A New York researcher has pinpointed for the first time brain regions in children with autism linked to “ritualistic repetitive behavior,” the insatiable desire to rock back and forth for hours or tirelessly march in place.

Collaborating with investigators at Duke University and the University of North Carolina in Chapel Hill, Dr. Keith Shafritz, an assistant professor of psychology at Hofstra University, unmasked brain regions in children with autism typified by reduced neural activity. In a series of high-tech mapping studies, he compared brain images of children with autism to those of neurologically normal youngsters.

Repetitive behavior is one of autism’s core traits and has driven some parents to extremes as they try to distract a child to engage in other activities.

Shafritz and colleagues used a form of magnetic resonance imaging _ MRI _ to explore sites in the brain. They report their findings in the current issue of Biological Psychiatry.

Mapping the brain constitutes a journey into the inner labyrinths of a 3-pound cosmos where countless frontiers have yet to be explored. In children with autism, Shafritz found deficits in specific regions of the cerebral cortex, the outer layer of gray matter linked to all higher human functions, including repetitive behavior. He also mapped deficits in the basal ganglia, a region deep below the cerebral hemispheres.

“We like to think about the research process as discovering clues why people engage in certain behaviors,” Shafritz said last week. “We were able to identify a series of brain regions that showed diminished activity when people were asked to alter certain behaviors, and were not able to do so.”

Autism is a neurodevelopmental disorder that is rapidly becoming a major public policy issue. Federal health officials estimate it affects 1 in every 150 children, impacting not only individual families but communities. School systems lack a sufficient number of appropriately trained teachers; social services departments are overwhelmed by parents in need of support and respite care.

Amid social concerns are the plodding attempts to understand the disorder’s basic biology. Some scientists are scanning the human genome in search of suspect DNA. Others like Shafritz, are exploring the geography of the brain.

Edward Carr, a psychology professor at Stony Brook University, said the Shafritz discovery is important because it helps demystify repetitive behavior.

“Repetitive behavior is sometimes called self-stimulatory behavior. A very common form of it is body rocking, a child will do it for hours,” Carr said. “Another child may wave his or her hands back and forth in front of their eyes. This is very common and it’s called hand-flapping. They extend their arms forward and wave their hands in front of them. It’s like a light show.

“Some kids will take 100 crayons and line them up over and over. If you move one of the crayons they get very upset. It might lead to a tantrum, a major outburst of problem behavior.”

Even though the brain mapping revealed sites associated with repetitious behavior, Shafritz emphasized these areas are not associated with injurious acts, which may occur as a result of dysfunctions elsewhere in the brain. Some children repeatedly slam their heads against a wall and indulge in other self-injurious behavior.

Still, Shafritz found a relationship between the newly identified brain areas and overlapping regions linked to schizophrenia, obsessive compulsive disorder and attention deficit hyperactivity disorder.

Dr. Anil Malhotra, director of psychiatric research at Zucker Hillside Hospital, said he is not surprised. He, too, is studying links between autism and schizophrenia, and autism and obsessive compulsive disorder.

“This is an area of great interest,” Malhotra said, adding that autism and schizophrenia are related because both disorders are marked by problems with social interaction.

“We also see an overlap between (obsessive compulsive disorder) and autism,” Malhotra said.

COLUMBUS, Ohio, May 27 /PRNewswire/ — The Ohio Association of Health Plans (OAHP) is pleased to announce the 2008 winners of its annual Pinnacle Awards, which recognize the efforts of Ohio’s health plans to improve the quality of health care for Ohioans.

“Health plans are a vital partner in Ohio’s health care system,” said Kelly McGivern, OAHP President and CEO. “Not only are these companies the source of a more than 51,000 insurance-related jobs for Ohioans and more than $2 billion in wages, they also create and implement innovative initiatives to improve the health of Ohioans and the efficiency of providing health care benefits. Unfortunately, these important contributions continue to go unrecognized by those outside of the health plan industry, so the Pinnacle Awards are one way we help highlight the important contributions these plans are making.”

This year’s winning programs included initiatives that optimized vaccinations to help reduce the severity infections in high risk infants, promoted better coordination of care for Medicaid consumers, established primary care medical services for consumers with behavioral health issues, and increased specific preventative care measures for high-risk pregnant mothers. The winners of the awards were as follows:

   Category:  Improvements in Business/Operational Performance   Winner:    CareSource, RSV Management: Process Improvements & Health               Outcomes    Category:  Community Outreach and Partnerships   Winners:   AMERIGROUP Community Care, Medical and Behavioral Health               Coordination for Medicaid Consumers              and              Buckeye Community Health Plan, Community Care: A Partnership in               Nurturing    Category:  Health Care Programs   Winner:    Buckeye Community Health Plan, 17-P    

OAHP invited all member plans to participate in the competition, which provided an opportunity for health plans to demonstrate what they are doing to provide exemplary care and service for their members and community. A panel of experts representing hospitals, doctors, businesses, consumer advocates, and regulators judged the submissions and selected the winners.

“The award-winning programs underscore the valuable role health plans play in providing quality health care for Ohioans, while helping to stimulating Ohio’s economy through innovations and jobs,” McGivern said. “Through programs that utilize medically-proven best practices to identify cost-saving measures, increase preventative care in high-risk populations and create opportunities for partnerships with providers, Ohio’s health plans not only improve access to care for Ohioans, but also ensure that the care they receive is of the highest quality possible.”

OAHP is a statewide trade association of companies providing health care benefits to more than 7 million Ohioans. The mission of the OAHP is to promote and advocate quality health care and access to a variety of affordable health care benefits for all Ohioans.

Ohio Association of Health Plans

CONTACT: Kelly McGivern, President and CEO of Ohio Association of HealthPlans, +1-614-228-4662, [email protected]

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

By P. Selvarani; Audrey Vijaindren

THEY are here to take care of our children and elderly parents, to cook and to clean. But some of these foreign domestic help may be doing us more harm than good, write P. SELVARANI and AUDREY VIJAINDREN.

You may think your maid’s doing a great job caring for your children or aged parents

But have you had a good look at her? Perhaps you should. In fact, it may be to your benefit to take her for a medical check-up.

This is because thousands of domestic maids are among the 42,000 foreign workers who entered the country last year with a host of diseases.

Ministry of Health statistics show that the workers had TB (16,697), hepatitis B (10,953) and syphilis (2,824).

Those who had HIV/AIDS numbered 683 while 147 were found to be suffering from psychiatric problems.

In addition, 2,329 workers were found to be pregnant.

Some 1.36 million legal foreign workers sought employment in Malaysia last year.

Dr Ramlee said the cases were detected through the Fomema medical screening, which all foreign workers have to undergo within a month of their arrival in Malaysia.

The screening was introduced three years ago after health officials here discovered that many foreign workers had infectious diseases although they had been declared medically fit by health authorities in their country.

But a number of these workers, especially maids, were also certified as disease-free by the Mal-aysian authorities.

The actual figure cannot be determined as no one is keeping track but complaints from employers are on the rise.

In fact, there is an increasing trend of employers sending maids for second-opinion medical tests because they do not trust the screening done in the country of origin and by Malaysian authorities.

Industry sources say that despite “stringent screening” by Fomema, the independent agency appointed by the government to monitor and supervise the mandatory health-screening programme, many unfit foreign workers continue to work here.

A doctor who spoke on condition of anonymity said some Fomema panel doctors were “certifying” foreign workers as fit without even physically examining them.

“Many employers, especially those in the manufacturing sector, do not want to suffer losses.

“If they bring in 60 workers and 20 of them are found to be medically unfit, they are not going to send the 20 back.

“They will work their way around the situation to obtain the medical clearance.

“I have seen foreign workers who were declared medically unfit working in some of these places.”

He said some clinics approved medical reports for a fee.

“This is why we have so many cases of infectious diseases such as malaria and tuberculosis, which had been eradicated or reduced decades ago.”

He said some Fomema-appointed labs were not doing the tests properly.

Another source said some employment agencies were making matters worse by “recycling” unfit workers instead of sending them back to their home country.

Health Ministry deputy director-general Datuk Dr Ramlee Rahmat said action would be taken against any doctor found to have falsified medical results.

He said 39 of the 3,432 Fomema panel clinics were suspended last year for various reasons, including the failure of doctors to examine foreign workers in their clinics and to verify the identity of foreign workers.

“We are not as worried about the legal foreign workers in the country as we are over the thousands of illegal workers here who may be carrying these highly-infectious diseases.”

Dr Ramlee said there was little chance of medically-unfit legal workers gaining legal entry into the country now because of Fomema’s strict entry requirements.

“Even if they present falsified documents from their host country, our medical tests here will detect them.”

However, he said, Fomema tests did not include screening for diseases such as herpes and hepatitis A and C.

“If it’s a case of non-sexually transmitted herpes or hepatitis which is not contagious, we do not include them in the compulsory medical check.

“We don’t look for these because they are not infectious.

“Our concern is more for the population at large and not just an individual employer or worker,” he said in response to the plight of employers who were saddled with medically-unfit maids.

The Malaysian Association of Foreign Maid Agencies said that although there were many rules in place, the qualification of panel doctors overseas was suspect.

Association vice-president Jeffrey Foo said: “There may be a lot of (deception) going on overseas.”

Dr Ramlee said before 2005, the ministry and its counterparts in Indonesia would accredit designated clinics in the republic to conduct medical tests for those applying to work in Malaysia.

“We randomly tested the workers at the point of entry and found that up to four per cent of the 10 per cent whom we tested did not pass our medical screening.

“But we could not act against their clinics for giving them the go-ahead.”

As a result, the ministry introduced a new system where every foreign worker had to undergo a second medical test within one month of entering the country. This test is repeated at the end of their first and second years of service.

“This has helped to weed out the problem of forged medical documents.”

Under this screening system, which is done at Fomema-appointed clinics, the worker is tested for infectious diseases such as HIV, TB and hepatitis. They are also screened for hypertension, heart disease, asthma and diabetes.

Dr Ramlee said Fomema was stringent in its medical examination and would not accept any foreign worker who had even the slightest hint of carrying a highly-infectious disease.

“Even someone whose X-ray screenings reveal old TB scars and who does not appear to have the disease will be rejected. We cannot take chances as the disease can flare up again.”

FAMILIES PAID THROUGH THE NOSE, AND NOW PAY DEARLY FOR IT

AFTER having two maids with medical problems within two months, Jason thought he would be third-time lucky.

Instead, the help turned out to be a nuisance. Her unreasonable attitude and actions led him to suspect that she was mentally unstable.

“It was the last straw for me, especially so soon after having one maid who had hepatitis C and another who had a lung infection,” said the 32-year-old businessman from Puchong, Kuala Lumpur

Jason’s problems began when, in anticipation of the arrival of their third child, he and his wife applied for a new domestic maid early this year to replace the one who was leaving.

“When the first maid arrived on March 4, we were happy with her until we received a call from the agency five days later saying that she had failed her medical test because she had hepatitis C.”

The agency offered to replace the maid with another and Jason picked up the second maid on March 10.

“We had her for about three weeks when we noticed that she tired easily. She would turn pale after doing heavy chores and even her breathing was laboured.”

He took the maid for a second medical test, although she had been given a clean bill of health by the authorities.

The X-ray revealed that she had a lung infection and half her lungs were badly scarred.

“The doctor told me that there was an old and new infection. How could this have gone undetected, considering the maid had supposedly had an X-ray taken in Indonesia and another one here?”

Jason’s woes got worse when the third maid began to act up, causing much distress to his wife who was eight months pregnant.

“We are now without a maid and I feel so cheated because we have been given one problematic maid after another despite paying so much for these maids.”

Ong, also of Puchong, was just as unlucky. His two maids tested positive for herpes.

The first maid arrived in October, after being certified medically fit by the Indonesian authorities and Fomema.

To be doubly sure, Ong sent her for an independent blood test and X-ray. The results showed she had herpes types 1 and 2.

“I informed the maid agency and wrote to Fomema in November highlighting the discrepancy in the medical report.

“Fomema said she was medically unfit and the agency agreed to give a replacement maid.”

When the second maid arrived in February, Ong sent her for a medical test.

She also tested positive for herpes type 1.

“But what was frustrating was that the maid agency initially said it could not replace the maid or ensure that any future maid I got would be free of herpes.”

The Malaysian Association of Foreign Maid Agencies could not give Ong an assurance about the medical condition of foreign maids either.

“I am now afraid to get another maid… A lot of people are not aware of the need to have a second medical test done.

“I do not understand why the authorities cannot include all types of herpes and other medical problems in the health screening.”

Ong has now opted to hire a babysitter for his children.

MCA WANTS MORE TESTS FOR DISEASES

MCA public service and complaints department head Datuk Michael Chong never fails to give this advice to maid employers: “Send your maid for an independent medical check-up as soon as you bring her home, even though she has been given a clean bill of health by the authorities.”

Chong’s department has received three complaints of medically- unfit maids this year.

Last year, the department received four complaints, one of which was about a maid who was found to have lupus eight months after she had started work here.

(Systemic lupus erythema-tosus or SLE is a chronic auto-immune disease that can be fatal.

It attacks the body’s cells and tissue, resulting in inflammation and tissue damage.)

In most of the other cases, the maids were reported to have herpes or hepatitis.

“I don’t understand why this happens.

“The medical report from the source country says the maids are medically fit and then they are also cleared by Fomema.

“But when their employers send them for an independent test, they are found to be carrying diseases which should have been detected during these tests.

“So, how do these cases escape their attention?

“Granted, herpes may flare up now and then so it may not be that easy to detect. But what about hepatitis, TB or venereal diseases?

“That (the reports not indicating these infections) is difficult for me to accept.

“This is worrying, more so when you have maids with infectious diseases such as tuberculosis, herpes or hepatitis, caring for children or elderly folk.

“So, who do you blame? The Indonesian authorities or us?”

But Chong was generally pleased with the stringent requirements of Fomema which, he said, would not compromise on the health of the foreign workers despite appeals.

He said he had had a few run-ins with the agency over this.

“We had cases where the family was willing to retain a maid who had a previous infection or illness but Fomema was adamant about rejecting the application on the grounds that the disease could flare up.”

However, he said, the fact that there were many legal foreign workers walking around with infectious diseases showed that the medical tests were not entirely fool-proof.

“To overcome this, I think the Ministry of Health should consider including tests for more diseases and ailments in the foreign workers’ medical examination.”

Meanwhile, the Human Resources Ministry advised employers who had problems with their maids or maid agencies to file complaints with its manpower department.

The department’s deputy director-general, Sheikh Yahya Sheikh Mohamed, said in many cases, unfit maids were supplied by unlicensed agencies.

LOSING YOUR MIND OVER THEIR MENTAL HEALTH

WITH more than 12 years of experience as the managing director of a maid employment agency in Subang Jaya, Selangor, Teresa Tong has learnt that mental illness can be more dangerous than physical diseases.

“Most employers ask about the physical health of a foreign domestic help, but they fail to think about the mental health of the maid they are going to get.

“There have been many cases where I have had to send back four out of five maids because they were mentally unstable. This type of illness is difficult to detect,” said Tong.

Some of these maids, she said, also viewed their two-year contract in Malaysia as a jail sentence and could crack under pressure.

But in the last two years, she has seen more stringent testing by Fomema.

“Lately, Fomema has been strict with its health-screening tests. It includes psychiatric illness in its list. But a lot of times most illnesses don’t flare up until much later.”

Hepatitis A and C, she said, were two common diseases that employers were concerned about.

She said most foreign domestic help failed the chest X-ray examination during the Fomema screening examination.

Malaysian Association of Foreign Maid Agencies vice-president Jeffrey Foo said: “There is no full-proof system. If you ask a doctor to perform a test, you expect him to be ethical. What more can you do?”

Asked about herpes being a cause for worry among employers, Foo said: “The herpes issue has been brought up many times by the association. It is not new to us.

“We have received many complaints about this disease. But it is still not included in the health screening list. Why?

“If it is a contagious disease, it should be included in the list, unless the Ministry of Health can assure the public that herpes is not a contagious disease.

“The ministry should be protecting Malaysians.”

FOMEMA SILENT ON GROUSES

SO what does Fomema have to say about the complaints?

A spokesman said it could only talk if it got the green light from the Health Ministry.

The following information taken from Fomema’s website answers some questions from employers.

One reply is about inconsistent medical reports.

Fomema said doctors who were not on their panel for the foreign workers’ health-screening programme may not have the criteria for certification for suitability for employment in this country.

It said a doctor may have the opinion that the worker was fit to work despite having detected the likelihood of a communicable disease.

In such cases, the benefit of the doubt is given to the country and not the worker.

On the possibility of tests performed on one patient by different doctors yielding conflicting results, Fomema said this could happen when X-ray findings or lab test results showed abnormalities.

In such cases, the worker’s status will be amended to “unsuitable” upon investigation.

(c) 2008 New Straits Times. Provided by ProQuest Information and Learning. All rights Reserved.

SAN JOSE, Calif. — When Barbora Bell wanted to have kids, she ditched the birth control pills, popped prenatal vitamins, and got more iron and calcium. Her husband’s pre-conception regimen was much easier: “He had a glass of wine,” Bell said, laughing.

The Los Gatos, Calif., couple didn’t hear a single dietary suggestion to help prospective fathers have healthy kids. If they had, Bell said, “we would have been doing it.”

Women contribute just half their children’s genes. Yet would-be dads are rarely bombarded with pre-pregnancy tips on diet missteps and toxic exposures, even though sperm DNA is vulnerable to defects that can cause possible health problems for their children.

There’s a growing push to better understand the male half of reproductive health. New technologies are allowing scientists to delve further into male fertility. Dads’ role in birth defects was the focus of a symposium this year at the American Association for the Advancement of Science meeting. And a recent University of California-Berkeley study was the first to link men’s diets to sperm DNA errors.

But much of this information never makes it to men.

The relative silence reflects a cultural reluctance to question men’s virility and potency, said Cynthia Daniels, a Rutgers University professor who studies the crossroads of science and culture.

“We assume the male reproductive system is like a simple machine,” Daniels said. Men’s role in fertilization seems so straightforward, it’s easy to forget things can go wrong with sperm DNA, she said. And there’s an assumption that defective sperm isn’t strong enough to get the job done anyway.

But some defective sperm do succeed in fertilizing eggs, potentially causing birth defects or childhood disease. One in 33 California children is born with a birth defect. And scientists still don’t know what causes most defects.

Despite the unanswered questions, there’s relatively little research on prospective fathers.

“People in the field have had a great deal of difficulty getting funding,” said Gladys Friedler, an emeritus professor of Boston University’s medical school. Throughout her career from the 1960s to the 1990s, Friedler often was told to abandon studies of male reproduction on the grounds that such research was unnecessary, she said.

A small amount of research has trickled out over the decades. Pesticides were scrutinized after Vietnam War veterans exposed to Agent Orange fathered many children with spina bifida. Older men’s sperm was found to have more DNA errors that cause dwarfism. And men who received chemotherapy for testicular cancer temporarily produced defective sperm, which could cause problems if conception occurred too soon after treatment.

In March, UC-Berkeley added to the growing knowledge. In a study utilizing new technology to label sperm DNA, men who ate little folate, a B-vitamin abundant in orange juice and green veggies, had more sperm with the wrong number of chromosomes. That could lead to miscarriages and birth defects like Down syndrome.

The study didn’t pinpoint an ideal folate dose, said author Brenda Eskenazi. “But we can still advise that men considering fathering a child should take a multi-vitamin and get enough leafy green vegetables,” she said.

Sperm develop over 10 weeks, giving men a defined window before conception to make healthier sperm, said San Jose urologist David Nudell. Women, in contrast, are born with a finite number of eggs. This means men’s genes, constantly dividing into new sperm, may be even more vulnerable than women’s.

Unlike women who often take vitamins while cutting out caffeine, sushi and pedicures before trying to conceive, “I’ve never seen a guy come in and say, `I started this three months before we tried,’ ” Nudell said. “It’s how our society is about getting pregnant.”

One reason for the uneven information is that most women can regularly ask for advice at their annual ob-gyn visits.

“Most men in their 20s and 30s are probably not seeing doctors at all,” Nudell said. “Who are they going to ask?”

But men are beginning to wake up to the problem, said professor Daniels.

“Younger men are quite incensed that these issues have not been addressed,” she said. “I’m hopeful that we might have raised a generation of young men willing to open their eyes, look at the evidence, and ask the questions that need to be answered.”

Because the science of male fertility is sparse, Nudell gives common-sense advice to the few men who bother asking about pre-conception health: avoid heavy alcohol and drug use, take vitamins and stop smoking _ even though studies of those lifestyle factors have been inconclusive.

And he emphasizes that couples having trouble conceiving should get both partners checked out. “A lot of women get unnecessary treatments,” he said. “Men are generally not that proactive about their health.”

That’s even true for devoted dads who attend every prenatal appointment.

“I didn’t talk to my doctor at all,” said Los Gatos father Dave Dooley, who fondly remembers his wife’s pregnancy ultrasounds. Like most couples, Dave and Melissa Dooley, whose children are now 4 and 2, assumed only mothers needed to consider pre-pregnancy health.

“We’re the ones who have to deal with the nine months,” said Melissa Dooley.

By Daniel Barbarisi

Rhode Island Hospital currently has a helipad one block away in a parking lot.

PROVIDENCE — Medical helicopters might soon touch down on the roof of Rhode Island Hospital, bringing patients to the emergency room faster and likely luring more helicopters to land there, rather than flying over on their way to Massachusetts hospitals.

The hospital has a helipad now, but it is a block away in a surface parking lot. When a helicopter lands, the hospital must close several streets and call an ambulance to bring the patient from the helicopter to the emergency room. The transfer takes 15 minutes, an eternity when dealing with the types of severe cases the helicopter brings in.

The hospital plans to build a helipad on the roof of one of its main buildings, cutting the transfer time to only a couple minutes. A ramp will lead from the pad to the elevator used by the so-called trauma alley.

“We have a trauma elevator that goes right into trauma alley, or into the [operating room],” said Charles Olmstead, director of shared services for the hospital.

Reducing the time it takes to transfer a patient from a chopper to the emergency room should result in more helicopter landings at the hospital, hospital officials say.

Helicopters are used for rapid transport in heart cases and life- threatening trauma. Helicopters are also used to fly in organs for transplants.

The hospital is served by four private helicopter companies and the Coast Guard. As the only level-one trauma center in Rhode Island, the hospital draws many helicopters from southern Rhode Island and Southeastern Massachusetts and Connecticut — but some helicopters pass over Rhode Island Hospital and take patients to hospitals in Massachusetts instead.

The flight surgeon determines where the helicopter should land, depending on the severity of the injury or illness, each hospital’s specialties and the time and distance involved.

Hospital spokeswoman Nancy Cawley said Rhode Island Hospital now lands one or two helicopters weekly. The hospital expects that number to rise with the new helipad.

“All five of the helicopter transport agencies thought this would be a huge improvement and because of that, we anticipate a higher usage,” Cawley said.

That’s consistent with the hospital’s goal of becoming more of a regional medical center. The helipad and the emergency department are in the Bridge Building, a brick structure built in 2005 over Dudley Street at a cost of $70 million.

“It fits with our mission. We want to be out there in the forefront of patient care,” Olmstead said.

The 54-foot-by-54-foot helipad will sit six feet off the roof and cover one-fifth of the roof of the Bridge Building, two stories above street level. It will feature an advanced fire suppression system and five feet of safety netting around each side.

The construction plan required an exemption on the number of exits used, which the hospital received from the Providence Building Board of Review on Thursday. Approval from the state fire marshal is still required, as are building permits from the city. None of those is expected to be a roadblock.

If the permitting process begins soon, the pad could be landing helicopters by early fall. The helipad would cost roughly $1 million to construct, Cawley said.

The location of the current helipad also makes for difficult landings — helicopters must fly over the site and then drop nearly straight down to the pad. The new helipad will allow for a more gradual landing, Olmstead said. [email protected] / (401) 277- 8062

Originally published by Daniel Barbarisi, Journal Staff Writer.

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

NOT FOR DISSEMINATION IN THE UNITED STATES OF AMERICA

Echelon Capital Corporation (“Echelon”)(TSX VENTURE: ECO.P), a capital pool company, is pleased to announce that it has entered into a letter agreement to complete a business combination (the “Qualifying Transaction”) with MBVax Bioscience Inc. (“MBVax”). If completed, the business combination will constitute Echelon’s qualifying transaction pursuant to the policies of the TSX Venture Exchange (the “Exchange”).

Information Concerning Echelon

Echelon is a company existing under the laws of Ontario and is a reporting issuer in British Columbia, Alberta and Ontario. Echelon currently has 2,360,000 common shares (“Echelon Shares”) outstanding, of which 1,160,000 are currently held in escrow pursuant to the policies of the Exchange.

Echelon has granted stock options to acquire up to an aggregate of 188,800 Echelon Shares at a price of $0.25 per share (the “Echelon Options”) to directors and officers. Echelon has also issued broker warrants to acquire up to an aggregate of 100,000 Echelon Shares at a price of $0.25 per share (the “Echelon Warrants”) as part of the compensation payable to the agent in connection with Echelon’s initial public offering. Other than these Echelon Shares, Echelon Options and Echelon Warrants, no other securities of Echelon are outstanding.

Further information concerning Echelon can be found in the prospectus of Echelon dated June 14, 2007, which is available on SEDAR at www.sedar.com.

Information Concerning MBVax

MBVax is a private company existing under the laws of Canada. MBVax currently has 4,829,376 common shares (“MBVax Shares”) outstanding. MBVax has no other securities outstanding.

MBVax manufactures Coley Fluid, a bacterial immune therapy for advanced cancer developed in 1893. Coley Fluid is not an approved therapy in the United States or Canada, but is a legal therapy in many countries. Clinics and hospitals approved to use Coley Fluid are located in Austria, Bahamas, China, Germany, Ireland, Israel, Mexico, Serbia, South Africa, Switzerland and Uzbekistan. In addition, individual patients have received Coley Fluid therapy as a compassionate therapy for advanced cancer in Albania, Australia and the United States.

Patients with advanced cancer have end-stage disease that can no longer be controlled by conventional therapies. Of the more than 650,000 annual cancer deaths in the United States and Canada, all 650,000 patients have advanced cancer prior to death. In addition to progressive cancer, most advanced cancer patients also have an extremely poor quality of life due to cancer pain, depression, extreme weakness, and/or immobility. By definition, there are no current treatments that regress the disease or improve the quality of life in advanced cancer patients.

To date, 44 advanced cancer patients have received between three weeks and 10 months of MBVax Coley Fluid therapy. Generally, these patients had severely compromised immune systems due to previous therapies and all were treated on a compassionate basis rather than in connection with a controlled clinical study. Physicians reported to MBVax that 42 of 44 patients appeared to benefit from the therapy and the majority of such patients experienced tumor regression. In three cases of advanced breast cancer, patients currently show no evidence of breast cancer.

During its long history, more than twenty formulations of Coley Fluid have been administered to patients by various manufacturers. These formulations used different proportions of the bacterial ingredients used in the manufacture of Coley Fluid and employed various methodologies to grow the bacteria and to sterilize the finished product. There were significant differences in potency between the various historical formulations and there were also variations in potency between batches of identical formulations.

MBVax’s intellectual property (United States patent application 2006/0292173, published December 28, 2006) protects its proprietary methods of manufacturing MBVax Coley Fluid. These methods eliminate batch-to-batch variations and ensure equivalent potency to the best historical formulation of Coley Fluid. MBVax plans to file more patents. In addition, because Coley Fluid targets orphan indications, MBVax plans to file for marketing exclusivity with the FDA.

In 2009, MBVax plans to commence clinical trials in Denmark, Germany, Switzerland, Canada, and in the United States at Harvard Medical School. It is anticipated that the planned clinical trials will be conducted with research collaborators who will bear all or most of the clinical trial costs.

Based on unaudited financial statements for the six months ended March 31, 2008, MBVax had total assets of $141,998 (2007 – $191,900) and total liabilities of $13,998 (2007 – $15,032), revenue of $143 (2007 – $5,152) and a loss of $48,868 (2007 – $95,909).

Based on audited financial statements for the year ended September 30, 2007, MBVax had total assets of $191,900 (2006 – $354,148) and total liabilities of $15,032 (2006 – $8,776), revenue of $7,720 (2006 – $8,507) and a loss of $168,504 (2006 – $235,131).

The MBVax Shares are principally held by Donald MacAdam and Rick Durst, both residents of Ontario, and Stephen Hoption Cann, a resident of British Columbia, each of whom holds 1,300,000 (26.9%), 937,800 (19.4%) and 600,000 (12.4%) MBVax Shares, respectively. The remaining 41.3% of the shares are held by 43 people who are investors or advisors to MBVax.

Information Concerning the Proposed Qualifying Transaction

Echelon and MBVax have entered into a letter agreement dated May 23, 2008 (the “Letter Agreement”) setting out certain terms and conditions pursuant to which the proposed Qualifying Transaction will be completed. The Qualifying Transaction is subject to the parties successfully negotiating and entering into a definitive amalgamation agreement, share exchange agreement or other similar agreement such that the Qualifying Transaction may be completed on a tax preferred basis to the parties thereto.

Pursuant to the Letter Agreement, Echelon has agreed to issue 10,000,000 Echelon Shares to the current shareholders of MBVax at a deemed value of $0.33 per share in consideration for the MBVax Shares.

The completion of the Qualifying Transaction is also subject to an arm’s length financing of a minimum of $2.0 million (the “Financing”). It is anticipated that under the Financing, MBVax will issue a minimum of 5,000,000 subscription receipts at a price of $0.40 per subscription receipt, with each subscription receipt being exchangeable upon completion of the Qualifying Transaction for one common share and one-half of one common share purchase warrant of Echelon (or the resulting issuer, as the case may be). Each whole warrant will be exercisable to acquire one common share of Echelon (or the resulting issuer, as the case may be) at a price of $0.50 per share for a period of two years from closing of the Financing. The proceeds from the Financing will be placed in escrow pending the closing of the Qualifying Transaction. The final negotiated terms of the Financing will be disclosed in a subsequent press release of Echelon and in the filing statement or management information circular, as the case may be, to be prepared by Echelon in respect of the Qualifying Transaction.

Assuming the completion of the minimum Financing and the Qualifying Transaction, current Echelon shareholders, current MBVax shareholders and purchasers pursuant to the Financing would hold approximately 13.6%, 57.6% and 28.8% of the then outstanding Echelon Shares (or shares of the resulting issuer), respectively.

The proceeds of the Financing will be used to fund the production of product for the multi-center clinical trial of the MBVax Coley Fluid and for working capital purposes.

The completion of the Qualifying Transaction is subject to the approval of the Exchange and all other necessary regulatory approvals. It is also subject to additional conditions precedent, including shareholder approvals of Echelon and MBVax as required under applicable corporate or securities laws, satisfactory completion of due diligence reviews by both parties, approvals of the boards of directors of Echelon and MBVax and certain other conditions customary for transactions of this nature.

Trading in the Echelon Shares will remain halted pending the review of the proposed Qualifying Transaction by the Exchange. There can be no assurance that trading in the Echelon Shares will resume prior to the completion of the Qualifying Transaction.

Sponsor

The proposed Qualifying Transaction is subject to the sponsorship requirements of the Exchange. The parties intend to apply for an exemption from the sponsorship requirements of the Exchange on the basis that the Financing will be brokered. In the event that an exemption is not available, a sponsor will be identified at a later date and will be announced in a subsequent press release of Echelon. An agreement to sponsor should not be construed as an assurance with respect to the merits of the transaction or the likelihood of completion of the proposed Qualifying Transaction.

Management and Board of Directors of Resulting Issuer

Upon completion of the Qualifying Transaction, it is anticipated that management of the resulting issuer will consist of the persons identified below.

Donald MacAdam – President, Chief Executive Officer and Director

Mr. MacAdam has served as President and Chief Executive Officer of MBVax since October 2005. Prior to that, Mr. MacAdam was the President of A360 Inc, a private company. Mr. MacAdam has served as a director of Hammond Power Solutions Inc. (TSX: HPSA) since 2001. Mr. MacAdam has served as Chief Executive Officer and a director of several other Canadian corporations, and was President and Chief Financial Officer of CRS Robotics Corporation (TSX: ROB) from 1993 until 1996, and was President and Chief Executive Officer of Tm Bioscience Corporation (TSX: TMC) from 1996 until 1999, and was President and Chief Executive Officer of L. A. Varah Ltd. (TSX) from 1984 until 1986. He is the inventor of several patents and the author of two books: Spontaneous Regression: Cancer and the Immune System and Startup to IPO: How to Build and Finance a Technology Company. Stephen Hoption Cann, Ph.D. – Chief Scientific Officer

Mr. Hoption Cann, Ph.D., is an assistant professor in the Department of Health Care & Epidemiology at the University of British Columbia. Dr. Hoption Cann has published 23 peer-reviewed papers, is a reviewer for several medical journals, and is a member of the American Association for Cancer Research. His research interests include the epidemiology of cancer, the phenomenon of spontaneous regression of cancer, and the work of Dr. William Coley.

David Wales, CMA – Chief Financial Officer

Mr. Wales, B. Comm., CMA, has held a number of high-level positions in finance including senior roles at Tm Bioscience Corporation (TSX: TMC) and CRS Robotics Corporation (TSX: ROB). In addition to extensive financial experience, Mr. Wales is highly proficient in corporate infrastructure development and business system implementation.

John Unsworth – Director

Mr. Unsworth is president of Vasotech Corp., a medical devices company. A biotechnology entrepreneur, Mr. Unsworth was formerly president of BioFrost Inc. and Hypercube Inc., and was a founder and director of GLYCODesign Inc (formerly listed on the TSX).

Ted Mayers – Director

Mr. Mayers is the Executive Vice President, Business Development of GBS Gold International Inc. (TSX: GBS). He served on its board of directors from August 2005, as a founding director, to May 2008 and as Chair of the Audit Committee until August 2006. Immediately prior to his executive appointment at GBS Gold in October 2007, Mr. Mayers served as Chief Financial Officer of LionOre Mining International Limited, from its inception in 1996 to its sale to Norilsk Nickel for $6.9 billion in 2007. LionOre was listed on the TSX, the Australian Stock Exchange, and on the Main Market of the London Stock Exchange. From September 2000 to August 2005, Mr. Mayers served as a director of Zaruma Resources Inc. and as Chair of its Audit Committee. Zaruma is an emerging copper producer listed on the TSX. Mr. Mayers is a Chartered Accountant and obtained an MBA from the University of Western Ontario. Mr. Mayers has a BSc in biochemistry from McGill University, and on graduation, conducted research at McGill in the laboratory of Dr. Murray Fraser on enzymes that split DNA.

John Eckert – Director

Mr. Eckert is the President and Chief Executive Officer and a director of Echelon, and the co-founder of McLean Watson Capital Inc., a Canadian based venture capital firm, funding high-growth entrepreneurial ventures. He has been a Managing Partner of McLean Watson Capital Inc. since October 1993. Prior to establishing McLean Watson Capital Inc., Mr. Eckert financed and advised Softimage Inc., a Montreal based 3D animation and post-production software company that was listed on NASDAQ in 1992 and sold to Microsoft Corporation in 1994. He served as the Joint Chief Operating Officer for Softimage Inc. from 1993 to its sale. Prior to 1992, Mr. Eckert had extensive experience in corporate finance, having served as a Vice President and Director in Corporate Finance and Capital Markets of Wood Gundy Inc. and CIBC Wood Gundy in Canada. He also served as Managing Director of CIBC Wood Gundy (Australia), a merchant bank. Mr. Eckert served on the board of the Canadian Venture Capital Association for five years, having previously held the positions of President (2000-2002) and Chairman (2002-2003). He also serves on the boards of directors of several private companies, including SkyWave Mobile Communications, SiteBrand.com Inc., Activplant Corporation and Fortiva Inc. Mr. Eckert holds a B.A. and an M.B.A from the University of Western Ontario.

Immunology Expertise

In addition to the proposed management of the resulting issuer following completion of the Qualifying Transaction, it is anticipated that the following individuals will form the Scientific Advisory Board of the resulting issuer:

Eric D. Brown, Ph.D., is an associate professor and holds the Canada research chair in microbial biochemistry at McMaster University, Hamilton, Ontario, and has published 26 scientific papers in peer-reviewed journals.

Jack Gauldie, Ph.D., is chairman of pathology and molecular medicine at McMaster University. Dr. Gauldie is a fellow of the Royal Society of Canada and recipient of the Canadian Medical Association medal of honour.

Peter N. Green, Ph.D., F.I. Biol., is Curator of the National Collection of Industrial and Marine Bacteria (NCIMB), the largest public service collection of bacteria in the United Kingdom. Dr Green has 31 peer-reviewed publications.

Thomas E. Ichim, Ph.D., is Chief Executive Officer Medistem Laboratories Inc, a stem cell therapy company. Dr. Ichim is an immunologist and has been extensively published in the fields of cell therapy and immunology.

Michael J. Lane, Ph.D., is a professor at SUNY – Upstate Medical University in Syracuse, New York. Dr. Lane was a founder of Genmap, Inc., of New Haven, CT, and Tm Bioscience Corporation, Toronto, Canada.

Xiang-Dong Lei, Ph.D., is a molecular biologist. Dr Lei has published 15 peer-reviewed papers, and was head of cancer vaccine development at a leading biotechnology company.

Liping Liu, Ph.D., is a bioorganic chemist with 19 peer-reviewed papers. Dr. Liu led a team of researchers that discovered more than one thousand novel tumor associated antigens in three years.

Johannes van Netten, Ph.D., is adjunct associate professor at the University of Victoria; director of research, Special Developmental Laboratory, Royal Jubilee Hospital; and a member of the consulting staff, Vancouver Island Cancer Centre, British Columbia Cancer Agency.

In addition to the proposed Scientific Advisory Board of the resulting issuer following completion of the Qualifying Transaction, it is anticipated that the following individuals will form the Clinical Advisory Board of the resulting issuer:

Leonid Bajenov, Ph.D., M.D., is a professor at the Vakhidov Research Center, Tashkent, Republic of Uzbekistan. Dr. Bajenov has published more than 300 scientific works, and is currently conducting clinical trials of Coley Fluid.

Zuhal Butuner, O.D., MSc, MBA, is a clinical and regulatory advisor. Previously Senior Clinical Program Manager at Biogen Inc., she led and managed the team responsible for obtaining FDA approval for the drug Avonex(R).

Peter Coy, M.D., is a retired radiation oncologist and formerly clinical assistant professor at the University of British Columbia. Dr. Coy was chair of the lung cancer sub-committee of the National Cancer Institute of Canada Clinical Trials Committee.

Hal Gunn, M.D., is co-founder of InspireHealth, Vancouver. Dr. Gunn is an authority in the field of bacterial cancer vaccines, and has a clinical appointment with the University of British Columbia School of Medicine.

Kenneth Wilson, M.D., is a medical oncologist at the Vancouver Island Cancer Centre and a clinical associate professor at the University of British Columbia. Dr. Wilson has published more than 150 papers and communications.

As noted above, completion of the Qualifying Transaction is subject to a number of conditions, including, but not limited to, acceptance by the Exchange. The Qualifying Transaction cannot close until the required approvals have been obtained. There can be no assurance that the Qualifying Transaction will be completed as proposed or at all.

Investors are cautioned that, except as disclosed in the filing statement or management information circular of Echelon to be prepared in connection with the proposed Qualifying Transaction, any information released or received with respect to the proposed Qualifying Transaction may not be accurate or complete and should not be relied upon. Trading in the securities of Echelon should be considered to be highly speculative.

This press release contains projections and forward-looking information that involve various risks and uncertainties regarding future events. Such forward-looking information can include without limitation statements based on current expectations involving a number of risks and uncertainties and are not guarantees of future performance of Echelon or MBVax. These risks and uncertainties could cause actual results and Echelon or MBVax’s plans and objectives to differ materially from those expressed in the forward-looking information. Actual results and future events could differ materially from those anticipated in such information. These and all subsequent written and oral forward-looking information are based on estimates and opinions of management on the dates they are made and expressly qualified in their entirety by this notice. Echelon assumes no obligation to update forward-looking information should circumstances or management’s estimates or opinions change.

The Exchange has in no way passed upon the merits of the proposed Qualifying Transaction and has neither approved nor disapproved the contents of this release.

 Contacts: Echelon Capital Corporation John Eckert President and Chief Executive Officer (416) 363-2000  MBVax Bioscience Inc. Donald MacAdam President (905) 304-8680  

SOURCE: Echelon Capital Corporation

A British study suggests that men routinely exposed to chemicals found in paint may be more likely to experience fertility problems.

The research found that men, such as painters and decorators, who work with glycol solvents are two-and-a-half times more likely to produce lower levels of “normal” sperm.

The study, a joint research project between the Universities of Manchester and Sheffield, examined more than 2,000 men attending 14 fertility clinics. The research found identified a wide variety of other chemicals that did not impact fertility.

In the study, the scientists examined two groups of men attending fertility clinics –those with sperm motility problems, and those without them. There had been previous concerns that exposure to many workplace chemicals might affect a man’s fertility, of which sperm motility is a critical variable.

The men were surveyed about their lifestyles, occupations and potential exposure to chemicals. The researchers found a 250% increase in risk of sperm motility issues among the men exposed to glycol ethers, chemicals widely used as solvents in water-based paints. This risk existed even after considering other lifestyle factors, such as smoking, testicular surgery, wearing tight underpants and manual work.

“We know that certain glycol ethers can affect male fertility and the use of these has reduced over the past two decades,” Dr Andy Povey of University of Manchester told BBC News.

“However, our work suggests they are still a workplace hazard and further work is needed to reduce such exposure,” he said.

However, the study found that this was the only chemical linked to fertility problems in men, which should put men’s minds at ease, said Dr Allan Pacey, a Sheffield University fertility specialist.

“Infertile men are often concerned about whether chemicals they are exposed to in the workplace are harming their fertility,” he told BBC News.

“Therefore it is reassuring to know that on the whole, the risk seems to be quite low.”

—

On the Net:

Occupational and Environmental Medicine

Health and Safety Executive

British Fertility Society

The international NoNoma Federation launched a worldwide campaign Thursday to create awareness about Noma, a condition that permanently deforms the faces of undernourished children.

The disease strikes an estimated 140,000 poor people every year, mainly in Africa, according to the World Health Organization (WHO).  Up to 80 percent of victims die from the gangrenous infection, while survivors are left with deep holes in their faces, unable to speak, eat, smile or breathe normally. The epicenter of the disease is Sub-Saharan Africa, but parts of Asia and Latin America are also affected.

Organizers who launched the first Noma Day said their goal is to eliminate the obscure disease. 

“We are bringing this scourge — unacceptable in the 21st century — out from the shadows,” Bertrand Piccard, president of the International NoNoma Federation, said during a presentation to experts. Piccard, a Swiss psychiatrist, is well known as the first hot-air balloonist to travel the globe in 1999 with Briton Brian Jones.

Noma is directly linked to malnutrition and poor hygienic conditions. If diagnosed early it can be effectively treated with vitamins, antibiotics and disinfecting mouthwash.

The disease epitomizes the breach between the world’s poor, starving populations and extravagant consumer societies, Piccard said. 

The destructive necrosis begins as a benign lesion in the mouth, often as gingivitis. But without treatment, it rapidly destroys the soft and bone tissues of the face, disfiguring victims that in most cases are very young children.

Luis Gomez Sambo, WHO’s regional director for Africa, reported that 22 countries on the continent had confirmed cases of Noma, of which WHO is able to support national prevention programs in only 12. With a budget of only $2.5 million over five years, the United Nations agency is inadequately funded for the task, he said.

“The world has no excuse to remain passive against this disease which disfigures victims beyond recognition. They go through psychiatric trauma for the rest of their lives,” Sambo told the audience, according to a Reuters report.

Razak Zampaligre and Soare Ouango, from Burkina Faso, are among the more fortunate Noma victims. With reconstructive surgery, both men survived but still bear scars. Zampaligre, who developed Noma as a two-year-old, recalled being “an object of mockery” as a child because of the deformity in his right eye. With the help of the “Hymne aux Enfants” foundation he received surgery in Switzerland as a teenager in 2000-01.

“It is a great joy for me to see that people are interested in this disease and are working to stop it,” he told Reuters.

CAMP HILL, Pa., May 22 /PRNewswire/ — Highmark Medicare Services will begin processing Medicare Part A claims in New Jersey on September 1, 2008 and Part B claims on November 14, 2008. In October 2007, the Centers for Medicare & Medicaid Services awarded Highmark Medicare Services the Jurisdiction 12 (J12) Medicare contract to provide the Medicare Fee-for-Service Part A and Part B administrative services for the states of Pennsylvania, Maryland, New Jersey, Delaware and the District of Columbia. The award is part of a Congressional requirement to replace all current Medicare Part A and B contracts with new contract entities called Medicare Administrative Contractors (MACs).

In fiscal year 2007, Highmark Medicare Services processed about 48.8 million claims and served approximately 2.3 million beneficiaries and 57,000 providers. As the MAC for J12, Highmark Medicare Services is expected to process approximately 131 million claims annually, accounting for more than 11 percent of the national Medicare fee-for-service workload. Highmark Medicare Services will be working on behalf of approximately 4.2 million beneficiaries and 137,000 physicians and practitioners.

As a MAC, Highmark Medicare Services will serve as a single point-of-contact entity processing Medicare Part A and B claims from hospitals and other institutional providers, physicians and other practitioners within the J12 region. Highmark Medicare Services currently administers the Medicare Fee-for-Service Part A business for Pennsylvania, Maryland, and the District of Columbia, and the Part B business for Pennsylvania.

“As this work transitions from other contractors to Highmark Medicare Services, we are committed to making this as seamless as possible for Medicare beneficiaries and health care providers,” said Patrick Kiley, president of Highmark Medicare Services. “We understand that one of the keys to accomplishing this is through timely and direct communications by the MAC and timely response by those who need to react to changes due to the transition.”

If you have any questions related to the transition or Highmark Medicare Services, visit http://www.highmarkmedicareservices.com/.

   About Highmark Inc.   Highmark Medicare Services is a wholly owned subsidiary of Highmark Inc.  

Highmark Inc. is a major force for Pennsylvania’s economy. According to a Tripp Umbach study, Highmark has a $2.5 billion impact on the economy and that includes about 11,000 employees of Highmark in Pennsylvania. Overall, Highmark and its subsidiaries have 19,000 employees.

As one of the leading health insurers in Pennsylvania, Highmark Inc.’s mission is to provide access to affordable, quality health care enabling individuals to live longer, healthier lives. Based in Pittsburgh, Highmark serves 4.6 million people through the company’s health care benefits business. Highmark contributes millions of dollars to help keep quality health care programs affordable and to support community-based programs that work to improve people’s health. Highmark exerts an enormous economic impact throughout Pennsylvania. The company provides the resources to give its members a greater hand in their health.

Highmark Inc. is an independent licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Highmark Medicare Services

CONTACT: Leilyn Perri of Highmark Inc., +1-717-302-4243,[email protected]

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

By Brunt, Ardith Rhee, Yeong; Zhong, Li

Abstract. Objective and Participants: The authors surveyed 557 undergraduate students aged 18-56 years to assess weight status, health behaviors, and dietary variety. Methods: They used body mass index (BMI) to divide students into 4 weight categories: underweight (BMI 30 kg/m^sup 2^). Results: Approximately 33% of respondents were overweight or obese, and 8% were underweight. Among the weight categories, the authors observed significant differences in diet (eg, cheese, pork, lamb, veal and game, fish, green leafy vegetables, other vegetables, and the cumulative total of all meats). Overall, 33% of the students consumed 1 fruit in 3 days. The authors found no differences among the weight categories related to eating fatty, sugary snacks. Conclusions: College administrators should create health promotion and skill-building programs to improve students’ diet variety. Keywords: body mass index, college health, dietary patterns, obesity

Obesity is a problem that it is not improving.1 Researchers estimate the prevalence of obesity in US college-aged people to have increased from 12% in 19912 to as high as 36% in 2004.3 Obesity in adolescence is the leading predictor of obesity in adulthood.4 This additional weight, most of which is excess body fat, has led to an increased risk for chronic disease development over a lifetime5; however, lifestyle changes can significantly reduce the risk.6

The increasing rates of obesity indicate an energy imbalance, with people taking in more than they expend. A healthy weight based on body mass index (BMI) ranges from 19 to 24.9 kg/m^sup 2^, with overweight being 25 to 29.9 kg/m^sup 2^ and obese being > 30 kg/ m^sup 2^. The dietary choices made by overweight and obese individuals are assumed to be higher in fat and less nutrient-dense than those made by individuals with lower body weight, yet no evidence links high dietary fat intake with long-term obesity.7,8

The college years are often the first time that students, living away from home, are faced with many different food choices. Most students are transitioning to independent living and are thus making their own food choices, which often results in poor eating habits.8 Against current dietary recommendations,9 college students typically consume a diet lacking in fruits, vegetables, and dairy products8,10- 13 and high in fat, sodium, and sugar.14,15 Students frequently have a diet of limited variety,16-19 snack,20,21 and consume fast food.20,22-24 To control weight, the student may develop a habit of skipping meals.24,25 These practices increase nutritional risk and unwanted weight gain for college students of all ages, as few differences in dietary intake exist between lower- and upperclassmen.26

Variety is one important aspect of total diet quality.27 Consuming many different foods from each food group increases the likelihood of meeting current dietary recommendations. 28 Moreover, consuming the same foods without variety in the food groups may be a factor in the increased prevalence of obesity.29

Reports of US college students’ quantified dietary intake are scarce.15 Several researchers30-32 have relied on 2 or 3 general questions to assess dietary intake. The 1995 National College Health Risk Behavior Survey used only 2 questions to assess dietary intake: (1) did you have 5 servings of fruit and vegetables yesterday? and (2) did you have = 2 servings of high-fat food yesterday?31,32 Simple questions such as these tend to underestimate mean daily consumption of fruits and vegetables by 1 serving or more33 and do not adequately assess dietary variety. Other researchers have focused on nutrient intake15,34 or only fruits and vegetables. 35 From a public health point of view, discussing groups of foods rather than specific nutrients may be more useful when introducing students to information on diet and health because a meal comprises several foods.34,36

Therefore, in this study, we examined dietary and lifestyle practices in college students across all BMI categories. Our purpose was to assess students’ weight status and the relationship between their BMI and dietary intake. Moreover, we investigated whether a difference exists in the kinds and groups of foods consumed among individuals in various BMI categories. We also examined how lifestyle habits relate to BMI.

METHODS

The university’s Institutional Review Board for the Protection of Human Participants in Research approved the protocol for this study, which we conducted during the first week of classes at a Canadian university. During implementation, a letter was read aloud and handed out with the Diet Variety Questionnaire (DVQ); implied student consent was given when students returned the survey. All students at this university are required to complete a semester of wellness education, and the class Principles of Nutrition fulfills the requirement. Therefore, we presumed that this course would generate a sample of students from a variety of majors. We asked all students in this nonmajor introductory nutrition class (N = 713) to complete a DVQ that included demographic, weight control, smoking, and anthropometric measures. On the DVQ, students identified which of the listed foods they had consumed in the past 3 days-1 day during the weekend and 2 days during the week.

The DVQ consisted of 42 items. Each food group was represented by foods that many college students commonly consume. We added an item to each food group for students who consumed foods other than those listed. For example, the dairy foods category contained 5 choices: milk, yogurt, cheese, ice cream and milk-based desserts, and other dairy products. The yes-no responses allowed us to assess variety from each food group and discretionary calories but did not allow quantification of calories and micronutrient intake. (Neither the concept of variety nor that of frequency requires minimum amounts to be set, if one assumes that quantitative estimates are not being made.) We previously pilot tested and validated the survey instrument by using 3-day food records from upper-level dietetics students (A. Brunt, PhD, unpublished data, October 2000).

Using Quetelet’s index,37 we calculated BMI from students’ self- reported height and weight. We excluded students who did not provide these measures. Self-reported height and weight were strongly correlated to measured height and weight (r2 = .98).38 Using goals set by Healthy People 2010, we divided BMI into 4 categories: underweight ( 30 kg/m^sup 2^).39

We combined each of the foods in specific categories to compare total variety within food groups. Total possible scores and category names (in parentheses) for the various food groups were 5 for dairy (all dairy); 7 for meat (all meat); 3 for meat alternatives, which included eggs, legumes, and nuts or seeds (all meat alternate); 5 for vegetables (all vegetables); 5 for fruits (all fruits); 7 for grains (all grains); and 7 for fatty, sugary snacks, including alcohol (all snacks). We did not place 2 other items-liquid supplements (eg, Slimfast) and water-in any food group.

We analyzed the data with SAS for the personal computer (version 9.1; SAS Institute Inc, Cary, NC), with a significance level set at p

RESULTS

Participants returned 557 usable surveys in which both height and weight were reported. Of the respondents, 60% were female. By comparison, 55% of the entire student body is male. Mean age was 21.3 +- 4.85 years, ranging from 18 to 56 years. Approximately 75% of the students were aged 21 years or younger (see Table 1 for additional descriptive characteristics). Most were white (96%), with the remaining racial groups divided among African American (1.5%), Native American (1.5%), and other (3%). By comparison, 90% of all students at this university, both graduate and undergraduate, are white; remaining racial percentages are similar to those in our study. Respondents included 29% freshman, 39% sophomores, and 32% upperclassmen. Approximately 60% of the respondents lived off campus, and 35% lived on campus. The remaining respondents lived off campus with their parents.

The mean BMI was 23.9 +- 4.5 kg/m^sup 2^, ranging from 16.5 to 44.4 kg/m^sup 2^. The median BMI was 23.1 kg/m^sup 2^. The mean BMI for men was 25.7 kg/m^sup 2^, compared with 22.7 kg/m^sup 2^ for women. Approximately 27% of the students (n = 148) were overweight, and 8% (n = 45) were obese. Another 8% (n = 43) were underweight, and the remainder (n = 321) were of healthy weight. Table 2 contains the distribution of BMI categories on the basis of sex and place of residence. The distribution of BMI categories was significantly different among male and female students and living arrangements. Men were almost 3 times more likely than women to be overweight or obese (55% vs 20%; p

According to students’ responses from the 3-day DVQ, at least 1 student consumed each of the 42 listed foods. Table 3 contains the mean variety score for each food group, both overall and by BMI category. The percentage of students consuming a serving or less from the fruit, meat, dairy, grain, or vegetable group was 33%, 17%, 10%, 9%, and 9%, respectively. Seven percent of respondents consumed no meat or meat alternatives; 6% consumed no more than 2 servings of fruits and vegetables combined. The majority (95%) of students consumed at least 2 servings of discretionary sweets or fats. Just as important, 60% of students consumed no alcohol in the 3 days prior to taking the DVQ.

We observed few differences in diet variety among the BMI groups; green leafy vegetables (p = .0115), white bread (p = .0440), liquid supplements (p = .0481), and all meats, which was the sum of all the meats listed (p = .0149), were the exception. Separating responses by sex, we found that the only foods significantly related to male BMI were poultry (p = .0150), beef (p = .0031), and other fruits, which included all fruits that were not citrus fruits, melons, and berries (p = .43). For women, we found no significant differences among the types of foods consumed by the 4 BMI groups.

On the basis of BMI, Table 4 lists the percentage of students who consumed each of the foods at least once, as well as the cumulative total of each food group. Our analysis showed that obese and overweight students were more likely to report consuming pork (p = .0461); lamb, veal, and game (p = .0314); and fish (p = .0004), with all meats significantly related to BMI across all 4 groups (p = .0015). Underweight students were likely to report consuming cheese (p = .0196), green leafy vegetables (p = .0437), and other vegetables (p = .0188). For men, only consumption of all meats (p = .0157) was related to being obese but not to being overweight. For women, consuming yogurt (p = .0177), green leafy vegetables (p = .0051), and all vegetables (which was the sum of all vegetables listed; p = .0350) was significant only for the underweight group.

Last, we compared diet variety in those who were underweight (the lowest quartile) with diet variety in those who were obese (the highest quartile). Students who were underweight consumed more cheese (p

COMMENT

Our purpose in this study was to compare differences in diet variety among BMI categories. The survey population was young, with 88% aged 24 years or younger. Approximately 27% (n = 148) were overweight, and 8% (n = 45) were obese. These percentages were similar to those found in the 1995 National College Health Risk Behavior Survey and other studies11,21,31 but much lower than those reported in the 2004 National Health and Nutrition Examination Survey III.3 Fifty-five percent of men and 20% of women had a BMI greater than 25 kg/m^sup 2^, which is similar to values observed by Silliman et al.21 Our respondents’ demographics (ie, sex and ethnicity) were similar to those of other universities in the US Midwest.26,32,34,35 Approximately 14% of students in our study smoked, which coincides with similar percentages (10% to 31%) in other studies.15 However, fewer students in our study than in others reported consuming alcohol.15 One explanation might be that this study took place on a dry campus (ie, alcohol consumption was prohibited) and because many students lived on campus, they did not consume alcohol. Moreover, only 25% of the respondents were of legal drinking age, which may have deterred some students from drinking alcohol.

Demographics associated with being overweight or obese were living off campus, being older, and being male. Overall, fruit variety was the most limited food group (with 33% reporting 1 or fewer daily servings); meat variety (17%) was the second-most limited. Ten percent of participants reported consuming 1 or fewer foods from each of the categories of grains, vegetables, and dairy products. These percentages indicate that there is room for improvement in college students’ dietary variety. Moreover, in regard to food type, 95% of all respondents reported consuming fatty, sugary, and salty snacks (ie, sources of discretionary calories). This finding coincides with that of Silliman et al,21 who also found that 95% of their participants consumed snacks at least once daily, with 31% snacking at least 3 times per day. These findings are worrisome, as snacking was coupled with low consumption of nutrient-dense foods-2 trends that increase the risk for developing chronic disease.

Our findings demonstrate significant differences in diet variety between those who are at a healthy weight and underweight compared with those who are overweight and obese. Students with higher BMIs reported a higher intake of pork, lamb, veal, game, and all meats; likewise, many of the saturated fats that Hendricks et al15 observed in participants’ diets were from meat. Furthermore, our participants with lower BMIs consumed more vegetables, especially green leafy vegetables. And in a review of adults’ dietary intake patterns, Togo et al36 found that a varied diet high in fruits and vegetables and low in meat and fat was associated with lower BMI. We found that these patterns develop before adulthood-at least by late adolescence.

A limitation of this study is the self-reported data. Students may have inaccurately reported dietary intake over the 3 days prior to the administration of the DVQ. Moreover, those 3 days may not be representative of participants’ usual dietary patterns. Furthermore, BMI is only a proxy measure of obesity, and using it instead of measures of body composition may result in misclassification. For example, a student who follows a strength-training regimen may be identified as overweight or obese yet may have a greater lean body mass than is estimated by BMI. Nevertheless, using self-reported height and weight is a common practice in epidemiological studies and enables researchers to predict obesity with reasonable accuracy.40 Study findings must be interpreted cautiously; however, our sizable sample suggests actual health risks in this age group.

Because weight loss programs have achieved only limited success,40,41 prevention of obesity is an important issue for all young adults. To ensure healthful dietary practice, nutrition education and healthy behaviors should start at least at the high school level. Healthy People 2010 recommends that postsecondary students receive information in 6 areas that carry significant health risks, and nutrition is one of those areas.39 Health promotion efforts should be targeted toward first-year college students because many are away from home for the first time. They need to be able to identify healthful foods and practice healthful dietary habits that encourage intake of a wide variety of foods. Health behavior change can be challenging; therefore, they also need social support and skill-building programs to assist with their behavior change. We must create an environment to make healthy positive choices. The early years of college are an important time to encourage individuals living healthful lifestyles and to develop interventions for individuals who could do better. Only changes at this level will reduce future chronic disease.

The authors are all with the Department of Health Nutrition and Exercise Sciences at North Dakota State University, Fargo.

Copyright (c) 2008 Heldref Publications

REFERENCES

1. Flegal KM, Carroll MD, Kuczmarski RJ, Johnson CL. Overweight and obesity in the United States: prevalence and trends, 1960-1994. Int J Obes. 1998;22:39-47.

2. Mokdad AH, Serdula MK, Dietz WH, Bowman BA, Marks JS, Koplan JP. The spread of the obesity epidemic in the United States, 1991- 1998. JAMA. 1999;282:1519-1522.

3. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999- 2004. JAMA. 2006;295:1549-1555.

4. Engeland A, Bjorge T, Tverdal D, Sogaard AJ. Obesity in adolescence and adulthood and the risk of adult mortality. Epidemiology. 2004;15:79-85.

5. Reilly JJ, Methven E, McDowell ZC, et al. Health consequences of obesity. Arch Dis Child. 2003;88:748-752.

6. National Research Council. Diet and Health: Implications for Reducing Chronic Disease Risk. Washington, DC: National Academies Press; 1989.

7. Willet WC. Is dietary fat a major determinant of body fat? Am J Clin Nutr. 1998;67: S556-S562.

8. Grace TW. Health problems of college students. J Am Coll Health. 1997;45:243-250.

9. Nicklas TA, Weaver C, Britten P, Stitzel K. The 2005 Dietary Guidelines Advisory Committee: developing a key message. J Am Diet Assoc. 2005;105:1418-1424.

10. Brevard PB, Ricketts CD. Residence of college students affects dietary intake, physical activity, and serum lipid levels. J Am Diet Assoc. 1996;96:35-38.

11. Anding JD, Suminski RR, Boss L. Dietary intake, body mass index, exercise, and alcohol: are college women following the Dietary Guidelines for Americans? J Am Coll Health. 2001;49:167- 171. 12. Dinger MK, Waigandt A. Dietary intake and physical activity behaviors of male of female college students. Am J Health Promot. 1997;11:360-362.

13. Haberman S, Luffey D. Weighing in college students’ diet and exercise behaviors. J Am Coll Health. 1998;46:189-191.

14. Harnack L, Stang J, Story M. Soft drink consumption among US children and adolescents: nutritional consequences. J Am Diet Assoc. 1999;99:436-441.

15. Hendricks KM, Herbold N, Fung T. Diet and other lifestyle behaviors in young college women. Nutr Res. 2004;24:981-991.

16. Huang Y, Song W, Schemmel R, Hoerr S. What do college students eat? Food selection and meal pattern. Nutr Res. 1994;14:1143-1153.

17. Pinto BM, Marcus BH. A stage of change approach to understanding college students’ physical activity. J Am Coll Health. 1995;44:27-31.

18. Evans AE, Sawyer-Morse MK, Betsinger A. Fruit and vegetable consumption among Mexican American college students. J Am Diet Assoc. 2000;100:1399-1402.

19. Schuette LK, Song WO, Hoerr SL. Quantitative use of the food guide pyramid to evaluate dietary intake in college students. J Am Diet Assoc. 1996;96:453-457.

20. Nicklas TA, Baranowski T, Cullen KW, Berenson G. Eating patterns, dietary quality and obesity. J Am Coll Nutr. 2001;20:599- 608.

21. Silliman K, Rodas-Fortier K, Neyman M. A survey of dietary and exercise habits and perceived barriers to following a lifestyle in a college population. Cal J Health Promot. 2004;2:10-19.

22. Hertzler A, Webb R, Frary R. Overconsumption of fat by college students, the fast food connection. Ecol Food Nutr. 1995;34:49-57.

23. Thompson OM, Ballew C, Resnicow K, Must A, Bandini LG, Cyr HDWH. Food purchased away from home as a predictor of change in BMI z score among girls. Int J Obes. 2004;28:282-289.

24. DeBate R, Topping M, Sargent R. Racial and gender differences in weight status and dietary practices among college students. Adolescence. 2001;36:819-833.

25. Sax LJ. Health trends among college freshmen. Health Trends. 1997;45:252-262.

26. Driskell JA, Kim Y-N, Goebel KJ. Few differences found in the typical eating and physical activity habits of lower-level and upperlevel university students. J Am Diet Assoc. 2005;105:798-801.

27. Dietary Guidelines for Americans, 2005. 5th ed. Washington, DC: US Dept of Agriculture and US Dept of Health and Human Services; 2005.

28. Krebs-Smith SM, Smiciklas-Wright H, Guthrie H, Krebs-Smith J. The effects of variety in food choices on dietary quality. J Am Diet Assoc. 1987;87:897-903.

29. Nicklas TA, Baranowski T, Cullen KW, Berenson G. Eating patterns, dietary quality and obesity. J Am Coll Nutr. 2001;20:599- 608.

30. Dinger MK. Physical activity and dietary intake among college students. Am J Health Stud. 1999;15:139-148.

31. Lowry R, Galuska DA, Fulton JE, Wechsler H, Kann L, Collins JL. Physical activity, food choice, and weight management goals and practices among US college students. Am J Prev Med. 2000;18:18-27.

32. Racette SB, Deusinger SS, Strube MJ, Highstein GR, Deusinger RH. Weight changes, exercise, and dietary patterns during freshman and sophomore years of college. J Am Coll Health. 2005;53:245-251.

33. Smith-Warner SA, Elmer PJ, Fosdick L, Tharp TM, Randall B. Reliability and comparability of three dietary assessment methods for estimating fruit and vegetable intakes. Epidemiology. 1999;8:196- 201.

34. Butler SM, Black DR, Blue CL, Gretebeck RJ. Change in diet, physical activity, and body weight in female college freshman. Am J Health Behav. 2004;28:24-32.

35. Huang T, Harris K, Lee R, Nazir N, Born W, Kaur H. Assessing overweight, obesity, diet, and physical activity in college students. J Am Coll Health. 2003;52:83-86.

36. Togo P, Osler M, Sorensen TIA, Heitmann BL. Food intake patterns and body mass index in observational studies. Int J Obes. 2001;25:1741-1751.

37. Garrow J, Webster J. Quetelet’s index (W/H2) as a measure of fatness. Int J Obes. 1985;9:147-153.

38. Burckes-Miller ME, Black DR. Male and female college athletes: prevalence of anorexia nervosa and bulimia nervosa. Athl Training. 1988;22:137-140.

39. Healthy People 2010. Washington, DC: US Dept of Health and Human Services; 2000.

40. Strauss RS. Self-reported weight status and dieting in a cross-sectional sample young adolescents: National Health and Nutrition Examination Survey 3. Arch Pediatr Adolesc Med. 1999;153:741-747.

41. Anderson JW, Konz EC, Frederich RC, Wood CL. Longterm weight- loss maintenance: a meta-analysis of US studies. Am J Clin Nutr. 2001;74:579-584.

Ardith Brunt, PhD; Yeong Rhee, PhD; Li Zhong, MS

NOTE

For comments and further information, address correspondence to Dr Ardith Brunt, North Dakota State University, Health, Nutrition and Exercise Sciences, 351 EML, Fargo, ND 58105, USA (e-mail: [email protected]).

Copyright Heldref Publications May/Jun 2008

(c) 2008 Journal of American College Health. Provided by ProQuest Information and Learning. All rights Reserved.

By Sathasivam, S Lecky, B; Manohar, R; Selvan, A

Neuralgic amyotrophy is an uncommon condition characterised by the acute onset of severe pain in the shoulder and arm, followed by weakness and atrophy of the affected muscles, and sensory loss as the pain subsides. The diversity of its clinical manifestations means that it may present to a variety of different specialties within medicine. This article describes the epidemiology, aetiopathogenesis, clinical features, differential diagnoses, investigations, treatment, course and prognosis of the condition. Neuralgic amyotrophy was described by Dreschfeld in 1887.1 He reported recurrent episodes of the condition in two sisters.1 Several other reports followed,2-6 but it was Parsonage and Turner7 who clearly detailed the clinical aspects of the condition in a cohort of 136 patients in 1948. Many case reports and series of patients with neuralgic amyotrophy have been described, expanding the clinical variants and nomenclature. It has been referred to as the Parsonage-Turner syndrome, acute brachial neuropathy, acute brachial plexitis, brachial plexus neuropathy, cryptogenic brachial neuropathy, idiopathic brachial plexopathy, idiopathic brachial neuritis, localised neuritis of the shoulder girdle, multiple neuritis of the shoulder girdle, paralytic brachial neuritis, serum neuritis, shoulder girdle neuritis and the shoulder girdle syndrome.

The diversity of presenting features means that patients with neuralgic amyotrophy may be seen by orthopaedic surgeons, neurosurgeons, neurologists, internal medicine physicians, accident and emergency physicians, general practitioners, sports medicine specialists, obstetricians and respiratory physicians.

Epidemiology

The incidence of neuralgic amyotrophy is approximately two to three per 100 000 person-years.8,9 It has been described in patients aged between three months10 and 81 years,11 with the highest incidence occurring in the third and seventh decades.10-12 Males are more commonly affected than females in ratios ranging between 2:1 and 11.5:1.10,13

Aetiology

Neuralgic amyotrophy exists as an idiopathic and a hereditary form. Although the aetiology of the idiopathic form is unknown, various antecedent events, or factors which may trigger an immune- mediated process, have been proposed to contribute to its development. Infection has preceded the development of symptoms in 25% to 55% of patients.10,13-15 A history of antecedent immunisation has been recorded in 15% of cases.7,10 Strenuous exercise has been undertaken prior to the onset of symptoms in approximately 8% of cases in two large series.10,16 Post-surgical neuralgic amyotrophy is well-recognised after operations in areas remote from the shoulder girdle.6,7,16,17 It has occurred during pregnancy andpostpartum.14,16,18,19

Idiopathic neuralgic amyotrophy may be a result of an autoimmune process. A study showed that lymphocytes of patients with the condition increased their blastogenic activity in cultures with nerve extracts from different nerves of the brachial plexus and their branches, but not in cultures with extracts of nerves from the sacral plexus.20 Another study showed an increase in complement- fixing antibodies to peripheral nerve myelin in the acute phase in three patients with neuralgic amyotrophy.21 The results of these two studies have yet to be replicated.22

The hereditary form of the condition is an autosomal dominant recurrent neuropathy affecting the brachial plexus. It is the first monogenic disease caused by defects in a septin family gene. Mutations in the gene septin 9 on chromosome 17q25 have been found in several families with hereditary neuralgic amyotrophy.23 Gene septin 9 is a member of the cytoskeleton-related septin family, which is highly expressed in glial cells in neuronal tissues. Sequence alterations in septin 9 may disrupt various cellular processes, leading to abnormal cytoskeleton events and signalling.24

Table I. Differential diagnoses of neuralgic amyotrophy

Clinical features

The characteristic clinical presentation is an acute, severe burning pain in the shoulder or arm lasting for several days or weeks, followed by muscle weakness, atrophy and sensory loss as the pain diminishes. However, this temporal profile is not universal. Symptomatic bilateral involvement of the brachial plexus occurs in approximately 30% of cases and is usually asymmetrical.7,10,16 Most of these patients note bilateral pain either simultaneously or within 24 hours.25,26 However, it is not uncommon for patients to present with bilateral neuralgic amyotrophy with only one side being symptomatic.27

Pain

Pain was the first symptom in 90% of cases in a study of 246 patients with neuralgic amyotrophy.16 The four loci for initial pain were in the shoulder or radiating from the shoulder to the arm (39.7%), from the neck radiating into the arms (35.4%), from the scapular or posterior chest wall region radiating to the arm or anterior chest wall or both (18.8%), or confined to a distribution in the lower plexus (6.1%). The pain is typically severe and unrelenting, often waking patients from sleep. It is commonly worsened by movement of the shoulder or arm, resulting in patients holding the arm with the elbow flexed and the shoulder adducted.28 A helpful feature in distinguishing neuralgic amyotrophy from cervical radiculopathy is that with a VaIsalva manoeuvre, the aggravation of the pain is typically less in the former.26 The pain may last for more than eight weeks. 6 Minimal or no pain is uncommon in neuralgic amyotrophy.29

Weakness and atrophy

Weakness develops within 24 hours in approximately one third of cases.16 In approximately 70%, it occurs within the first two weeks of the onset of pain.10,16 It characteristically worsens as the pain subsides. Weakness affecting the distribution of the upper part of the brachial plexus, either with or without involvement of the long thoracic nerve is the most common pattern.1,10,16 The muscles commonly affected include the infraspinatus, supraspinatus, serratus anterior, biceps, deltoid and triceps.6,10,13,16,27 [t is well recognised that individual nerves can be affected in isolation or several at a time, mimicking a ‘mononeuritis multiplex’ pattern.26 This may occur in 75% of cases.14 Isolated involvement of a particular nerve, for example, the anterior interosseous branch of the median nerve, has also been described.30,31 Unilateral or bilateral phrenic neuropathy resulting in paralysis of the diaphragm may occur in isolation or in association with other nerve involvement.32-35 Hemidiaphragmatic paralysis may be present on the contralateral side to the affected extremity. Involvement of cranial nerves VII, IX, X, XI and XII has also been reported.14,34-37

Sensory involvement

Sensory involvement may occur in 78% of cases.16 Hypoaesthesia or a combination of paraesthesia and hypoaesthesia are the most common complaints,”‘ seen most often over the deltoid and lateral aspect of the upper arm and the radial aspect of the forearm.10,13,16,27 Isolated sensory manifestations have been described in eight patients; in three, the lateral cutaneous nerve of the forearm was affected, while partial involvement of the distal median nerve was documented in the orher five.

Autonomic dysfunction

Signs of involvement of the peripheral autonomic nervous system, such as vegetative and trophic skin changes, oedema at the onset of the attack, temperature dysregulation, increased sweating and changes in nail or hair growth were documented in approximately 15% of a series of 246 cases.16 In addition, one patient with hereditary neuralgic amyotrophy suffered a persistent Horner’s syndrome combined with involvement of the brachial plexus.39

Craniofacial and cutaneous findings

Minor dysmorphic features including hypotelorism, palate and unusual skin folds have been observed in some patients with the hereditary form of the condition.40,41

Differential diagnosis

The diagnosis of neuralgic amyotrophy can be challenging, especially in the early stages. There are many differential diagnoses (Table I). It can mimic other conditions which cause acute pain and weakness around the shoulder. The pain can be so severe that patients may be investigated for myocardial infarction. The correct diagnosis is important to avoid unwarranted treatment, including inappropriate surgery.

Investigations

Blood tests occasionally reveal abnormalities including elevated liver enzymes and positive antiganglioside antibodies, ‘6 although the significance of these remains unclear. Examination of the cerebrospinal fluid is usually normal, although mildly elevated protein, slight pleocytosis and oligoclonal bands have been reported.10,13,16 A chest radiograph is useful to exclude a Pancoast tumour of the lung and may detect an elevated hemidiaphragm caused by involvement of the phrenic nerve. An MRI of the cervical spine may reveal cervical disc disease or cervical root lesions, and of the shoulder may identify other causes of pain at this site such as rotator cuff tears, lahral tears, impingement syndromes or other local lesions. Abnormalities in the musculature of the shoulder girdle related to denervation may be detected. The mechanism and time course of changes in the signal intensity of the muscles on MRI are not fully understood. In the acute phase of denervation, the intensity may be normal.42 The earliest detectable change in denervated muscles is a diffuse increase of the T^sub 2^-weighted signal as a result of oedema, without a T^sub 1^-weighted change.42- 44 In the subacute and chronic stages of denervation, the T^sub 2^- weighted changes persist and muscle atrophy may develop.42,43,45 Atrophy is suggested by a reduced muscle mass and an increase in the intramuscular linear T^sub 1^weighted signal because of fatty infiltration, which may return to normal several months after the chronic stage. An increased T^sub 2^-weighted signal in the supraspinatus, infraspinatus and deltoid muscles at initial presentation and T^sub 1^-weighted changes of atrophy without fatty infiltration during follow-up, were reported in three cases.46 A retrospective study of 27 patients with neuralgic amyotrophy showed T^sub 1^- and T^sub 2^-weighted signal changes in the muscles compatible with predominant involvement of the suprascapular (supraspinatus and infraspinatus) and axillary (deltoid and teres minor) nerves. These changes matched or nearly matched electromyographic changes where these were available.” Similarly, in another retrospective study of 26 cases, T^sub 1^- and T^sub 2^- weighted signal changes were most commonly seen in the supraspinatus, infraspinatus, deltoid and teres minor muscles.47 Conventional MRI of the brachial plexus is not sensitive enough to identify pathological changes in neuralgic amyotrophy. Of 50 patients studied in one series, focal T^sub 2^ hyperintensities in two patients and focal thickening of the plexus in one patient were detected.16 Magnetic resonance neurography provides better image resolution. Using this technique in an acute case of neuralgic amyotrophy, the affected brachial plexus was found to be thickened and hyperintense, while in a chronic case there was also hyperintensity.

Electrophysiological evaluation is useful for the diagnosis of neuralgic amyotrophy and to distinguish it from cervical root lesions. It is helpful in localising the symptoms to the brachial plexus. Nerve conduction studies and needle electromyography are best performed at least three weeks after the onset of symptoms.26 Nerve conduction velocities are usually normal, although proximal conduction block has been recorded,50,51 although the primary pathology is thought to be axonal degeneration.10,52 In three of five cases with proximal conduction block, there was complete resolution of the block when the studies were repeated three to nine months later, suggesting that in some cases demyelination may predominate in the early stages.50,51 Delayed distal latencies and a decreased amplitude of compound muscle action potentials may also be seen.14,15,38,53 Electromyography reveals acute denervation, indicating axonal degeneration, with positive sharp waves and fibrillation potentials three to four weeks after the onset of symptoms.14,25,27 Electromyography performed three to four months after the initial symptoms may show chronic denervation and early reinnervation with polyphasic motor unit potentials.54

Treatment

Corticosteroids may reduce the time to the start of improvement of weakness, although treated patients appeared to suffer more attacks than untreated ones. Corticosteroids may reduce pain in the early stages.10,16 Analgesics may also be helpful, with a combination of a non-steroidal anti-inflammatory and an opiate appearing to be best.16 Physiotherapy and rehabilitative exercises are recommended as the pain subsides and the weakness improves,26 although these measures have not been shown to hasten recovery.

Course and prognosis

Some studies have recorded that between 80% and 90% of patients had recovered after two to three years.10,14,55 However, others have suggested a less favourable outcome with less than 50% of patients recovering fully from pain or weakness after six years.16,56 Recurrence has been reported in between 5% and 26% of patients with idiopathic neuralgic amyotrophy,10,16 although referral bias may have affected the study with the higher figure.16

References

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2. Feinberg J. Fall von Erb-Klumpke scher: lahmung nach influenza Centralbl 1897;16:588-637.

3. Bramwell E, Struthers JW. Paralysis of the serratus magnus and lower part of the trapezius muscles. Rev Neurol Psychiat 1903;1:717- 30.

4. Richardson JS. Serratus magnus palsy. Lancet 1942;1:618.

5. Wyburn-Mason R. Brachial neuritis occurring in epidemic form. Lancet 1941;1:6623.

6. Spillane JD. Localised neuritis of the shoulder girdle: a report of 46 cases in the MEF. Lancet 1943;2:532-5

7. Parsonage MJ, Turner JWA. Neuralgic amyotrophy: the shoulder- girdle syndrome. Lancet 948;1:973-8.

8. Beghi E, Kurland LT, Mulder DW, Nicolosi A. Brachial plexus neuropathy in the population of Rochester, Minnesota 1970-1981. Ann Neurol 1985;18:320-3.

9. MacDonald BK, Cockerell OC, Sander JW, Shorvon SD. The incidence and lifelime prevalence of neurological disorders in a prospective community-based study in the UK. Brain 2000;123:665-76.

10. Tsairis P, Dyck PJ, Mulder DW. Natural history of brachial plexus neuropathy: report on 99 patients. Arch Neurol 1972;27:109- 17.

11. Gaskin CM, Helms CA. Parsonage-Turner syndrome. MR imaging findings and clinical information of 27 patients. Radiology 2006;240:501-7.

12. van Allen N. The neuralgic amyotrophy consultation. J Neurol 2007;254:695-704.

13. Magee KR, DeJong RN. Paralytic brachial neuritis: discussion of clinical features with review of 23 cases. JAMA 1960;174:1258- 62.

14. Cruz-Martinez A, Barrio M, Arpa J. Neuralgic amyotrophy: variable expression in 40 patients. J Peripher; Nerve Syst 2002;7:198-204.

15. Mullins GM, O’Sullivan SS, Neligan A, et al. Non-traumatic brachial plexopathies, clinical, radiological and neurophysiological findings from a tertiary centre. Clin Neurol Neurosurg 2007;109:661- 6.

16. van Allen N, van Engelen BGM. The clinical spectrum of neuralgic amyotrophy in 246 cases. Brain 2006;129:438-50.

17. Malamut RI, Marques W, England JD, Sumner AJ. Postsurgical idiopathic brachial neuritis. Muscle Nerve 1994;17:320-4.

18. Ungley CC. Recurrent polyneuritis in pregnancy and the puerperium affecting three members of a family. J Neurol Psychopathology 1933;14:15-26.

19. Lederman RJ, Wilbourn AJ. Postpartum neuralgic amyotrophy. Neurology 1996;47:1213-19

20. Sierra A, Prat J, Bas J, et al. Blood lymphocytes are sensitized to brachial plexus nerves in patients with neuralgic amyotrophy. Acta Neurol Scand 1991;83:183-6.

21. Vriesendorp FJ, Dmytrenko GS, Dietrich T, Koski CL. Anti- peripheral nerve myelin antibodies and terminal activation products of complement in serum of patients with acute brachial plexus neuropathy. Arch Neurol 1993;50:1301-3

22. England JD. The variations of neuralgic amyotrophy. Muscle Nerve 1999;22:435-6.

23. Kuhlenbaumer G, Hannibal MC, Nelis E. Mutations in SEPT9 cause hereditary neuralgic amyotrophy. Nat Genet 2005;37:1044-6.

24. Sudo K, Ito H, Iwamoto I, et al. SEPT9 sequence alternations causing hereditary neuralgic amyotrophy are associated with altered interactions with SEP4/SEPT11 and resistance to Rho/Rhotekin- signalmg. Hum Mutat 2007;28:1005-13.

25. Vanermen B, Aertgeerts M, Hoogmartens M, Fabry G. The syndrome of Parsonage and Turner discussion of clinical features with a review of 8 cases. Acta Orthop Belg 1991;57:414-19

26. Rubin DI. Neuralgic amyotrophy clinical features and diagnostic evaluation. Neurologist 2001;7:350-6.

27. Dillin L, Hoaglund FT, Scheck M. Brachial neuritis. J Bone Joint Surg [Am] 1985;67-A:878-90.

28. Waxman SG. The flexion-adduction sign in neuralgic amyotrophy. Neurology 1979;29:301-4.

29. Schott GD. A chronic and painless form of idiopathic brachial plexus neuropathy. J Neurol Neurosurg Psychiatry 1983;46:555-7

30. Kilon LG, Nevin S. Isolated neuritis of the anterior interosseous nerve. Br Med J 1952;1:850-1.

31. Rennels GD, Ochoa J. Neuralgic amyotrophy manifesting as anterior interosseous nerve palsy. Muscle Nerve 1980;3:160-4.

32. Lahrmann H, Grisold W, Authier FJ, Zifko UA. Neuralgic amyotrophy with phrenic nerve involvement. Muscle Nerve 1999;22:437- 42.

33. Tsao BE, Ostrovskiy DA, Wilbourn AJ, Shields RW Jr. Phrenic neuropathy dug to neuralgic amyotropby. Neurology 2006;66:1582-4.

34. Dinsmore WW, Irvine AK, Callender ME. Recurrent neuralgic amyotraphy with vagus and phrenic nerve involvement. Clin Neurol Neurosurg 1985;87;39-40.

35. Chen YM, Hu GC, Cheng SJ. Bilateral neuralgic amyotrophy presenting with left vocal cord and phrenic nerve paralysis. J Formos Med Assoc 2007;106:680-4.

36. To WC, Traquina DN. Neuralgic amyotrophy presenting with bilateral vocal cord paralysis in a child: a case report. Int J Pediatr Otorhinolaryngol 1999;48:251-4.

37. Pierre PA, Laterre CE, Van den Bergh PY. Neuralgic amyotrophy with involvement of cranial nerves IX, X, XI, XII. Muscle Nerve 1990;13:704-7.

38. Seror P. Isolated sensory manifestations in neuralgic amyotrophy: report of eight cases. Muscle Nerve 2004;29:134-8.

39. van Alfen N, van Engelen BG, Reinders JW, Kremer H, Gabreels FJ. The natural history of hereditary neuralgic amyotrophy in the Dutch population: two distinct types? Brain 2000;123:718-23.

40. Airaksinen EM, Livanainen M, Karli P, Sainio K, Haltia M. Hereditary recurrent brachial plexus neuropathy with dysmorphic features. Acta Neurol Scand 1985;71.309-16.

41. Jeannet PY, Watts GD, Bird TD, Chance PF. Craniofacial and cutaneous findings expand the phenotype of hereditary neuralgic amyotraphy. Neurology 2001;57:19638.

42. Uetani M, Hayashi K, Matsunaga N, Imamura K, Ito N. Denervated skeletal muscle: MR imaging, work in progress. Radiology 1993;189:511-15.

43. Fleckenstein JL, Watumull O, Conner KE, et al. Denervated human skeletal muscle: MR imaging evaluation. Radiology 1993;187:213- 18.

44. West GA, Haynor DR, Goodkin R, et al. Magnetic resonance imaging signal changes in denervated muscles after peripheral nerve injury. Neurosurgery 1994;35:1077-85 45. Sallomi D, Janzen DL Munk PL, Connell DG, Tirman PF. Muscle denervation patterns in upper limb nerve injuries: MR imaging findings and anatomic basis. AJR Am J Roentgenol 1998;171:779-84

46. Helms CA, Martinez S, Speer KP. Acute brachial neuritis (Parsonage-Turner syndrome). MR imaging: report of three cases. Radiology 1998;207:255-9.

47. Scalf RE. Wenger DE, Frick MA, Mandrokar JN, Adkins MC. MRI findings of 26 patients with Parsonage-Turner syndrome. AJR Am J Roenigenol 2007;189-39-44.

48. Duman I, Givenc I, Kalyon TA. Neuralgic amyotrophy, diagnosed with magnetic resonance neurography in acute stage: a case report and review of the literature. Neurologist 2007;13:219-21.

49. Sankaya S, Sumer M, Ozdolap S, Erdem CZ. Magnetic resonance neurography diagnosed brachial plexitis: a case report Arch Phys Med Rehabil 2005;86:1058-9

50. Lo YL, Mills KR. Motor rooi conduction in neuralgic amyotrophy: evidence of proximal conduction block. J Neural Neurosurg Psychiatry 1999;66:586-90

51. Watson BV, Nicolle MW, Brown JD. Conduction block in neuralgic amyotrophy. Muscle Nerve 2001;24:559-63.

52. Bradley WG, Madrid R, Thrush DC, Campbell MJ. Recurrent brachial plexus neuropathy. Brain 1975;98:381-98.

53. Walsh NE, Dumitru D, Kalantri A, Roman AM Jr. Brachial neuritis involving the bilateral phrenic nerves. Arch Phys Med Rehabil 1987;68:46-8.

54. Aymond JK, Goldner JL, Hardaker WT Jr. Neuralgic amyotrophy Orthop Rev 1989;18:1275-9.

55. Tonali P, Uncini A, Di Pasqua PG. So-called neuralgic amyotrophy. clinical features and long term follow-up. Ital J Neurol Sci 1983;4:431-7.

56. Geertzen JH, Groothoff JW, Nicolai JP, Rietman JS. Brachial plexus neuropathy: a long-term outcome study. J Hand Surgery [Br] 2000;25:4610-4.

S. Sathasivam,

B. Lecky,

R. Manohar,

A. Selvan

From The Walton

Centre for Neurology

and Neurosurgery,

Liverpool, England

* S. Sathasivarn, MRCP(UK),

PhD, Consultant Neurologist

* B. Lecky, MD, FRCP,

Consultant Neurologist

Department of Neurology

* R. Manohar, MRCP(UK),

Specialist Registrar in

Neurophysiologv

* A. Selvan, DM, MRCP(UK),

Consultant Neurophysiologist

Department of

Neurophysiologv

The Wallon Centre for

Neurology and Neurosurgery,

Lower Lane, Liverpool L9 7LJ,

UK.

Correspondence should be sent to Mr S. Sathasivam; e-mail: sivakumar.sathasivam@ thewaltoncentre.nhs.uk

(c)2008 British Editorial Societv of Bone and Joint Surgery

doi:10.1302/0301-620X.90B5. 20411 $2.00

J Bone Joint Surg [Br] 2008;90-B;550-3.

Copyright British Editorial Society of Bone & Joint Surgery May 2008

(c) 2008 Journal of Bone and Joint Surgery; British volume. Provided by ProQuest Information and Learning. All rights Reserved.

Infectious disease experts announced Monday that seasonal flu viruses are growing resistant to antiviral drugs. While the problem is worldwide, Europe is the worst affected by the resistant viruses, they told a meeting of the Infectious Diseases Society of America.

“A significant proportion of resistant viruses were observed in Europe this winter,” Dr. Bruno Lina of Claude Bernard University in Lyons, France, told the audience.

The resistance varies by strain, with one in four H1N1 flu viruses resistant in Europe and about one in ten in the United States. There are far fewer cases of H3N2 and influenza B resistant viruses, the experts reported.

Already known to mutate rapidly, flu viruses may be even more unpredictable than previously believed, they said.

Health experts fear antiviral drugs may quickly become unable to combat a severe flu season or the appearance of a new strain, something that might result in a pandemic. They urge the need to develop new flu drugs, with better and faster methods to make vaccines.

The World Health Organization (WHO) and the U.S. Centers for Disease Control and Prevention (CDC) have been gathering samples of the annual flu viruses to track them against the four available flu drugs: rimantadine, amantadine and the newer drugs Tamiflu and Relenza. Roche AG’s Tamiflu, known generically as oseltamivir, is a pill that can treat symptoms and also prevent infection.

But according to Lina, the viruses changed quickly over the past 2007-2008 flu season.

“We started with something like 10 percent in Europe,” he said, adding that in April of this year 25 percent of the viruses were Tamiflu-resistant.

“U.S. flu viruses developed a sudden ability to evade the effects of the older drugs amantadine and rimantadine during the 2005-2006 flu season,” Dr. Larisa Gubareva of the CDC told Reuters.

In fact, in 2006 the CDC said no one should use the drugs any more.

Experts were optimistic about two newer drugs ““ Tamiflu and GlaxoSmithKline’s Relenza, known generically as zanamivir ““ but resistance to Tamiflu is already being observed.

Lina’s team analyzed more than 2,600 samples of flu viruses from European patients, and found puzzling patterns of resistance that appeared to be unrelated to the actual use of Tamiflu.

For instance in Paris, more than half of those tested carried the mutation that would give resistance to Tamiflu, compared with only 29 percent in southeastern France.

“Which makes absolutely no sense,” said Lina, noting that patients exhibited no difference in symptoms whether infected with resistant virus or not.

“It’s difficult to understand. I have no idea why these viruses emerged,” he said.

In Europe, the most resistant viruses were the H1N1.

Gubareva said tests across the U.S., Canada and Mexico showed very rapid development of drug resistance among H1N1 viruses.   As of May 15, resistant viruses had been detected in 18 out of the 43 U.S. states where virus samples were tested, she said.   In Canada, resistant viruses were found in nine of 13 provinces.  However, only 6 percent of H3N2 and influenza B samples tested in the three countries showed the genetic mutations for Tamiflu resistance, she said.

—

On the Net:

Infectious Diseases Society of America

Compliance 360, the most widely used provider of compliance and risk management software in the health care industry, announces Billings Clinic has selected the Compliance 360 solution for the management of their compliance and risk program.

Billings Clinic serves communities in Montana, Wyoming and North Dakota and is the region’s largest multi-specialty health care organization. With over thirty five facilities and affiliates in the region, their large geographical presence contributed to their need for a comprehensive internet based, on demand software for their compliance, regulatory and risk management program.

Key goals for Billings Clinic include automation and standardization of Policy Management, Contract Management and the implementation of a consistent Enterprise Risk Management methodology. Once implemented, Billings Clinic will have real time visibility of their compliance initiatives and risk events, standard policy management, contract management and other documentation through Compliance 360’s Virtual Evidence Room(SM). Billings Clinic has licensed the full suite of Compliance 360 products.

“We are impressed by the breadth and depth offered by Compliance 360. There are many products on the market today that only address niche health care compliance requirements, but Compliance 360’s ability to offer a holistic approach to health care compliance set them apart,” says Gerele Pelton, Director of Corporate Compliance at Billings Clinic. “Compliance 360’s On Demand software capabilities are helping us reduce our IT Department’s workload so resources can be directed to other mission critical projects.”

Steve McGraw, President and CEO of Compliance 360, Inc., states, “Billings Clinic has a fabulous reputation and we are very pleased that Billings Clinic’s chose our platform for their risk and compliance management. This is yet another validation of our ability to offer comprehensive solutions to leading health care systems.”

About Billings Clinic

Billings Clinic is a leading health care organization and the largest employer in Billings, Montana with over 3300 employees. At its core is a multi-specialty group practice of over 230 physicians and 55 physician assistants and nurse practitioners on staff. Billings Clinic is a community-owned, not-for-profit medical foundation governed by a 12-member board consisting of nine community members, two physicians, and a physician CEO. Billings Clinic is a community of physicians’ working together toward the mission to provide outstanding health care, education and research. Primary and specialty-care clinics are located in Bozeman, Colstrip, Columbus, Miles City and Red Lodge, Montana as well as Cody, Wyoming.

About Compliance 360

Compliance 360 helps companies in regulated industries address the most important facets of a comprehensive governance, risk and compliance management program. The results are reducing risks, improving efficiencies and protecting a company’s image. The Compliance 360 on-demand software suite includes products that address policies and procedures management, incident management, compliance management, surveys, Sarbanes Oxley compliance and enterprise risk management. Compliance 360 is the only company to offer the Virtual Evidence Room(SM) which is a central repository of all evidence of compliance. This feature allows clients to communicate with auditors remotely and much quicker than if they would have had to gather the appropriate documentation. Compliance 360 has headquarters in Atlanta, GA and assists over 93,000 active users everyday in a variety of highly regulated complex business environments. For more information, visit Compliance 360 at www.compliance360.com.

Editor’s Note: Compliance 360 is a registered trademark of Compliance 360, Inc. Virtual Evidence Room is a registered service mark of Compliance 360, Inc. All other trademarks are recognized as proprietary to their owners.

ANAHEIM, Calif., May 20 /PRNewswire/ — With the financial support of Sechrist Industries, Inc., The Center for Minimally Invasive Surgery (CMIS) at the Ohio State University Medical Center has begun testing the efficacy of hyperbaric oxygen medicine on experimental stroke models. CMIS is a multidisciplinary center dedicated to excellence in patient care, clinical training, research and outcomes studies pertaining to the techniques and technology of minimally invasive surgery.

Currently utilized for the treatment of chronic, non-healing wounds, carbon monoxide poisoning, crush injuries as well as other indications, the use of hyperbaric medicine for stroke victims is at the forefront of hyperbaric research. Hyperbaric oxygen therapy is the treatment of the entire body with 100-percent oxygen at greater than normal atmospheric pressures. Hyperbaric medicine greatly increases oxygen concentration in all body tissues, even with reduced or blocked blood flow, stimulates the growth of new blood vessels to locations with reduced circulation (improving blood flow to areas with arterial blockage) and causes a rebound arterial dilation after treatment, resulting in an increased blood vessel diameter greater than when therapy began, thus improving blood flow to compromised organs. The CMIS team is hopeful that these benefits of hyperbaric oxygen treatments will positively affect stroke patients.

“Ohio State University Medical Center is one of the finest health care institutions in the country,” stated Jack Rollins, President and CEO of Sechrist Industries, Inc. “As the world leader in hyperbaric oxygen technology, we feel that it is important to join forces with CMIS to support research in the field of hyperbaric medicine.”

“We believe that there is a window of opportunity to treat stroke related injury of the brain using hyperbaric oxygen. The challenge lies in accurately defining the perimeters of that window,” says Chandan Sen, Director of the Comprehensive Wound Center at the Ohio State University Medical Center.

For additional information, contact Monica Gutierrez ([email protected]) or visit http://www.sechristusa.com/.

ABOUT Sechrist Industries — Sechrist is the leading manufacturer of monoplace HBO chambers in the USA, and supplies more monoplace chambers than all other manufacturers combined with over 2000 installed around the world.

Sechrist Industries, Inc.

CONTACT: Monica Gutierrez of Sechrist Industries, Inc., 1-800-SECHRIST(732-4747), fax, +1-714-579-0814, [email protected]

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

Six Herbalife products have been shown to contain “dangerously high levels” of lead toxins, according to a report from the Fraud Discovery Institute.

The FDI report said that when taken as recommended, these common Herbalife weight management products result in cumulative lead exposure 45 times (4,636 percent) higher than the legal maximum exposure.

Herbalife disagreed with the report’s findings, and insisted that all of its products met regulatory standards.

“The FDA hasn’t established a general limit on lead in foods, but we are certainly well within their suggested guidelines,” Herbalife spokesman George Fischer said.

The study included lab analysis by an FDA-registered lab, medical literature, Herbalife’s product literature and various peer reviewed medical journal articles. Christopher Grell, co-founder of the Dietary Supplement Safety Committee and lawyer specializing in dietary supplement litigation wrote a letter in response to the findings.

Grell said that the products tested showed “”¦levels of lead that are both dangerous and that are in excess of what the law allows under California’s Safe Drinking and Toxic Environment Act of 1994, more commonly known as Prop. 65.”

Proposition 65 was written to protect California’s citizens and drinking water from harmful chemicals that could lead to cancer, birth defects or other reproductive harm. According to California law, the maximum daily exposure to lead is 0.5 micrograms per day.

The FDI reported that Herbalife’s Thermojetics contained 0.663 mcg of lead per tablet, which is well over the maximum daily exposure level. Herbalife recommends that users take the tablet three times daily, resulting in 5.967 mcg of lead every day, and more than 11 times (1100  percent) the maximum  exposure allowed per day.  

Other products ShapeWorks Protein Drink Mix, Healthy Meal Nutritional Shake Mix, Tang Kuei Plus herbal tablets, ShapeWorks Cell Activator and Multivitamin Complex were all found to contain high levels of lead if used as directed.

Grell said that the daily exposure to lead from taking the recommended dosage would warrant a warning label.

Barry Minkow, founder of the Fraud Discovery Institute, has a history of scrutinizing Herbalife.

In April, Herbalife said its president and chief operating officer, Gregory Probert, had not finished his MBA degree as stated in his biography. The company said Probert had been enrolled at California State University during the 1980’s but never obtained a degree.

At the time, The Wall Street Journal reported that Minkow had uncovered the discrepancy about the degree, but on Monday Herbalife declined to comment on that. The newspaper also reported that Minkow had “put” options in a bet that Herbalife’s stock price would fall.

Herbalife shares closed down 4.2 percent at $40.17 on Monday on the New York Stock Exchange.

Last month, Herbalife said that Spain’s Ministry of Health had issued an alert cautioning consumption of Herbalife products due to suspicious cases of hepatic toxicity, or liver damage, presumably associated with Herbalife products. Herbalife said it was in discussions with the ministry.

“For more than 28 years, tens of millions of Herbalife consumers worldwide have been safely using Herbalife products with an extremely low incidence of serious adverse event reports citing liver function abnormalities,” the company said.

—

On the Net:

Fraud Discovery Institute

Herbalife

By Tracy Correa, The Fresno Bee, Calif.

May 20–For four months, Edward Hobbs believed he might die. A biopsy on his lung had come back positive for cancer, and he had surgery to remove a portion of his lung.

But it was all a mistake. He didn’t have cancer.

Doctors didn’t tell him they were wrong until two months after the December 2006 surgery.

Hobbs and his wife, Christina Hobbs, are now suing doctors involved in his care, Saint Agnes Medical Center and its pathology department.

The medical malpractice lawsuit, filed in February, alleges that Hobbs’ cancer diagnosis and surgery were based on a biopsy, or tissue sample, that belonged to another patient. That patient had breast cancer, said Hobbs’ Fresno attorney, John Ormond.

It’s unknown how many mix-ups like Hobbs’ lead to such medical mistakes. But the Institute of Medicine says up to nearly 100,000 people die in hospitals each year as a result of medical errors. Many more are harmed.

The Hobbs family went through a terrible ordeal, Ormond said. “He and his wife and daughter and son believed he had cancer, which of course could be terminal,” he said.

Ormond said his clients did not want to be interviewed. They did not respond to attempts to reach them at their home.

Cases such as Hobbs’ have prompted a greater call for hospitals to reveal and take responsibility for medical errors.

In California, a new law took effect July 1, 2007, that requires hospitals to report 28 specific adverse events — from surgery on the wrong body part to anything that causes death or serious injury to a patient. The California Department of Public Health must make information on investigations related to the mistakes publicly available next year.

And Medicare announced last year it will no longer pay the extra costs of treating preventable errors in hospitals.

Dr. Robert Wachter, professor of medicine at University of California at San Francisco and author of the 2004 book “Internal Bleeding: The Truth Behind America’s Terrifying Epidemic of Medical Mistakes,” said millions of people are victims each year of mistakes — from minor to serious — made in hospitals and doctors’ offices.

Wachter said it’s not that mistakes are occurring more often, “we are just hearing about them more.”

Saint Agnes spokeswoman Jaime Huss, citing the Hobbses’ pending litigation, said hospital officials wouldn’t comment on the case.

The hospital and Dr. Tai-Po Tschang, head of pathology at Saint Agnes, also named in the lawsuit, deny the negligence allegations in court documents.

Tschang said of the lawsuit, “I’m aware of it,” but gave no additional comment.

Dr. Howard S. Robin, a San Diego pathologist who testifies as a medical expert in litigation, said medical cases are not always clear-cut and mistakes happen. “It’s a shame when these things happen,” he said.

But mistakes are rare, he said.

Robin said he didn’t know enough to comment specifically on the Hobbs case, but he relayed how such a case might be confused by a doctor: “The tissues don’t look the same, but the cancers can look the same.”

Laboratories typically have safeguards, he said. “I don’t want patients to be unduly concerned that the hospital is going to make this mistake,” Robin said. “It’s exceedingly uncommon.”

Monica Medina, a Fresno woman who had her kidney removed two years ago at University Medical Center, experienced a records mix-up similar to Hobbs’.

Her kidney was removed in April 2006 based on a computed tomography, or CT, scan that belonged to another patient, said Kent Henderson, a Southern California lawyer who is representing Medina.

Medina’s case sparked a state health investigation and an order that Community Medical Centers, a nonprofit group that owns UMC, fix its records policies. The state’s six-page report said a CT scan of a patient with a mass above the kidney about the size of a grapefruit was inadvertently assigned to Medina.

In September 2006, Medina filed her lawsuit against Community Medical Centers for the unnecessary operation. She also is suing several doctors involved in her care, and in March added Fuji Film, General Electric and Hewlett Packard, each of which contributed to the computerized imaging system used by Community.

John Zelezny, spokesman for Community, said he is not aware of Medina’s lawsuit and could not comment on it.

Following the state investigation, Community said it made corrections to its computerized records system.

Henderson suggested that many mistakes are happening because of increasing reliance on computer technology and digital data with too few human checks and balances.

“It’s quite a thing to be told they cut out a piece of your body there was nothing wrong with,” he said.

The reporter can be reached at [email protected] or (559) 441-6378.

—–

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.

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NYSE:GE, NYSE:HPQ,

By Siegel, Karen Hall

A winter morning, 2003: Stirring oatmeal, letting Al Roker’s banter distract from my sister-in-law’s fresh death and my faraway sick mother’s plight, I abruptly glanced over my left shoulder to locate an unfamiliar noise. Wide, high flames were the disturbance- rising from that shoulder and resembling a cartoonist’s hell-sleeve caught fire? no cloth burns that fast. . . . Snapping off the oatmeal burner, I dove from the kitchen and rolled. Rolling, I struggled to untie the belt of my blazing kimono, but bows can turn to knots when you’re rolling. Pace common wisdom, rolling didn’t work. Fire towered above me; my task was to wrestle down this tiger. Or die-my son, my loves, I can’t never see them again. . . . Still, I made one minuscule pause: sitting straight up, I mouthed the word “help” knowing none could be forthcoming-husband out of town, door triple-locked from inside. Even if I wasted time screaming, by the time anyone rounded up the super and he came and broke down the door I’d be literally toast. No, it was show time, inferno just a piece of cake, smother its oxygen, fast.

I rolled near the Murphy bed I’d slept on and yanked my favorite blanket from that. Hoping it wouldn’t be ruined, I swaddled it around myself and finally stifled the flames. When I unwrapped the blanket my kimono was gone except for a charred piece hanging from the knot. A gift from a traveler to Japan, it must have been their blackestmarket flammable cloth. (Of course, I shouldn’t have been cooking in any robe with droopy sleeves. That part was a little ignominious for a one-time scientist with good lab technique.) My bra right underneath, sanctioned by the U.S.A., wasn’t even slightly scorched!

First Aid Second

Forgetting all that, I rushed to the bathroom to check in the mirror: Flushed face intact, though brows and lashes slightly singed. Hair a bit jaggedly shorter, nothing a trim couldn’t fix. Finally I surveyed my back and left arm, which both looked alarmingly red. But nothing particularly hurt, so I figured I was probably home free-meaning no doctors. I sauntered back to the living room and looked out at the Empire State Building, thinking as I did each post-Towers morning, We’re both still here. I checked that the rug and the floor weren’t burnt and didn’t see much damage to my blanket. Back in the kitchen I finally heard the weather before shutting off the TV. Then I telephoned my husband.

“Call 911,” he choked. “Right now.” I thought, okay, it couldn’t hurt to have some medics come over and apply the right ointment and so forth. Within minutes of my 911 call-during which I’d pointedly emphasized that the fire was out-a large party of firemen, police, and medical people flocked into the apartment. I sat, bemused, on my bed as someone wet my back with water and firelighters scouted all around. The super stood expressionless, watching from the hall; he’d grown up in Saigon.

Then I learned that I wasn ‘t home free. In concert, my visitors readied me for what they avowed was the world’s most spectacular burn unit, as if it were someplace I’d really enjoy. I doubted the need for all this drama and was peeved because a cop wouldn’t let me lock my own door or even carry my purse. Being borne on a stretcher through the lobby was a low point even though the doormen stayed cool.

Irrationally I thought, / killed a raging tiger and didn’t let this building burn down, and suddenly Fm forced to be passive? Where were you people when it mattered? Outside, I was inserted in an ambulance in which sat a man, but I have no further memory of the journey.

The Tank

After an hour or so of ER flurry, some burn-unit folks removed me to The Tank, a large room containing several single-bed-sized metal rectangles fitted with hoses and drains. I loved the name-The Tank sounded like something out of a prison movie. Cheerfully I mentioned this, causing a couple of nurses to exchange is-she-psychotic glances. I quickly gleaned that the mental status of a lady who sets herself on fire is automatically suspect. (Statistically, I later learned, I should have been poor and/or drunk.) As I sat in one of the rectangles, the head burn surgeon and his efficient minions scraped and washed and calculated that 17 percent of my body surface was burned, much of it third-degree (meaning that both the thin epidermis and the thicker dermis beneath it were history, with zero chance of recovery). What remained was some infection-prone dead stuff called eschar.

It was obvious they planned to admit me. Of course I could simply have retrieved my precious purse and walked out. But then I’d probably die of infection or wind up somewhat deformed, so I figured I’d have to play along. Worried about work, I asked when I could go home: two weeks, minimum-depending on whether I’d need skin grafts. SKIN GRAFTS? HOLY SHIT! At that, I finally grasped that for a while I’d need to cede control. And that the only way to traverse that “while” would be to watch, indifferently, whatever happened. To just let it be a movie.

What happened was that each morning for ten days I was doped with morphine and taken to The Tank, there to be scraped and washed by a very kindly crew. (Scraped, because eschar tends to break up on its own, so some could be readily removed.) Often other rectangles were occupied, too, and privacy was incomplete. But there was no Tank camaraderie. In fact, the room brought to mind a graveyard with inhabitants posing on their stones. And there was no camaraderie on the intensive-care burn floor where I roomed. Strolling around it, I saw that patients were in no shape to chat. Screams of burnt babies sometimes pierced the normal nursing bustle.

At each Tanking, a resident burn doctor would arrive to check whether any of my third-degree burns had shifted down to second, which they never had. (Sometimes what at first looks like third turns out not to be.) Then, because infection is a major bane of burns, I would be anointed with a soothing infection-fighter, silver sulfadiazine, and tightly bandaged back up. Each night one or two people would scrape and re-anoint me as I sat on my bed. The night personnel were constantly changing, as were their official qualifications. One woman who had the air of recruitment off the street was such a bandaging ace that she must have worked with mummies in a previous life.

One night, an RN, possibly somehow impaired, accidentally stuck herself with a needle she’d just used on me and rushed off nervously. Next morning, the jollies! burn nurse popped in and asked me to sign permission for an HIV test, which I readily did so his colleague would have peace of mind. I never got that night nurse again-and never got my test result. I didn’t ask about it, because I suspected that her fellow nurses kept the mishap off the record. She’d been the nurse I liked best.

Watching, Watching

Things hummed along. Family and friends visited and called. My horrified blind mother managed to call, but not dead Eileen. I kept imagining how Eileen, just sixteen when we long ago swore “real” sisterhood, would find a way to make me screech with laughter about my predicament. A year or two earlier, during a still-optimistic radiation session she’d wailed to her technician, “I’m too cute to die!” and he agreed. It was funny, yet it summed up the subjective crux of the human condition. For two or three seconds per day I pondered the hoary psychoanalytic dictum that “there are no accidents.” Was my near self-immolation a way to exorcise survivor guilt, or was it merely carelessness? Either way it felt part of an ineluctable script, so I just kept watching the movie.

My husband brought my computer and papers and often lugged in restaurant food and wine. The hospital rations seemed less healthful than you’d expect in this era of Big Nutrition, yet I had to eat a lot in order to get enough protein, which leaks out fast through the eschar. (If you lose too much protein, your immune system sputters and your “metabolic profile” gets deranged.) Thus a bossy dietitian insisted that I down several cans of protein drink per day, and the staff kept count of the empties.

So, as I sat at a table next to my bed, translating medical journal articles into “patient information” and tossing back protein drinks, things didn’t seem half bad. Occasionally I went to a therapy space, where I obligingly stretched my burnt arm. The women there urged me to join a burnt-people discussion group huddled in a corner of the room, whose ambulatory members seemed culled from a step-down burn floor. Hello, my name is Karen and although I feel infinite pity for all beings burnt or un-burnt, talking to you won’t mitigate a thing. . . . No thanks, no time. Work deadlines.

Two women doing an academic study asked if they could interview me. For nearly an hour they kept digging for symptoms of posttraumatic stress disorder, which I simply didn’t have. They left looking disappointed. But this wasn’t the worst thing that ever happened to me, and in the cavalcade of human woe it was peanuts.

After several days of this doable routine, the burn surgeon himself arrived at my Tank session and informed me that I would shortly be getting skin grafts. This was heartening, because the buzz was that you got to go home soon after grafting.

Frankenstein Time

First they slice off any eschar. Then they peel skin off your thighs (or other un-burnt spots), stick it on a stretching machine, and staple it over the wounds. This requires general anesthesia and lots of morphine later. What hadn’t been adequately impressed on me was that before going home I would have to spend five days almost totally immobilized, flat on my back with a splint that kept my left arm extended like a wing. The Frankenstein grafts needed this undisturbed time to “take”-to stop being thighs and start being neck, back, and arm. Grafts do that very quickly, albeit far from simply. Most critically, adventurous blood vessels in the wound beds start worming up into the grafts-delivering them second life-and many other processes get rolling. So, five days of little but watching. I tried to view it as a morphined-up mental vacation; luckily I’d finished my work and emailed it in. And at least I was done with The Tank (except for one last post-immobilization visit, when they hosed off a trillion staples). Immobilization

One night during the immobilization, a young, new-seeming nurse, who kept complaining that he hadn’t intended to come in to work because of some contretemps with his girlfriend, suddenly announced that I needed a blood transfusion. Although I’d had two during surgery, now I was slightly anemic. For an hour or more he struggled with the transfusion apparatus, all the while scowling and complaining about not having stayed at home. The bag of blood languished on a visitor’s chair. After conferring with a colleague he finally hooked things up, but somehow the hooking up entailed my head being a lot nearer the floor than were my thickly bandaged thighs. I mused that if gravity trumped heartbeats, someone else’s blood would start pooling in my head.

I was fascinated: Generally I don’t expect much empathy from the public, including the nursing sector. We’re each stuck at the center of our private universes-romantic glitches, health concerns, dinner, kids … to say nothing of rollings in the fathomless unconscious. Or, our minds might be compared to atoms that have tremendous forces keeping their nuclei intact, but not necessarily many bonding electrons in their outer orbits. Anyway, for that upside-down stretch of hours I was as objectified as a crummy-model car in for bothersome repairs.

A censorious day nurse disliked me. I got the feeling that it was something like “Yeah, Miss Thing sets herself on fire and I’m supposed to care, what with toddlers and firemen to treat.” That could have been projection, though; I constantly thought it myself.

Once, despite my button calls and voice messages, this unfriendly nurse left me alone-immobilized-for several hours. When she did bring my medications, way late, I saw that one dose was seriously wrong. Through the bedside message system I succeeded in speaking to the charge nurse, who finally came in with the miscreant in tow. When I showed the damning evidence, the charge nurse frowned and said she’d discuss it with the younger woman later, but I doubt there was much dressing down. Some weeks later, a friend who’d been a nurse in the sixties told me that in those days a wrong dose meant instant dismissal. But a nursing shortage, long-sought upgrades in training and respect, and, I’m sure, some variant of politically correct workplace “rights” have changed all that. (Say, what’s that statistic? Each year one hundred thousand U.S. patients perish due to hospital mistakes?)

Home!

Nearly three weeks after my arrival, abruptly I was told to go home, be out before fast-approaching noon. As I hurriedly threw clothes over my bandages, I received instruction screeds, prescriptions for painkillers, and appointments for physical therapy. Once home, I stayed in bed for a day, allowing my husband to pamper me, then decided to get over it.

Ha! I did not imagine that nearly five years later-today-I would still be dealing with itchy, swollen red scars. The main game in skin transplantation (providing it “takes” instead of falling off) is battling the hypertrophie scars that tend to form, especially on the edges of the grafts. You could say that collagen-the main structural component of skin-is appalled at finding itself in a new neighborhood, and its production typically goes wild. But instead of arranging itself in its usual orderly way, the insulted collagen forms thick raised whorls.

Days after leaving the hospital, I was back in an outpatient clinic being fitted for a custom-made pressure shirt. This was a tight black spandex and nylon affair with one short sleeve and one long. Pressure is supposed to inhibit collagen production and thus the flowering of scars. I dubbed it my Spiderwoman suit. It featured circular cutouts for breasts, allowing me to wear the right-sized bra on top; this added to the cartoon effect. My physical therapist was always shaping thick pink silicone things to stick under the shirt, to increase local pressures over problem sites. And I also wore large sheets of translucent silicone next to my flesh. Silicone is supposed to help with scars; I can’t say if it did or did not. All this junk needed washing every day, as did the pressure suit. Thus I actually needed two suits, which perplexed my insurance no end.

I never minded the suit, which curtailed itching and narrowed my waist, except that it posed a sartorial challenge. While it wasn’t a problem under T shirts, it was hard to dress up with this unlovely black thing zippered to my throat. Sometimes I unzipped it a few inches and folded the edges under to get away with slightly lower necklines. In any case, I wore it night and day for exactly two years. Just once, when my husband’s son was nominated for a Tony, I sallied forth to Radio City Hall sans Spiderwoman suit in a normal dress with a wrap casually thrown around it. Less than two hours into the show we had to rush home-without the suit, the scars swelled up mightily and itched. Anyway, before we left he lost out to Billy Joel.

Scars and Stripes Forever

My physical therapist, an exuberant Russian emigre, explained that hypertrophic scars take six months to one year to “mature.” (Not the same as “heal”; the grafts themselves heal quite quickly, like most other surgical wounds, and their scars are not open sores.) By the end of a year, latest, she said, I’d have flat, flesh- colored scars that wouldn’t hurt or itch. So for six months I was fairly patient, although daily in unexpected pain. Maybe burnt nerves were springing back to life or fresh ones were taking their place. Whatever the reason, I often needed opioids like Percocet.

The burn surgeon, leery of prescribing these addictive drugs, referred me to a pain-management clinic, but I didn’t want any more appointments. I simply got the drugs from my doctor. With them and the help of my husband I got through those six months. Every day he massaged the scars, and often he took me to movies. Movies, and only movies, afforded a pain-free, itch-free two hours, although more than once after the show we had to bolt from a restaurant mid-meal because I was suddenly dizzy with pain. Several times I lost it, and my husband would rock me as I violently sobbed.

Yet during those six months (and the following years) I pretty much lived my normal life. Sure, I sometimes dashed to bathrooms for lotion or pills, which hardly disturbed a noisy party. Even close friends tended to assume my burn was “over.” For reasons lost to history, I’d learned as a child not to show psychic discomfort.

The pain attacks abruptly stopped, but at six months and still at one year the scars remained “immature” – not flat and flesh- colored. At two years, almost the very same story. At that point, the burn surgeon deemed that the pressure shirt wasn’t helping. Since discarding it, I’ve stuck to soft clothes, nothing ribbed or scratchy.

In the first post-Spiderwoman years I tried all kinds of ways to appease the angry scars. Acupuncture-for fifteen weeks -didn’t do a thing. My dermatologist injected steroids to no effect. She then tried a laser treatment said to work on scars, but mine were recalcitrant. Long her patient, I mentioned that the fire had an interesting upside: I’d read about some expensive new beauty treatment that used radiant heat to tighten the skin. I joked that I’d opted for do-it-yourself – that the fire left my face noticeably “refreshed!” I thought she’d like that, but she gave me that blank- faced mental-status look. (For that matter, the tiger must have kissed me, because it etched a small scar along my bottom lip, making it more fashionably full.)

Every six months I checked in with the burn surgeon, who did nothing but look, then at year three he dismissed me.

Now

The scars still need lotion a couple of times a day, but they no longer play a grievous role. Obviously I can’t parade around in clothes that bare my back without shocking the populace, and anyway skin grafts should never see the sun. The back scars stay stubbornly red, although now and then a small spot might blanch. I no longer wait for any big change because it seems like a chronic disease. In fact, the scars itch and swell if I’m tense or upset, perfectly consonant with the latest thinking in “psychodermatology.”

On the bright side, my arm is totally “matured.” However, thanks to that skin-stretching machine the surgeon employed, the matured grafts boast a faintly checkered pattern. So my pale arm, when bent, resembles an outsized raw chicken leg. It’s not the most dashing buccaneer scar, but by now I almost like it.

As everyone (including me) declared from day one of this adventure, I was lucky. Most people whose clothes catch on serious fire either die or are tragically disfigured. I’m endlessly grateful for this peculiar stroke of luck. Yet younger Eileen-never very lucky outside charm and good looks-died of cancer thirty-one days before my event. And my mother followed her to the land of shades after more gruesome elder years. A friend from first grade suffered and died, and two uncles bit the dust. Nearly four thousand Americans perished in Iraq, and what with flood, craze, and germs the world kept going to hell. None of that was aberration, we know it in our guts. So what’s “luck”? Doubtless there are blips of relative luck, but as far as I can see every single human’s in the same leaky boat. All we can do is cheerfully watch it sink.

Karen Hall Siegel is a writer and translator living in New York City.

Copyright Antioch Review, Incorporated Spring 2008

(c) 2008 Antioch Review, The. Provided by ProQuest Information and Learning. All rights Reserved.

Another regional healthcare network in Spokane, Wash. is starting to use smart card technology, attendees learned during the healthcare track at the joint Smart Card Alliance annual meeting and CTST conference last week.

LifeNexus is starting to deploy its smart card-based Personal Health Card with Inland Northwest Health Services (INHS), a member of the Northwest Regional Health Information Organization (RHIO) connecting 38 hospitals in northwest Washington and Idaho, Christopher Maus, president and CEO of LifeNexus, announced.

The goal of a RHIO is to facilitate the sharing of electronic medical records between physicians, labs and hospitals across large geographic areas, but to make that work, “we have to engage the consumer,” Maus said. “We are going to focus on the patients. The LifeNexus Personal Health Card will act as a personal key people use to unlock access to their medical information,” he said.

Maus sees two important advantages to using smart card technology for storing personal health and insurance information — security and portability. The LifeNexus card will store personal, insurance and medical information that people normally provide when they fill out forms at a doctor’s office or hospital. It will also store any allergies, medicine restrictions, health conditions, and information about recent medical results and lab tests. The information is protected by a PIN, so consumers have control over who can access it. Initially the firm will focus on equipping emergency rooms to accept the card, speeding up admission and providing important medical information.

Paul Contino, Mount Sinai Medical Center’s vice president of IT, agrees accurate patient identification is a critical issue in healthcare data management. “The challenge with RHIOs is the highly error prone process they use to match patients and data,” said Contino. “Doctors won’t use information unless they are certain the data is accurate.”

Contino has led an effort at Mount Sinai to issue smart card-based Personal Health Cards (PHC) to patients. The goal is to make sure patients are accurately linked with their personal medical information. Language barriers, common names or even common addresses can lead to errors and result in commingled or duplicate patient records. Correcting those records is a big expense for hospitals; Mount Sinai has had two major database cleanup projects in the last three years, costing more than two million dollars each.

Mount Sinai joined with nine other institutions in the greater New York City area to create a regional HealthSmart Network and accept a common PHC.

More information about the Smart Card Alliance and these healthcare projects can be found at www.smartcardalliance.org.

About the Smart Card Alliance

The Smart Card Alliance is a not-for-profit, multi-industry association working to stimulate the understanding, adoption, use and widespread application of smart card technology.

Through specific projects such as education programs, market research, advocacy, industry relations and open forums, the Alliance keeps its members connected to industry leaders and innovative thought. The Alliance is the single industry voice for smart cards, leading industry discussion on the impact and value of smart cards in the U.S. and Latin America. For more information please visit http://www.smartcardalliance.org.

 Contact: Deb Montner Montner & Associates 203-226-9290 [email protected]

SOURCE: The Smart Card Alliance

Aureon Laboratories, Inc., a specialized laboratory dedicated to advancing personalized cancer treatment through predictive pathology, today announced the introduction of Prostate Px(R)+, the first commercial test to predict prostate cancer progression and disease recurrence at the time of diagnosis. The announcement was made at the American Urological Association Annual Meeting, now underway at the Orange County Convention Center in Orlando (Booth# 505).

According to the National Prostate Cancer Coalition, 218,890 new cases of prostate cancer were diagnosed in 2007 and an estimated 27,050 American men died from the disease. It is estimated that by 2015, more than 300,000 men will be diagnosed annually. Existing guidelines from the American Urological Association assess patient risk based on information available at diagnosis: biopsy Gleason scores, prostate specific antigen (PSA) levels and clinical stage. However, as more men are diagnosed with lower-risk disease, these subjective parameters are becoming less useful.

Annual PSA screening has resulted in more men being caught earlier in the disease process than ever before. As a result, each year approximately 186,000 men with newly diagnosed prostate cancer will be assessed as low or intermediate risk, making it harder to determine which men have aggressive disease and which do not.

“Although the majority of prostate cancer cases are detected early and categorized as lower risk, there are a significant number of men within this segment whose tumors will grow aggressively, and jeopardize lives,” said Dr. Vijay Aggarwal, President and Chief Executive Officer of Aureon Laboratories. “It is imperative that physicians have access to better tools that will assess disease severity and identify high-risk patients hidden within these lower-risk groups.”

Prostate Px+ is based on the results of a large study utilizing data and samples from a cohort of 1,027 men assembled from the Mayo Clinic, Uppsala University, University of Connecticut and Duke University Medical Center. In validation, Aureon’s predictive model identified twice as many high-risk events in low and intermediate risk patients than the best available method.

“Prostate Px+ is the first prognostic test to provide this critical information at diagnosis. This technology represents a new integrated approach known as systems pathology that combines molecular biomarkers, histological and clinical information with advanced mathematics,” said Dr. Ricardo Mesa-Tejada, Vice President of Pathology and Medical Director of Aureon Laboratories. “At the time a man is diagnosed, Prostate Px+ will forecast disease progression after treatment, detect high-risk patients presenting as low risk and undetectable by other methods, reclassify intermediate-risk patients and help identify those with less aggressive disease.

“Newly diagnosed men with prostate cancer face difficult choices regarding treatment options, each of which can be curative but all with different side-effects that can negatively impact quality-of-life. The assessment of patient risk at diagnosis is critical to making the most appropriate treatment plans,” added Dr. Mesa-Tejada. “Prostate Px+ will provide integrated and objective information to assist physicians and patients in making more educated and informed treatment decisions.”

About Aureon Laboratories

Aureon Laboratories’ mission is to enable personalized patient care through predictive pathology. Aureon has developed a high throughput systems pathology technology platform to predict individual clinical outcomes through the interrogation of tissue. The platform generates and analyzes an integrated, digital view of clinical findings, tissue micro-anatomy and tissue molecular pathology to determine which combination of features predicts specified individual clinical outcomes. Allied with major cancer centers, Aureon operates a CLIA certified and CAP accredited laboratory that provides predictive pathology services to the practicing physician. For more information about Aureon, go to www.aureon.com or call 1-888-SYS-PATH.

COLUMBIA, Mo. — Your heart is failing critically. A transplant would save your life, but the waiting list is long and the odds are stacked against you.

So instead, doctors extract some of your bone marrow, heart and muscle cells, go back to their laboratory and return in four to six weeks with … a freshly grown heart.

Engineering body parts — tissues and whole organs that are genetically compatible and available on demand — sounds like science fiction. But researchers at medical centers around the world are working to make it a reality.

Already, a handful of children with spina bifida have received new bladders. Replacement blood vessels are being tested on dialysis patients. And researchers have re-created a beating rat heart.

Replacement parts grown in the lab may provide the best hope for fulfilling the unmet demand for organ transplants.

More than 95,000 people in the United States are on waiting lists for transplants. On average, one person dies every 90 minutes while waiting for an organ.

Other alternatives to organ transplants have proved elusive.

Transplants from animals, for example, face serious risks of rejection or viral infections. And mechanical organs, such as heart pumps, have been only a temporary solution.

“If we want to live forever, we need to do better,” said Gabor Forgacs of the University of Missouri in Columbia.

Forgacs, a Hungarian-born biophysicist, directs the university’s bioprinting program. In his basement lab, he is using a gleaming metal machine, a distant cousin of a computer printer, to build living blood vessels.

He has succeeded in making vessels that branch the way real veins and arteries do. He hopes to make replacement blood vessels that can be used in surgery, then fabricate human tissues with fully functioning blood systems that can be used to test new drugs. Ultimately, he wants to build replacement organs in his lab.

“That’s everybody’s dream,” Forgacs said.

Tissue engineering, as Forgacs’ field is called, is still very much in its infancy, the National Science Foundation says.

Even so, it has attracted more than $3.5 billion in investments for research, almost all from the private sector.

Because it relies on patients’ cells, tissue engineering avoids the ethical controversies surrounding embryonic stem cells and therapeutic cloning.

Recent advances in growing human cells in the lab and in creating artificial materials that are compatible with living tissue have opened new possibilities for building organs.

But just like any infant, tissue engineering took some early tumbles.

Investors began pumping money into research and development in the 1990s. But the science had not advanced far enough. Some pioneering tissue engineering companies sought bankruptcy protection.

“I think it was very much hyped in the 1990s,” said Robert Nerem, director of the Parker H. Petit Institute for Bioengineering and Bioscience at Georgia Tech. “Timelines were unrealistic; companies relied on investors with short time frames.”

That first wave of tissue engineering did yield some useful products, such as artificial skin grafts that are used to treat diabetic skin ulcers. But many of the awe-inspiring breakthroughs that scientists are talking about are still many years away, Nerem cautioned.

“The real potential for tissue engineering is the vital organs, but we’re a ways away from that, even though there’s some exciting things being done,” Nerem said.

Replacement parts for orthopedic surgery, such as bones, tendons and ligaments, may be 10 years from the operating room, Nerem said. Organs will take significantly longer.

One engineered organ that is available, though, is the urinary bladder.

Anthony Atala of Wake Forest University has successfully implanted new bladders in children, and they are being tested on adults.

It’s a project Atala started 18 years ago.

“The research does go slow,” he said. “You can only push the technology so fast.”

But Atala, a pediatric urological surgeon, had strong motivations for proceeding with his research. Among his young patients were children with spina bifida whose bladders had malfunctioned, leaving them at risk of kidney failure.

Atala would perform surgery to replace their organs with new ones built from pieces of their intestines. But substituting the bladder with intestinal tissue can lead to long-term complications, from metabolic problems to infections and an increased risk of cancer.

“Here we were putting these things into babies with a life expectancy of 70 years,” Atala said.

The first hurdle Atala faced was getting bladder cells to grow in the lab.

“They were thought to be types that couldn’t grow well outside the body. We had to go through several years, and finally we were successful after much trial and error.”

The next step was creating a “scaffold” that would hold the cells as they grew into the shape of a bladder. Atala devised a biodegradable scaffold made of collagen, the protein that gives structure to skin.

To make a new bladder, Atala plants the patient’s cells onto the bladder-shaped scaffold. After about seven weeks, the cells have grown to cover the structure, and the new bladder is implanted. The patient’s body adopts the new organ, branching out blood vessels to nourish it.

In 2006, Atala published results on the first seven children to receive the engineered bladders. Tests have shown that their new organs functioned as well as bladders fashioned from intestines, but without the complications.

A Pennsylvania-based company, Tengion Inc., is hoping to commercialize Atala’s discovery, calling it the Neo-Bladder. The company is conducting clinical trials on children and adults as it seeks Food and Drug Administration approval.

Meanwhile, Atala and his team of more than 50 researchers are working to create a full catalog of body parts _ heart valves, blood vessels, livers, hearts, pancreases, even a uterus and a vagina for cancer patients.

“There’s a definite learning curve, but with every organ we’re accelerating the process,” he said. “A lot of the strategies are the same, but you have to tweak it some.”

It can take years to determine how well an engineered organ will work, Atala said. He followed each of his bladder patients for four years or more before publishing his study. His work on a liver and a uterus has been going on for 10 years.

“It’s stuff you do slowly and carefully,” Atala said. “We ask the acid question: Would you put this in your loved one, your child or spouse?”

Doris Taylor and her colleagues at the University of Minnesota say they were lucky to get an engineered heart beating as quickly as they did.

Taylor, a stem-cell researcher, recalled a chance hallway conversation four years ago with one of her colleagues.

“Cell therapy is our bread and butter, but wouldn’t it be cool to make (patients) a new heart?” Taylor suggested.

“It was one of those ideas that made a lot of sense.”

A member of her research team came up with a detergent solution that could be pumped into hearts taken from rats to wash away the cells. What was left was the heart’s natural scaffold of translucent connective tissue.

“We had something that had the geometry and architecture of a heart,” she said. “It was pretty clear to me we probably couldn’t have built that in my lifetime.”

Heart cells from newborn rats were cultured in the lab and injected into the walls of the scaffolds. The cells were kept alive with nutrients. After about a week, the newly reformed heart began to beat.

“I can’t tell you how exciting it was,” Taylor said. “It was flabbergasting. It was thrilling. It was one of those eureka moments in life.”

If this technique can be adapted for human hearts, it will eliminate many of the problems of heart transplants, Taylor said. Because a patient’s cells would be used, there would be no problem of rejection.

A donor heart must be transplanted within four hours. But if a donor heart is to be used only as a scaffold, it can be taken from a body that has been dead for a day or longer.

Taylor thinks she has gotten around the problem of how to build scaffolds for complex organs. The same approach could be used to grow kidneys, livers, lungs or pancreases, she said.

Forgacs is trying to engineer tissue without using scaffolds.

“That has been a big challenge to find the right scaffold for each cell type or for more than one cell type,” he said.

Instead, Forgacs is using his machinery to “print” cells in the shape of blood vessels.

Forgacs loads two heads of his bioprinter with tiny spheres of 10,000 or more cells. Another printer head lays down a film of gel that serves as “biopaper.” In this biopaper, the machine prints a circle of spheres. On top of the spheres goes another layer of biopaper and a second circle of spheres. The process is repeated until a cylinder is created.

“High precision, fairly quick _ there’s really no limit to it,” Forgacs said.

The spheres and gel are incubated until the spheres fuse together and the vessel matures. Each sphere contains a mixture of the cells that form the three layers of a blood vessel.

“Now comes the magic,” Forgacs said. “Under appropriate conditions, the cells sort themselves.”

Cells that form the outer layer of the vessel migrate to the outside, while the cells that form the smooth inner layer migrate inward. Muscle cells find their way in between.

A California company, Cytograft Tissue Engineering, is using a different method to engineer blood vessels. It is testing them on kidney dialysis and heart bypass patients.

The Cytograft vessels start with sheets of tissue grown in the lab. The sheets are rolled over a rod to form the tissue into a cylinder.

Forgacs said his tissue-printing technique would make it possible to create the structures of branching blood vessels needed to nourish the tissues of an engineered organ.

“There’s no method other than ours that can produce a branched tube,” he said. “We can build anything you want.”

“It’s really changing the paradigm to be scaffold-free,” said Glenn Prestwich, a chemist at the University of Utah-Salt Lake City and one of Forgacs’ collaborators. “We have a very simple technology and ask for the cells to do the heavy lifting.”

When it comes to making spare parts for people, technology can only go so far, Forgacs said: “You have to rely on nature. And if you don’t, I think this whole activity is futile.”

___

THREE TECHNIQUES

1. Make an organ-shaped “scaffold” from collagen, then seed it with cells from the patient. Urinary bladders have been implanted in people.

2. Wash cells from an organ, leaving behind its natural scaffold, then seed with cells from the patient. Researchers have re-created rat hearts.

3. Go scaffold-free by “printing” clumps of cells into the shape of an organ, layer by layer. Vessels similar to veins and arteries have been created.

By Kathleen Kernicky, South Florida Sun-Sentinel

May 18–Patti Ershowsky had been through the thinning hair, dry mouth and chipped fingernails. When she developed an annoying case of acne that made her feel like a teenager stuck in puberty, the 51-year-old soccer mom went looking for relief.

“I was so depressed. I was feeling so bad about myself,” said Ershowsky, of Cooper City, who is on her third regimen of chemotherapytreatment since she was diagnosed with colon cancer more than a year ago.

Although she rarely wore makeup, Ershowsky decided it was time for a mini-makeover at the Image Recovery Center. Its full-range of beauty services and skin-care products are designed for patients battling the side effects of chemotherapy and radiation.

Opened in March by the Memorial Cancer Institute in Pembroke Pines, it is the first center of its kind in South Florida catering exclusively to cancer patients, said Trish Alonso, a cancer survivor and the center’s manager.

“I felt the best I’d felt in a whole year,” Ershowsky said after a recent visit for a haircut and makeup session. “It makes such a difference.”

A licensed cosmetologist, Alonso teaches women how to pencil in eyebrows to replace those they’ve lost, use concealer to hide dark circles, or add color to make their cheeks look fuller or thinner.

“You want to feel you can leave the house, and no one’s going to look at you funny,” Alonso said. “You want to feel like you have control over what’s happening.”

Such side effects as hair loss, dry or discolored skin and brittle nails can be devastating to women already overwhelmed by a cancer diagnosis, she says.

Alonso has been there. After a cancer diagnosis seven years ago, she had six months of chemo and six months of radiation. She lost her hair. She remembers sitting in the “wig room,” and shaking.

“It was very frightening,” she said. “Most of what I learned, I learned as I went along. … My background was beauty and all of a sudden, it was all gone. It was very humbling.”

Designed with a spa-like atmosphere, the center offers makeup and skin-care sessions, therapeutic manicures and pedicures (no cutting, and a bright array of polish colors), haircuts and wigs, and mastectomy products and fitting services. There’s an acupuncturist, and Alonso plans to add massage therapy and facials.

The center sells makeup, hair and skin-care products designed for chemotherapy patients. The makeup and skin-care items are made without chemical preservatives or perfumes. A bee-pollen shampoo “calms the scalp” and relieves the pain that occurs when roots die and hair falls out. Another helps the hair grow back when treatment is over.

When Donna Demirgian, 49, of Miami Lakes, was diagnosed with breast cancer six years ago, doctors could tell her all about her cancer. But they couldn’t tell her why her scalp hurt when her hair fell out, that her hair would fall out first in strands, and later in clumps, or how to buy the right wig.

“To lose your hair, I won’t say it’s as traumatic as losing a breast, but it’s right up there,” Demirgian said.

Now cancer-free, Demirgian came to the center with her sister, Diane Mogel, 54, who was diagnosed with breast cancer this year.

Mogel, an accountant from Pembroke Pines, takes a no-fuss approach to her makeup and sports a ponytail most of the time. She wasn’t convinced she wanted a makeover.

At the center, Alonso cut her shoulder-length brown hair into a short, stylish bob — a strategy Alonso uses to help women prepare for the loss of their hair. Mogel starts chemotherapy soon.

Mogel tried out different hair colors and styles, modeling wigs for her longtime boyfriend, before settling on a light-brown style with a “messy layered look.”

“I said, ‘OK, I’ll do it,'” she said. “And I felt so much better when I left, without my hair in a ponytail.”

Ershowsky, a respiratory therapist, went home with a new line of skin-care products to treat the acne.

The mother of two girls, ages 15 and 20, she was used to spending time outdoors, especially on the soccer fields. Her younger daughter plays on a travel team. Until she got sick, Ershowsky rarely missed a game.

When the most recent drug treatment left tiny bumps across her nose and cheeks, she was embarrassed to go out.

After trying the new products, her acne is beginning to clear. Alonso did her makeup and cut her hair, which had thinned but not fallen out.

“It’s a blessing,” she said of the center. “It was the happiest I’d felt in a year.”

Kathleen Kernicky can be reached at [email protected] or 954-385-7907.

—–

To see more of The South Florida Sun-Sentinel or to subscribe to the newspaper, go to http://www.sun-sentinel.com/.

Copyright (c) 2008, South Florida Sun-Sentinel

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.

PITTSBURGH, May 16 /PRNewswire/ — UPMC for Life, the Medicare product of UPMC Health Plan, is the Pennsylvania state sponsor for the 15th annual National Senior Health & Fitness Day, which has as its theme, “Fitness … A Lifetime Investment.”

National Senior Health & Fitness Day is scheduled for May 28, 2008. On that day, UPMC for Life will serve as host for three events in Pennsylvania. The theme of each event is “Fitness … A Lifetime Investment.”

“UPMC Health Plan is proud to serve as the Pennsylvania state sponsor for National Senior Health & Fitness Day for a second consecutive year,” said Diane P. Holder, President and CEO, UPMC Health Plan. “Our sponsorship reinforces our commitment to helping our members to keep active and fit, regardless of age. We always want to do what we can to encourage our members to take advantage of the many health resources offered in their communities.”

In Pittsburgh, the event will be held at the Pittsburgh Zoo & PPG Aquarium from 10 a.m. to 1 p.m. Included among the fitness activities for older adults that day will be an exercise session conducted by a team of fitness experts from “Leslie Sansone’s In-Home Walking Program” at 10:30 a.m. and 11:30 a.m.

KDKA-TV personalities will serve as emcees for this event, which also features representatives from America On the Move in Pittsburgh, health screenings, and health information workshops.

UPMC for Life members will be admitted to the event at no charge. Members are also entitled to bring one Medicare-eligible guest. The guest must bring his or her Medicare card.

In Erie, UPMC for Life is sponsoring a free event at the Presque Isle Cookhouse Pavilion at 10 a.m. A variety of fitness-related activities will be offered, including an exercise demonstration by a representative of Silver&Fit(TM).

In Altoona, UPMC for Life is sponsoring an event in conjunction with Blair County Senior Services on the campus of Penn State Altoona, starting at 10 a.m. The event will feature an exercise demonstration by PEPPI (Peer Exercise Program Promotes Independence).

National Senior Health & Fitness Day is an annual event held on the last Wednesday in May. On that day, more than 150,000 older adults across the country are expected to participate in organized health and fitness events. UPMC Health Plan is one of over 1,000 organizations nationwide that are sponsoring fitness events for older adults that day.

UPMC for Life is available in 25 Pennsylvania counties including Allegheny, Beaver, Butler, Armstrong, Westmoreland, and Washington,

About UPMC Health Plan

UPMC Health Plan, the second-largest health insurer in Western Pennsylvania, is owned by the University of Pittsburgh Medical Center (UPMC), one of the nation’s top-ranked health systems. The integrated partner companies of the UPMC Insurance Services Division — which includes UPMC Health Plan, UPMC Work Partners, EAP Solutions, UPMC for You (Medical Assistance), and Community Care Behavioral Health — offer a full range of group health insurance, Medicare, CHIP, Medical Assistance, behavioral health, employee assistance, and workers’ compensation products and services to nearly 1.2 million members. Our local provider network includes UPMC as well as community providers, totaling more than 80 hospitals and more than 7,600 physicians in a 29-county region. For more information, visit http://www.upmchealthplan.com/.

UPMC Health Plan

CONTACT: Gina Pferdehirt, Director, Public Relations & CommunityRelations of UPMC Health Plan, +1-412-454-4953, [email protected]

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

NATICK, Mass., May 16 /PRNewswire-FirstCall/ — Boston Scientific Corporation today announced that results from an international, multi-center patient registry documenting the safety and clinical utility of the SpyGlass(R) Direct Visualization System will be presented at Digestive Disease Week(R) (DDW), which runs from May 17-22 in San Diego, CA. Registry results will be announced in three separate scientific oral presentations scheduled for Tuesday, May 20. In addition, a total of 15 abstracts on the clinical utility of the SpyGlass System will be presented at the conference, underscoring its widespread acceptance in physician practices.

The SpyGlass patient registry reports on clinical data from 296 patients at 15 U.S. and European medical centers who required peroral cholangioscopy (PO) for the treatment or diagnosis of biliary stones or indeterminate strictures with suspected pathology.

The SpyGlass System is the first single-use direct visualization system that requires only a single physician operator and provides four-way steerability in a four lumen single-use catheter. The catheter provides two dedicated irrigation channels in addition to a 1.2 mm working channel through which diagnostic and therapeutic devices can be used in the biliary ducts. The system includes a miniature 6,000-pixel fiber optic probe attached to a camera that provides physicians with a direct view of a patient’s bile ducts, overcoming some of the visual challenges of conventional endoscopic retrograde cholangiography (ERC) procedures.

“We are excited that DDW provides an opportunity to highlight the safety and therapeutic benefits of the SpyGlass System at the one-year anniversary of its worldwide launch,” said Michael P. Phalen, President, Boston Scientific Endoscopy. “We have received positive feedback from the GI community regarding the ability of the SpyGlass System to provide excellent direct visual access to the bile ducts. We have nearly 300 patients enrolled in our comprehensive patient registry, which enables us to build further evidence of the clinical utility of cholangioscopy using the SpyGlass System.” Schedule of SpyGlass Patient Registry Presentations:

   Tuesday, May 20th (all times are PT)   -- Peroral Cholangioscopy Using a Disposable Steerable Single Operator      Catheter for Biliary Stone Therapy and Assessment of Indeterminate      Strictures - A Multi-Center Experience      Yang K. Chen, M.D., Division of Gastroenterology and Hepatology,      University of Colorado at Denver and Health Sciences Center, and      primary principal investigator of the SpyGlass registry, will present      results that document the performance and utility of PO using the      SpyGlass System over a 12-month period.  The presentation will take      place at 4:00 p.m. in Room 1 at the San Diego Convention Center.   -- Peroral Cholangioscopy Guided Stone Therapy - Report of an      International Multi-Center Registry      Mansour Parsi, M.D., Department of Gastroenterology and Hepatology, The      Cleveland Clinic Foundation, and principal investigator in the SpyGlass      registry, will present results on a subset of patients that underwent      PO using the SpyGlass System to determine its effectiveness in the      treatment of difficult-to-remove biliary stones and assess its utility      for the detection of missed stones by ERC.  The presentation will take      place at 4:36 p.m. in Room 1 at the San Diego Convention Center.   -- Biopsy of Indeterminate Biliary Strictures - Does Direct Visualization      Help?      Kenneth F. Binmoeller, M.D., Interventional Endoscopy Services,      California Pacific Medical Center, San Francisco, CA, and principal      investigator in the SpyGlass registry, will present results on a subset      of patients with indeterminate biliary strictures or filling defects      that underwent ERC followed by PO using the SpyGlass System and the      SpyBite(R) Biopsy Forceps.  The lead author of the analysis is Douglas      Pleskow, M.D., Division of Gastroenterology, Beth Israel Deaconess      Medical Center, Boston, MA, and principal investigator in the SpyGlass      registry.  The presentation will take place at 5:00 p.m. in Room 1 at      the San Diego Convention Center.    

The SpyGlass Direct Visualization System will be available for demonstrations at Boston Scientific’s booth #3314. The Company will also offer hands-on demonstration sessions in its Simulated Clinical Endoscopy Suite for the following products: WallFlex(R) Stents, Polyflex(R) Esophageal Stents, Radial Jaw(R) 4 Biopsy Forceps, Resolution(R) Clip, CRE(TM) Balloon Dilators and the RX Biliary System(TM).

About Digestive Disease Week(R)

DDW is the largest international gathering of physicians, researchers and academics in the fields of gastroenterology, hepatology, endoscopy and gastrointestinal surgery. Jointly sponsored by the American Association for the Study of Liver Diseases, the American Gastroenterological Association (AGA) Institute, the American Society for Gastrointestinal Endoscopy and the Society for Surgery of the Alimentary Tract, DDW takes place May 17-22, 2008, at the San Diego Convention Center, San Diego, CA. The meeting showcases approximately 5,000 abstracts and hundreds of lectures on the latest advances in GI research, medicine and technology. For more information, visit http://www.ddw.org/.

About Boston Scientific

Boston Scientific is a worldwide developer, manufacturer and marketer of medical devices whose products are used in a broad range of interventional medical specialties. For more information, please visit: http://www.bostonscientific.com/.

About Boston Scientific Endoscopy

Boston Scientific Endoscopy develops innovative technology for less invasive, more efficient gastrointestinal procedures. We stand beside our physicians, surgeons and nurses, providing comprehensive support locally and through hands-on education and industry sponsorships, to help improve patient outcomes.

Cautionary Statement Regarding Forward-Looking Statements

This press release contains forward-looking statements within the meaning of Section 21E of the Securities Exchange Act of 1934. Forward-looking statements may be identified by words like “anticipate,””expect,””project,””believe,””plan,””estimate,””intend” and similar words. These forward- looking statements are based on our beliefs, assumptions and estimates using information available to us at the time and are not intended to be guarantees of future events or performance. These forward-looking statements include, among other things, statements regarding clinical trials, scientific activities, product performance, competitive offerings and growth investment. If our underlying assumptions turn out to be incorrect, or if certain risks or uncertainties materialize, actual results could vary materially from the expectations and projections expressed or implied by our forward-looking statements. These factors, in some cases, have affected and in the future (together with other factors) could affect our ability to implement our business strategy and may cause actual results to differ materially from those contemplated by the statements expressed in this press release. As a result, readers are cautioned not to place undue reliance on any of our forward- looking statements.

Factors that may cause such differences include, among other things: future economic, competitive, reimbursement and regulatory conditions; new product introductions; demographic trends; intellectual property; litigation; financial market conditions; and, future business decisions made by us and our competitors. All of these factors are difficult or impossible to predict accurately and many of them are beyond our control. For a further list and description of these and other important risks and uncertainties that may affect our future operations, see Part I, Item 1A- Risk Factors in our most recent Annual Report on Form 10-K filed with the Securities and Exchange Commission, which we may update in Part II, Item 1A – Risk Factors in Quarterly Reports on Form 10-Q we have filed or will file thereafter. We disclaim any intention or obligation to publicly update or revise any forward- looking statements to reflect any change in our expectations or in events, conditions, or circumstances on which those expectations may be based, or that may affect the likelihood that actual results will differ from those contained in the forward-looking statements. This cautionary statement is applicable to all forward-looking statements contained in this document.

    CONTACT: Paul Donovan             508-650-8541 (office)             508-667-5165 (mobile)             Media Relations             Boston Scientific Corporation              Larry Neumann             508-650-8696 (office)             Investor Relations             Boston Scientific Corporation  

Boston Scientific Corporation

CONTACT: Media Relations, Paul Donovan, +1-508-650-8541 (office),+1-508-667-5165 (mobile), or Investor Relations, Larry Neumann,+1-508-650-8696 (office), both of Boston Scientific Corporation

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We know that vitamin D helps the bones by preventing osteoporosis and fractures, but did you know that vitamin D also plays an important role in the prevention of many other diseases, including cancer, heart disease, autoimmune diseases like MS and type 1 diabetes, arthritis, infections, chronic pain and muscle weakness? Here is the latest research on this versatile vitamin:

_Vitamin D helps pain control. A fascinating study from the Mayo clinic published last month online in the journal Pain Medicine looked at vitamin D levels in people with chronic pain. They found that those patients who had low vitamin D levels required almost twice as much narcotic pain medication compared to those with normal levels. The vitamin D deficient folks also perceived their health as poor. Another study from the Mayo Clinic in 2003 looked at the prevalence of vitamin D deficiency in people aged 10-65 with chronic pain syndromes like fibromyalgia and chronic fatigue _ 93 percent of them were found to be vitamin D deficient.

_Vitamin D helps the heart. A study published last month in the journal Circulation looked at the impact of vitamin D blood levels on heart health in people with high blood pressure. Participants in the study with low vitamin D levels were two times as likely to have angina, a heart attack, heart failure and stroke compared to those with normal vitamin D levels.

_Vitamin D reduces the risk of falls. Another study from the Archives of Internal Medicine published in March of this year looked at the effect of vitamin D supplements on falls in older women. A team of researchers in Australia gave 1,000 IU of vitamin D per day to 300 women aged 70-90, all of whom had low blood levels of D and who had also fallen in the past year. They found that in those women who had fallen once in the past year, vitamin D supplementation reduced the risk of falls, but only in the winter months when the sun’s rays are weaker and less vitamin D is made in the skin. In women who had fallen multiple times, vitamin D did not seem to help, possibly because these women were more frail and were falling for other reasons.

Who is deficient in vitamin D? Perhaps you are! Multiple studies of adults have suggested a widespread incidence of low vitamin D blood levels of less than 30 ng/ml. An adequate blood level is probably at least 40-60 ng/ml. It is estimated that 25 to 100 percent of adults are deficient, depending on the population and time of year; many children are deficient as well.

Primitive people used to rely on sun exposure for all of their vitamin D; nowadays however, most of us work inside, and when we do go out, we slather on the sun screen which impairs our ability to make vitamin D. Older folks, people of color and people who live at higher latitudes are also at higher risk of deficiency. Most vitamin D in food, such as dairy products, does not occur naturally; it is added as a supplement, and is not considered a reliable form of intake as amounts may vary from product to product. The old recommended amounts of 200-400 IU/day are no longer considered adequate; most of us need at least 800-1,000 units per day.

Bottom line? It may help you to take supplemental vitamin D 1,000 IU per day of vitamin D3 (cholecalciferol) should do the trick.

Kaiser Permanente awarded mentoring scholarships to 12 medical students committed to providing quality and sensitive care to Southern California’s uniquely diverse patient population. Each awardee will participate in a mentoring program with a Kaiser Permanente clinician, complete a 4-6 week clinical rotation at a Kaiser Permanente facility, and receive a $5,000 scholarship for their education.

The Kaiser Permanente Oliver Goldsmith, MD, Scholarship program is dedicated to the promotion and advancement of culturally responsive care, and it is named after Dr. Goldsmith, who championed this issue throughout his career at Kaiser Permanente before he retired in 2003 as the medical director of the Southern California Permanente Medical Group (SCPMG). With this year’s awardees, the program, which was established in 2004, will have given out 41 awards and a total of $205,000 to assist medical students.

Jeffrey Weisz, MD, executive medical director of SCPMG, created this program, and said, “I am honored to bestow these awards on such an impressive group of young medical students. They have already demonstrated a commitment to serving all population groups, especially those that have traditionally been underserved. Hopefully, this program will nurture them even more before they start practicing in Southern California.”

Kaiser Permanente continues Dr. Goldsmith’s instrumental efforts in developing culturally responsive care by maintaining initiatives that ensure doctors are prepared to meet the clinical, cultural, and linguistic needs of patients, and that ensure physicians are aware of the varying epidemiologic incidence of disease among different racial, ethnic, and cultural groups. This year’s awardees have demonstrated a commitment to diversity through community service, clinical volunteering, or research.

The mentoring scholarship recipients are a diverse group. Nearly all have roots in Southern California and most are attending local medical schools.

For example, one recipient is Jose Luis Ocampo. Jose is a student in the Drew/UCLA Medical Education Program, where he is a mentorship coordinator for the Latino Medical Student Association. Jose has served as planning coordinator for both the Lennox Health Fair and the Harbor-UCLA Summer Urban Fellowship Health Fair. At the Harbor-UCLA fair, he conducted research in community needs assessment and learned how to implement and evaluate programs that empower medically underserved communities.

Jose said he has a “desire to not only address many of the health issues and medical conditions that disproportionately affect minorities and the poor, but also a desire to advance the science and practice of medicine,” a sentiment that is shared by his fellow mentoring scholarship recipients.

Attached is a sheet that gives brief profiles of the 12 Kaiser Permanente Oliver Goldsmith, MD, Scholarship program awardees.

Kaiser Permanente is one of the nation’s leading integrated health plans. Founded in 1945, it is a nonprofit, group practice prepayment program with Southern California headquarters in Pasadena, California. Kaiser Permanente serves the health care needs of 3.3 million members in Southern California. Today it encompasses the nonprofit Kaiser Foundation Health Plan, Inc., Kaiser Foundation Hospitals and their subsidiaries, and the for-profit Southern California Permanente Medical Group. Kaiser Permanente’s Southern California Region includes more than 55,800 technical, administrative and clerical employees and caregivers, and more than 6,400 physicians representing all specialties. More information about Kaiser Permanente can be found at www.kaiserpermanente.org.

OLIVER GOLDSMITH, MD, SCHOLARSHIP BRIEF PROFILES

OF THE 12 AWARDEES (listed alphabetically)

Ms. Negin Agange

UC Irvine School of Medicine

A student at the University of California, Irvine School of Medicine, Negin Agange is coordinator and founding leader of a student-run free clinic project at UCI. She also helped establish a course elective for the medical school aimed at sustaining the clinic volunteer base and the principles behind the community clinic. In addition to her leadership and community work, Negin is a student in the Medical Education for the Latino Community program, a combined-degree program dedicated to providing the highest quality care to the medically underserved.

Ms. Paola Case

UC Irvine School of Medicine

A student at the University of California, Irvine School of Medicine, Paola Case is secretary of the Latino Medical Student Association and a volunteer for the UC Irvine student-run free clinic. She has a long history of community volunteerism and health education, which has been pivotal in shaping her understanding of culturally competent health care. Paola was also a community mentor at a women’s clinic, which exposed her to the linguistic barriers encountered by patients. Having emigrated from Mexico, Paola uses her bicultural perspective to support culturally relevant, quality medical care, and hopes to enhance her linguistic and clinical skills while training with the Southern California population.

Mr. David Chao

Michigan State University College of Human Medicine

David Chao is a student at Michigan State University, College of Human Medicine. He is the National Hepatitis B Director for the Asian Pacific American Medical Student Association (APAMSA), where he works to improve Hepatitis B awareness and research, and to encourage chapters to reach out to recent immigrant and refugee populations. David is also APAMSA’s chapter president for his medical school, where he focuses on recruitment, diversity education, fundraising, and community-building. He is active on several community initiatives, including serving as a medical student volunteer at Friendship Clinic, where he helps provide basic health care services for low income individuals and families.

Mr. Edward Seung Lee

UCLA School of Medicine

Edward Seung Lee is a student at the David Geffen School of Medicine at UCLA. He is active in learning about community development in different cultures and settings: his pursuit has taken him around the world–from rural Dominican Republic to urban San Jose–working with Latino farmers and Vietnamese immigrants. Edward is a founding Board member and currently chairman of the Board of Directors of the Los Angeles Mission Community Clinic, which gives him an opportunity to use what he’s gained from his unique experiences and to bring about positive health care changes for the underserved and disadvantaged.

Mr. Jose Luis Ocampo

Drew/UCLA Medical Education Program

Jose Luis Ocampo is a student in the Drew/UCLA Medical Education Program, where he is a mentorship coordinator for the Latino Medical Student Association. Jose has served as planning coordinator for both the Lennox Health Fair and the Harbor-UCLA Summer Urban Fellowship Health Fair; at the latter fair, he conducted research in community needs assessment and learned how to implement and evaluate programs that empower medically underserved communities. Jose is co-president of the Family Medicine Interest Group and the Pediatrics Interest Group, where he organizes a lecture series on topics such as covering the uninsured. As a UCLA Mobile Clinic Volunteer, Jose continues to hone his clinical skills in culturally-sensitive medicine.

Mr. Chul-Kyun Park

UC Davis School of Medicine

Chul-Kyun Park is pursuing his medical degree at the University of California at Davis Medical School. He is co-director of the Paul Hom Asian Clinic, a free student-run clinic where he organizes preceptors, medical students, and patient advocates to serve the underserved population in Sacramento County. Since 2005, he has been a Catholic Medical Volunteer, where he helps with the annual health fair, educates people about diabetes, hypertension, and hyperlipidemia, administers flu shots, and performs Dexa-scans for bone density. An immigrant, Chul-Kyun’s commitment to caring for the underserved extends to other countries as well. He is scheduled to serve a small community in Nicaragua during his fourth year of medical school.

Mr. Ricardo Salas

Drew/UCLA Medical Education Program

Ricardo Salas is a student of the Drew/UCLA Medical Education Program. He is a former class president for the UCLA School of Medicine and is currently a medical student representative of the Latino Medical Student Association. Ricardo, who also has a Master of Public Health degree, comes from a family of farm workers. He was an outreach advocate for the San Diego County Cancer Navigator, where he was responsible for advocating the treatment of individuals living with cancer. Many of these individuals were undocumented, and their cases required Ricardo to collaborate with various health care agencies, organizations, and hospitals to help get these individuals proper access to health care.

Mr. Luis Salazar

USC Keck School of Medicine

Luis Salazar is a student at USC’s Keck School of Medicine. He has served in numerous roles for the Latino Medical Student Association, including regional conference coordinator and co-president. He is currently one of only five medical students serving on the Keck School of Medicine Admissions Committee, where he is an advocate for underrepresented minority students. In the community, Luis has taught and mentored students of all ages, promoting science and the medical field for underrepresented groups.

Ms. Mariamawit Tamerat

USC Keck School of Medicine

Mariamawit Tamerat is a student at USC’s Keck School of Medicine. She is co-president of the Student National Medical Association Keck School of Medicine Chapter, where she organizes programs to educate students of color about the medical profession and raise awareness about health issues in underserved communities. Once a month, Mariamawit volunteers for the Tom Bradley Mini Medical School, where she facilitates discussions with fourth grade students about medical topics, such as nutrition and diabetes. Globally, she has worked as a medical volunteer in Ethiopia for Hiwot HIV/AIDS Prevention, where she designed a format for assessing the health of at-risk youth in Ethiopia and taught health education classes.

Mr. Christopher Tang

UCLA School of Medicine

A student at the David Geffen School of Medicine at UCLA, Christopher Tang is the former national vice president of the Asian Pacific American Medical Student Association (APAMSA). In that role, he worked on national media campaigns that helped build public awareness of Asian Americans’ prevalence for diseases such as tuberculosis and Hepatitis B. Christopher also has established a long history of organizing health fairs, mentoring undergraduate minority students, and helping to start a school cultural diversity policy. Internationally, Christopher has traveled to Mexico on medical missions to provide care in poor regions.

Mr. Andres Turner

University of Pittsburgh School of Medicine

Andres Turner is a student at the University of Pittsburgh School of Medicine, where he is a peer advisor for medical students. He has held several leadership roles, including serving as student co-coordinator for Pittsburgh’s only Spanish-speaking free clinic, where he designed and led the first interpreter training and screening program to improve patient safety and quality interpreting services. Andres also founded the “shadowing program” for future volunteer Spanish interpreters at the clinic. His commitment to eradicating health disparities and working with the underserved is also evidenced through his service as a volunteer Spanish medical interpreter in the U.S. and abroad.

Mr. Jesus Ulloa

UC Irvine School of Medicine

A student at the University of California, Irvine School of Medicine, Jesus Ulloa is in the Medical Education for the Latino Community program, a combined-degree program dedicated to providing the highest quality care to the medically underserved. Jesus has worked to strengthen health awareness in disadvantaged communities by serving as a heath promoter, both through Latino Health Access in Santa Ana and with the “Support Team for Health and Community Education” in the Mexican State of Chiapas. In these programs, he recruited and trained people to be health advocates for their communities. Along with classmates, Jesus presented his experiences to the UC Irvine School of Medicine, inspiring fellow classmates to advocate for underserved communities.

By Lee, Yung Tanaka, Motoshi; Carvalho, Jose C A

Background and Objectives: Preprocedural lumbar ultrasound is a valuable tool to assess anatomical landmarks and predict the depth of the epidural space. Variations of the ligamentum flavum sonoanatomy are occasionally observed; however, no literature is available as to their incidence or clinical significance. We hypothesize that abnormal sonoanatomy of the lumbar spine detected by ultrasound can be associated with an increase in unintentional dural punctures. This study was undertaken to determine if the sonoanatomy of the lumbar spine of patients who had documented unintentional dural punctures differs from that of patients with a history of uneventful epidural placement for labor analgesia. Methods: Ultrasound of the entire lumbar spine was performed on 18 patients with a documented history of unintentional dural punctures, and 18 volunteers with a history of uneventful labor epidurals. At each interspace, we studied the quality of the ligamentum flavum (normal or abnormal), the symmetry of the bony structures (symmetric or asymmetric), and the distance from the skin to the ligamentum flavum. These parameters were compared in both groups.

Results: The incidence of asymmetric sonoanatomy and the distance from the skin to the ligamentum flavum was similar in both groups. The incidence of abnormal ligamentum flavum sonoanatomy was higher in the dural puncture group (overall odds ratio for the 5 interspaces was 8.21, 95% confidence interval 3.07-22.0, P

Conclusions: Abnormal sonoanatomy of the ligamentum flavum may represent anatomical variations of this structure, which may be related to an increased incidence of unintentional dural punctures during epidural placements. Reg Anesth Pain Med 2008;33:266-270.

Key Words: Unintentional dural puncture, Epidural anesthesia, Ligamentum flavum, Spinal sonoanatomy, Spinal ultrasound.

Epidural analgesia is the most common technique used to control labor pain. Although it has a high success rate, it is associated with some complications, notably unintentional dural punctures, ranging from 0.6% to 1.6%.1,2 Unintentional durai punctures might be related to the operator’s skill or to the individual’s anatomical variations. There are limited data in the literature to suggest the relative contribution of either factor.

The presence of a normal ligamentum flavum is fundamental to successfully identifying the epidural space when the loss of resistance technique is used during epidural needle placement. However, many studies have reported the presence of ligamentum flavum midline gaps, and implicated them as a potential cause of failure to recognize the loss of resistance.3,4 It is unknown whether these midline gaps and other ligamentum flavum abnormalities play a clinically significant role by increasing the risk of unintentional durai punctures.

Ultrasound has recently been introduced to facilitate the placement of epidurals, and the sonoanatomy of the lumbar spine is usually quite distinct and easily identified.5,6 Sometimes, however, some of the distinguishing elements of the pattern are not present, notably the ligamentum flavum. The exact significance of these abnormal patterns is unknown. There have been no previous reports correlating abnormal sonoanatomy of the lumbar spine with technical difficulties or complications during epidural insertion.

We hypothesize that abnormal sonoanatomy of the lumbar spine can be detected by ultrasound, and can be associated with an increase in complications of epidural placement. This study was undertaken to determine if the sonoanatomy of the lumbar spine of patients who had documented unintentional durai puncture is different than that of patients with a history of uneventful epidural placement for labor analgesia.

Methods

This case-control study was conducted after obtaining approval from the Mount Sinai Hospital Research Ethics Board and signed informed consent from the participants.

For the study group, the cases were selected from a database of 94 patients who had previously experienced a documented unintentional durai puncture during their labor epidurals. For the control group, staff volunteers working on the labor and delivery unit who had received uneventful epidurals in the past were recruited. All participants with known/visible spinal deformities, and those with previous lumbar spine surgery, were excluded from the study. In all the patients, the unintentional durai puncture had occurred during a midline approach.

Each of the participants underwent a Ll-Sl spine ultrasound scan with the aid of a portable MicroMaxx Ultrasound System equipped with a 2-5 MHz curved array probe (Sonosite Canada Inc, Markham, Ontario, Canada). All three investigators had been using ultrasound routinely for the placement of epidurals for at least 6 months. Images were obtained with the participants in the sitting position. The scanning consisted of a longitudinal approach to locate the interspaces L5- S1 to Ll-2, and a transverse approach for each of the interspaces. First, a paramedian longitudinal scan was performed by positioning the ultrasound probe vertically and perpendicularly to the long axis of the spine. The probe was initially placed over the sacrum, 3 cm to the left of the midline. At this point, a continuous hyperechoic line representing the ultrasound image of the sacrum was visualized. The probe was then moved cephalad until a hyperechoic saw-like image representing the articular processes and the interspaces was seen on the ultrasound screen. The exact level of each of the interspaces was pen-marked on the skin. Once the interspaces were determined, a transverse scanning of each individual interspace was performed. The spinous process, corresponding to the midline of the spine, was identified as a hyperechoic signal immediately underneath the skin, and continuing as a long vertical triangular hypoechoic acoustic shadow. The probe was then moved cephalad or caudad to capture a view of an acoustic window (interspace), which contained the ligamentum flavum, dorsal dura, durai sac, ventral dura, posterior longitudinal ligament, and vertebral body. Within the interspace, on the midline, a hyperechoic band corresponding to the ligamentum flavum and the dorsal dura was visualized. A second hyperechoic band, parallel to and deeper than the first band, corresponded to the ventral dura, posterior longitudinal ligament, and vertebral body unit. In addition to these midline structures, paramedian hyperechoic structures corresponding to the transverse and articular processes on each side were visualized on the same screen.

For each interspace, the best possible image of the transverse approach was captured and saved. At least 2 out of the 3 investigators were present and agreed upon the best images for each of the patients enrolled. Upon completion of all the cases, the 3 investigators reviewed and analyzed each image obtained for the presence of normal ligamentum flavum, and symmetry of the structures. The conclusion was based on at least 2 investigators agreeing on the images. The investigators were not blinded to the study groups or to each other’s assessments.

The primary outcome of this study was the presence of an abnormal ligamentum flavum, as seen in the transverse approach. Sonoanatomy of the ligamentum flavum was described as either normal or abnormal. It was considered normal if a hyperechoic midline band, aligned with the hyperechoic signals of the transverse processes, was present and continuous (Fig 1). Conversely, it was defined as abnormal if a hyperechoic midline band was either absent or grossly discontinuous (Fig 2). When the ligamentum flavum was described as normal, the image was frozen and the ligamentum flavum depth was measured using a built-in caliper. This measurement was a secondary outcome of our study. The other secondary outcome was the symmetry of structures in relation to the midline. At each interspace, symmetric anatomy was described if the distances measured from the left and right articular processes and the transverse processes to the midline appeared to be the same, and the size and location of the articular and transverse processes also appeared to be similar on each side (Fig 1). When one of the above conditions was not satisfied, the interspace was considered asymmetric (Fig 3).

Fig 1. Normal lumbar spine sonogram with symmetric anatomy and typical ligamentum flavum (LF). AP, articular process; TP, transverse process; VB, vertebral body.

Statistical Analysis

For abnormal and asymmetric outcomes, exact (mid-P adjusted) P values and 95% confidence intervals (CI) of the odds ratios (OR) were calculated using StatXact Version 3 software (Cytel Software Corp, Cambridge, MA). The overall OR for each of these binary outcomes (with 95% CI and P value) was estimated by modeling the data using a generalized estimating equation (GEE) approach and an autoregressive (AR(I)) covariance structure to model the within- subject correlation using Proc GENMOD in SAS Version 9.1.3 (SAS Institute, Gary, NC).

Skin-ligamentum flavum depth data were log transformed to make the variances at each interspace independent of the means, so relative differences between groups are estimated. SAS Proc MIXED was used to model the data using a mixed linear model with an autoregressive covariance structure and heterogeneity between groups, as there was some evidence of a greater variance in the control group. At each interspace, the unequal variances f test was used to test for differences between groups using the SAS Proc TTEST. Fig 2. Abnormal lumbar spine sonogram with discontinuous ligamentum flavum (LF). AP, articular process; TP, transverse process; VB, vertebral body.

Fig 3. Abnormal lumbar spine sonogram with asymmetric articular processes (AP) and only a partial view of the vertebral body (VB). LF, ligamentum flavum; TP, transverse process.

Results

For the study group, the information was sent to 94 potential participants by regular mail, but only 41 could be reached by telephone. Of the 41 reached, 24 agreed to participate but only 18 came to the appointment. For the control group, 18 staff volunteers were recruited. Patients were recruited between March 22 and July 23, 2007.

The mean +- SD for age, height, and weight in the study and control groups respectively were 35 +- 4 years and 42 +- 10 years; 160 +- 13 cm and 162 +- 5 cm; and 59 +- 12 kg and 61 +- 9 kg.

The incidence of asymmetric sonoanatomy and abnormal ligamentum flavum, and the ligamentum flavum depth as measured by ultrasound, are presented in Table 1. Both groups were similar with respect to the incidence of asymmetric sonoanatomy, and the distance from the skin to the ligamentum flavum. No patient had a distance from the skin to the ligamentum flavum less than 3 cm (range 3.42-7.21 cm). The incidence of abnormal ligamentum flavum sonoanatomy was significantly higher in the group of patients that had experienced durai punctures, especially at the levels of L4-5 and L3-4 (overall OR 8.21, 95% CI 3.07-22.0, P

Discussion

Cork et al.7 and Currie8 were the first to observe a strong correlation between the depth of the epidurai space as estimated by ultrasound and the actual depth as confirmed by the epidural needle insertion. Further to those publications. Grau et al.6,9-12 and Arzola et al.5 also used ultrasound to assist epidurals, and proved its efficacy and consistency for localizing the site of needle insertion, and predicting the depth of the epidural space. All ultrasound estimations of the epidural space depth in the aforementioned studies relied on the presence of a clear ultrasound image of the ligamentum flavum. However, the image of this fundamental structure is sometimes grossly abnormal or entirely missing. There have been no previous reports on either the incidence of these abnormal patterns, or on the correlation of these abnormal patterns with technical difficulties or complications.

Table 1. Incidence of Asymmetric Anatomy and Abnormal Ligamentum Flavum and Skin-Ligamentum Flavum Distances at Different Interspaces

The present study compared the lumbar sonoanatomy of patients, who had previous documented unintentional durai punctures, to that of volunteers, who had uneventful labor epidurals. The results clearly indicated a higher incidence of abnormal sonoanatomy in the durai puncture group. While 72% of the study group sonograms showed abnormal patterns at level L4-5, only 17% of the control group images were abnormal at the same interspace. Significant discrepancies between the 2 groups were also observed at L3-4 and L5- S1.

The differences between the groups with respect to asymmetric sonoanatomy, and depth of the ligamentum flavum, conversely, were not significant. Asymmetric spine anatomy and “shallow” epidural space are commonly associated with a higher incidence of unintentional durai punctures, although a systematic correlation has never been established. In the general population, the distance from the skin to the epidural space, on the midline, varies from 4.23 cm to 4.93 cm on average, depending on the spinal level.13 The skin to ligamentum flavum distances measured in the present study were consistent with those findings.

Ligamentum flavum midline gaps have been documented in many anatomical and radiological studies, and are believed to be a cause of failure to recognize the loss of resistance to air or saline.3,4 Anatomical studies involving the direct dissection of embalmed cadavers showed the presence of ligamentum flavum midline gaps in variable frequencies at cervical and high thoracic,14 low thoracic,3 and lumbar4 levels. Hogan investigated cadavers by cryomicrotomy and also found, at the lumbar levels, a variable incidence of ligamentum flavum midline gaps.15 Lirk et al. were the first to document the frequency of lumbar spine ligamentum flavum midline gaps.4 Their results showed a frequency of up to 22.2%, with a higher incidence in the upper lumbar interspaces. In contrast to their results, our study showed a higher incidence of abnormal ligamentum flavum sonoanatomy at the lower lumbar interspaces. At this point in time, we can only suggest that the abnormal sonoanatomy does not necessarily reflect midline gaps, but rather something else to be further clarified.

Modern advances in medical imaging, such as computerized tomography and magnetic resonance imaging,16-18 have made it possible to evaluate the lumbar spine anatomy, ligamentum flavum included, without the potential for causing artifacts, such as in cadaver dissection. Further studies comparing images obtained by ultrasound and these other methods should be performed to clarify our results.

This study has limitations. First, the investigators were not blinded to the groups. We tried to minimize this factor by having all 3 investigators review the images. The final decision for each image was based on at least 2 agreeing on the assessment. second, this is the first study to investigate abnormal sonoanatomy patterns of the lumbar spine, and we are uncertain about the clinical relevance of our findings. Moreover, we are unable to rule out technical artifacts inherent in the imaging method as the cause of our results. In any case, there is a clear difference between normal and abnormal sonoanatomy, and this is what is clinically accessible at the bedside to guide clinicians.

In our opinion, lumbar spine ultrasound is a very useful clinical tool to facilitate epidural needle placement. It may be possible that, by detecting abnormal sonoanatomy, we can decrease complications such as unintentional durai punctures. Further prospective studies are necessary to prove our hypothesis. Until that happens, we suggest that clinicians should choose the interspace with the clearest sonoanatomy whenever ultrasound is being used to facilitate epidural placement.

Acknowledgments

The authors acknowledge Mr. Robert K. Parkes, B.Math, M.Sc., Senior Biostatistician, Samuel Lunenfeld Research Institute, Mount Sinai Hospital, for the statistical analysis.

References

1. Pan PH, Bogard TD, Owen MD. Incidence and characteristics of failures in obstetric neuraxial analgesia and anesthesia: A retrospective analysis of 19,259 deliveries. Int J Obstet Anesth 2004:13:227-233.

2. Okell RW, Sprigge JS. Unintentional durai puncture: A survey of recognition and management. Anaesthesia 1987;42:1110-1113.

3. Lirk P, Colvin J, Steger B, Colvin HP, Keller C, Rieder J, Kolbitsch C, Moriggl B. Incidence of lower thoracic ligamentum flavum midline gaps. Br J Anaesth 2005; 94:852-855.

4. Lirk P, Moriggl B, Colvin J, Keller C, Kirchmair L, Rieder J, Kolbitsch C. The incidence of lumbar ligamentum flavum midline gaps. Anesth Analg 2004;98: 1178-1180.

5. Arzola C, Davies S, Rofaeel A, Carvalho JCA. Ultrasound using the transverse approach to the lumbar spine provides reliable landmarks for labor epidurals. Anesth Analg 2007; 104:1188-1192.

6. Grau T, Leipold RW, Conradi R, Martin E, Motsch J. Efficacy of ultrasound imaging in obstetric epidural anesthesia. J Clin Anesth 2002; 14:169-175.

7. Cork R, Kryc J, Vaughan R. Ultrasonic localization of the lumbar epidural space. Anesthesiology 1980;52: 513-516.

8. Currie JM. Measurement of the depth to the extradural space using ultrasound. Br J Anaesth 1984;56: 345-347.

9. Grau T, Leipold RW, Conradi R, Martin EO, Motsch J. Ultrasound imaging facilitated localization of the epidural space during combined spinal and epidural anesthesia. Reg Anesth Pain Med 2001;26:64-67.

10. Grau T, Leipold RW, Horter J, Conradi R, Martin EO, Motsch J. Paramedian access to the epidural space: The optimum window for ultrasound imaging. J Clin Anesth 2001;13:213-217.

11. Grau T, Leipold RW, Horter J, Conradi R, Martin EO, Motsch J. The lumbar epidural space in pregnancy: Visualization by ultrasonography. Br J Anaesth 2001; 86:798-804.

12. Grau T, Leipold RW, Conradi R, Martin E. Ultrasound control for presumed difficult epidural. Acta Anaesth Scand 2001;45:7660 – 771.

13. Harrison GR, Clowes NWB. The depth of the lumbar epidural space from the skin. Anaesthesia 1985;40: 685-687.

14. Lirk P, Kolbitsch C, Putz G, Colvin J, Colvin HP, Lorenz I, Keller C, Kirchmair L, Rieder J, Moriggl B. Cervical and high thoracic ligamentum flavum frequently fails to fuse in the midline. Anesthesiology 2003;99:1387-1390.

15. Hogan QH. Epidural anatomy examined by cryomicrotome section. Influence of age, vertebral level, and disease. Reg Anesth 1996;21:395-406.

16. Harrison GR. Topographical anatomy of the lumbar epidural region: An in vivo study using computerized axial tomography. Br J Anaesth 1999;83:229-234.

17. Westbrook JL, Renowden SA, Carrie LES. Study of the anatomy of the extradural region using magnetic resonance imaging. Br J Anaesth 1993;71:495-498.

18. Grenier N, Kressel HY, Schiebler ML, Grossman RL Dalinka MK. Normal and degenerative posterior spinal structures: MR imaging. Radiology 1987;165:517-525.

Yung Lee, M.D., Motoshi Tanaka, M.D., and Jose C. A. Carvalho, M.D., Ph.D., F.A.N.Z.C.A., F.R.C.P.C.

From the Department of Anesthesia and Pain Management (Y.L., M.T., J.C.A.C.), and Obstetrics and Gynecology (J.C.A.C.), Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.

Accepted for publication December 19, 2007. Financial source: Departmental funds. Disclosures: None of the authors has any conflict of interest relative to this project.

Reprint requests: Jose C. A. Carvalho, M.D., Department of Anesthesia and Pain Management, Mount Sinai Hospital, 600 University Avenue, Room 781, Toronto, Ontario M5G 1X5, Canada. E-mail: [email protected]

(c) 2008 by the American Society of Regional Anesthesia and Pain Medicine.

1098-7339/08/3303-0001$34.00/0

doi:10.1016/j.rapm.2007.12.002

Copyright Churchill Livingstone Inc., Medical Publishers May/Jun 2008

(c) 2008 Regional Anesthesia and Pain Medicine. Provided by ProQuest Information and Learning. All rights Reserved.

By Tsui, Ban C H Ozelsel, Timur J-P

To the Editor: Ultrasound-guided anterior sciatic nerve block has been described using a medially positioned curved array probe to scan the nerve transversely at the anterior proximal thigh (Fig I).1 The ultrasound image of sciatic nerve in cross section is typically seen as an oval-to-circular hyperechoic structure deep to the adductor muscles (Fig 2).1,2,3 It is often vaguely delineated or appears isoechoic to the surrounding muscles (anisotropic), the latter particularly if using a tangential ultrasound beam plane.2 In our experience, identification of the sciatic nerve with the sole use of transverse scanning is usually difficult if not impossible in most patients, particularly in those who are obese and when using a portable ultrasound system (MicroMaxx, SonoSite Inc., Bothell, WA). This may be due to the fact that the sciatic nerve is deep to relatively thick muscles and is potentially hidden behind the acoustic shadow of the femur, depending on the rotation of the leg. We felt that the imaging technique for this block needed improvement to increase the reliability of nerve localization.

Fig 1. Schematic diagram of the probe positioning and movements during scanning to identify the sciatic nerve. (A) The probe (rectangle) is placed to capture a transverse view of nerve. (B) The sagittally placed probe can be tilted medially or laterally to optimize the longitudinal view of the nerve.

The sciatic nerve is the largest nerve of the body; however, blocking this deep nerve remains one of the most challenging procedures for an ultrasound-guided approach. The nerve exits through the sciatic notch and passes anteriorly to the piriformis muscle to then lie between the ischial tuberosity and the greater trochanter of the femur. It curves caudally and descends the posterior thigh adjacent and almost parallel to the femur (Fig 1). From the anterior aspect, the sciatic nerve continues its longitudinal course deep to the adductor magnus muscle, superficial to the biceps femoris muscle, and immediately adjacent to the lesser trochanter of the femur. Based on the distinct anatomical course of the sciatic nerve from the anterior perspective, we have discovered that the nerve can be more consistently visualized along its longitudinal axis when compared with its transverse axis. In contrast to the small oval shadow in transverse view, the nerve appears as a long cable-like structure with a characteristic fascicular pattern in longitudinal view. This maximizes the amount of nerve exposed under the ultrasound beam. In this view, we find it easier to identify the sciatic nerve not only as a more hyperechoic, linear structure deep to the clearly delineated adductor magnus muscle, but also without the influence of the position of the lesser trochanter (Fig 2).

To perform a longitudinal ultrasound-guided approach for an anterior sciatic nerve block, one needs to use a low-frequency curved ultrasound transducer (e.g., C-60, MicroMaxx, Sonosite, Bothell, WA). In general, a longitudinal view of the nerve can be immediately obtained by directly placing the probe sagittally/ longitudinally over the medial side of the upper midthigh at a level similar to the typical anterior block needle insertion site, in the gap between the sartorius and rectus femoris muscles.4 The image can be further optimized by tilting the scanner medially and laterally (Fig 1). The nerve is typically located medial to the femur bone and approximately 6 to 10 cm deep to the skin. If uncertainty remains as to where the muscle gap is, rotating the probe to the transverse axis may be helpful. In this transverse view, one can simply place the hyperechoic femur shadow at the lateral edge of the screen and the transducer is then rotated back 90 degrees to obtain a longitudinal image of the target structure. With this maneuver, a clear view of the distinct cable-like fascicular structure crossing from one side to the other is often obtained with ease.

Fig 2. Images of the sciatic nerve (indicated by arrowheads) in the anterior thigh. (A) Cross-sectional and (B) longitudinal views of a thigh in a cadaver. The sciatic nerve (SN) is medial to the femur (F) and its consistent cable-like structure deep to the adductor magus (AM) muscle continues during the majority of its course in the thigh. Ultrasound images from a live adult using corresponding (C) transverse and (D) longitudinal views. The large cable-like structure of the sciatic nerve in the longitudinal view is more readily identifiable than the small oval shadow in the transverse view. (A) and (B) were generated with permission using Visible Human Visualization Software.3

Once accurately positioning the needle in plane (aligned) to the ultrasound beam’s longitudinal axis, one is able to view the entire needle during its trajectory (to improve the safety of the block) and then confirm the nerve’s identity using an optimal nerve stimulation threshold (0.4-0.5 mA). From experience, we have had an easier time following the course of the needle tip when directing the needle from cephalad to caudad. More often than not, a fascial “click” can be felt when the needle tip passes through the posterior fascia of the adductor magnus. After nerve localization, local anesthetic solution can be injected. In this longitudinal view, it is also very reassuring to be able to observe the spread of local anesthetic solution along the sciatic nerve. We have found this approach to be very practical and now have little trouble performing these blocks using in plane real time ultrasound guidance. As technology advances and we gain more experience with the application of ultrasound in regional anesthesia, there will be a continual search for “expanding the view” using different angles or approaches in visualizing the target nerve.

References

1. Chan VW, Nova H, Abbas S, McCartney CJL, Perlas A, Xu DQ. Ultrasound examination and localization of the sciatic nerve: A volunteer study. Anesthesiology 2006;104:309-314.

2. Chantzi C, Saranteas T, Zogogiannis J, Alevizou N, Dimitriou V. Ultrasound examination of the sciatic nerve at the anterior thigh in obese patients. Ada Anaesthesiol Scand 2007;51:132.

3. Visible Human Visualization Software, courtesy Ecole Polytechnique Federale de Lausanne, http://visiblehuman.epfl.ch.

4. Meier G, Buettner J. Proximal sciatic nerve block. In: Meier G, Buettner J, eds. Peripheral Regional Anesthesia: An Atlas of Anatomy and Techniques. New York: Thieme; 2006:126-158.

Accepted for publication November 28, 2007.

doi: 10.1016/j.rapm.2007.11.008

Ban C.H. Tsui, M.D., M.Sc., F.R.C.P.(C)

Timur J.-P. Ozelsel, M.D., D.E.S.A.

Department of Anesthesiology and Pain Medicine

University of Alberta Hospital

Edmonton, Alberta, Canada

Copyright Churchill Livingstone Inc., Medical Publishers May/Jun 2008

(c) 2008 Regional Anesthesia and Pain Medicine. Provided by ProQuest Information and Learning. All rights Reserved.

By Sheryl Ubelacker, THE CANADIAN PRESS

TORONTO – Nearly one-fifth of the nurses in hospitals across the country acknowledge making errors when giving patients medications, with understaffing and working too much overtime primarily blamed for the likelihood of those mistakes occurring, a report by Statistics Canada says.

In its report released Wednesday, Statistics Canada said that in settings in which nurses ended up working beyond their regular shifts due to understaffing and inadequate resources, patients were more likely to receive the wrong medication or dosage.

The study is based on findings from a 2005 survey of 19,000 nurses, which found 19 per cent of respondents reported having made “occasional” or “frequent” drug errors in the previous year while caring for patients.

The study found there was a strong link between medication mistakes and workplace organization and environment, including covering some nursing shifts through overtime, increasing workload, perceived staffing shortages, unsupportive colleagues and poor on-the-job relations with doctors.

“The study is very clear that these errors are not related to the nurses’ experience or level of education and that these are truly related to aspects of the work environment,” said Lisa Little, acting director of public policy for the Canadian Nurses Association.

“And these aspects are things around role overload, which means that nurses are caring for many more patients than they used to,” she said Wednesday from Ottawa.

“So nurses may have had five patients in a medical ward to look after and now they’re looking after eight or nine patients. And what does that mean about the time that you have to spend with patients and the quality of care and how rushed you are that can lead to those kinds of errors happening?”

The survey found that nurses face a broad range of physical and emotional challenges in a demanding and often hectic workplace.

“It validates what we know that nursing work environment is inadequate to support quality patient care, so too often nurses are having to work in situations where they’re understaffed, where they’re working overtime, where they may not have the resources they need,” said Prof. Diane Doran, who specializes in patient health at the University of Toronto’s faculty of nursing.

“So your workload is higher than what is optimal, and it’s a combination of those factors that leads to bad outcomes like medication errors,” she said.

The study found that among registered nurses who routinely worked overtime, 22 per cent reported making medication mistakes, compared with 14 per cent of those who did not work extra hours.

“Nurses who are, I don’t want to say forced, but are strongly encouraged to come in on their days off and work overtime because they’re short-staffed, there’s an element of fatigue that probably comes into play on this,” said Little, adding that appropriate levels of work hours for nurses need to be looked into.

Dealings with physicians also appeared to affect performance: among nurses whose working relations with doctors were least favourable, 27 per cent reported medication error, compared with 12 per cent among those with good nurse-doctor interactions.

Little said the study showed that most respondents reported good on-the-job rapport with doctors.

“I think that perhaps when there is not a good collegial relationship, the nurses may not feel comfortable to go back and approach the physician to say: ‘I’m not really sure what you said there. Can you clarify that.”‘

The study also found that nurses who perceived they were not getting enough support from co-workers were significantly more likely to report medication errors than were those who felt more bolstered by colleagues.

Low co-worker support might result from inadequate staffing as busy and stressed nurses may be less able or unwilling to help their colleagues, the study authors suggested.

Linda McGillis Hall, associate dean of research for the University of Toronto’s nursing department, said she is in the midst of studying the impact of interruptions faced by hospital RNs as they care for patients.

Those concentration-destroying disturbances can include questions from co-workers, meeting demands from patients and the general hubbub of a hospital ward – from the sounds of call bells and pages to noisy equipment.

“When a nurse is preparing a medication and trying to think it through and drawing it up, if you have all kinds of environmental noise, that can cause interruptions as well,” McGillis Hall said.

“One of the things we found when I did a pilot test was when nurses were interrupted it was leading to medication errors or delays in procedures or treatments or delays in medication.”

Little said there is a nursing shortage across the country that affects hospitals and other health-care facilities, both large and small.

“It’s systemic,” she said.

“Nurses are telling us it’s not healthy for the patients, it’s not healthy for them … they’re committed to their patients, but they need the support of the employer and work environment to help them do their jobs safely and effectively.”

McGillis Hall said the fact that nurses are admitting to medication errors should be seen as a good thing by the public.

“I think it’s really important that we have a climate or a culture where people do come forward and identify errors,” she said.

“It means that health-care workers, nurses in particular, are becoming more transparent, and that means they’re reporting them and organizations are trying to respond and do something about it.”

EL PASO, Texas, May 14 /PRNewswire/ — Texas Community Care, a subsidiary of Arcadian Health Plan, has provided Medicare Advantage plans for the El Paso community for three years. Although their business is healthcare, Texas Community Care’s local involvement goes beyond serving that one section of the community.

When expanding a portion of their corporate operations, Texas Community Care looked first to the community they serve. Since November of 2007, the Member Services team supporting all of Arcadian Health Plan’s national operations has maintained a staff location in El Paso. This decision was made in hopes of supporting the economic development of the area by providing jobs in the community, and Texas Community Care has been greatly pleased by the talent they have found in El Paso.

Texas Community Care feels fortunate to be able to contribute to the economy of such a vibrant area. “It has been exciting to be a part of the Arcadian Health Plan expansion in El Paso,” says Diana Mauk, Manager of Member Services in El Paso. “Our customer care representatives take pride in walking our members through Medicare every step of the way.”

One of the original Arcadian Health Plan markets, Texas Community Care provides El Paso’s Medicare-eligible population with an alternative option for Medicare coverage (called Medicare Advantage Plans, or Medicare Part C). Their health plans help Medicare beneficiaries keep their costs low by offering more benefits than original Medicare and lower copays on many essential benefits such as routine physical exams. Texas Community Care serves a membership of over 7,000.

“Arcadian Health Plan’s goal has always been to choose mid-size to smaller markets to enter so that we’re able to interact with members and health care providers on a personal level,” said Garrison Rios, Chief Marketing Officer for Arcadian Health Plan.

A long-term player in the El Paso community, Texas Community Care looks forward to serving their members and the El Paso community as a whole through 2008 and beyond.

Please contact Garrison Rios for more information on Texas Community Care’s involvement in the El Paso community. 800-699-5125 ext. 1042.

Arcadian Health Plan

CONTACT: Garrison Rios, 1-800-699-5125, ext. 1042, for Arcadian HealthPlan

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

It’s the number one complication of pregnancy, affecting an estimated 10 to 15 percent of new mothers, according to a recently-released analysis by the CDC. But until El Camino Hospital in Mountain View, California opened its Maternal Outreach Mood Services Program this month, there wasn’t a single hospital program in Northern California devoted to diagnosis and treatment of perinatal mood disorders.

The hospital’s new regional program serving all of Northern California provides free assessment, and outpatient referral to community-based counseling and support services. It also offers a day treatment program, including group and individual counseling and evaluation by the program’s medical director, Dr. Nirmaljit Dhami.

The program was born of a response to growing concerns about the substantial unmet mental health needs affecting pregnant and postpartum women in the community. El Camino Hospital’s departments of Maternal Child Health and Behavioral Health Services convened a multi-disciplinary task force in November 2006 to look at the problem, and found not a single other hospital in Northern California had a program addressing this need. And even though a majority of obstetricians said they screen for postpartum depression, many said they need help identifying referral and treatment resources for their patients, with nearly two-thirds citing an insufficient number of psychiatrists with expertise in postpartum mood disorders.

“There’s a huge need for education about this problem–even in the physician community,” said Kris Peterson, MFT, Perinatal Mood Specialist. “Problems often are dismissed by family members, primary care physicians, and even obstetricians as ‘just baby blues.’ But while many new mothers may experience a short period of weepiness and worry, anything that lasts longer than about two weeks is more than baby blues. Postpartum depression is most easily treated when it is caught early and our program is designed to provide intensive, focused treatment to prevent the progression of symptoms.”

According to Dr. Dhami, many physicians are frustrated and reluctant to identify depression when they have few options for helping patients deal with it. “Unfortunately, untreated maternal depression and anxiety can cause significant problems for the babies involved, ranging from attachment disorders to cognitive and language delays, and emotional and behavioral problems in childhood and adolescence,” she said. “This is a health issue that has important long term implications.”

The confidential, therapy-based El Camino Hospital program starts with a free assessment and referral to a community provider or support group, if possible. If more intense support is needed, the hospital’s day treatment program is covered by most insurance plans through the mental health coverage. Outpatient moms and infants spend up to five hours a day in intensive individual and group therapy, treated separately from other behavioral health patients.

“For many women, this is the first time they have experienced any significant feelings of depression or anxiety,” Peterson said. “These moms simply don’t fit neatly into the rest of our patient base and treating them together with other patients isn’t a good solution, so we have tailored a program specifically for them.”

Although it can happen to any woman, regardless of prior history or demographics, there are several risk factors that increase vulnerability to mood disorders, including a personal or family history of depression, anxiety or bipolar disorder; marital and financial problems; major recent life changes such a move or job loss or change; inadequate social support; or fertility problems. Teen mothers appear to have an elevated risk, too.

“The good news is that it’s a very treatable condition with a high successful outcome rate,” Peterson said. “Our goal is to prevent progression.”

For more information or to schedule a complimentary consultation, call 650-988-7841. Details about Maternal Outreach Mood Services may also be viewed online at http://www.elcaminohospital.org/body.cfm?id=1444.

To learn more about El Camino Hospital and its services, visit the web site at www.elcaminohospital.org. For a physician referral, visit our web site or call the El Camino Health Line at 800-216-5556.

Myocor, Inc. announced that its percutaneous iCoapsys™ device was successfully implanted by Dr. Wes Pedersen, an interventional cardiologist with the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, on May 7, 2008.

iCoapsys is one of two Myocor devices designed to treat patients with mitral valve insufficiency caused by heart failure and coronary artery disease (CAD). It is the subject of the Valvular and Ventricular Improvement Via iCoapsys Delivery (VIVID) study, which was conditionally approved for investigational use by the U.S. Food and Drug Administration on November 3, 2007.

According to Dr. Pedersen, “The iCoapsys device offers patients — especially those patients with mitral regurgitation who are not good candidates for major heart surgeries — an innovative, less invasive option designed to treat a debilitating condition. This device and the percutaneous implant procedure, delivered without open-heart surgery, offer the hope of a significant improvement in the patient’s quality of life.”

Reshaping Therapy

The Coapsys® and iCoapsys devices represent two delivery options for a single reshaping therapy designed to address mitral valve regurgitation. Both devices consist of two pads that are positioned on the outside of the heart and connected by a flexible cord. They are designed to reshape the geometry of the heart and to realign the leaflets of the mitral valve to restore valve integrity and function. The original, surgically implanted Coapsys device is currently being evaluated in the RESTOR-MV (Randomized Evaluation of a Surgical Treatment for Off-pump Repair of the Mitral Valve) clinical trial.

Myocor CEO Jim Hickey said, “This first human implant of our iCoapsys device is a significant milestone and a great step forward for the patients who will have the option of a less invasive therapy.”

According the Dr. Pederson, “We are seeing a surge of interest in percutaneous valve procedures. As we demonstrate the safety and efficacy of percutaneously implanting the iCoapsys device, we expect greater interest on the part of primary care physicians and cardiologists. There are significant numbers of patients with functional mitral regurgitation who could eventually benefit from this therapy.”

Dr. Pedersen has significant clinical research experience in percutaneous valve procedures and has been a practicing cardiologist at the Minneapolis Heart Institute since 1991.

About the technology:

The Coapsys® and iCoapsys™ devices are designed to deliver the only complete, less invasive reshaping therapy for Functional Mitral Regurgitation and left ventricle dysfunction. These products are currently for investigational use only.

About the company:

Myocor is a Minneapolis-based, clinical-trial stage medical device company. Its primary focus is on developing pioneering therapies that restore heart geometry and function. By addressing both ventricular and valvular issues, Myocor’s therapies offer a complete reshaping solution for the millions of people worldwide who suffer from debilitating functional mitral regurgitation.

About the Minneapolis Heart Institute Foundation:

Through groundbreaking clinical research and innovative education programs, the Minneapolis Heart Institute Foundation is creating a world without heart disease. Using more effective diagnostic techniques and treatment protocols, the Foundation is improving individuals’ health and reducing the mortality rate associated with cardiovascular disease.

Americare Services, Inc. today announced Value Health Plus will offer as an ancillary service to its comprehensive package of discount healthcare programs for individuals, employees and families Americare’s CallMD physician phone consultation service, a network of physicians available 24/7/365 to answer medical questions and provide non-emergency medical advice.

“VHP’s mission is to provide a comprehensive, practical program that makes it easy for individuals, businesses and families to secure the peace of mind that comes with having access to quality healthcare services at an affordable price. We believe VHP’s value shines forth as gold against today’s backdrop of spiraling healthcare costs and the alarming and growing number of uninsured and underinsured,” said Dwight Dowell, vice president of business development for Value Health Plus. “Americare’s CallMD service is a perfect complement to VHP’s comprehensive menu of healthcare products. We’re always on the lookout for ways to deliver further value to our customers, and we anticipate an enthusiastic response to the CallMD service.”

“CallMD is the answer for people with a non-emergency medical question, or who need a non-narcotic prescription, and would like a doctor’s advice at a time that’s convenient for them — without missing work, or spending hours waiting at the doctor’s office. Our network of licensed medical physicians is available for personal one-on-one phone consultations 24/7/365,” said Edward Mandel, chairman of Americare Services, Inc. “We are very pleased to join ranks with Value Health Plus in making convenient and affordable quality healthcare services available to individuals, families, businesses and organizations. The synergy between our organizations is strong. We are equally committed to providing healthcare programs and services that stand out as timely and relevant options that make quality medical care more accessible to millions, particularly to individuals and businesses most afflicted by our nation’s acute healthcare crisis.”

About Value Health Plus

Value Health Plus, an affiliate of Benefit Plans of America, a discount medical plan organization, provides individuals, families and businesses an affordable, bundled package of healthcare programs, including: the VHP discount medical program for physician office visits, lab services, prescription medications, dental and vision; VBA’s Value Health &Value ER limited benefit insurance plans for inpatient hospital coverage, surgery/anesthesia coverage and ER coverage; and The C.A.R.E. Hospital Program, providing a specially trained case manager to minimize hospital hassles and maximize the value of insurance dollars. For more information visit www.valuehealthplus.com.

About Americare Services, Inc.

Americare Services, Inc. offers an affordable, single-source portfolio of health support services to meet the supplemental healthcare needs of every company, association member, organization, family and individual. Americare’s product offerings include: CallMD, a national physician network for affordable and convenient phone consultation medical advice; CallRN, on-call registered nurses available by phone 24/7/365; FileMD, an online electronic health record (EHR) for secure storing and easy retrieval of up-to-date personal medical information; and DocsServe, an automated, HIPAA-compliant medical and care-related data management service. For more information visit www.americareservicesinc.com.