevent and control infections.

Saint Agnes officials would not discuss the plan.

“We do not feel comfortable commenting on our specific efforts until our program is reinstated,” said Jaime Huss, a hospital spokeswoman.

Among the steps spelled out in the plan: hiring an additional infection-control nurse, and contacting all cardiac surgery patients who had surgery since January to ask them about any signs or symptoms of infections.

The plan also calls for unannounced monitoring of surgeons in the operating room to observe what they are doing to prevent infections.

“The department’s monitoring includes observation, staff interviews and clinical record reviews of randomly selected patients having cardiovascular surgeries,” August said.

The reporter can be reached at [email protected] or (559)441-6310.

—–

To see more of The Fresno Bee, or to subscribe to the newspaper, go to http://www.fresnobee.com

Copyright (c) 2008, The Fresno Bee, Calif.

Distributed by McClatchy-Tribune Information Services.

For reprints, email [email protected], call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.

Private Hospitals & Clinics (UK) – Portfolio Analysis Available Now for Your Specialised Research

Research and Markets (http://www.researchandmarkets.com/research/d1b0ee/private_hospitals) has announced the addition of the “Private Hospitals & Clinics (UK) – Portfolio Analysis” report to their offering.

The Plimsoll Portfolio Analysis – Private Hospitals & Clinics is a comprehensive evaluation of the UK market. The revised and updated 2008 edition analyses the financial performance of the companies important to the success of your business. Using the most up to date information available, the analysis is ideal both as a tool to benchmark your own companys results and to study the market in more depth. Aimed at the busy manager, the Plimsoll Portfolio Analysis is both quick and easy to use thanks to the unique visual layout. The Analysis lays bare the performance of each company highlighting their strengths and weaknesses. Do you know which companies are best to do business with? Do you know which companies are selling at a loss and whose profit margins are plummeting? Find out the answers to all these questions and more with the newly published Plimsoll Portfolio Analysis.

The report is divided into two colour-coded sections for your ease of use, Sector Analysis and Individual Company Analysis. Sector Analysis: Sales growth, market share and profitability are all analysed over a 10 year period giving you the fulllest picture possible of the health of the market. Companies are ranked on these categories so you can see which companies are outshining the rest. Use the industry average tables to benchmark your own companys performance- how do you compare to the rest of the industry? Industry Analysis: Each company receives a full page of analysis, evaluating their financial performance over the last five years so you get a full picture of the long term prospects of each company. Each company page of analysis is also packed with the following information: Full business name and address, Names and ages of directors, contact details and website address, seven unique Plimsoll charts showing at a glance the performance of each company, averages for the industry are also shown indicating the bare minimum each company should be looking to achieve, and five years of the latest accounts available, New! Written summary on each company highlighting their key strengths and weaknesses.

Companies Mentioned:

96 HARLEY STREET

CARE NURSING

ABBEY HOSPITALS

CARISBROOKE MEDICAL CENTRES

ABBEY HOSPITALS (HOLDINGS)

CASTLEBAR HEALTHCARE

ABBEY HOSPITALS (PROPERTY)

CASTLEBECK CARE (TEESDALE)

ABBEY PARK HOSPITAL

CELLITE CLINIC

ABERMED INTERNATIONAL

CENTRE FOR REPRODUCTIVE MEDICINE

ADVANCED HARLEY STREET CLINICS

CENTRELAND HOSPITAL RETAIL

AFFINITY HOSPITALS GROUP

CHANCELLOR CARE

AFFINITY HOSPITALS HOLDING

CHARTERED PHYSIOTHERAPY CLINIC

(THE) AFFINITY HOSPITALS

CHEADLE ROYAL HEALTHCARE

ALBANY MEDICAL CLINIC

CHESHMACK

ALBYN HOSPITAL

CHESHUNT CHIROPRACTIC CLINIC

(THE) ALEXANDRA CLINIC

(THE) CHICHESTER INDEPENDENT HOSPITAL

ALL CREATURES CLINIC

CHILTERN MEDICAL CLINIC

ALLCLEAR CLINIC

CHIROPRACTIC CONSULTANTS

ALLEN CARR’S EASYWAY (INTERNATIONAL)

CHOICE HEALTHCARE SERVICES

ALLSOP & FRANCIS

CITYMEDICAL

AM MEDICAL

CLARENDON CHIROPRACTIC CLINIC

ANELCA CLINIC

CLAUDY CHIROPRACTIC CLINIC

APK CARDIAC SERVICES

CLIFFS CHIROPRACTIC CLINIC

(THE) ARK OCCUPATIONAL HEALTH

CO HEALTH EUROPE

ARTERIAL DISEASE CLINIC

CONQUEST CARE HOMES (SOHAM)

ASPEN HEALTHCARE HOLDINGS

CORPORATE HEALTH

ASPEN HEALTHCARE

COSMETIC SURGERY CLINIC

(THE) AXIS-SHIELD DIAGNOSTICS

COURT HOUSE CLINICS

BABYBOND

COVENANT HEALTHCARE GROUP

BACK TO HEALTH CHIROPRACTIC CLINICS

COVENANT HEALTHCARE

BACKSHOP CLINIC

(THE) COVENTRY AND RUGBY HOSPITAL CO PLC (THE) BARON CLINICS

COVENTRY AND RUGBY HOSPITAL CO (HOLDINGS)

(THE) BARONS CLINIC

(THE) CPL INTERNATIONAL SERVICES

BEXLEY OSTEOPATHIC CLINIC

(THE) CRAEGMOOR GROUP

BHS LEASING (1992)

CRYSTAL CLEAR INTERNATIONAL

BIRKDALE CLINIC (ROTHERHAM)

(THE) CYGNUS STATISTICAL SERVICES

BIRMINGHAM AND DISTRICT GENERAL PRACTITIONER EMERGENCY ROOM

DERMA LASER CLINIC

BIRMINGHAM GENDER CLINIC

DHARAM P MAUDGAL & CO

BIRTH CO

(THE) DIRECT HEALTH 2000

BLUESPARKLE

DIRECT MEDICAL IMAGING

BMI HEALTHCARE

DOCTORS LABORATORY

(THE) BODY IMAGE – BEAUTY & LASER CLINIC

DOVE CLINIC

(THE) BODYVIE

DR DOROTHY KELLY & ASSOCIATES

BOOTS OPTICIANS

DR S KEINI

BOURN HALL

DR W J WALKER

BREAKSPEAR MEDICAL GROUP

DROITWICH KNEE CLINIC

BROADGATE SPINE CENTRE

DURHAM CARE LINE

BROADWAY LODGE

DYKE ROAD HEALTH CLINIC

BROMHEAD MEDICAL CHARITY E L F ASSOCIATES

BROWNCROSS HEALTHCARE

E & O LABORATORIES

BSKYB HEALTHCARE SCHEME

ELLIOT-SMITH CLINIC

BUPA CARE HOMES (GL)

EUMEDIC

BUPA HOSPITAL EDINBURGH

EVERWELL CHINESE MEDICAL CENTRE

CALTHORPE CLINIC

EXPRESS MEDICALS

CAMBRIDGE DOCTORS ON CALL

FERNBRAE HOSPITAL

CARDIO-ANALYTICS

FETAL MEDICINE CENTRE

(THE) FLORENCE NIGHTINGALE HOSPITALS

ISLE OF WIGHT PRIVATE HOSPITAL PLC FOCUS MEDICAL SERVICES

J & L HYDE

FOSCOTE COURT (BANBURY) TRUST

JAPAN GREEN MEDICAL CENTRE

FRENCH COSMETIC MEDICAL CO

(THE) K N HAKIN

FRESENIUS MEDICAL CARE RENAL SERVICES

KASHODY CLINICS

FRESENIUS MEDICAL CARE RENAL SERVICES (UK)

KENT MEDICAL IMAGING

G W BOWYER

LANGFORD CLINIC

GALAN INVESTMENTS

LANGSTONE LEISURE

GENERAL HEALTHCARE GROUP

LASER EYE CLINIC

(THE) GENERAL MEDICAL CLINICS PLC LASER IMAGE MEDICAL CLINICS (UK)

GENERAL & MEDICAL FINANCE PLC LASER TREATMENT CLINIC

(THE) GORDON’S CHEMIST

LASERASE SOUTH WEST

GREAT BRIDGE PARTNERSHIPS FOR HEALTH

LASERASE (WALES)

GUY PILKINGTON MEMORIAL HOME

(THE) LASERCARE CLINICS (HARROGATE)

GYNAE CENTRE

LINDA RICHARDSON

HADLEY WOOD HEALTH CARE CENTRE

LITFIELD HOUSE MEDICAL CENTRE

HALE CLINIC (LONDON)

(THE) LODESTONE PATIENT CARE

HARLEY MEDICAL CENTRE

(THE) LONDON ALLERGY CLINIC

(THE) HARLEY STREET CANCER CLINIC

(THE) LONDON BREAST CLINIC

(THE) HARLEY STREET FERTILITY CENTRE

(THE) LONDON HYPERBARIC AND WOUND HEALING CENTRES

HARLEY STREET ORAL IMPLANT CLINIC

(THE) LONDON SPINE CLINIC

HARLOW OCCUPATIONAL HEALTH SERVICE

LYNDEN HILL CLINICS

HATLEY INVESTMENTS MEDICAL CENTRES

MAC UK NEUROSCIENCE

HCA INTERNATIONAL HOLDINGS

MANAGED MEDICAL CARE

HCA INTERNATIONAL

MANSFIELD CLINIC

(THE) HCA UK HOLDINGS

MAPPERLEY PARK MANAGEMENT SERVICES

HEALIX RISK RATING

MARBLE ARCH MEDICAL CENTRE

HEALTH CARE EXPRESS

MCINDOE SURGICAL CENTRE

HEALTH CARE PROJECTS

MCKINNON MEDICAL

HEALTH MATTERS (UK)

MDA CLINIC

HEALTH RESPONSE UK

MEDICAL CENTRE

(THE) HEALTH SURE UK

MEDICAL CENTRES SCOTLAND 2000

HEALTHCARE 2000

MEDICAL SERVICES INTERNATIONAL

HERMES CONTINENTAL

MEDICALS DIRECT CLINICS

HIGHBANK PRIVATE HOSPITAL

MEDICARE FRANCAIS HIGHFIELD HEALTHCARE

MEDIGOLD HEALTH CONSULTANCY

HIGHGATE PRIVATE CLINIC

MEDITECH GROUP

HMT HOSPITALS

MEDIVENTURE

HODGSON & HARDMAN

MERIDIAN HOSPITAL CO PLC HOLBEACH & EAST ELLOE HOSPITAL TRUST MIDLAND FERTILITY SERVICES

HOLTON E N T PRACTICE

(THE) MILD PROFESSIONAL HOMES

HOME FROM HOSPITAL

MILTON KEYNES ORTHOPAEDIC & SPORTS CLINIC

HOYLAKE COTTAGE HOSPITAL TRUST

(THE) MOBILE DOCTORS

INDEPENDENT BRITISH HEALTHCARE (DONCASTER)

MPS RISK SOLUTIONS

INDEPENDENT HEALTHCARE PROCUREMENT

MULTIPLE FOCUS

INFECTION CONTROL SERVICES

NATURE CURE CLINIC

(THE) INITIAL HOSPITAL SERVICES

NESTOR HEALTHCARE GROUP PLC INJURY CARE CLINICS

(THE) NEW STREET CLINIC

INSTITUTE FOR OPTIMUM NUTRITION (THE) NEWBURY & THATCHAM HOSPITAL BUILDING TRUST INTEGRATED MEDICAL CENTRE

NIGEL CARVER

INTERNATIONAL PRIVATE HEALTHCARE

NOBEL CLINIC (U K)

(THE) ISIGHT

NOMAD TRAVELLERS STORE & MEDICAL CENTRE

ISIS FERTILITY

NORTH BRISTOL DOCTORS

NORTH WEST INDEPENDENT HOSPITALS

SPORT AND ORTHOPAEDIC CLINIC (BRISTOL)

NORTON CLINIC

(THE) SPRINGMARSH HOMES

NUFFIELD HOSPITALS SQUADRON MEDICAL

OCEAN PARK LEISURE

ST GEORGE’S HOSPITAL

OLD CLINIC

(THE) ST MARTINS GROUP

OLDFIELD LODGE MEDICAL PRACTICE

ST MARTINS HEALTHCARE

OMNICARE CLINICAL RESEARCH

ST MARTINS LE GRAND

ORCHARD CLINIC

ST PAULS MEDICAL SERVICES

PARK ROAD (MEDICAL CENTRE)

ST VINCENT’S HOSPITAL PARKVIEW PRIVATE CLINIC

SURGICARE

PARTNERSHIP IN CARE

(THE) SUSSEX CLINIC

PATCH TEST AND PHOTOTHERAPY CLINIC

(THE) SYNEXUS

PATHWAYS (TREBANOS)

T G DEVELOPMENTS

PERTH ACUPUNCURE CLINIC

TERCIO

PHARMANET

THAMES VALLEY ANAESTHETIC SERVICES

PHYSIO CLINIC

(THE) THIRD SPACE MEDICINE

(THE) PHYSIOTHERAPY CLINIC

(THE) THREE SHIRES HOSPITAL

PIC

TLC LEISURE (BROMLEY)

PIVOTAL LABORATORIES

TRANSFORM HOLDINGS

PJ CARE

TRANSFORM MEDICAL GROUP (CS)

PLYMOUTH CHIROPRACTIC CLINIC

TRICHOLOGICAL CLINIC

(THE) PLYMOUTH EYE CLINIC

ULSTER INDEPENDENT CLINIC

PLYMOUTH MEDICAL CENTRE UNITY MEDICAL SERVICES

POUNTNEY CLINIC

VECTASEARCH CLINIC

PRIORY GROUP

VISUALASE

PRIORY OLD ACUTE SERVICES

WELLBEING CLINICS (UK)

PRIVATE CLINIC

(THE) WEST PENNINE CONSULTING ROOMS

PROHEALTHCARE

WESTHOLME CLINIC

PROPACARE

WIMBLEDON CLINIC

R W SURGICAL

WIMPOLE STREET MEDICAL CENTRE

RAMSAY EYE UK

WINDSOR HAND SURGERY

RAMSAY HEALTH CARE UK OPERATIONS

WORCESTERSHIRE IMAGING CENTRE

(THE) RAPHAEL MEDICAL CENTRE

(THE) WPH CHARITABLE TRUST (THE) RECRUITMENT GROUP

(THE) YORKSHIRE EYE HOSPITAL

REGIONAL HEALTH SERVICES

ZOLL MEDICAL UK

REHABILITATION SERVICES

RICHMOND DEVELOPMENT CO

RIDGEWAY CHIROPRACTIC CLINIC

RIVERDALE GRANGE

RMO INTERNATIONAL

SAYER CLINIC

(THE) SEEMA HEALTH & BEAUTY CLINIC

SEVEN SISTERS HOSPITAL SERVICES

SHC HOLDINGS

SHC MEDICAL SUPPLIES

SHRUBLAND HEALTH CLINIC

SLEEP DISORDER CLINIC

(THE) SOUTH MANCHESTER HEALTHCARE

SOUTHERN INDEPENDENT HOSPITALS

SOVEREIGN HOSPITAL SERVICES

SPIRE HEALTHCARE

SPIRE REDWOOD HOSPITAL

SPIRE WASHINGTON HOSPITAL

For more information visit http://www.researchandmarkets.com/research/d1b0ee/private_hospitals

Medical Spa Comes to St. Joe

By Jennifer Hall, St. Joseph News-Press, Mo.

Jul. 4–Kim Dragoo had never heard of an aesthetician or exactly what they do. So when a student studying to be one joined her salon, she paid attention.

“They go to (cosmetology) school with us, but they go to work at doctor’s offices after they graduate instead of salons like us,” Ms. Dragoo said.

Aestheticians are trained in giving facials, manicures, pedicures and other beauty treatments. They typically work for dermatologists or other medical professionals who perform skin treatments such as botox and peels.

That’s why the St. Joseph woman got the idea to open a medical spa, A New Day Salon at 312 Illinois Ave. It will feature services expected in a full-service salon. But under Dr. Robert Kline, customers will be able to get chemical peels, body contouring, which is a nonevasive form of liposuction, botox therapy and weight-loss programs.

Dr. Kline currently runs Kline Women’s Health Care in St. Joseph. As an obstetrician and gynecologist, Dr. Kline is used to women but is undergoing rigorous training to extend his current practice to that of the world of cosmetology.

“Medical spas are all over except for (St. Joseph),” Ms. Dragoo said.

Since employees are working under a physician, they have had to be certified and trained to aid customers with the skin care line available at the salon and chemical peels.

“It’s only available because we have a doctor,” Ms. Dragoo said. Dr. Kline will soon be at the spa on Saturdays, Wednesday mornings and Thursday afternoons. The salon’s regular hours are Tuesday through Saturday from 8 a.m. to 7 p.m.

“Everybody is already excited,” Ms. Dragoo said. “It will really help with people who have rosacea and other skin problems.”

The salon staff also can perform deep pedicures for those with foot problems, something Ms. Dragoo said patients would normally go to see a specialist for.

“They can go to the doctor and get their toenails clipped, but we go deeper and we can make them pretty,” she said.

For more information, call 238-0942.

Business Reporter Jennifer Hall can be reached at [email protected].

—–

To see more of the St. Joseph News-Press or to subscribe to the newspaper, go to http://www.stjoenews-press.com/.

Copyright (c) 2008, St. Joseph News-Press, Mo.

Distributed by McClatchy-Tribune Information Services.

For reprints, email [email protected], call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.

Baylor Medical Center in Dallas Closes Inpatient Psychiatric Unit

By Sherry Jacobson, The Dallas Morning News

Jul. 4–Baylor University Medical Center at Dallas quietly closed its inpatient psychiatric unit last week, eliminating nine beds reserved for mental-health patients.

“The decision to close this unit was not made lightly,” said a statement released Thursday by Baylor officials.

Advocates for mental-health patients say the loss of Baylor’s psychiatric unit will exacerbate an already serious shortage of psychiatric hospital beds in the region and state.

However, Baylor spokeswoman Maria Carpenter noted that the nine-bed psychiatric unit had been “underutilized,” perhaps because of the growth of specialty psychiatric hospitals.

The unit was averaging about three patients a day because such patients often were transferred from Baylor to other psychiatric facilities after a day or so, said Dr. Irving Prengler, Baylor’s vice president of medical affairs.

“We’ve been shifting away from inpatient [psychiatric] care in recent years,” he said.

The psychiatric unit was closed after the last patient was discharged last week. No employees lost their jobs as a result, Ms. Carpenter said.

Baylor officials said the closure was not announced because they did not consider it newsworthy.

Teams from other psychiatric facilities are evaluating psychiatric patients who show up in Baylor’s emergency room and are deciding where to send them. Psychiatrists who had hospitalized their patients at Baylor were told to send them elsewhere.

The unit’s closure was news this week to many people who work in Dallas’ mental health community.

“We’ve heard nothing about it,” said Josh Floren, a senior vice president who oversees Parkland Memorial Hospital’s medical services, including its busy 18-bed psychiatric unit.

“We operate at about 75 percent occupancy, so we should be able absorb their volume,” he said of the former Baylor patients. “We’re one of the few places in Dallas that can handle the medical needs of psychiatric patients.”

In an average month, Parkland’s psychiatric unit accommodates 50 to 60 patients for eight-to-10-day stays. Most are elderly Medicare patients who suffer severe psychosis, schizophrenia or other psychiatric conditions, and must be brought to the hospital by police escort.

John Dornheim, a spokesman for the Dallas branch of the National Alliance of Mental Illness, a mental-health advocacy group, said the loss of Baylor’s beds would be felt widely.

“Nine beds doesn’t sound like a lot, but if you’re one of those nine patients, it is,” he said. “We know we’re way short on beds already, and that just makes it more difficult.”

Mr. Dornheim said Dallas County has about 400 psychiatric beds and needs at least 100 more.

The shortage of psychiatric hospital beds creates a backlog of patients needing care, Mr. Dornheim said. He added that people with serious illness could end up with outpatient care when hospitalization is needed.

Jeanine Hayes, a mental-health advocate who works with several organizations, said she received treatment for depression at Baylor’s psychiatric ward in 1993.

“We have such problems finding and getting mental-health services,” Ms. Hayes said, adding that Texas ranks 48th in the nation for spending on public mental health services. “I think it’s a real loss for the community.”

—–

To see more of The Dallas Morning News, or to subscribe to the newspaper, go to http://www.dallasnews.com.

Copyright (c) 2008, The Dallas Morning News

Distributed by McClatchy-Tribune Information Services.

For reprints, email [email protected], call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.

Good and Evil in the Garden of Digitization

By Koehler, Wallace

Google and Fair Use In a January 2008 Searcher article, Beth Ashmore and Jill Grogg discuss the Open Content Alliance (OCA) and Amazon.com’s book digitization projects. They point out that Amazon and OCA did not invent book digitization and acknowledge the dragon in the corner – Google Book Search. As important and interesting as all projects by Google are, Google, by virtue of its size and leverage and because of its digitization model, has assumed dinosaur proportions with Google Book Search. An interesting history of its activities and reactions to them appears in an article by Ken Auletta for a January 2008 issue of the New Yorker. Auletta’s interview with Eric Schmidt, Google’s CEO, is intriguing. Schmidt recognized his critics and acknowledged that Google would be challenged, in part, because of its size. Auletta concludes his article and Schmidt’s interview with a quote: “What kills a company is not competition but arrogance. We control our fate.”

Google practices have raised the occasional hackle here and there in the copyright and fair use domains. Even back in 2003 (see Olsen), questions were being asked as to whether Google’s caching policies represented copyright violations. In our book, Fundamentals of Information Studies, June Lester and I raise the question – as do many others – that Google’s book digitization project pushes the very limits of fair use (2007: 303-4). I strongly suspect that fair use doctrine is insufficiently elastic to withstand Google’s assault, at least as copyright and fair use are now understood. And in what some have seen as a quixotic exercise and others as a necessary challenge to “Googlepower,” Siva Vaidhyanathan weighed in against Google Book Search back when it was still called Google Print. He worried that a finding against Google could destabilize intellectual property concerns. He questioned Google and Google’s university and public library partners’ rights to exercise fair use so broadly.

Win, lose, or draw, court decisions about the Google Book Project could have a chilling effect on the very concept of retrospective digitization (First Monday 2007):

[W]hat I’m afraid of is that Google will certainly lose in court, and what will happen is courts will generate an indelicate view of fair use, a highly restricted view of fair use and will ultimately reign in a lot of future experiments. That’s problem number one and that’s the legal problem I have with Google’s experiment.

The Google book digitization project has caused something of fervor, perhaps even a fire storm in the realm of intellectual property management. This issue is not solely for lawyers and academics; it can touch all of us in the information professions. On the one hand, Google may well provide researchers, users, and readers with an ever widening and invaluable resource. I just downloaded Thomas Greenwood’s 1902 Edward Edwards. The “meatspace” copy of this particular PDF version comes from the University of Michigan. Thank you, Google. Go, Wolverines.

On the other hand, it also may mean that a single economic for- profit entity could gain effective centralized control over much of the world’s information. Google’s intent may be quasialtruistic today, but, in the absence of oversight and regulation, that intent could morph into an Orwellian vision.

Centralization of Knowledge

The Google project to copy, digitize, and render documents to the world in snippets, if copyrighted, or full-text, if public domain, is the most recent manifestation of a long-held desire to centralize knowledge. Denis Diderot and other French Encyclopedists of the 18th century and Paul Otlet and Henri La Fontaine in the early 20th century sought to develop what H. G. Wells called a “World Brain” in 1938. The urge traces back as far as the 1st century B.C. with the Library at Alexandria and echoes in the development of national libraries in the 18th and 19th centuries. Sir Thomas Bodley can perhaps be credited with the idea of the deposit of newly published books at a central library with the library he established at Oxford in the early 17th century. Sir Anthony Panizzi gave teeth to book deposit in the mid19th century. In the U.S., Thomas Jefferson revitalized and doubled the size of the Library of Congress after its destruction by the British in the War of 1812.

Of course, the Google project is not the first one to digitize books or other documents. Important services such as Westlaw and LexisNexis have provided digital access together with sophisticated indexing to legal and government documents for a quarter-century or more. Other online data vendors and database aggregators have provided similar services to a wide range of clients for almost half a century, each year with greater and more sophisticated service. These services, such as Dialog, Ovid, STN, and a growing array of specialized Thomson and OCLC products, all offer access to specialized literatures with sophisticated search and retrieval features at a price.

Books have been digitized and made available over the internet by a variety of producers. Perhaps first and best known of these is Project Gutenberg [http://www.gutenberg.org]. Drama EServer [http:// drama.eserver.org] provides play scripts. Many academic libraries provide access to a variety of collections (e.g., University of Pennsylvania’s Online Books Page, http://online books.library.upenn.edu).

The idea of digitizing “books” is, of course not original to Google. What is original to Google is the taking of “knowledge products,” in copyright without permission of the copyright holder. This taking is sometimes shrugged off because (a) copyright holders of so-called orphaned works may be difficult to identify or contact and (b) because identifiable copyright holders have the right to opt out of digitization. This taking, according to Google, is acceptable under fair use provisions because Google proposes to only make snippets garnered from the digitized collection based on the end user’s keyword query available to users.

Intellectual Property

Is Google’s argument valid? To answer that question, we need to turn to the law and to history. First question, what is the law on fair use? That depends in large part on where you are. Is Google a U.S. company? Will its takings from Oxford University be guided under U.K. law, U.S. law, international law?

The history of copyright is an interesting one. The first copyright law as such was the British Statute of Anne of 1710. Prior to the Statute of Anne, publishing was regulated by patents and licenses granted by the state. The first publication license was granted to a Venetian publisher of classical authors in 1469. Licenses had two primary purposes: censorship and legal deposit.

The Statute of Anne represented an important shift in European thinking on intellectual property. It individualized ownership of intellectual products. Before Gutenberg, copying was common practice. Historians of the book have shown that there was little regard for authorship; that scholars and other authors often “borrowed” quite liberally from the works of others, often with the aid of scissors and a paste pot. Miguel de Cervantes Saavedra was unprotected in early 17th century practice and law from others who sought to profit from his intellectual creation, Don Quixote de la Mancha. Two hundred years later, important literary figures such as Charles Dickens, Victor Hugo, and Edgar Allen Poe campaigned for bilateral and multilateral copyright protection. The U.S. and the U.K. did not enter into a bilateral copyright treaty until 1891. The U.S. did not become party to a multilateral copyright agreement until 1952. And it was not until 1989 that the U.S. became a party to the Berne Convention, which first came into effect in 1886.

The Law and Fair Use

Copyright coverage and its exceptions, such as fair use, are complex. Fair use as a term of practice has moved from little or no regulation over the use of the intellectual property of others to an interesting morass of sometimes conflicting ideas and jurisdictions. Today, fair use is defined in the U.S. by the U.S. Copyright Act of 1976 and by federal court decisions that have interpreted it. The Act provides a four-part test for fair use. Under section 107:

[T]he use made of a work in any particular case is a fair use the factors to be considered shall include

1. the purpose and character of the use, including whether such use is of a commercial nature or is for nonprofit educational purposes;

2. the nature of the copyrighted work;

3. the amount and substantiality of the portion used in relation to the copyrighted work as a whole; and

4. the effect of the use upon the potential market for or value of the copyrighted work.

The fact that a work is unpublished shall not itself bar a finding of fair use if such finding is made upon consideration of all the above factors.

In the U.S., defining case law includes Basic Books, Inc. v. Kinko’s Graphics Corp. (1991); Maxtone-Graham v. Burtchaell (1987); Encyclopaedia Britannica Educational Corp. v. Crooks (1982); and American Geophysical Union v. Texaco, Inc. (1994, 1995). The Basic Books case found that Kinko’s infringed copyright when it created student course packs without appropriate payment of royalties. In Burtchaell, the court found that extensive quotations from another work did not per se represent an unfair taking. The use of appropriately cited material was, in fact, a fair use of copyrighted material. In the Encyclopaedia Britannica Educational Corp. case, the court held that wholesale copying and distribution of educational television programming, even for purely educational purposes, was beyond fair use and an illegal use of copyrighted material. In the Texaco case, the court found that the making of multiple copies of journal articles for distribution to Texaco researchers from a single subscription was an unfair taking of copyrighted materials. The Purpose and Character test is an interesting one. It includes not only whether the fair use taking is for economic purposes but also why the taking was done. Thus Purpose and Character justifications include criticism, parody, and artistic expression. I believe that Google cannot claim that its purposes include criticism, parody, or artistic expression. And since it has an economic interest in the project (although, to Google’s credit, it has never included its standard advertising as part of Google Book Search results – yet), its purposes are not purely altruistic.

The Nature of the Copyrighted Work test is concerned with the motive behind the creation of the copyrighted work. It also addresses the kind of work taken. Scholarly publications may have, by their very nature, a different level of protection than entertainment. “Sweat of the brow” is also important. Is the original work merely a collection of facts or does it represent an interpretative effort? In the U.S., the Feist case requires some intellectual effort (U.S. Supreme Court [1991], Feist Publications v. Rural Telephone Services Co. 499 US 340 [1991]. 499 US 340). According to the Desktop Marketing rule in Australia, the mere effort of compiling a list (sweat of the brow) is sufficient to convey copyright protection (Australia, Federal Court of [2002]), Desktop Marketing Systems PtyLtdv Telstra Corporation Limited [2002] FCAFC 112 (15 May 2002).

As Google proposes to copy everything, the nature of the copyrighted work test would seem to work against them. The Amount Taken test is an argument that the taking of very small parts of a copyrighted work is fair use. Google proposes to take all and offer little. The taking of all is not a small part. Again, a problem?

The Market Impact test addresses the economic damage a fair use taking might have on the copyright holder. Under U.S. law, market impact can be claimed as a fair use consideration. If a taking adversely impacts the value of the infringed work, then an unfair use may result. American law differentiates between commercial and noncommercial takings. In “noncommercial” actions, the plaintiff (copyright holder) must demonstrate the damage. But in “commercial” action, the burden lies on the defendant. Google has a commercial interest in providing snippets of books. Though to what extent keeping sticky eyeballs sticking to Google constitutes a commercial interest, most likely only the Supreme Court will tell.

I Am Not a Lawyer

Here comes the standard disclaimer: I am not a lawyer. Both tradition and the law guide us in our understanding of copyright and fair use. The Google initiative will have far-reaching implications for the definition and use of intellectual property. In one sense, Google’s project is a welcome one and represents an interesting return to the treatment and taking of the works of others in 16th century Europe and in some parts of the world today. Remember that the U.S., the largest producer and exporter of intellectual property today, was not an enthusiastic participant in global intellectual property regulation until very recently.

Yet many of us are uncomfortable with the Google plan. It looks like an unfair taking of intellectual property. Google tells us that it will only serve up snippets. But we need to remember that Google is serving up snippets from the whole thing copied from the original. That “whole thing” may well be a copy of a work still in copyright. Though most of the library partners for Google Book Search limit participation to public domain content, some – e.g. the University of Michigan – have provided Google digitizers access to in-copyright material as well.

Second, and far more importantly, according to Tom Turvey (2006:1), partnership head for Google Book Search, Google tells us it wants to be the information provider for the world. Given its size and economic leverage, will Google become the only important repository of the world’s literature? What are the implications for information stewardship if Google were to be successfully hacked? Or could Google some day become the instrument of an Orwellian plot where the collection is edited at will to serve another purpose? What will become of the collection if Google were to fail? Recall the quote from Eric Schmidt at the beginning of this paper.

I’m of two minds on the Google project. I like having access to “the literature” online, though I still turn to Project Gutenberg for the classics. I like the ability to search documents. We can acquire most materials fairly easily by purchase – online booksellers have made this virtually painless. Libraries and services such as interlibrary loan are excellent but not immediate.

The Google project represents a new ripple for copyright practice and law, maybe a new tsunami. Laws and customs change as the needs of societies change. So perhaps the Google project is simply a giant nudge to the future. It has us thinking and discussing intellectual property with a new enthusiasm. Is the project legal? I don’t think so, but in the end it will be for legislatures and particularly courts in many places to work it out. Is it good for us as information professionals or as citizens? It has the potential of both good and evil. That is for us all to work out.

Doom and Gloom

In an editorial discussion about this article, Barbara Quint and I debated the likelihood that Google might fail or fall prey to some sinister happenstance. Perhaps, as she feels, these are unlikely in the third millennium. We must remember we are thinking in historical time. Many human institutions have come and gone or been redefined. Who is to say, except perhaps for Walter Miller (A Canticle for Leibowitz) how the human record will be maintained into the fourth millennium?

References

Beth Ashmore and Jill Grogg, “The Race to the Shelf Continues. The Open Content Alliance and Amazon.com,” Searcher, vol. 16, no. 1, January 2008, pp. 18-23, 55-56.

KenAuletta, “The Search Party: Google Squares Off With Its Capitol Hill Critics,” New Yorker, Jan. 14, 2008 [http:// www.newyorker.com/reporting/2008/01/14/080114fa_fact_auletta]. Accessed Jan. 18, 2008.

First Monday, “Siva Vaidhyanathan” First Monday Podcast Transcript September 2007 [http://www.firstmonday.org/podcasts/ transcripts/transcripts_siva07.html]. Accessed Jan. 18, 2008.

June Lester and Wallace Koehler, Fundamentals of Information Studies: Understanding Information and Its Environment, 2nd ed. New York: Neal-Schuman, 2007.

Stephanie Olsen, “Google Cache Raises Copyright Concerns,” C/net News.Com, 2003 [http://www.news.com/2100-1038_3-1024234.html]. Accessed Jan. 16, 2008.

Tom Turvey, “A Perspective of Google Book Search. Viewpoint: Google Offers Its Side,” Information Today, vol. 23, no. 1, January 2006, pp. 1, 25.

Siva Vaidhyanathan, “Siva in Chronicle of Higher Ed: A Risky Gamble with Google,” 2005 [http://www.sivacracy.net/archives/ 002445.html].

H.G.Wells, World Brain, Meuthuen & Co. Ltd., 1938.

by

Wallace Koehler

Director/Professor

Master of Library and Information Science Program

Odum Library, Valdosta State University

Copyright Information Today, Inc. Jun 2008

(c) 2008 Searcher. Provided by ProQuest Information and Learning. All rights Reserved.

Polish Up on Past Pestilence and Present Pathogens

By Schofield, Cynthia B

Smallpox, diphtheria, typhoid fever, polio, cholera, and tuberculosis (TB) are among the diseases that struck fear into citizens of 18th- and 19th-century America. Discovery of antibiotics and antiseptic techniques in 20th-century America made the threat of death from an infectious disease seem like a horror of the past. In 1882, Robert Koch isolated and identified the Mycobacterium tuberculosis (MTB) bacillus, followed by Vibrio cholerae a year later. Louis Pasteur, renowned for his “germ theory” of disease, developed sterilization techniques that revolutionized the practice of medicine. Another early researcher, Edward Jenner, introduced the world to vaccination when he discovered that the cowpox vaccine conferred immunity to the dreaded smallpox disease; smallpox was thought to have been eliminated in 1977.

Beginning with the discovery of streptomycin in the 1940s, the rate of tuberculosis declined as new and more effective antibiotics were developed. Unfortunately, the 1980s brought co-infection with TB to many patients already suffering from HIV/AIDS. Resistant strains of TB also appeared; the multidrug resistant (MDR-TB) strain was followed by extensively-resistant TB (XDR-TB).1 By the 1990s, an escalating incidence of antibiotic resistance in many strains of bacteria was occurring. Nosocomial infection was out of control when resistant organisms began spreading in the hospital environment: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin resistant Entewcoccus spp. (VRE), and Clostridium difficile- associated disease (CDAD).

Despite years of intensive measures by the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) to prevent and control the recent transmission of infection, emerging and re-emerging pathogens are creating serious infectious threats in today’s world. The following illustrates their epidemic/pandemic nature and our present limitations for controlling them.

CASE I: Corymbacterium diphtherias – After a recent trip to Haiti where he had helped build a church, a 63-year-old man presented to the emergency department (ED) near his home complaining of severe sore throat and difficulty swallowing. He also reported that he was never vaccinated against diphtheria. After tests for Group A streptococcal antigen and infectious mononucleosis were negative, he was given oral augmentin (amoxicillin and clavulanate potassium) and discharged.

Four days later, he returned to the ED, afebrile but with worsening symptoms: chills, sweating, stridor (sounds indicating obstruction in the larynx), labored breathing, swollen neck, wheezing, nausea, and vomiting. His arterial pO2 was diminished, and X-rays showed soft-tissue swelling, an enlarged epiglottis, and an opaque left lung. He was intubated and admitted to the intensive- care unit with a diagnosis of impending respiratory failure. Laryngoscopy produced yellow exudates from the tonsils, posterior pharynx, soft palate, and anterior pharyngeal folds. For the next four days, the patient was treated with azithromycin, ceftriaxone, nafcillin, and steroids. Nevertheless, he became hypotensive and febrile, and continued to fail. Culture results showed MRSA was present in the sputum, and a throat swab for C diphtheriae was negative.

After eight days, a chest X-ray showed infiltrates were present in both lungs. Atracheostomy produced white exudates consistent with C diphtheriae infection. A typical C diphtheriae pseudomembrane covered the epiglottis and associated structures. Gram stains revealed the presence of Gram-positive rods, Gram-positive cocci, and yeast. More antibiotics were given – penicillin, gentamicin, vancomycin – and a diphtheria antitoxin (DAT) was added. Specimens cultured from the pseudomembrane were negative, but a polymerase chain reaction (PCR) test performed at the CDC proved that C diphtheriae toxin genes were present. Despite 17 days of treatment, cardiac complications ensued, and the patient died. The state health department and the CDC were notified. All previous contacts, possibly exposed to his respiratory secretions, were tested by PCR and cultured for C diphtheriae according to the CDC protocol. All contacts were given prophylactic antibiotics and a diphtheria toxoid vaccine, unless a booster had been given within the last five years.2

Diphtheria – Diphtheria is a life-threatening disease caused by a toxin produced by C diphtheriae and rarely by C ulcerans or C pseudotuberculosis. The deadly toxin produced is responsible for the pseudomembrane formed in the throat when the respiratory system is attacked. Transmission is through respiratory droplets, contact with skin lesions, and consumption of raw milk and dairy products. Though sporadically reported in the United States, diphtheria is endemic in many developing countries from unvaccinated populations. Travelers who are not immunized or have not had updated booster vaccine are at extreme risk if they are exposed.2

Clinical diagnosis’. The disease symptoms are sore throat, low- grade fever, and difficulty swallowing. Membranous nasopharyngitis or obstructive laryngotracheitis with swelling of the neck are observed in severe cases. Skin ulcers and the complications of airway obstruction, myocarditis, polyneuritis, and acute tubular necrosis may also occur. The diagnosis of diphtheria is primarily clinical, and suspected cases must be reported immediately to the CDC. Treatment, screening by a microbiology lab, and confirmation by the CDC are paramount. The patient must be isolated with universal precautions observed.2,3

Laboratory diagnosis – Culture and identification: Multiple swab samples are taken from the nose, throat, or any membranes present and transported (e.g., in Aimes semisolid media) without delay to the microbiology lab for culture. Advance notice is necessary to assure that correct processing for C diphtheriae will be performed. State departments of health and the CDC require notification of a suspected case.

Primary plating is done on routine 5% sheep-blood agar (SBA) and at least one selective medium, such as Cystine Tellurite blood agar (CTBA) or fresh Tinsdale medium. Growth on SBA produces white or opaque colonies; on CTBA, black colonies appear, providing presumptive identification after 18 to 24 hours at 37[degrees]C in 5% CO2. Because other coryneform bacteria produce similar colonies (usually smaller), fresh Tinsdale medium is recommended to demonstrate both tellurite reductase (black colonies) and cystinase enzyme activity (brown halo around colonies). Also available is selective media made with 5% SBA and 100 mug of fosfomycin per mL plus 12.5 [mu]g of glucose-6-phosphate per mL that inhibits most other coryneforms. Disks containing 50 [mu]g of each compound (BD Diagnostics, Sparks, MD) can be used as an alternative. Gram stain of colonies reveals pleomorphic Gram-positive rods. Subculture to Loeffler or Pai slants for purity is required prior to biochemical testing. Methods of biochemical testing include von Graevenitz and Funke (the CDC Special Bacteriology Reference Lab); API (RAPID) Coryne System (bioMerieux, Marcy l’Etoile, France); and the RapID CB Plus system (Remel, Lenexa, KA).3,4

Susceptibility testing: Until recent interpretive data supplied by the Clinical and Laboratory Standards Institute (CLSI) became available, testing methods and susceptibility results created confusion to a laboratory isolating any Corynebacterium spp. CLSI recommends the broth-dilution method with media designed for such fastidious organisms as Campylobacter spp. and Helicobacter spp. (CAMHB-LHB) but not disk diffusion. Some researchers have used the E- test (AB Biodisk, Piscataway, NJ) successfully; however, because Cdiphtheriae continues to exhibit in vivo susceptibility to penicillin and – with some exception – to erythromycin and other macrolides, susceptibility testing has not had high priority.5

Toxin testing; The WHO Streptococcus and Diphtheria Reference Unit (SDRU) modified the Elek Test, which employs antitoxin- impregnated disks that create precipitin lines (a positive reaction) when toxin-producing C diphtheriae is present on an agar plate after 24 hours of incubation. This method was found useful to detect the diphtheria toxin in the 1990s epidemic in Russia and the Ukraine. More recently, the WHO SDRU has developed a three-hour enzyme- linked immunosorbant assay, which can be performed on a culture- grown isolate of the organism. At present, a real-time PCR fluorescence test can be performed directly (from a clinical specimen) to detect the A and B subunits of the tax gene in C diphtheriae or (C ulcerans or C pseudotuberculosis. PCR results require confirmation with culture, histopathology, or an epidemiologic source before diagnosis is considered complete.4

Epidemiologic testing: Originally, the three biotypes of C diphtheriae – gravis, intermedius, and mitis – were differentiated on the basis of size and colony morphology. Discovery of numerous other biotypes not as easily distinguished, however, makes complete laboratory identification necessary (refer to Culture and identification). Outbreaks in Russia and the Ukraine in the 1990s were coincident with improved epidemiologic methods that applied molecular techniques to the typing of C diphtheriae elsewhere in the world. Examples include whole-cell peptide analysis, whole-genome restriction fragment-length polymorphism or (RFLP), ribotyping, and the more recent spoligotyping system, similar to the oligonucleotide typing for M tuberculosis. Methods, such as clonal grouping, genetic spacer region information, and so forth are also useful in differentiating endemic strains from those imported from other countries.3,4 Therapy: Diphtheria antitoxin is available only from the CDC and should be given, without waiting for laboratory confirmation, when nasopharyngeal or laryngotracheal symptoms appear. Because the disease may not produce immunity during convalescence, a diphtheria-toxoid vaccine should be given as well.3 Antibiotics are effective against C diphtheriae bacteria but not against the toxin. Thus, they are administered to eradicate and prevent transmission of the bacteria. Patient contacts must be sputum cultured for presence of the organism, and they should receive prophylactic antibiotics to eliminate any bacteria that may be toxin producing. Penicillin and erythromycin are usually given along with diphtheria toxoid vaccine unless vaccination or a booster has been performed within five years. The CDC protocol for children to receive diphtheria-pertussis-tetanus vaccine (DTaP) should be followed with appropriate boosters from two months to 12 years, followed by boosters every 10 years thereafter. Information is available for travelers from state health departments and at www.cdc.gov.2,3,4

Epidemiology: Because vaccination has become part of U.S. children’s health-maintenance program, the incidence of diphtheria has not been a threat since the 1950s. The increase in foreign travel, however, particularly to endemic areas (e.g., Haiti), changed previous patterns of transmission. When information regarding a patient’s travel, vaccination history, and possible exposure to infection are not immediately available to the attending physician, the patient fatality rate is 5% to 10%. Otherwise, standard procedure in any ED is first to rule out the common infections of Group A streptococcus, infectious mononucleosis, or viral infection. These procedures were followed in the case presented here.2,3

Worldwide immunization with DTaP vaccine has also prevented outbreaks of infection with C diphtheriae since the 1950s, but the most widespread and devastating outbreak in history occurred in 1994 in former Soviet countries. In Tajikstan, there were 31.8 cases per 100,000; in Russia, 26.2 cases per 100,000 – rates nearly 30 times those in the United States. WHO workers discovered that a diphtheria epidemic of 14,000 cases originated during the Soviet/ Afghanistan war in the 1980s. Soldiers returning home carried with them the deadly toxin-producing C diphtheriae. While outbreaks reached 12,000 victims in 1991, only 60% of Russian children (

Another astounding discovery was that immunologists, trained in the former Soviet Union, were not allowed access to “Western medical journals.” Lack of expertise led to the erroneous opinion among physicians that giving vaccines to children or families who were ill (for any other reason) was dangerous. Even after the 1994 epidemic ended, pertussis and tetanus were not combined with diphtheria (as in the western DTaP) because of continuing unfounded fears, use of outdated vaccine, or the unmanageable cost to purchase, transport, and store effective vaccines.6

In 2001, the incidence of U.S. children (ages 19 to 35 months) who had the required three doses of diphtheria-toxoid vaccine was 95%. When all U.S. residents were tested for antibodies considered “protective,” however, the percentage in children ages six to 11 years with a protective titer was 91%, but declined to 30% in adults aged 60 to 69 years. These startling changes occurred because the recommended boosters were not given every 10 years (or five years for contact exposure). From 1980 to 2001, there were 53 sporadic cases of possible or confirmed cases of C diphtheriae reported to CDC. Genetic testing revealed clonal similarity among all isolates found in the United States and the former Soviet Union.2,3

CASE II: Vibrio cholene – After vacationing in Southeast Asia, a 21-year-old U.S. college student became ill and presented to the ED. He admitted eating fried rice and an iced drink from a street vendor the day before his flight back to the United States. Nausea and vomiting were followed by watery diarrhea, abdominal cramps, and the devastation resulting from 15 bowel movements per day. Examination showed the patient suffered dehydration and orthostatic blood- pressure changes. Noted among his blood-chemistry test results were electrolytes, potassium (K) 2.8 mEq/L (critical 6.0 mEq/ L), and pCO^sub 2^ 22 mm/Hg (critical 40 mm/Hg). Fortunately, the physician had prior knowledge of the patient’s travel history to an endemic region. That information led him to order a microbiology culture and to notify the lab to look for Vibrio spp. Thus, the selective agar for Vibrio spp, thiosulfate- citrate-bile salts (TCBS) agar, was included in the initial stool processing. Immediate therapy, followed with intravenous Ringer’s lactate (electrolyte) solution administered as “replacement therapy” until he was stabilized. The stool culture grew toxigenic Vibrio cholerae O1.7 [Note: Information regarding antibiotic therapy was not available.]

Cholera – The cholera enterotoxin produced by Vibrio cholerae stimulates adenyl cyclase, an intestinal enzyme that causes secretion of large volumes of watery fluid (as much as one L/hour). The loss electrolytes – sodium, bicarbonate, potassium – leads to rapid dehydration, shock, and death in 50% of its victims. Unless immediate treatment is provided, hypokalemia, metabolic acidosis followed by hypovolemic and shock, renal and circulatory failure, are likely. Without benefit of rehydration therapy given intravenously along with antibiotic therapy, a patient experiencing severe diarrhea may rapidly progress to dehydration and death.7,8

Although cholera is not spread from person to person, the ingestion of V cholerae O1 through contaminated shellfish, water, ice, rice, and other foods exposed to “brackish” water (warm, salty- fresh), is a common source of contamination. The causes of epidemic cholera disease usually involve the non-invasive, toxin-producing V cholerae O1 serogroup (biotypes “Classical” and “El Tor”) or the more recent O139 serogroup found in India and Bangladesh, 1994. The antigenic, epidemic, and clinical characteristics of these toxic strains are distinctively different from those of the non-toxigenic strain, non-O1 V cholerae. The non-O1 strains do not agglutinate O1 or 0139 antisera but have phenotypic similarities to the toxigenic strains. Clinically, the gastroenteritis infection is usually mild to moderate, but unlike their toxigenic counter-species, the non-O1 strains often cause septicemia, particularly in high-risk groups (e.g., patients with liver disease and malignancies); the fatality rate can be from 47% to 65%. Non-O1 strains are associated with smaller, less severe outbreaks related to ingestion of contaminated seafood.7,8,9,10

Laboratory diagnosis – Isolation and culture: Routine enteric microbiology does not include special media to isolate V cholerae from stool. The lab must be alerted to the possibility of patient exposure to ensure that isolation and biochemical processing, specific for Vibrio spp., will be performed. Without information regarding seafood consumption or wound exposure to brackish water, this crucial diagnosis can be missed. Unless inoculation of media occurs within two to four hours, specimens should be preserved in a transport medium (e.g., Cary-Blair) to preserve viability. Vibrio spp. will grow on routine sheep-blood agar and MacConkey agar (MAC), but they cannot be distinguished from other sucrose-fermenting intestinal flora that may be present. Selective media, such as TCBS agar or a chromogenic agar (CHROMagar Microbiology, Paris, France), can be employed to select out these pathogens from normal enteric organisms. Phenotypic characteristics of the species include Gram- negative; facultative-anaerobic; and straight, curved, or comma- shaped rods. Noted for motility when grown in liquid medium, they are described as “darting” or “twisting,” a result of their mono- or multitrichous flagella.7,9

Identification: Agglutination tests using O1 or O139 antisera can provide presumptive identification. Other methods such as direct fluorescent-antibody and latex-agglutination tests require experienced interpretation of results. Commercial identification systems, manual or automated, have poor reliability for speciation ranging from 50% to 96% for V cholerae. Because microbiology labs may not have personnel or appropriate supplies to detect members of the Vibrionaceae family, specimens in question are usually referred to public-health labs for complete identification. Examples of biochemical tests needed to screen members of the Vibrio spp. found in human specimens are shown in Table 1. Characteristic of many Vibrio spp., other than V cholerae, is the growth requirement of 1% NaCl, which must be added to all media and biochemicals. The unique motility feature and variable biochemical characteristics cannot be evaluated by the commercial/automated systems used by most clinical labs.9

Susceptibility testing: Antimicrobial testing, when clinically indicated, usually is performed by public-health laboratories where cases of suspected V cholerae have been referred for confirmation and toxin testing. Though not available for other Vibrio spp., CLSI guidelines are available for V cholerae and include testing for ampicillin, the tetracyclines, folate pathway inhibitors, and chloramphenicol. The strains – 01,0139, and non-O1, collectively, – are 90% susceptible in vitro to aminoglycosides, azithromycin, fluroquinolones, extended-spectrum cephalosporins, carbapenems, and monobactams. Resistance exists in certain strains (e.g., O1, El Tor, and O139 from India and Bangladesh) to the antibiotics sulfamethoxazole, trimethoprim, and chloramphenicol.9 Therapy: Treatment with oral rehydration salts (ORS, electrolyte solution) had proven success during cholera outbreaks dating back to World War II. But in recent years, the use of intravenous therapy and administration of antibiotics has helped decrease fatality rates in severe cases. Fluid loss and the duration of illness have been dramatically reduced by antimicrobial therapy. When mild or moderate disease is present, ORS without antibiotic therapy is usually sufficient. Use of normal saline – because it does not contain the necessary electrolytes – should never be used to treat cholera.7 To avoid selective resistance, antimicrobial treatment is administered only when clinically relevant and after lab confirmation. Therapy with ciprofloxacin and doxycycline (for adults) and erythromycin (for children) is effective. WHO guidelines confirm the possibility of selective resistance and suggest that indiscriminate use may be ineffective in some cases. There are no vaccines authorized for travelers to endemic areas. Genetic engineering may resolve this dilemma with the development of a probiotic, a bacterial agent capable of binding to and neutralizing the cholera toxin. Scientists engineered a harmless strain of Escherichia coli to mimic GMl host receptors that, in turn, interfere with the attachment of Vcholerae to the small intestine.” At present, the best protection includes avoiding drinking water that is not treated or boiled and ingesting raw or undercooked food (particularly seafood). Physician recognition of cholera symptoms and prompt adherence to recommended therapy are imperative to decrease mortality and morbidity.7

Epidemiology: Endemic in the Indian subcontinent (Bangladesh, India, and Pakistan), cholera has spread seven times in 185 years to involve the entire world. Prior to 1905, the Classical biotype of serogroup 01 was responsible for six pandemics. Biotype El Tor has spread from Asia to Africa and South America in the past 35 years. First seen in the 1990s in South Asia, serogroup O139 continues to be endemic there.9

In the former Soviet states in the late 1990s, sewage pipes leaked into pipes used for drinking water. The outcome was an onslaught of enteric pathogens that created some of the most devastating epidemics ever seen – typhoid, Shigella dysentery, cholera-diseases usually seen only in developing countries. Another disaster allowed Vibrio cholerae O1 to thrive in the brackish salty water created in southern Ukraine during a project to bring fresh water for irrigation from the north. The Dnieper River emptied into Saslyk Lake, a salty marsh and estuary of the Black Sea that offered a perfect ecologic niche for warm-saltwater-loving Vibrio spp. The result was not only an outbreak of cholera but also a breeding ground for malaria as well as West Nile and Sindbis viruses added to the mix as a result of the increased mosquito population.6

From 1995 to 1999, there were 51 U.S. cases of V cholerae O1 but none of O139. Because the safety of U.S. drinking water and sewage systems is rarely compromised, cases of cholera have been limited to victims who travel to endemic countries. Outbreaks have been sporadic, and related to foreign travel or consumption of Gulf Coast seafood.9 During the two major hurricanes in 2005 in Louisiana, water was compromised when levee damage and subsequent flooding destroyed sewage systems. Two cases of cholera caused by V cholerae O1, ensued after victims ingested contaminated seafood. Both were susceptible to all antibiotics tested. Pulse field gel electrophoresis confirmed that the isolates were identical. No epidemics were reported, and the patients were treated with ORS and ciprofloxacin. Despite one patient’s co-morbidities, the two returned to their previous states of health.10

CASE III: Mycobacterium tuberculosis – A 31 -year-old man from Atlanta, GA, was presumed to be infected with XDR-TB. Against the CDC’s advice, he traveled to Paris and Greece, then to Italy and Prague, before he returned to the United States via Montreal. A preliminary diagnosis was made four months earlier when a chest X- ray revealed a lung lesion consistent with TB, and his tuberculin skin test (TST) was positive. The patient demonstrated none of the usual TB symptoms: productive cough, fever, chills, night sweats, and weight loss. Thus, he was not considered “highly infectious.” After 18 days of incubation, a culture performed at the Georgia Department of Human Resources grew mycobacteria, from which an isolate was referred to the CDC for confirmation and susceptibility testing. The patient was treated and told the organism was probably the MDR-TB, not XDR-TB, as originally suspected. He was then transferred to the National Jewish Medical and Research Center in Denver for specialized treatment. There he was quarantined in a negative-pressure room, in which the air is decontaminated by ultraviolet light. He was isolated with universal precautions to prevent transmission of the highly resistant strain should there be any change in his infectious state. He had possibly compromised the health of some 80 airline passengers during his travels. Pending surgery to remove the lung lesion, treatment was begun with five of the second- and third-line antimycobacterial drugs: moxifloxacin, cycloserine, para-aminosalicylic acid or PAS, amikacin, clofazamine, thionamide, and linezolid. Later, physicians surgically removed the lung lesion and confirmed his isolate as MDR-TB, treatable with the fluoroquinolones, among other drugs. His antibiotic therapy will undoubtedly continue for two years.12,13,14

MDR-TB and XDR-TB – From 1993 to 1999, the U.S. National TB Surveillance System reported declining rates of both TB and MDR-TB, defined by its resistance to the first-line drugs, isoniazid (INH) and rifampin (RMP), and susceptible to second-line drugs. In October 2006, the WHO was forced to revise the MDR definition when a new strain appeared that was resistant to second- and even third-line drugs – the fluoroquinolones and the injectable drugs amikacin, capreomycin, and kanamycin. Infection with the XDR-TB strain leaves a paucity of treatment choices in the armamentarium of antibiotics. Spread like diphtheria through respiratory droplet nuclei, the transmission of TB bacilli from person to person can threaten many populations. From 2000 to 2006, researchers were encouraged when a decreasing number of HIV/TB-infected patients was noted. That number was soon offset by an increase in foreign-born cases, particularly Asian. The exact number of XDR-TB cases continues to be incomplete because of limited data from developing countries (e.g., Africa, India) where the strain predominates. Worldwide data for cases identified as TB and MDR-TB for 1993 through 2006 totaled 202,436. cases in the United States (only) identified as XDR-TB for 1993 through 2006 totaled 49.15

Diagnostic tests: In 2005, the CDC and the FDA approved a new test, known as the Quanti-FERON-TB Gold test (Cellestis Limited, Carnegie, Victoria, Australia), that detects both active and latent TB. Performed with an enzyme-linked immunosorbent assay technique, it measures the amount of interferon-gamma produced in a patient’s blood. Long recognized as the standard test for infection with M tuberculosis, the reliability of the TST has been contested. Crossreactivity with other mycobacteria, an increased positive reaction on repeat testing, and dependence for test results on an observer’s eye all are problematic. Though the newer test is not as subjective, controversy exists regarding which method has greater sensitivity and specificity when testing all populations: normal, HIV-infected, and other immune-compromised groups.16

Laboratory diagnosis – Specimen processing: Digestion and decontamination of both sputum and bronchoscopy specimens is accomplished first by liquefaction (to release mycobacteria into the mucin), then with sodium hydroxide (NaOH) to aid in removing bacterial contamination. Though not without limitations, the combined reagents, N-acetyl-L-cysteine (NALC), dithiothreitol and 2% NaOH, are agents commonly used for this purpose. Other contaminated specimens may require NaOH alone. Processing is required prior to planting a specimen on culture media (e.g., Lowenstein-Jensen or Middlebrook 7H10 agar) or transfer to a broth suitable for an automated detection system [e.g., BACTEC 12B broth used with the radiometric BACTEC 460TB system (BD Diagnostic Systems, Sparks, MD)].

Safety requirements, guidelines for equipment, and methods used, as well as recommendations for transport and storage of specimens in approved clinical labs, are published in the CDC and National Institutes of Health (NIH) instruction manual, Biosafety in Microbiological and Biomedical Laboratories.

Staining: Acid-fast stains are required to penetrate the mycolicacid residues present in the cell walls of mycobacteria. The fluorochrome-staining method, demonstrated with fluorescent microscopy, is preferred for high sensitivity and easier detection of acid-fast bacilli. Confirmation of positive smears continues to require the gold-standard Ziehl-Neelson smear. Together, these stains have a predictive value of >90% for M tuberculosis complex (MTBC) in sputum. They provide rapid screening for patients who may be highly infectious and require isolation precautions for the protection of others.16,17 Note: MTBC includes M tuberculosis, M bovis, M africanum, M microii, M canettii, M caprae, and M pinnipedii.

Culture and identification: Both solid and broth media are used to culture mycobacteria. A broth medium is used for rapid growth and suitable for automated detection and susceptibility-testing systems. Solid media, – Lowenstein-Jensen (egg-based), Middlebrook 7H10 or 7H11 (agar-based), and selective media containing antibiotics to deter overgrowth by non-mycobacteria – are considered the gold standard for confirmation and susceptibility testing. From slow- growing (seven to 14 days) solid media, the characteristics of growth, colony morphology, pigmentation, and optimal temperature requirements (35[degrees]C, 37[degrees]C, and 30[degrees]C) can be evaluated. Biochemical tests for speciation (e.g., niacin accumulation and nitrate reduction for M tuberculosis) can also be performed. For more rapid growth (

More recently, a rapid method of MTBC identification has been described by researchers at the Tuberculosis Research Laboratory, Beijing, China, as the PCR-reverse dot-blot hybridization assay. Results are available in only 2.5 hours after PCR processing. The procedure does not require an expensive sequencer and can be performed in clinical labs. Agreement with DNA sequencing was 99% for clinical strains compared to 90.6% for more conventional methods. Reference strains tested in the study had specificity and sensitivity of 100%.19

Strain typing; Epidemiologic studies require definitive information made possible by the development of molecular methods. Table 2 lists some of the methods commonly used for strain typing.18

Susceptibility testing – Agar proportion method: In the United States and Europe, the agar proportion method of susceptibility testing of slow-growing mycobacteria was initiated in the 1960s to become the gold standard for all antimycobacterial-drug testing, except pyrazinamide (PZA), which can be determined by automation. Middlebrook 7H10 agar is infused with specific concentrations of antibiotic agents (agar diffusion) or overlaid with disks impregnated with these drugs (disk elution). Both “low-” and “high- ” level susceptibility are tested. The proportion of resistant “mutants” and drug concentrations in the media is critical. A significant proportion of MTBC resistance, above which a drug may not be effective, is set at 1%.20

BACTEC 460TB: The BACTEC 460TB radiometric method continues as the automated system of choice, despite availability of several acceptable non-radiometric systems. Growth in BACTEC 12B broth and metabolism by mycobacteria of the [^sup 14^C] palmitic acid present in the broth produces ^sup 14^CO2 at a rate and amount proportional to the growth of mycobacteria present. Results are rapid – growth occurs in seven days compared to two to three weeks for the agar proportion method and both first- and second-line drugs can be tested. The percent of resistant mycobacteria cannot be estimated, and both false-positive and false-negative susceptibility can occur. The automated method is used as a “screen” until definitive results from the agar-proportion test are available. Confirmation of any new MDR- or XDR-TB strain requires results from the agar-proportion method.20

Therapy: The first-line drugs recommended by the CLSI for MTBC are INH, RMP, ethambutol (EMB), and PZA. INH, which acts mainly on the organism’s cell-wall mycolic-acid synthesis, is the drug of choice for latent or active TB infection. Its effectiveness against MTBC continued from its first introduction in 1952 until resistance appeared in the 1960s.20,21 The second-line drugs, (ethionamide, the aminoglycosides [e.g., amikacin, kanamycin] and the fluoroquinolones [e.g., moxifloxacin and levofloxacin]), are used when first-line drugs fail. They require a longer term of therapy, and are more toxic, less effective, and more expensive. Of primary concern, however, is the enhancement of opportunity for selective resistance.21,22

Two types of drug resistance are found in M tuberculosis’, primary – occurring in an untreated person – or, the more common, and acquired – emerging during therapy as a result of selective resistance. Typical of all bacteria, antibiotic resistance occurs in mycobacteria by a variety of mechanisms that include decreased uptake (e.g., dormant acid-fast bacilli), drug inactivation, (e.g., beta-lactamase production), increased efflux, (e.g., fluoroquinolone resistance), and alteration of the target site (e.g., INH and RMP).20

Epidemiology: Outbreaks of MDR-TB appeared in the United States in the 1980s and 1990s. Prompted to stop the increasing incidence, the CDC initiated the 1992 National Action Plan to Combat Resistant MDR-TB. The plan was instrumental in improving laboratory services with rapid and more accurate identification technology, more rapid susceptibility testing, improved infection control, and coordination with HIV test results. The result was a dramatic decrease in MDR-TB cases from 1993 to 1999 that correlated with an overall total U.S. decrease of 34% in total number of TB cases.15

After New York City’s MDR-TB epidemic in 1991 was attributed to inadequate antibiotic therapy in a group of homeless victims and AIDS patients, the first monitoring system, Directly Observed Therapy System, or DOTS, was instituted. The WHO had endorsed the method with a worldwide endeavor to monitor compliance. Unfortunately, former Soviet countries (e.g., Russia, Ukraine, and Belarus) that were medically uninformed and financially devastated, persisted in adhering to the outdated programs of the 1950s. Isolation in sanitariums (institutions for treatment of chronic diseases, e.g., TB) and treatment with one or two antibiotics (only part of worldwide therapy from 1980 to 1990) were still in place from the Soviet rule of Nikita Krushchev. Lack of funding was the primary factor that forced early discharge of patients and insufficient therapy – a perfect setup for selective resistance and the appearance of the MDR-TB strain. The cost of X-rays and surgical procedures to remove infected lungs and other organs, combined with the expense of antibiotics, made treating these patients prohibitive. Even the old methods of confining patients to sanatoriums and treating with one or two drugs became unmanageable with drug resistance spreading. They were simply left there to die. By 1998, the WHO noted that 25% of the former Soviet cases were multidrug resistant.6

At present, the greatest threat lies in developing countries where HIV/AIDS rampages out of control. According to a recent study in Natal, South Africa, co-infection with TB affects 80% of patients and mortality is nearly 40% per year despite therapy. The rate of 1.7% in MDR-TB cases (2000 through 2002) had increased to 9% (2003 through 2006) by the second survey. Analysis of 53 cases of XDR-TB showed only 50% had received therapy for TB. Within 16 days of the culture report, 52 of the 53 had died.23

In 2006, treatment guidelines for MDR-TB were prepared by the WHO, the American Thoracic Society (ATS), the CDC, and the Infectious Disease Society of America (IDSA). Further guidelines were written by the WHO in the Global Plan to Stop TB 2006-2015. Included are instructions for the proper management and administration of drugs in cases of MDR-TB and XDR-TB. The strategy and financial burden will require as much as $56 billion U.S. to cover all programs, (e.g., DOTS, the research and development of newer technology tools, and so forth).21,22

Summary – The cases presented here illustrate potential epidemic or pandemic events that once-silent pathogens portend. Developing countries, where defenses are limited, are primary targets. Of future concern are the developed countries that fail to use rigorous control measures established by the CDC, the WHO, and others to prevent the spread of infectious diseases. International travel has brought changes in demographics and a greater need for surveillance programs to control selective antibiotic resistance. In our first case, the patient’s death would likely have been avoided if he had adhered to the CDC-recornmended vaccine program. The fact remains that 20% to 60% of U.S. adults, including travelers to endemic areas, have not followed the diphtheria booster-vaccine schedule.2,3,4

Our second case demonstrates the ease of transmission through food and water that contribute to illness from cholera. The success of intravenous therapy or ORS treatment has reduced the number of deaths by approximately 3 million per year in Asia and Africa. Though development of oral vaccines may be promising, without water and sewage control, waterborne transmission of cholera is a continuing threat.7,8,10

The panic following our third case was a sample of the pandemonium an outbreak of XDR-TB would create. Lack of access to medical care and lack of funding in developing countries made selection of resistance from MDR- to XDR-TB a predictable event. The Global Plan to Stop TB 2006-2015, initiated to improve on the DOTS strategy to control TB/HTVand MDR-TB cases, targets 2015 for reducing overall prevalence and mortality from TB.21,22 Based on the principle that community healthcare is the best prevention, organizations that are dedicated to the control of emerging and re- emerging infection include the CDC, NIH, IDSA, ATS, and the National Academy of Science’s Institute of Medicine, to mention a few. Recently, they have established plans and programs to address problems of communication among scientists and to improve surveillance in the detection and monitoring of dangerous pathogens.1 The remarkable and ever-changing dynamics of microbial adaptation, however, requires enormous vigilance and financial priorities worldwide. A coordinated effort by both scientists and public-health leaders is needed if the onslaught of infectious threats is to be controlled.

Rapid nucleic-acid tests for identification

1. The AMTD kit (Gen-Probe, San Diego, CA) is adaptable for smear positive or smear negative specimens by targeting the 16S rRNA region of the genome to detect MTBC, but does not differentiate among species in the group.

2. For smear positive samples only and for species identification (M tuberculosis) the Amplicor system, (Roche Molecular Systems, Branchburg, NJ) targets the same 16S region.

3. The third method, BD Probe Tec strand displacement amplification (BD Diagnostic Systems, Sparks, MD) is an isothermal enzymatic process that uses IS6110 (MTBC) and the 16S rRNA gene of mycobacteria.17,18

Molecular Methods for Strain Typing MTBC

1. IS6110a – restriction fragment-length polymorphism, known as RFLP, was first used as a DNA probe to sequence MTBC strains. This insertion sequence is commonly found in these strains. A newer method, “mycobacterial interspersed repetitive units” (MIRU-VNTR) that can accurately cluster epidemiologically related strains is expected to replace the older IS6110 RFLP.

2. Spoligotyping-The “spacer oligotyping” method is based on a region of the genome that has non-repetitive short spacer sequences. PCR amplification aids in the specific identification of a group of oligonucleotides in the M tuberculosis genome. Not recommended for routine clinical laboratories, the method requires complex and multistep hybridization.

3. PCR strategies-Certain genetic regions “variable-number tandem repeats” (VNTR) that can be amplified and coded to correspond to the number of repeated units in each region.

4. Whole-genome fingerprinting- High-density oligonucleotide microarray testing: 20 probe pairs target the intergenetic region of M tuberculosis and can be used to analyze a small number of strains by detecting patterns of deletions. This method is expected to become commercially available for future clinical-laboratory use.18

References

1. Satcher D. Emerging infections: getting ahead of the curve. Emerg Infect Diseases. 1995;1(1).

2. Centers for Disease Control and Prevention (CDC). Fatal respiratory diphtheria in a U.S. traveler to Haiti: Pennsylvania 2003 and travelers’ health. MMWR. 2004;52(53):1285-1286.

3. Sutphen SK. Vaccine-preventable illnesses: are they under control? Medscape Today. http://www.medscape.com/viewprogram/6330. Accessed May 8, 2008.

4. Funke G, Bernard KA. Coryneform gram positive rods. In: Murray PR, Jorgensen JH, Pfaller MA, et al. Manual of Clinical Microbiology. Vol 1. 9th ed. Washington, DC: ASM Press; 2007.

5. Hindler JF, Patel JB. Susceptibility test methods: fastidious bacteria. In: Murray PR, Jorgensen JH, Pfaller MA, et al. Manual of Clinical Microbiology. Vol 1. 9th ed. Washington, DC: ASM Press; 2007.

6. Garrett L. Bourgeois physiology. In: Betrayal of Trust New York, NY: Hyperion; 2000.

7. Daniels NA, Shafaie A. A review of the pathogenic Vibrio infections for clinicians. Infectious Medicine. 2000;17(10):665- 685.

8. Sack DA, Sack RB, Nair GB, Siddique AK. Cholera. Lancet 2004;363(9404):223-233.

9. Abbott SL, Janda M, Johnson JA, Farmer JJ III. Vibrio and related organisms. In: Murray PR, Jorgensen JH, Pfaller MA, et al. Manual of Clinical Microbiology. Vol 1. 9th ed. Washington, DC: ASM Press; 2007:723-733.

10. Streif-Bourgeois S, Sokol T, Thomas A, et al. Two cases of toxigenic Vibrio cholerae 01 infection after hurricanes Katrina and Rita. MMWR. 2006;55(2):31-32.

11. Paton JC and University of Adelaide, Australia Colleagues. Genetically engineered probiotic designed to treat and prevent cholera. Gastroenterology. 2006;130:1688-1695.

12. Smith M. XDR-TB patient apologizes to contacts who must be tested. Medpage Today. http://www.medpagetoday.com/ InfectiousDisease/Tuberculosis/tb/5799. Published June 1, 2007. Accessed May 8, 2008.

13. Phend C. ATS: XDR-TB gains ground around the world. Medpage Today. http://www. medpagetoday.com/MeetingCoverage/ATS/tb/5779. Published May 29, 2007. Accessed May 8, 2008.

14. 2007 tuberculosis scare. Wikipedia. http://en.wikipedia.org/ wiki/Andrew_Speaker. Accessed May 8, 2008.

15. Masur H. Tuberculosis: advances in diagnosis and therapy. Medscape Today. http:// www.medscape.com/viewarticle/522380. Accessed May 8, 2008.

16. Pfyffer GE. Mycobacteriunr. general characteristics, laboratory detection and staining procedures. In: Murray PR, Jorgensen JH, Pfaller MA, et al. Manual of Clinical Microbiology. Vol 1. 9th ed. Washington, DC: ASM Press; 2007:543-572.

17. Vincent V, Gutierrez MC. Mycobacteriunr. laboratory characteristics of slowly growing mycobacteria. In: Murray PR, Jorgensen JH, Pfaller MA, et al. Manual of Clinical Microbiology. Vol 1. 9th ed. Washington, DC: ASM Press; 2007:573-588.

18. Wu X, Zhang J, Liang J, et al. Comparison of three methods for rapid identification of mycobacterial clinical isolates to the species level. J Clin Microbiol. 2007;45(6):1898-1903.

19. Woods GL, Warren NG, Inderlied CB. Susceptibility test methods: mycobacteria, Nocardia, and other actinomycetes. In: Murray PR, Jorgensen JH, Pfeller MA, et al. Manual of Clinical Microbiology. Vol 1. 9th ed. Washington, DC: ASM Press; 2007:1223- 1247.

20. Lettieri CJ. The emergence and impact of extensively drug- resistant tuberculosis. Medscape Today. http://www. medscape.com/ viewarticle/557459. Accessed May 8, 2008.

21. Migliroi GB, Loddenkemper R, Blasi F, Raviglione MC. 125 years after Robert Koch’s discovery of the tubercle bacillus: the new XDR-TB threat. Is “science” enough to tackle the epidemic? Eur Respir J. 2007;29:423-427. http://www.erj.ersjournals.com/cgi/ reprint/29/3/423.pdf. Accessed May 8, 2008.

22. Bartlett J. MDR and XDR tuberculosis literature: commentary by Dr. John G. Bartlett-April 2007. Medscape Today. http:// www.medscape.com/viewarticle/555306. Accessed May 8, 2008.

By Cynthia B. Schofield, MT(CAMT), MPH

Cynthia B. Schofield, MT(CAMT), MPH, is a microbiology technical supervisor (Ret.) from the VA San Diego Healthcare System in California.

Copyright Nelson Publishing Jun 2008

(c) 2008 Medical Laboratory Observer; MLO. Provided by ProQuest Information and Learning. All rights Reserved.

An Overview of Current Practice in Hepatitis C Testing

By Liang, Shu-Ling

Hepatocyte injury, commonly encountered in the practice of medicine, can be caused by a number of diseases such as hepatitis, autoimmune disorders, and congenital or acquired disorders of metabolism, or by exposure to alcohol, chemicals, and drugs. The most common cause of liver injury worldwide is infection with viruses that primarily infect the liver, often termed hepatitis viruses. Viral infections are the most common cause of acute hepatitis. The range of responsible viruses is very broad, but those of greatest importance are the hepatitis viruses A, B, C, D, and E. The viral hepatitis “alphabet” is still growing. In 1996, novel RNA viruses were identified from the sera of patients with liver disease by two research groups. These possible agents have been named hepatitis GB virus type C (GBV-C) and hepatitis IG virus (HGV), respectively.1 These viruses are distinguished from each other by their morphology, modes of transmission, and propensity for development of chronic infections. The A and E viruses are transmitted via the fecal-oral route and cause acute hepatitis very rarely with any long-term complications, while the B, C, and D viruses are transmitted by exchange of body fluids; major methods of transmission include serum, sexual intercourse, illegal drug injections, and transmission from mother to infant (usually occurring during delivery), and are associated with development of chronic hepatitis infections, which might, ultimately, lead to cirrhosis (scarring) of the liver, hepatocellular carcinoma, liver failure, and death. Viral hepatitis is a major public-health problem, affecting people of all ages, races, and ethnicities. The World Health Organization (WHO) estimates that over 2 billion people alive today have been infected with the hepatitis B virus (HBV) at some point in their lives, and about 350 million of these remain chronically infected. In addition to this, available data indicate that approximately 3% of the world’s population is infected with hepatitis C virus (HCV), giving an estimated total of 170 million people. With all of these viruses, the highest prevalence is among the people in Asia, Africa South America, and eastern, central, and southern Europe. The actual number is hard to obtain because many people are not aware that they are infected and are not clinically ill.

In the United States, chronic liver disease and cirrhosis is the 12th leading cause of death among adults; deaths from cirrhosis are predicted to increase 360% by 2028 due to cases developing from chronic hepatitis-C infection. Hepatocellular-carcinoma or cancer incidence has doubled in the past 20 years and is expected to rise another 68% over the next decade from cancers developing in hepatitis-C-infected individuals.2 Due to the extensive implementation of HBV vaccine and well-established protocols, the infection and complications of HBV have gone down tremendously. HBV vaccine is considered the first vaccine against cancer. It is estimated that 1.25 million Americans have chronic HBV infection. Although prototype vaccines that induce antibodies to HCV-envelope proteins have been developed, currently, hepatitis-C vaccination is not feasible practically. Genotype and quasispecies viral heterogeneity, as well as rapid evasion of neutralizing antibodies by this rapidly mutating virus, conspire to render HCV a difficult target for immunoprophylaxis with a vaccine. An estimated 3.9 million Americans have been infected with HCV, and 2.7 million people have chronic infection; HCV is the most common reason for liver transplantation, making HCV infection the most common chronic (long-term) blood-borne viral infection in the United States.2

Liver disease is often clinically silent until late in its course. For this reason, laboratory tests are usually needed for recognition and characterization of the type of liver injury present. This is a field that combines different principles of laboratory medicine, such as clinical chemistry, immunology, virology, and molecular diagnostics. We will focus our discussion on the current practice of HCV testing. Serologie and nucleic-acid- based tests (NATs) are required to document exposure to and presence of the virus, and are also used to monitor treatment of infected individuals.

Hepatitis C virus (HCV)

HCV is an RNA (ribonucleic) virus of the flaviviridae family. The structure of the HCV consists of a core of genetic material (the RNA), surrounded by an icosahedral protective shell of protein, and further encased in a lipid (fatty) envelope of cellular origin. Two viral envelope glycoproteins, El and E2, are embedded in the lipid envelope.1

Clinical and laboratory features of hepatitis-C infection

Diagnosing acute hepatitis-C infection with certainty can be difficult, primarily because more than 70% of patients do not have symptoms associated with the acute infection.3 It is even more challenging due to lack of a reliable and specific IgM-based serologic test, and potential overlapping laboratory findings with acute and chronic hepatitis-C infection (elevated alanine transaminase of ALT levels, positive serum HCV RNA, and anti-HCV IgG antibodies).

Overall, approximately 25% of all patients with acute HCV present with jaundice, and 10% to 20% develop gastrointestinal symptoms (nausea, vomiting, or abdominal pain).3 On average, when symptoms do occur, they typically manifest six to eight weeks after exposure (range five to 12 weeks) and last for two to 12 weeks.3 In many cases, laboratory abnormalities may provide the initial clue to suggest a diagnosis of acute HCV infection. Rising ALT levels are typically observed approximately 40 to 50 days after infection.4 Mean peak ALT values have tended to range between 400 IU/Lto 1,000 IU/L. Serum bilirubin levels may also be elevated, but they do not typically exceed 12 mg/dL. Occasionally, acute hepatitis C can manifest as a severe illness, but no cases of acute liver failure have been reported in the United States.

Overall, approximately 70% to 80% of individuals infected with hepatitis C will progress to persistent infection and about 20% to 30% will spontaneously resolve the infection. Serum HCV levels generally peak within six to 10 weeks of infection, regardless of eventual progression to chronic or resolved infection. In most individuals, anti-HCV antibodies appear seven to eight weeks after exposure. Notably, up to 3% of patients with chronic hepatitis C may never seroconvert.4 Among those individuals who have spontaneous resolution of the HCV, it typically occurs within one year after infection. Both the presence of jaundice at the time of initial infection and a rapid decline in viral load during the first four to eight weeks after infection4 correspond with sustained viral clearance. Acute hepatitis C can be diagnosed with a high level of certainty when the following three criteria are met:

* the patient reports recent risk factors for acquiring HCV;

* laboratory studies show positive HCV RNA levels, an elevated ALT level, and a positive anti-HCV-antibody test; and

* laboratory studies obtained within the prior 12 months demonstrate negative HCV viremia, normal serum hepatic aminotransferase levels, and negative HCV antibodies.

In the absence of historical data, several studies of acute HCV have relied on a stricter biochemical criterion of an ALT level greater than 10 or 20 times normal.3,4 The presence of HCV RNA without detectable antibody response may also suggest acute hepatitis C, but, as previously noted, some individuals with chronic hepatitis C may never seroconvert. People who have recovered from a prior HCV infection often continue to make HCV-specific antibodies for decades. Consequently, their screening HCV EIA will remain positive even though they do not have ongoing infection.

Treatment recommendations for hepatitis C

The goal of therapy for hepatitis C is to achieve a sustained virologie response, defined as undetectable HCV RNA at least six months after cessation of therapy. Despite controversial findings among studies in the literature, the American Association for the Study of Liver Disease (AASLD) 2004 has generated interim recommendations, stating sufficient data exist to support serious consideration for treatment in most instances for patients with acute hepatitis C, after waiting two to four months for possible spontaneous clearance and assuming no contraindication for therapy exists. In addition, the AASLD has issued interim recommendations regarding length of therapy and possible therapeutic regimens.5

The length of treatment for acute hepatitis C has varied, depending on the response rates patients with acute hepatitis-C infection. HCV has six major genotypes and 50 subtypes. The prognosis is closely related to the genotype. Genotype 1 causes 70% to 75% of infections in the United States and is characterized by a lower rate of response to treatment (50% cure rate). Genotypes 2 and 3 have a much better response to treatment (80% cure rate). It is estimated that 70% to 80% of adults who are infected with HCV go on to have chronic infection, which is defined as the presence of HCV RNA in the blood for more than six months. Chronic infection is promoted by a high rate of viral mutation, lack of a vigorous host T- cell response, and replication in hepatocytes without cytotoxicity.

Infants born to HCV-infected mothers have passively acquired maternal antibody for up to 18 months after birth and, therefore, should only be screened using an HCV-antibody screening test after 18 months of age.6 If earlier diagnosis is required, a qualitative polymerase chain reaction (PCR) can be performed at three months of age6; however, a positive result does not mean the child will be chronically infected and false-positive results occur. Currently, there is no safe and effective intervention known to prevent perinatal transmission of HCV. An effective hepatitis C vaccine has not been developed, and the drugs used most commonly to treat hepatitis C in both children and adults, interferon and ribavirin, are not recommended for use in pregnancy. There are no Food and Drug Administration- (FDA-) licensed therapies for children younger than 18 years of age. Therapy, however, may be indicated in select cases. Consultation with a pediatric specialist with experience in treating HCV infections in children is warranted.

Screening for HCV infection – flow chart

Because testing for the presence of HCV is complicated, and false- positive and false-negative results occur, an algorithm for the use of laboratory tests to diagnose patients with hepatitis C was developed by the Centers for Disease Control and Prevention (CDC) in 2003.7 The HCV-antibody screen that we offer at our medical center gives us the ability to separate probable false-positive reactions from true-positive reactions by means of a signal-to-cutoff ratio.

1) Positive screens that have a low signal-to-cutoff ratio will be automatically reflexed to a recombinant immunoblot assay, or RIBA, confirmatory test before reporting the antibody screen.

2) If the RIBA is negative, the patient will be considered not infected with HCV, and the screen will be considered to be a false positive.

2a) If the RIBA is positive, which should happen rarely with a low signal-to-cut-off ratio, the physician will be called and blood obtained for a HCV quantitative PCR and, if positive, reflex to genotype, if possible and clinically appropriate.

3a) If the PCR quantitative test is positive, the genotype will be done and the patient considered to have active infection with hepatitis C and recommended for evaluation by a specialist in hepatitis-C disease.

3b) If the PCR is negative, then the patient may be one of the 20% to 30% who has spontaneous cure of the disease, in which case he will be positive for HCV antibodies but negative for active dis ease by the PCR results (no viral RNA detected). A comment will be in the report that a single negative PCR result does not rule out active infection, and a second PCR (qualitative test) is recommended within a month.

4) If the HCV antibody screen has a high signal-to-cutoff ratio, this indicates the patient has a greater than 95% chance of truly being infected. The physician will be called and blood obtained for the supplemental tests (HCV quantitative PCR) to confirm the antibody screen.

5) If the quantitative PCR is positive, the specimen will automatically have a genotype done, and the patient will be considered to have active infection with HCV and recommended for evaluation by a specialist in hepatitis-C disease.

5a) If the quantitative PCR is negative, the specimen will automatically be reflexed to a RIBA confirmatory test.

6) If RIBA is negative, the screen result would be reported as negative, and the patient considered not infected with hepatitis C (false-positive antibody screen).

6a) If the RIBA is positive, then the patient is positive for hepatitis-C antibodies and a single negative PCR result does not rule out active infection. The recommendation is a second PCR (qualitative) in a month to confirm spontaneous cure.

HCV-antibody screening test – EIA

The algorithm for diagnosing HCV infection begins with detection of antibodies to HCV using an PDA-approved enzyme immunoassay (EIA). In order to increase sensitivity, each reagent bead is coated with multiple HCV antigens (recombinant HCV polypeptides representing core [c22p], c200 [NS3 and NS4], and NS5 sequences). Indeed, the sensitivity is almost 100% in healthy adults with chronic HCV infection. There are two situations in which the HCV EIA test can be falsely negative. After exposure to HCV, it takes six to eight weeks to develop HCV IgG antibodies.4,5 Thus, the HCV EIA can fail to detect acute HCV infection. In addition, immunosuppressed persons, including those with relatively advanced HIV infection, can have a false-negative HCV EIA test.5 In all other cases, the HCV EIA serves as an outstanding screening test for HCV infection because of its high sensitivity and relatively low price. The specificity of the HCV EIA is good.

There are two different strategies for confirming a positive HCV EIA. When a patient has a positive HCV EIA test, the primary objective is to confirm the EIA results by RIBA and also to determine whether they have chronic hepatitis C, a goal most expeditiously achieved by testing for HCV RNA.

HCV-antibody confirmation test -RIBA

RIBA contains the same HCV antigens, as do the EIA tests, separately on a strip along with Superoxide dismutase (SOD) to detect non-specific antibodies to yeast proteins (recombinant HCV antigens are typically derived using yeast as the vector). A positive RIBA is defined as reactivity against two or more HCV antigens from different regions of the genome, without reactivity to SOD. Reactivity to a single HCV antigen or to a multiband with reactivity to SOD is considered indeterminate. Reactivity to none of the HCV antigen or to SOD only is considered negative. The advantage of the confirmatory anti-HCV test is that it can be performed on the same serum or plasma sample that was collected for the screening anti-HCV assay.

A positive RIBA result is interpreted as anti-HCV positive but does not distinguish between current or past infection; further HCV RNA testing is required to diagnose active infection. A negative RIBA result indicates a false-positive screening-test result. Several studies have demonstrated that HCV RNA is not detected in these sera, and HCV was not transmitted from blood units that were found to be EIA positive, RIBA negative. Thus, patients with EIA- positive, RIBA-negative sera do not require further testing and are considered “true negative;” and these patients are considered uninfected, although similar results may occur early after infection (prior to seroconversion) or in some chronically infected patients; additional NAT testing is appropriate if there is high clinical suspicion.

RIBA has lower sensitivity but higher specificity than the EIA method, therefore serving a perfect purpose for a confirmatory test. HCV-antibody result should not be reported until the initial EIA result is confirmed by the subsequent RIBA test. When HCV infection is not suspected, this approach is very helpful because the patient can be counseled accordingly, generally to his great relief.

HCV RNA assays

There are several HCV RNA assays that have been approved by the FDA for detecting chronic HCV infection. Some tests merely determine the presence or absence of HCV RNA; these tests are often referred to as qualitative tests, and the lower limits of detection of approximately 50 IU/mL (100 RNA copies/mL). Other assays can determine the quantity of HCV RNA; these are referred to as quantitative tests. The lower limit of detection is 200 lU/mL (500 RNA copies/mL). In general, qualitative assays are more sensitive, but this is not universal. Results from different methods cannot be directly compared because different standards are used. A WHO international standard for HCV RNA for NAT testing is now available8 and is being introduced to use by kit manufacturers.

HCV RNA is very susceptible to degradation by the high activities of RNase present in blood; therefore, serum specimens for HCV RNA should be centrifuged as soon as possible after clot formation. EDTA or sodium-citrate plasma are preferred specimens for HCV RNA tests. Heparinized plasma is inhibitory for many NAT assays, and serum specimens provide suboptimal stability unless serum is frozen soon after specimen collection. If centrifugation is performed immediately, less than 10% of HCV RNA is lost, even if the plasma or serum is not separated from the formed elements for up to six hours.9 If a serum-separator tube is used, specimens are stable after centrifugation for up to 24 hours.9 Short-term (

The quantitative assays, however, were configured to detect HCV RNA in more than 95% of persons with chronic HCV infection. Since they almost always are “positive” in persons with chronic hepatitis C – and because they also provide information used to predict treatment response – many clinicians prefer to use quantitative tests to confirm a positive HCV EIA in a person suspected of having HCV infection. A positive NAT not only confirms infection, it indicates active HCV infection; however, if the NAT is negative, then the positive screening HCV EIA still needs to be confirmed with RIBA. The added analytic sensitivity of the qualitative assays is probably important in monitoring response to treatment since persons who still have trace amounts of HCV RNA detected at the end of treatment will very likely relapse.10

If HCV RNA is used to confirm a positive EIA result instead of RffiA, there are some issues to consider. Because there are rare instances in which HCV RNA is intermittently undetectable in persons with chronic HCV infection, a negative RNA test result in a person with a positive screening HCV EIA needs to be repeated several months later. This is one of the reasons that HCV RNA testing is inferior to RffiA for persons who have a low pre-test probability of HCV infection. On the other hand, EIA- and RIBA-positive sera usually contain HCV RNA. The ELA-positive, RIBA-indeterminate sera may also contain HCV RNA, especially if the reactivity was to core or NS3 antigens. When EIA- and RIBA-reactive sera do not contain HCV RNA, it still represents prior HCV infection that has resolved. Genomic amplification and sequencing, followed by sequence comparison and phylogenetic-tree construction is the reference method for genotype determination. ‘ ‘ A variety of genotype- screening assays have been described, including PCR using genotypespecific primers, restriction fragment-length polymorphism of amplified sequences, and a commercially available line-probe assay.” These methods compare favorably with the reference method for determining HCV genotype.

Other tests

Liver-function tests and liver biopsies are not sensitive or specific enough to be used for screening. They may be the initial test that triggers testing for hepatitis C, and they are used as adjunct tests by specialists in treatment of hepatitis C who are caring for patients with the disease.

RIBA has lower sensitivity but higher specificity than the EIA method, therefore serving a perfect purpose for a confirmatory test.

Liver-function tests and liver biopsies are not sensitive or specific enough to be used for screening.

Viral hepatitis is a major public-health problem, affecting people of all ages, races, and ethnicities.

References

1. Kazuhiko N, Khin MW, San SO, et al. Molecular characteristic- based epidemiology of hepatitis B, C, and E viruses and GB virus C/ hepatrtis G virus in Myanmar. J Clin Microbiol. 2000;39(4): 1536- 1539.

2. National Center for Health Statistics. National vital statistics reports. 2008:56(10).

3. Centers for Disease Control and Prevention (CDC). Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR Recomm Rep. 1998;47(RR-19):1-39.

4. Bowen DG, Walker CM. Adaptive immune responses in acute and chronic hepatitis C virus infection. Nature. 2005;436:946-952.

5. Strader DB, Wright T, Thomas OL, et al. American Association for the Study of Liver Diseases. Diagnosis, management, and treatment of hepatitis C. Hepatology. 2004:39:1147-1171.

6. Mast AF, Hwang L-Y, Seto D, et al. Perinatal hepatitis C virus transmission: maternal risk factors and optimal timing of diagnosis. Hepatology. 1999;30:499A.

7. Alter MJ, Kuhnert WL, Finelli L Guidelines for laboratory testing and result reporting of antibody to hepatitis C virus. MMWR Recomm Rep. 2003:52:1-16.

8. Saldanha J, Lelie N, Heath A. Establishment of the first international standard for nucleic acid amplification technology assays for HCV RNA. Vox Sanguinis. 1999:76:149-158.

9. Davis GL, Lau JY, Urdea MS, et al. Quantitative detection of hepatitis C virus RNA with a solid-phase signal amplification assay: definition of optimal conditions for specimen collection and clinical application in interferon-treated patients. Hepatology. 1994;19:1337-l341.

10. Sarrazin C, Teuber G, Kokka R, et al. Detection of residual hepatitis C virus RNA by transcription-mediated amplification in patients with complete virologie response according to polymerase chain reaction-based assays. Hepatology. 2000:32:818-823.

11. Forns X, Bukh J. Methods for determining the hepatitis C virus genotype. Viral Hepatitis. 1998:4:1-19.

By Shu-Ling Liang, PhD

Shu-Ling Liang, PhD, is an instructor in pathology at the Harvard Medical School, and an assistant director of Clinical Chemistry in the Department of Pathology at Beth Israel Deaconess Medical Center in Boston.

Copyright Nelson Publishing Jun 2008

(c) 2008 Medical Laboratory Observer; MLO. Provided by ProQuest Information and Learning. All rights Reserved.

California Pharmacies Expect Disaster After Loss in Lawsuit Loss to Stop the 10 Percent Medi-Cal Provider Cuts

Today, a state court denied eight retail pharmacies’ motion to stop the ten percent Medi-Cal provider cuts. The pharmacies sought a temporary restraining order (TRO) from Sacramento Superior Court against the California Department of Health Care Services and its director Sandra Shewry to block the cuts from being implemented. The court sided with the Department of Health Care Services (DHCS) finding that the pharmacies had not demonstrated that DHCS had to obtain federal approval prior to implementing the cuts. The court also found that the risk of harm presented by the pharmacies was speculative. Specifically, the court found that:

1.) Only a select number of branded drugs would be reimbursed below cost;

2.) That it was speculative that the rate cuts would result in pharmacies operating at a loss; and

3.) That the risk of loss of services to Medi-Cal beneficiaries overall was speculative. That is, the court determined it was speculative that the pharmacies would close, lay off workers, reduce hours and refuse to fill prescriptions.

“We are sorely disappointed with the outcome of this lawsuit,” said Lynn Rolston, chief executive officer of the California Pharmacists Association. “However, the fight is far from over. There are two other lawsuits pending in federal court and we are confident that we have a strong case to stop the ten percent provider cuts. Unfortunately, for now, the cuts will be implemented as scheduled, which could result in tragic consequences for pharmacies and the patients they serve.”

A recent report showed that if the ten percent Medi-Cal provider cuts are implemented, pharmacies will be faced with tough decisions including turning away new Medi-Cal beneficiaries, dropping Medi-Cal altogether or going out of business. Smaller and rural pharmacies will be hardest hit, forcing other pharmacies to pick up a larger portion of the Medi-Cal population, which they may not be prepared to do. As part of the domino effect, these other pharmacies will feel the strain and might cope with reduced revenue in other ways, such as cutting staff and hours, which would mean longer lines and slower service for everyone.

The eight pharmacies, including Farmacia Remedios, Inc., Ross Valley Pharmacy, South Sacramento Pharmacy, Horton and Converse Pharmacies, Zweber Apothecary, Komoto Pharmacy and Medical Pharmacy, Pucci’s Leader Pharmacy and Gregg’s Pharmacy vowed to continue the fight to seek a preliminary and permanent injunction against the ten percent Medi-Cal provider cuts.

Butner Psychiatric Hospital Readying for Open

By Michael Biesecker, The News & Observer, Raleigh, N.C.

Jul. 3–BUTNER — State mental health officials said today they are finally ready to move patients into North Carolina’s newest psychiatric hospital — a project dogged by doubt, delays, cost overruns and safety concerns.

Opening day for Central Regional Hospital in Butner has been called off at least four times since November, when it was originally set to receive patients.

The facility is now scheduled to open by the middle of July with patients transferred from two aging hospitals set to close — John Umstead Hospital in Butner and Dorothea Dix Hospital in Raleigh.

In the past year, internal safety reviews have raised repeated questions about design flaws with the $130 million building, including places where suicidal patients might hang themselves or jump to their deaths.

In a concerted effort to change negative perceptions about the new hospital, administrators invited members of the media to walk through the facility this morning. Tours for the families of patients, mental health advocates and others will be held this weekend.

Michael Lancaster, co-director of the state mental health division, was appointed as interim director of Central Regional last month following the resignation of former director Patsy Christian over a portrait of herself she commissioned for the building using vending machine money intended to benefit patients.

While careful not to concede the hospital had ever been unsafe, Lancaster said today the delays had allowed the time to improve safety.

“We’ve had lessons learned,” Lancaster said. “And we will continue to improve after patients arrive. This will be a safer hospital in 12 months than it is today.”

Among the issues that have been addressed are handicapped grab bars in patient bathrooms safety inspectors warned could be used to anchor a noose made from a bedsheet or clothing.

State workers initially tried to solve the problem by adding a steel plate below the bars, which are located in the private bathrooms inside every patient suite. But that fix left sharp metal edges exposed and a remaining gap that a sheet could still be threaded through.

Workers have since added a second plate to cover the gap and filled the remaining crack with special “pick-proof” caulk.

The remaining contraption isn’t elegant, but officials said they are satisfied it is now safe.

In other parts of the hospital, new walls have been added to cover overlooks in stairwells where a patient might have jumped.

New locks have been added to some bathroom doors so nurses can lock out suicidal patients or those who suffer from a condition that causes unquenchable thirst. Such patients might drink themselves to death if allowed access to an unmonitored spigot.

In a major reversal of policy, dozens of surveillance cameras have been added throughout the facility, including in restraint rooms and seclusion rooms. The cameras, which digitally retain footage for weeks, could provide a deterrent to staff members tempted to abuse patients, as well as clear those falsely accused.

Christian had vigorously opposed adding such cameras.

“The juice isn’t worth the squeeze,” she had said on a similar tour in December.

It was decided not to fix some other issues pointed out by the inspectors, however, such as hundreds of door handles that could be used to anchor a noose.

Steve Oxley, clinical director of the new hospital, said Thursday the door handles did not offer a major risk.

“We believe we have a safe facility,” Oxley said.

—–

To see more of The News & Observer, or to subscribe to the newspaper, go to http://www.newsobserver.com.

Copyright (c) 2008, The News & Observer, Raleigh, N.C.

Distributed by McClatchy-Tribune Information Services.

For reprints, email [email protected], call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.

Have a Say on Health Centres

PEOPLE in the region are being asked for their views on the development of new health services in the region.

NHS North of Tyne, a management team working across Newcastle Primary Care Trust (PCT), North Tyneside PCT and Northumberland Care Trust is seeking views on where a new health centre and GP practices should be sited.

Members of the public are welcome to attend drop-in sessions on the consultation organised.

The first session is on July 11, at Scotswood Neighbourhood Centre, from 10am to 1.30pm.

There are also sessions at St Aidan’s Community Centre, Brunton Park, on July 15, at 4pm and Cowgate Neighbourhood Centre on July 16, at 10am or St James’s Park on July 28 at 6.30pm.

Dr Mike Guy, medical director for NHS North of Tyne, pictured, said: “These new services are aimed at providing more flexibility. They will also result in more health services being provided closer to where people live.”

(c) 2008 Evening Chronicle – Newcastle-upon-Tyne. Provided by ProQuest Information and Learning. All rights Reserved.

Cities Plan for World Where Oil is Scarce

If Greensboro leaders became convinced the years of cheap fuel are gone forever, what would they do?

Residents could soon find out. A citizen effort to educate the public about peak oil is making its way to City Hall. Mayor Yvonne Johnson said she expects a briefing on the issue later this month.

Knowledge of peak oil, the point at which the amount of petroleum that is economically feasible to extract and refine goes into decline — and prices go through the roof — has spurred some cities in the United States to curb their oil use. Some activists cry out for a World War II-scale mobilization that would transform the economy to run on a fraction of its fossil fuel base.

“The stark reality is that we’re looking at a world where not too long in the future, fossil fuel energy will not be around,” said David Noer, professor of business leadership at Elon University. “We’re in deeper trouble than we think.”

Now, Guilford County residents and leaders must decide how that transformation should take place and who should lead the effort: local governments or businesses.

The recent spikes in oil prices startled consumers, businesses and governments, and have sparked protests around the globe.

Darlene Garrett, a member of the Guilford County Board of Education, said she wants the district to evaluate programs that bus students outside their attendance zones and the possibility of cutting back to a four-day school week. The district’s diesel costs rose 260 percent over five years.

“I really do believe we need to have frank discussions, because I’m afraid it’s going to come to a point where we have to cut transportation,” Garrett said.

Keith Debbage, a UNCG urban planning professor, called high fuel prices “a blessing and a blight” to the region’s transportation industry. While trucking companies suffer layoffs, logistics companies — responsible for making deliveries quick and timely — are in demand, he said.

Noer said other Triad businesses fear that transportation costs will compel commuting workers to quit. Companies should explore van pooling and telecommuting to reduce turnover and Internet sales to make up for reduced foot traffic.

Businesses can’t handle these challenges alone, Noer said; state and federal lawmakers must play a role.

“Everybody is in denial except for some thinkers,” he said. “I don’t think our politicians can tell the truth because people don’t want to hear the truth.”

Some cities have seen the storm clouds gathering and begun the arduous task of severing their ties to oil.

The city of Portland, Ore., convened a peak oil task force in 2006 and committed to cutting fossil fuel use by half within 25 years. Last year, Portland’s City Council budgeted $1.4 million to open city land for community gardens, help businesses and homeowners install solar technology, support green building and motivate residents to reduce driving.

On June 12, Connecticut Gov. M. Jodi Rell signed a law that will help cities plan for energy scarcity and cost increases.

And a citizens group called N.C. Powerdown met this year with officials in Carrboro and Chapel Hill.

“In some ways, the wheels are still slow to turn,” said Abraham Palmer, a Carrboro resident who coordinates the three-year-old group.

Local government officials need to initiate conversations about how to respond to declining oil supplies, said Daniel Lerch, a program manager with the Post Carbon Institute in California.

The nonpartisan group helps government and grass-roots groups prepare for peak oil.

“At the end of the day, government has the capacity and the resources to step in when the market has not prepared us, for when the community has not prepared us,” Lerch said.

Not everyone believes government should advocate lifestyle changes.

People can decide for themselves whether they can afford oil, said Daren Bakst, a legal and regulatory policy analyst for the John Locke Foundation, a libertarian think tank in Raleigh.

“What should North Carolina do?” Bakst asked. “Nothing. The government doesn’t need to do anything.”

Except perhaps pressure the federal government to lift restrictions on offshore drilling, Bakst added.

In mid-June, Bakst released a report for the foundation that criticizes North Carolina’s recent efforts to address global warming, including a 2007 law that requires 12.5 percent of the state’s energy to come from renewable sources, such as solar or wind, by 2021. Bakst argues that the law, as well as a possible cap and trade program to limit carbon dioxide emissions, would drive up energy costs.

“The problems being discussed, there’s nothing new here,” said Bakst, referring to peak oil. “What are we going to do? Spend more money because some people think it will be a problem some time in the future?”

U.S. Rep. Howard Coble, a Republican whose district includes Guilford County, supports both an increase in alternative fuels use and offshore drilling.

“If we had explored over the past two decades, I believe we would be in a better position with gas prices than we are now,” Coble said.

President Bush called for an end to the federal ban on offshore drilling in June. But a 2007 federal report said drilling access to the Pacific, Atlantic and eastern Gulf regions would have an insignificant impact on domestic production or prices before 2030.

Miracle technologies, such as the hydrogen fuel cell, hold little immediate promise. The U.S. Department of Energy counted fewer than 200 hydrogen-powered vehicles on the road in 2006 after decades of expensive research.

Jason Hoyle, coordinator of the N.C. Fuel Cell Alliance, called fuel cell cars the “holy grail” of the automobile industry because they run more efficiently and don’t emit pollutants. But fuel cells primarily power buildings and electronics, such as computers.

“After years of floundering, (the industry) has finally figured out that they can think about cars, but they have to sell something,” he said.

North Carolina businesses hope to have more success with biodiesel and ethanol production. Ten percent of the liquid fuels sold in North Carolina by 2017 should come from biofuels produced from local weeds, vegetable oil waste and other feedstocks, according to one state goal.

Universities drive some of that development. The Center for Energy Research and Technology at N.C. A&T received $720,000 from the state this year to work on various energy projects, including the creation of a biofuels refinery and farm cooperative.

Harmohindar Singh, the center’s director, said he believes it will take $10 a gallon gasoline to drive conservation in the country. “Other countries are paying it,” Singh said. “Why can’t we pay?”

Singh supports special gas taxes to pay for alternative fuels use and public transit.

Debbage, of UNCG, said North Carolina also could change its tax codes to reward businesses that offer four-day work weeks, telecommuting and ride-sharing.

But Hoyle said lawmakers should beware of unintended consequences in favoring certain industries and technologies or misspending taxpayer money.

“It all goes back to ‘How much do we know?'” he said. “What do our decision makers have to work with?”

In the meantime, North Carolina officials are working to reduce their own fuel consumption.

State agencies, universities and community colleges must reduce their petroleum use by 20 percent by 2010. Those agencies cut fuel purchases by 2 million gallons, or 7.5 percent, between 2005 and 2007.

“We’ve got to get our own house in order before we have the credibility to lead other people in this direction,” said Larry Shirley, director of the state energy office.

Debbage said Greensboro should diversify its economy and encourage denser development that allows people to live and shop close to work.

“One of the problems with the Triad is that we have been sprawling for so long, that we are really paying the price,” he said.

Greensboro could follow a trend by some cities to “relocalize,” or produce more of their food, energy and products at home, Debbage said.

“That is something I think Greensboro should embrace wholeheartedly,” he said.

WANT TO GO?

–What: Presentation on peak oil by Peter Kauber of Guilford Solar Communities

–When: 10 a.m.-noon July 12

–Where: Kathleen Clay Edwards Family Branch Library, 1420 Price Park Road, Greensboro

–Cost: Free

–Information: 375-5876 or send an e-mail to [email protected]

—–

To see more of the News & Record or to subscribe to the newspaper, go to http://www.news-record.com.

Copyright (c) 2008, News & Record, Greensboro, N.C.

Distributed by McClatchy-Tribune Information Services.

For reprints, email [email protected], call  800-374-7985  or  847-635-6550 , send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.

Report Assails Ohlone Trustees’ Infighting

By Todd R. Brown, The Argus, Fremont, Calif.

Jul. 3–FREMONT — Ohlone College has received an official warning from an accrediting commission that the school’s trustees need to set aside their differences, delegate policy work to staff and ensure stability and empowerment in the Ohlone community — or risk the college’s academic standing.

“A warning is a sanction issued by the commission,” said Gari Browning, Ohlone’s new president/superintendent. “If we were to ignore the commission and not respond to it in a timely fashion … it could linger. We would have two years to comply.”

Browning served as associate director of the commission for four years. While the college responds to the critique, Ohlone’s accreditation will stand and students should not worry about transferring credits or losing financial aid, she said.

Yet the stinging report by a team of evaluators who visited the college in the spring listed serious problems that must be addressed in order to lift the warning. The 50-page assessment went public this week with the commission’s decision mailed out Monday.

“There is significant dysfunctionality within the Board of Trustees that is perceived to have a negative impact on student learning and the quality of the institution,” the report says. “Board members often act as individuals, which has led to micromanagement of the president and other college staff.

“Board members who do not vote with the majority have an ethical obligation to not undermine the decisions

of the majority.”

The criticism, however, is part of a mostly favorable picture of the college. From a collaborative spirit among teachers and students, to the strides Ohlone has made in building its Newark campus and broadening its programs, the report says people in all walks of the academic community help in its success.

“All college constituencies are very proud of Ohlone, and only the inappropriate behavior of the trustees detracts from the very positive climate and progressive approach to challenges and opportunities demonstrated by faculty, staff, administrators and students,” the report says.

The Novato-based Accrediting Commission for Community and Junior Colleges certifies those schools in California and elsewhere on a six-year schedule. It has the power to uphold a college’s academic status, put it on probation or revoke its accreditation.

The commission considered Ohlone board activity going back to 2002, when the last accrediting process took place. The evaluators’ report detailed how one board member “has engaged in negative newspaper articles regarding the college” and pointed to other trustee actions that have sandbagged the group.

“Several students felt uncomfortable when approached by a board member who recently, and without the knowledge of his board colleagues, solicited complaints about faculty and administrators,” it said. “The board member set up a table on campus for the purpose.”

Browning called such behavior inappropriate for a representative of the college.

“The board is a body,” she said. “It’s not that they can’t speak, it’s that they can’t speak for the college.”

Board President Garrett Yee said the trustees already are working on recommendations by the commission, including plans for a July 19 meeting on the warning letter and report and an Aug. 13 workshop on improving the board’s self-evaluation process.

“We take the findings very seriously,” he said, adding of the unnamed renegade, “I hope the board member now knows that that kind of act is really beyond the scope of what a board member should be doing.”

The commission directed Ohlone to complete two reports, the first due Oct. 15 on the board and the next due March 1 on employee evaluations and other matters. Browning said evaluators also will return in November before the next commission meeting in January.

Trustee Rich Watters, who came aboard in 2006, said much of the bad behavior documented in the report occurred before his time and should not detract from the praise.

“Everything else was positive academically,” he said. “The board is really committed to making sure we aren’t going to be a thorn in the college’s side and that we hold each other accountable.”

Reach Todd R. Brown at 510-353-7004 or [email protected]. Visit our blog at www.ibabuzz.com/tricitybeat.

—–

To see more of The Argus or to subscribe to the newspaper, go to http://www.insidebayarea.com/argus/.

Copyright (c) 2008, The Argus, Fremont, Calif.

Distributed by McClatchy-Tribune Information Services.

For reprints, email [email protected], call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.

Piramal Healthcare Acquires PlasmaSelect’s Haemaccel Brands

Piramal Healthcare, a part of the Piramal Group, has completed a definitive agreement with Germany-based PlasmaSelect to acquire its polygeline-based blood plasma products marketed under the brand name ‘Haemaccel’ in over 38 countries.

Piramal Healthcare will pay cash consideration of E7.7 million for the transaction. The transaction includes the brand rights, contracts, registrations, dossiers and know-how relating to Haemaccel and associated brands. It excludes the manufacturing facility of PlasmaSelect at Marburg, Germany.

Piramal Healthcare is setting-up a new EDQM and UKMHRA-compliant Haemaccel manufacturing facility at Baddi, India with an initial rated capacity of 4.2 million units. This capacity would be able to service the expanded Haemaccel sales. PlasmaSelect will continue to manufacture Haemaccel as per Piramal Healthcare’s requirements to facilitate orderly migration of manufacturing to the new facility at Baddi, India.

Ajay Piramal, chairman of Piramal Group, said: “This acquisition is a stepping stone in that direction and a reflection of our commitment to knowledge and innovation, dynamic action and care that empowers – consistent with our group’s values.”

Iran Paper Warns About Influence of Foreign Media

Text of commentary by Azar Mansuri headlined: “Foreign media, opportunity or threat” published by Iranian newspaper E’temad website on 30 June

As the fourth pillar of civil society, the media provides an important part of the requirements of a democratic system. If this pillar of civil society can play its role in a democratic and free climate, not only it can strengthen other pillars of the civil society, such as political parties, NGOs and professional guilds and organizations, it can furthermore play the biggest role in narrowing the gap between the government and the nation.

The free flow of information will, on the one hand, deepen people’s awareness and information; and, on the other hand, by exposing domestic and foreign issues it will force the government to be accountable. However, it is absolutely certain that all these important gains will not be achieved unless the fourth pillar of democracy is able to work without censorship and free from threats, if its rights are recognized, and if it is able to pursue its activities in a dynamic way.

It has been reported that the Persian programme of the BBC television network will start its work in the near future. With the start of the activities of that network, another Persian language channel will be added to many networks that are already operating from abroad. According to the information available to the present writer, there has been a considerable increase in the number of similar radio and television channels during the past few years. At the moment, tens of Persian language networks with different leanings are broadcasting from abroad. Mainly two issues form the basis of the aims of those who make the programmes of those networks, and those programmes are more prominent in two areas:

1- Politics: A major part of the activities of those networks is devoted to news and domestic and foreign political developments relating to Iran. Some of those networks also try to act as the eloquent voice of many domestic critics, friends or foes of the Islamic Republic of Iran who are deprived of any media [of their own]. The influence of those networks is such that almost none of the domestic media has the capacity to cover all the views of that group of people who are addressed by that [foreign] media. In fact, providing an analysis of the domestic and foreign policies of our country and expressing some of the viewpoints of different groups are only done by such networks. Many of their audiences believe that in order to gain access to news and to learn of different developments, they must turn to those networks.

BBC Radio is one of those networks, which seems to have the largest audience from that point of view. It is probable that when the new [BBC] television channel starts to broadcast, its influence would be even greater than that of the BBC Radio. The German Voice [Deutsche Welle], the French Radio and … [Ellipses as published] also belong to the same category, but none of them has the same level of influence as the BBC has.

2. Culture: A considerable number of those networks provide varied television programmes and, as a result, they have attracted a large audience. It seems that two main points have helped to increase the audiences of those programmes:

A- Those programmes are mainly broadcast on television channels that can be accessed through satellite dishes.

B- A large part of the productions of those channels is such that they do not have any domestic rivals or similar programmes at home. It is important to look at this issue from different aspects: Firstly, the policy that has resulted in the production and broadcasting of those programmes by those networks; and secondly, a considerable number of Iranian audiences that such programmes attract both in the country and abroad.

Without doubt, there will be no rational basis for supplying something for which there is no demand. According to the law of supply and demand, each product tries to satisfy some of the needs of the customers. If our domestic products had the capacity to satisfy the different media requirements of the people, most certainly the extent, the depth and the influence of such [foreign] media would be reduced to a minimum. On the other hand, if the domestic media lacks the capacity to satisfy those needs, those who demand those services will try to satisfy their needs from other sources.

The increase in the number of Persian language media broadcasting from abroad can be regarded as an opportunity for our country only if, on the one hand, our national media (including both the radio and television) is able to deal with the current affairs of the country without censorship, and if they can provide a platform for different viewpoints and can provide news and analysis in such a way that it would satisfy the needs of the society; and, on the other hand, alongside the national media, there are other permitted [presumably private] media and press that can publish and broadcast domestic and foreign reports without censorship.

In any case, it seems that not only the existence of foreign media will not be regarded as a threat, if they provide an opportunity to increase the level of public trust and public participation at home. The strengthening of these two factors [presumably free national and private media] will reduce the gap between the government and the nation to the least possible level.

May be one can prove the lack of balance between supply and demand in the country by looking at the number of Persian language networks that broadcast from abroad and their considerable increase during recent years. In order to clarify the issue further we can raise a fundamental question, namely has not the lack of response to the existing media requirements in the country resulted in the supply of such productions from abroad? Or is it the special position of Iran at the present juncture that has encouraged others to produce Persian language news and programmes to respond to the requirements of our people? In either case, the increase in the number of such foreign media confirms the fact that one should provide a greater capacity for domestic media, especially the national media, so that there is a proper balance between supply and demand. On the other hand, one should pave the ground for the setting up of the media by the critics [of the government] both inside and outside the country.

Otherwise, as the result of the ever-increasing demand by the customers and the limitations imposed on domestic media, and of course the expansion of technology and information, only others [from abroad] will be able to respond to the needs of the audiences inside the country. If that situation is strengthened, the limitations imposed on domestic media will also become more serious.

Originally published by E’temad website, Tehran, in Persian 30 Jun 08.

(c) 2008 BBC Monitoring Media. Provided by ProQuest Information and Learning. All rights Reserved.

Local Tomatoes in Demand

By Johanna D. Wilson, The Sun News, Myrtle Beach, S.C.

Jul. 3–While the Food and Drug Administration expands its investigation of the nation’s salmonella outbreak beyond tomatoes, area farmers said business continues to be brisk for homegrown tomatoes.

“I can hardly keep my tomatoes,” said Wanda Bellamy, of Bellamy Farms in Loris, where the average customer is buying at least five pounds of tomatoes. “They have been going, and our customers don’t care how they look. They don’t care if they have spots or anything on them. They just want them to be homegrown, which ours are, and they want them to taste good, which ours do.”

Tomatoes harvested and grown in the Carolinas are deemed safe to eat by the Food and Drug Administration.

The FDA announced Tuesday that its probe of the salmonella outbreak would expand to items commonly served with fresh tomatoes.

Dr. David Acheson, the FDA food safety chief, would not say what types of produce will be included in the investigation.

“Tomatoes aren’t off the hook,” Acheson said. “It’s just that there is clearly a need to think beyond tomatoes.”

Thus far, the national Centers for Disease Control and Prevention have identified 869 people in 36 states who have been infected with salmonella.

The CDC said the illness began between April 10 and June 20, with 179 individuals becoming ill on June 1 or later.

That’s why some folks who love tomatoes have refused to eat them, even if they are grown by local farmers.

“Some people are shying off from them,” said Keith Elliott, owner of Elliott’s Farm in the Duford community of Horry County, who has grown about an acre of tomatoes this season.

Eva Jensen, a Garden City Beach resident, said she only eats tomatoes she grows.

“I have been growing my own tomatoes for about 50 years,” said Jensen, who eats them fresh and makes sauce. “Once you have grown your own tomatoes, the others taste like cardboard.”

Nevertheless, plenty of folks are keeping area farmers busy by buying local tomatoes.

“They are coming here and running us raggedy,” said Lillie Holmes, who owns Cad’s Produce, along with her husband, Cad, in Myrtle Beach. “I am so tired.”

Holmes is also happy, and she is not alone.

However, area growers said they realized some tomato farmers around the nations are having a hard time.

David Holden, owner of Holden Brothers Farm Market in Shallotte, N.C., said he sympathizes with producers affected by the salmonella outbreak.

“I feel sorry for the farmers who have lost millions of dollars because of unsold product,” said Holden, who added his tomatoes are selling steadily.

For now, the FDA continues to urge consumers nationwide to avoid raw red plum, red Roma or red round tomatoes unless they were grown in specific states or countries that the agency has cleared of suspicion. Also safe are grape tomatoes, cherry tomatoes and tomatoes sold with the vine still attached.

“As long as they are not shipped in, people are buying them,” said Lora Curry of Tyler’s Produce in Conway, where her father, L.D. Tyler, 77, works daily.

Martin Eubanks, director of marketing for the S.C. Department of Agriculture, said the state’s local tomato sales have remained solid.

“Our tomatoes have been good because we are a clear state,” Eubanks said. “Our products have not been related to any of the salmonella.”

Last Friday, North Carolina had Tomato Day at the State Farmers Market in Raleigh.

The state provided homegrown and harvested tomatoes, mayonnaise and bread so folks could feast on tomato sandwiches.

And they did.

“We probably gave away at least 400 tomato sandwiches,” said Monica Wood, marketing specialist with the N.C. Department of Agriculture and Consumer Services. “I had to have one, too. There is nothing like a good tomato sandwich in the summertime.”

The Associated Press contributed to this story.

—–

To see more of The Sun News, or to subscribe to the newspaper, go to http://www.MyrtleBeachOnline.com

Copyright (c) 2008, The Sun News, Myrtle Beach, S.C.

Distributed by McClatchy-Tribune Information Services.

For reprints, email [email protected], call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.

Parents Applaud LifeNet Organ Donation Effort

By CINDY BUTLER FOCKE

By Cindy Butler Focke

Correspondent

Princess Anne

Although their 8-year-old daughter, Melissa, died in 1991 in an accident at the Oceanfront, Don and Linda Chapman say they found solace in knowing their daughter helped others through tissue and organ donation.

“Missy was a loving and giving child,” Linda Chapman said. “This was a way we could love and give to somebody else.”

Last week, the Chapmans, who live in Lynnhaven, were among the guests applauding local officials who have helped save lives and improve the quality of life for many.

LifeNet Health sponsored the event held at its headquarters on Concert Drive.

A year ago, LifeNet Health, the nonprofit agency that provides organs and tissues for transplant, launched the Law Enforcement Partnership for Life Program.

It involves police officers and medical examiners in organ donation by encouraging them to call LifeNet Health’s donor center following the pronouncement of death at the scene of an accident.

Through the program, tissue donations from 64 individuals have included heart valves, bone for spinal fusions and tendons for knee replacements .

“A tissue donor can enhance up to 100 people’s lives,” Teresa Norrell , who coordinates the program for LifeNet Health, said.

Forty percent of deaths don’t take place in a hospital, she said, noting that law enforcers play a crucial role when they see the heart symbol on an individual’s driver’s license.

That indicates the person has agreed to be an organ, eye and tissue donor.

“We have a simple and important task,” said Master Police Officer Jeff Menago, a member of the city’s fatal crash team. “When I notice the heart symbol, I put the wheels in motion so that the deceased’s wishes are carried out.”

Norrell praised the police department for being the first in Virginia to create a mandatory referral policy and encouraged others to follow suit.

More than 20 certificates of appreciation were awarded to members of participating police departments – Virginia Beach, James City County, Hampton, Newport News and Chesapeake. The Tidewater Medical Examiner Office and sheriff’s departments of Accomack and Isle of Wight counties were recognized.

Patti Maloney of the Chesapeake police was commended for being the first officer to call in a referral under the new program, and investigator Rob Robinson of the medical examiner’s office was recognized for his commitment to the program.

“If you take on this program, it’s a little bit more work, but every once in a while you see letters of thanks,” he said. “It’s all worth it.”

Retired state trooper Dwight Gochenour spoke with emotion about his gift of sight, the corneal transplant he received in 1994, thanks to a Newport News police officer, who died in the line of duty.

“It made a huge difference in my life,” he said.

For more information on becoming an organ, eye and tissue donor, call 1-800-847-7831 or visit save7lives.org

Cindy Butler Focke, [email protected]

Originally published by BY CINDY BUTLER FOCKE.

(c) 2008 Virginian – Pilot. Provided by ProQuest Information and Learning. All rights Reserved.

CrossFit: Chattanooga in Latest Wave of High-Intensity Workouts

By Kathy Gilbert, Chattanooga Times/Free Press, Tenn.

Jul. 3–EDITOR’S NOTE: CrossFit instructors contact participants via Web site and e-mail only.

Could CrossFit — a fast-paced, Internet-based, total-body personal training system — revolutionize fitness?

Hundreds of thousands of fans worldwide certainly think so.

“For broad, general, inclusive fitness, there is no better methodology or approach,” said David Stout, a Chattanooga martial arts instructor who became Chattanooga’s first certified CrossFit affiliate last December.

Since 2001, CrossFit (www.crossfit.com) has spread via word of mouth and the Web from soldier to soldier, police officer to fire marshal, karate fan to kung fu fighter around the globe, proponents say.

“It is entirely a grassroots movement,” Mr. Stout said.

Short, grueling workouts designed to push bodies to the limit as fast as possible are posted on the CrossFit Web site daily.

All exercises are videotaped and demonstrated.

Equipment is minimal.

There are no fees.

Participants are encouraged to post their performance and results to the site.

“We want people to come in, try the program and provide feedback so that it is a constantly evolving program,” Mr. Stout said.

Last month, Mike Alley and Katrina Fomich launched Get Built Chattanooga, the area’s first CrossFit gym, in the Chattanooga-Hamilton County Business Development Center.

“I don’t believe you have to have someone holding your hand to get an effective workout. My goal is to teach you how to do the workouts,” said Mr. Alley, a National Strength and Conditioning Association certified personal trainer at the Fairyland Club in Lookout Mountain, Ga.

CrossFit workouts use moves from Olympic and power lifting, martial arts, gymnastics, traditional physical education exercises such as pushups and pullups, running, rowing, swimming and even parkour.

The method’s appeal comes partly from the high intensity of the workouts. CrossFit also relies heavily on sports and competition.

“CrossFit is, quite simply, a sport,” the Web site states.

All workouts are timed, and participants are constantly working against the clock, their best time and other CrossFitters, Mr. Alley said.

Still, all moves are scaled back for safety’s sake. All ages, all levels of fitness and both genders are welcome, Mr. Stout added.

Marc Mayes, a 32-year-old physician’s assistant at Siskin Hospital for Physical Rehabilitation, began doing CrossFit about a year ago. He learned about the Web site while studying martial arts with Mr. Stout at Gracie Jiu Jitsu.

At the time, his routine included three-hour bicycle rides. Then his wife had a baby, and time became limited.

Today, he follows the Web routines and comes to Get Built Chattanooga’s free Saturday class.

“This is a way to get a really good workout in 20 to 40 minutes, and it affects every facet of exercise. When I get back on the bike I go farther, I power up the hills and in running I’m a lot stronger,” Mr. Mayes said.

Blake Coddington, a 17-year-old rising senior at McCallie, said he enjoyed hurtling down Finley Stadium’s field carrying a sack of kitty litter and pushing a pickup across First Tennessee Pavilion last Saturday.

“School workouts are tough, but this is definitely a butt-kicker. You almost forget you’re working out. It’s more of a game,” he said.

—–

To see more of the Chattanooga Times/Free Press, or to subscribe to the newspaper, go to http://www.timesfreepress.com.

Copyright (c) 2008, Chattanooga Times/Free Press, Tenn.

Distributed by McClatchy-Tribune Information Services.

For reprints, email [email protected], call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.

Resolvyx Scientific Advisors Publish First In-Vivo Data Showing Resolvins Suppress IL-23 and IL-17, Key Mediators of Inflammatory Disease

Resolvyx Pharmaceuticals, Inc., the leading resolvin therapeutics company, today announced that a research team led by a Resolvyx scientific advisor and a company co-founder has demonstrated that the resolvin E1 (RvE1) effectively suppresses IL-23 and IL-17, two key inflammatory mediators of chronic inflammatory disease, in a preclinical model of asthma. RvE1 is the active ingredient in RX-10001, one of Resolvyx’s leading clinical candidates. The paper, titled “Resolvin E1 regulates interleukin 23, interferon-(delta) and lipoxin A4 to promote the resolution of allergic airway inflammation,” published in the journal Nature Immunology.

“This study demonstrates that RvE1 potently suppresses IL-23 and IL-17, which are critical in regulating airway inflammation in chronic asthma,” said Bruce D. Levy, M.D., lead author of the study, scientific advisor to Resolvyx and Associate Professor of Medicine at the Department of Internal Medicine Pulmonary and Critical Care Medicine Division, Brigham and Women’s Hospital. “As the IL-23/IL-17 pathway has been increasingly linked to chronic inflammation, tissue remodeling, pathological neovascularization and bone loss, these results have implications for the therapeutic potential of resolvins in a range of human diseases.”

The research team evaluated RX-10001 (RvE1) in a well established mouse model of asthma and showed that RX-10001 (RvE1), when administered at the peak of inflammation, significantly suppressed airway inflammation and prevented lung hyperreactivity. The levels of IL-17 and IL-23 were reduced by 70% and 60%, respectively, contributing to a greater than 80% reduction in infiltrating leukocytes including eosinophils, which are a major driver of the allergic airway hyper-responsiveness.

“The finding that RX-10001 suppresses IL-23 and IL-17 suggests that resolvins can potentially treat not only asthma but also inflammatory bowel disease, rheumatoid arthritis, atherosclerosis and other diseases,” said Charles Serhan, Ph.D., co-author of the study, co-founder of Resolvyx and Director of the Center for Experimental Therapeutics and Reperfusion Injury, Brigham and Women’s Hospital. “Given their broad potential to treat human disease, it is very exciting that Resolvyx is advancing resolvin drug candidates into clinical trials in the coming months.”

Resolvyx also has conducted preclinical studies with RX-10001 (RvE1) in asthma and other systemic inflammatory diseases. Resolvyx has announced plans to initiate human clinical trials for RX-10001 in the first half of 2009.

About Resolvins

Resolvins are a recently discovered family of naturally-occurring, small molecule lipid mediators that can be targeted to treat a wide range of diseases. In particular, resolvins act to protect healthy tissue during an immuno-inflammatory response to infection, injury or other environmental challenge, and then act to resolve inflammation and promote healing after the insult has passed. Resolvins are shown to be highly potent and efficacious in pre-clinical models of asthma, atherosclerosis, rheumatoid arthritis, inflammatory bowel disease, dry eye and retinal disease, among others.

Resolvins are potential drug candidates to treat a broad range of acute and chronic diseases caused by a failure to resolve the inflammatory response and restore immune homeostasis. Such diseases include auto-immune diseases (like Crohn’s disease, psoriasis and rheumatoid arthritis), allergic diseases (like asthma) and chronic inflammatory diseases (like atherosclerosis, degenerative retinal diseases, chronic dry eye and Alzheimer’s disease). Resolvins offer an entirely novel biological approach to treating significant inflammatory diseases, with a decreased potential for immuno-suppression.

About Resolvyx Pharmaceuticals

Resolvyx Pharmaceuticals is a privately-held biopharmaceutical company dedicated to the discovery, development and commercialization of resolvins, a novel class of therapies to treat inflammatory diseases and their complications. Resolvyx’s drug R&D programs are focused on characterizing and developing resolvin-based compounds. With its experienced management team, world-class scientists and leading investors, Resolvyx is well-positioned to capitalize on its extensive portfolio of more than 55 patents and applications. The company’s headquarters are in Bedford, Massachusetts.

For additional information, please visit www.resolvyx.com.

Daily Exercise, Diet Bring Good Health – Minus 40 Lbs.

By JOHN STREIT

By John Streit

Correspondent

At 250 pounds, Bart Morrison faced a myriad of health challenges when he walked into Great Neck’s Anytime Fitness for the first time last winter.

His high blood pressure required two medications , his cholesterol was high and he suffered from sleep apnea.

“I tried a bunch of different things to lose weight, because the doctor kept saying, ‘You got to lose weight,'” said Morrison, 44, of Alanton. “Nothing really seemed to work: starving yourself, seven- day diets.”

But under the guidance of Anytime’s personal trainer Chad “CJ” Havunen, Morrison faced a new set of challenges to rid him of the health problems .

Through the gym’s Total Body Challenge, a contest designed to inspire Anytime clients to shed pounds and tone muscles by pitting them against each other, Morrison lost more than 40 pounds, and reversed his health fortunes in short order.

After the three-month recent contest, Morrison no longer needed blood-pressure medication , his cholesterol numbers dropped into a healthy range and his sleep apnea disappeared.

The icing on the cake: He took first place in the contest, which rewarded him with a free year’s membership to Anytime.

Anytime’s Total Body Challenge judged contestants on overall body change from start to finish, not just weight loss percentage.

Morrison weighed in at 196 pounds at the final weigh-in and sported larger, toned muscles. He estimated that from the start of his workouts at Anytime (a month before the contest began), he’s lost about 60 pounds in fat-weight and gained 10 pounds in lean muscle.

The formula for Morrison’s success was simple: alternating cardiovascular and weightlifting exercises while eating a measured, high-protein, low-fat diet, he said.

It’s a professional approach to weight-cutting and bodybuilding concocted by Havunen, a World Natural Bodybuilding Federation professional.

“Both of those aspects, diet and exercise, have to work together, they can’t work alone,” Havunen said. “Especially in competitive bodybuilding. It’s like a fine-tuned recipe: If you remove or change the amount of something, it’s no surprise that the food will taste bad.”

By the end of the contest, Morrison was exercising daily, putting in as many as 15 hours per week of gym time. He’s scaled back his routine since completing the contest, exercising twice a day four times a week while still logging cardio hours six days a week.

He says the resulting health benefits have been worth every drop of sweat.

“My doctor always said that if I lost 40 to 50 pounds that this would happen,” Morrison said. “But I could never imagine it being like this.”

John Streit, 639-4805, [email protected]

Originally published by BY JOHN STREIT.

(c) 2008 Virginian – Pilot. Provided by ProQuest Information and Learning. All rights Reserved.

Pediatrix Acquires Atlanta Anesthesia Group Practice

Pediatrix Medical Group, Inc. (NYSE: PDX) has completed the acquisition of Georgia Perioperative Consultants, LLC, an anesthesia physician group practice that provides services to patients treated at facilities in the Atlanta metropolitan area.

Georgia Perioperative consists of 28 physicians and 66 certified registered nurse anesthetists (CRNAs) and anesthesia assistants who practice at Atlanta’s Piedmont Hospital, Piedmont Fayette Hospital, and five ambulatory surgery centers in the Atlanta area.

The transaction is Pediatrix’s second anesthesia group practice acquisition and advances the Company’s strategy of building a national group practice of anesthesia services to parallel its neonatal, maternal fetal, pediatric cardiology and pediatric intensivist physician services. Pediatrix’s first anesthesia acquisition, Fairfax Anesthesiology Associates, based in northern Virginia, was completed in September 2007.

The physicians at Georgia Perioperative joined Pediatrix for a variety of reasons, including the opportunity to collaborate with anesthesia practices across the United States to improve patient care, as well as to gain needed administrative support to manage anticipated growth.

“We expect that as part of Pediatrix we’ll enjoy some relief from many of the pressures on the business side of our practice, and that we’ll play a role in helping to shape the future of anesthesia services within this organization,” said Jeffrey D. Shapiro, M.D., President of Georgia Perioperative Consultants. “We’re excited about building on Pediatrix’s approach to clinical quality and best practices and working with other groups to transfer those skills to anesthesia.”

The Georgia Perioperative practice was formed in 1970 and has worked with Piedmont Hospital, a 481-bed tertiary care center, to provide anesthesia services since then. The practice has grown with the hospital system and the surrounding communities. Piedmont Fayette is a 143-bed acute care community hospital located in Fayetteville, GA. Pediatrix physicians staff the neonatal intensive care units at both hospitals.

“With Georgia Perioperative, and Fairfax Anesthesiology, we’re demonstrating that we have the right model to attract leading anesthesia practices, in growing markets, to help us to build a national practice within this specialty,” said Roger J. Medel, M.D., Chief Executive Officer of Pediatrix. “As we execute on our strategy, we will be very deliberate in delivering added value to those physicians who join us, to our hospital partners and ultimately to our patients.”

Georgia Perioperative will be integrated into American Anesthesiology, a division of Pediatrix, which will apply Pediatrix’s core competency of managing the numerous administrative functions of hospital-based physician groups to anesthesia practices, allowing anesthesiologists, nurse anesthetists and anesthesia assistants more time to provide patient care. Pediatrix also encourages its physicians to use aggregated clinical data to conduct ongoing research, education and collaborative initiatives to improve patient care.

Pediatrix paid cash for the practice, which is expected to contribute annual earnings of approximately three cents per share after considering amortization expense and foregone investment income. The estimated earnings are based on Georgia Perioperative’s current operations and does not include potential improvements under Pediatrix’s processes. Additional terms of the transaction were not disclosed.

Pediatrix now has more than 200 anesthesia providers, including more than 80 anesthesiologists and more than 120 CRNAs and anesthesia assistants providing patient care in Georgia and Virginia.

The Company remains focused on expanding its historical physician services around newborn, maternal fetal and pediatric subspecialty care, as well as building its anesthesia physician services. In addition to Georgia Perioperative, Pediatrix has acquired one neonatal, one maternal fetal and three pediatric cardiology group practices, during 2008.

Separately, the Company announced that it has completed the $100 million share repurchase program that had been authorized in late May.

About Pediatrix

Pediatrix Medical Group, Inc. is the nation’s leading provider of neonatal, maternal-fetal and pediatric physician subspecialty services and recently expanded to include anesthesiology services. Pediatrix physicians and advanced practitioners are reshaping the delivery of care within their subspecialties using evidence-based tools, continuous quality initiatives and clinical research to enhance patient outcomes and provide high-quality, cost-effective care. Founded in 1979, its neonatal physicians provide services at more than 250 neonatal intensive care units, and in many markets they collaborate with affiliated maternal-fetal medicine, pediatric cardiology physician subspecialists and pediatric intensivists to provide a clinical care continuum. Combined, Pediatrix and its affiliated professional corporations employ more than 1,100 physicians in 32 states and Puerto Rico. Pediatrix is also the nation’s largest provider of newborn hearing screens. Additional information is available at www.pediatrix.com.

Certain statements and information in this press release may be deemed to be “forward-looking statements” within the meaning of the Federal Private Securities Litigation Reform Act of 1995. Forward-looking statements may include, but are not limited to, statements relating to our objectives, plans and strategies, and all statements (other than statements of historical facts) that address activities, events or developments that we intend, expect, project, believe or anticipate will or may occur in the future are forward-looking statements. These statements are often characterized by terminology such as “believe,””hope,””may,””anticipate,””should,””intend,””plan,””will,””expect,””estimate,””project,””positioned,””strategy” and similar expressions, and are based on assumptions and assessments made by Pediatrix’s management in light of their experience and their perception of historical trends, current conditions, expected future developments and other factors they believe to be appropriate. Any forward-looking statements in this press release are made as of the date hereof, and Pediatrix undertakes no duty to update or revise any such statements, whether as a result of new information, future events or otherwise. Forward-looking statements are not guarantees of future performance and are subject to risks and uncertainties. Important factors that could cause actual results, developments, and business decisions to differ materially from forward-looking statements are described in Pediatrix’s most recent Annual Report on Form 10-K, including the section entitled “Risk Factors”.

Evotec’s EVT 101 Well Tolerated in Four Week Higher Repeat Dose Safety Study

HAMBURG, Germany, July 3, 2008 (PRIME NEWSWIRE) — Evotec AG (Frankfurt:EVT) (Nasdaq:EVTC) announced today top-line results of a double-blind, 4-week Phase Ib study with EVT 101, an orally active NR2B-subtype selective antagonist of NMDA receptors with potential in Alzheimer’s disease, neuropathic pain and other indications. The study showed in both young and elderly subjects that the drug was well tolerated up to the highest dose tested.

The study was designed to evaluate safety/tolerability, pharmacokinetics, and pharmacodynamics during prolonged dosing with EVT 101 as compared to placebo, but at higher dose levels and for a longer duration that the previously completed Phase I study. The study was conducted and completed as planned per protocol.

EVT 101 was administered to 48 young and elderly healthy subjects over four weeks. Up to the highest dose level (12 mg/day in elderly, 15 mg/day in young subjects) EVT 101 was well tolerated by both populations. No severe or serious adverse events were reported, and only few transient, mostly mild, adverse events occurred. This safety and tolerability profile is extremely encouraging as the doses evaluated are predicted to be well into the anticipated therapeutic range. As previously reported (see press release, March 28, 2008), this trial contained a sub-study in which drug CSF levels were measured to determine the extent of brain penetration.

Psychometric tests, examining different aspects of cognitive function, revealed a mixed pattern of minor transient changes, as expected from populations of healthy subjects performing optimally in cognitive tasks.

“Together with results from the fMRI brain imaging which we announced in March, these results provide a robust Phase Ib package. We have found doses of this highly specific compound that achieve a high level of brain exposure to achieve a high level of NR2B receptor blockade. These doses produce specific modulation of relevant brain areas and, importantly, are also well tolerated. This provides a good foundation for moving forward with the clinical development of this compound and enables us to investigate EVT 101 in relevant patient groups,” commented Dr. Tim Tasker, Executive Vice President Clinical Development, Evotec AG.

About Evotec AG

Evotec is a leader in the discovery and development of novel small molecule drugs. Both through its own discovery programs and through research collaborations, it is generating the highest quality research results to its partners in the pharmaceutical and biotechnology industries. In proprietary projects, Evotec specializes in finding new treatments for diseases of the Central Nervous System. Evotec has three programs in clinical development: EVT 201, a partial positive allosteric modulator (pPAM) of the GABAA receptor complex for the treatment of insomnia, EVT 101, a subtype selective NMDA receptor antagonist for the treatment of Alzheimer’s disease and/or pain, and EVT 302, a MAO-B inhibitor in development for smoking cessation. Evotec’s proprietary preclinical research programs focus on the purinergic receptors, P2X3 and P2X7, for the potential treatment of pain and inflammatory diseases. In addition, Evotec has worldwide collaboration and license agreements with Pfizer to research, develop and commercialize small molecule vanilloid receptor (VR1) antagonists. For additional information please go to www.evotec.com

Forward-Looking Statements

Information set forth in this press release contains forward-looking statements, which involve a number of risks and uncertainties. Such forward-looking statements include, but are not limited to, statements about our expectations and assumptions concerning regulatory, clinical and business strategies, the progress of our clinical development programs and timing of the results of our clinical trials, strategic collaborations and management’s plans, objectives and strategies. These statements are neither promises nor guarantees, but are subject to a variety of risks and uncertainties, many of which are beyond our control, and which could cause actual results to differ materially from those contemplated in these forward-looking statements. In particular, the risks and uncertainties include, among other things: risks that product candidates may fail in the clinic or may not be successfully marketed or manufactured; risks relating to our ability to advance the development of product candidates currently in the pipeline or in clinical trials; our inability to further identify, develop and achieve commercial success for new products and technologies; competing products may be more successful; our inability to interest potential partners in our technologies and products; our inability to achieve commercial success for our products and technologies; our inability to protect our intellectual property and the cost of enforcing or defending our intellectual property rights; our failure to comply with regulations relating to our products and product candidates, including FDA requirements; the risk that the FDA may interpret the results of our studies differently than we have; the risk that clinical trials may not result in marketable products; the risk that we may be unable to successfully secure regulatory approval of and market our drug candidates; and risks of new, changing and competitive technologies and regulations in the U.S. and internationally.

The list of risks above is not exhaustive. Our Annual Report on Form 20-F, filed with the Securities and Exchange Commission, and other documents filed with, or furnished to the Securities and Exchange Commission, contain additional factors that could impact our businesses and financial performance. We expressly disclaim any obligation or undertaking to release publicly any updates or revisions to any such statements to reflect any change in our expectations or any change in events, conditions or circumstances on which any such statement is based.

This news release was distributed by PrimeNewswire, www.primenewswire.com

 CONTACT: Evotec AG          Anne Hennecke           SVP, Investor Relations & Corporate Communications          +49.(0)40.56081-286          Fax: +49.(0)40.56081-333          [email protected] 

Delgado to Step Down From Local UH Centers

By Mark Todd, Star Beacon, Ashtabula, Ohio

Jul. 3–CONNEAUT –The president of University Hospitals facilities in two Ashtabula County cities will step down from those posts next week, officials said.

Laurie Delgado will leave UH’s Conneaut and Geneva medical centers effective Monday to oversee the UH Richmond Medical Center in Richmond Heights, according to a statement.

“In this role, Ms. Delgado will have full responsibility for all clinical programs and services provided by UHRMC,” according to the statement.

Delgado became president at the Geneva hospital in 2003 and its Conneaut brethren in December 2005. At the latter hospital, she replaced long-time president William Lawrence.

Under her guidance Geneva Medical Center completed a $1.5 million facelift of its emergency department and began construction of the UH Geneva Medical office building. At Conneaut, she monitored the launch of a state-of-the-art surgical suite.

“Both entities also have exhibited strong operating performance and consistently improving quality outcomes under Ms. Delgado’s direction,” according to the statement.

She received the YWCA Women of Professional Excellence Award in 2005 and sits on the board of the Geneva Area Chamber of Commerce, LEADERship Ashtabula and the Community Care Ambulance Network.

Rob David, UH’s director of finance, will serve as acting president of both hospitals. Delgado is on vacation, a spokeswoman at CMC said Wednesday, and unavailable for comment.

—–

To see more of the Star Beacon or to subscribe to the newspaper, go to http://www.starbeacon.com/.

Copyright (c) 2008, Star Beacon, Ashtabula, Ohio

Distributed by McClatchy-Tribune Information Services.

For reprints, email [email protected], call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.

Foreign Aid and Human Development: The Impact of Foreign Aid to the Health Sector

By Williamson, Claudia R

Claudia R Williamson, Department of Economics, West Virginia University, P.O. Box 6025, Morgantown, WV 26506-6025, USA; E-mail [email protected]. face=+Bold; [Acknowledgment]face=- Bold;

I would like to thank the editor and two anonymous referees for their time, valuable comments, and helpful suggestions. I would also like to thank Peter T. Leeson and Russell S. Sobel for their valuable comments and suggestions. Also, I would like to thank Matt E. Ryan for his helpful comments. In addition, I appreciate the comments received from Tomi Ovaska and the 2006 Southern Economic Association Conference participants.

face=+Bold; 1. Introductionface=-Bold;

face=+Italic; International aid is one of the most powerful weapons in the war against poverty. Today that weapon is underused and badly targeted. There is too little aid and too much of what is provided is weakly linked to human development. (United Nations Development Programme 2005, p. 75)face=-Italic;

According to the 2005 Human Development Report (United Nations Development Programme 2005), there is a general consensus that foreign aid’s first objective should be human development. In 2000, governments from various countries met at the United Nations and signed the Millennium Declaration, a pledge “to free our fellow men, women and children from the abject and dehumanizing conditions of extreme poverty.” One way of achieving these goals is through development assistance (United Nations Development Programme 2005). This advice has been widely accepted in the donor community during the past five years because total aid to the health sector has more than doubled. For example, as illustrated in Figure 1, from 1999 to 2004 aid to the health sector rose from $1930 to $4435 millions of 2004 dollars (OECD 2007).

face=+Bold; Figure 1face=-Bold; Foreign Aid to the Health Sector 1973-2004 (Figure omitted. See article image.)

With growing intensity given to international human development aid, an analysis of its effectiveness is worthwhile. Both conceptual and empirical literature debates the effectiveness of foreign aid for economic development without a general consensus on the role of foreign assistance in economic development. Two contrasting hypotheses have emerged. One is a public interest argument where some authors state that aid can and should be used to assist in the development process (Sen 1999; Sachs 2005). The other is a public choice hypothesis that presents arguments indicating that foreign assistance is ineffective and has the potential to damage future growth opportunities (Bauer 2000; Easterly 2001).

These two competing hypotheses lead to different predictions on the use of foreign aid for human development. For a clear answer, one must turn to empirical analysis. Current empirical literature primarily supports the public choice perspective, indicating that foreign aid is ineffective in promoting economic development (Filmer and Pritchett 1999; Svensson 1999; Filmer, Hammer, and Pritchett 2000, 2002; Knack 2001; Brumm 2003; Brautigam and Knack 2004; Economides, Kalyvitis, and Philippopoulos 2004; Djankov, Montalvo, and Reynal-Querol 2005; Hartford and Klein 2005; and Heckelman and Knack 2005). In these studies, the authors focus on the impact of foreign aid on economic development and find no significant impact. However, in a recent study by Gomanee, Girma, and Morrissey (2005), the authors show that aid can improve human welfare through increases in certain public expenditures, supporting the public interest predictions. Their methodological approach neglects to control for endogeneity, and this could lead to biased results. Thus, further analysis is required.

With the recent shift in the promotion of aid from economic to human development, it is timely to investigate the role of foreign aid for human development purposes. This paper provides the next step in the literature by establishing the link between foreign aid and human welfare. This is the first examination to utilize aid earmarked specifically to the health sector (health aid) to determine its effect on human development. Other studies have generally analyzed the impact overall foreign aid has had on human welfare, but none uses aid specifically to the health sector. To effectively perform this analysis, I build off the existing development literature and extend the same empirical methodology, including instrumental variable estimation to control for reverse causality. My results support the public choice perspective, indicating that international aid to the health sector is ineffective in improving human welfare. My findings are robust to different model specifications and a variety of health indicators. This suggests that foreign aid may not be an effective way of improving health in developing countries.

The next section outlines the empirical model and data used in the analysis. A fixed effects model is the benchmark specification. The core analysis builds off of this basic specification by implementing an instrumental variable to control for possible reverse causality issues. A detailed discussion of the validity of the instruments is provided. Section 3 presents the results of the fixed effects model and the instrumental variable model. Section 4 presents three different robustness checks that confirm my results. Also, results are presented that strengthen the legitimacy of my instruments. Section 5 concludes.

face=+Bold; 2. Empirical Model and Dataface=-Bold;

The first model presented is a fixed effects regression that is used as the baseline specification. Next, instrumental variable estimation is implemented as the core analysis. A detailed description of the data is also provided in this section, including defining all variables, listing the data sources, and providing the descriptive statistics.

face=+Bold; Benchmark Specificationface=-Bold;

The strategy employed is a fixed effects model that controls for country and year effects with robust standard errors:face=+Superscript; 1face=-Superscript; (Forumla omitted. See article image.) where face=+Italic; Yface=-Italic; = health indicators, face=+Italic; AIDface=-Italic; = health aid, and face=+Italic; Zface=-Italic; = control vector. The main variable of interest is foreign aid to the health sector. Health aid over the past five years accounts for roughly 7% of all official development assistance granted. The data for this variable was taken from OECD’s Credit Reporting System that gives detailed breakdowns of official development assistance and official aid in developing and transitioning countries by sector (in 2004 dollars). I collected foreign aid to the health sector for all countries that received this type of aid. Detailed flow analysis is only available from 1973 onward, so this has limited my data set for the period 1973 to 2004.

Five main health indicators are used to capture the overall quality of health in a country. These include infant mortality, life expectancy, death rate, and immunizations (DPT and measles). These variables were collected from the 2006 World Development Indicators. The death rate is a crude measure that estimates the number of deaths occurring during the period. It is estimated per 1000 of the population at midyear. If aid is effective on human development, it should have a negative relationship with the death rate: As more aid flows to the health sector, the death rate should fall. Life expectancy at the time of birth, reported in years, is another variable we would expect effective health aid to affect, raising the expectancy of one’s life. Immunizations (DPT and measles) are the percent of children 12-23 months that receive the vaccine before reaching one year of age. Health aid should increase this percentage, especially because immunizations are easier to administer than other health projects and specific programs have been established especially for this purpose. Infant mortality (per 1000 of births) is the number of infants dying before one year of age in a given year. This number should decrease as foreign aid flows to the health sector increase.

A variety of control variables are included in the model: percentage urban population, number of physicians, gross domestic product (GDP), the Fraser freedom index, and a political freedom index (Freedom House Organization). Gross domestic product, percentage urban population, and the number of physicians were taken from the 2006 World Development Indicators. GDP per capita is based on purchasing power parity and is reported in constant 2000 international dollars. GDP represents the overall level of economic development and should exhibit a positive relationship with human development. The number of physicians (per 1000) is any graduate from a medical school or facility practicing medicine in the country. This should have a positive influence on health, while urban population may provide mixed results.

To control for the institutional environment, I include the Fraser freedom index or the political freedom index in the regression. The Fraser freedom index captures the economic institutions, while the political freedom index controls for political rights and civil liberties. The Fraser freedom index is scaled from 1 to 10 with 10 representing the highest level of freedom. This index measures the degree to which a country allows personal choice over collective choice, voluntary exchange, the freedom to compete, and security of private property (Gwartney and Lawson 2005). The political freedom index is collected from Freedom House (2007) and is scaled from 1 to 7, with 1 representing the highest level of freedom. This index averages scores from an index on political rights and an index on civil liberties to calculate one comprehensive measure of political freedom. It has been shown that increases in economic and political freedom positively impact economic development (Gwartney, Lawson, and Holcombe 1999; Acemoglu, Johnson, and Robinson 2001, 2002). Thus, a country’s institutional environment may influence human development as well and should be included in the analysis. Because of the importance of controlling for the quality of institutions and the level of income, several different regression specifications are necessary. It is well documented that GDP is highly correlated with institutional indices and is usually not included in the same regression.face=+Superscript; 2face=-Superscript; In my sample, GDP has a correlation of 0.62 with both the Fraser freedom index and with the political freedom index. Including both GDP and either one of the freedom indices may cause inaccurate results; however, it is crucially important that both growth and institutional quality be accounted for in the model specification. Therefore, I estimate my model with five different regression specifications: (1) GDP only, (2) Fraser freedom index only, (3) political freedom index only, (4) both GDP and the Fraser freedom index, and (5) both GDP and the political freedom index. All five regressions include urban population, the number of physicians, and country and year dummies (to eliminate any variation due to country-specific and time- specific effects) as additional control variables.

A panel data set from 1973 to 2004 is constructed and averaged over five-year intervals to control for business cycle fluctuations and measurement error (Boone 1996).face=+Superscript; 3face=- Superscript; Therefore, the data set has seven points in time: 1977, 1982, 1987, 1992, 1997, 2002, and 2004.

face=+Bold; Fixed Effects With Instrumental Variable Estimationface=-Bold;

To ensure that endogeneity is not driving my results using the fixed effects model, I estimate a model that uses fixed effects and an instrumental variable approach to control for potential reverse causality. Because I am specifically analyzing aid to the health sector, it is necessary to implement an instrument for health aid. Aid may be endogenous because of the possibility that the current health in a country more than likely determines the amount of health aid received. Therefore, it is necessary to instrument for this variable.

Past studies have been able to use income, population, and infant mortality as valid instruments (Burnside and Dollar 2000; Ovaska 2003; Djankov, Montalvo, and Reynal-Querol 2005). However, these variables are not valid for my model specification because they would be correlated with the dependent variables. Previous literature has indicated that aid is not given primarily to help the poor, but instead it is given to reflect the special interests of the donors (Mosley 1985a, 1985b; Frey and Schneider 1986; Trumbull and Wall 1994). Another standard instrument in the literature is lagged aid. Boone (1996) shows that lagging aid two periods can be used as a valid instrument for current aid because it will reflect the relatively permanent strategic interests of donors. A potential concern that arises from this instrument is that past health aid could influence the current level of human development. In other words, the instrument would be affecting the dependent variables through channels other than its influence on the current level of health aid. According to the Boone argument, foreign aid should reflect the long-term special and strategic interests of donors, while remaining uncorrelated with the current conditions in recipient countries. This argument is based on the idea that aid is given as a strategic, political move, not necessarily based on need. Thus, the standard instrument from the existing literature that best fits my model is lagged aid.

To provide validity for using lagged aid as an appropriate instrument, it is necessary to use both two- and three-period lags to be overidentified in the first stage.face=+Superscript; 4face=- Superscript; Appendix A provides the results of the first stage for each of the five regressions. These results suggest that both two-period and three-period lagged aid perform as valid instruments in my model. The face=+Italic; Fface=-Italic; -test for joint significance between the two instruments ranges from 4.43 to 7.81, depending on the regression specification. This indicates that the instruments are providing predictive power in the first stage. Also, adding strength to this argument are the face=+Italic; Fface=- Italic; -statistics for the overall significance of the regression and the face=+Italic; Rface=-Italic; -squared coefficient. It is evident that past health aid is highly explanatory in determining current health aid. Of equal importance is the requirement that lagged health aid is not correlated with measures of human development. This is in fact the case. The two-period and three- period lags are uncorrelated with all five human development indicators, as discussed in a later section and presented in Appendix B.

The fixed effect model with instrumental variable estimation specification is: (Forumla omitted. See article image.) where face=+Italic; Health Aidface=+Subscript; iface=-Subscript; face=- Italic; = foreign aid specifically to the health sector, face=+Italic; Lface=+Subscript; iface=-Subscript; face=-Italic; = two-period lagged health aid and is the first instrument, and face=+Italic; Hface=+Subscript; iface=-Subscript; face=-Italic; = three-period lagged health aid and is the second instrument. This specification limits by model to four points in time: 1992, 1997, 2002, and 2004.

face=+Bold; Descriptive Statisticsface=-Bold;

The panel data set includes all 208 countries that the World Bank collects data for, even though some of these countries may have a zero value for health aid.face=+Superscript; 5face=-Superscript; Table 1 summarizes the data.

face=+Bold; Table 1face=-Bold; Summary Statistics (Table omitted. See article image.)

For each variable, the number of observations, mean, standard deviation, minimum, and maximum are provided. I convert health aid to health aid per capita and all other variables control for population. Therefore, it is not necessary to have population on the right side. The log form of health aid, both of the instruments, gross domestic product, number of physicians, death rate, life expectancy, and infant mortality are used in the empirical analysis.face=+Superscript; 6face=-Superscript;

face=+Bold; 3. Resultsface=-Bold;

Table 2 shows the results for the fixed effects model. Recall that it is necessary to run the model with five different regression specifications to gain a more accurate description. The layout of the table is as follows: Column 1 includes GDP as a control variable; column 2 includes the Fraser freedom index as a control variable; column 3 includes the political freedom index as a control variable; column 4 includes both GDP and the Fraser freedom index as control variables; and column 5 includes both GDP and the political freedom index as control variables.

face=+Bold; Table 2face=-Bold; The Impact of Health Aid on Human Development Indicators (Table omitted. See article image.)

A clear result emerges: Foreign aid specific to the health sector does not significantly improve the overall health in recipient countries, even after controlling for GDP and the quality of institutions. Health aid exhibits the correct sign but is statistically insignificant on life expectancy. The sign switches depending on the regression specification for death rate and both immunizations but is statistically insignificant. Health aid on infant mortality enters with the “wrong” sign but remains statistically insignificant. The number of physicians has the most significance throughout the different regression specifications and always enters with the correct sign. GDP and the Fraser freedom index are consistently negative and significant on infant mortality, but do not seem to play a significant role on the other dependent variables. The political freedom index and urban population do not have a significant effect overall on health.

In general, health foreign aid does not have the effect proposed by those who advocate its need to increase human development in developing countries. This table suggests that foreign aid to the health sector is ineffective at improving health in recipient countries. To determine these results more definitively, I implement an instrumental variable estimation to control for reverse causality. Recall that my two instruments for health aid are a two- period lag and a three-period lag of health aid. The first stage results are presented in Appendix A. All exogenous variables that enter into the second stage also enter into the first, including both country and year dummies.

The results of the fixed effects model with instrumental variable estimation are presented in Table 3. The results from this reestimation uniformly confirm my previous results. After controlling for reverse causality, health aid has no significant impact on the health indicators. In three out of the five regressions, health aid enters with the wrong sign on both life expectancy and the death rate, but remains insignificant in all of the regressions. Most of the other control variables are also insignificant on both life expectancy and the death rate. Health aid has the correct sign on infant mortality but is insignificant in all five regressions, while GDP is negatively and significantly impacting infant mortality in two out of three regressions. For example, in regression 1, a 1% increase in GDP per capita would translate into lowering infant mortality by 0.337%. For both measles immunizations and DPT immunizations, health aid has a negative, but insignificant impact. The Fraser freedom index always has a positive and significant impact on these two variables. In all regression specifications, a one unit increase in this index would increase immunizations between 3 and 4%. The number of physicians only matters for a few regression specifications for immunizations. Both the political freedom index and urban population remain insignificant. face=+Bold; Table 3face=-Bold; The Impact of Health Aid on Human Development Indicators (Table omitted. See article image.)

This core analysis supports my baseline specification, suggesting that foreign aid is ineffective at improving human development. Because of the important conclusions to be drawn from this analysis, I implement three different robustness checks to the main specification: (1) the inclusion of additional control variables, (2) a reestimation of the main model replacing health aid with general foreign aid, and (3) a semireduced form of the main model to include lagged aid as an explanatory variable.

face=+Bold; 4. Robustness Checksface=-Bold;

To ensure the validity of the previous results, I provide three robustness checks. Because of data restrictions in the panel regressions, the analysis is limited in control variables. To relax this restriction, I constructed a limited data set from my original to allow the inclusion of two additional controls that were not in the previous regressions. The second robustness check replaces foreign aid to the health sector with general foreign aid. The third check provides support that my instruments are valid by running the model with lagged aid as an explanatory variable. All robustness checks confirm my original results. The results from the robustness checks are omitted to save space, but they are available from the author on request.

face=+Bold; Robustness Check 1: Additional Control Variablesface=- Bold;

The five regressions from the main fixed effects model with instrumental variable estimation are reestimated to allow for additional controls to provide a robustness check. Because of data restrictions, factors that could be affecting human development were not included previously. Therefore, I create a smaller data set to allow for the inclusion of two more control variables that could significantly affect human development. Because of data limitations, the inclusion of these additional controls significantly lowers the number of observations. Private health expenditures and the prevalence of HIV are included in this specification. Private spending on health should play a vital role on the health indicators in the analysis. Also, one would expect that the HIV epidemic that exists in many developing countries would significantly affect human development.

The results support my previous two estimations, even after the inclusion of additional control variables. This continues to suggest that foreign aid to the health sector is not a strong determinant of human development. Most of the other control variables lose significance in this specification.

face=+Bold; Robustness Check 2: Replacing Health Aid with Overall Foreign Aidface=-Bold;

One criticism of using health aid as the main variable of interest is that health aid only accounts for 7% of all foreign aid given. Therefore, the reason health aid is not having an impact may be that the amount given is not actually large enough. For example, the maximum per capita amount of health aid in my sample is $152, while the maximum per capita amount of general aid (including health aid) is $2200. Potentially, health aid may also perform differently than other types of aid. To combat these arguments, I reran the fixed effects model with instrumental variable estimation replacing health aid with overall foreign aid.

In all five regression specifications, across all dependent variables, the insignificance of aid remains. Foreign aid has the correct sign on life expectancy, the death rate, and infant mortality, but remains insignificant. In one out of two regressions, the Fraser freedom index significantly reduces infant mortality and the death rate. In three out of four regressions, it significantly increases immunizations. GDP significantly reduces infant mortality in all three regressions. The number of physicians does play an important role in improving these health indicators.

face=+Bold; Robustness Check 3: Health Aid as an Explanatory Variableface=-Bold;

A potential concern with my instrumental variable approach is that lagged aid may be affecting human development through channels other than current health aid. One way to circumvent this problem is to examine the semireduced form specification, where health aid is instrumented with the two-period lag, but the three-period lag enters the second stage directly (Acemoglu and Johnson 2005). To perform this specification effectively, I use three-year averages instead of five-year averages to create more periods (11 vs. 7 periods in the original data set).face=+Superscript; 7face=- Superscript;

As presented in Appendix B, the results indicate that lagged health aid is not significantly affecting the variables of interest. In most of the regression specifications, lagged health aid enters with the incorrect sign, but always remains insignificant across all regression specifications. Most of the other control variables perform as in previous estimations. This result lends support to the validity of instrumenting with lagged aid.

face=+Bold; 5. Conclusionface=-Bold;

The empirical analysis suggests that health aid is ineffective at improving human development, supporting other works within public choice and development literature. There is a lack of evidence to indicate that health aid should be pursued as a policy objective to promote increases in human welfare. In this sense, health is not “special” relative to other forms of development assistance. Just like general aid, which is shown to have an insignificant effect on economic development, aid used specifically for health goals has an insignificant effect on human development.

This paper is the first to empirically test the effectiveness of aid specifically to the health sector. I develop and test a fixed effects model controlling for reverse causality that demonstrates the inability of foreign aid to translate into significant results. These results are robust to different model specifications, including replacing health aid with overall foreign aid and using lagged aid as an explanatory variable. These results suggest that foreign aid to the health sector is not establishing real effects in human development. Despite this argument, the development community pushes for the advancement of society by increasing foreign aid. My results suggest that international aid is not one of the most powerful weapons against poverty, as suggested by the 2005 Human Development Report. Thus, it may not be able to end extreme poverty or facilitate human development, as argued by those authors from the public interest viewpoint.

With these results, we are still left questioning what will help improve the quality of life in developing countries. My findings weakly suggest an important role for institutions in determining human development, as captured by the Fraser freedom index. This indicates an avenue for future research in determining whether health is an outcome, rather than an input, of development. It may be worthwhile to investigate the connection between institutions, economic development, and human development and the channels through which each operates.

1. A Hausman test was run on each indicator to confirm the superiority of a fixed effects model over random effects.

2. See Acemoglu, Johnson, and Robinson (2001, 2002) and Acemoglu and Johnson (2005) for more discussion of the correlation between GDP and institutional indices.

3. For example, 1977 is averaged from 1973 to 1977. The time point 2004 is a two-year average covering 2003-2004.

4. Aid 1977 and 1982 are the instruments for Aid 1992; Aid 1982 and 1987 are the instruments for Aid 1997; Aid 1987 and 1992 are the instruments for Aid 2002; and Aid 1992 and 1997 are the instruments for Aid 2004. Sargan-Hansen tests for overidentifying restrictions are performed to confirm the validity of the instruments. These statistics are insignificant, indicating that the instruments are uncorrelated with the error term and are correctly excluded. The statistics are 0.154, 0.421, 0.591, 0.322, and 0.160 for the regressions including GDP as a control variable, the Fraser freedom index as a control variable, the political freedom index as a control variable, both GDP and the Fraser freedom index as control variables, and both GDP and the political freedom index as control variables, respectively.

5. A list of all countries is provided in Appendix C.

6. See Appendix D for data sources.

7. Both the original fixed effects model and the instrumental variable model were reestimated with three-year averages and the result did not change. Therefore, they have not been reported to save space.

face=+Bold; Appendix Aface=-Bold; (Table omitted. See article image.)

face=+Bold; Appendix Bface=-Bold; (Table omitted. See article image.)

face=+Bold; Appendix Cface=-Bold; (Table omitted. See article image.)

face=+Bold; Appendix Dface=-Bold; (Table omitted. See article image.)

Acemoglu, Daron and Simon Johnson. 2005. Unbundling institutions. Journal of Political Economy 113:949-95.

Acemoglu, Daron, Simon Johnson and James A. Robinson. 2001. The colonial origins of comparative development: An empirical investigation. The American Economic Review 91:1369-1401.

Acemoglu, Daron, Simon Johnson and James A. Robinson. 2002. Reversal of fortune: Geography and institutions in the making of the modern world income distribution. The Quarterly Journal of Economics 117:1231-94.

Bauer, Peter. 2000. From subsistence to exchange. Princeton, NJ: Princeton University Press.

Boone, Peter. 1996. Politics and the effectiveness of foreign aid. European Economic Review 40:289-329.

Brautigam, Deborah and Stephen Knack. 2004. Foreign aid, institutions and governance in sub-Saharan Africa. Economic Development and Cultural Change 52:255-86.

Brumm, Harold J. 2003. Aid, policies and growth: Bauer was right. Cato Journal 23:167-74.

Burnside, Craig and David Dollar. 2000. Aid, policies and growth. American Economic Review 90:847-68.

Djankov, Simeon, Jose G. Montalvo and Marta Reynal-Querol. 2005. The curse of aid. Washington, DC: The World Bank.

Easterly, William. 2001. The elusive quest for growth. Cambridge, MA: MIT Press.

Economides, George, Sarantis C. Kalyvitis and Apostolis Philippopoulos. 2004. Do foreign aid transfers distort incentives and hurt growth? Theory and evidence from 75 aid-recipient countries. CESifo Working Paper Series No. 1156

Filmer, Deon, Jeffrey S. Hammer and Leon H. Pritchett. 2000. Weak links in the chain: A diagnosis of health policy in poor countries. World Bank Research Observer 15:199-224.

Filmer, Deon, Jeffrey S. Hammer and Leon H. Pritchett. 2002. Weak links in the chain II: A prescription for health policy in poor countries. World Bank Research Observer 17:47-66.

Filmer, Deon and Leon H. Pritchett. 1999. The impact of public spending on health: Does money matter? Social Science and Medicine 49:1309-23.

Freedom House. 2007. Freedom in the world history rankings. Washington, DC: World Bank.

Frey, Bruno and Frederich Schneider. 1986. Competing models of international lending activity. Journal of Development Economics 20:225-45.

Gomanee, Karuna, Sourafel Girma and Oliver Morrissey. 2005. Aid public spending and human welfare: Evidence from quantile regressions. Journal of International Development 17:299-309.

Gwartney, James G. and Robert A. Lawson. 2005. Economic freedom of the world: 2005 annual report. Vancouver: The Fraser Institute.

Gwartney, James G., Robert A. Lawson and Randall G. Holcombe. 1999. Economic freedom and the environment for economic growth. Journal of Institutional and Theoretical Economics 155:1-21.

Hartford, Tim and Michael Klein. 2005. Aid and the resource curse. The World Bank Group No. 291.

Heckelman, Jac and Stephen Knack. 2005. Foreign aid and market- liberalizing reform. World Bank Policy Research Working Paper No. 3557.

Knack, Stephen. 2001. Aid dependence and the quality of governance: A cross country empirical analysis. Southern Economic Journal 68:310-29.

Mosley, Paul. 1985a. The political economy of foreign aid: A model of the market for a public good. Economic Development and Cultural Change 33:373-93.

Mosley, Paul. 1985b. Towards a predictive model of overseas aid expenditures. Scottish Journal of Political Economy 32:1-19.

Organisation for Economic Co-operation and Development (OECD). 2007. Credit reporting system. Paris: International Development Statistics.

Ovaska, Tomi. 2003. The failure of development aid. Cato Journal 23:175-88.

Sachs, Jeffery D. 2005. The end of poverty. New York: The Penguin Press.

Sen, Amartya. 1999. Development as freedom. New York: Anchor Books.

Svensson, Jacob. 1999. Aid growth, and democracy. Economics & Politics 11:275-97.

Trumbull, William N. and Howard J. Wall. 1994. Estimating aid- allocation criteria with panel data. Economic Journal 104:876-82.

United Nations Development Programme. 2005. Aid for the 21st century. Human development report. New York: Oxford University Press.

World Bank. 2006. World development indicators. Washington, DC: World Bank.

Copyright Southern Economic Association Jul 2008

(c) 2008 Southern Economic Journal. Provided by ProQuest Information and Learning. All rights Reserved.

5 McLean Co. Pharmacies Join Drug Disposal Program

By Paul Swiech

BLOOMINGTON – Five McLean County pharmacies are accepting unused prescription and nonprescription medicines for proper disposal in an expansion of the Livingston County program to keep leftover drugs out of the water supply.

Mike Novario, director of pharmacy at OSF St. Joseph Medical Center, said the following are accepting leftover medicines during regular business hours: Eastland Pharmacy in OSF’s Eastland Medical Plaza I, Bloomington; Atrium Pharmacy at BroMenn Regional Medical Center, Normal; Merle Pharmacy, Bloomington; Chenoa Pharmacy, Chenoa; and Doc’s Drugs, LeRoy.

“Our goal is to keep medications out of our water supply,” Novario said Monday. “My hope is that we’ll have more pharmacies participate.”

“Now people (in McLean County) don’t have to worry about where to take their medicine,” said Paul Ritter, the Pontiac Township High School science teacher who began the Pontiac Prescription Drug Disposal (P2D2) Program in Livingston County with fellow teacher Eric Bohn and their students in January.

Individuals may bring their medicines to participating pharmacies, even if they didn’t buy the medicines there, Novario and Ritter said. Patients are asked to black out their names on the prescription labels but to leave the name of the medicine exposed.

Controlled substances – usually strong painkillers such as codeine, morphine, hydrocodone and oxycodone – will not be accepted by the pharmacies, nor will needles, syringes or thermometers, Novario said. Plans for collecting and disposing of controlled substances still are under consideration.

Pharmaceuticals – including antibiotics and antidepressants – have been found in most waterways tested nationwide because people have disposed of leftover drugs by dumping them down the drain or flushing them down the toilet. Because that water contributes to our water supply, scientists are concerned that trace amounts of medicines are in our drinking water.

Illinois Environmental Protection Agency is taking care of the cost of transferring and disposing the drugs, Novario said. Veolia Environmental Services will transport and dispose of the waste at one of two bulk medication incineration facilities, he said.

The program’s expansion to McLean County kicked off with a P2D2 Green Day event Saturday outside St. Joseph. Collected were a 55- gallon barrel full of liquid medicines and ointments, a nearly full barrel of tablets and capsules, and a half-barrel of controlled substances collected by the Bloomington Police Department, Novario said.

“I am thrilled by the number of people who came out and handed over their non-used medications,” Novario said. “My guess is this is only the tip of the iceberg.”

Ritter said that 32 pharmacies are collecting medicines in 11 counties.

(c) 2008 Pantagraph. Provided by ProQuest Information and Learning. All rights Reserved.

One on One With Maki Kato

By JONATHAN NELSON

You’re the fitness director at 360 Physical Therapy in Vancouver. What does the job entail?

We’re just launching a new fitness program. My job was to create everything from scratch.

So what did you come up with?

We offer personal training and group training. My personal training program is based on what the client has at home. A lot of people own a PhysioBall, resistance bands and dumbbells. Whether they collect dust in the garage, a lot of people have them.

Our group exercise classes gather four to seven friends or family members. They choose the day, time and frequency. I’ve got class descriptions like core components and cardio components. They are going to design their own class.

You obviously have an interest in exercise and fitness. Where did that come from?

I started taking group exercise classes (in college) and then I started teaching them. Exercising to me is such a relief for everything that goes on in my life.

Did that training make you change your major?

No. It was always exercise and sports science.

How did you land your job?

My best friend, Amy Tran, is at the University of Southern California and Ike (Ike Anunciado, owner of 360 Physical Therapy) was her mentor for a long period of time. She got a job at 360 as an aide. After I graduated, I was hired by 24 Hour Fitness. My (former) boss is a close friend with Ike. I called Ike up (when Amy moved to California).

What are your hours?

Forty hours.

What is the most challenging aspect of your job?

Starting everything from nothing. How do I reach out to people who know nothing about the program? I have no business or marketing background.

What do you consider to be your biggest career break?

Making that decision to start working for 360 PT.

What was your first job? And what did you learn from it?

My first job was as a fitness instructor at Oregon State. I learned to pursue what I love.

What are you reading for fun?

“Making the Cut: The 30-Day Diet and Fitness Plan for the Strongest, Sexiest You,” by Jillian Michaels.

What’s playing on your iPod these days?

A bunch of running songs, high-energy, motivating songs to put me through workouts.

As a kid, what did you dream about doing when you grew up?

I wanted to be a dolphin therapist, where you allow children with disabilities to swim with dolphins.

What’s your favorite restaurant?

Sungari Pearl Restaurant in Portland.

What is the most you’ve ever splurged on a hobby or personal indulgence?

Right now I’ve been getting into running. I got a puppy to train with me.

What’s the best business advice you’ve ever received?

Love what you do.

What kind of advice would you give someone looking to enter your field?

Learn from others. Go to seminars, read. Be willing to learn different techniques.

Favorite vacation spot?

Hawaii.

One on One is a weekly feature profiling Clark County business people.

Vital statistics

Age: 23.

Education: Bachelor’s degree in exercise and sport science from Oregon State University.

Personal: Hikes, climbs, surfs and swims.

Jonathan Nelson covers retail, banking and the Port of Vancouver for The Columbian. He can be reached at 360-735-4543 or via e-mail at [email protected]

Originally published by JONATHAN NELSON Columbian staff writer.

(c) 2008 Columbian. Provided by ProQuest Information and Learning. All rights Reserved.

Baby Found on Porch Near Downtown Lexington

By Shawntaye Hopkins, The Lexington Herald-Leader, Ky.

Jul. 2–Lexington police are investigating after a newborn was found Wednesday morning on the front porch of a home off Richmond Road.

A woman who lives on the 100 block of Lincoln Avenue found the baby boy as she was leaving for work about 8:30 a.m. He was lying in a laundry basket wrapped in blankets with a note from a parent asking the homeowner to take care of the child.

Lexington police have not found the baby’s parents.

The newborn, who appears to be about 2 or 3 days old, was taken to a local hospital, but he seemed healthy Wednesday morning, Lexington police said. The Cabinet for Families and Children will care for the baby after he is released from the hospital.

“It was very apparent that she wanted the baby to be taken care of,” Lexington police Officer Ann Gutierrez said of the boy’s mother.

It is not clear how long the baby was on the porch.

At the hospital’s request, Gutierrez declined to say which hospital is treating the child. But doctors do not think the baby was born in a hospital.

Gutierrez said it is legal to anonymously leave a child at a hospital or police station, but statutes prevent adults from intentionally abandoning minors and placing them at risk of injury.

Investigators will have to decide whether to place charges against the mother if she’s located, Gutierrez said, adding that it doesn’t look as if the mother wanted to harm the child.

Gutierrez said it would be nice to see the mother get help from social services and the community to raise the child.

Lexington police have requested that anyone with information about the newborn call (859) 258-3690.

Reach Shawntaye Hopkins (859) 231-1386 or 1-800-950-6397, Ext. 1386.

—–

To see more of the Lexington Herald-Leader, or to subscribe to the newspaper, go to http://www.kentucky.com.

Copyright (c) 2008, The Lexington Herald-Leader, Ky.

Distributed by McClatchy-Tribune Information Services.

For reprints, email [email protected], call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.

Dentist System Failing Patients

By JANE KIRBY

A NEW contract for dentists is failing to improve services for patients, a committee of MPs said today.

Changes in how dentists are paid may mean they have no financial incentive to give appropriate treatment, it suggests.

Evidence presented to the Commons Health Select Committee found that the number of tooth extractions has risen since the new contract was introduced, while the volume of more complex work like crowns, bridges and dentures has fallen by 57%.

Dentists used to be paid a fee for each item of treatment they provided but they now receive an annual income in return for carrying out an agreed amount of work, known as units of dental activity (UDAs).

Today’s report said it was “extraordinary” that the Department of Health did not carry out pilot studies on the UDA system before introducing it across England.

And it said that, despite assurances from the Government that the new arrangements would work if PCTs (Primary Care Trusts) and dentists acted more flexibly and used common sense and goodwill, the committee “saw little evidence this will happen”.

It also found little evidence that preventative care has increased – one of the Government’s key aims for the contract.

The British Endodontic Society (BES) also said the new contract provided dentists with a “financial incentive to persuade a patient to have a decayed tooth extracted rather than undergo the more complex procedure of restoring it,” the report said.

MPs also heard how the number of patients being referred to dental hospitals and community dentists shot up following the introduction of the new contract in April 2006.

Dentists now had no financial incentive to treat complex cases, the MPs heard.

The MPs said in their report: “We are concerned about the increase in referrals of patients requiring complex treatment to dental hospitals and community dentists.

“This can be bad for those patients who would prefer to be treated by their general dental practitioner and can also have adverse effects on patients who are traditionally treated in these settings and have to wait longer for treatment.”

Figures released last month showed almost a million fewer people are now seeing an NHS dentist than before the Government’s reforms.

Committee chairman and Labour MP Kevin Barron said: “It is disappointing that so far the new dental contract has failed to improve the patient’s experience of dental services.”

A spokeswoman for the Department of Health said: “We will carefully consider the Committee’s recommendations and respond formally to them.

“It takes time for the extra services now being commissioned to feed through into the access figures that currently do not provide an up to date picture.”

(c) 2008 Evening Chronicle – Newcastle-upon-Tyne. Provided by ProQuest Information and Learning. All rights Reserved.

Cure for Herpes May Be Coming Soon

DURHAM, N.C. ““ Now that Duke University Medical Center scientists have figured out how the virus that causes cold sores hides out, they may have a way to wake it up and kill it.

Cold sores, painful, unsightly blemishes around the mouth, have so far evaded a cure or even prevention. They’re known to be caused by the herpes simplex virus 1 (HSV1), which lies dormant in the trigeminal nerve of the face until triggered to reawaken by excessive sunlight, fever, or other stresses.

“We have provided a molecular understanding of how HSV1 hides and then switches back and forth between the latent (hidden) and active phases,” said Bryan Cullen, Duke professor of molecular genetics and microbiology.

His group’s findings, published in Nature, also provide a framework for studying other latent viruses, such as the chicken pox virus, which can return later in life as a case of shingles, and herpes simplex 2 virus, a genitally transmitted virus that also causes painful sores, Cullen said.

Most of the time, HSV1 lives quietly for years, out of reach of any therapy we have against it. It does not replicate itself during this time and only produces one molecular product, called latency associated transcript RNA or LAT RNA.

“It has always been a mystery what this product, LAT RNA, does,” Cullen said. “Usually viral RNAs exist to make proteins that are of use to the virus, but this LAT RNA is extremely unstable and does not make any proteins.”

In studies of mice, the team showed that the LAT RNA is processed into smaller strands, called microRNAs, that block production of the proteins that make the virus turn on active replication. As long as the supply of microRNAs is sufficient, the virus stays dormant.

After a larger stress, however, the virus starts making more messenger RNA than the supply of microRNAs can block, and protein manufacturing begins again. This tips the balance, and the virus ultimately makes proteins that begin active viral replication.

The new supply of viruses then travels back down the trigeminal nerve, to the site of the initial infection at the mouth. A cold sore always erupts in the same place and is the source of viruses that might infect another person, either from direct contact, or sharing eating utensils or towels, Cullen said.

The approach to curing this nuisance would be a combination therapy, Cullen said. “Inactive virus is completely untouchable by any treatment we have. Unless you activate the virus, you can’t kill it,” he said.

Cullen and his team are testing a new drug designed to very precisely bind to the microRNAs that keep the virus dormant. If it works, the virus would become activated and start replicating.

Once the virus is active, a patient would then take acyclovir, a drug that effectively kills replicating HSV1.

“In principle, you could activate and then kill all of the virus in a patient,” Cullen said. “This would completely cure a person, and you would never get another cold sore.”

He and the team are working with drug development companies in animal trials to begin to answer questions about how to deliver this drug most effectively.

On the Net:

Duke University Medical Center

Sen. Kennedy Begins Healthcare Push

U.S. Sen. Edward Kennedy, D-Mass., has begun meetings to lay the groundwork for a new plan for universal healthcare, the Boston Globe reports.

Among those involved are experts on healthcare and members of U.S. Sen. Barack Obama’s staff. Kennedy supports Obama, D-Ill., the presumptive Democratic nominee for president.

The senator is trying to learn from health reform attempts in the past and to build a fair amount of consensus among his Senate colleagues, House colleagues, and the Obama campaign … and find a strategy that could carry with some momentum into the new administration, said Dr. Jay Himmelstein, a former Kennedy staffer now teaching health policy at the University of Massachusetts.

Kennedy, who was recently diagnosed with brain cancer, told his staff to begin meetings while he was being treated at Massachusetts General Hospital.

The last major push for universal healthcare occurred at the beginning of President Bill Clinton’s first term.

Legacy Hospital to Complete Vacant Floor

By Paul Craig, The Columbian, Vancouver, Wash.

Jul. 2–Legacy Salmon Creek Hospital plans to build out its vacant sixth floor in a $12 million project that will expand services and capacity at the three-year-old hospital.

The expansion comes as the hospital’s profits are increasing along with its patient volumes. Legacy Salmon Creek had net operating income of $4.06 million in fiscal year 2008, which ended in March, even though it had budgeted for a loss of $4.5 million. It was the hospital’s second full fiscal year, following a loss of $11.8 million in 2007.

“We definitely feel we’re on a stable fiscal footing now,” said Jonathan Avery, hospital chief administrative officer. “The losses of the ramp-up period are behind us.”

The hospital turned a profit faster than expected thanks to greater demand for its services. Its average in-patient volume, according to daily census reports, jumped to 94 in 2008, up from 81 the previous year. For the first few months of the new year, the hospital’s in-patient average increased to 109 patients a day, Avery said. Emergency visits, births and surgical cases also continued growing.

If the permitting process goes as planned, sixth-floor construction could begin by September. It will take 10 to 12 months to complete and will all be done in one phase. The hope is to have the floor open to patients by midsummer 2009.

The construction will include moving the hospital’s progressive care unit to the sixth floor and adding a second such unit. The former progressive care area on the third floor would then be converted into a neurosciences unit. An orthopedic unit for joint medicine will also be built on the sixth floor and a general surgical care unit will move from the fifth floor to the sixth floor. The fifth-floor space will then be used to care for overflow patients from the hospital’s birth center.

The project will add 64 beds, bringing Legacy Salmon Creek up to its capacity of 220 active beds, the maximum it was licensed for when it opened in August 2005.

Paul Craig covers the health care industry for The Columbian. He can be reached at 360-735-4520 or via e-mail at [email protected].

—–

To see more of The Columbian, or to subscribe to the newspaper, go to http://www.columbian.com.

Copyright (c) 2008, The Columbian, Vancouver, Wash.

Distributed by McClatchy-Tribune Information Services.

For reprints, email [email protected], call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.

Geisinger Workers Face Job Opportunities

By Andrew M. Seder, The Times Leader, Wilkes-Barre, Pa.

Jul. 2–If you’re going to be laid off from a hospital job, there are a lot worse places to have it happen than in Northeastern Pennsylvania.

That’s the message being offered by hospital officials throughout the region.

It’s directed at the approximately 400 employees of Geisinger South Wilkes-Barre who were notified Thursday their positions were being eliminated this fall. But there are opportunities in the region.

There are nearly 20 hospitals or medical centers within 70 miles of Wilkes-Barre — in addition to numerous nursing homes, rehabilitation facilities and medical offices. All facilities have open positions, ranging from a half-dozen at Montrose General Hospital to nearly 200 within the Lehigh Valley Health System. Positions include nurses, technicians, dietary staff and housekeeping.

Some nursing positions — of which there are at least 500 currently available within an hour’s drive of Wilkes-Barre — come with signing bonuses of up to $10,000. Advertisements placed by Mercy Health Partners in Scranton offer those furloughed Geisinger workers who are former employees of Mercy Hospital in Wilkes-Barre positions at their facilities in Scranton and Nanticoke. This would enable them to receive credit for their previous time with Mercy, as far as pay, vacation time and pension are concerned.

The Danville-based Geisinger Health System purchased Mercy Hospital in Wilkes-Barre in December 2005 and renamed it Geisinger South Wilkes-Barre.

John M. Starcher Jr., interim president and chief executive officer of Mercy, said the incentives seemed to be the right thing to do based on the history between Mercy and its former employees and the mission preached by the Sisters of Mercy. The offer also includes health benefits that go into effect the first day of the month following the date of hire. Usually new hires have to wait 90 days to be eligible for benefits.

The offers, coupled with the employees’ familiarity with the health system, may give Mercy an advantage in swaying employees to rejoin them, Starcher said.

Other hospitals are trying to position themselves as a viable destination.

Tim Farley, vice president of human resources at Greater Hazleton Health Alliance, said the dearth of hospitals in the region offers a number of positions for the Geisinger employees and “there’s no question we can absorb it (the job seekers).” He said the influx of hundreds of qualified employees into the work force has human resource offices abuzz.

Hazleton General Hospital, a member of the alliance, will host a job fair July 16. It’s early this year, Farley said, because he knows there will be a healthy competition to recruit the displaced workers.

“It’s selfish and it’s not selfish,” Farley said. The goal is to keep the talent in Northeast Pennsylvania so the best medical care is offered locally, he said.

Starcher was more to the point.

“We’d be disingenuous if we didn’t say this goes a long way to helping us (fill the depleted ranks),” Starcher said. Job fairs also are planned for Mercy.

Some workers aren’t waiting. They’ve scoured the wants ads in the days after the lay-off announcement and dozens of resumes and phone calls have been received by local hospital human resource offices.

Geisinger spokesman Dave Jolley said the system is working closely with employees and employment agencies to line up jobs for laid-off workers. A job fair is in the works for mid-August and a Chicago firm that specializes in helping workers prepare resumes and improve job search and interview techniques has been hired.

Jolley said about 160 of the workers will be able to remain with Geisinger at another one of the company’s facilities.

“The good part,” Jolley said, “is that they’re in a field that’s in demand.” After last week’s announcement, Geisinger received numerous calls from other health care providers looking for qualified workers. Among them is Tyler Memorial Hospital in Tunkhannock.

Tyler spokeswoman Gladys Bernet said human resources officials will meet today to discuss strategies to land some of the Geisinger staff. She said a job fair is among the options.

Hospital officials who said they’ve received calls or resumes from employees facing layoffs include Community Medical Center and Mercy Health Partners in Scranton and Wilkes-Barre General Hospital, which is operated by Wyoming Valley Health Care System. Wilkes-Barre General is the closest hospital to Geisinger South Wilkes-Barre and would serve as an attractive option for those wishing to keep similar travel schedules and routes, spokesman Kevin McDonald said, adding that there are plenty of positions available.

McDonald said hospitals are always looking for qualified employees, especially nurses. While the news from South Wilkes-Barre was sad, he said workers who will lose their jobs “should know there are plenty of options and jobs out there.”

Jim Carmody, the health care system’s vice president of human resources, said Wilkes-Barre General went through a similar situation in 2000, when nearly 300 support staff positions were eliminated. While Wyoming Valley Health Care would like to fill its staffing holes with some Geisinger workers, Carmody said they will not “raid their employees.”

—–

To see more of The Times Leader, or to subscribe to the newspaper, go to http://www.timesleader.com.

Copyright (c) 2008, The Times Leader, Wilkes-Barre, Pa.

Distributed by McClatchy-Tribune Information Services.

For reprints, email [email protected], call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.

Belarusian Crackdown on Home Computer Networks Behind Schedule

Text of report in English by Belarusian privately-owned news agency Belapan

Minsk, 2 July: Efforts to crack down on “illegal” home computer networks are being foiled by the difficulty of discovering such networks, Stsyapan Vaytsyashonak, chief engineer at the Minsk Television Information Networks, told Belapan.

This past February, the Minsk Television Information Networks announced plans to disable home networks by July.

When asked how many networks were disabled, Vaytsyashonak said that he was not aware as the crackdown was not coordinated. He said that the work continued, with the administration of the city’s districts helping detect illegal networks.

Vaytsyashonak stressed that tenants should obtain permission from the city executive committee for establishing networks.

Under the plan, the state-run company was to establish the names and addresses of all home computer network administrators before 1 April and take stock of all equipment used by the networks by 1 May.

The company has the right to authorize electricians to cut off wires to disable home computer networks.

Originally published by Belapan news agency, Minsk, in English 1335 2 Jul 08.

(c) 2008 BBC Monitoring Former Soviet Union. Provided by ProQuest Information and Learning. All rights Reserved.

LifeGas Named Exclusive U.S. Distributor of BPR Medical FireSafe(TM) Cannula Valve

LifeGas, an affiliate of The Linde Group, has agreed to become the exclusive U.S. distributor of BPR Medical Ltd’s innovative FireSafe(TM) Cannula Valve – a fire-arresting device that fits into standard oxygen cannula tubing to protect patients in all healthcare settings from the risk of oxygen fires.

The FireSafe(TM) Cannula Valve seals off and stops oxygen fires before they reach the source. This has the potential to limit patient injuries, improve the probability of their survival and limit the structural damage caused by fire.

“In the U.S., over 1,000 oxygen fires occur each year, causing patient injury and often, sadly, death. Fires that are closer to patients are more likely to be fatal. The lightweight and disposable FireSafe Cannula Valve sits close to the patient’s face. This stops the fire early and fast, meaning patients are less likely to suffer fatal injury from oxygen in the supply tubing,” said Mark Sanda, LifeGas product manager for the FireSafe Cannula Valve.

“LifeGas is committed to keeping patients healthy and safe. It has been mandatory in the UK since 2006 to install these devices in all patient home oxygen supply systems. While there is no such requirement yet in the U.S., the FireSafe Cannula Valve provides healthcare providers with a cost-effective solution to lower the risk of serious patient injury in dangerous oxygen fires,” Sanda said.

Richard Radford, managing director, BPR Medical Ltd., said, “We believe LifeGas is the ideal partner to bring the benefits of the FireSafe(TM) Cannula Valve to the United States. LifeGas continues to demonstrate that the health and safety of patients is of paramount importance to them – mirroring the philosophy here at BPR Medical. LifeGas’ eagerness to adopt new products like the FireSafe Cannula Valve is testament to that.”

Learn more and see a demonstration of the product at www.lifegas.com.

BPR Medical Ltd is a provider of medical gas control equipment, including the Carnet brand – a market leading portfolio of precision instruments for the respiratory and anesthetic markets. Through individual and corporate expertise, care and professionalism BPR Medical are committed to the design, manufacture and delivery of absolute best product solutions – combining higher customer value with enhanced patient safety and lower life cycle costs.

For more information visit: www.bprmedical.com and www.carnetmedical.com.

LifeGas is the U.S. medical gases business of The Linde Group. The company specializes in providing premier medical gases and gas-enabled solutions to hospitals, clinics, nursing facilities, emergency management services and home healthcare providers with service to over 1,000 hospitals and home care providers.

The Linde Group has more than 50,000 employees working in around 100 countries worldwide. In the 2007 financial year it achieved sales of EUR 12.3 billion (USD 18.7 billion). The strategy of The Linde Group is geared towards earnings-based and sustainable growth and focuses on the expansion of its international business with forward-looking products and services.

Linde acts responsibly towards its shareholders, business partners, employees, society and the environment – in every one of its business areas, regions and locations across the globe. Linde is committed to technologies and products that unite the goals of customer value and sustainable development.

For more information, see The Linde Group web site at www.linde.com.

BVCASA Gets Grant for at-Risk Women

By Selena Hernandez, The Eagle, Bryan, Texas

Jul. 2–New education and intervention programs for pregnant and postpartum women will soon be available in the Brazos Valley, thanks to a $200,000 grant from the Department of State Health Services.

Officials with the Brazos Valley Council on Alcohol and Substance Abuse said they would use the grant to help women at risk for substance abuse. The money will also be used to address infant health.

BVCASA Director of Prevention and Intervention Services Mary Mattingly said she is excited to add the programs to the agency’s services.

The programs will teach women about the effects drugs and alcohol could have on their children. Infant care, parenting classes and counseling will also be offered.

Mattingly said the grant would help broaden programs such as Baby Luv. The agency’s case management service, which is set to begin in September, will coordinate assistance for mothers and offer referrals.

“It’s very difficult to get through the health services maze,” she said. “We are trying to help and make things easier.

“This is important because it helps reduce the potential for fetal alcohol and drug-abuse syndrome,” Mattingly said. “We’re trying to prevent anything that takes away from a developing child.”

–Selena Hernandez’s e-mail address is [email protected].

—–

To see more of The Eagle or to subscribe to the newspaper, go to http://www.theeagle.com/.

Copyright (c) 2008, The Eagle, Bryan, Texas

Distributed by McClatchy-Tribune Information Services.

For reprints, email [email protected], call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.

Takeda Merges With Tap Pharmaceutical Products

Takeda Pharmaceutical has announced that Takeda Pharmaceuticals North America and Takeda Global Research & Development Center merged with Tap Pharmaceutical Products, forming one of the top 15 pharmaceutical companies in the US.

The merger is a result of the conclusion of a 30-year joint venture between Takeda Pharmaceutical Company and Abbott announced March 19, 2008.

According to terms previously announced, Takeda received the rights to Tap’s product Prevacid, its non-Lupron related commercial organization, Tap’s support organizations, and Tap’s pipeline. Effective May 1, 2008 Tap became a wholly-owned subsidiary of Takeda America Holdings.

As a result, Tap will no longer exist as a separate entity reporting to Takeda America Holdings and former Tap employees who were part of this reporting structure will become employees of Takeda Pharmaceuticals North America, its subsidiary, Takeda Pharmaceuticals America or Takeda Global Research & Development Center.

Yasuchika Hasegawa, president of Takeda Pharmaceutical, said: “The merger of Tap and Takeda represents a significant milestone in the integration of two successful companies, and we look forward to maximizing future growth opportunities.”

FDA Approves Interventional Spine’s IDE Application for PercuDyn System

Interventional Spine has announced that the FDA has approved its investigational device exemption application for its PercuDyn System for the treatment of degenerative disc disease.

This approval is conditional upon the company providing some additional information to the FDA.

Walter Cuevas, CEO of Interventional Spine, said: “We believe that the PercuDyn System is the first and only product of its kind, and we look forward to a day when it can be marketed in the US as it already is in international markets.

“To that end, we now move to the next phase in the FDA approval process in gathering the data required for submission and pre-market approval.”

MedAvant Closes Sale of Its Lab Services Business to ETSec

ATLANTA, July 2, 2008 (PRIME NEWSWIRE) — MedAvant Healthcare Solutions (MedAvant) (Nasdaq:PILL), a leader in healthcare technology and transaction services, today announced it has closed the sale of its Laboratory services business (“Lab”) to ETSec.

The transaction includes all products and services of MedAvant’s Lab business, including the ongoing support of more than 50,000 deployed remote printers and devices. The sale also includes Pilot, MedAvant’s proprietary patented technology that enables the remote delivery of lab results to providers, and Fleet Management System, which provides real-time status information and unparalleled remote printer management and support.

“We have been focused for the past year on divesting our non-core businesses,” said Peter Fleming, MedAvant Interim Chief Executive Officer. “These divestitures allow us the renewed ability to focus exclusively on building our EDI (Electronic Data Interchange) business which is our core competency. We continue to expand our payer and provider connectivity which today includes nearly 1,400 payers and more than 200,000 providers nationwide. With our real-time Phoenix platform, we can seamlessly link any payer to any provider in the nation in order to allow the transparent exchange of administrative, financial and clinical information. This capability, performed in a real-time environment, puts us at the forefront of our industry and allows us to offer our EDI customers greater efficiencies, fast payment, and improved clinical outcomes.”

Cain Brothers & Company, LLC acted as exclusive financial advisor to MedAvant for this transaction. Foley & Lardner LLP acted as legal counsel to MedAvant in this transaction.

About MedAvant Healthcare Solutions

MedAvant is a national connectivity network that connects payers with providers in a real-time environment for the purpose of transparently messaging administrative, financial and clinical information in order to lower total administrative costs, improve payer, provider and member relationships, and to ultimately improve clinical outcomes. For more information, visit http://www.medavanthealth.com. MedAvant is a trade name of ProxyMed, Inc.

The MedAvant Healthcare Solutions logo is available at http://www.primenewswire.com/newsroom/prs/?pkgid=3540

About ETSec

ETSec is an enterprise security company that is 100% focused on providing clients with the proven strategies, solutions, and services they need to protect vital technical assets against potential security threats. Our expertise in providing a wide range of clients with security solutions and services has given us an appreciation for the economic constraints and real security threats that today’s companies face. To help clients cope with these challenges, we take a holistic – yet practical – approach to enterprise security, helping clients stay ahead of near-term threats, while driving toward a longer-term plan to minimize risk.

For more information, visit http://www.etsec.com.

Forward Looking Statement

Statements in this release that are “forward-looking statements” are based on current expectations and assumptions that are subject to risks and uncertainties. In some cases, forward-looking statements can be identified by terminology such as “may,””should,””potential,””continue,””expects,””anticipates,””intends,””plans,””believes,””estimates,” and similar expressions. Actual results could differ materially from projected results because of factors such as:

    * The soundness of our business strategies relative to the    perceived market opportunities;  * Our ability to successfully develop, market, sell, cross-sell,    install and upgrade our clinical and financial transaction    services and applications to current and new physicians, payers    and medical laboratories;  * Our ability to satisfy the listing requirements of the Nasdaq    Global Market or Nasdaq Capital Market;  * Our ability to compete effectively on price and support services;  * Our ability and that of our business associates to perform    satisfactorily under the terms of our contractual obligations,    and to comply with various government rules regarding healthcare    and patient privacy;  * Entry into markets with vigorous competition, market acceptance    of existing products and services, changes in licensing programs,    product price discounts, delays in product development and    related product release schedules, any of which may cause our    revenues and income to fall short of anticipated levels;  * The availability of competitive products or services;  * The continued ability to protect our intellectual property    rights;  * Implementation of operating cost structures that align with    revenue growth;  * Uninsured losses;  * Adverse results in legal disputes;  * Unanticipated tax liabilities; and  * The effects of a natural disaster or other catastrophic event    beyond our control that results in the destruction or disruption    of any of our critical business or information technology    systems 

Any of these factors could cause the actual results to differ materially from the guidance given at this time. For further cautions about the risks of investing in MedAvant, we refer you to the documents MedAvant files from time to time with the Securities and Exchange Commission, including, without limitation, its most recently filed Annual Report on Form 10-K. MedAvant does not assume, and expressly disclaims, any obligation to update information contained in this document. Although this release may remain available on our website or elsewhere, its continued availability does not indicate that we are reaffirming or confirming any of the information contained herein.

This news release was distributed by PrimeNewswire, www.primenewswire.com

 CONTACT:  Institutional Marketing Services, Inc.           Investor Relations Contact:           John G. Nesbett/Jen Belodeau           203-972-9200           [email protected]            MedAvant Healthcare Solutions           Media Contacts:           Teresa Stubbs           812-206-4332           [email protected] 

Weapons Destruction Will Miss Deadline

By John Norton, The Pueblo Chieftain, Colo.

Jul. 2–The Defense Department agency responsible for weapons destruction programs in Pueblo, and at the Blue Grass Army Depot in Kentucky, reaffirmed to Congress this week that it is not going to finish the work by a treaty deadline of 2012.

It was the same message former Secretary of Defense Donald Rumsfeld gave Congress two years ago.

The Assembled Chemical Weapons Alternatives program report also stated that meeting a separate 2017 deadline set by Congress would take round-the-clock operations in Pueblo and the use of something other than water neutralization for the 98 tons of mustard agent weapons in Kentucky.

“I found that report woefully lacking in any real information,” said Irene Kornelly, chairwoman of the Colorado Chemical Demilitarization Citizens Advisory Commission. “I don’t know why it took six months to come up with this. Six or eight of us could have done it in an hour.”

The real questions, Kornelly said, are whether the Defense Department plans to ask for the funds necessary to accelerate the program and Congress is willing to spend the money. Rep. Mark Udall, D-Colo., one of the authors of the legislation mandating the 2017 deadline, said the report includes some good news and some bad news.

Udall, a member of the House Armed Services Committee, explained: “The good news is that 2017 is doable. “The bad news is that we won’t know until early next year whether the Defense Department can come up with the funds and the plans that are needed to complete weapons destruction at the Pueblo Depot by 2017.

“I believe DOD understands that Congress was serious when it passed the 2017 deadline into law, so I am hopeful that the next administration’s budget request will include the funds necessary to make 2017 a reality,” Udall said.

The ACWA program manager, Kevin Flamm, is expected to have a report later this month on what it’s going to cost to reach that goal, but Kornelly said that time is slipping away.

The 2009 budget process already is under way and because the program lacks authorization to spend the money already appropriated, some work at the Pueblo Chemical Depot has had to be deferred.

Kornelly said she will be in a conference call with Flamm this afternoon and hoped to receive more information.

The Pueblo Chemical Depot has a stockpile of 780,000 artillery shells and mortar rounds containing 2,611 tons of mustard agent.

The destruction plan calls for the weapons to be opened by robotic equipment and the mustard agent neutralized in a solution of hot water and other chemicals. The remaining wastewater then either would be treated on-site and recycled in the plant or hauled away for further treatment.

The report did state that of three options, meeting the treaty deadline, transporting the weapons to plants already in operation and acceleration, only the third was practical.

Federal law prohibits transporting chemical weapons and changing that now, it said, would be difficult.

—–

To see more of The Pueblo Chieftain, or to subscribe to the newspaper, go to http://www.chieftain.com.

Copyright (c) 2008, The Pueblo Chieftain, Colo.

Distributed by McClatchy-Tribune Information Services.

For reprints, email [email protected], call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.

Toledo Group Home Where 2 Fell Ill, Died May Be Closed

By Laren Weber, The Blade, Toledo, Ohio

Jul. 2–The Ohio Department of Health has proposed closing the Pamela Shay Angel Arms Family group home, where two residents were found unconscious last month in an upstairs bedroom and later died, a spokesman for the agency said yesterday.

An investigation following the deaths revealed violations “that jeopardized the health and safety of the residents of your facility,” according to a letter sent Thursday to Pamela Shay, who owns the facility.

Sara Morman, a department spokesman, said the agency is proposing the group home’s license be revoked.

Ms. Shay has 30 days to request an administrative hearing with health department representatives during which she can present her position, contentions, or arguments in an effort to retain her license.

If one is not requested, state officials will issue an order to revoke the license, which was issued in 2005, Ms. Morman said.

Ms. Shay could not be reached for comment last night.

Police responded to the group home at 1577 Bow St., off of Western Avenue, about 1:15 p.m. June 9 on a report of two unresponsive males.

Thomas Calhoun, 47, was found dead in an upstairs bedroom, where authorities said the temperature was measured at more than 90 degrees.

His roommate, John Jones, 79, died the following week in the University of Toledo Medical Center, the former Medical College of Ohio Hospital. His temperature was measured at 105.5 degrees when he arrived at the hospital, Dr. Diane Barnett, a Lucas County deputy coroner, said.

A third resident, a 60-year-old man, no longer lives at Angel Arms.

A nine-page report detailing findings of the investigation revealed that on the afternoon the men were found, Angel Arms employees — knowing of the excessive heat — had not taken responsibility to ensure the victims took their morning medications and drank fluids, provided them with breakfast and lunch, or checked on them until 1 p.m.

Nothing was presented by the facility to demonstrate that the residents were being monitored in the heat for safety, according to the report.

Steve Kahle, an investigator with the coroner’s office, said the men were found at least eight to 15 hours after they became incapacitated despite a witness’ report to police that he had checked on the men at 11 a.m. that day.

State officials reported that Mr. Calhoun’s body already had begun decomposing.

The investigation also revealed the bedroom Mr. Jones and Mr. Calhoun shared had not been checked for “excessive heat in spite of a heat wave for several days in the 90s with high humidity.”

The high temperature June 9 was 94. At 1 p.m., just before the men were found, the temperature was 91 with 45 percent humidity, according to the National Weather Service in Cleveland.

An inspection in January of Angel Arms found 29 violations, including inadequately trained staff and failure to provide a clean, healthy environment, among others.

The state notified Angel Arms in April that it would be fined if it didn’t correct the violations.

Ms. Morman said all the necessary changes had been made when the state returned to the facility May 28 for a follow-up investigation.

Dr. Barnett said the preliminary cause of death for Mr. Calhoun and Mr. Jones, each of whom suffered from schizophrenia, was complications from heat stroke.

The exact cause is pending results of toxicology and other tests, she said.

Toledo police Detective Jeff Clark, who is investigating the case, said charges are pending final autopsy results.

The men were taking anti-psychotic medication, which Dr. Barnett said increases the risk of heat stroke.

The medication impairs the body’s ability to regulate its temperature.

Contact Laren Weber at: [email protected] or 419-724-6050.

—–

To see more of The Blade, or to subscribe to the newspaper, go to http://www.toledoblade.com.

Copyright (c) 2008, The Blade, Toledo, Ohio

Distributed by McClatchy-Tribune Information Services.

For reprints, email [email protected], call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.

Utah Valley Entertainment Calendar

Events

Wednesday, July 2

— Monte L. Bean Life Science Museum, 645 E. 1430 North, weekly live animal shows. Today: Utah Plants and Animals at 7:30 p.m. Call 422-5052. Free.

— Shakespeare for Kids at 4 p.m. at the storytelling wing, Orem Public Library, 58 N. State. Becky and Joel Wallin present Henry V. For ages 6-up. Call 229-7391. Free.

Thursday, July 3

— Monte L. Bean Life Science Museum, 645 E. 1430 North, weekly live animal shows. Today: Ecosystems at 7:30 p.m. Call 422-5052. Free.

— Timp Tellers Work Session at 7 p.m. in the media auditorium, Orem Public Library, 58 N. State. Share stories and receive valuable feedback from new and experienced tellers. Call 229-7391. Free.

— Provo Freedom Days, July 3-5, all-day activities at Center Street off University Avenue. Free.

Friday, July 4

— Lehi fireworks, dusk at Thanksgiving Point in Lehi. Free.

— Pleasant Grove fireworks at dusk at Pleasant Grove Junior High School, 100 E. 900 North. Free.

— America’s Freedom Festival at Provo, 9 a.m. parade, University Avenue; 8 p.m., Stadium of Fire with Miley Cyrus, The Blue Man Group, Glenn Beck, BYU Lavell Edwards Stadium. See: www.freedomfestival.org

Saturday, July 5

— Monte L. Bean Life Science Museum, 645 E. 1430 North, Provo, weekly live animal shows. Today: reptiles at 1 p.m. Call 422-5052. Free.

Stage shows:

— “Footloose: The Musical,” July 5-19 at 8 p.m., SCERA Shell Outdoor Theater, 699 S. State, Orem. Cost: $10/$12/$14; $8/$10/$12 for children, seniors and students. Buy at the SCERA Center for the Arts, 745 S. State, Orem from 10 a.m. to 6 p.m. weekdays. Call 225- 2569.

— “Never Kiss On A Park Bench,” through July 26 at 7:30 p.m. (Friday, Saturday and Monday), Valley Center Playshouse, 780 N. 200 East. Lindon. Cost: $6/$5 students, children, seniors/$25 family. Call 785-1186.

— “Les Miserables the School Edition,” through July 19 (Fridays, Saturdays & Mondays) at 7:30 p.m., 2 p.m. matinees July 12, 19 at Center Street Musical Theatre, 177 West Center, Provo. Tickets: $10/ $8 seniors, students, children. Monday Night Family Pass/$45. Dinner:$10 more. Call 373-4485.

Concerts:

— Patriots in Petticoats, July 2, 3 at 5 p.m. and 7 p.m.; July 4 and 5 at 1p.m., 3 p.m. and 5 p.m. at the Crandall Historical Printing Museum Colonial Theatre, 275 E. Center, Provo. This historical production features life stories of women of the Revolution as told in History of the American Revolution by Mercy Otis Warren. Free.

— “We The People,” July 2-3 at 6 and 8 p.m. July 4 at 4 p.m. at the Provo Tabernacle, 100 S. University Ave. This is a musical celebration of the U.S. Constitution and the Founding Fathers written and directed by Janie Thompson. Free.

— Nathan Osmond and Guests in concert July 5 at 8 p.m. at the Crandall Historical Printing Museum Colonial Days, 275 E. Center, Provo. Free.

— Abba Live! in concert July 24 at 8 p.m. at the SCERA Shell Outdoor Theater, 699 S. State (inside SCERA Park). Cost: $10, $12, $15, $18. Call 225-2569.

Museums and exhibits:

— “Turning Point: The Demise of Modernism and the Rebirth of Meaning in American Art” at the Brigham Young University Museum of Art July through Jan. 3 will explore how two groups of American artists in the late 1960s rebelled against Modernist abstraction by creating artworks that directly challenged Modernism’s theoretical tenets. The Museum of Art is open Monday through Friday from 10 a.m. to 9 p.m. and Saturday from noon to 5 p.m. The museum is closed on Sunday. For more information about the museum, visitors can call 801- 422-8287 or visit moa.byu.edu. Free.

— Uncommon Ground exhibit through July 25 at the Terra Nova Gallery, 41 W. 300 North, Provo. Open Monday-Friday from 10 a.m. to 6 p.m. Other times by appointment. Call 374-0016. Free.

— The Da Vinci Experience at UVSC’s Woodbury Art Museum at the University Mall now through Oct. 4. The exhibit features working mechanical models based on the drawings found in Leonardo Da Vinci’s notebooks. Cost: $14/$11 seniors, $6 students, active military and family. Family group rates available. Children 5-under free. Open Monday from 12-9 p.m. and Tuesday-Friday from 11 a.m. to 7 p.m. Open Saturday from 11 a.m. to 6 p.m.

— The Pioneer Village and Museum, 500 W. 700 North. Open through Labor Day Mondays from 5-8 p.m. Tuesday-Friday from 4-7:30 p.m. and Saturdays from 1-5 p.m. Contributions accepted. See: www.pioneervillage-museum.org or call 377-8294 for the village, 852- 6609 for the museum. Free.

— “American Dreams,” selected works from the permanent collection of American Art, BYU Museum of Art, BYU campus, Provo. Call 422-ARTS. Free.

— Orem Heritage Museum, SCERA Center, 745 S. State. Guided tours 3-7 p.m. Monday-Friday or by appointment. Call 225-2569. Free.

— Crandall Historical Printing Museum, 275 E. Center, Provo. Open weekdays 9 a.m. to 2 p.m. Cost: $3. Tours by appointment. Call 377-7777.

— Hutchings Museum, 55 N. Center, Lehi. Check the Web site for classes, workshop and exhibit information: www.hutchingsmuseum.org Call 768-7180. Free.

— “Wayne Thiebaud: 70 Years of Painting” exhibit featuring 84 paintings and drawings by the artist, through July 27. Also “84th Annual Spring Salon” through July 6. Springville Museum of Art, 126 E. 400 South, Springville. Open Tuesday-Saturday from 10 a.m. to 5 p.m. Wednesday from 10 a.m. to 9 p.m.; Sunday from 3-6 p.m. Call 489- 2727. Free.

— Camp Floyd/Stagecoach Inn State Park, 18035 W. 1540 North, Fairfield, 9 a.m. to 5 p.m. daily. Cost: $2. Call 768-8932.

— Monte L. Bean Life Science Museum, BYU campus in Provo, 10 a.m. to 9 p.m., Monday through Friday, 10 a.m.-5 p.m., Saturday. Call 422-5051. Free.

Comedy clubs:

— Thrillionaires Improv Theater, every Saturday at 8 p.m., Cheap Thrills presented by the workshop performance group every Tuesday at the Covey Center for the Arts Little Theater, 425 W. Center, Provo. Cost: $10. See: www.coveycenter.org or call 852-7007.

— Wiseguys Comedy Cafe, corner of Geneva Road and University Parkway behind the Chevron station. Shows every Friday and Saturday at 8 p.m. This week featuring comedy hypnosis. Cost: $10. Call 377- 6910.

— Fat, Dumb and Happy’s Comedy Club, 1350 W. 1140 South, Orem, Suite 3. Must be 18. Cost: $8 adults, $6.50 students. Buy online or at the door.

— Comedy Sportz, 36 W. Center, Provo. Clean improv comedy each Friday and Saturday at 8 and 10:15 p.m. Cost: $8 in advance/$10 at the door, $4/$5 children. Pre-payment required to hold reservations. Call 377-9700. See: www.comedysportzutah.com for more information. Every Thursday ComedySportz laughletes perform musicals, Shakespeare, MST3K-style heckling. Cost: $3. No reservations needed.

(c) 2008 Deseret News (Salt Lake City). Provided by ProQuest Information and Learning. All rights Reserved.

Teen Pregnancy Rate in Region is Above State Average

By Lauren Roth, The Virginian-Pilot, Norfolk, Va.

Jul. 2–Each year, several dozen teenage girls in Franklin get pregnant.

The number might seem small compared with the 2,716 teen pregnancies in South Hampton Roads in 2006. But in this city of 8,400 surrounded by Southampton and Isle of Wight counties, a few dozen adds up to more than 6 percent of the community’s teenage girls.

The rate of teen pregnancies in Franklin was nearly 2-1/2 times the state average every year from 2004 to 2006, according to the latest data from the state Department of Health.

City and school officials said they are aware of the pattern and are searching for ways to derail it.

“Young girls are defining themselves through motherhood,” said Beth Reavis, director of social services for the city of Franklin. She is seeking grant funding to start programs aimed at preventing teen pregnancies. “The only thing that changes that dynamic is education,” she said.

The reports that a group of girls at Gloucester High School in Massachusetts may have coordinated their pregnancies has drawn attention to the issues of teen sexuality and contraception. A school nurse and doctor there resigned in protest after city officials spurned their plan to offer contraceptives without a prescription, according to Time magazine.

In the area stretching from Southampton County in the west to Virginia Beach in the east, teen pregnancies dropped 5.6 percent between 2004 and 2006, bucking the state trend. However, the pregnancy rate for teenagers in this region remains well above state norms, particularly in Norfolk and Portsmouth. In Virginia Beach alone, 837 teen girls were pregnant in 2006, state figures show.

Statewide, 13,704 girls were pregnant that year, a rate of 2.7 percent. Nearly 20 percent of those pregnancies were in the South Hampton Roads area.

In Franklin, Planned Parenthood of Southeastern Virginia offered an abstinence-based sex education curriculum for grades six to 10 during the 2006-07 school year. The classes were well-received, said Planned Parenthood spokeswoman Erin Zabel, but the group was not invited back the following year. The organization considers Franklin a priority area because the teen pregnancy rate there is one of the state’s highest.

“A new administration came on and had different opinions about teaching kids sex education,” Zabel said.

Of the 37 teen pregnancies in Franklin in 2006, 26 resulted in births. Nine of those were to girls age 15 to 17.

William Lawrence, an assistant principal at Franklin High School, said high numbers of teen pregnancies spurred his school to begin separating male and female students for more frank sex education sessions several years ago.

Lawrence said the school also started girls’ and boys’ clubs last fall that match students with mentors in the community.

“It’s to build morale and positive self-image and help that roll over into reducing the pregnancy rate,” he said.

Lawrence said it’s too early to tell whether the initiatives are working.

Beverly Rabil, associate director of instruction for Franklin schools, is to meet with the city’s guidance counselors in August to discuss strategies for reducing teen pregnancies.

“First, you have to come to the table and discuss that it’s an issue,” Rabil said. “That’s where we are now. It’s a good start.”

Both Rabil and Reavis, the social services director, said it will need to be a citywide effort.

“I see a great disempowerment of women in this community,” Reavis said. “It’s definitely something we need to address.”

Lauren Roth, (757) 222-5133, [email protected].

—–

To see more of the The Virginian-Pilot, or to subscribe to the newspaper, go to http://www.pilotonline.com.

Copyright (c) 2008, The Virginian-Pilot, Norfolk, Va.

Distributed by McClatchy-Tribune Information Services.

For reprints, email [email protected], call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.

Comprehensive Evaluation of the UK Pharmaceutical Manufacturers Market

Research and Markets (http://www.researchandmarkets.com/research/76d7a6/pharmaceutical_man) has announced the addition of the “Pharmaceutical Manufacturers (UK) – Portfolio Analysis” report to their offering.

The Plimsoll Portfolio Analysis – Pharmaceutical Manufacturers is a comprehensive evaluation of the UK market. The revised and updated 2008 edition analyses the financial performance of the companies important to the success of your business. Using the most up to date information available, the analysis is ideal both as a tool to benchmark your own companys results and to study the market in more depth. Aimed at the busy manager, the Plimsoll Portfolio Analysis is both quick and easy to use thanks to the unique visual layout. The Analysis lays bare the performance of each company highlighting their strengths and weaknesses. Do you know which companies are best to do business with? Do you know which companies are selling at a loss and whose profit margins are plummeting? Find out the answers to all these questions and more with the newly published Plimsoll Portfolio Analysis.

The Portfolio Analysis includes the following:

— Individual analysis of the Top 200 companies.

— The very latest accounts from Companies House.

— Every company ranked and rated.

— Easy to identify acquisition prospects.

— Complete industry overview section.

Key Topics Covered:

The report is divided into two colour-coded sections for your ease of use, Sector Analysis and Individual Company Analysis.

Sector Analysis: Sales growth, market share and profitability are all analysed over a 10 year period giving you the fulllest picture possible of the health of the market. Companies are ranked on these categories so you can see which companies are outshining the rest. Use the industry average tables to benchmark your own companys performance- how do you compare to the rest of the industry?

Industry Analysis: Each company receives a full page of analysis, evaluating their financial performance over the last five years so you get a full picture of the long term prospects of each company. Each company page of analysis is also packed with the following information: Full business name and address, Names and ages of directors, contact details and website address, seven unique Plimsoll charts showing at a glance the performance of each company, averages for the industry are also shown indicating the bare minimum each company should be looking to achieve, and five years of the latest accounts available, New! Written summary on each company highlighting their key strengths and weaknesses.

Companies Mentioned:

— 2007 GAL

— BIOSYNERGY (EUROPE)

— 3M HEALTH CARE

— BIOVATION

— 3M UK HOLDINGS

— BR PHARMA INTERNATIONAL

— A P LOVERIDGE

— BRAY GROUP

— A1 PHARMACEUTICALS

— BREATH

— ABBOTT LABORATORIES

— BRISTOL-MYERS SQUIBB HOLDINGS 2002

— ABBOTT (UK) HOLDINGS

— BRISTOL-MYERS SQUIBB PHARMACEUTICALS

— ACACIA BIOPHARMA

— C P PHARMACEUTICALS

— ACCORD HEALTHCARE

— CASEVIEW (P L )

— ACS DOBFAR UK

— CATALENT PHARMA SOLUTIONS

— ACTAVIS UK

— CEPHALON HOLDINGS

— ADALLEN PHARMA

— CEUTA HEALTHCARE

— AEROPAK (CHEMICAL PRODUCTS)

— CHATFIELD PHARMACEUTICALS

— AESICA PHARMACEUTICALS

— CHEFARO UK

— ALLERGY THERAPEUTICS

— CHUGAI PHARMA EUROPE

— ALLERGY THERAPEUTICS (UK)

— COBRA BIOLOGICS

— ALLIANCE BOOTS

— COBRA BIO-MANUFACTURING

— ALLIANCE PHARMACEUTICALS

— COLORCON

— ALLIANCE UNICHEM

— CO-PHARMA

— ALSTOE

— CSL BEHRING UK

— AMERICAN HOME PRODUCTS HOLDINGS (U K )

— CSL UK HOLDINGS

— AMYLIN EUROPE

— CUSTOM HEALTHCARE

— ARCHIMEDES PHARMA UK

— CUSTOM PHARMACEUTICALS

— ARK THERAPEUTICS

— D D D

— ASHTON PHARMACEUTICALS

— DABUR ONCOLOGY

— ASPAR PHARMACEUTICALS

— DALKEITH LABORATORIES

— ASPEN PHARMACARE INTERNATIONAL

— DECHRA PHARMACEUTICALS

— ASTERAND

— DERMAL LABORATORIES

— BARD PHARMACEUTICALS

— DESTINY PHARMA

— BAXTER HEALTHCARE

— DIOMED DEVELOPMENTS

— BAYER

— DIOSYNTH

— BEACON PHARMACEUTICALS

— DOWELHURST

— BELL SONS & CO (DRUGGISTS)

— DR REDDY’S LABORATORIES (UK)

— BIOENVISION

— EDEN BIOPHARM

— BIOLINE

— EFAMOL

— BIOLITEC PHARMA

— EISAI

— BIOLOGICA (UK)

— ELAN PHARMA

— BIOREX LABORATORIES

— ELDON LABORATORIES

— ELI LILLY AND CO

— MAELOR

— EXELGEN

— MANX HEALTHCARE GROUP

— FERRING LABORATORIES

— MAY & BAKER

— FLYNN PHARMA

— MEDIMMUNE U K

— FOCUS PHARMACEUTICALS

— MENTHOLATUM CO

— (THE) FOREST LABORATORIES UK

— MERCK

— FRESENIUS KABI

— MERCK SHARP & DOHME

— G R LANE HEALTH PRODUCTS

— MERCK SHARP & DOHME (HOLDINGS)

— GALLOWS GREEN SERVICES

— METSCO

— GEA PROCESS ENGINEERING (NPS)

— MILTON PHARMACEUTICAL CO UK

— GENERICS (U K )

— MUNDIPHARMA INTERNATIONAL

— GENPLUS

— MUREX BIOTECH

— GENZYME

— MW ENCAP

— GERHARDT PHARMACEUTICALS

— NAPP PHARMACEUTICAL GROUP

— GETINGE – LA CALHENE UK

— NAPP PHARMACEUTICALS

— GILEAD SCIENCES

— NEW NORDIC

— GLAXOSMITHKLINE

— NORBROOK LABORATORIES

— GOLDSHIELD GROUP

— NORGINE

— GRIFOLS UK

— NOVARTIS PHARMACEUTICALS UK

— HELIOS HOMOEOPATHY

— NOVO NORDISK

— HMC

— NOVOZYMES BIOPHARMA UK

— HOSPIRA UK

— OBG PHARMACEUTICALS

— IDEAL MANUFACTURING

— ONYX SCIENTIFIC

— INNOVATA

— ORBIS CONSUMER PRODUCTS

— INYX PHARMA

— ORGANON LABORATORIES

— IPSEN

— ORION PHARMA (UK)

— IVAX UK

— OXFORD IMMUNOTEC

— JANSSEN-CILAG

— PAINES & BYRNE

— JOHN WYETH & BROTHER

— PENN PHARMACEUTICAL SERVICES

— KENT PHARMACEUTICALS

— PENN PHARMACEUTICALS GROUP

— KOWA PHARMACEUTICAL EUROPE CO

— PENN PHARMACEUTICALS

— LABORATORIES FOR APPLIED BIOLOGY

— PFIZER

— LALEHAM HEALTHCARE

— PHARMACIA ANIMAL HEALTH

— LONZA BIOLOGICS

— PHARMACIA

— LONZA GROUP UK

— PHARMASERVE

— LUNDBECK

— PHARMASOL

— M & A PHARMACHEM

— PHARMCHEM INTERNATIONAL

— MAELOR PHARMACEUTICALS

— PHARMVIT

— PIERRE FABRE

— VERICORE

— PLIVA PHARMA

— VERNALIS

— PROCTER & GAMBLE PHARMACEUTICALS UK

— VIRAGEN (SCOTLAND)

— PROTHERICS

— VITABIOTICS

— PROTHERICS UK

— WARWICK PHARMACEUTICALS

— PROVALIS DIAGNOSTICS

— WILLIAM RANSOM & SON

— PROVALIS

— WINTHROP PHARMACEUTICALS UK

— QUINTILES

— WOCKHARDT UK HOLDINGS

— ROBINSON BROTHERS

— WRAFTON LABORATORIES

— ROSEMONT PHARMACEUTICALS

— XENTION

— S T D PHARMACEUTICAL PRODUCTS

— SAFC BIOSCIENCES

— SANDOZ

— SANOFI PASTEUR MSD

— SANOFI-SYNTHELABO

— SAUFLON PHARMACEUTICALS

— SCHERING HEALTH CARE

— SCHERING-PLOUGH

— SCHWARZ PHARMA

— SCIPAC

— SERONO

— SERVIER LABORATORIES

— SINCLAIR PHARMACEUTICALS

— SKYEPHARMA

— STIEFEL LABORATORIES (U K )

— SUREPHARM SERVICES

— TCS BIOSCIENCES

— TEVA PHARMACEUTICALS

— TEVA UK

— THORNTON & ROSS

— TILLOMED LABORATORIES

— TISSUE SCIENCE LABORATORIES

— TOCRIS COOKSON

— TRIGEN

— UCB PHARMA

— UNIVERSAL PRODUCTS (LYTHAM) MANUFACTURING

— UPSTATE

— VALEANT PHARMACEUTICALS

For more information visit http://www.researchandmarkets.com/research/76d7a6/pharmaceutical_man

Artwork By Homeless Men on Display in Tremont Cafe

CLEVELAND, July 2 /PRNewswire/ — An exhibition of paintings by homeless men in the Joseph’s Home Art Program is now on display at Grumpy’s Cafe, 2621 West 14th Street, in the Tremont neighborhood of Cleveland.

The exhibition includes several paintings from residents of Joseph’s Home, a ministry of the Sisters of Charity Health System and the only transitional housing facility of its kind in Northeast Ohio. Joseph’s Home provides home health care for homeless men recuperating from illness or injury. The Art Program, recently begun and led by Joseph Home Board Chair William M. Denihan, current President of the Cuyahoga County Mental Health Board, provides participants with art instruction and lessons about various artists and methods. The program engages the residents and provides a creative outlet as they recover.

“When we first began this art program, the Joseph’s Home residents participating in the art program were surprised with the quality of the paintings. They have realized that they have a tremendous gift to offer through their creativity and individual styles.”

Due to the energy and support for this art program, Denihan now hosts the art instruction twice per week.

“Our men are normally limited as to ways they can express themselves,” said Georgette Jackson, executive director of Joseph’s Home. “We want them to stay invested in what they are doing, and this is a way for them to have something to look forward to and help build their self esteem.”

The paintings are on display at Grumpy’s Cafe, until July 10. In addition, Joseph’s Home residents participating in the Joseph’s Home Art Program will be selling their paintings at the St. John West Shore Hospital’s Festival of the Arts July 11 – July 13, with proceeds benefiting Joseph’s Home.

About Joseph’s Home

Joseph’s Home provides residential space for homeless men recovering from temporary or chronic illnesses who are referred from area agencies, shelters or health care facilities. Residents participate in activities of daily living and literacy, sobriety and other self-improvement programs. Joseph’s Home prepares and motivates its residents for a new life by offering opportunities for education, job skill development and permanent housing. It is the only facility of its kind in Northeast Ohio and has helped nearly 300 men recover from acute illness and move on to permanent housing since its inception in 2000.

About the Sisters of Charity Health System

Headquartered in Cleveland, Ohio, the Sisters of Charity Health System was established in 1982 as the parent corporation for the sponsored ministries of the Sisters of Charity of St. Augustine in Ohio and South Carolina. In 1999, Sisters of Charity Health System formed two Ohio not-for-profit corporations with University Hospitals to equally own and operate St. John West Shore Hospital, St. Vincent Charity Hospital, Mercy Medical Center, Cuyahoga Physician Network, West Shore Primary Care and Professional Medical Equipment. Through this equal ownership, the Sisters of Charity of St. Augustine continue their legacy of high quality, compassionate care that began at the time of the founding of these organizations.

The Sisters of Charity Health System is the sole sponsor of Sisters of Charity Providence Hospitals, a leading cardiovascular center in South Carolina, which includes Providence Hospital/Providence Heart Institute and Providence Hospital Northeast in Columbia, South Carolina. The organization also oversees three grantmaking foundations located in Cleveland and Canton, OH and Columbia, SC. Each foundation sponsors significant community initiatives and collaborations that address causes and consequences of poverty.

Other health and human services and education-related organizations within the Sisters of Charity Health System include Cleveland’s Joseph’s Home, a unique residential care center for homeless men, Canton’s Early Childhood Resource Center for people working in childcare in all settings; and Healthy Learners, a South Carolina health care resource for children from low-income families. The Sisters of Charity Health System also provides residential eldercare services at Regina Health Center in Richfield, Ohio and Light of Hearts Villa in Bedford, Ohio. Light of Hearts Villa is jointly sponsored by the Sisters of Charity of Cincinnati.

Joseph’s Home

CONTACT: Heather Stoll, +1-216-875-4615, for Joseph’s Home

Daman Includes Second Opinion Service in Its Enhanced Benefits Plan

Daman includes Second Opinion Service in its Enhanced Benefits Plan – Daman in cooperation with the biggest European private health insurer provides the finest network of medical experts to their customers

As part of its strategy to improve its health insurance schemes and offer its customers the best possible healthcare, the National Health Insurance Company – Daman in cooperation with ArztPartner almeda AG (all shares of ArztPartner almeda AG are held by Deutsche Krankenversicherung AG (DKV), the biggest European private health insurer), has included an exclusive Second Opinion Service in some of its enhanced plans.

Dr. Michael Bitzer, CEO of Daman, commented “Our customers deserve the best care possible, and the VIPmed almeda service will provide them with an exclusive service through their top European medical network.”

Daman’s Second Opinion Service ‘VIPmed almeda’ provides access to the ArztPartner almeda network of renowned top medical experts in Europe to obtain a second opinion on diagnosing and treatment recommendations for specific diseases including Alzheimer, Asthma, Atherosclerosis, Benign Brain Tumor, Cancer, Congenital Deformities, Coronary Heart Disease, Complications of Diabetes Mellitus, Complications of Hypertension, Leukemia, Malignant Tumors, Multiple Sclerosis, Major Organ Transplant, Major Trauma, Parkinson’s Disease, Paralysis, Severe Burn, Sleep Apnoea, Slipped Vertebral Disk, and Strokes.

“Second opinions are often crucial in the medical field, especially when treating patients with serious illnesses,” Dr. Bitzer added. “Through a second opinion the patient will be provided further re-assurance. He can benefit through the huge knowledge of top experts, who confirm their second opinion with the latest scientific papers if required and available.”

The VIPmed almeda network consists of over 70 reputable medical experts. Only the top 3 – 5 experts within their respective fields are selected to be part of the network. This constricted selection process guarantees a high quality of service for Daman’s customers.

The entire process of applying for this service usually takes an average of 6 11 working days, from the time Daman receives the complete medical information. If additional information or laboratory results are required or if the most appropriate specialists are not immediately available, it can take longer. Insured customers can contact Daman to receive the required forms and any additional information required, through the website, toll free number 800 4 32626, fax no. +971 (2) 614 9787, e-mail : [email protected] or personally by visiting any of Daman’s branches. 2008 Al Bawaba (www.albawaba.com)

Originally published by By Al-Bawaba Reporters.

(c) 2008 Al Bawaba. Provided by ProQuest Information and Learning. All rights Reserved.

Platelet-Derived Growth Factor Expression and Function in Idiopathic Pulmonary Arterial Hypertension

Rationale: Platelet-derived growth factor (PDGF) promotes the proliferation and migration of pulmonary artery smooth muscle cells (PASMCs), and may play a role in the progression of pulmonary arterial hypertension (PAH), a condition characterized by proliferation of PASMCs resulting in the obstruction of small pulmonary arteries. Objectives: To analyze the expression and pathogenic role of PDGF in idiopathic PAH.

Methods: PDGF and PDGF receptor mRNA expression was studied by real-time reverse transcription-polymerase chain reaction performed on laser capture microdissected pulmonary arteries from patients undergoing lung transplantation for idiopathic PAH. Immunohistochemistry was used to localize PDGF, PDGF receptors, and phosphorylated PDGFR-beta. The effects of imatinib on PDGF-B- induced proliferation and chemotaxis were tested on human PASMCs.

Measurements and Main Results: PDGF-A, PDGF-B, PDGFR-alpha, and PDGFR-beta mRNA expression was increased in small pulmonary arteries from patients displaying idiopathic PAH, as compared with control subjects.Western blot analysis revealeda significant increase in protein expression of PDGFR-beta in PAH lungs, as compared with control lungs. In small remodeled pulmonary arteries, PDGF-A and PDGF-B mainly localized to PASMCs and endothelial cells (perivascular inflammatory infiltrates, when present, showed intensive staining), PDGFR-alpha and PDGFR-beta mainly stained PASMCs and to a lesser extent endothelial cells. Proliferating pulmonary vascular lesions stained phosphorylated PDGFR-beta. PDGF- BB-induced proliferation and migration of PASMCs were inhibited by imatinib. This effect was not due to PASMC apoptosis.

Conclusions: PDGF may play an important role in human PAH. Novel therapeutic strategies targeting the PDGF pathway should be tested in clinical trials.

Keywords: imatinib; pulmonary arterial hypertension; platelet- derived growth factor; remodeling; smooth muscle cells

Pulmonary arterial hypertension (PAH) is characterized by a progressive increase in pulmonary vascular resistance leading to right ventricular failure and ultimately death (1). Remodeling of small pulmonary arteries represents the main pathologic finding related to PAH with marked proliferation of pulmonary artery smooth muscle cells (PASMCs), resulting in the obstruction of resistance pulmonary arteries (2, 3). Several mechanisms have been described in the pathogenesis of PAH, including those related to current therapeutic targets such as endothelin-1, prostacyclin, and nitric oxide (1, 3). In recent years, recognition of germline mutations of genes coding for receptor members of the transforming growth factor- b superfamily (4) in heritable PAH has emphasized the potential role of growth factors in the development of PAH. Among them, plateletderived growth factor (PDGF) has been identified as a novel possible therapeutic target in PAH (5, 6).

Active PDGF is built up by polypeptides (A and B chain) that form homo- or heterodimers and stimulate alpha- and beta-cell surface receptors (7). Recently, two additional PDGF genes have been identified, encoding PDGF-C and PDGF-D polypeptides (8). PDGF is synthesized by many different cell types, including smooth muscle cells (SMCs), endothelial cells, and macrophages (7). PDGF has the ability to induce the proliferation and migration of SMCs and fibroblasts, and it has been proposed as a key mediator in the progression of several fibroproliferative disorders such as atherosclerosis, lung fibrosis, and pulmonary hypertension (6-8). It can also induce the contraction of rat aorta strips in vitro (9).

Novel therapeutic agents such as imatinib mesylate (Gleevec; Novartis, Horsham, UK) inhibit several tyrosine kinases associated with disease states, including BCR-ABL (breakpoint cluster region- Abelson) in patients with chronic myelogenous leukemia, c-kit in patients with gastrointestinal stromal tumors, and PDGF receptors alpha and beta in patients with certain myeloproliferative disorders and dermatofibrosarcoma protuberans, respectively (10, 11). Imatinib has been demonstrated to reverse pulmonary vascular remodeling in animal models of pulmonary hypertension (6) and a few cases of clinical and hemodynamic improvements have also been reported in human PAH (12-14). Due to the lack of comprehensive human data, we performed a complete analysis of the pathogenic role of PDGF in human PAH. We first confirmed increased expression of PDGF and PDGF receptors by means of real-time reverse transcription-polymerase chain reaction (RT-PCR) performed on laser capture microdissected pulmonary arteries from lung transplanted patients displaying severe idiopathic PAH. Western blot analysis showed increased PDGFR-beta protein expression in PAH lungs, as compared with controls. Immunohistochemistry techniques were then used to localize PDGF-A and PDGF-B and PDGFR-alpha and PDGFR-beta proteins in PAH lungs. The effect of imatinib on PDGFR phosphorylation in cultured PASMCs was studied by Western blot, and PASMC apoptosis was analyzed by fluorometric detection of caspase 3 and 7 activity. Last, we analyzed the effects of imatinib on PDGF-B-induced proliferation and chemotaxis on control and PAH PASMCs. Our data support the concept that PDGF is overproduced within the pulmonary artery wall of patients with PAH and promotes pulmonary arterial remodeling.

METHODS

Lung Samples and PASMC Cultures

Human lung specimens were obtained at the time of lung transplantation (PAH, n = 13) or from tissue obtained during lobectomy or pneumonectomy for localized lung cancer (controls, n = 8), then snap frozen or paraffin embedded, as previously described (15). PASMCs were cultured from the same explants as previously described (16). In brief, arteries (diameter: 5-10 mm) were kept in Dulbecco’s modified Eagle medium (DMEM) at 4[degrees]C before their intimal cell layer and residual adventitial tissue were stripped off using forceps. The dissected media of the vessels was then cut into small pieces (3-5 mm), which were transferred into cell culture flasks. To allow the PASMCs to grow out, the vessel tissues were incubated in DMEM supplemented with 20% fetal calf serum (FCS), 2 mM L-glutamine, and antibiotics (100 U/ml penicillin and 0.1 mg/ml streptomycin). After 2 weeks of incubation, the PASMCs collected in the culture medium and the vessel tissues were transferred into new cell culture flasks. This study was approved by the local ethics committee and patients agreed to contribute to the study.

Laser Capture Microdissection of Pulmonary Arteries, cDNA Preparation, and RT-PCR

Small pulmonary arteries (100-200 [mu]m) were captured using the ASLMD laser microdissection microscope (Leica, Rueil-Malmaison, France). RNA was extracted from microdissected pulmonary arteries with a PicoPure RNA isolation kit (Arcturus, Mountain View, CA) and then eluted from silicate columns and reverse-transcribed using Sensiscript Reverse Transcription kit (Qiagen, Courtaboeuf, France). Constitutively expressed beta-actin was selected as an internal housekeeping gene control for the comparative cycle threshold (CTau) method for the relative quantification of PDGF-A and PDGF-B, and PDGF receptor alpha and beta. PDGF-A and PDGF-B, PDGF receptor alpha and beta, and beta-actin expressions were quantified by RT-PCR with TaqMan gene expression assays (assay ID number in brackets) (beta- actin [Hs99999903_m1], PDGF-A [Hs00234994_m1], PDGFR-alpha [Hs00183486_m1], PDGF-B [Hs00234042_m1], PDGFR-beta [Hs00182163_m1]), and Taq-Man Universal PCR Master Mix performed on an ABI Prism 7000 Sequence Detection System (Applied Biosystems, Courtaboeuf, France).

Western Blot

Lung tissue samples from 10 control subjects and 10 patients with PAH were homogenized in lysis buffer containing 50 mM Tris-HCl, pH 7.4, 50 mM NaCl, 1.5 mM ethylenediaminetetraacetic acid, 1% Triton X- 100, 3% glycerol, 0.2 mM orthovanadate, and protease inhibitor cocktail (aprotine, leupeptine, and PefaBloc [Roche, Meylan, France]). Lysates were normalized and separated on 8% polyacrylamide gels and transferred to nitrocellulose membranes. After blocking, the membranes were probed with rabbit anti-PDGFR-beta (1[mu]g/ml, cat. no. sc432) or anti-phospho-PDGFR-beta (1[mu]g/ml, cat. no. sc12909-R) and anti-actin-beta loading control (0.2 [mu]g/ml, cat. no. sc-1615) (all from Santa Cruz Biotechnology, Inc., Santa Cruz, CA), followed by incubation with secondary antibodies conjugated with horseradish peroxidase. Bound antibodies were detected by chemiluminescence with the use of an enhanced chemiluminescence (ECL) detection system (Millipore, Paris, France) and quantified by densitometry.

Immunohistochemistry

Immunohistochemistry was either performed on 8-mm-thick sections of frozen tissue (PDGF-AA and PDGF-BB, and PDGFR-alpha and PDGFRb), or on 3-[mu]m-thick sections of paraffin embedded tissue (PDGF-BB, phosphorylated PDGFR-beta, proliferating cell nuclear antigen [PCNA]). After routine preparation and microwave unmasking, slides were processed with rabbit anti-PDGF-BB (1 [mu]g/ml, ab15499; Abcam, Paris, France), PDGFR-beta (2 [mu]g/ml, sc-432), PDGF-AA (2 [mu]g/ ml, sc-128), PDGFR-alpha (2 [mu]g/ml, sc-338), phospho-PDGFR-beta (2 [mu]g/ml, sc-12909-R), and PCNA (2 [mu]g/ml, sc-7907) (all sc catalog numbers are from Santa Cruz Biotechnology, Inc.). According to the manufacturer’s recommendations, the Envision kit (K4065; Dako, Trappes, France) was used for primary antibody detection. Controls used for these antibodies included omission of the primary antibody and substitution of the primary antibody by rabbit IgG. PASMC Proliferation Assay

PASMCs were serum-starved for 48 hours (0.2% FCS), then incubated with PDGF-BB (10 and 50 ng/ml), epithelial growth factor (EGF) or basic fibroblast growth factor (bFGF) (50 ng/ml; R&D Systems Europe, Lille, France), with or without 5 [mu]M imatinib (STI571; Novartis, Basel, Switzerland) for 24 hours with [3H]thymidine (Amersham France, Les Ulis, France), and cell proliferation was detected by thymidine incorporation (16).

For cell counting, PASMCs were allowed to adhere overnight on Labtek 8 chamber slides (Nunc, Wiesbaden, Germany), then were treated with the above conditions during 48 days. The chambers were then removed, the slides washed in phosphate-buffered saline, fixed in acetone, and stained with 4′-6-diamidino-2-phenylindole (DAPI). The DAPI-stained cells were visualized under a Nikon eclipse 80i fluorescent microscope and the DAPI-positive cells were automatically counted (NIS Element BR2.30 software) (Nikon France, Champigny sur Marne, France).

Apoptosis Assay

The apoptosis was quantified by the measurement of caspase 3 and 7 activity in PASMCs. Caspase activity was detected within whole living cells using Immunochemistry Technologies (ICT)’s Magic Red substrate-based MR-caspase assay kit according to the manufacturer’s instructions (Serotec, Dusseldorf, Germany). Hydrogen peroxide 1 mM was chosen as a positive control for SMC apoptosis (17).

PASMC Migration Assay

PASMC migration was evaluated by the transwell assay. Trypsinized PASMCs were transferred into the upper chambers of 8-[mu]m-pore transwell plates (VWR, Fontenay-sous-Bois, France). PDGF-BB (10 or 100 ng/ml), EGF, or bFGF (50 ng/ml; R&D Systems Europe, Lille, France), with or without 5 [mu]M imatinib, was added to the lower chamber. After 24 hours at 37[degrees]C, migration was quantified by counting cells in the bottom of the membrane stained with DiffQuick (Dade Behring S.A., Paris la Defense, France). The number of cells on the lower surface of filter was counted by light microscopy under highpower field ( x 200). Eight fields were counted in each of three different experiments.

Statistical Evaluation

Quantitative variables were presented as means +- SD. Between groups, comparisons were made with Student’s t test; multiple group comparisons were performed with analysis of variance and the least significant difference method as a post hoc analysis. P values less than 0.05 were considered to reflect statistical significance.

RESULTS

PDGF and PDGF-Receptor mRNA Expression in Microdissected Pulmonary Arteries

PDGF-A, PDGF-B, PDGFR-alpha, and PDGFR-beta mRNA expression was increased in microdissected small pulmonary arteries from patients displaying severe PAH, as compared with control subjects (P

PDGF-Receptor Protein Expression in Total Lung

Western blot analysis revealed a significant increase in protein expression of PDGFR-beta in PAH lungs compared with control lungs. PDGFR-beta protein expression normalized to beta-actin was 0.89 +- 0.43 in control lungs and 1.64 +- 0.77 in PAH lungs (P = 0.01) (Figure 2).

Immunohistochemistry

In small pulmonary arteries with constrictive or plexiform remodeling, PDGF-A and PDGF-B expression was mainly localized to smooth muscle and endothelial cells (Figures 3A, 3C, and 4A). In addition, perivascular inflammatory infiltrates, when present, showed intensive staining (Figures 3A, 5A, and 5B). PDGFR-alpha and PDGFR-beta were mainly expressed in SMCs and to a lesser extent in endothelial cells (Figures 3B and 3D). The phosphorylated form of PDGFR-beta was detected in both smooth muscle and endothelial cells, depending on the predominant proliferating vascular compartment of constrictive and plexiform lesions (Figures 4C-4D). Proliferating cells were identified with PCNA and corresponded to endothelial and SMCs within pulmonary vascular lesions (Figure 4B).

Effect of PDGF-BB and Imatinib on PDGFR-beta Phosphorylation

PDGF-BB 10 ng/ml significantly increased phosphorylated PDGFR- beta protein expression compared with control conditions (P

Effect of Imatinib on Cultured PASMC Proliferation

PASMC proliferation, induced by PDGF-BB 10 ng/ml, was inhibited by imatinib (5 [mu]M), as demonstrated by [3H]thymidine incorporation assay. To determine the selectivity of STI571 on PDGF- induced PASMC proliferation, other growth factors (EGF or bFGF, both at 50 ng/ml) were used to stimulate PASMCs. Although imatinib demonstrated a significant inhibition of PDGF-BB-induced proliferation (P

We confirmed the inhibitory effect of imatinib on PDGFBB-induced PASMC proliferation by cell counting (Figure 8). PDGF-BB (50 ng/ml) induced PASMC proliferation similar to PDGF-BB (10 ng/ml) (155.6 +- 24.9% and 173.7 +- 15.3% of control conditions, P = 0.21). Imatinib inhibited significantly the proliferation induced by PDGF-BB 10 ng/ ml or 50 ng/ml (P = 0.001 and P

Effect of Imatinib on Cultured PASMC Apoptosis

Although H2O2 induced a marked apoptosis (89 +- 7.2% active caspase 3 and 7-containing apoptotic cells), no significant increase in apoptosis was detected in imatinib-treated cells as compared with untreated cells (12.2 +- 5.1% and 10.8 +- 3.8%, respectively; P = 0.68) (Figure 9). Moreover, the measured imatinib-linked inhibition of PASMC proliferation was not due to PASMC cell death, because in our experimental conditions, imatinib did not induce significant caspase 3- and 7-dependent PASMC apoptosis (Figure 9).

Effect of PDGF and Imatinib on PASMC Migration

PDGF-BB increased PASMC migration (P

DISCUSSION

Our study indicates that PDGF and PDGF receptor mRNA is overexpressed in the pulmonary arteries of human pulmonary hypertensive lungs and that immunostaining localizes PDGF/PDGFR in PASMCs and endothelial cells from pulmonary arteries of patients displaying severe PAH. Phosphorylated (activated) PDGFR proteins are localized into proliferating pulmonary arteries with PCNA and PDGF- B-positive cells. In vitro, PDGF-BB-induced proliferation and migration of cultured human PASMCs are specifically inhibited by imatinib, through blockade of PDGFR phosphorylation. These in vitro effects are not due to the induction of PASMC apoptosis. Because PASMC proliferation and migration are believed to be a major contributor to pulmonary vascular remodeling (neointima formation and media hypertrophy), these findings plead in favor of the potential relevance of PDGF inhibition in the treatment of human PAH.

Many experimental data support the concept that PDGF pathways could play an important role in the pulmonary vascular remodeling process responsible for the progression of PAH (6, 10). Indeed, PDGF is known to induce proliferation of SMCs of different origins (18, 19). Nevertheless, its effects in the proliferation and migration of SMCs are better described in the systemic circulation where it is regarded as an important contributor to major vascular conditions such as atherosclerosis (20). Our present study focused on PASMCs and human idiopathic PAH, to better analyze the role of PDGF in humans, as well as the possible interest of novel therapeutic agents targeting the PDGF pathway, such as imatinib in PAH. Proliferation and migration of PASMCs represent a singular step in the pathogenesis of pulmonary vascular remodeling. Many studies have addressed the phenotypes of the cells involved in neointima formation. Early findings suggested that endothelial cells were the predominant phenotype in plexiform lesions (21), but more recently the role of PASMCs and PASMC migration in neointima formation has been better clarified (22, 23). Our present findings of overexpression of PDGF and PDGF receptors in the pulmonary arterial wall of patients with PAH, together with the demonstration of PDGF pathway activation in PAH vascular lesions (detection of PDGFR-beta phosphorylated by immunohistochemistry) associated with cellular proliferation (PCNA-positive cells) and with the confirmation of in vitro PDGF-induced migration and proliferation of PASMCs, support the hypothesis that PDGF is a major contributor of pulmonary vascular remodeling in PAH.

Inhibition of PDGF-induced PASMC migration and proliferation with imatinib supports the possible therapeutic role of PDGF inhibition as a novel approach in PAH, as previously suggested by pioneer studies in monocrotaline-induced pulmonary hypertension in rats (6), as well as by case reports in subjects displaying refractory PAH (12, 13), or severe PAH in the context of chronic myeloid leukemia (14). Imatinib is a competitive inhibitor of the ATP-binding site of PDGF receptor tyrosine kinases that is currently used for the treatment of chronic myeloid leukemia and gastrointestinal stromal tumors (24, 25). Extracellular signal-related kinase (ERK) phosphorylation has been shown to be a key downstream signal for PDGFR stimulation. It leads to proliferation, inhibition of apoptosis and matrix metalloproteinase activation, a key step for vascular cell migration. Schermuly and colleagues (6) have previously shown that ERK1/2 was strongly suppressed by treatment with 50 mg/kg/day imatinib in rats exposed to monocrotaline, and that imatinib reversed pulmonary hypertension in this experimental model. Because PASMC proliferation and migration are a major characteristic of PAH pathology (2, 3), the effects of imatinib on PDGF-induced PASMC proliferation and migration are presumably relevant to PAH therapy (26). Currently available PAH therapies have in vitro antiremodeling effects in addition to their vasodilator characteristics (1). However, robust demonstration of antiremodeling effects on pulmonary vascular processes in human PAH is still lacking. Indeed, lung pathology of patients with long-standing treatments with currently approved PAH therapy (including prostaclin derivatives, endothelin receptor antagonists, and type 5 phosphodiesterase inhibitors) still shows major pulmonary vascular remodeling. Because pathology is only available from patients refractory to PAH treatments (i.e., data obtained from lung explant or postmortem specimens), one may claim that patients with a good response to PAH-specific therapy may have better antiremodeling effects. Nevertheless, it is well demonstrated that pulmonary hemodynamics remain extremely abnormal even in patients with long- term beneficial effects of PAH treatment, indicating that pulmonary vascular remodeling is presumably still significant even in good responders (1). To reduce pulmonary vascular remodeling in PAH, growth factor inhibition has to be properly evaluated. This proof- of-concept study in human cells and tissue supports the idea that PDGF-targeted therapies should be tested in future well-designed clinical trials evaluating safety and efficacy in human PAH (26).

Conflict of Interest Statement: F.P. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. D.M. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. P.D. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. I.D.-G. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. C.T. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. J.L.P. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. M.M. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. E.F. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. S.M. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. O.M. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. P.H. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. D.E. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. S.E. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. G.S. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. R.S. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. M.H. has received V3,000 from Novartis in 2004, 2005, and 2006 to contribute to severe asthma advisory boards. He received V3,000 in 2004, 2005, and 2006 from Novartis to lecture on severe asthma.

AT A GLANCE COMMENTARY

Scientific Knowledge on the Subject

Platelet-derived growth factor (PDGF) plays an important part in the progression of experimental pulmonary hypertension, but its role in human pulmonary arterial hypertension is only partly understood.

What This Study Adds to the Field

Expression of PDGF and PDGF receptors is increased in the pulmonary arteries of patients with pulmonary arterial hypertension. PDGF induces proliferation and migration of human pulmonary artery smooth muscle cells, which is inhibited by imatinib, a PDGF receptor inhibitor.

References

1. Humbert M, Sitbon O, Simonneau G. Treatment of pulmonary arterial hypertension. N Engl J Med 2004;351:1425-1436.

2. Pietra GG, Capron F, Stewart S, Leone O, Humbert M, Robbins IM, Reid LM, Tuder RM. Pathologic assessment of vasculopathies in pulmonary hypertension. J Am Coll Cardiol 2004;43(12, Suppl S): 25S- 32S.

3. Humbert M, Morrell NW, Archer SL, Stenmark KR, MacLean MR, Lang IM, Christman BW, Weir EK, Eickelberg O, Voelkel NF, et al. Cellular and molecular pathobiology of pulmonary arterial hypertension. J Am Coll Cardiol 2004;43(12, Suppl S):13S-24S.

4. Machado RD, Pauciulo MW, Thomson JR, Lane KB, Morgan NV, Wheeler L, Phillips JA III, Newman J, Williams D, Galie N, et al. BMPR2 haploinsufficiency as the inherited molecular mechanism for primary pulmonary hypertension. Am J Hum Genet 2001;68:92-102.

5. Humbert M, Monti G, Fartoukh M, Magnan A, Brenot F, Rain B, Capron F, Galanaud P, Duroux P, Simonneau G, et al. Plateletderived growth factor expression in primary pulmonary hypertension: comparison of HIV seropositive and HIV seronegative patients. Eur Respir J 1998;11:554-559.

6. Schermuly RT, Dony E, Ghofrani HA, Pullamsetti S, Savai R, Roth M, Sydykov A, Lai YJ, Weissmann N, Seeger W, et al. Reversal of experimental pulmonary hypertension by PDGF inhibition. J Clin Invest 2005;115:2811-2821.

7. Heldin CH, Westermark B. Mechanism of action and in vivo role of platelet-derived growth factor. Physiol Rev 1999;79:1283-1316.

8. Reigstad LJ, Varhaug JE, Lillehaug JR. Structural and functional specificities of PDGF-C and PDGF-D, the novel members of the platelet-derived growth factors family. FEBS J 2005;272:5723- 5741.

9. Berk BC, Alexander RW, Brock TA, Gimbrone MA Jr, Webb RC. Vasoconstriction: a new activity for platelet-derived growth factor. Science 1986;232:87-90.

10. Balasubramaniam V, Le Cras TD, Ivy DD, Grover TR, Kinsella JP, Abman SH. Role of platelet-derived growth factor in vascular remodeling during pulmonary hypertension in the ovine fetus. Am J Physiol Lung Cell Mol Physiol 2003;284:L826-L833.

11. Druker BJ. Imatinib as a paradigm of targeted therapies. Adv Cancer Res 2004;91:1-30.

12. Ghofrani HA, Seeger W, Grimminger F. Imatinib for the treatment of pulmonary arterial hypertension. N Engl J Med 2005;353:1412-1413.

13. Patterson KC, Weissmann A, Ahmadi T, Farber HW. Imatinib mesylate in the treatment of refractory idiopathic pulmonary arterial hypertension. Ann Intern Med 2006;145:152-153.

14. Souza R, Sitbon O, Parent F, Simonneau G, HumbertM. Long term imatinib treatment in pulmonary arterial hypertension. Thorax 2006;61:736.

15. Dorfmuller P, Zarka V, Durand-Gasselin I, Monti G, Balabanian K, Garcia G, Capron F, Coulomb-Lhermine A, Marfaing-Koka A, Simonneau G, et al. Chemokine RANTES in severe pulmonary arterial hypertension. Am J Respir Crit Care Med 2002;165:534-539.

16. Eddahibi S, Humbert M, Fadel E, Raffestin B, Darmon M, Capron F, Simonneau G, Dartevelle P, Hamon M, Adnot S. Serotonin transporter overexpression is responsible for pulmonary artery smooth muscle hyperplasia in primary pulmonary hypertension. J Clin Invest 2001;108:1141-1150.

17. Deshpande NN, Sorescu D, Seshiah P, Ushio-Fukai M, Akers M, Yin Q, Griendling KK. Mechanism of hydrogen peroxide-induced cell cycle arrest in vascular smooth muscle. Antioxid Redox Signal 2002;4:845-854.

18. Yahiaoui L, Villeneuve A, Valderrama-Carvajal H, Burke F, Fixman ED. Endothelin-1 regulates proliferative responses, both alone and synergistically with PDGF, in rat tracheal smooth muscle cells. Cell Physiol Biochem 2006;17:37-46.

19. Deng DX, Spin JM, Tsalenko A, Vailaya A, Ben-Dor A, Yakhini Z, Tsao P, Bruhn L, Quertermous T. Molecular signatures determining coronary artery and saphenous vein smooth muscle cell phenotypes: distinct responses to stimuli. Arterioscler Thromb Vasc Biol 2006;26: 1058-1065.

20. Raines EW. PDGF and cardiovascular disease. Cytokine Growth Factor Rev 2004;15:237-254.

21. Tuder RM, Groves B, Badesch DB, Voelkel NF. Exuberant endothelial cell growth and elements of inflammation are present in plexiform lesions of pulmonary hypertension. Am J Pathol 1994;144:275-285.

22. Yi ES, Kim H, Ahn H, Strother J, Morris T, Masliah E, Hansen LA, Park K, Friedman PJ. Distribution of obstructive intimal lesions and their cellular phenotypes in chronic pulmonary hypertension: a morphometric and immunohistochemical study. Am J Respir Crit Care Med 2000;162:1577-1586.

23. Nishimura T, Vaszar LT, Faul JL, Zhao G, Berry GJ, Shi L, Qiu D, Benson G, Pearl RG, Kao PN. Simvastatin rescues rats from fatal pulmonary hypertension by inducing apoptosis of neointimal smooth muscle cells. Circulation 2003;108:1640-1645.

24. Druker BJ, Talpaz M, Resta DJ, Peng B, Buchdunger E, Ford JM, Lydon NB, Kantarjian H, Capdeville R, Ohno-Jones S, et al. Efficacy and safety of a specific inhibitor of the BCR-ABL tyrosine kinase in chronic myeloid leukemia. N Engl J Med 2001;344:1031-1037.

25. Peng B, Lloyd P, Schran H. Clinical pharmacokinetics of imatinib. Clin Pharmacokinet 2005;44:879-894.

26. Humbert M. Update in pulmonary arterial hypertension 2007. Am J Respir Crit Care Med 2008;177:574-579. Frederic Perros1,2,3, David Montani1,2, Peter Dorfmuller1,2, Ingrid Durand-Gasselin2, Colas Tcherakian1,2, Jerome Le Pavec1, Michel Mazmanian3, Elie Fadel3, Sacha Mussot3, Olaf Mercier3, Philippe Herve3, Dominique Emilie2, Saadia Eddahibi4, Gerald Simonneau1, Rogerio Souza1,2, and Marc Humbert1,2

1 Universite Paris-Sud 11, UPRES EA 2705, Centre National de Reference de l’Hypertension Arterielle Pulmonaire, Service de Pneumologie et Reanimation Respiratoire, Institut Paris-Sud Cytokines, Hopital Antoine-Beclere, Assistance Publique Hopitaux de Paris, Clamart, France; 2 INSERM U764, Clamart, France; 3 UPRES EA 2705, Laboratoire de Chirurgie Experimentale, Centre Chirurgical Marie Lannelongue, Universite Paris-Sud 11, Le Plessis Robinson, France; and 4 INSERM U841 and Departement de Physiologie Explorations Fonctionnelles, Hopital Henri-Mondor, Assistance Publique Hopitaux de Paris, Creteil, France

(Received in original form July 14, 2007; accepted in final form April 15, 2008)

Supported in part by grants from Ministere de l’Enseignement Superieur et de la Recherche (GIS-HTAP), Chancellerie des Universites, Legs Poix, and Universite Paris-Sud. This research project received financial support from the European Commission under the 6th Framework Program (contract no. LSHM-CT-2005-018725, PULMOTENSION). This publication reflects only the authors’ views and the European Community is in no way liable for any use that may be made of the information contained therein. F.P. is supported by a grant from Ministere de l’Enseignement Superieur et de la Recherche. R.S. is supported by a grant from European Respiratory Society. The authors thank Steve Pascoe, M.D., M.Sc., Novartis, Horsham, UK, for the kind gift of imatinib.

Correspondence and requests for reprints should be addressed to Marc Humbert, M.D., Ph.D., Service de Pneumologie et Reanimation Respiratoire, Hopital Antoine-Beclere, 157 rue de la Porte de Trivaux, 92140 Clamart, France. E-mail: [email protected]

Am J Respir Crit Care Med Vol 178. pp 81-88, 2008

Originally Published in Press as DOI: 10.1164/rccm.200707-1037OC on April 17, 2008

Internet address: www.atsjournals.org

Copyright American Thoracic Society Jul 1, 2008

Originally published by Perros, Frederic Montani, David; Dorfmuller, Peter; Durand- Gasselin, Ingrid; Tcherakian, Colas; Pavec, Jerome Le; Mazmanian, Michel; Fadel, Elie; Mussot, Sacha; Mercier, Olaf; Herve, Philippe; Emilie, Dominique; Eddahibi, Saadia; Simonneau, Gerald; Souza, Rogerio.

(c) 2008 American Journal of Respiratory and Critical Care Medicine. Provided by ProQuest Information and Learning. All rights Reserved.

Poly(Ester Amine)-Mediated, Aerosol-Delivered Akt1 Small Interfering RNA Suppresses Lung Tumorigenesis

By Xu, Cheng-Xiong Jere, Dhananjay; Jin, Hua; Chang, Seung-Hee; Chung, Youn-Sun; Shin, Ji-Young; Kim, Ji-Eun; Park, Sung-Jin; Lee, Yong- Hoon; Chae, Chan-Hee; Lee, Kee Ho; Beck, George R Jr; Cho, Chong- Su; Cho, Myung-Haing

Rationale: The low efficiency of conventional therapies in achieving long-term survival of patients with lung cancer calls for the development of novel therapeutic options. Recent advances in aerosol-mediated gene delivery have provided the possibility of an alternative for the safe and effective treatment of lung cancer. Objectives: To demonstrate the feasibility and emphasize the importance of noninvasive aerosol delivery of Akt1 small interfering RNA (siRNA) as an effective and selective option for lung cancer treatment.

Methods: Nanosized poly(ester amine) polymer was synthesized and used as a gene carrier. An aerosol of poly(ester amine)/Akt1 siRNA complex was delivered into K-ras^sup LA1^ and urethane-induced lung cancer models through a nose-only inhalation system. The effects of Akt1 siRNA on lung cancer progression and Akt-related signals were evaluated.

Measurements and Main Results: The aerosol-delivered Akt1 siRNA suppressed lung tumor progression significantly through inhibiting Akt-related signals and cell cycle.

Conclusions: The use of poly(ester amine) serves as an effective carrier, and aerosol delivery of Akt1 siRNA may be a promising approach for lung cancer treatment and prevention.

Keywords: poly(ester amine); Akt1 siRNA; lung cancer; K-ras^sup LA1^ mice; urethane; aerosol gene delivery

Great effort has been invested in the field of pulmonary medicine in the hopes of finding feasible therapeutic approaches for diverse lung diseases, including cancer (1-3). Different approaches for gene delivery to the lung have been reported in various animal models (4, 5). However, these strategies are either invasive or the methods may not be suitable for effective delivery of the gene throughout pulmonary tissues.

Viral and nonviral vectors are being used for gene therapy. Viral vectors are frequently used because of their intrinsic ability to enter the cells and promote the expression of the gene of interest. However, many factors, such as immune response against repeated administration and difficulties of large-scale production, limit their practical use (6). On the other hand, nonviral vectors continue to attract interest because of several advantages, such as easy manipulation, low cost, safety, and less immunogenicity (7). Many nonviral vectors have been developed for delivering genes to various organs (8). Aerosol-mediated gene delivery is effective and represents a noninvasive alternative for the targeting of genes to the lungs (9). Recently, our group has synthesized a new biocompatible nanocarrier, poly(ester amine) (degradable polyethylenimine-alt-poly[ethylene glycol] copolymer), by reaction of low-molecular-weight polyethyleneimine (PEI) with polyethyleneglycol (PEG) diacrylate (number average molecular weight [M^sub n^] = 258) as a cross-linker. Our previous study has proven that the poly(ester amine) carrier is less than 150 nm and offers effective delivery potential due to a biodegradable complex formation with genes with little toxicity and enhanced gene transfer efficiency (10).

Akt (protein kinase B) is an important regulator of cell survival and cell proliferation (11). Akt plays a key role in cancer by stimulating cell proliferation, inhibiting apoptosis, and modulating the protein translation (12, 13). Amplification of genes encoding Akt isoforms has been found in many tumors (11). Dominant negative alleles of Akt have been reported to block cell survival and to induce an apoptotic response (14). Thus, specific inhibition of its signals may be a rational therapeutic strategy for tumors with amplification of the Akt gene.

Of the three members of the ras family, K-ras, N-ras, and H-ras, K-ras is found to be the most frequently mutated member in lung cancer (33-50%) (15, 16). Mice carrying the mutation are highly predisposed to tumors and exhibit short latency and high penetrance (17). Moreover, K-ras gene mutation enhances motility of lung adenocarcinoma cells via Akt activation (18), and radioresistance of K-ras-mutated human tumor is mediated through the epidermal growth factor receptor-dependent PI3K-Akt pathway (19). Blocking of the PI3K-Akt pathway in K-ras-mutated A549 cells caused radiosensitivity (20). Multidrug resistance of gastric cancer cells was decreased by Akt1 downregulation (21), and Akt1 null mice were resistant to carcinogenesis (22). Primary lung tumors in the mice have morphologic, histogenic, and molecular features similar to human lung adenocarcinoma (23). Therefore, in this study, K-ras^sup LA1^ mice, a laboratory animal model of non-small lung cancer (NSLC), were used for in vivo effects of aerosol-delivered Akt1 small interfering RNA (siRNA) in lung tumorigenesis. In K-ras^sup LA1^ mice, oncogenic alleles of K-ras can be activated on a spontaneous recombination event, and mice carrying these mutations are highly predisposed to a range of tumor types from hyperplasia/dysplasia to carcinomas, predominantly early-onset lung cancer similar to human NSLC (17). In the present study, we also used urethane-induced lung cancer model mice because most (~80%) urethane-induced lung tumors harbor a mutation in the K-ras gene and lung cancer model mice frequently have been used in chemoprevention studies (24, 25).

RNA interference (RNAi) is a post-transcriptional genesilencing mechanism (26-28). siRNA must be dissociated into its component single strands to act as a guide for RNA-induced silencing complexes, the protein complexes that repress gene expression (29). In this regard, development of siRNA technology has opened the possibility of effective genetic manipulation. In fact, many studies clearly demonstrate the potential of siRNA-based therapeutics in various animal disease models (30). However, efficient uptake of siRNAs still represents a significant obstacle in establishing RNAi as a therapeutic approach (31). Therefore, effective delivery of siRNA with the aid of appropriate carrier is the most challenging target for the development of an RNAi-based therapeutic platform.

Here, we report that aerosol delivery of poly(ester amine)/Akt1 siRNA can suppress lung tumorigenesis in K-ras^sup LA1^ and urethane- induced lung cancer model mice through altering Akt signals and cell cycle. Our results support the hypothesis that the poly(ester amine) carrier may serve as an effective carrier, and that aerosol delivery of Akt1 siRNA may be a promising approach for lung cancer treatment and prevention.

METHODS

Materials

PEI (97% purity), PEG (97% purity), and urethane were purchased from Sigma-Aldrich (St. Louis, MO), and pcDNA3.1-green fluorescent protein (GFP) (6.1 kb) was purchased from Invitrogen (Carlsbad, CA). The following antibodies were obtained from Cell Signaling Technology (Beverly, MA): anti-phospho-Akt1 at Ser473, anti-phospho- Akt1 at Thr308, anti-phospho-mammalian target of rapamycin (anti- pmTOR) at Ser2448, and anti-p70S6K at Thr389. Monoclonal antibodies against Akt1 and phospho-Akt at Thr308 were produced using a general method described elsewhere. The following antibodies were purchased from Santa Cruz Biotechnology (Santa Cruz, CA): anti-Akt2, anti- Akt3, anti-Bcl-2 antagonist of cell death protein (anti-BAD), anti- cell division cycle (CDC) 2, anti-cyclin-dependent kinase 2 (anti- CDK2), anti-CDK4, anti-cyclin A, anti-cyclin B1, anti-cyclin D1, anti-cyclin D3, anti-cyclin E, anti-4E-BP1, anti-phospho-4E-BP1 at Ser65, anti-phospho-4E-BP1 at Thr69, anti-mTOR, anti-p70S6K, and anti-proliferating cell nuclear antigen (anti-PCNA).

Construction of Akt 1 siRNA and Preparation of Poly(ester amine)/ siRNA Complex

Chemically synthesized siRNAisknown to induce only a transient reduction of endogenously expressed target mRNA (32). To overcome this problem, a number of groups have developed effective delivery systems for optimizing siRNA-mediated down-regulation of gene expression in mammalian cells viaRNAinterference (33). In this regard, the oligonucleotides encoding the 19-mer hairpin sequence of siRNA specific to Akt1 were designed using siRNAconverter software. The sequences of targetingAkt1were as follows: sense strand GGCCACGATGACTTCCTTC, antisense strand GAAGG GAGTCGTCGTGGCC. A scrambled siRNA with the same nucleotide composition as the siRNA but which lacks significant sequence homology to the genome was also designed. These oligonucleotides were ligated into the siXpress Human U6 PCR vector system (Mirus Bio, Madison, WI) according to the manufacturer’s instructions.

Poly(ester amine) was synthesized as described in our previous work. The poly(ester amine)/siRNA complex at a charge ratio of 45 was chosen as the most efficient condition for gene delivery on the basis of previous results (10). Briefly, self-assembled poly(ester amine)/siRNA complex was initiated in distilled water by adding 1 mg of plasmid DNA to poly(ester amine), drop by drop, under gentle vortexing, and the final volume was adjusted to 50 ml. The complex was then incubated at room temperature for 30 minutes before use.

In Vivo Aerosol Delivery of Poly(ester amine)/siRNA Complex

Experiments were performed on 5-week-old ICR mice, K-ras^sup LA1^ mice, C57BL/6 mice, and 6-week-old A/J mice, respectively. ICR mice, C57BL/6 mice, and A/J mice were purchased from Joongang Laboratory Animal (Seoul, Korea) and breeding K-ras^sup LA1^ mice were obtained from the National Cancer Institute (Frederick, MD). The animals were kept in the laboratory animal facility with temperature and relative humidity maintained at 23 +- 2[degrees]C and 50 +- 20%, respectively, under a 12-hour light/dark cycle. All methods used in this study were approved by the Animal Care and Use Committee at Seoul National University (SNU-061110-5, SNU-070910-1). For gene delivery, mice were placed in the nose-only exposure chamber and exposed to the aerosol based on the methods used previously (34, 35). For the test of gene delivery efficiency of poly(ester amine), ICR mice were divided into three groups (3 mice/group). Two treatment groups were exposed to aerosol containing GFP plasmid DNA with or without poly(ester amine) and one remaining group was used as a control. Two days after exposure, these mice were killed and the lungs were collected for the detection of GFP green signal.

For the toxicity test of poly(ester amine) inhalation on the lungs of mice, the C57BL/6 mice (background of K-ras^sup LA1^ mice) were divided into two groups (6 mice/group). The control group was not treated with anything and the other group was exposed to aerosol containing 43.92 mg poly(ester amine) in distilled water (1 mg DNA). The C57BL/6 mice were exposed to aerosol twice a week for total of 4 weeks. At the end of the experiment, C57BL/6 mice were killed, and the bronchoalveolar lavage (BAL) fluid was collected for the measurement of lactate dehydrogenase (LDH) activity as described by Shvedova and colleagues (36). After collection of BAL fluid, the lungs were fixed in 10% neutral buffered formalin for histopathologic examination.

To determine the effects of Akt1 siRNA on lung cancer development, the K-ras^sup LA1^ mice were divided into three groups (7 mice/group). The control group was not treated with anything and the other two groups were exposed to aerosol containing poly(ester amine) with Akt1 siRNA or scrambled siRNA (scrambled control), respectively. The K-ras^sup LA1^ mice were exposed to aerosol twice a week for total 4 weeks. At the end of the test period, K-ras^sup LA1^ mice were killed, and the lungs were collected. During the autopsy procedure, the neoplastic lesions of lung surfaces were carefully counted and the lesion diameter was measured with the aid of digital calipers under a microscope as described by Singh and coworkers (37). Simultaneously, the lungs were perfused and fixed in 10% neutral buffered formalin for histopathologic examination and immunohistochemistry (IHC). Lungs from seven mice per group were used for histopathologic and immunohistochemical analysis. Remaining lungs were stored at 280[degrees]C for further study. We also tested the effects of Akt1 siRNA on a different model of lung carcinogenesis. Sixweek-old A/J male mice were given a single intraperitoneal injection of urethane (1 mg/g body weight) freshly dissolved in 0.9% saline or of saline only, as described by Kisley and colleagues (38). Six weeks after the urethane injection, the mice were divided into three groups (7 mice/group) and exposed to aerosol using the same method as described with the experiment using K-ras^sup LA1^ mice.

LDH Activity Assay in BAL Fluid

The activity of LDH in the BAL fluid was measured spectrophotometrically by monitoring the reduction of nicotinamide adenine dinucleotide at 340 nm in the presence of lactate (Pointe Scientific, Lincoln Park, MI).

Reverse Transcriptase-Polymerase Chain Reaction Experiments

Total RNA was isolated from the lung tissue with Trizol reagent (Invitrogen). Primers used for the polymerase chain reaction (PCR) were designed to be isoform specific. The sequences were as follows: for Akt1, sense 5′-GCC AAA GTC CAG CAA GAA GG-3′ and antisense 5′- CTG AAC CGC ATG GGA CAC AG-3′; for Akt2, sense 5′-CTG CCC TGA GCT CAC TCA AG-3′ and antisense 5′-CGG GCC TCT CCT TAT ACC CA-3′; for Akt3, sense 5′-CCT ACC AAC TCC ACC TTG AC-3′ and antisense 5′-CAA GAA GTC AGC TCC GAG AA-3′; for GAPDH (glyceraldehyde phosphate dehydrogenase), sense 5′-GAA GGA CTC ATG ACC ACAG-3′ and antisense 5′-CTTCAC CAC CTT CTT GATG-3′. The amplification conditions were as follows: 94[degrees]C for 5 minutes; 30 cycles of 30 seconds each of denaturation at 94[degrees]C, annealing at 58[degrees]C (54[degrees]C for Akt2, 56[degrees]C for Akt3, and 50[degrees]C for GAPDH), and extension at 72[degrees]C; and a final extension for 5 minutes at 72[degrees]C.

Western Blot Analysis

For Western blot analysis, lungs of six mice from the group of seven mice were selected by random sampling. After measuring the protein concentration of homogenized lysates using a Bradford kit (Bio-Rad, Hercules, CA), 30 [mu]g protein was separated on sodium dodecyl sulfate-polyacrylamide gel electrophoresis and transferred to nitrocellulose membranes. The membranes were blocked for 1 hour in tris-buffered saline with Tween 20 (TTBS) containing 5% skim milk, and immunoblotting was done by incubating the membranes overnight with their corresponding primary antibodies in 5% skim milk at 4[degrees]C, and then with secondary antibodies conjugated to horseradish peroxidase (HRP) for 3 hours at room temperature or overnight at 4[degrees]C. After washing, the bands of interest were analyzed by the luminescent image analyzer LAS-3000 (Fujifilm, Tokyo, Japan), and quantification of Western blot analysis was done by using the Multi Gauge version 2.02 program (Fujifilm, Tokyo, Japan).

Histopathologic Analysis and IHC

The lung tissues were fixed in 10% neutral buffered formalin, paraffin processed, and sectioned at 4 mm. For histologic analysis, the tissue sections were stained with hematoxylin and eosin. For IHC, the tissue sections were deparaffinized in xylene and rehydrated through alcohol gradients, then washed and incubated in 3% hydrogen peroxide (Appli-Chem, Darmstadt, Germany) for 30 minutes to quench endogenous peroxidase activity. After washing in phosphate- buffered saline (PBS), the tissue sections were incubated with 5% bovine serum albumin in PBS for 1 hour at room temperature to block unspecific binding sites. Primary antibodies were applied on tissue sections overnight at 4[degrees]C. The following day, the tissue sections were washed and incubated with secondary HRPconjugated antibodies (1:50) for 1 hour at room temperature. After careful washing, tissue sections were counterstained with Mayer’s hematoxylin (Dako, Carpinteria, CA) and washed with xylene. Cover slips were mounted using Permount (Fisher, Pittsburgh, PA), and the slides were reviewed using a light microscope (Carl Zeiss, Thornwood, NY). The evaluation of phospho-Akt (Ser473 and Thr308) staining was done according to the scoring system of Tang and coworkers (39), and the evaluation of PCNA staining was done as described by Zhang and colleagues (40).

Statistical Analysis

All data are given as means +- SE, and statistical differences among treatment groups were analyzed by one-way analysis of variance and Duncan’s multiple range test (41) using SAS statistical software package version 6.12 (SAS Institute, Cary, NC).

RESULTS

Poly(ester amine) Can Be Used as a Good Carrier for Aerosol Gene Delivery

In a previous study, we confirmed the low cytotoxicity and high transfection efficiency of poly(ester amine) polymer in cell culture (10). On the basis of this study, we confirmed the in vivo transfection efficiency and toxicity of poly(ester amine) in the mouse lung. As shown Figure 1A, the green signal of green fluorescent protein (GFP) was dominant in poly(ester amine)/GFP complex-exposed group compared with other two groups. The results indicated that our delivery system functioned efficiently. Results of both histopathologic examination of the lung and LDH activity in BAL fluid demonstrated that the poly(ester amine) carrier did not cause any significant toxicity (Figures 1B and 1C).

Aerosol Delivery of Akt1 siRNA Significantly Suppresses Lung Tumorigenesis in K-ras^sup LA1^ Mice

To determine whether aerosol-delivered Akt1 siRNA might affect other isoforms of Akt, the mRNA and protein expressions of Akt1, Akt2, and Akt3 were measured by reverse transcriptase-PCR and Western blot in the lungs of K-ras^sup LA1^ mice. As shown in Figure 2, aerosol-delivered Akt1 siRNA suppressed the mRNA (Figures 2A and 2B) and protein expression (Figures 2C and D) of Akt1 specifically without affecting the Akt2 and Akt3 in the lungs of K-ras^sup LA1^ mice. Moreover, aerosol delivery of Akt1 siRNA did not affect the protein expression of Akt1 in other organs (Figures 2E and 2F). Because Akt requires phosphorylation of both Thr308 and Ser473 for full activity (34, 42), phosphorylation status of Akt1 was examined in the lungs of K-ras^sup LA1^ mice. Akt1 siRNA significantly inhibited the phosphorylation of Akt1 at Thr308 as well as Ser473 (Figure 2G), and suppressed phosphorylation at the critical sites was clearly reconfirmed by densitometric analysis (Figure 2H). Such suppressed Akt phosphorylation was further confirmed by IHC as shown in Figure 2I and also by the scoring of immunopositive cells as shown in Figure 2J. To determine the effect of suppressed Akt activity on tumorigenesis, the number and size of tumors were measured in the lungs of K-ras^sup LA1^ mice. As shown in Figures 3A and 3B (arrows and dashed circles) and Table 1, the number of tumors and the mean of tumor diameter were significantly decreased by Akt1 siRNA. Histopathologic examination also indicated that pulmonary tumor formation was significantly suppressed (arrows in Figure 3C and Table 1). Taken together, Akt1 siRNA suppressed tumor numbers as well as tumor progression significantly in the lungs of K-ras^sup LA1^ mice.

Aerosol Delivery of Akt1 siRNA Inhibits Proteins Important for Protein Translation in Lungs of K-ras^sup LA1^ Mice

Activation of Akt by phosphorylation plays a central role in tumorigenesis. The Akt/mTOR pathway controls cellular protein translation through regulation of 70-kD ribosomal protein S6 kinase (p70S6K) and eukaryotic initiation factor 4E binding protein 1 (4E- BP1) phosphorylation, and protein translation closely related with cancer cell growth (12). To obtain mechanistic insight into how Akt1 siRNA suppresses lung tumorigenesis, we analyzed the proteins important for Akt-related protein translation signals. Our results showed that inhibition of Akt1 significantly decreased mTOR and phospho-mTOR protein expressions. Also, aerosol delivery of Akt1 siRNA suppressed the protein expression of p70S6K and phosphor- p70S6K. Expression of Akt1 siRNA did not affect the protein expression of total 4E-BP1, but suppressed phosphorylation at Ser65 as well as Thr69 in lungs of K-ras^sup LA1^ mice significantly (Figures 4A and 4B). Aerosol Delivery of Akt1 siRNA Significantly Inhibits Proteins Important for Cell Cycle Regulation in Lungs of K- ras^sup LA1^ Mice

Akt is known to regulate cell cycle progression (12), thus, we evaluated the effects of Akt1 siRNA on cell cycle-regulated proteins in the lungs of K-ras^sup LA1^ mice. Results demonstrated that aerosol delivery of Akt1 siRNA suppressed the proteins important for cell cycle regulation, such as cyclin D1, cyclin D3, cyclin A, cyclin E, CDK4, CDK2, CDC2, and PCNA (Figures 5A-5D). The expression of PCNA, a marker of cell proliferation, was further analyzed. Results obtained by IHC (Figure 5E) and by PCNA labeling index of the immunopositive cells (Figure 5F) clearly indicated that Akt1 siRNA suppressed cell proliferation in the lungs of K-ras^sup LA1^ mice.

Aerosol Delivery of Akt1 siRNA Significantly Suppresses Lung Tumorigenesis in Urethane-induced Lung Cancer Model Mice

To determine if our aerosol delivery of siRNA is broadly applicable, we additionally examined the effects of Akt1 siRNA on a urethane-induced lung cancer model in A/J mice. Obtained results showed that Akt1 siRNA significantly suppressed the tumor development in urethane-induced lung cancer model mice. The mean number of tumor foci (Figure 6A and Table 2) and the mean tumor diameter (at least 1.0 mm in diameter) (Figure 6B) were significantly decreased by Akt1 siRNA. Histopathologic examination also demonstrated that pulmonary tumor formation was significantly suppressed (arrows in Figure 6C and Table 2). Results are summarized in Table 2.

DISCUSSION

Two major advantages of aerosol delivery are instant access and high ratio of the drug/gene deposited within the lung noninvasively (43). In recent years, much effort has focused on the development of aerosol gene delivery technology for the treatment of diverse lung diseases, including cancer. This effort has involved finding appropriate nonviral DNA delivery carriers that both withstand the sheering force of nebulization and also function optimally in the lungs (34). PEI is a well-known cationic polymer, which can deliver the DNA both in vitro and in vivo due to unique buffering capacity- mediated high transfection activity (5, 44). However, PEI is toxic and nondegradable (45). To enhance the biocompatibility of PEI, Ahn and colleagues (46) synthesized a PEI derivative, PEI-PEG copolymer; however, transfection efficiency of the copolymer was not satisfactory, although the copolymer was degradable and less toxic. The above example in combination with many unsatisfactory efforts for the synthesis of PEI derivatives prompted us to synthesize a novel copolymer as new gene carrier, producing new degradable poly(ester amine) copolymer with high transfection efficiency and low toxicity (10). The current study clearly demonstrates a high transfection efficiency with satisfactory safety of poly(ester amine) (Figure 1).

siRNA-based RNAi has been used widely to study gene functions and disease therapeutics because RNAi is activated in mammalian cells by introducing siRNAs (47), and is known to silence the gene of interest specifically at low concentration (30). Transfection of siRNA into lung cells has been demonstrated in vivo in transgenic enhanced GFP mice using intranasal administration of enhanced GFP siRNA with chitosan nanoparticles (48). Ge and colleagues (49) also reported satisfactory transfection of siRNA into lung cells in vivo in mouse models of influenza infection using PEI as a vector via intravenous administration, and this transfected siRNA specific to conserved regions of influenza virus genes significantly reduced the influenza production in the lungs.

Akt is one of the most frequently hyperactivated signaling pathways in cancer, including lung cancer (50). The Akt pathway can be hyperactivated by several gene mutations (30), such as the K-ras gene (18), and 33-50% of patients with lung adenocarcinoma have specific mutations in the K-ras gene (16). Recently, several in vitro studies examined the effect of Akt on cancer development using Akt siRNA treatment and demonstrated that Akt was an important molecular target for cancer treatment (32, 51, 52). Here, our in vivo study clearly demonstrated the significant anticancer effect of Akt1 siRNA in the lungs through aerosol inhalation. Our results showed that aerosol-delivered Akt1 siRNA decreased about 80% of the Akt1 protein expression specifically in the lungs (Figure 2) and significantly inhibited the progression of lung cancer in different mouse models (Figure 3 and Table 1; Figure 6 and Table 2). These findings suggest that aerosol delivery of Akt1 siRNA may be a promising approach for lung cancer treatment and prevention. In addition, recent studies reported that resistance of chemo- and radiotherapy might be associated with constitutive activated Akt in lung cancer (53). Such findings also suggest that aerosol delivery of Akt1 siRNA may be useful for the treatment of chemotherapy- or radiotherapy-resistant lung cancer, and combined treatment with other classical chemotherapeutic treatments may enhance the therapeutic efficacy.

The Akt family is composed of three isoforms (Akt1, Akt2, and Akt3), which, in general, are broadly expressed, although there are some isoform-specific features (11). In fact, Akt1 is implicated in the treatment resistance of NSLC (54), suggesting that Akt1 inhibition is a key factor for specific cancer cell death. Although Akt1 activation has been implicated in up-regulated cell proliferation, in vivo effects of Akt1 in terms of cell proliferation and critical downstream effectors, such as mTOR, p70S6K, and 4E-BP1, remain largely uncertain. As such, we undertook the function of Akt1 in lung cancer progression with the aid of Akt1 siRNA to address these issues.

We demonstrated that the knockdown of Akt1 activity, and not Akt2 and Akt3 (Figure 2) is sufficient to suppress Akt1-related signals important for protein translation (Figure 4) and cell cycle progression (Figure 5), and thus inhibit pulmonary tumor progression (Figure 3 and Table 1) in K-ras^sub LA1^ mice and urethane-induced lung cancer mice (Figure 6 and Table 2). As mentioned earlier, the current study was performed to verify that Akt1 suppression by siRNA might be sufficient to confer resistance to tumorigenesis in vivo. Our results demonstrated that Akt1 knockdown was sufficient to delay the tumor progression and to provide profound resistance to lung tumor development. In part, this result may be related with the attenuated Akt/mTOR-mediated protein translation signaling because translation defects due to aberrant Akt activation may be a critical underlying mechanism leading to tumorigenesis (13). In mammals, Akt can phosphorylate mTOR on Ser2448 to activate this kinase (55), and subsequently activated mTOR leads to translation initiation through phosphorylation of p70S6K and 4E-BP1 protein (56). A recent report also has shown that phosphorylation of p70S6K and of 4E-BP1 is well correlated with PI3K-induced tumorigenesis (57). 4E-BP1 is an important regulator of capdependent translation through binding to eIF4E, resulting capdependent protein translation, and this binding can be disrupted by hyperphosphorylation of 4E-BP1 (56). Jacobson and colleagues (58) reported that repression of cap-dependent translation attenuated the transformed phenotype in NSCLC. Another main target protein of mTOR, p70S6K also plays an important role in lung tumorigenesis. Wislez and associates (59) reported that high levels of phosphor-p70S6K were prominently associated with atypical alveolar hyperplasia, an early neoplastic change, and that inhibition of mTOR/p70S6K reversed alveolar epithelial neoplasia induced by oncogenic K-ras. A recent line of evidence also demonstrated that Akt1 deficiency was sufficient to significantly attenuate tumor development induced by phosphatase and tensin homolog deleted on chromosome 10 (PTEN) deficiency (60). Our group also provided strong evidence that aerosol delivery of PTEN suppressed Akt1 downstream pathways in the lungs of K-ras^sup LA1^ mice (35). In addition, a recent study reported that Akt1 knockout mice were not impaired in their lifespan and might possibly live longer than wild-type mice (61). Taken together, targeted inhibition of Akt1 activity may be used as a therapeutic approach for cancer without causing significant physiologic problems.

In the last decade, many studies have focused on the correlation between cell cycle control and lung carcinogenesis. Just as apoptosis is controlled by highly conserved machinery, cell cycle is also a highly conserved mechanism by which eukaryotic cells proliferate. The cell cycle progression is principally governed by several families of CDKs, each pairing with cell cycle-specific regulatory subunits known as cyclins (62). In this study, the effects of aerosol-delivered Akt1 siRNA on cell cycle control in lungs of K-ras^sup LA1^ mice were investigated. Initiation of cell cycle control via extracellular signals induces the transcription of several proteins, including cyclin D, which, when complexed with CDK4, moves into the next cell cycle (63). Cyclin A and cyclin E, which paired with CDK2, were found to be required for the G1/S transition and progression through the S phase. Finally, cyclin B governs the G2/M transition paired with CDC2 (64). In our study, aerosol-delivered Akt1 siRNA suppressed the lung cancer growth through inhibiting the cell proliferation proteins such as cyclins A, D, and E; CDK4; CDK2; CDC2; and PCNA (Figure 5). Our results are supported by the findings that Akt1 is associated with cyclin D1 up- regulation, which helps in the disruption of the G1/S regulatory point of the cell cycle and leads to abnormal cell proliferation during carcinogenesis (65). Our additional studies with a urethane- induced lung cancer model (Figure 6) also strongly support that aerosol delivery of Akt1 siRNA is a promising approach to treat lung cancer. This study emphasizes the importance of developing effective and selective preventive options for lung cancer through extensive in vivo research into the therapeutic effects of Akt1 siRNA. In conclusion, aerosol-delivered poly(ester amine)/Akt1 siRNA complex efficiently suppressed lung cancer progression through regulating proteins important for Akt-related signals, and cell cycle regulation. The results of our study strongly suggest that aerosol gene delivery may provide an effective noninvasive model of gene delivery and Akt1 siRNA may be effective in targeting protein translation and cell cycle regulation for lung cancer prevention as well as treatment.

Conflict of Interest Statement: None of the authors has a financial relationship with a commercial entity that has an interest in the subject of this manuscript.

AT A GLANCE COMMENTARY

Scientific Knowledge on the Subject

Recent advances in aerosol-mediated gene delivery suggest that this approach may be useful in the treatment of lung cancer.

What This Study Adds to the Field

Poly(ester amine) carrier may serve as an effective carrier, and aerosol delivery of Akt1 small interfering RNA may be a promising approach for lung cancer treatment and prevention.

References

1. Dailey LA, Kleemann E, Merdan T, Petersen H, Schmehl T, Gessler T, Hanze J, Seeger W, Kissel T. Modified polyethylenimines as non viral gene delivery systems for aerosol therapy: effects of nebulization on cellular uptake and transfection efficiency. J Control Release 2004; 100:425-436.

2. Ferrari S, Geddes DM, Alton EW. Barriers to and new approaches for gene therapy and gene delivery in cystic fibrosis. Adv Drug Deliv Rev 2002;54:1373-1393.

3. Merdan T, Kopecek J, Kissel T. Prospects for cationic polymers in gene and oligonucleotide therapy against cancer. Adv Drug Deliv Rev 2002;54:715-758.

4. Gautam A, Densmore CL, Golunski E, Xu B, Waldrep JC. Transgene expression in mouse airway epithelium by aerosol gene therapy with PEI-DNA complexes. Mol Ther 2001;3:551-556.

5. Godbey WT, Wu KK, Mikos AG. Poly(ethylenimine) and its role in gene delivery. J Control Release 1999;60:149-160.

6. Densmore CL. Advances in noninvasive pulmonary gene therapy. Curr Drug Deliv 2006;3:55-63.

7. Romano G. Current development of nonviral-mediated gene transfer. Drug News Perspect 2007;20:227-231.

8. Parker AL, Newman C, Briggs S, Seymour L, Sheridan PJ. Nonviral gene delivery: techniques and implications for molecular medicine. Expert Rev Mol Med 2003;5:1-15.

9. Merlin JL, Dolivet G, Dubessy C, Festor E, Parache RM, Verneuil L, Erbacher P, Behr JP, Guillemin F. Improvement of nonviral p53 gene transfer in human carcinoma cells using glucosylated polyethylenimine derivatives. Cancer Gene Ther 2001;8:203-210.

10. Park MR, Han KO, Han IK, Cho MH, Nah JW, Choi YJ, Cho CS. Degradable polyethylenimine-alt-poly (ethylene glycol) copolymers as novel gene carriers. J Control Release 2005;105:367-380.

11. Vivanco I, Sawyers CL. The phosphatidylinositol 3-kinase Akt pathway in human cancer. Nat Rev Cancer 2002;2:489-501.

12. Lawlor MA, Alessi DR. PKB/Akt: a key mediator of cell proliferation, survival and insulin responses? J Cell Sci 2001;114:2903-2910.

13. Ruggero D, Sonenberg N. The Akt of translational control. Oncogene 2005;24:7426-7434.

14. Li J, Simpson L, Takahashi M, Miliaresis C, Myers MP, Tonks N, Parsons R. The PTEN/MMAC1 tumor suppressor induces cell death that is rescued by the Akt/protein kinase B oncogene. Cancer Res 1998;58:5667-5672.

15. Pellegata NS, Antoniono RJ, Redpath JL, Stanbridge EJ. DNA damage and p53-mediated cell cycle arrest: a reevaluation. Proc Natl Acad Sci USA 1996;93:15209-15214.

16. Lechner JE, Fugaro JM. RAS and ERBBZ. In: Pass HI, Mitchell JB, Johnson DH, Turrisi AT, editors. Lung cancer: principles and practice. Philadelphia: Lippincott Raven Publishers; 2000. pp. 89- 97.

17. Johnson L, Mercer K, Greenbaum D, Bronson RT, Bronson RT, Crowley D, Tuveson DA, Jacks T. Somatic activation of the K-ras oncogene causes early onset lung cancer in mice. Nature 2001;410:1111-1116.

18. Okudela K, Hayashi H, Ito T, Yazawa T, Suzuki T, Nakane Y, Sato H, Ishi H, KeQin X, Masuda A, et al. K-ras gene mutation enhances motility of immortalized airway cells and lung adenocarcinoma cells via Akt activation: possible contribution to non-invasive expansion of lung adenocarcinoma. Am J Pathol 2004;164:91-100.

19. Toulany M, Dittmann K, Kruger M, Baumann M, Rodemann HP. Radioresistance of K-ras mutated human tumor cells is mediated through EGFR-dependent activation of PI3K-Akt pathway. Radiother Oncol 2005;76:143-150.

20. Toulany M, Kasten-Pisula U, Brammer I, Wang S, Chen J, Dittmann K, Baumann M, Dikomey E, Rodemann HP. Blockage of epidermal growth factor receptor-phosphatidylinositol 3 kinase-AKT signaling increases radiosensitivity of K-RAS mutated human tumor cells in vitro by affecting DNA repair. Clin Cancer Res 2006;12:4119-4126.

21. Han Z, Hong L,Wu K, Han S, Shen H, Liu C, Han Y, Liu Z, Han Y, Fan D. Reversal of multidrug resistance of gastric cancer cells by downregulation of Akt1 with Akt1 siRNA. J Exp Clin Cancer Res 2006;25: 601-606.

22. Skeen JE, Bhaskar PT, Chen CC, Chen WS, Peng XD, Nogueira V, Hahn-Windgassen A, Kiyokawa H, Hay N. Akt deficiency impairs normal cell proliferation and suppresses oncogenesis in a p53-independent and mTORS1-dependent manner. Cancer Cell 2006;10: 269-280.

23. Malkinson AM. Primary lung tumors in mice as an aid for understanding, preventing, and treating human adenocarcinoma of the lung. Lung Cancer 2001;32:265-279.

24. You M, Candrian U, Maronpot RR, Stoner GD, Anderson MW. Activation of the Ki-ras protooncogene in spontaneously occurring and chemically induced lung tumors of the strain A mouse. Proc Natl Acad Sci USA 1989;86:3070-3074.

25. Benfield JR, Malkinson AM, Schuller HM, Sunday ME. Preclinical models of lung cancer. In: Kane MA, Bunn PA, editors. Biology of lung cancer. New York: Marcel Dekker; 1998. pp. 247-293.

26. Cogoni C, Macino G. Post-transcriptional gene silencing across kingdoms. Curr Opin Genet Dev 2000;10:638-643.

27. Hu L, Hofmann J, Lu Y, Mills GB, Jaffe RB. Inhibition of phosphatidylinositol 39-kinase increases efficacy of paclitaxel in in vitro and in vivo ovarian cancer models. Cancer Res 2002;62:1087- 1092.

28. Elbashir SM, Harborth J, Lendeckel W, Yalcin A, Weber K, Tuschl T. Duplexes of 21-nucleotide RNAs mediate RNA interference in cultured mammalian cells. Nature 2001;411:494-498.

29. Matranga C, Tomari Y, Shin C, Bartel DP, Zamore PD. Passengerstrand cleavage facilitates assembly of siRNA into Ago2- containing RNAi enzyme complexes. Cell 2005;123:607-620.

30. de Fougerolles A, Vornlocher HP, Maraganore J, Lieberman J. Interfering with disease: a progress report on siRNA-based therapeutics. Nat Rev Drug Discov 2007;6:443-453.

31. Pai SI, Lin YY, Macaes B, Meneshian A, Hung CF, Wu TC. Prospects of RNA interference therapy for cancer. Gene Ther 2006;13:464-477.

32. Meng Q, Xia C, Fang J, Rojanasakul Y, Jiang BH. Role of PI3K and AKT specific isoforms in ovarian cancer cell migration, invasion and proliferation through the p70S6K1 pathway. Cell Signal 2006;18:2262-2271.

33. Amarzguioui M, Rossi JJ, Kim D. Approaches for chemically synthesized siRNA and vector-mediated RNAi. FEBS Lett 2005;579:5974- 5981.

34. Tehrani AM, Hwang SK, Kim TH, Cho CS, Hua J, Nah WS, Kwon JT, Kim JS, Chang SH, Yu KN, et al. Aerosol delivery of Akt controls protein translation in the lungs of dual luciferase reporter mice. Gene Ther 2007;14:451-458.

35. Kim HW, Park IK, Cho CS, Lee KH, Beck GR Jr, Colburn NH, Cho MH. Aerosol delivery of glucosylated polyethylenimine/phosphatase and tensin homologue deleted on chromosome 10 complex suppresses Akt downstream pathways in the lung of K-ras null mice. Cancer Res 2004;64:7971-7976.

36. Shvedova AA, Fabisiak JP, Kisin ER, Murray AR, Roberts JR, Tyurina YY, Antonini JM, Feng WH, Kommineni C, Reynolds J, et al. Sequential exposure to carbon nanotubes and bacteria enhances pulmonary inflammation and infectivity. Am J Respir Cell Mol Biol 2008;38:579-590.

37. Singh RP, Deep G, Chittezhath M, Kaur M, Dwyer-Nield LD, Malkinson AM, Agarwal R. Effect of silibinin on the growth and progression of primary lung tumors in mice. J Natl Cancer Inst 2006;98: 846-855.

38. Kisley LR, Barrett BS, Bauer AK, Dwyer-Nield LD, Barthel B, Meyer AM, Thompson DC, Malkinson AM. Genetic ablation of inducible nitric oxide synthase decreases mouse lung tumorigenesis. Cancer Res 2002;62:6850-6856.

39. Tang JM, He QY, Guo RX, Chang XJ. Phosphorylated Akt overexpression and loss of PTEN expression in non-small cell lung cancer confers poor prognosis. Lung Cancer 2006;51:181-191.

40. Zhang Z, Liu Q, Lantry LE, Wang Y, Kelloff GJ, Anderson MW, Wiseman RW, Lubet RA, You M. A germ-line p53 mutation accelerates pulmonary tumorigenesis: p53-independent efficacy of chemopreventive agents green tea or dexamethasone/myo-inositol and chemotherapeutic agents taxol or adriamycin. Cancer Res 2000; 60:901-907.

41. Steel RGD, Torrie JH. Principles and procedures of statistics. New York: McGraw-Hill; 1980. 42. West KA, Brognard J, Clark AS, Linnoila IR, Yang X, Swain SM, Harris C, Belinsky S, Dennis PA. Rapid Akt activation by nicotine and a tobacco carcinogen modulates the phenotype of normal human airway epithelial cells. J Clin Invest 2003;111:81-90.

43. Gautam A, Waldrep JC, Densmore CL. Aerosol gene therapy. Mol Biotechnol 2003;23:51-60.

44. Boussif O, Lezoualc’h F, Zanta MA, Mergny MD, Scherman D, Demeneix B, Behr JP. A versatile vector for gene and oligonucleotide transfer into cells in culture and in vivo: polyethylenimine. Proc Natl Acad Sci USA 1995;92:7297-7301.

45. Kim YH, Park JH, Lee M, Kim YH, Park TG, Kim SW. Polyethylenimine with acid-labile linkages as a biodegradable gene carrier. J Control Release 2005;103:209-219.

46. Ahn CH, Chae SY, Bae YH, Kim SW. Biodegradable poly(ethylenimine) for plasmid DNA delivery. J Control Release 2002;80:273-282.

47. Coumoul X, Deng CX. RNAi in mice: a promising approach to decipher gene functions in vivo. Biochimie 2006;88:637-643.

48. Howard KA, Rahbek UL, Liu X, Damgaard CK, Glud SZ, Andersen MO, Hovgaard MB, Schmitz A, Nyengaard JR, Besenbacher F, et al. RNA interference in vitro and in vivo using a chitosan/siRNA nanoparticle system. Mol Ther 2006;14:476-484.

49. Ge Q, Filip L, Bai A, Nguyen T, Eisen HN, Chen J. Inhibition of influenza virus production in virus-infected mice by RNA interference. Proc Natl Acad Sci USA 2004;101:8676-8681.

50. Crowell JA, Steele VE, Fay JR. Targeting the AKT protein kinase for cancer chemoprevention. Mol Cancer Ther 2007;6:2139- 2148.

51. Han S, Khuri FR, Roman J. Fibronectin stimulates non-small cell lung carcinoma cell growth through activation of Akt/mammalian target of rapamycin/S6 kinase and inactivation of LKB1/AMP- activated protein kinase signal pathways. Cancer Res 2006;66:315- 323.

52. Xin M, Deng X. Nicotine inactivation of the proapoptotic function of Bax through phosphorylation. J Biol Chem 2005;280:10781- 10789.

53. Shah AS, Swain WA, Richardson D, Edwards J, Stewart DJ, Richardson CM, Swinson DE, Patel D, Jones JL, O’Byrne KJ. Phospho- Akt expression is associated with a favorable outcome in non-small cell lung cancer. Clin Cancer Res 2005;11:2930-2936.

54. Brognard J, Clark AS, Ni Y, Dennis PA. Akt/protein kinase B is constitutively active in non-small cell lung cancer cells and promotes cellular survival and resistance to chemotherapy and radiation. Cancer Res 2001;61:3986-3997.

55. Nave BT, Ouwens M, Withers DJ, Alessi DR, Shepherd PR. Mammalian target of rapamycin is a direct target for protein kinase B: identification of a convergence point for opposing effects of insulin and amino acid deficiency on protein translation. Biochem J 1999;344: 427-431.

56. Manning BD. Balancing Akt with S6K: implications for both metabolic diseases and tumorigenesis. J Cell Biol 2004;167:399-403.

57. Gingras AC, Raught B, Sonenberg N. eIF4 initiation factors: effectors of mRNA recruitment to ribosomes and regulators of translation. Annu Rev Biochem 1999;68:913-963.

58. Jacobson BA, Alter MD, Kratzke MG, Frizelle SP, Zhang Y, Peterson MS, Avdulov S, Mohorn RP, Whitson BA, Bitterman PB, et al. Repression of cap-dependent translation attenuates the transformed phenotype in non-small cell lung cancer both in vitro and in vivo. Cancer Res 2006;66:4256-4262.

59. Wislez M, Spencer ML, Izzo JG, Juroske DM, Balhara K, Cody DD, Price RE, Hittelman WN, Wistuba II, Kurie JM. Inhibition of mammalian target of rapamycin reverses alveolar epithelial neoplasia induced by oncogenic K-ras. Cancer Res 2005;65:3226-3235.

60. Chen ML, Xu PZ, Peng XD, Chen WS, Guzman G, Yang X, Di Cristofano A, Pandolfi PP, Hay N. The deficiency of Akt1 is sufficient to suppress tumor development in Pten+/-mice. Genes Dev 2006;20: 1569-1574.

61. Wyszomierski SL, Yu D. A knotty turnabout? Akt1 as a metastasis suppressor. Cancer Cell 2005;8:437-439.

62. Morgan DO. Cyclin-dependent kinases: engines, clocks, and microprocessors. Annu Rev Cell Dev Biol 1997;13:261-291.

63. Caputi M, Russo G, Esposito V, Mancini A, Giordano A. Role of cellcycle regulators in lung cancer. J Cell Physiol 2005;205:319- 327.

64. Sa nchez I, Dynlacht BD. New insights into cyclins, CDKs, and cell cycle control. Semin Cell Dev Biol 2005;6:311-321.

65. Parekh P, Rao KV. Overexpression of cyclin D1 is associated with elevated levels of MAP kinase, Akt1 and Pak1 during diethylnitrosamine-induced progressive liver carcinogenesis. Cell Biol Int 2007;31: 35-43.

Cheng-Xiong Xu1, Dhananjay Jere2, Hua Jin3, Seung-Hee Chang1,4, Youn-Sun Chung1, Ji-Young Shin1, Ji-Eun Kim1,4, Sung-Jin Park1, Yong- Hoon Lee5, Chan-Hee Chae5, Kee Ho Lee6, George R. Beck, Jr.7, Chong- Su Cho2*, and Myung-Haing Cho1,4,8*

1Laboratory of Toxicology, College of Veterinary Medicine, Seoul National University, Seoul, Korea; 2Department of Agricultural Biotechnology, Seoul National University, Seoul, Korea; 3Center for Developmental Pharmacology and Toxicology, Seattle Children’s Hospital Research Institute, Seattle, Washington; 4Nano Systems Institute-National Core Research Center, Seoul National University, Seoul, Korea; 5Department of Veterinary Pathology, College of Veterinary Medicine, Seoul National University, Seoul, Korea; 6Laboratory of Molecular Oncology, Korea Institute of Radiological and Medical Sciences, Seoul, Korea; 7Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, Georgia; and 8National Institute of Toxicological Research, Seoul, Korea

(Received in original form July 12, 2007; accepted in final form February 28, 2008)

Supported in part by grants from the KOSEF (M20704000010-07M0400- 01010) of the Ministry of Science and Technology in Korea. M.-H.C. J.-E.K., and S.-H.C. were supported by the Nano Systems Institute- National Core Research Center program of Korea Science and Engineering Foundation. C.-X.X., H.J., Y.-S.C., J.-Y.S., and S.- J.P. were awarded the BK21 fellowship. K.H.L was supported by the 21C Frontier Functional Human Genome Project (FG03-0601-003-1-0-0) and the National Nuclear R&D Program from the Ministry of Science and Technology. G.R.B. was supported by National Cancer Institute grant CA84573.

*These authors contributed equally to this manuscript and share corresponding authorship.

Correspondence and requests for reprints should be addressed to Myung-Haing Cho, D.V.M., Ph.D., Laboratory of Toxicology, College of Veterinary Medicine, Seoul National University, Seoul 151-742, Korea. E-mail: [email protected] or Chong-Su Cho at [email protected]

Am J Respir Crit Care Med Vol 178. pp 60-73, 2008

Originally Published in Press as DOI: 10.1164/rccm.200707-1022OC on February 28, 2008

Internet address: www.atsjournals.org

Copyright American Thoracic Society Jul 1, 2008

(c) 2008 American Journal of Respiratory and Critical Care Medicine. Provided by ProQuest Information and Learning. All rights Reserved.

PIN Numbers Are Vulnerable to Hackers

Hackers stole PIN codes from a network of Citibank ATMs located in 7-Eleven stores, allegedly stealing millions of dollars and revealing a major flaw in Citibank’s security efforts.

According to recent court filings, the hackers were able to steal the money and access PINs ““ numeric passwords used by customers to access their accounts ““ by attacking the back-end computers responsible for approving cash withdrawals.

The infrastructures of ATM systems are increasingly being built on Microsoft Corp.’s Windows operating system, which allows them to be diagnosed and repaired via the Internet. Despite industry standards that call for protecting PINs with strong encryption – which means encoding them to cloak them to outsiders – some ATM operators apparently aren’t properly doing that.

The PINs seem to be leaking while in transit between the automated teller machines and the computers that process the transactions.

“PINs were supposed be sacrosanct – what this shows is that PINs aren’t always encrypted like they’re supposed to be,” said Avivah Litan, a security analyst with the Gartner research firm. “The banks need much better fraud detection systems and much better authentication.”

The case involving ATMs at 7-Eleven convenience stores has brought three people – Yuriy Rakushchynets, Ivan Biltse and Angelina Kitaeva – before a U.S. District Court for the Southern District of New York. It is still unclear how many Citibank customers’ accounts may have been tampered with during the breach, which extended at least from October 2007 to March of this year.

Citibank has almost 5,700 ATMs in 7-Eleven stores throughout the U.S., but it does not own or operate any of them. Houston-based Cardtronics Inc. owns all the machines but only operates some, and Brookfield, Wis.-based Fiserv Inc. operates the others.

Investigators still haven’t publicly discussed exactly how the hackers were able to steal the PINs, all that’s known is they broke into the ATM network through a server at a remote third-party processor.

They could have gained administrative access to the machines – which means they had carte blanche to grab information – through a flaw in the network or by figuring out those computers’ passwords. Or it’s possible they installed a piece of malicious software on a banking server to capture unencrypted PINs as they passed through.

So, there have been no visible signs of tampering they could detect, unlike previous heists in which thieves used more noticeable methods such as sending “phishing” e-mails or installing false-front keypads on ATMs.

Don Jackson, director of threat intelligence for SecureWorks Inc., said he has seen an “alarming” spike in the number of attacks on back-end computers for ATM networks over the past year.

“This was fairly large, but I don’t think it’s anything out of the ordinary – these kinds of scams go on every day,” Jackson said. “What makes this case unique is the sheer luck of happening upon these guys and catching them red-handed. But there are a whole lot of other ATM and PIN compromises going on that aren’t reported.”

Each of the hackers have been indicted on two counts each of conspiracy and fraud. Prosecutors say their activities generated at least $2 million in illegal profits.

Citibank, part of Citigroup Inc., said it notified affected customers and issued them new debit cards.

“We want our customers to know that, consistent with legal requirements, we do not hold them responsible for fraudulent activity in their accounts,” the bank said in a statement.

Mercy Making Pitch to Workers Who Lost Their Jobs at Geisinger

By David Singleton, The Times-Tribune, Scranton, Pa.

Jul. 2–Geisinger South Wilkes-Barre employees who learned last week their jobs will be eliminated in September are now learning something else.

Their skills are in demand.

In newspapers ads this week and a direct mail effort that will follow, Mercy Health Partners is making an aggressive pitch for soon-to-be-displaced nurses and other employees who worked at the hospital when it was known as Mercy Wilkes-Barre to rejoin the Mercy organization.

Other area health care facilities have also been quick to recognize the cutbacks at South Wilkes-Barre as a chance to plug critical staffing holes.

“Given the size of our health care system and the diverse opportunities for professionals and other employees, we would always have openings for talented, experienced people,” said Jim Carmody, vice president of human resources for Wyoming Valley Health Care System.

Geisinger said Thursday it will cut about 400 jobs at South Wilkes-Barre as it restructures services there and at Geisinger Wyoming Valley. Of the jobs that will be eliminated, approximately 170 are in nursing, 100 are technicians or aides, and the rest are support staff and maintenance, Geisinger spokesman Dave Jolley said.

Mercy Health Partners views the shake-up as an opportunity to welcome back former employees dispossessed when Mercy sold the Wilkes-Barre hospital to Geisinger in 2005 but who are still passionate about the Mercy ministry, said John M. Starcher Jr., interim president and CEO.

Between its hospitals in Scranton and Nanticoke, Mercy has more than 100 openings in a variety of positions.

“To the extent we can create a win-win out of this and fill our needs with former Mercy employees, I can’t think of anything better than that,” Mr. Starcher said.

Mercy is sweetening its invitation by offering former employees credit for their previous years of service with the organization, which can affect a worker’s salary, pension, vacation accrual and tuition reimbursement.

Community Medical Center has been in touch with the human resources department at South Wilkes-Barre and “will be working with them in accommodating some of these (displaced) employees,” spokeswoman Jane Gaul said.

Hazleton General Hospital is inviting South Wilkes-Barre workers to an open house July 16. Although the event was scheduled before last week’s announcement, the timing will work out well for the hospital, which has more than 25 open nursing positions, said Jim Edwards, CEO of the Greater Hazleton Health Alliance.

“We are looking at this as an opportunity for us to fill some vacant positions and provide some people who aren’t going to have jobs an opportunity … to join a successful team,” Mr. Edwards said.

Daniel J. West, Ph.D., associate professor and chairman of health administration and human resources at the University of Scranton, said displaced workers whose specialities are in high demand — nurses, pharmacists, physical therapists — will be snatched up quickly.

Others will have a more difficult search for employment, especially at a time when no hospitals in Northeastern Pennsylvania are truly expanding, he said.

Contact the writer: [email protected]

—–

To see more of The Times-Tribune or to subscribe to the newspaper, go to http://www.thetimes-tribune.com/.

Copyright (c) 2008, The Times-Tribune, Scranton, Pa.

Distributed by McClatchy-Tribune Information Services.

For reprints, email [email protected], call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.