Promise Healthcare, Inc. Establishes Promise Behavioral Health Division

Promise Healthcare, Inc., a leader in the long-term acute care (LTAC) hospital industry, is enhancing its current behavioral health services and expanding availability of those services to additional markets with its establishment of the Promise Behavioral Health (PBH) Division. The announcement was made today by Promise Healthcare, Inc. Chairman and Chief Executive Officer Peter R. Baronoff.

PBH will help to ensure the delivery of high quality, cost-effective, acute inpatient and intensive outpatient behavioral health services to adults 18 years and older. Its mission is to enhance the mental health condition status of the communities it serves by providing leadership and management with a focus on comprehensive, appropriate and quality driven inpatient and outpatient behavioral health services.

The population in need of behavioral health services has been underserved and under financed for decades, and today, communities throughout the nation are feeling the effects, Baronoff noted. It is in recognition of and response to the growing demand that Promise Healthcare, Inc. — as evidenced by the establishment of its new PBH Division — has significantly increased and expanded its commitment to this type of specialized healthcare.

“Legislation and regulations promoting transformation, reform and redesign of the entire behavioral healthcare delivery system are gaining momentum nationwide,” said Baronoff. “Promise Behavioral Health will work diligently and collaboratively with all state and federal government agencies to ensure this movement serves the need of this vulnerable population.”

According to the National Alliance on Mental Illness (NAMI), mental illnesses are medical conditions that disrupt a person’s thinking, feeling, mood, ability to relate to others, and daily functioning. Just as diabetes is a treatable condition, so too is mental illness. NAMI notes that mental illness can affect persons of any age, race, religion or income, and that mental illnesses are treatable and recovery is possible.

PBH will be led by behavioral health industry veterans Denise Dugas, as director of behavioral health, and Salina Creswell, RHIA, as assistant director of behavioral health. Their initial focus will be to assess and analyze the services, quality and delivery of care, marketing strategies, census, revenue, reimbursement and operating expenses of the behavioral health locations at Promise Hospitals in Shreveport and Gonzalez, Louisiana, and San Diego, California. They then will seek future inpatient and intensive outpatient program (IOP) opportunities within other Promise markets. This will include a dedicated IOP section at its newest LTAC hospital under construction in Vidalia, Louisiana.

“With an experienced, specialized team of professionals in place, the Promise Behavioral Health Division will meet the physical, mental, and emotional needs of each community its program serves,” Dugas said. “Our mandate is to create a positive environment of friendly, kind, compassionate, quality care that will promote comfort, healing, and recovery.”

Promise Healthcare, Inc. (www.promisehealthcare.com) is one of the largest long-term acute care (LTAC) hospital companies in the country. It owns and operates 14 LTAC hospitals in six states, with additional locations under construction or development. Locations owned and managed by Promise in Louisiana include Shreveport, Bossier City, Baton Rouge (two campuses), Gonzalez, and Ferriday, with the latter location to relocate to a new, freestanding facility currently under construction in Vidalia. Additional Promise locations include Vicksburg, Mississippi; San Antonio and Nederland, Texas; Phoenix, Arizona; Salt Lake City, Utah; and Los Angeles and San Diego, California.

Promise Healthcare, Inc. is headquartered at 999 Yamato Road, Boca Raton, FL 33431. For more information on Promise Behavioral Health, contact Denise Dugas, PBH director of behavioral health at Promise Healthcare at 561-869-3100 or via [email protected].

Milliman Care Guidelines Expands, Updates Clinical Content and Software

SEATTLE, March 26 /PRNewswire/ — More than 1,000 leading payors, hospitals and providers are accessing updated clinical decision-support resources with release of the evidence-based Milliman Care Guidelines(R) 12th Edition.

In addition to clinical content changes made for the 12th Edition, Milliman Care Guidelines also has added or improved clinical workflow software, and expanded software integration efforts with 25 Strategic Alliance Partners for 2008. To help clients gain full benefit from the updated clinical guidelines and tools, the company also has enhanced training resources.

Used by seven of the country’s ten largest managed care organizations, the annually updated Care Guidelines product line spans the continuum of care, including behavioral health and management of chronic conditions, all delivered within robust, interactive software. The 12th Edition expands outpatient authorization criteria and evidence summaries; adds new inpatient guidelines and education information, and updates chronic patient education material in English and Spanish.

New Integrations, Improved Software and Access

The Care Guidelines are integrated with nearly 30 care management programs from 25 Strategic Alliance Partners. This year, clients can expect expanded integrated solutions from TriZetto(R), MEDecision(R), SHPS and McKesson. Also coming are integrations with programs from Allscripts, CaseNet(R), Click4Care, Canopy(R), MIDAS+(TM), Gaudette International Corporation, and 3M, among others.

Milliman’s CareWebQI(R) software, now with interactive access to all seven Care Guidelines products, can be locally installed and integrated with other systems to document patient care in electronic health records. Guidelines can now be modified, and variance categories, discharge status and levels of care customized, to fit local resources, practice patterns and protocols.

In addition, handheld access is now available for the Recovery Facility Care and Home Care products, allowing users to access five Care Guidelines products at the patient’s bedside.

Expanded Clinical Coverage

Milliman Care Guidelines clinical editors reviewed more than 100,000 articles, trials and other evidence from sources worldwide during the guideline development process. The 12th Edition includes some 14,000 references in the expanded seven-product Care Guidelines series. Product changes that may significantly increase the Care Guidelines impact on patient outcomes, and usability in a clinical setting, include:

    -- Behavioral Health Management -- The Behavioral Health Guidelines       include 15 guideline groups, each containing detailed criteria for       five levels of care, including admission and discharge.  This new       product helps to integrate behavioral health with other in-house       medical management and avoid inappropriate care and under-diagnosis.     -- Expanded Outpatient Authorization Criteria and Tools -- Twenty-one new       Ambulatory Care authorization guidelines cover procedures, diagnostic       tests, imaging studies and injectables.  Imaging criteria now include       seven CT angiography guidelines, and 12 new injectable guidelines have       been added.     -- Access to Outpatient Evidence -- Evidence summaries enhance access to       clinical evidence cited in Ambulatory Care criteria.  These       interpretive synopses of best-practice evidence explain the basis for       key authorization guideline statements.     -- New Inpatient Guidelines and Education Information -- The Inpatient       and Surgical Care product adds a number of new guideline topics, such       as shoulder arthroplasty and central venous catheter complications.       Enhanced content also helps healthcare providers to develop education       and information programs for patients.     On-Demand Training and Expanded Access  

On-demand training, coming later this year, will give users convenient, interactive, modules to learn basic guideline applications. Expanded training opportunities in 2008 will include advanced training content, monthly web- based sessions for medical directors hosted by our physician editors, and more than 200 scheduled web seminars.

Milliman Care Guidelines

Milliman Care Guidelines LLC, A Milliman Company, is headquartered in Seattle, and independently develops and licenses evidence-based clinical guidelines and a variety of software options that are used to support the care of more than one in three Americans. Covering the continuum of care, the seven-product Care Guidelines series is updated annually by an experienced team of clinicians, and includes Ambulatory Care, Inpatient and Surgical Care, General Recovery Guidelines, Recovery Facility Care, Home Care, Chronic Care Guidelines and Behavioral Health Guidelines. For more information, visit http://www.careguidelines.com/

Milliman Care Guidelines is a wholly owned subsidiary of Milliman, which serves the full spectrum of business, financial, government, and union organizations. Founded in 1947 as Milliman & Robertson, the company has 48 offices in principal cities in the United States and worldwide. Milliman employs more than 2,000 people, including a professional staff of more than 900 qualified consultants and actuaries. The firm has consulting practices in employee benefits, healthcare, life insurance/financial services, and property & casualty insurance. For more information, visit http://www.milliman.com/.

Milliman Care Guidelines

CONTACT: Scott Harris, Senior Vice President of Sales and Marketing ofMilliman Care Guidelines, +1-206-381-8160, Cell, +1-480-203-7268,[email protected]

Web site: http://www.milliman.com/http://www.careguidelines.com/

Bayer HealthCare Affiliate MEDRAD Successfully Completes Tender Offer for Shares of Possis Medical

LEVERKUSEN, Germany, and PITTSBURGH, Pennysylvania, March 26 /PRNewswire-FirstCall/ — Bayer HealthCare affiliate MEDRAD, Inc. announced today that it has successfully completed its tender offer for the outstanding shares of common stock of Possis Medical, Inc. . The depositary for the offer has advised MEDRAD that, as of the expiration of the offer at 5:00 p.m., New York City time, on Tuesday, March 25, 2008, a total of 14,951,550 Possis Medical shares were validly tendered in the offer and not withdrawn which, together with 715,141 shares to be tendered under guaranteed delivery procedures, represents approximately 92.0 percent of the outstanding common stock of Possis Medical. Shares to be tendered under guaranteed delivery procedures are required to be delivered by Friday, March 28, 2008. MEDRAD, through its wholly owned subsidiary Phoenix Acquisition Corp. has accepted for purchase all shares that were validly tendered in the offer.

MEDRAD also announced that Phoenix Acquisition Corp. has commenced a subsequent offering period for all the remaining untendered shares that will expire at 5:00 p.m. New York City time, on Tuesday, April 1, 2008. During this subsequent offering period, Possis Medical shareholders who have not tendered their shares into the offer may do so and will promptly receive US-Dollar 19.50 per share, net to the seller in cash, without interest thereon and subject to reduction for any applicable withholding taxes. Shares tendered during the subsequent offering period may not be withdrawn.

About MEDRAD

MEDRAD, Inc. is a worldwide leading provider of medical devices and services that enable and enhance imaging procedures of the human body. Used in diagnostic imaging, MEDRAD’s product offerings include a comprehensive line of vascular injection systems, magnetic resonance (MR) surface coils and patient care products, and equipment services. Total 2007 revenues were US-Dollar 525 million. MEDRAD is a 2003 recipient of the Malcolm Baldrige National Quality Award, the top honor a U.S. company can receive for quality and business excellence. The company’s world headquarters is near Pittsburgh, Pennsylvania, in the United States. MEDRAD is an affiliate of Bayer AG and employs over 1,700. More company information is available at http://www.medrad.com/.

About Possis Medical

Possis Medical develops, manufactures and markets pioneering medical devices for the large and growing cardiovascular and vascular treatment markets. The Company’s AngioJet System is the world’s leading mechanical thrombectomy system with FDA approval to remove large and small thrombus from coronary arteries, coronary bypass grafts, peripheral arteries and veins, A-V grafts and native fistulas.

About Bayer HealthCare

Bayer AG is a global enterprise with core competencies in the fields of health care, nutrition and high-tech materials. Its subgroup Bayer HealthCare is one of the world’s leading, innovative companies in the healthcare and medical products industry and is based in Leverkusen, Germany. The company combines the global activities of the Animal Health, Consumer Care, Diabetes Care, and Pharmaceuticals divisions. The Pharmaceuticals division comprises the following business units: Women’s Healthcare, Diagnostic Imaging, Specialized Therapeutics, Hematology/Cardiology, Primary Care, and Oncology. The company’s aim is to discover and manufacture products that will improve human and animal health worldwide. The products enhance well being and quality of life by diagnosing, preventing and treating diseases.

Bayer Schering Pharma is a worldwide leading specialty pharmaceutical company. Its research and business activities are focused on the following areas: Diagnostic Imaging, Hematology/Cardiology, Oncology, Primary Care, Specialized Therapeutics and Women’s Healthcare. With innovative products, Bayer Schering Pharma aims for leading positions in specialized markets worldwide. Using new ideas, Bayer Schering Pharma aims to make a contribution to medical progress and strives to improve the quality of life. Find more information at http://www.bayerscheringpharma.de/.

Forward-Looking Statements

This release may contain forward-looking statements based on current assumptions and forecasts made by Bayer Group or subgroup management. Various known and unknown risks, uncertainties and other factors could lead to material differences between the actual future results, financial situation, development or performance of the company and the estimates given here. These factors include those discussed in Bayer’s public reports which are available on the Bayer website at http://www.bayer.com/. The company assumes no liability whatsoever to update these forward-looking statements or to conform them to future events or developments.

   Contact Details    Bayer HealthCare   Oliver Renner, Tel: +49-30-468-12431   Head Global Public Relations & Public Affairs   [email protected]    MEDRAD   Luanne Radermacher, Tel: +1-724-940-7968   Director, Corporate Affairs   [email protected]  

Bayer HealthCare

CONTACT: Contact Details: Bayer HealthCare, Oliver Renner, Tel:+49-30-468-12431, Head Global Public Relations & Public Affairs,[email protected]. MEDRAD, Luanne Radermacher, Tel:+1-724-940-7968, Director, Corporate Affairs, [email protected]

Walgreens Selected As Specialty Pharmacy Provider for Prime Therapeutics

Drugstore operator Walgreens has announced that it will be the exclusive specialty pharmacy provider for Prime Therapeutics under a new, multi-year contract the companies have signed. The company will provide the service through its Pittsburgh-based Medmark, A Walgreens Specialty Pharmacy.

The services provided by Medmark, A Walgreens Specialty Pharmacy, will be part of Prime Therapeutics’s new Triessent specialty pharmacy program.

Medmark will provide Prime with medication fulfillment and complement Prime’s existing patient education and clinical support services. Its pharmacists and nurses will counsel patients on the importance of medication adherence and the management of side effects.

Stanley Blaylock, president of Walgreens Health Services, said: “While we can’t predict the exact value of this contract, the annual specialty pharmacy spending by Prime’s total client base is significant. Our partnership with Prime gives us the opportunity to manage specialty pharmaceuticals that are covered under both the medical and pharmacy benefit. We believe many – if not most – of those plans to use our services through Prime over time.”

Cod Oil Offers Hope to Arthritis Patients

Researchers looking for an alternative to non-steroidal anti-inflammatory drugs (NSAIDs), found that 10g of cod liver oil each day could be beneficial for people who suffer from rheumatoid arthritis.

The Dundee University team published their study in the journal “ËœRheumatalogy.’ Their findings showed that by taking a cod liver oil supplement, people could reduce their reliance on anti-inflammatory drugs by more than 30 percent.

Professor Jill Belch at the University of Dundee School of Medicine led the study that analyzed 97 patients with rheumatoid arthritis who were taking NSAIDs. Participants received either 10g of cod liver oil or a placebo. Indicators linked to the condition were documented at the start of the study and after four, 12, 24 and 36 weeks.

“The main objective of the study was to assess whether RA patients were able to reduce their NSAID intake without any worsening of their disease activity. This was achieved in all of the clinical parameters studied,” they wrote.

A total of 58 completed the study, after they were told to gradually reduce or stop their NSAID usage.

Of the 49 patients taking cod liver oil, 19 were able to cut their daily NSAID usage by more than 30 percent after nine months.

Only five of the 48 patients in the placebo group were able to reduce their daily NSAID intake by more than 30 percent.

“This study suggests that cod liver oil supplements containing n-3 fatty acids can be used as NSAID-sparing agents in RA patients,” authors said.

Some reported side effects of NSAIDs have been known for a long time, including an increased risk of stomach bleeding.

Belch said the study should offer hope to patients with rheumatoid arthritis who want to reduce their NSAID intake.

“Every change in medication should be discussed with a GP but I would advise people to give cod liver oil a try for 12 weeks alongside their NSAIDs and then try to cut it down if they can manage it but if they don’t manage it, that’s fine,” she said.

“If you can get off NSAIDs it will be much safer.”

Dr. Andrew Bamji, president of the British Society for Rheumatology said the study was too small to make solid conclusions, while echoing the possible hope it offers patients.

“Anything that can help to reduce NSAID use is going to be safer for patients,” Bamji said. It does look as if the results are positive and that is quite interesting.

“I would say to patients by all means take cod liver oil and when you feel ready start to reduce your NSAID dose.”

Bamji echoed Belch’s advice that patients discuss plans with their doctor.

Rheumatoid arthritis affects about 350,000 people in the UK, where the study was conducted. Of that number, women are more likely to suffer from the condition than men. Rheumatoid arthritis also adds to the risk of strokes and heart attacks.

On the Net:

Rheumatalogy

Dundee University

British Society for Rheumatology

National Arthritis Foundation

Male Infant Fatality Rate Higher Than Female Infants

Researchers have found that male infants are more likely to die than females, although male infant mortality rates have declined since 1970.

The team studied 15 developed countries and showed the peak of male infant mortality was more than 30 percent higher than females in the 1970s. This rate tripled from that of 1751. After its peak in the 1970s, the male disadvantage began to normalize in most countries.

Researchers attribute the lowered infant mortality rate to improved methods of neonatal care. The study was published in the journal Proceedings of the National Academy of Sciences.

Also, boys were found to be 60 percent more likely to be born prematurely and suffer from pre-term birth conditions such as neonatal respiratory distress syndrome, which occurs in infants with underdeveloped lungs.

Previously, men have been blamed for their behavior as a factor for their higher mortality rates, but behavior is replaced by biological explanations, according to Eileen Crimmins of the University of Southern California, one of the researchers.

“Males and females can have very different mortality at an age when behavior is not a factor,” Crimmins said. “We tend to think that males have higher mortality at all ages because they behave worse, basically. But this (infant mortality) is a case where they don’t behave any differently.”

“It was so large, so consistent across so many countries, and it couldn’t be explained by behavior,” Crimmins added.

On the Net:

PNAS – “The rise and fall of excess male infant mortality

University of Southern California

RedOrbit – “Premature Male Babies Should Get Special Treatment

Pearson Announces Exclusive Partnership With Nationally-Acclaimed Curriculum Designer Grant Wiggins

SACRAMENTO, Calif., March 25 /PRNewswire-FirstCall/ — Looking to help California’s educators boost students’ reading comprehension, Pearson School educational publishers today announced an exclusive partnership with Grant Wiggins, considered one of the nation’s preeminent experts in curriculum design.

Wiggins will serve as an author and consultant for Pearson on programs across all disciplines and grade levels. These include the publisher’s K-12 reading and language arts programs being developed for California.

“This collaboration brings together one of the nation’s premier experts in curriculum design and our team of the most prominent reading authors in the country,” said Pearson Senior Vice President for Literacy Dean Brown. “Our priority right now is creating programs for California that will address all of the literacy-related issues that teachers and students struggle with on a daily basis. California teachers know and respect Grant. We are extremely fortunate to have him joining us at this critical time to help tailor our offerings to meet the needs of the teachers and children in California.”

“Reading is a model case of understanding, and understanding by design only happens if you help students learn on their own which skills to use when,” Wiggins reminds us. “I have joined the Pearson team because they have made clear that understanding, not ‘coverage’ is the point.”

As part of his two decades of work in curriculum-reform, Wiggins notes that author David Pearson and his work on ‘the gradual release of responsibility’ has been a key influence in Understanding by Design and in their work with teachers in all other subjects. He said, “Transfer is the goal of learning, yet too few teachers design ‘backward’ from it. The folks at Pearson are clearly and explicitly determined to make understanding, not ‘coverage’ the purpose that informs their materials.”

Wiggins is perhaps best known as co-author, with Jay McTighe, of Understanding By Design and The Understanding By Design Handbook, the award- winning publications on curriculum published by the Association for Curriculum Development (ASCD). Understanding by Design offers a comprehensive way of thinking, supported by rich tools and resources, to help teachers design, edit, critique, peer-review, share, and improve their lessons and assessments. Wiggins’ notes that the “understanding by design” approach focuses on organizing lessons around tasks that require transfer as well as the exploration of thought-provoking, open-ended questions that lead students toward clearly-articulated goals or objectives. Wiggins says this process helps to avoid the twin problems of “textbook coverage” and “activity- oriented” teaching in which no clear priorities and purposes are apparent. “Everyone I have worked with so far at Pearson has been eager to engage, to work with me on integrating our ideas into Pearson materials, and to help me understand the process of textbook development. I am honored and grateful to be a part of such a thoughtful and committed group of educators.”

Wiggins’ “understanding by design” concept addresses the needs of all students, including English language learners, a component especially relevant for California which has the nation’s highest percentage of English learning students — 25 percent. This means that nearly 1.6 million K-12 students in the State face the daunting task of learning the academic curriculum and a new language concurrently. They are challenged with learning English quickly enough and fluently enough to participate in academic work, and like their peers, learn grade-level mathematics, reading/language arts, social studies, and science.

Wiggins’ work has been supported by the Pew Charitable Trusts, the Geraldine R. Dodge Foundation, and the National Science Foundation.

Pearson’s announcement comes on the heels of a National Endowment for the Arts study citing a number of troubling statistics about the state of reading in the United States:

   -- Americans are reading less -- teens and young adults read less often      and for shorter amounts of time compared with other age groups and with      Americans of previous years. On average, Americans ages 15 to 24 spend      almost two hours a day watching TV, and only seven minutes of their      daily leisure time on reading    -- Americans are reading less well -- reading scores continue to worsen,      especially among teenagers and young males    -- Nearly two-thirds of employers ranked reading comprehension "very      important" for high school graduates. Yet 38 percent consider most high      school graduates deficient in this basic skill    -- American 15-year-olds ranked fifteenth in average reading scores for 31      industrialized nations, behind Poland, Korea, France and Canada    

Over the past 20 years, Wiggins has worked on some of the most influential reform initiatives in the country, including Vermont’s portfolio system and Ted Sizer’s Coalition of Essential Schools. He has established statewide Consortia devoted to assessment reform for the states of North Carolina and New Jersey. Wiggins is the author of Educative Assessment and Assessing Student Performance, both published by Jossey-Bass. His many articles have appeared in such journals as Educational Leadership and Phi Delta Kappan.

About Pearson in California:

Pearson, the world’s leading education publisher, has been providing education materials to California schools as far back as the 1800s. You may know us individually as Scott Foresman, Prentice Hall, Longman, SuccessMaker, NovaNet, AGS, Pearson School Systems, Pearson Assessment, Learning Teams, Achievement Solutions, and so many more — names in the world of education that are recognized and respected across the State and the globe. In fact, most teachers in California have learned their profession by studying with Pearson’s Merrill or Allyn & Bacon textbooks, and many have benefited from our professional development programs. Today, nearly a thousand Pearson people are living and working in the State, providing educational materials that cover the gamut from birth through professional learning. Whether in science, math, social studies, music, middle/high school language arts, foreign languages, English as a Foreign Language or AP courses, hundreds of thousands of California’s preK-12 students are learning with our Pearson products every day. In addition to Education, Pearson’s other major businesses include The Financial Times Group and The Penguin Group. For more information, go to: http://www.californiareading.com/ or http://www.pearsonschool.com/.

Pearson

CONTACT: Kate Miller of Pearson, +1-800-745-8489,[email protected]

Web site: http://www.pearsoned.com/http://www.californiareading.com/http://www.pearsonschool.com/

Alcoholism’s Potential Cure

Scientists studying drunken fruit flies have discovered that the hormone insulin, which surges after we eat, may make the brain less sensitive to alcohol intoxication.

Some Dogs are Allergic to their Owners

Sure, people are allergic to dogs.

But dogs to people?

Absolutely. Just ask Fui (pronounce that Phooey).

The 6-year-old Shar-Pei, a “princess,” according to her owner, Pam Escobar, loves to be petted. But if Fui didn’t take pills twice a day and get allergy shots every two weeks, she would scratch and lick. A lot.

Canine allergic reactions to human dander are skin-related and don’t include sneezing.

“It’s never an obvious and direct reaction,” said Dr. Tom Lewis, a Phoenix-based veterinary specialist in dermatology who sees a number of cases in Tucson. “They’ll scratch and get a lot of secondary infections. Some of these dogs just are miserable.”

Lewis noted that because it takes time and exposure, the average dog is 2 to 5 years old before reactions to human dander begin.

Before she was diagnosed, Fui would lick her paws and sometimes even scratch her cornea because of her allergies. The 52-pound dog has taken medication since she was 7 months old.

In 2004, Escobar had Fui tested for 62 allergens. She was allergic to 61 of them.

“I was like, ‘Oh my God, this poor dog is going to be tortured,'” Escobar said. “It’s really sad.”

Treating Fui’s allergies costs $17 a month in pills and $230 every six months for the shots.

With medicine, Fui’s a different dog.

“She’s completely under control,” Escobar said. “I’ve been told that she’s a poster child for allergies — she looks so good.”

The Dermatology Clinic for Animals’ site, www.dermvet.com, contains a host of information about animal allergies and before-and-after photos.

An allergy to human dander is far from unusual. At the Gilbert location of Dermatology Clinic for Animals, 42 out of 100 recent allergy panel tests on mostly dogs tested positive for allergies to human dander. A response to each of the 69 allergens on the panel is rated from zero to four. The 42 that tested positive rated at least a two. Cats, like dogs, also can be allergic to human dander.

Lewis said that purebred dogs are more susceptible than mixed breeds to having these types of allergies. Labs, golden retrievers and some terriers are some breeds more likely to have a reaction to human dander.

Sylvia and Larry Fox, who own Insty-Prints on East Speedway, have owned Boston bull terriers for 32 years. The couple took in Bosco about 4 1/2 years ago.

“We noticed about six months into having him that he was having a lot of scratching problems,” said Sylvia Fox, noting that an initial regimen of Benadryl “wasn’t cutting it.”

Sylvia recalled Bosco scratching his ears to the point where he almost “shredded them” and licking his paws until they developed sores.

Bosco’s medical regimen includes a pill every day, whether it’s an antibiotic, antihistamine or Prednisone; eye medicine once or twice a day; a medicated bath once a week; and twice-monthly allergy shots.

Bosco also eats a rabbit-and-potato food diet. His treats consist of plain potato chips.

Escobar says people often are surprised when told that Fui is allergic to human dander.

“People have never heard of it,” said Escobar, whose two other Shar-Peis also take pills for allergies. “They want to know how we found out and what we do for it.”

Lewis has been testing for human dander on allergy panels for four or five years. A complete panel in Tucson tests for 70 things.

Treatments for human dander allergies include cortisone drugs, shots, frequent bathing and reduced exposure.

“A lot of the same treatments for humans apply to dogs,” Lewis said. “By the time (the dogs) get to me, they’ve already seen their regular vet. (Owners) know they’re in for a battle, but we can usually control it.”

One holistic veterinarian believes that allergies are rising among pets for several reasons.

“Animals keep getting sicker every generation because of over-medication, over-vaccination and poor quality of food,” said Dr. Judy Stolz, a Casa Grande-based holistic veterinarian who has been practicing about 20 years. “Dogs, like people, tend to be allergic to many things.”

Stolz might prescribe remedies made from plants and changes in nutrition.

Treatment is available

Some hypoallergenic dog breeds:

American hairless terrier

Airedale terrier

Basenji

Bichon Frise

Bichon/Yorkie

Border terrier

Cairn terrier

Chinese Crested

Cockapoo

Giant schnauzer

Irish water spaniel

Kerry blue terrier

Labradoodle

Maltese

Poodle

Portuguese water dog

Schnoodle

Shih-Tzu

Soft coated wheaten terrier

Schnauzer

West Highland white terrier

Wirehaired fox terrier

Yorkshire terrier

Test-Retest Reliability and Minimal Detectable Change of Gait Speed in Individuals Undergoing Rehabilitation After Stroke

By Fulk, George D Echternach, John L

Background and Purpose: Gait speed is commonly used to assess walking ability in persons with stroke. Previous research related to the psychometric properties of gait speed has been conducted primarily with individuals who were able to walk independently and/ or were in the later stages of recovery after stroke. The purpose of this research was to examine the test-retest reliability and minimal detectable change (MDC^sub 90^) of gait speed in individuals with stroke who required varying levels of assistance to ambulate during rehabilitation. Methods: Patients who could ambulate with or without physical assistance and were undergoing inpatient rehabilitation were recruited. Gait speed was measured over the middle five meters of a nine-meter walk at a comfortable pace. Data were analyzed using the intraclass correlation coefficient (ICC^sub 2,1^) and the MDC^sub 90^.

Results: Thirty-five patients who were a mean 34.5 (standard deviation = 17.7) days post-stroke agreed to participate. For all the subjects combined, the ICC^sub 2,1^ was 0.862 and MDC^sub 90^ was 0.30 m/sec. For the 13 subjects who required physical assistance to walk, the ICC^sub 2,1^ = 0.971 and MDC^sub 90^ = 0.07 m/sec. For the 22 subjects who could walk without physical assistance, the ICC^sub 2,1^ = 0.80 and MDC^sub 90^ = 0.36 m/sec.

Discussion: Gait speed is a reliable measure of walking ability for a wide variety of patients undergoing rehabilitation after stroke. Gait speed is more sensitive to change in patients who require physical assistance to walk than in those who can walk without assistance. A change of more than 0.30 m/sec may be necessary in order to determine whether a change in gait speed exceeds measurement error and patient variability.

Key words: gait speed, reliability, stroke

(JNPT 2008;32: 8-13)

INTRODUCTION

Stroke is the leading cause of disability in the United States, affecting approximately 5.6 million people in the United States, with an estimated 700,000 Americans experiencing a new or recurrent stroke each year.1 More than 1 million Americans with stroke report difficulties with basic activities of daily living (ADL) due to their stroke, and many also experience significant difficulty with mobility. ‘ Initially after stroke, two thirds of individuals are not able to walk or require assistance to walk.2 After three months, one third of individuals who experience a stroke still require assistance or are not able to walk.2 Many of these individuals will require rehabilitative services in order to optimize their level of recovery. It is therefore important for physical therapists to have useful and clinically meaningful measures to detect change in walking ability.

Gait speed measured over a short distance, ie, five or 10 meters, is one of the most widely used methods of measuring walking ability both in the clinic and in research.3,4 Overground gait speed can be measured in practically any setting and at all stages of recovery after stroke and has high clinical utility. The validity of gait speed as a method for measuring walking ability has been extensively studied.5-12 Gait speed has been found to be moderately to strongly related to paretic lower limb muscle performance.5,7,9 daCunha and colleagues6 found that gait speed was strongly related to energy expenditure and energy cost of gait. Gait speed is strongly related to balance after stroke as measured by the Berg Balance Scale.8 Perry and colleagues10 used gait speed to categorize individuals with stroke into different levels of home and community walking ability. Gait speed can also be used to predict discharge destination from inpatient rehabilitation after stroke.11

The reliability of gait speed has also been investigated by other authors.13-16 Test-retest reliability coefficients reported in the literature range from 0.92(13) to 0.97.15 The variability associated with measuring gait speed has also been reported. In a group of patients who could walk independently without assistive devices undergoing rehabilitation, Evans and colleagues13 reported an estimate of error for measuring gait speed of -0.11 m/sec to +0.17 m/ sec (95% confidence interval). Hill et al14 and Stephens et al15 reported similar findings with 95% confidence intervals for error estimates between -0.08 m/sec and +0.16 m/sec and -0.13 m/sec and +0.17 m/sec, respectively. In people with chronic stroke (>6 months), Flansbjer and colleagues16 reported a 95% confidence interval for the smallest real difference in gait speed of -0.15 m/ sec to +0.25 m/sec.

The minimal detectable change (MDC) values reported above are important for both clinicians and researchers. For example, suppose a physical therapist is providing interventions designed to improve walking ability with a client with a chronic stroke and the physical therapist is using gait speed as an outcome measure to assess walking ability. Using the results from the study by Flansbjer et al,16 in order to be 95% confident that a true change in walking ability occurred after physical therapy, the client’s gait speed needs to increase by at least 0.25 m/sec. If the change in gait speed is

MDC values are also important to consider when interpreting the results of clinical trials. Researchers often compare mean change values in gait speed between experimental and control groups. For example, Ada and colleagues17 explored the effect of a treadmill and overground walking program in community-dwelling people with chronic stroke. The mean change in gait speed after the four-week intervention for the group who received treadmill and overground walking training was 0.18 m/sec (standard deviation [SD] = 0.19) compared to 0.04 m/sec (SD = 0.07) in the control group who received a home exercise program. Although there was a statistically significant difference between the two groups, it is difficult to determine whether the change in gait speed in the experimental group was clinically significant. Since the mean change was 0.18 m/sec and the SD was 0.19 m/sec, some of the subjects did not exceed 0.25 m/ sec. Thus, for at least some of the subjects, the change in gait speed did not exceed the potential error in the measurement.

In other cases, a small change in gait speed may be clinically important. Plummer et al18 examined the effect of locomotor training using a body weight support and treadmill system in seven people with subacute stroke. After 36 sessions, one subject’s gait speed improved from 0.18 m/sec to 0.29 m/sec, an improvement of 0.11 m/ sec. While this change does not exceed the measurement error reported by Evans et al13 (0.17 m/sec), this change in gait speed may have indicated that the subject improved from being a physiologic ambulator to a full-time home ambulator as defined by walking categories developed by Perry and colleagues.10

When examining change scores in gait speed in both clinical practice and with research results, it is to important use MDC values that have been established in subjects with similar characteristics. A limitation of the findings described above to clinical practice is that the subjects in these studies were included based on their ability to walk without physical assistance13-16 or assistive devices13 or were in the chronic stages of recovery after their stroke.15,16 Since many of the patients who are undergoing rehabilitation after a stroke require physical assistance to walk and/or an assistive device, it is important to examine the reliability of gait speed in this population. The purpose of this study was to examine the test-retest reliability of gait speed in individuals undergoing rehabilitation after stroke who require varying levels of assistance to walk with varying locations of stroke.

METHODS

Participants were recruited from two inpatient rehabilitation facilities. Inclusion criteria were undergoing inpatient rehabilitation after stroke and being able to ambulate with at most maximal assistance of one person. The level of physical assistance was defined as follows: maximal assistance is when the participant expends 25%; moderate assistance is when the participant expends between 50% and 74% of the effort; and minimal assistance is when the participant expends between 75% and 99% of the effort; any physical contact by another person while walking was considered at least minimal assistance. Participants were excluded if they had a premorbid condition that affected their ability to walk independently prior to their stroke such as severe rheumatoid arthritis or Parkinson’s disease. Diagnosis and location of stroke were confirmed by reviewing the participants’ medical record and imaging study report if available. All participants provided informed consent, and the institutional review boards of all the involved facilities approved the study.

Four physical therapists and two physical therapist assistants who were working with the patients served as the raters. Experience of the raters ranged from six months to 15 years. None of the raters had experience using gait speed as an outcome measure prior to this study, but all underwent training in the data collection procedure described below. Procedure

Gait speed was measured over the middle five meters of a nine- meter walk using a stopwatch.19 Patients were instructed to walk at their comfortable pace. Patients started walking two meters before the start line and were timed from the moment their lead foot crossed the start line until the front foot crossed the finish line, five meters away. They continued walking for another two meters after crossing the finish line. Patients walked the additional two meters in front and at the end of the timed five meters to take into account acceleration and deceleration effects. The amount of physical assistance, assistive device, and/or orthotic used was determined by the patient’s primary physical therapist. Patients underwent two measurement sessions separated by one to three days during the week prior to their discharge from the inpatient rehabilitation hospital. One trial during each of the two sessions was used to determine the subject’s gait speed. If the amount of physical assistance, use of assistive device and/or orthotic, or Functional Independence Measure (FIM) locomotion score changed between the two measurement sessions, then the subject was excluded from study.

Data Analysis

Test-retest reliability was assessed using the intraclass correlation coefficient (ICC^sub 2,1^) with 95% confidence intervals as described by Shrout and Fleiss,20 and MDC at the 90% confidence level (MDC^sub 90^) as described by Stratford21 and more recently by Haley and Fragala-Pinkham.22 The MDC^sub 90^ determines the magnitude of change that must be observed before the change can be considered to exceed the measurement error and variability at the 90% confidence level. The MDC90 was calculated by determining the standard error of the measurement (SEM) using the formula (SD x [the square root of][1 – r]), where r is the test-retest reliability coefficient (ICC^sub 2,1^ in this case) and SD is the SD of the measures.21,22 The SD was calculated from the combined gait speed measured in both sessions 1 and 2. The SEM was multiplied by 1.65 to determine the 90% confidence interval.21-23 The 90% confidence level was chosen as this appears to be most commonly reported in the literature.22 This value was multiplied by the square root of 2 to account for error associated with repeated measurements.21,22,24 The ICC is a reliability coefficient whose value ranges from 0.00 to 1.00. It is calculated using variance estimates from an analysis of variance; because of this, it reflects both the degree of correlation and level of agreement between measures. A correlation coefficient such as Pearson r only reflects the degree of the relationship between measurements and not the level of agreement.25

ICCs and MDC values were calculated for all subjects combined, for those who required physical assistance to ambulate, those who could walk without physical assistance, and those who used an assistive device to walk. Additionally, a Kruskal-Wallis one-way analysis of variance was performed to determine whether there were differences in gait speed between individuals with different locations of stroke, ie, cortical versus subcortical versus brainstem versus cerebellar stroke.

RESULTS

Thirty-five individuals agreed to participate. The mean age of the participants was 67.4 years (SD = 13.8), with a mean time of 34.5 days (SD = 17.7) post-stroke. The median score on the locomotion section of the FIM was 5 (range, 2-7). Thirteen of the 35 participants required physical assistance to walk, 10 required minimal assistance, and three required moderate assistance to walk. Twenty-two participants were able to ambulate without physical assistance. Twenty-eight individuals used an assistive device to walk (15 using a two-wheel rolling walker, four using a straight cane, four using a large-base quad cane, two using a small-base quad cane, two using a hemiwalker, and one using a standard walker) and six required an orthotic (ankle-foot orthosis [five], knee-ankle- foot orthosis [one]). Seventeen were diagnosed with a cortical stroke, eight with a subcortical stroke, seven with a brainstem stroke, and three with a cerebellar stroke. The Kruskal-Wallis test revealed no significant difference in gait speed among participants with different locations of stroke, H(3) = 2.10, P > 0.05.

The mean gait speed for the first session for all participants was 0.45 m/sec (SD = 0.30) and the mean for the second session was 0.54 m/sec (SD = 0.39). The ICC^sub 2,1^ was 0.862 and the MDC^sub 90^ was 0.30 m/sec. Mean gait speed, ICC^sub 2,1^, and MDC^sub 90^ results for all subjects and subgroups are presented in Table 1, raw data for gait speed for sessions 1 and 2 are presented in Figure 1.

DISCUSSION

Gait speed measured over a short distance in the clinic is a reliable measure of walking ability in people who are undergoing inpatient rehabilitation after stroke. The MDC^sub 90^ of 0.30 m/ sec indicates that the gait speed of 90% of persons with stroke demonstrating characteristics similar to those of the subjects in this study will vary by / =0.30 m/sec is necessary in an individual patient in order to be 90% certain that the change is not due to intertriai variability. The ICC of 0.862 is indicative of good reliability.25 The MDC is a measure of sensitivity to change and is useful for interpreting change scores in individual patients, whereas the ICC calculated here is a testretest reliability index, which is useful for examining the reliability of group data.

When selecting outcome measures for assessing change in individuals after stroke, clinicians and researchers should use tools with sound psychometric properties. However, outcome measurement can be difficult in people post-stroke due the heterogeneity of symptoms, variability in severity, and various etiologies.26 The results of this study can be used to measure change in walking ability in three different subgroups of patients post-stroke: patients who require physical assistance to walk (MDC^sub 90^ = 0.07 m/sec), patients who can walk without physical assistance (MDC^sub 90^ = 0.36 m/sec), and patients who use an assistive device to walk (MDC^sub 90^ = 0.18 m/sec) who are two to six weeks post-stroke. When attempting to determine whether a true change in gait speed has occurred, researchers and clinicians should use MDC values established from subjects with similar characteristics. An area of further research would be to determine MDC values for other subpopulations of patients post-stroke, ie, patients who use an orthotic to walk.

One interesting finding from this study is that gait speed is more reliable and sensitive to change in individuals who require physical assistance to walk than in patients who can ambulate without physical assistance. The ICC^sub 2,1^ for the patients who required physical assistance to walk was 0.971 and the MDC^sub 90^ was 0.07 m/sec as compared to an ICC^sub 2,1^ of 0.800 and an MDC90 of 0.36 m/sec in patients who could ambulate without physical assistance. There was greater variability in gait speed for participants who could walk without physical assistance. The SD for the two walks in these patients was 0.30 and 0.39 m/sec. In the patients who required physical assistance to ambulate, the variability between the two walks was much less (SD = 0.17 and 0.18 m/sec).

One possible explanation for this finding is that patients who require physical assistance to walk are not able to vary their gait speed by as much because they rely on another person to assist them. The physical therapist, or physical therapist assistant, who was working with the patient throughout his or her rehabilitation, provided the assist during the walk. Because of their familiarity with the patient, the therapist may have been able to consistently provide the amount of physical assistance required to walk, thus reducing variability in gait speed while walking. Patients who can ambulate without physical assistance are not limited by the physical assistance of another person. This may allow for greater variability in walking performance at this stage of recovery. Another possible explanation for this finding is that there is less capacity for change in gait speed in people who require physical assistance to walk after stroke. As a person progresses in his or her rehabilitation and is able to ambulate without physical assistance, there may be a much greater capacity for change in gait speed and this may be reflected in the larger MDC^sub 90^ value.

The results of this study indicate that there is slightly more error and variability when measuring gait speed compared to previous studies.13-16 Evans and colleagues13 reported an ICC^sub 2,1^ of 0.92 and a 95% confidence interval for error estimate of -0.11 m/ sec to +0.17 m/sec. Hill et al14 reported an ICC^sub 2,1^ of 0.95 and 95% confidence interval for error estimate of -0.08 m/sec to +0.16 m/sec. Stephens and Goldie15 reported an ICC^sub 2,1^ of 0.97 and 95% confidence interval for error estimate of -0.13 m/sec to +0.17 m/sec. Flansbjer et al16 reported an ICC^sub 2,1^ of 0.94 and a 95% confidence interval for the smallest real difference of -0.15 m/sec to +0.25 m/sec.

Two possible explanations for this discrepancy are the differences in the subject characteristics and the methods used to calculate the amount of variability in gait speed. In all the studies listed above, the subjects were capable of independent ambulation and were in a more chronic phase of recovery than the subjects in this study. The mean length of time post-stroke in these studies was 1.5 months,13 2.8 months,14 3.7 months,15 and 18 months, respectively.16 As more time elapses post-stroke, it is likely the more stable a person’s walking ability becomes. The Copenhagen Stroke Study reported that walking ability plateaus in 95% of patients by 11 weeks post-stroke.2 The two studies13,14 in which the time since stroke was nearest the time post-stroke in this study used a foot switch system to time the patients. This automated system may have less error than a hand-held stopwatch. Another automated data collection system that may improve accuracy of gait speed data collection is the GAITRite portable walkway system (CIR Systems, Inc., Havertown, PA). The GAITRite walkway has sensors embedded in a portable mat that can accurately gather temporospatial measures of gait such as speed, cadence, step length, and single limb support time. Although these automated systems (foot switch or GAITRite) may improve accuracy, they take time to gather data and require special equipment and training. The simple stopwatch method used in this study is easy to perform in the clinic and requires very little time or training to perform. Three of the studies13-15 determined the 95% confidence interval for error estimate in gait speed by determining the mean change in gait speed from one trial to the next and the mean of the SD of the change scores. They multiplied the SDs of the change scores by 1.96 (Z score for 95% confidence level) and added or subtracted this from the mean change in gait speed to arrive at the 95% confidence interval for error estimate. By not taking into account the reliability coefficient and error associated with multiple measures, the error estimate may be underestimated.

Flansbjer and colleagues16 used the Bland Airman27 method of determining the smallest real difference (SRD) in gait speed. The SRD was defined as the smallest change that indicates real improvement or deterioration in gait speed.16 Their findings were the closest to the findings of this study, a 0.05-m/sec difference (0.30 m/sec compared to 0.25 m/sec). This difference is likely due to the fact that participants in the study by Flansbjer et al16 were 16 to 18 months post-stroke and were all independent community ambulators. The walking ability of people with chronic stroke is likely to be more stable and less variable than patients undergoing rehabilitation within one month after a stroke.

A potential limitation in the findings of this study is the time between successive measures of gait speed of one to three days was not standardized for each patient. This time range was chosen due to the time constraints of collecting data during clinical practice and other studies had used a similar time range.14,16 The measures were taken over the last week of their inpatient stay in an attempt to minimize any potential changes in walking ability over the one- to three-day time frame. However, during this one- to three-day period, it is possible that the gait speed of some participants may have actually improved. If this was the case, then this true change would be erroneously included in the measurement variability calculated by the MDC^sub 90^ and the ICC^sub 2,1^. Thus, the MDC^sub 90^ would actually be less and the ICC^sub 2,1^ would be greater than the data indicate.

However, these data were collected while the subjects were undergoing inpatient rehabilitation under conditions similar to physical therapy practice, which suggests that the results are appropriate for interpreting change in gait speed in patients with similar characteristics in the clinic. Despite any changes in walking ability that may have occurred, the results demonstrate that variability in gait speed is quantifiable for people undergoing rehabilitation in the first month poststroke with different levels of walking ability. These results can be used to interpret change in walking ability in people with stroke who are undergoing active rehabilitation shortly after stroke.

Although the MDC is an important characteristic to know in order to determine whether the amount of change that occurred in a patient exceeded measurement error, it does not let us know whether the change was clinically meaningful.21,22 Further research is necessary to determine the minimal clinically important difference in gait speed.

The results of this study may be used to interpret findings from research studies that examine the efficacy of physical therapy interventions designed to improve walking ability after stroke in patients with similar characteristics as those in this study. In addition to presenting their findings in terms of statistically significant differences between groups, researchers could express the results in terms of the proportion of patients in the experimental group who exceeded the amount of change that is necessary in order to be 90% certain that the change is a true amount of change compared to the same proportion of subjects in the comparison group. From these percentages, the number needed to treat could be calculated, which may provide a more clinically relevant method of examining the differences between interventions strategies.28

Gait speed is a reliable measure of walking ability for a wide variety of patients undergoing rehabilitation after stroke. The results of this study can also be used to interpret change in walking ability in individual patients. Our results suggest that a change of >0.30 m/sec in patients undergoing inpatient rehabilitation after stroke may be necessary in order to determine whether a change in gait speed exceeds measurement error and patient variability. As an outcome measure, gait speed is more sensitive to change in patients who require physical assistance to walk than in patients who can walk without physical assistance during the first two to six weeks after stroke. The measurement error and variability associated with gait speed are only 0.07 m/sec in patients who require physical assistance to walk as compared to 0.36 m/sec in patients who are able to walk without physical assistance during the relatively early stages of rehabilitation. This information is useful for the clinician trying to interpret gait speed measures in patients two to six weeks post-stroke.

ACKNOWLEDGMENT

Funding for this research was provided by the New York Physical Therapy Association.

REFERENCES

1. Rosamond W, Flegal K, Friday G, et al. Heart disease and stroke statistics-2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2007;115:e69-el71.

2. Jorgensen HS, Nakayama H, Raaschou HO, Olsen TS. Recovery of walking function in stroke patients: the Copenhagen Stroke Study. Arch Phys Med Rehabil. 1995;76:27-32.

3. Richards CL, Malouin F, Dean C. Gait in stroke: assessment and rehabilitation. Clin Geriatr Med. 1999;15:833-855.

4. Richards CL, Olney SJ. Hemiparetic gait following stroke. Part II: Recovery and physical therapy. Gait Posture. 1996;4:149-162.

5. Bohannon RW, Walsh S. Nature, reliability, and predictive value of muscle performance measures in patients with hemiparesis following stroke. Arch Phys Med Rehabil. 1992;73:721-725.

6. daCunha IT, Lim PA, Henson H, et al. Performance-based gait tests for acute stroke patients. Am J Phys Med Rehabil. 2002;81:848- 856.

7. Maeda A, Yuasa T, Nakamura K, et al. Physical performance tests after stroke: reliability and validity. Am J Phys Med Rehabil. 2000;79:519525.

8. Wolf SL, Catlin PA, Gage K, et al. Establishing the reliability and validity of measurements of walking time using the Emory Functional Ambulation Profile. Phys Ther. 1999;79:1122-1133.

9. Hsu AL, Tang PF, Jan MH. Analysis of impairments influencing gait velocity and asymmetry of hemiplegic patients after mild to moderate stroke. Arch Phys Med Rehabil. 2003;84:1185-1193.

10. Perry J, Garrett M, Gronley JK, et al. Classification of walking handicap in the stroke population. Stroke. 1995;26:982-989.

11. Rabadi MH, Blau A. Admission ambulation velocity predicts length of stay and discharge disposition following stroke in an acute rehabilitation hospital. Neurorehabil Neural Repair. 2005;19:20-26.

12. Roth EJ, Merbitz C, Mroczek K, et al. Hemiplegie gait. Relationships between walking speed and other temporal parameters. Am J Phys Med Rehabil. 1997;76:128-33.

13. Evans MD, Goldie PA, Hill KD. Systematic and random error in repeated measurements of temporal and distance parameters of gait after stroke. Arch Phys Med Rehabil. 1997;78:725-729.

14. Hill KD, Goldie PA, Baker PA, et al. Retest reliability of the temporal and distance characteristics of hemiplegic gait using a footswitch system. Arch Phys Med Rehabil. 1994;75:577-583.

15. Stephens JM, Goldie PA. Walking speed on parquetry and carpet after stroke: effect of surface and retest reliability. Clin Rehabil. 1999;13: 171-181.

16. Flansbjer UB, Holmback AM, Downham D, et al. Reliability of gait performance tests in men and women with hemiparesis after stroke. J Rehabil Med. 2005;37:75-82.

17. Ada L, Dean CM, Hall JM, et al. A treadmill and overground walking program improves walking in persons residing in the community after stroke: a placebo-controlled, randomized trial. Arch Phys Med Rehabil. 2003;84:1486-1491.

18. Plummer P, Behrman AL, Duncan PW et al. Effects of stroke severity and training duration on locomotor recovery after stroke: a pilot study. Neurorehabil Neural Repair. 2007;21:137-151.

19. Salbach NM, Mayo NE, Higgins J, et al. Responsiveness and predictability of gait speed and other disability measures in acute stroke. Arch Phys Med Rehabil. 2001;82:1204-1212.

20. Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing rater reliability. Psychol Bull. 1979;86:420-428.

21. Stratford P. Getting more from the literature: estimating the standard error of measurement from reliability studies. Physiother Can. 2004;56: 27-30.

22. Haley SM, Fragala-Pinkham MA. Interpreting change scores of tests and measures used in physical therapy. Phys Ther. 2006;86:735- 743.

23. Fritz JM, Irrang JJ. A comparison of a modified Oswestry Low Back Disability Questionnaire and the Quebec Back Pain Disability Scale. Phys Ther. 2001;81:776-788. 24. Wyrwich K, Tierney W, Wolinsky F. Further evidence supporting a SEM-based criterion for identifying meaningful intra-individual changes in health related quality of life. J Clin Epidemiol. 1999;52:861-873.

25. Portney LG, Watkins MP. Foundations of Clinical Research: Applications to Practice, 2nd ed. Upper Saddle River, NJ: Prentice Hall Health, 2000.

26. Barak S, Duncan PW. Issues in selecting outcome measures to assess functional recovery after stroke. NeuroRx. 2006;3:505-524.

27. Bland JM, Altman DG. Measuring agreement in method comparison studies. Stat Methods Med Res. 1999;8:135-160.

28. Dalton GW, Keating JL. Number needed to treat: a statistic relevant for physical therapists. Phys Ther. 2000;80:1214-1219.

George D. Fulk, PT, PhD, and John L. Echternach, PT, DPT, EdD, FAPTA

Physical Therapy Department (G.D.F.), Clarkson University, Potsdam, New York, and School of Physical Therapy (J.L.E.), Old Dominion University, Norfolk, Virginia.

Address correspondence to: George D. Fulk, E-mail: [email protected].

Copyright (c) 2008 Neurology Section, APTA

ISSN: 1557-0576/08/3201-0008

DOI: 10.1097/NPT0b013e31816593c0

Copyright Neurology Report Mar 2008

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

Creating Quiet: Make Own Meditation Garden

Every home has enough space for some dream-building — an out-of- the-way spot for relaxing after a hectic day’s work, a quiet corner where your mind is free to drift, a site too distant to hear the doorbell’s chime.

With some thoughtful landscaping, those out-of-the-way spots can emerge as meditation gardens, spirit gardens, healing gardens or Japanese rock gardens. All are created to raise consciousness or reduce stress.

“Just as there are many forms of meditation, people have a variety of needs from a meditation garden,” says Nicole Kistler, an artist and environmental designer from Seattle. “Any space where people feel comfortable and safe will be a good place to meditate.”

A meditation garden should be sensory-rich — rich in plants, trees or shrubs that are aromatic, soothing to the ears and appealing to the eyes.

That would mean calming background sounds such as the breeze- driven rustling of ornamental grass, the delicate clatter of bamboo, water gurgling from a fountain or splashing from a waterfall. Muted foliage works better than a distracting bold, along with the scent of blooms or herbs that have been crushed underfoot.

“I often see three key elements in gardens for reflection and meditation: water, lush green plants and comfortable seating,” Kistler says.

Moving water masks distractions like the noise of traffic. Plants provide shade, visual interest and oxygen. Natural lighting also is an important ingredient in the design mix.

Cultivating the minimalist look is a plus for any meditation garden, artistically and practically.

“These should be healing and relaxing gardens. Low maintenance. Not large. Not places where you have to work,” says Osamu Shimizu, a Japanese garden designer from Glen Echo, Md., who created a rooftop meditation garden at Mount Holyoke College in South Hadley, Mass., and several Japanese-inspired landscapes at the Lewis Ginter Botanical Garden in Richmond, Va.

“It would be nice to have them surrounded by hedges or trees so they’re isolated from everything. It also would be nice to have areas that you can focus on using some sculpture, pottery or water.”

Many of the elements designed into meditation gardens are borrowed from Zen or temple gardens. Examples include:

Rocks, gravel and sand that can be groomed with a rake to symbolize the look of rippling water, islands rising from the sea, mountains peeking above the clouds or anything your imagination might suggest.

Natural pieces reinforcing the look of the immediate surroundings. That might consist of some gnarled remnants of weathered wood or the rocky outwash from an eroding slope.

Treescaping or landscaping with trees. “That depends largely upon their sizes, but you can create some interesting shapes with the trees you have growing in your yard,” Shimizu says.

Labyrinths, pathways and gently curved planting beds. “Even small trails can create the illusion of space or the potential for discovery around the next bend,” Shimizu says.

Meditation gardens can become year-round retreats with the proper plant selection: Shimizu suggests evergreens in winter and perennial plants that mature in succession. And they can be enjoyed night and day with proper lighting — lights aimed at trees or fountains can be dramatic.

Even city-dwellers can create meditation gardens that overcome the racket made by helicopters, sirens, jackhammers and street traffic.

“Turn things inside out. Install or take advantage of a large window and enjoy your (meditation) garden from indoors,” he says. “You also could place an intercom near a fountain to hear the splashing water or somewhere where you could pick up the sounds of plants blowing in the wind. The intercom can act as your own natural wind chime.”

But beware the temptation to continue adding on.

“It’s human nature to add more and more. If you have a pond, then you add an aerator. Then you add some fish. Then you have to add filters,” Shimizu says. “People can lose what they’re seeking in a meditation garden by making it too complicated, too much work.”

Dream gardens

Less is more when designing a meditation garden, where the minimalist approach can be functional as well as aesthetically pleasing. These gardens are meant for dreaming, not for tending.

Choose low-maintenance plants — for the most part perennials — with features that appeal to the senses.

Here are selections that have proven popular in dream gardens. Many were inspired by the temple gardens of Japan.

Japanese maple trees. More than 400 cultivars have been developed, making this a great, all-purpose, all-season tree whether it’s used as a centerpiece or in groups. Japanese maples are not the hardiest of trees but usually do well in USDA zones 4 through 8. Japanese maples are prized for their fall colors, but they also outperform many other showy ornamentals with their springtime radiance. Their spectacular leaves continue “flowering” long after fruit trees have dropped their blossoms.

Japanese or Siberian iris. These are simple to grow. They do best in acid soils and require full sun for at least a half-day. Both varieties like water, which makes them good choices for planting alongside ponds or near streams. The Siberians are hardy from Zones 3 through 10; Japanese iris is partial to Zones 4 through 9.

Apricot and cherry trees do double duty by flowering and providing fruit. They also can be pruned or shaped to add more interest, summer or winter. Zones 6 through 9.

Water fixtures. Few sounds are more lulling than those made by moving water. Ponds, streams, waterfalls or fountains are design standards for meditation gardens, often serving as the focal point. They also attract many species of wildlife.

Ferns and moss provide lush green color from early spring through the first few killing frosts and beyond. Moss placed between paving stones invites walking barefoot through the garden. Ferns and moss do best when planted in areas tending toward shade and moisture. Hardiness varies according to type, but all are safe to grow in Zones 5 through 8.

Evergreens add four-season interest and serve as efficient sound baffles on borders. Cedars and certain old-world species of junipers are attractive choices, suggesting the twists and turns of Bonsai.

Black Carbon is Major Player in Global Warming

Soot from biomass burning, diesel exhaust has 60 percent of the effect of carbon dioxide on warming but mitigation offers immediate benefits

Black carbon, a form of particulate air pollution most often produced from biomass burning, cooking with solid fuels and diesel exhaust, has a warming effect in the atmosphere three to four times greater than prevailing estimates, according to scientists in an upcoming review article in the journal Nature Geoscience.

Scripps Institution of Oceanography at UC San Diego atmospheric scientist V. Ramanathan and University of Iowa chemical engineer Greg Carmichael, said that soot and other forms of black carbon could have as much as 60 percent of the current global warming effect of carbon dioxide, more than that of any greenhouse gas besides CO2. The researchers also noted, however, that mitigation would have immediate societal benefits in addition to the long term effect of reducing greenhouse gas emissions.

The article, “Global and regional climate changes due to black carbon,” was posted in the online version of Nature Geoscience on Sunday, March 23.

“Observationally based studies such as ours are converging on the same large magnitude of black carbon heating as modeling studies from Stanford, Caltech and NASA,” said Ramanathan. “We now have to examine if black carbon is also having a large role in the retreat of arctic sea ice and Himalayan glaciers as suggested by recent studies.”

In the paper, Ramanathan and Carmichael integrated observed data from satellites, aircraft and surface instruments about the warming effect of black carbon and found that it’s forcing, or warming effect in the atmosphere, is about 0.9 watts per meter squared. That compares to estimates of between 0.2 watts per meter squared and 0.4 watts per meter squared that were agreed upon as a consensus estimate in a report released last year by the Intergovernmental Panel on Climate Change (IPCC), a U.N.-sponsored agency that periodically synthesizes the body of climate change research.

Ramanathan and Carmichael said the conservative estimates are based on widely used computer model simulations that do not take into account the amplification of black carbon’s warming effect when mixed with other aerosols such as sulfates. The models also do not adequately represent the full range of altitudes at which the warming effect occurs. The most recent observations, in contrast, have found significant black carbon warming effects at altitudes in the range of 2 kilometers (6,500 feet), levels at which black carbon particles absorb not only sunlight but also solar energy reflected by clouds at lower altitudes.

Between 25 and 35 percent of black carbon in the global atmosphere comes from China and India, emitted from the burning of wood and cow dung in household cooking and through the use of coal to heat homes. Countries in Europe and elsewhere that rely heavily on diesel fuel for transportation also contribute large amounts.

“Per capita emissions of black carbon from the United States and some European countries are still comparable to those from south Asia and east Asia,” Ramanathan said.

In south Asia, pollution often forms a prevalent brownish haze that has been termed the “atmospheric brown cloud.” Ramanathan’s previous research has indicated that the warming effects of this smog appear to be accelerating the melt of Himalayan glaciers that provide billions of people throughout Asia with drinking water. In addition, the inhalation of smoke during indoor cooking has been linked to the deaths of an estimated 400,000 women and children in south and east Asia.

Elimination of black carbon, a contributor to global warming and a public health hazard, offers a nearly instant return on investment, the researchers said. Black carbon particles only remain airborne for weeks at most compared to carbon dioxide, which remains in the atmosphere for more than a century. In addition, technology that could substantially reduce black carbon emissions already exists in the form of commercially available products.

Ramanathan said that an observation program for which he is currently seeking corporate sponsorship could dramatically illustrate the benefits. Known as Project Surya, the proposed venture would provide some 20,000 rural Indian households with smoke-free cookers and equipped to transmit data. At the same time, a team of researchers led by Ramanathan would observe air pollution levels in the region to measure the effect of the cookers.

Carmichael said he hopes that the paper’s presentation of the immediacy of the benefits will make it easier to generate political and regulatory momentum toward reduction of black carbon emissions.

“It offers a chance to get better traction for implementing strategies for reducing black carbon,” he said.

The National Science Foundation, the National Oceanic and Atmospheric Administration and the National Aeronautics and Space Administration funded the review.

Image 1 Caption: Pollution in Asia from 2004-2005 – The polluting effects of cooking using biomass like wood or cow dung in south Asia are illustrated through a measurement of aerosol optical depth, a way of measuring the quantity of pollutants in the air by the relative ability of light to penetrate through them. This representation shows reconstructed levels of pollution from 2004 and 2005 with the effects of biofuel cooking removed. Credit: Scripps Institution of Oceanography, UC San Diego

Image 2 Caption: Polluting Effects of Cooking Using Biomass – The polluting effects of cooking using biomass like wood or cow dung in south Asia are illustrated through a measurement of aerosol optical depth, a way of measuring the quantity of pollutants in the air by the relative ability of light to penetrate through them. This representation shows reconstructed levels of pollution from 2004 and 2005. Credit: Scripps Institution of Oceanography, UC San Diego

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University of California – San Diego

Nature Geoscience

Scripps Institution of Oceanography

Children’s Hospitals and Clinics of Minnesota COO, Julie Morath, Appointed to National Quality Forum Committee

MINNEAPOLIS and ST. PAUL, Minn., March 24 /PRNewswire/ — Children’s Hospitals and Clinics of Minnesota today announced the recent appointment of Julie Morath, RN, chief operating officer and vice president of care delivery, to the Steering Committee of the National Quality Forum (NQF), a private, not-for-profit membership organization created to develop and implement a national strategy for healthcare quality measurement and reporting.

Morath will be joined by 14 other committee members responsible for reviewing and recommending amendments to the NQF-endorsed(TM) Safe Practices for Better Healthcare, a set of 30 safe practices that should be universally utilized in applicable clinical care settings to reduce the risk of harm to patients.

“Julie Morath’s contributions to the field of patient safety and her work at Children’s have set new standards for leadership,” said Alan L. Goldbloom, MD, President and CEO of Children’s. “Children’s is proud of her appointment to this important committee that continues to address the issues of patient safety and quality.”

With more than 30 years of health care experience, Morath joined Children’s in 1999, and set about immediately to build what has become known as “a culture of safety” in the organization. Her emphasis includes perfecting complex systems of medical care so that patients are never vulnerable to harm. Under her leadership, Children’s core focus is to “do the right thing at the right time for every single child, each and every time.”

Morath earned her master’s degree at the University of California at San Francisco and her bachelor’s degree from the University of Michigan. A Minneapolis resident, she and her husband, Don Morath, MD, have four grown children.

Children’s Hospitals and Clinics of Minnesota is the seventh-largest children’s health care organization in the U.S., with 332 staffed beds at its two hospital campuses in St. Paul and Minneapolis. An independent, not-for-profit health care system, Children’s of Minnesota provides care through more than 14,000 inpatient visits and more than 200,000 emergency room and other outpatient visits each year.

Children’s Hospitals and Clinics of Minnesota

CONTACT: Allison Sandve, +1-612-813-6615, pager, +1-612-526-3440, forChildren’s Hospitals and Clinics of Minnesota

Salmonella Lethal To AIDS Patients

Animal study reveals mechanism behind rise in salmonella bacteremia in AIDS patients

Nearly half of all HIV-positive African adults who become infected with Salmonella die from what otherwise would be a seven-day bout of diarrhea. Now, UC Davis School of Medicine scientists have discovered how salmonella becomes lethal for AIDS patients. Their findings also implicate a mechanism by which HIV evades the powerful drugs used to treat AIDS.

“We have found the defect in the immune response that allows Salmonella to cross the mucosal barrier of the gut, enter the bloodstream and infect other organs,” said Andreas Bäumler, a UC Davis professor of medical microbiology and immunology and co-author of the study.

The results of the study, which were published online by Nature Medicine March 23, revealed that viral infection of the intestine results in the depletion of a type of white blood cell, called Th-17, in the gut mucosa. This T helper lymphocyte produces IL-17, a cytokine or chemical messenger that plays a crucial role in the inflammatory response, recruiting other immune system cells to the site of infection.

This kind of interruption in the gut’s immune response could be allowing HIV to maintain reservoirs that evade drug treatments, said Satya Dandekar, professor and chair of the department of medical microbiology and immunology.

“It’s like putting out the fire, but leaving the embers smoldering,” Dandekar said.

The rise in patients with acquired immune deficiency syndrome (AIDS) in sub-Saharan Africa has led to a dramatic increase in the frequency of non-typhoidal Salmonella serotypes (NTS), the strains of the bacteria that cause acute food-borne disease world wide. Normally, this infection is limited to the intestine, causing gastroenteritis. In AIDS patients, however, the infection spreads to the bloodstream and causes what is called NTS bacteremia.

While at a conference, Bäumler was surprised to learn from epidemiologist and physician Melita Gordon of the University of Liverpool that Salmonella was quickly becoming one of the leading causes of death in parts of Africa. (Gordon is a co-author on the current paper.) Bäumler returned to Davis and approached Dandekar about collaborating.

Dandekar had been studying the role of gut-associated lymphoid tissue in HIV. In a 2006 study, she found that HIV continued to replicate in the gut mucosa and suppress immune function in patients being treated with antiretroviral therapy “” even when T-cell counts from blood samples from the same individuals indicated antiretroviral treatment was working.

“We think the real battle between an individual’s immune system and HIV is happening in the gut mucosa where there is massive destruction of immune cells,” Dandekar said. Gut-associated lymphoid tissue, she pointed out, accounts for 70 percent of the body’s immune system.

In HIV-infected patients, there is a gradual loss of CD4+ T cells over time. These cells, also called T helper cells, organize the immune system’s attack on disease-causing invaders, like Salmonella. Unlike the steady decline of T cells in peripheral blood, there is a very rapid loss of CD4+ T cells in the gut mucosa, Dandekar said.

“We wanted to know whether the loss of the CD4+ T-cells in the gut contributed to the inactivation of the immune system one sees in HIV-infected patients,” she said.

Both Bäumler and Dandekar said the timing was perfect for their collaboration. Together, they developed a novel technique that allowed them to study early intestinal responses to Salmonella infection in rhesus macaques infected with simian immunodeficiency virus (SIV), an established model for HIV infection.

“We found that animals that had no SIV infection were able to generate immediate responses to bacterial exposure, producing Th17 cells in large amounts,” Dandekar said. The SIV-infected animals, however, had either a significantly lower response or lacked did not produce measurable amounts of the cytokine.

“This muted Th17 response led to dissemination of Salmonella from the gut to the peripheral blood,” Dandekar said.

The team of researchers also used mice that lacked the IL-17 receptor, an arm of the mucosal immune response, to confirm that IL-17 deficiency leads to increased systemic dissemination of Salmonella.

“We believe IL-17 deficiency causes defects in the mucosal barrier of the gut,” Dandekar said.

Both Bäumler and Dandekar agreed that the results of their collaboration have exciting implications for both HIV and Salmonella research and, more importantly, get scientists closer to finding treatments for HIV and the deadly form of Salmonella.

In terms of HIV, the results suggest that Th17 may make a good biomarker for monitoring HIV infection and testing the efficacy of vaccines and other therapies. They also suggest that efforts to enhance Th17 function may improve existing antiretroviral treatments.

“We are interested in looking at different molecules and compounds to see if we can boost mucosal immune defenses in the gut,” she said.

Dandekar is also interested in looking at Th17 function in those who respond well to treatment and in long-term non-progressors, those individuals who carry HIV for years without going onto develop AIDS.

“Now we know these cells are playing a big role, but we need to better understand how they are contributing to immune inactivation and inflammation,” Dandekar said.

In terms of Salmonella, Bäumler’s next step is to discover the mechanisms by which non-immunocompromised patients are able to rid themselves of the infections.

“We now know which cytokines orchestrate the mucosal barrier function, but we still don’t know what kills these bacteria,” he said.

The study was funded by the National Institutes of Health.

Photo Caption: Color-enhanced scanning electron micrograph showing Salmonella typhimurium (red) invading cultured human cells. Credit: Rocky Mountain Laboratories, NIAID, NIH

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University of California – Davis – Health System

National Institutes of Health

Nature Medicine

Height Of Pitching Mound Affects Throwing Motion, Injury Risk

Medical College study on pitching mound height provides insight into baseball injuries

A study involving several Major League Baseball pitchers indicates that the height of the pitcher’s mound can affect the athlete’s throwing arm motion, which may lead to potential injuries because of stress on the shoulder and elbow.

The study was led by William Raasch, M.D., associate professor of orthopaedic surgery at the Medical College of Wisconsin in Milwaukee, who also is the head team physician for the Milwaukee Brewers. Major League Baseball funded the study in an effort to help prevent injuries among professional baseball players.

The results of the study were presented at the 2007 MLB Winter Meetings at the joint session of the Major League Baseball Team Physicians Association and Professional Baseball Athletic Trainers Society.

The researchers recruited 20 top-level, elite pitchers from Major League Baseball organizations and Milwaukee-area NCAA Division I-A college pitchers for the study, which was conducted both during 2007 spring training in Arizona and at the Froedtert & Medical College Sports Medicine Center in Milwaukee.

“Our researchers employed a motion analysis system using eight digital cameras that recorded the three-dimensional positions of 43 reflective markers placed on the athletes’ bodies. Then we analyzed the pitching motion at mound heights of the regulation 10-inches, along with eight-inch and six-inch mounds, as well as having the athletes throw from flat ground,” Dr. Raasch explains.

The study focused on determining if there is increased stress on the shoulder or the elbow based on the height from which the pitcher has thrown. A kinematic analysis provided information regarding pitching motion (position and velocity), while the kinetic analysis determined the forces and torques generated at the shoulder and elbow.

“We found that compared to flat ground, pitchers using a 10-inch mound experience an increase in superior shear and adduction torque in the shoulder ““ meaning there’s a greater amount of stress on the joint surface and surrounding structures. That greater stress may result in injury to the shoulder including tearing of the rotator cuff or labrum which may result in surgery and long-term rehabilitation. It also can make it difficult for the athlete to replicate the same throw and develop a consistent strike,” Dr. Raasch says.

“The most notable kinematic difference was the increase in shoulder external rotation at foot contact. This probably represents a change in the timing of the foot contact relative to arm position, because the foot lands earlier in the pitch delivery during flat ground throwing than with a slope,” he says.

While the study did not result in enough data to recommend reducing the 10-inch mound height, which became standard in 1968 and also used in college and high school baseball, Dr. Raasch says the findings give trainers information that can help them determine if pitchers would be better off practicing on flat ground especially after an injury.

“Nolan Ryan, who played major league baseball for 27 years, often threw pitches more than 100 mph, even past the age of 40, and he liked to throw on flat ground in his waning years. I think others might follow his lead,” Dr. Raasch says. He adds that he hopes subsequent research during spring training in 2008 will provide even more valuable findings for baseball players and trainers.

Coauthors of the study include Jeremy R. O’Brien, M.S., research engineer; Craig C. Young, M.D., professor of orthopaedic surgery; and Mark W. Lydecker, MPT, OCS, ATC, physical therapist at the sports center.

To view videos of the study, please follow the links below.

Picher throwing baseball

Computer generated dots only

Computer generated dots with wireframes

Skeleton version

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Medical College of Wisconsin

Prime Therapeutics Introduces Triessent(TM) Specialty Pharmacy Program

ST. PAUL, Minn., March 24 /PRNewswire/ — Prime Therapeutics (Prime), a thought leader in pharmacy benefit management, announced today the launch of its specialty pharmacy program, Triessent(TM). Prime will begin enrollment in Triessent in mid 2008, offering patients complete specialty pharmacy management services, including comprehensive support to members with conditions that require specialty medications, as well as distribution of the medications themselves.

The introduction of Triessent represents the next stage for specialty pharmacy management for members and clients. The program directly addresses one of the leading contributors to rising health care costs by providing an approach to specialty pharmaceutical management that integrates pharmacy and medical benefits for Blue Cross and Blue Shield clients across the nation.

The development of Triessent has focused on three core capabilities as a foundation for a complete specialty management program: safe and efficient delivery of specialty medications; education and guidance from experienced professionals for both clinical care management and benefit design; and integrated management of medical and pharmacy programs. Through Triessent, members will experience the high-touch, personalized and coordinated care management they need to manage their specialty conditions.

As an important milestone in the development of Triessent, Prime has selected Pittsburgh-based Medmark, A Walgreens Specialty Pharmacy , as its single-source distribution provider.

“Prime believes the complexity of specialty pharmacy is too important to simply outsource,” says Tom Solberg, Assistant Vice President of Specialty at Prime. “Medmark’s proven track record complements Prime’s existing specialty core capabilities as a pharmacy benefit manager and will allow Prime to offer a complete specialty pharmacy program through Triessent. Prime is committed to providing a variety of solutions to help our clients manage specialty spend and strengthen their ability to compete effectively in the specialty marketplace with a complete specialty solution.”

Prime Therapeutics is a pharmacy benefit management company dedicated to providing innovative, clinically based, cost-effective pharmacy solutions for clients and members. Providing pharmacy benefit services nationwide to approximately 14.6 million covered lives, its client base includes Blue Cross and Blue Shield Plans, employer and union groups, and thirdparty administrators. Headquartered in St. Paul, Minnesota, Prime Therapeutics is collectively owned by 10 Blue Cross and Blue Shield Plans, subsidiaries or affiliates of those Plans. Learn more at http://www.primetherapeutics.com/.

Prime Therapeutics

CONTACT: Sheila Thelemann, Sr. Manager, Public Relations and CorporateCommunications of Prime Therapeutics, +1-651-414-1863,[email protected]

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

At-Home Test For Bipolar Disorder Causes Concern

Last December, Dr. John Kelsoe, a prominent psychiatric geneticist at the University of California who had spent his entire career identifying the biological roots of bipolar disorder, announced he had discovered several gene mutations closely associated with the disease.

Then, Kelsoe, 52, did something unheard of in the world of academic research by selling genetic tests for the condition directly to the public via the Internet for $399. 

Psynomics, Kelsoe’s La Jolla, CA-based company, is among many startups embracing the boom in research that connects genetic variations to a whole host of health conditions.  Indeed, there are now over 1,000 at-home do-it-yourself genetic tests on the market.

Although Psynomics has sold only a few tests so far, the company is projecting sales of 1,800 tests this year and 30,000 in the next five years.

But many public health officials, doctors and medical ethicists worry about the proliferation of these tests, which are without any significant government oversight, even though many of them are being sold as tools for making important medical decisions.

Experts are concerned that many of these tests prey on people’s deepest anxieties, and are based on shaky data.

“People are always rushing to the market on the basis of one or two studies,” Dr. Muin Khoury, director of the National Office of Public Health Genomics at the Centers for Disease Control and Prevention (CDC), told the Associated Press.

“We have very little evidence that telling people their genetic information is going to make any difference.”

Some of the available tests claim the ability to predict and diagnose conditions as wide ranging as cancer, Alzheimer’s disease, athletic ability and even a person’s ideal diet.

However, Psynomics’ offering is one of the first psychiatric gene tests on the market.

Kelsoe admits that bipolar disorder is likely the result of a combination of both genetic and life experience factors, and that the presence of certain gene variations alone does not indicate someone will, in fact, develop the disease.  He also acknowledges that his studies about the genetic basis of manic depression are incomplete.

But he said his test is a critical starting point in the departure from the notoriously tricky practice of diagnosing bipolar disorder based solely on a person’s behavior.

“The goal of this is to try and help doctors make an accurate diagnosis more quickly so the patient can be treated appropriately,” Kelsoe told the AP.

“Anything is going to help, even if it just helps a little bit.”

People with bipolar disorder experience intense mood swings, cycling through delusional highs and depressive lows that untreated could lead to suicide.  The disease is often misdiagnosed as depression, delaying proper treatment and resulting in improper prescribing of medications such as antidepressants that could even aggregate symptoms in some patients.

To take the Psynomics test, patients spit into a plastic cup they receive by mail from the company, and then seal and return the cup to Psynomics, who then analyze the DNA in the saliva.  To avoid self-diagnosis by the customer, Psynomics will only send test results to the customer’s doctor, along with an accompanying report instructing the doctor that a positive test means patients are two to three times more likely to have bipolar disorder.

But the studies from which those figures derive also show such gene mutations are rare, even among those with bipolar disorder.

For now, the test is valid only in whites of Northern European ancestry who demonstrate some behavioral symptoms and have at least one bipolar family member.

Hank Greely, a professor of law and genetics with the Stanford Center for Biomedical Ethics, said patients taking Psynomics’ bipolar test might feel branded by a positive result, even if they are not ultimately found to have the disorder. Or, on the other hand, they may get a false hope from a negative result, despite Psynomics’ disclaimers about the test.

Doctors have little training beyond what companies such as Psynomics tell them when it comes to interpreting and applying the test results.

“They may make a foolish decision that backfires to put you on meds,” Greely told the Associated Press.

“Or they may make a decision that backfires not to put you on meds.”

The Psynomics test is intended only to be used as a purely diagnostic tool for patients already showing symptoms, unlike tests on the market for other conditions.  And the company does not claim its test can predict a person’s risk of developing bipolar disorder later in life.  

According to Dr. Greg Feero, head of genomic health care at the National Human Genome Research Institute, it’s an important distinction that differentiates Psynomics as more responsible than others that promise a glimpse into the future.

“Now you’re talking about an individual who has symptoms or signs that already put them in a very different risk category than someone who has no symptoms or signs,” Feero told AP.

Kelsoe has studied hundreds of families, and discovered one of the gene variations in the Psynomics test showed up in 1 percent of those unaffected by bipolar disorder versus 3 percent who are affected. Another variation appeared in 7 percent of those without the disorder, compared to 15 percent who have the disease.

Kelsoe and his team believe that no single genetic variation is ultimately responsible for bipolar disorder, and many other genes outside of those identified by Kelsoe interact with a patient’s environment to contribute to the development of the disease.   Researchers in Kelsoe’s lab are working to identify more genes.

“Why are we starting before it’s finished? You’ve got to start somewhere,” Kelsoe said. “Even if we knew everything about the genes, which we certainly don’t, it’s never going to be 100 percent predictive.”

At least two other startups led by genetic researchers are set to release their own psychiatric genetic tests in the coming months — one to predict a person’s risk of developing schizophrenia, and the other to forecast the likelihood that some medications for major depression could intensify a patients’ suicidal thoughts.

To date, the American Psychiatric Association has not yet adopted an official policy on genetic testing.  A Federal Trade Commission fact sheet cautions consumers to be skeptical of claims made by at-home genetic testing companies.  A Food and Drug Administration panel is working to establish standards for the nascent industry, but does not evaluate the tests for accuracy.

For now, many remain concerned about the proliferation of these tests, and that there is too little understanding of them to interpret the results.

“We just don’t know how people will use the information,” Dr. Jinger Hoop, a professor of psychiatric genetics and medical ethics at the Medical College of Wisconsin in Milwaukee, told the Associated Press.

“We don’t know whether it will be helpful to them in the long run.”

Memes Help Keep Internet Interesting

Part of the allure of the Internet is the way seemingly obscure photos, videos and Web pages gain momentum and begin to invade pop culture. Before the advent of sites such as YouTube and Flickr, these Internet memes clogged our e-mail inboxes. Now they’re also on blogs, prime-time television and nightly newscasts.

Last year’s most notable meme was Chris Crocker’s infamous “Leave Britney Alone” video. Even today, people make references to the video.

Another began circulating last year based on actor Chuck Norris and fictitious claims about his abilities (“Chuck Norris’ tears cure cancer. Too bad Chuck Norris has never cried.”). Presidential candidate Mike Huckabee picked up on the phenomenon and released a campaign commercial that featured Norris himself.

Memes are created daily – some intentionally, others not. Companies try to create their own memes and viral videos in hopes of getting their name in front of millions of eyeballs with little financial investment. Others happen by accident.

One of the more popular memes over the past few months is the Lolcats phenomenon. Lolcat photos are spread over Weblogs and message boards and feature a photograph of a cat with a broken, misspelled phrase beneath it – such as a picture of a cat tucked inside a woman’s purse, tagged with “Watz in ur wallet,” an altered version of the Capital One catchphrase.

Many of the photos are hosted on the popular icanhascheezburger.com Web site, which also allows visitors to create their own Lolcat photos.

Similar to Lolcats is the FAIL meme. FAIL photos have a picture of a person or an animal in a compromising situation and tagged with one word: FAIL. Some of the more popular photos feature people captured in mid-tumble off a bicycle or a woman trying to snap a photo with the lens cover still on.

The FAIL blog (failblog.wordpress.com) is updated several times a week with new photos contributed by readers and offers its own apparel line.

By far the oddest of the recent Internet memes is the concept of “rolling,” or having a person link to a supposedly legitimate Web site relevant to the discussion, but instead forwarding the person to a photo or video. The most popular version of rolling is “Rickrolling,” where the link a user clicks redirects to a page that shows the music video for Rick Astley’s 1980s hit, “Never Gonna Give You Up.”

Why Astley’s video was chosen to be the root of the meme is anyone’s guess.

Winners Announced for Second Annual YouTube Video Awards

YouTube(TM), the leading online video community that allows people to discover, watch and share originally created videos, is turning on the spotlights to celebrate the announcement of the 2007 YouTube Video Awards winners (http://www.youtube.com/ytawards07winners). The awards recognize the achievements of the YouTube community and encourage the creation of outstanding online videos.

“In 2007 the YouTube community showed the world that there’s something for everyone on the site,” said Mia Quagliarello, manager of community for YouTube. “This year’s YouTube Video Award winners not only include entertainers, they include those who served as a mouthpiece for everyday people, those who inspired and those who informed.”

“It’s definitely exciting to receive a YouTube Video Award,” said TayZonday, this year’s Music Video Award recipient. “YouTube’s provided me with a place to experiment, showcase my creativity and share my identity. It’s really an honor to get a YouTube Video Award. I’m looking forward to seeing future winners.”

The community has made their decisions and the 2007 YouTube Video Awards go to… drum roll please… :

— Adorable: Laughing Baby —

Nine-month-old Ethan falls over laughing — apparently ripping magazines is hilarious — and just can’t stop, igniting a laughing fit in his dad, too. It’s infectiously cute and earned Ethan a spot in an insurance commercial, allowing millions of people beyond YouTube to chuckle along with this adorable munchkin.

— Comedy: Potter Puppet Pals in “The Mysterious Ticking Noise” —

Neil Cicierega is the talented puppeteer who offers a twisted take on the world of Harry Potter. On a fraction of the budget of the Hogwarts movies, he’s created his own series of Potter puppet parodies, of which “The Mysterious Ticking Noise” is a blockbuster in its own right. Cicierega’s talents go beyond the Potter videos as he can be seen in a number of funny short films and sketches. However, it’s the videos where he’s the hidden hands and voices of the Potter pals that have cemented his reputation as a comedic talent to watch.

— Commentary: LonelyGirl15 is Dead! —

The WhatheBuckShow, an entertainment vlog with several original episodes posted each week, manically covers hot Hollywood and celebrity news. Hosted by gossip extraordinaire Michael Buckley, the series is the #7 Most Subscribed Channel of All Time on YouTube. Inexhaustible and abundantly enthusiastic, Buckley occasionally talks sports and politics but would much rather dish on Top Model and anything to do with “lady bits.”

— Creative: Human Tetris —

Swiss artist Guillaume Reymond of the NOTsoNOISY creative agency is the mastermind behind this innovative video, which uses humans to re-enact a game of Tetris. The stop-motion clip is the fourth video installation of the GAME OVER Project, and took 4.5 hours to shoot using 88 extras and 880 pictures. It was performed and shot at the “Les Urbaines” festival in Lausanne, Switzerland, on November 24, 2007.

— Eyewitness: Battle at Kruger —

Exquisite footage of nature in action, “Battle at Kruger” documents a raw scene from a safari in Kruger National Park, South Africa. Lions attack a calf in a temporary tug-of-war with a crocodile over the meat. Then, the herd of buffalo returns to fight for their young one. National Geographic Channel was so impressed with this footage, they sent the filmmakers back to Africa for a behind-the-scenes special about the making of the clip. This special airs in May.

— Inspirational: Blind Painter —

This video by the Texas Country Reporter chronicles the life and times of blind painter John Bramblitt, who started to gain international exposure in 2007, with notices by media in the U.S., the UK and Korea. After losing his sight from epilepsy, Bramblitt took up the hobby for its calming effects and turned out to be quite gifted at it. This video shows how he uses touch where most painters use sight.

— Instructional: How to solve a Rubik’s Cube (Part One) —

Even though he wasn’t born when it was invented, Dan Brown is a master of the Rubik’s Cube. He figured out the algorithm to solve the puzzle and has shared it with the YouTube community in nearly a dozen videos on the subject. (His winning video has 3.6 million views.) Not only can the Nebraska native and high school senior quickly solve a Rubik’s Cube, he can also do it while jumping on a pogo stick.

— Music: Chocolate Rain —

TayZonday took the summer of 2007 by storm with his stunning baritone, perplexing lyrics and quirky gestures, single-handedly establishing the move-away-from-the-mic meme that was replicated in hundreds of video responses by everyone from Gruff the Crime Dog to Tre Cool of Green Day. The 25-year-old Minneapolis native continues to experiment with diverse musical works and voice compositions that he primarily shares on the Internet. “Yes, I have a deep voice,” he says on his YouTube channel.

— Politics: Stop the Clash of Civilizations —

In the wake of strife in Iraq and the Middle East, “Stop the Clash” makes us confront the stereotypes we have about each other, particularly the conceptions the West has about Islam and vice versa. The force behind the video is www.Avaaz.org — “Avaaz” means “voice” or “song” in several languages, including Hindi, Urdu, Farsi, Nepalese, Dari, Turkish, and Bosnian. A community of “global citizens” grappling with the major issues facing the world today, Avaaz has members in every country on earth and strives to give all the world’s people — not just the elites — a voice.

— Series: The Guild —

The Guild is an independent Web series about a group of online gamers staring “Buffy the Vampire Slayer”‘s Felicia Day. Written for gamers about gamers by a gamer, the show follows Guild members’ lives online and offline in episodes that usually range between three and five minutes in length. The series has nearly 30,000 subscribers through YouTube, and it’s already won a SXSW/On Networks Greenlight Award this year.

— Short Film: My Name is Lisa —

U.S. filmmaker Ben Shelton is the creator of “My Name is Lisa,” a short film that won third place in the YouTube Project Direct contest and now has been selected by the YouTube community as the top short film on the site. “Lisa” is the moving story of a girl on the cusp of womanhood and her relationship with her mother, who suffers from Alzheimer’s disease. Shelton is no stranger to Internet video: his previous works have led him to projects with Fox Entertainment, the NBA and MySpace. Ben’s brother, Josh, co-wrote the script and created the music for the film.

— Sports: Balloon Bowl —

When the makers of this video had the idea to fill a skate bowl with balloons and try to ride through them, they never though it would work. But, as this video demonstrates, it not only worked, it became an Internet sensation. The project consumed over three hours and nearly 8,000 balloons… plus all the sound effects are real. The clip was filmed on location at the “department of skateboarding” in Portland, Oregon.

About YouTube

YouTube is the world’s largest online video community allowing millions of people to discover, watch and share originally created videos. YouTube provides a forum for people to connect, inform and inspire others across the globe and acts as a distribution platform for original content creators and advertisers large and small. YouTube is based in San Bruno, CA and is a subsidiary of Google, Inc.

SOURCE: YouTube

Folate Deficiency In Men May Cause Birth Defects

Researchers at University of California, Berkeley, report that men with low levels of folate are at an increased risk for sperm containing too many or too few chromosomes, which can cause birth defects and miscarriages. 

The research is the first study to find a link between diet and sperm health.

While the benefits of folate for women in preventing birth defects are widely known, the Berkeley research suggests it also boosts sperm health. In fact, the research found that folate deficiency increases the chance a man will have sperm with either too few or too many chromosomes.

Found in fruits and beans, leafy green vegetables, chickpeas and lentils, folate is one of the B vitamins. By law, breads and grains sold in the U.S. are also now specially fortified with added folate to help stem birth defects.

“We looked at sperm to find different kinds of genetic abnormalities,” said Brenda Eskenazi, the study’s lead researcher and a professor of maternal and child health and epidemiology and director of the Center for Children’s Environmental Health at Berkeley’s School of Public Health. “The abnormalities we looked at here were having too few or too many chromosomes,” she told the Washington Post. Healthy human sperm have 23 pairs of chromosomes.

“In sperm you normally have one of each, but sometimes there are two and sometimes there are none of a particular chromosome,” Eskenazi said.

Eskenazi said that if a normal egg was fertilized with one of these abnormal sperm, it could result in a birth defect such as Down’s syndrome.

“This can also result in an increase in miscarriage,” she said.

In conducting the study, researchers examined three specific chromosomes: X, Y and 21.

“We saw an association between [male] folate intake and how many abnormal sperm there were, in terms of the chromosome number for these three different chromosomes,” Eskenazi said.

In the study, Eskenazi’s group analyzed sperm from 89 healthy men, and surveyed the men about their daily consumption of zinc, folate, vitamin C, vitamin E and beta-carotene.

The researchers discovered that men with the highest folate intake, 722 to 1,150 micrograms a day, had a 20 percent to 30 percent lower frequency of sperm abnormalities. 

Until now, researchers in birth defects have focused on women’s diet during the conception period, Eskenazi said. “Based on these data, maybe men, too, need to consider their diet when they are considering fathering a child,” she said.

Eskenazi advises men who are thinking of becoming fathers to increase their folate intake, perhaps with a supplement or a multivitamin.

“This is another common-sense article that says good nutrition is associated with a better reproductive outcome,” Dr. Jamie Grifo, director of reproductive endocrinology at New York University Medical Center, told the Washington Post.

He added, however, that abnormal sperm rates seen in the Berkeley study were four to six per 1,000, meaning that even men with poor nutrition still had more than 99 percent normal sperm.

“Even though this may be the case, don’t smoke, drink modestly, eat healthy unprocessed food and take your vitamins,” Grifo said.

The study findings are published in the March 20 issue of the journal Human Reproduction.  The full report can be viewed here.

On the Net:

UC Berkeley

A Deeply Impressive Bit of Kit; World’s Biggest Subsea Robot

By Tony Henderson

HISTORY repeated itself yesterday as a subsea company unveiled the latest pioneering piece of Tyneside technology.

SMD, a leading designer and maker of specialised underwater robot vehicles, is setting up a new base at the Turbinia works site at Davy Bank in Wallsend, which will be officially opened on April 25.

This is where, from 1898, the steam turbine inventor Sir Charles Parsons worked on his engines and Turbinia, then the fastest boat afloat.

Yesterday SMD loaded UT1 (Ultra Trencher 1), a remote controlled submersible robot (ROV), on to a ship for delivery to CTC Marine Projects. The pounds 10m machine will be the world’s largest ROV which is capable of self propelling and supporting its own weight in water.

Weighing 50 tonnes and the size of small house, it is designed to bury largediameter oil and gas pipelines laid on the ocean floor.

It does this by “flying” down up to a mile deep below the surface using powerful propellers.

It then lands over the pipeline and deploys a pair of “jet swords” either side of the pipe which inject high pressure water to “fluidise” the surface. Burying the pipelines protects them from fishing, shipwrecks and natural currents. This enables oil and gas to be safely transported from the offshore fields to land to provide secure energy supplies.

There is an extensive network of pipelines across the North Sea enabling gas to be exported to countries such as the UK, Germany and other places from the oil-rich areas such as Norway and, in the future, Russia.

SMD, founded in 1980 by Newcastle University lecturer Alan Reece, works with fuel pipelines, telecommunications, subsea mining and offshore windfarm renewable energy fields.

In 2005 SMD, which is moving from its base in Walker, Newcastle, employed 40 people and had an annual turnover of pounds 10m. Last year the workforce was 150 and the turnover pounds 40m.

Of the giant ROV, Mr Jones said: “This is a step change in technology to put this kind of high power in deep water.

“There is a lot of development in oil and gas, in looking for more and more new fields and getting the most out of existing fields, and there is a big subsea sector in the North East.”

Darlington company CTC, which specialises in subsea trenching and installation of pipelines and cables, will deploy its new ROV worldwide and next month is due to take delivery of a sophisticated subsea rock trenching machine from SMD.

CTC head of marketing Fiona Duckworth said: “The new ROV will be the most powerful machine in its class.”

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

Safeway Offers Vaccination to Prevent Shingles

Drugstore operator Safeway has announced that it is offering vaccination to prevent against shingles in over 700 pharmacies in the states of Alaska, California, Colorado, Delaware, Hawaii, Idaho, Illinois, Montana, Nebraska, Nevada, Oregon, Pennsylvania, Texas, Virginia and Washington administered by Safeway pharmacists.

Dave Fong, senior vice president of pharmacy at Safeway, said: “The only way to prevent against contracting this debilitating disease is to get a single shot. By administering vaccines on site, Safeway is making it easy for anyone to protect themselves. Receiving a shingles vaccination is as easy as stopping at the pharmacy during your regular shopping trip.”

The company said that the vaccine will be provided on a walk-in basis at in-store pharmacies. Safeway said that it also offers full-service adult and adolescent immunization services for the prevention of such ailments as tetanus, hepatitis, pneumococcal, meningococcal, etc.

Happiness Linked to Low Blood Pressure

Couples in a happy marriage have lower blood pressure than those who are single. And the single folks fare better on blood pressure tests than those in “distressed” marriages, according to BYU research.

“We were interested in looking at the impact of marital status and relationship quality on health, including mental health and ambulatory blood pressure,” said Brigham Young University psychologist and assistant professor Julianne Holt-Lunstad. The findings are being published today in the Annals of Behavioral Medicine.

Holt-Lunstad and undergraduate students Wendy Birmingham and Brandon Jones found that a supportive social network did not compensate for the differences among those who are either single or less-happily married.

“This research suggests that it is not marriage per se that is beneficial, as some research has suggested, but rather a happy marriage,” she said.

They looked at 99 single people and 204 married individuals. The married participants were given a survey that’s widely used to measure marriage quality, the results sorted into happy marriage and distressed marriage categories, although they weren’t told what their results showed. All the participants also completed a survey that outlined their social networks and support systems.

For 24 hours, all 303 participants wore portable blood pressure monitors that randomly recorded blood pressure about 72 times. The results showed those in happy marriages had blood pressure about four points lower than that of single adults. The highest blood pressure belonged to the group with unhappy marriages. Blood pressure has been linked to a number of health woes, including cardiovascular disease.

Those classified as happily married experienced a greater “dipping” of blood pressure at night. When blood pressure doesn’t drop at night, there’s more risk of cardiovascular problems, among other things. The middle-of-the-night decreases may provide a health- protective factor, she said.

Previous studies have linked lower blood pressure to marriage. But whether the quality of the marriage itself makes a difference had not been shown. This study found a five-point difference between those who were single and those in low-quality marriages, she said. That level was classified as “pre-hypertensive.”

The Anthony Marchionne Foundation and BYU’s Family Studies Center funded the research. Next, Holt-Lunstand hopes to study couples participating in marriage counseling to see if fixing marriages can improve health.

Co-author Jones is now in medical school at George Washington University, while Birmingham is working on a Ph.D. in social psychology at the University of Utah.

Urinary Enzyme Measurements As Early Indicators of Renal Insult in Type 2 Diabetes

By Kalansooriya, A Jennings, P; Haddad, F; Holbrook, I; Whiting, P H

ABSTRACT The association between urine microalbumin, alpha^sub 1^- rtnicroglobulin concentration (alpha1MG) and the urinary enzyme activities of alanine aminopeptidase (AAP), N-acetyl-beta-D- glucosaminidase (NAG), alpha-glutathione-S-transferase (alphaGST) and pi-glutathione-S-transferase (piGST) is investigated in 36 type 2 diabetic and 15 age- and sex-matched non-diabetic subjects. Diabetic subjects were grouped into those with microalbuminuria

KEY WORDS: Diabetic nephropathies.

Enzymuria.

Glutathione transferase.

Introduction

Diabetic nephropathy is characterised structurally both by glomerular lesions and changes to the tubulo-interstitial compartment of the kidney, and functionally by increasing severity of microalbuminuria and altered glomerular filtration rate (GFR), the latter usually being assessed in the laboratory by measurements of serum or plasma creatinine concentrations.1-3 Furthermore, end- stage renal disease (ESRD) in diabetics is increasing and now accounts for approximately 40% of treated ESRD by either transplantation or dialysis.4 Although incipient diabetic kidney disease is usually characterised functionally by the presence of microalbuminuria, serum creatinine is of limited value in the early detection of renal insult due to its poor sensitivity to early nephron insult and renal dysfunction.5

It is now well established that chronic hyperglycaemia, and consequently effective glycaemic control, is the main metabolic determinant associated with irreversible kidney damage in diabetes mellitus.6 Although microalbuminuria has been used for many years as a predictor of incipient diabetic nephropathy, reflecting the loss of glomerular selectivity,2 estimation of renal tubular function and integrity may yet provide an early indication of renal insult and thus identify those at risk of developing kidney dysfunction.7 Consequently, decreased renal tubular reabsorption capacity is characterised by elevated low molecular weight protein (e.g. alpha^sub 1^-microglobulin and beta2-microglobulin) levels in the urine, and early renal tubular insult is characterised by increased proximal tubular enzymuria.7-9

In this regard, elevated urine alanine aminopeptidase (AAP) and N- acetyl-beta-D-glucosaminidase (NAG) activities have been used to indicate the early onset of proximal renal tubular insult in several clinical states in general (e.g., drug-induced nephrotoxicity),10 and the diabetic state in particular.11-18 Other studies indicate that the isoforms of glutathione S-transferase (GST), alphaGST and piGST, are located in the cells of the proximal and distal renal tubules, respectively, and their urine measurement has allowed the identification of site-specific renal insult following nephrotoxin- induced renal damage.19-21

However, renal dysfunction in general and glomerular dysfunction in particular are observed only rarely in early diabetic nephropathy, and the identification of early renal insult and those at risk of developing renal dysfunction is important so that corrective therapies can be applied at an early stage. Consequently, the aim of this study is to investigate the association between the urinary enzyme activities of NAG, AAR alphaGST and piGST in subjects with type 2 diabetes and the severity of microalbuminuria, the standard laboratory indicator of the onset of nephropathy.

Materials and methods

Thirty-six type 2 diabetic subjects and 15 age- and sex-matched non-diabetic control subjects were recruited. Mean age (standard deviation [SD]) was 48 (10) years and duration of diabetes was between eight and 10 years. Diabetic subjects with renal disease characterised by proteinuria, hypertension (with or without antihypertensive treatments), dyslipidaemia or cardiovascular disease, evidence of renal insufficiency, chronic urinary tract infection, renal stones and renal humours were excluded from the study. Diabetic subjects were grouped according to urine protein concentration into those with microalbuminuria

Fasting blood and urine samples (mid-stream) were taken and plasma creatinine and microalbuminuria concentrations were quantitated by standard laboratory methods, while urine activities of AAP and NAG and urine alpha^sub 1^-microglobulin (alpha1MG) levels were measured, as previously described,11,22,23 and alphaGST and piGST urine activities were measured using a commercial enzyme immunoassay (EIA) kit (Biotrim, Dublin, Ireland). Enzyme activities were expressed on the basis of urinary creatinine to allow for inter- individual variations in urine flow rate. Results, expressed as mean (SD), were analysed using two-way analysis of variance (ANOVA) with post hoc analysis performed using Dunnett’s test. P values

Results

All the diabetic subjects had serum creatinine concentrations within the laboratory reference range (

Urine activities of NAG, a lysosomal hydrolase found predominantly in the renal proximal tubule, were significantly increased (three-fold) in diabetic subjects with microalbuminuria 3mg/L. Similar and significant four-fold elevations in AAP activity were noted in groups B and C, compared to the control values and those obtained from diabetic subjects with microalbuminuria

A 1.3-, two- and three-fold increase in urinary alphaGST activity was observed in groups A, B and C, respectively (P

The proximal tubular enzyme NAG and the small molecular weight protein alpha1MG demonstrated similar patterns of urinary excretion with increasing severity of microalbuminuria, albeit with serum creatinine concentrations within the reference range, but showed elevated values in the absence of significant microalbuminuria. alphaGST and the distal tubular marker piGST were elevated only when significant proteinuria was present in a manner similar to that seen with AAP excretion. Discussion

Incipient diabetic nephropathy is characterised by structural, functional and biochemical changes associated with glomerular and tubular elements of the kidney.3 The results of the present study demonstrated clearly that increased severity of microalbuminuria, the standard clinical predictor of incipient diabetic nephropathy,3 and increased glomerular permeability, are associated with early changes in urinary parameters (i.e. alpha1MG proteinuria, NAG, AAP, alphaGST and piGST enzymuria), indicating renal tubular dysfunction in a cohort of type 2 diabetic subjects. Furthermore, urine NAG activity and alpha1MG concentration were elevated in those diabetic subjects with microalbumuria

In diabetic kidney disease, increased NAG and AAP enzymuria has been observed.7,8,13 Both enzymes are localised predominantly to the proximal renal tubule, with NAG being of lysosomal origin and AAP being of mitochondrial origin in the renal brush border. Both have been shown to be sensitive indicators of renal proximal tubular insult in several disease processes,7 and in early diabetic nephropathy in particular.7-15 In the present study, while increased AAP activity was only observed in individuals with significantly elevated microalbuminuria, elevated NAG enzymuria was seen in the absence of significant microalbuminuria, but with serum creatinine concentrations still within the laboratory reference range. These findings are consistent with altered lysosomal function due to an autophagic response to early epithelial cell injury initiated by chronic hyperglycaemia.

Indeed, while previous studies have suggested that increased NAG enzymuria is a consequence of chronic or fluctuating hyperglycaemia, and not necessarily a reflection of diabetic renal insult,24,25 it is now accepted that hyperglycaemia resulting from poor long-term glycaemic control is a major underlying cause of diabetic complications, fuelling interrelated pathophysiological processes such as increased polyol pathway activity, protein glycation, advanced glycation end-products and free radical effects.26-28

However, while elevated GST activities have been noted in the diabetic state,19,29,30 the present study also demonstrated elevated activity of the cytosolic isoenzymes of GST. These different patterns of GST isoenzyme excretion are especially interesting because alphaGST is only found in the proximal renal tubule, whereas the intrarenal localisation of piGST is to the distal tubule.19-21 Consequently, the presence of elevated piGST suggests the presence of distal tubule insult in diabetics with proteinuria, and suggests that while proximal tubular and glomerular insult may be initial events in the natural history of diabetic nephropathy, as demonstrated by increased alpha1MG excretion, elevated NAG, AAP and alphaGST urine activities and microalbuminuria, this is followed by distal tubular insult indicated by increased piGST activity.

In conclusion, the present study demonstrates clearly that proximal tubular insult, characterised by increased NAG, AAP and alphaGST enzymuria, is present in type 2 diabetics and that generally it is associated with increasing proteinuria, as indicated in other studies.19 However, NAG activity was elevated in patients without significant proteinuria or increased serum creatinine concentration, which is consistent with its role as an early indicator of diabetic renal insult. Furthermore, the results suggest that renal tubular insult may precede increased glomerular permeability in diabetic renal disease. Consequently, as these urinary biomarkers assess different areas of the renal architecture, estimation of renal tubular function and integrity may provide a site-specific and early indication of renal insult in subjects with diabetes.

References

1 Panchapakesan U, Xin-Ming C, and Pollock CA. Drug insight: thiazolidinediones and diabetic nephropathy – relevance to renoprotection. Nat Clin Pract Nephrol 2005; 1: 33-43.

2 Mogenson CE, Christensen CK, Vittinghus E. The stages in diabetic renal disease. Diabetes 1993; 32: 64S-78S.

3 Mogensen CE, Christensen CK. Predicting diabetic nephropathy in insulin-dependent diabetic patients. N Engl J Med 1984; 311: 89-93.

4 Friedman EA, Friedman AL. Is there really good news about pandemic diabetic nephropathy? Nephrol Dial Transplant 2007; 22: 681- 3.

5 Perrone RD, Madias NE, Levy AS. Serum creatinine as an index of renal function: new insights into old concepts. Clin Chem 1992; 38: 1933-53.

6 Turner RC. The UK Prospective Diabetes Study: a review. Diabetes Care 1998; 15 (Suppl 4): S47-S50.

7 Whiting PH, Price RG. Importance of early detection of renal dysfunction: value of markers of early renal disease and damage. Clin Biochem 2001; 3: 3-8.

8 Jung K, Pergande M, Schimke E, Ratzman KP, Illus A. Urinary enzymes and low molecular mass protein as indicators of diabetic nephropathy. Clin Chem 1988; 34: 544-77.

9 Uslu S, Efe B, Alatas O et al. Serum cystatin C and urinary enzymes as screening markers of renal dysfunction in diabetic patients. J Nephrol 2005; 18: 559-67.

10 Price RG, Whiting PH. Urinary enzymes and nephrotoxicity in humans. In: Jung K, Matternheimer H, Burchards U eds. Urinary enzymes. Heidelberg: Springer-Verlag, 1992: 203-21.

11 Whiting PH, Ross IS, Borthwick L. Serum and urine N-acetyl- beta-D-glucosaminidase in diabetics on diagnosis and subsequent treatment, and stable insulin-dependent diabetics. Clin Chim Acta 1979; 92: 459-63.

12 Watts GF, Vitos MA, Morris RW, Price RG. Urinary N-acetyl- beta-D-glucosaminidase excretion in insulin-dependent diabetes mellitus: relation to microalbuminuria, retinopathy and glycaemic control. Diabetes Metab 1988; 14: 653-8.

13 Nakamura S. Clinical evaluation of urinary alanine aminopeptidase in the patients with diabetes mellitus -comparison among AAP, microalbumin and N-acetyl-beta-D-glucosaminidase (Japanese). Hokkaido Igaku Zasshi 1991; 66: 522-33.

14 Jones AP, Lock S, Griffiths KD. Urinary N-acetyl- betaglucosaminidase activity in type 1 diabetes mellitus. Ann Clin Biochem 1995; 32: 58-62.

15 Koh KTC, Chia KS, Tan C. Proteinuria and enzymuria in noninsulin-dependent diabetics. Diabetes Res Clin Pract 1993; 20: 215-21.

16 Hong C-Y, Hughes K, Chia K-S, Ng V, Ling S-L. Urinary al- microglobulin as a marker of nephropathy in type 2 diabetic Asian subjects in Singapore. Diabetes Care 2003; 26: 338-42.

17 Aksun SA, Ozmen, Ozmen B et al. beta2-microglobulin and cystatin C in type 2 diabetes: assessment of diabetic nephropathy. Exp Clin Endocrinol Diabetes 2004; 112: 195-200.

18 Whiting PH, Ross IS, Borthwick. N-acetyl-beta-D- glucosaminidase levels and the onset of diabetic microangiopathy. Ann Clin Biochem 1983; 20:15-9.

19 Branten AJ, Mulder TP, Peters WH, Assmann KJ, Wetzels JF. Urinary excretion of glutathione S transferase alpha and pi in patients with proteinuria: reflection of the site of tubular injury. Nephron 2000; 85:120-6.

20 Harrison DJ, Kharbanda R, Cunningham DS, McLellan, Hayes LI. Distribution of glutathione S-transferase isoenzymes in human kidney: basis for possible markers of renal injury. J Clin Pathol 1989; 42: 624-8.

21 Shaw M. The use of histologically defined specific biomarkers in drug development with special reference to the glutathione transferases. Cancer Biomark 2005; 1: 69-74.

22 Pergande M, Jung K, Precht S, Fels LM, Herbort C, Stolte H. Changed excretion of urinary proteins and enzymes by chronic exposure to lead. Nephrol Dial Transplant 1994; 9: 613-8.

23 Kurrle-Weittenhiller A, Engel W. Immunoturbidometric determination of urinary alpha1-microglobulin on Hitachi analysers. Clin Chem 1992; 38:1090-1.

24 Sanchez-Hueso MC, Mateo-Caas J, Zamora-Madaria E. Influence of glycaemic blood glucose control and incipient diabetic nephropathy on the urinary excretion of N-acetylglucosaminidase (NAG) in diabetes mellitus (Spanish). An Med Interna 1995; 12: 216-20.

25 Watts GF, Vlitos MA, Morris RW, Price RG. Urinary N- acetylbeta-D-glucosaminidase excretion in insulin-dependent diabetes mellitus: relation to microalbuminuria, retinopathy and glycaemic control. Diabetes Metab 1988; 14: 653-8.

26 Brownlee M. Biochemistry and molecular cell biology of diabetic complications. Nature 2001; 414: 813-20.

27 Nishikawa T, Eidelskein D, Brownlee M. The missing link: a single unifying mechanism for diabetic complications. Kidney Int 2000; 71: S26-S30.

28 Nishikawa T, Araki E. Impact of mitochondrial ROS production in the pathogenesis of diabetes mellitus and its complications. Antioxid Redox Signal 2007; 9: 343-53.

29 Fujita H, Haseyama T, Kayo T et al. Increased expression of glutathione S-transferase in renal proximal tubules in the early stages of diabetes: a study of type-2 diabetes in the Akita mouse model. Exp Nephrol 2001; 9: 380-6.

30 Vanderjagt DJ, Harrison JM, Ratliff DM, Hunsaker LA, Vander Jagt DL. Oxidative stress indices in IDDM subjects with and without long-term diabetic complications. Clin Biochem 2001; 34: 265-70.

A. KALANSOORIYA*, P. JENNINGS[dagger], F. HADDAD[dagger], I. HOLBROOK[dagger] and P. H. WHITING*

* School of Allied Health Sciences, De Montfort University, Leicester LE1 9BH, UK

and [dagger] Department of General Mediane, York District General Hospital, York, UK

Accepted: 20 September 2007

Correspondence to: Professor P. H. Whiting

School of Allied Health Sciences, De Montfort University

Hawthorn Building, The Gateway, Leicester LE1 9BH, UK

Copyright Step Communications Ltd. 2007

(c) 2007 British Journal of Biomedical Science. Provided by ProQuest Information and Learning. All rights Reserved.

Report Exposes Vietnam’s Illegal Timber Trade

A report from two environmental groups found that Vietnam’s illegal logging is threatening some of the last intact forests in South-East Asia.

The report from UK-based Environmental Investigation Agency and Indonesia’s Telapak says that increasing raw timber prices has caused some countries to attempt to thwart illegal logging.

However, while the problem subsides in one country, it rises in another, a situation authors call “Ëœprogress undermined by corruption.’

“Over the last decade, governments around the world have made a raft of pronouncements regarding the seriousness of illegal logging and their determination to tackle it,” the authors of the Borderlines report say.

“Yet the stark reality is ‘business as usual’ for the organized syndicates looting the remaining precious tropical forests for a quick profit.”

The report said some of the timber is coming to the UK in the form of garden furniture, which they believe accounts for about 90 percent of the country’s total wood exports. This violates Laotian laws, which ban the export of logs and sawn timber.

The Vietnamese government has been counterproductive in their attempt to regulate logging while simultaneously encouraging the wooden furniture industry to expand.

“Vietnam is now exploiting the forests of neighbouring Laos to obtain valuable hardwoods for its outdoor furniture industry,” they wrote.

The authors reported meeting a Thai businessman who claimed to have paid bribes to secure a batch of timber.

“They gain virtually nothing from this trade; instead, the money goes to corrupt officials in Laos and businesses in Vietnam and Thailand,” said EIA’s head of forest campaigns, Julian Newman.

Both groups agreed that western importers of such goods must take responsibility and refuse to accept uncertified lumber.

“To some extent, the dynamic growth of Vietnam’s furniture industry is driven by the demand of end markets such as the European Union and US,” the report wrote.

“Until these states clean up their act and shut their markets to wood products made from illegal timber, the loss of precious tropical forests will continue unabated.”

While researchers found that many retailers had “taken the necessary steps” to purchase legal timber from Vietnamese producers, they also found that some companies in the UK had not.

In 2003, the EU has formed an initiative called Forest Law Enforcement, Governance and Trade, aimed at forming partnerships with timber producing countries.

In 2006, Malaysia began establishing a Voluntary Partnership Agreement. In 2007, Indonesia followed suit.

Around 60 percent of Indonesia is forested, accounting for 10 percent of the world’s tropical forests.

However, the report notes that a problem with VPAs “is that end products such as furniture are currently not included on the list of timber categories to be controlled.”

Gareth Thomas, the UK’s International Trade and Development Minister, said the report raised a number of concerns.

“We will explore with G8 colleagues whether there is G8 action we can take in this area.”

http://www.eia-international.org/cgi/background/background.cgi?t=template&a=24

“ËœFearful’ Robot Receives Top Honors

A robot named “Phobot” that mimics human fear took top honors during the International Conference on Human-Robot Interaction in Amsterdam last week.

Seven teams from technical universities competed in the contest, with attendees voting Phobot, designed by University of Amsterdam students, their top pick.

All of the competing teams used the same National Instruments software and  Lego robotics set with light, sound, touch and ultrasound sensors.

“This robot is there as a sort of buddy to help a child having any kind of actual fear, doing it step by step,” said winning team member Ork de Rooij.  “The child would say, ‘Hey, not only am I scared, but this robot is also scared, so maybe we can help each other.'”

Phobot displayed his fear by retreating and spinning around when exposed to a fear-inducing object, in this case a threatening larger robot.   Then, mimicking the psychological principle of “graded exposure”, the robot overcomes its fear by first getting comfortable with exposure to smaller robots, then being exposed to increasingly larger ones.

Taking jury prize in the competition, and second place in popular vote, was “Pot Bot”, a device that monitors potted plants to determine whether they need sunlight or water.   If so, its sensors then locate and signal the strongest available light source using two front panels that resemble hands.  

Pot Bot uses Lego strips hanging at its sides like wind chimes to signal wind conditions.   The strips can also be spread like wings in a display of gratitude when the plant is watered.

“The robot acts as a mediator to make communication between humans and nature more fluid,” said Sonya Kwak, who led the combined team from Carnegie Mellon University and the Korea Advanced Institute of Science and Technology that created Pot Bot.

“The robot itself was not so sophisticated, but it had an artistic quality to it, and it was very different, very original,” said conference organizer Christoph Bartneck while explaining the jury decision.

On the Net:

University of Amsterdam

Medicare Announces Expanded Coverage for Anticoagulation Patients, Opening the Door for More Patients to Test PT/INR at Home

INDIANAPOLIS, March 19 /PRNewswire/ — Medicare Part B will now cover and pay for meter training, equipment and supplies for all long-term warfarin users who monitor their own PT/INR results at home with portable meters, such as the CoaguChek XS System for Patient Self-Testing. This expansion opens the door to increased patient access to testing, which could lead to better outcomes.

Medicare previously reimbursed these expenses only for patient self- testers who had mechanical heart valves. The new coverage expands to include those on anticoagulant medication with chronic atrial fibrillation and venous thromboembolism.

“The decision to expand coverage to additional disease states allows physicians to manage more of their patients on warfarin therapy through home testing,” said Dr. Alan Jacobson, cardiologist, Loma Linda University School of Medicine. “Studies show that more frequent PT/INR testing leads to improved clinical outcomes. The benefits of providing patients with improved access to testing are reductions in strokes, bleeds and deaths.”

According to a 2006 international meta-analysis led by Dr. Carl Heneghan and published in the Lancet, patient self-monitoring of oral anticoagulation leads to a significant one-third reduction in death from all causes. The study also showed that thromboembolism was decreased by 55 percent and major hemorrhage was also decreased.(1)

Studies suggest that anticoagulation patients who self-test may experience fewer complications overall than those who do not because self-testing may increase patient time in therapeutic range. A 2001 study published in Z Kardiol reported that over a two-year period, 80 percent of PT/INR values recorded by mechanical heart valve patients who performed self-testing were in target therapeutic range, compared to only 64.9 percent of PT/INR values monitored by family practitioners.(2)

Studies also suggest that PT/INR self-testing is just as accurate as testing performed by a healthcare professional.

In a 2001 study published by the American Journal of Clinical Pathology, there were no significant differences between PT/INR results gathered from the laboratory and self-testing patients.(3) Performance testing with the CoaguChek XS System also showed a 97-percent correlation between results obtained by healthcare professionals and by patients testing themselves.(4)

“I feel comfortable with more of my patients monitoring from home because handheld meters like the CoaguChek XS System are easy to use, cause less pain and improve compliance,” said Dr. Jacobson. “I also know the results will be consistent with the results from our office meter and from the lab.”

Patients prefer fingerstick testing over painful venous draws, according to a 2002 study measuring the results of the Prothombin Office-Testing Benefit Evaluation (PROBE) published in Cardiovascular Reviews and Reports.(5) Several studies also show that the accuracy of results from fingerstick testing is comparable to that of outside laboratories.(6, 7)

For more information on the CoaguChek XS System for Patient Self-Testing, visit http://www.poc.roche.com/ .

About Anticoagulation Monitoring

Certain patients with atrial fibrillation, a mechanical heart valve or deep vein thrombosis require protection against thrombosis, or blood clots. They are typically put on lifelong oral anticoagulation therapy with warfarin sodium (e.g., Coumadin) to thin their blood. Each patient reacts differently to anticoagulant medications, so it is imperative to monitor therapeutic effects closely to minimize potential risks.

About CoaguChek products

Physicians have been using CoaguChek instruments for point-of-care PT/INR testing since 1994. Today, in the U.S., more point-of-care PT/INR tests are performed with a CoaguChek system than with all other devices combined.(8) The CoaguChek XS System represents the fifth generation of point-of-care anticoagulation monitoring devices from Roche Diagnostics.

About Roche

Headquartered in Basel, Switzerland, Roche is one of the world’s leading research-focused healthcare groups in the fields of pharmaceuticals and diagnostics. As the world’s biggest biotech company and an innovator of products and services for the early detection, prevention, diagnosis and treatment of diseases, the Group contributes on a broad range of fronts to improving people’s health and quality of life. Roche is the world leader in in-vitro diagnostics and drugs for cancer and transplantation, and is a market leader in virology. It is also active in other major therapeutic areas such as autoimmune diseases, inflammatory and metabolic disorders and diseases of the central nervous system. In 2007, sales by the Pharmaceuticals Division totalled 36.8 billion Swiss francs, and the Diagnostics Division posted sales of 9.3 billion francs. Roche has R&D agreements and strategic alliances with numerous partners, including majority ownership interests in Genentech and Chugai, and invested more than 8 billion Swiss francs in R&D in 2007. Worldwide, the Group employs about 79,000 people. Additional information is available on the Internet at http://www.roche.com/.

   References    (1) Heneghan C., Alonso-Coello P, Garcia-Alamino JM, Perera R, Meats E,       Glasziou P. Lancet. 2006; 367:404-411.   (2) Kortke H, Minami K, Breymann T, et al. INR self-management after       mechanical heart valve replacement: ESCAT. Z Kardiol. 2001;90(6)118-       124.   (3) Oral Anticoagulation Group. American Journal of Clinical Pathology.       2001; 115: 280-287.   (4) CoaguChek XS system package insert. Indianapolis, IN.  Roche       Diagnostics Corporation; 2006.   (5) Giles TD, Roffidal L. Results of the Prothrombin Office-Testing       Benefit Evaluation (PROBE). CVR&R. 2002;23:27-28, 30, 32-33.   (6) Bussey HI, Chiquette E, Bianco TM, et al. A statistical and clinical       evaluation of fingerstick and routine laboratory prothrombin time       measurements. Pharmacotherapy. 1997;17(5): 861-866.   (7) Kaatz SS, White RH, Hill J, et al. Accuracy of laboratory and portable       monitor international normalized ratio determinations. Comparison with       a criterion standard. Arch Intern Med. 1995;155:1861-1867.   (8) Second Quarter 2007 total market share of projected distributor unit       sales of the Point of Care Testing Coagulation Reagents and Kits       product class by HPIS Market Intelligence, a division of GHX Global       Healthcare Exchange.    

All trademarks used or mentioned in this release are legally protected by law.

   For further information please contact:    Media :                            Physicians and Patients :    Lori McLaughlin   Corporate Communications   Roche Diagnostics Corporation,   Indianapolis, Ind.   Phone: 317-521-3112                Phone: 800-852-8766   [email protected]          Option 2 for Healthcare                                      Professionals and Option 4 for Patients  

Roche

CONTACT: Media, Lori McLaughlin Corporate Communications RocheDiagnostics +1-317-521-3112, [email protected]

Web site: http://www.roche.com/http://www.poc.roche.com/

Men Vs. Women ““ Meat Vs. Veggie

Study finds men prefer meat and poultry, women prefer fruits and vegetables

When it comes to what we eat, men and women really are different according to scientific research presented today (March 19) at the 2008 International Conference on Emerging Infectious Diseases in Atlanta, Georgia. In general, men are more likely to report eating meat and poultry items and women are more likely to report eating fruits and vegetables.

The findings come from the most recent population survey of the Foodborne Disease Active Surveillance Network (FoodNet). From May 2006 to April 2007 over 14,000 American adults participated in an extensive survey outlining their eating habits, including high risk foods for foodborne illness.

“There was such a variety of data we thought it would be interesting to see whether there were any gender differences. To our knowledge, there have been studies in the literature on gender differences in eating habits, but nothing this extensive,” says Beletshachew Shiferaw, a lead researcher on the study.

Shiferaw and her colleagues found that men were significantly more likely to eat meat and poultry products especially duck, veal, and ham. They were also more likely to eat certain shellfish such as shrimp and oysters.

Women, on the other hand were more likely to eat vegetables, especially carrots and tomatoes. As for fruits, they were more likely to eat strawberries, blueberries, raspberries and apples. Women also preferred dry foods, such as almonds and walnuts, and were more likely to consume eggs and yogurt when compared with men.

There were some exceptions to the general trend. Men were significantly more likely to consume asparagus and brussel sprouts than women while women were more likely to consume fresh hamburgers (as opposed to frozen, which the men preferred).

The researchers also looked at reported behavior in regards to consumption of 6 risky foods: undercooked hamburger, runny or undercooked eggs, raw oysters, unpasteurized milk, cheese made from unpasteurized milk and alfalfa sprouts. Men were significantly more likely to eat undercooked hamburger and runny eggs while women were more likely to eat alfalfa sprouts.

This information is important to public health officials because better understanding of gender differences in eating habits can help them create more targeted strategies for prevention.

“The reason we looked at consumption and risky behaviors was to see if there was a statistically significant difference between men and women and if there is this information could be used by health educators to target interventions,” says Shiferaw.

The International Conference on Emerging Infectious Diseases is organized by the Centers for Disease Control and Prevention (CDC), the American Society for Microbiology, the Council of State and Territorial Epidemiologists, the Association of Public Health Laboratories and the World Health Organization.

On the Net:

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Foodborne Disease Active Surveillance Network (FoodNet)

Parents Need Spring Training Too

As cries of “play ball” ring out this spring, they undoubtedly will be followed by complaints of anxiety and stress from young athletes wanting to quit sports.

Parents and coaches can make youth sports a fun, learning experience or a nightmare, according to sport psychologists at the University of Washington. But to achieve the former, sports officials and organizations must provide more training programs, especially for parents, according to Frank Smoll and Ron Smith, who have been studying the youth sport experience and designing programs to improve it for a quarter of a century.

“There is no problem in getting coaches to attend educational workshops. The challenge is convincing organizations to offer parent workshops and getting parents to come,” said Smoll. “Many youth sport organizations are saying, “ËœYes, we are interested’ in offering these programs, but that’s it. They are not delivering them to parents.

“There has been a drive in the last 20 years to teach coaches how to create a healthy psychological environment for young athletes. A culture has been created and there is an expectation that coaches will receive training. Unfortunately, too many moms and pops are all too willing to assume they don’t have a role in youth sports. However, they should support what trained coaches are trying to do. Parents and coaches working together are a powerful combination,” he said.

The UW researchers recently demonstrated the effectiveness of this approach in a study of 151 boys and girls playing in two different basketball leagues. The average age of the athletes was 11.6 years. Coaches in one league participated in a training workshop emphasizing a Mastery Approach to Coaching developed by Smoll and Smith.

This method emphasizes teaching youngsters about personal improvement, giving maximum effort, having fun, sportsmanship and supporting their teammates, rather than a winning-at-all-costs approach. Parents participated in a companion Mastery Approach to Parenting in Sports workshop that explained how to apply the mastery principles and how they can reduce performance anxiety in their children. Coaches and parents in the second, or control, league were not offered the workshops.

Pre-season questionnaires showed little difference in the levels of performance anxiety among the boys and girls in the two leagues. However, by the end of the season athletes playing for trained coaches and whose parents attended the workshop reported that their levels of physical stress, worry and concentration difficulties on the court had decreased. Players in the other league, however, reported that their anxiety had increased over the course of the season.

“This combined approach helps both parents and coaches to create a mastery-oriented climate,” said Smoll. “We don’t ignore the importance of winning because it is an important objective in all sports. But we place winning in its proper perspective. As a result, young athletes exposed to the mastery climate were able to concentrate more and they had less worries about their performance. Their bodies also reacted more positively. They were less tense, had fewer queasy stomachs and they didn’t experience feeling tight muscles.”

“Fear of failure is an athlete’s worst enemy, and the sport situation can easily create this type of anxiety,” said Smith. “The encouraging thing is that brief, one-time workshops for coaches and parents can give them the keys to decreasing pressure and increasing enjoyment. And an added bonus is that athletes who are not fearful of failure typically perform better. Given a few key guidelines, coaches and parents can be a winning combination for kids.”

The William T. Grant Foundation partially funded the research which was co-authored by Sean Cummings, a former UW post-doctoral researcher who is now at the University of Bath in England. The study appeared in the Journal of Youth Development.

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Gastric Duplication Cysts Expressing Carcinoembryonic Antigen Mimicking Cystic Pancreatic Neoplasms in Two Adults

By Johnston, Jeffrey Wheatley, Grayson H III; Sayed, Hosam F El; Marsh, William B; Ellison, E Christopher; Bloomston, Mark

Gastric duplication cysts in adults are very rare and usually found incidentally during evaluation for an unrelated ailment. When they are found in close proximity to the pancreas, they can be confused with cystic neoplasms of the pancreas, which are typically also asymptomatic yet more common. As part of the evaluation of cystic pancreatic lesions, cyst fluid analysis for carcinoembryonic antigen (CEA) is undertaken to determine malignant potential. Herein we present two cases of cystic lesions thought to arise from the pancreas found to have elevated preoperative cystic CEA levels. At operation, they were found to be gastric duplication cysts and were resected. We report the histologic findings and review of the current literature. DUPLICATION OF THE ALIMENTARY tract is a relatively rare congenital anomaly. It can affect any part of the entire gastrointestinal tract with the ileum being the most common site.1 Duplication cysts of the stomach represent four per cent of all alimentary tract duplications.2 Approximately 67 per cent of gastric duplication cysts (GDC) are identified within the first year of life.2 Symptoms usually include abdominal pain, vomiting, weight loss, and hematemesis. Abdominal tenderness and an epigastric mass might be present on physical examination.

Duplication cysts in adults are generally asymptomatic and are commonly incidental findings at gastrointestinal endoscopy or barium contrast radiography. Complications that arise with GDC include gastric outlet obstruction, infection, peptic ulcer development within the cyst, and carcinoma, though carcinoma is rare (five cases reported in literature).3 When in close proximity to the pancreas, GDC can be confused with a primary cystic pancreatic neoplasm. We report two adult patients with gastric duplication cysts initially diagnosed as cystic lesions of the pancreas associated with elevated carcinoembryonic antigen (CEA) in the cyst fluid and positive CEA staining of the cyst lining.

Case One

A previously healthy 24-year-old man presented to his family physician with a 3- to 4-week history of intermittent midepigastric abdominal pain. He also complained of lethargy with occasional nausea and loose stools. His past medical history was significant only for an episode of blunt trauma from a sledding accident 8 years prior with no associated injuries. In addition, he consumed 12 to 24 beers each weekend. His physical examination was unremarkable, and there was neither abdominal tenderness nor a palpable mass.

His initial workup consisted of a right upper quadrant ultrasound, which demonstrated two cystic structures located within the tail of the pancreas. The gallbladder and biliary system were unremarkable. Computed tomography (CT) of the abdomen confirmed the presence of a 4 x 5 cm cyst in the tail of the pancreas, which appeared separate from the stomach (Fig. 1). Endoscopic retrograde cholangiopancreatography showed normal common bile and pancreatic ducts without communication with the cyst. Upper endoscopy was also unremarkable. Laboratory values, including complete blood count, serum chemistries, liver function tests, amylase, lipase, serum gastrin, CEA, and carbohydrate antigen (CA) 19-9, were all within normal limits. Preoperative cyst aspiration was undertaken and returned a CEA level of 555.7 ng/mL (normal

The most likely clinical diagnosis was cystic tumor of the distal pancreas and the patient was taken to the operating room for resection. At the time of exploration, the tail of the pancreas appeared to be normal, without evidence of the cystic structures. However, a large, bilobed cystic structure was located in the lesser sac posterior to the stomach and superior to the tail of the pancreas. The cyst measured 10 x 4 x 2 cm, did not seem to communicate with the stomach or pancreas, and seemed to be tethered only by a short mesentery containing a short gastric artery. Within the cyst was a milky, mucinous fluid. The lesion was felt to be a gastric duplication cyst and it was completely excised. A thorough exploration of the patient’s abdomen was otherwise unremarkable. The patient recovered uneventfully and was discharged home on postoperative day 6. In follow-up, he had complete resolution of his symptoms.

FIG. 1. Computed tomography scan of 4 x 5 cm cystic lesion in the tail of the pancreas.

On pathological examination, the cyst measured 6.0 x 5.5 x 2.0 cm, with a wall thickness of 0.2 to 0.3 cm. The cyst wall was smooth with no masses or papillae. Microscopically, the cyst wall was composed of mucosa, submucosa, and muscularis propria. Focally, the cyst was lined by gastric mucosa (Fig. 2A) with rare parietal cells, focally dilated foveolar glands, and chronic inflammation. Focally, the cyst lining was a single layer of columnar to mucinous epithelium. In much of the cyst, the mucosa was ulcerated and showed inflamed granulation tissue, macrophages, fibrosis, and lymphoid aggregates. Immunostain for polyclonal CEA was positive in the surface epithelium of the gastric mucosa and single-layered mucinous epithelium (Fig. 2B).

FIG. 2. Histological examination of resected gastric duplication cysts. (A) Hematoxylin and eosin stain (250 x ) of cyst lining in patient 1, showing gastric mucosa. (B) Immunohistochemistry for CEA is positive in the cyst lining. (C) Hematoxylin and eosin (250 x ) of cyst lining in patient 2, showing gastric mucosa.

Case Two

A healthy 49-year-old woman was referred from an outside hospital for further evaluation of an asymptomatic cystic lesion in the lesser sac. The patient had no significant past medical or surgical history. She had no history of abdominal trauma and no history suggestive of acute or chronic pancreatitis. She had no history of any abdominal or gastrointestinal complaints. She was not a smoker and had no history of alcohol intake. On physical examination, she had no palpable masses and no tenderness. Her complete blood count, routine chemistries, liver enzymes, amylase, and lipase were all normal. She also had normal CEA and CA 19-9. The patient was referred because CT scan and magnetic resonance imaging of the abdomen and pelvis showed a 3 x 4 cm single cystic lesion that was between the greater curve of the stomach, the hilum of the spleen, and the tail of the pancreas without any other abnormal findings in the scans.

The cystic lesion was suggestive of a cystic neoplasm of the pancreatic tail versus the less common gastric duplication or splenic cyst. Fluid analysis showed a CEA of 2381 ng/mL and CA 19-9 of 79,069 U/mL. At the time of operation, the lesion was found to be arising from the greater curve of the stomach, separate from the pancreas and spleen. The lesion was cystic, oval, measuring 4 x 6 x 3 cm, and seemed somewhat pedunculated. The lesion was dissected from the wall of the stomach and did not communicate with the lumen of the stomach, though it did share the same outer muscle layer. The cyst contained clear, mucinous fluid. The rest of abdominal exploration was essentially unremarkable. The patient had an uneventful recovery and was discharged home on postoperative day 3.

On pathological examination, the cyst was 4.8 x 3.4 x 2.2 cm with a wall thickness of 0.2 cm and contained clear mucoid material. The cyst wall was smooth and tan/pink in color. Microscopically, the cyst wall was composed of mucosa, submucosa, and muscularis propria. The mucosa lining the cyst varied from gastric with focal parietal cells and chronic inflammation (Fig. 2C) to cuboidal/columnar. Immunostains showed that the lining was positive for polyclonal CEA and negative for gastrin.

Discussion

Alimentary tract duplications are congenital anomalies, which may occur anywhere along the gastrointestinal tract. Ileal duplications are most common, followed by those of the esophagus, colon, jejunum, and stomach. Nearly two-thirds of gastric duplications occur in women. Greater than 80 per cent of gastric duplications are cystic and do not communicate with the lumen of the stomach or alimentary tract.1 The remainder are tubular duplications with some communication. The majority of GDC occur on the greater curvature of the stomach.4

Rowling5 established several criteria for defining gastric duplication: 1) the cyst wall must be contiguous with the stomach wall, 2) the cyst is surrounded by smooth muscle, which is contiguous with that of the stomach, and 3) the cyst is lined by gastric epithelium. Gastric duplications are typically symptomatic during childhood with 67 per cent diagnosed within the first year of life and less than 25 per cent discovered after age 12.4, 6 Additional anomalies such as esophageal duplication, vertebral abnormalities, aberrant pancreas, and duodenal duplication are found in 50 per cent of patients with gastric duplication.1 When identified in the pediatric population, duplications are always benign.4

Gastric duplications present a difficulty in diagnosing the adult population. The symptoms are frequently nonspecific with intermittent abdominal pain being the most common. Imaging modalities such as CT are frequently of insufficient resolution to determine the nature of the cystic structure. Because the majority of duplications are noncommunicating, barium studies and upper endoscopy are often nondiagnostic, though both modalities may disclose a filling defect, particularly in the antrum of the stomach.7- 8 Similarly, endoscopic retrograde cholangiopancreatography is usually normal, except in the rare case that the duplication communicates with the pancreatic duct.8 The most common method of definitive diagnosis is by exploratory laparotomy.9 Because of the rarity of adult gastric duplications, it is difficult to outline with certainty their natural history. As with native gastric mucosa, the cyst lining may ulcerate. In a noncommunicating cyst, increased fluid production may result in pressure-induced necrosis of the mucosa.4 Both of these scenarios may lead to bleeding into the cyst or perforation into the peritoneum.10, 11 Communicating cysts may connect with the pancreatic ducts and cause recurrent pancreatitis.12 Up to 10 per cent of gastric duplications may contain ectopic pancreatic tissue which may be prone to pancreatitis.9

Duplication cysts also have the potential for neoplastic transformation.4 Of the 11 reported cases of malignancy arising within duplication cysts, eight have been adenocarcinoma. Five of the carcinomas have originated from gastric duplication.13 Adenomyoma arising from a gastric duplication has also been reported.12 Malignancies arising from duplication cysts are likely to present at more advanced stages because of their unusual symptoms and difficulty of diagnosis.4

Surgical resection is the mainstay of therapy with the goal of complete cyst excision. Drainage and marsupialization of the cyst have been suggested. However, marsupialization into the stomach exposes the unprotected mucosa to gastric contents with the risk of ulceration. Drainage procedures, such as cystjejunostomy, may be complicated by stenosis of the anastomosis or blind loop syndrome and are, therefore, discouraged.14 Furthermore, leaving the cyst in place is ill-advised given the potential for malignant transformation.

Gastric duplications are exceedingly rare in adults but can mimic cystic neoplasms of the pancreas. To our knowledge, this report represents two of three known cases of gastric duplication where radiographic and cyst fluid analysis were suggestive of mucinous cystic neoplasms of the pancreas, the third being recently reported in a 29-year-old woman.15 All three of these cases demonstrated CEA staining along the cyst lining and in the cyst fluid, similar to those seen in duodenal and ileal duplications.1, 16 The presence of CEA within the cyst aspirate and along the cyst lining is of uncertain significance. This may represent a form of mucosal sequestration of embryonic tissue, with the high level of CEA reflecting its high level in the circulation during embryogenesis of the cyst. Increased intracystic CEA and CA 19-9 may be a precursor to neoplastic changes or demonstrate a malignant potential. Given the rarity of GDC, such an implication would be difficult to substantiate.

The presence of increased CEA in gastric duplication cysts can confound the preoperative work-up of a pancreatic cystic lesion where cyst aspiration is often used to guide therapy. As a gastric duplication can be mistaken for a cystic lesion of the pancreas, preoperative aspiration demonstrating elevated CEA within the cyst may suggest a premalignant or malignant lesion. This finding suggests that GDC should be in the differential diagnosis of “pancreatic cysts” with increased CEA in the cyst fluid if the lesion is in close proximity to the stomach.

REFERENCES

1. Wiczorek RL, Seidman 1, Ranson JHC, Ruoff M. Congenital duplication of the stomach: case report and review of the English literature. Am J Gastroenterol 1984;79:597-602.

2. Blinder G, Hiller N, Adler SN. A double stomach in an adult. Am J Gastroenterol 1999;94:1100-2.

3. Nomura T, Shirai Y, Hatekaeyama K, et al. An adult ileal duplication cyst containing markedly elevated concentrations of CEA and CA19-9. Am J Gastroenterol 2002;97:208-9.

4. Armstrong CP. Miscellaneous conditions of the stomach. In: Taylor, TV, Williamson, RCN, Walker A, eds. Upper Digestive Surgery. New York: WB Sanders, 1999, pp 652-655.

5. Rowling JT. Some observations on gastric cysts. Br J Surg 1959;46:441-5.

6. Blinder G, Hiller N, Adler SN. A double stomach in an adult. Am J Gastroenterol 1999;94:1100-2.

7. Wiczorek RL, Seidman I, Ranson JHC, Ruoff M. Congenital duplication of the stomach: case report and review of the English literature. Am J Gastroenterol 1984;79:597-602.

8. Coit DG, Mies M. Adenocarcinoma arising within a gastric duplication cyst. J Surg One 1992;50:274-7.

9. Luks FI, Shah MN, Bulauitan MC, et al. Adult foregut duplication. Surgery 1990;108:101-4.

10. Blinder G, Hiller N, Adler SN. A double stomach in an adult. Am J Gastroenterol 1999;94:1100-2.

11. Kleihaus S, Boley SJ, Winslow P. Occult bleeding from a perforated gastric duplication. Arch Surg 1981;116:22.

12. Widdon DR, Olutoye OO, Broderick TJ, et al. Recurrent acute pancreatitis caused by a gastric duplication communicating with an aberrant pancreas. Am Surg 1999;85:121-4.

13. Kuraoka K, Nakayama H, Kagawa T, et al. Adenocarcinoma arising from a gastric duplication cyst with invasion to the stomach: A case report with literature review. J Clin Pathol 2004; 57:428-31.

14. Ikehata A, Sakuma T. Gastric duplication cyst with markedly elevated concentration of carbohydrate antigen 19-9. Am J Gastroenterol 2000;95:842-3.

15. D’Journo XB, Moutardier V, Turrini O, et al. Gastric duplication in an adult mimicking mucinous cystadenoma of the pancreas. J Clin Pathol 2004;57:1215-8.

16. Shah KJ, Guiseppe M, Low J, et al. Duodenal Cyst with profound elevation of intracystic CA19-9 and CEA: A rare but important differential in the diagnosis of Cystic tumours of the pancreas. J Pancreas. 2006;7:200-4.

JEFFREY JOHNSTON, B.S.,* GRAYSON H. WHEATLEY III, M.D.,* HOSAM F. EL SAYED, M.D.,*

WILLIAM B. MARSH, M.D.,[dagger] E. CHRISTOPHER ELLISON, M.D.,* MARK BLOOMSTON, M.D.*

From the Departments of *Surgery and [dagger]Pathology, Ohio State University Medical Center, Columbus, Ohio

Address correspondence and reprint requests to Mark Bloomston, M.D., Assistant Professor of Surgery, N924 Doan Hall, 410 West Tenth Avenue, Columbus, OH 43210. E-mail: [email protected].

Copyright Southeastern Surgical Congress Jan 2008

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

Chivalry and the Moderating Effect of Ambivalent Sexism: Individual Differences in Crime Seriousness Judgments

By Herzog, Sergio Oreg, Shaul

Previous studies have shown that female offenders frequently receive more lenient judgments than equivalent males. Chivalry theories argue that such leniency is the result of paternalistic, benevolent attitudes toward women, in particular toward those who fulfill stereotypical female roles. Yet to date, studies have not examined whether such leniency is indeed associated with paternalistic societal attitudes toward women. The present study goes beyond the investigation of demographics and employs Click and Fiske’s (1996) concepts of hostile and benevolent sexism. We use these concepts to highlight the role of individual differences in attitudes toward women as a key to our understanding of lenient attitudes toward female offenders. Eight hundred forty respondents from a national sample of Israeli residents evaluated the seriousness of hypothetical crime scenarios with (traditional and nontraditional) female and male offenders. As hypothesized, hostile and benevolent sexism moderate the effect of women’s “traditionality” on respondents’ crime seriousness judgments and on the severity of sentences assigned. Principles of justice require that arrestees, suspects, defendants, and sentenced offenders (henceforth offenders) be treated equally. Accordingly, offenders’ characteristics, such as their demographics, ought to be disregarded. However, a vast amount of theoretical and empirical research suggests that in practice this is not the case (see Daly & Tonry 1997). Most of this literature reports discrimination against disadvantaged social groups, such as African Americans, and individuals who are financially underprivileged.

Even though women are members of a socially weak group, several studies have demonstrated that female offenders tend to receive more lenient treatment than male offenders who have committed the same crimes (see Daly 1989; Daly & Tonry 1997; Spohn 1999). Chivalry theory has arisen as the primary theoretical framework for understanding these findings, suggesting that protective and benevolent societal attitudes toward women lead (predominantly male) decision makers throughout the criminal justice system to take a relatively lenient approach toward female offenders. However, despite the theory’s logical appeal, several of its assumptions remain untested. First, most studies of chivalry theory maintain their focus on the characteristics of the offender (e.g., Johnson & Scheuble 1991; Spohn & Beichner 2000; Bickle & Peterson 1991), whereas a test of the theory’s assumptions actually requires examination of the characteristics of the evaluators of crime.

In addition, the majority of studies on crime judgments adopt a sociological perspective and take into account demographic characteristics, such as gender (e.g., Allen & Wall 1993; Coontz 2000). The premise of this sociological perspective is that demographics represent the underlying attitudes that ultimately guide crime judgments. However, even if members of different demographic categories (e.g., men and women) tend to form different crime judgments, such a perspective forgoes the possibility of exploring individual differences among members of the same demographic group. When trying to explain differences in crime judgments, there is no reason to presume that all men or all women will hold the same attitudes. Therefore, instead of restricting the investigation to demographics, a direct assessment of attitudes toward women is more likely to provide meaningful insights for our understanding of the chivalry phenomenon.

Finally, because the theory proposes societal norms and attitudes as the basis for the differential treatment of offenders, one would need to study crime judgments among the general public in order to complement extant evidence from concrete decisions taken by law enforcement employees (e.g., police officers, prosecutors, judges). Even though some studies have revealed corresponding judgment patterns for law enforcement personnel and society as a whole (e.g., Corbett & Simon 1991; Levi & Jones 1985; McCleary et al. 1981), chivalry theory has not been tested on a sample of the general public, which would more closely represent overarching societal norms.

The need to examine public opinion in this context is further supported by claims for the direct influence of public opinion on the formation of judicial decisions. Sentencing policies and judicial decisions are strongly influenced by what is considered to be a “community standard” (e.g., Rossi & Berk 1997; Samuel & Moulds 1987; Seron et al. 2006). Judgments by law enforcement and judicial personnel are made in the context of a given society, with its particular set of norms and shared values. These norms and shared values hold a key role in formulating a community standard of justice, which, whether consciously or not, influences the decisions ultimately made by police officers, lawyers, and judges. A study of the general public can empirically inform what the community standard in a given society may be. In the present study, a representative sample of the Israeli public was used to account for individuals’ attitudes in explaining differential judgments of male and female offenders.

Chivalry Theory

Although the number of female offenders convicted and incarcerated has increased dramatically in recent years, the biased lenient approach toward them has persisted and has been empirically demonstrated at practically every stage of the judicial process. Studies have shown that wherever discretionary decisions are made, women are less likely than men to be detected, arrested, charged, convicted, and sentenced (e.g., Daly & Tonry 1997; Demuth & Steffensmeier 2004; Spohn 1999; Spohn & Beichner 2000; Stolzenberg & D’Alessio 2004). If sentenced, women are likely to receive milder sentences than men (e.g., O’Neil 1999; Steffensmeier, Kramer, et al. 1993; Steffensmeier, Ulmer, et al. 1998). These results have held, albeit somewhat attenuated, even after controlling for important legal variables, such as the type of offense and the offender’s criminal history (e.g., Farnworth & Teske 1995; Spohn 1999; Spohn & Beichner 2000).

To explain this pattern, a number of researchers have developed what is known as chivalry theory. Of several explanations offered within this framework (for a review see Steffensmeier 1980), the most prevalent is termed true chivalry (Edwards 1989:168), according to which protective and benevolent societal attitudes toward women are responsible for the lenient approach toward female offenders. The theory suggests that patriarchal cultures tend to identify women as weak, submissive, childlike, and defenseless, and as not being fully responsible for their actions. In this context, “well”- socialized individuals come to believe that female offenders need to be protected rather than punished (e.g., Kulik et al. 1996; O’Neil 1999; Scheider 2000; Steffensmeier, Kramer, et al. 1993; Stolzenberg & D’Alessio 2004). Contrary to how these individuals would view a male offender-as an independent and mature individual who is responsible for his actions-female offenders are often considered victims of an environment that has failed to provide the necessary guidance and supervision that women generally deserve (Steffensmeier 1980).1 Thus chivalry theory suggests that society’s view of women as weak and defenseless leads to an overall lenient approach toward female offenders.

Nevertheless, a number of studies have found no empirical backing for chivalry arguments, failing to discover gender differences in the treatment of criminal offenders, or even finding women treated more harshly than men (see Daly & Tonry 1997; Spohn & Beichner 2000; Steffensmeier, Kramer, et al. 1993). Some researchers have suggested that the differential treatment of female offenders is not applied to all female offenders, but rather depends on the type of women involved (e.g., Corley et al. 1989; Crew 1991; Farnworth & Teske 1995). We now turn to review these studies.

Selective Chivalry

In light of research inconsistencies regarding the leniency shown toward female offenders, more elaborate formulations of chivalry theory suggest that only women who meet a certain set of social criteria will benefit from preferential treatment (e.g., Crew 1991; Farnworth & Teske 1995; Johnson & Scheuble 1991). The chivalry effect can be thought of as a form of exchange in which society grants female offenders more lenient treatment in return for maintaining “appropriate” and traditional gender-role attributes and behaviors (Steury & Frank 1990). Specifically, in order to enjoy chivalrous treatment, women need to be socially and economically subordinate to their male partners and are expected to fulfill utilitarian familial functions: they should be married, preferably with children (Bickle & Peterson 1991; Daly 1987, 1989); live with their husband; serve as a housewife; and be in paid employment for only a few hours a day at most (Corley et al. 1989; Crew 1991).2

Accordingly, the selective chivalry argument is that only female offenders who conform to traditional gender roles (henceforth “traditional” women) are entitled to the protection granted by society in the form of leniency (see Bickle & Peterson 1991; Spohn & Beichner 2000). However, female offenders who fail to conform to such traditional roles (e.g., by being single, careerist, or feminist; henceforth “nontraditional” women) forfeit the advantages normally granted to traditional women and in some cases draw even harsher treatment than men (e.g., Johnson & Scheuble 1991; O’Neil 1999; Steury & Frank 1990). According to this perspective (also known as the “evil woman” thesis; see Crew 1991; Daly 1989; Spohn 1999), evaluations of crimes take into consideration not only what the woman has done but also who she is with respect to her position in the family and in society (Laster 1994). In this sense, nontraditional women are accused of a double deviance: once for the crime they have committed, and once more for departing from what is considered gender-appropriate behavior (e.g., Bickle & Peterson 1991; Steury & Frank 1990). Thus it appears that societal attitudes toward female offenders are not so much a result of chivalry as they are a result of an attempt to enforce sex-role expectations (e.g., Crew 1991; Edwards 1989). This portrayal is consistent with postmodern gender theory (e.g., Butler 1990), whereby women’s performances are expected to adhere to socially constructed regulative discourses. These regulative discourses, or disciplinary regimes, predetermine the acts that will appear as coherent and “normal” in a given society. Thus, gender roles consist of a rehearsed set of acts that serve as scripts by which women behave. In paternalistic societies, the common scripts by which women are considered “normal,” and whereby their behavior is deemed appropriate, portray a submissive, family-oriented role. From this perspective, crime judgments can be considered one possible means by which women are led to abide by expected scripts.

In support of selective chivalry theory, a number of studies found that nontraditional women were treated more harshly than men by the criminal justice system (e.g., Daly 1987, 1989; Farr 2000; Johnson & Scheuble 1991; Laster 1994; Spohn & Beichner 2000).3 Nevertheless, even after taking women’s traditionality into consideration, the expected leniency toward women is still not always found (see Bickle & Peterson 1991). Contrary to this theory’s propositions, women’s parental status did not predict offenders’ sentence outcomes (Steffensmeier, Kramer, et al. 1993), pretrial release decisions (Kruttschnitt & Green 1984), or the likelihood of being incarcerated (Spohn 1999). Thus the picture appears to be even more complex than has been conceptualized in selective chivalry theory. An examination of the proposed sources of chivalry may help explain the inconsistent findings in both chivalry theories, neither of which addresses the presumed sources of this differential approach. Although it is part of the theory’s main argument, previous research has not yet tested the assumption that differential treatment stems from protective attitudes toward women in society, and in particular toward traditional women.

While chivalry theories argue that chivalry is contingent on the type of offender (i.e., traditional or nontraditional women versus men), we suggest that any form of chivalry (selective or not) is also contingent on characteristics of the person evaluating the situation (e.g., a sexist or egalitarian individual). When judging the actions of female offenders, some evaluators may exhibit chivalry, while others may not. Beyond demographic influences, chivalrous judgments will depend on the extent to which decision makers hold sexist attitudes toward women. Although it is without explicit reference to chivalry theory, the literature on ambivalent sexism offers a deeper understanding of the chivalry phenomenon and presents a possible explanation of the inconsistencies in current findings.

Ambivalent Sexism

Sexism is commonly defined as the endorsement of discriminatory or prejudicial beliefs based on gender (e.g., Campbell et al. 1997:89). This definition typically involves negative discrimination based on hostility toward, and negative stereotyping of, women, and the endorsement of traditional gender roles (i.e., confining women to roles that are less powerful or esteemed than those of men; Glick & Fiske 1997). Challenging this common view, Glick and Fiske (1996, 1997) argue for a reconceptualization of both the nature and measurement of sexism. In their opinion, sexism and traditional attitudes toward women are not necessarily negative or hostile but may also involve subjectively positive and benevolent feelings, as embodied in traditional beliefs such as protectiveness, paternalism, and chivalry (Glick, Fiske, et al. 2000:765). In other words, sexist attitudes toward women are fundamentally ambivalent, encompassing both hostile and benevolent attitudes.

Glick and Fiske (1996, 1997) note that despite the contradictory emotions involved, the two types of sexism share a paternalistic approach to women. Hostile sexism explicitly regards women as inferior. While less explicit, benevolent sexism also reinforces patriarchy by portraying women as weak and needy. Both hostile and benevolent sexism justify and maintain patriarchal social structures that emphasize men’s domination of women (Glick, Fiske, et al. 2000). Nevertheless, the two are still distinct, and several studies have found them to correlate only moderately (Glick & Fiske 1996, 1997; Glick, Fiske, et al. 2000).

Glick and Fiske’s framework closely corresponds with tenets of the chivalry arguments. Almost by definition, the benevolent sexist approach toward women implies lenient and forgiving judgments, whereas the denigration involved in hostile sexism suggests harsher judgments. More specifically, Glick and Fiske (1996, 1997) propose that the two types of sexism constitute a form of “carrot and stick” aimed at maintaining women’s traditional gender roles (Glick & Fiske 1997:129). Hostile sexism, they argue, “may be directed most strongly at women who challenge men’s power (e.g., feminists) and status (e.g., career women)” (Glick, Fiske, et al. 2000:765). Conversely, benevolent sexism is usually associated with affection for women who fulfill traditional female stereotypes, such as stay- at-home mothers. In this case, the benevolent approach toward traditional women excuses the hostile approach to nontraditional women, who allegedly “deserve” it. “Whereas hostile sexism serves to punish women who fail to conform to (male-defined) acceptable roles, benevolent sexism represents the rewards women reap when they do conform” (Glick, Fiske, et al. 2000:765).

Indeed, the two forms of sexism have been found to correlate with men’s views of traditional and nontraditional women. Some studies have found hostile sexism to correlate positively with negative attitudes toward women in nontraditional roles: in one study, hostile sexism correlated positively with negative attitudes toward women managers (Sakalli Ugurlu & Beydogan 2002). A second study found hostile sexism to be associated with negative evaluations of female job candidates for a masculine-typed occupational role (Masser & Abrams 2004). In yet another study, benevolent sexism was positively associated with attitudes toward women whose behavior was consistent with a “positive” (i.e., chaste) female subtype, whereas hostile sexism was associated with attitudes toward women who depicted a “negative” (i.e., promiscuous) subtype (Sibley & Wilson 2004).

The Present Study

In light of these formulations, we propose that benevolent and hostile sexism have a central role in explaining chivalry effects. The leniency toward female offenders, and toward traditional female offenders in particular, may not be so much a general phenomenon as specifically characteristic of evaluators who hold benevolent attitudes toward women (i.e., those who espouse benevolent sexism). On the other hand, the reprimanding approach that, according to selective chivalry theory, is displayed toward nontraditional women, may in fact be characteristic only of evaluators who tend to hold negative and hostile views of women (i.e., those who espouse hostile sexism). The present study aims to test the claim posited in chivalry theory that paternalistic attitudes are the source of chivalry effects. At the same time, by incorporating the concepts of benevolent and hostile sexism, we also challenge the underlying assumption that such attitudes are uniform across individuals.

Unlike most empirical research into chivalry theory, which is based on data collected from decisions made by law enforcement officials, in the present study we focus on crime seriousness judgments among the general public. This is important for several reasons: first, research has shown that judicial decisions are influenced by the social, cultural, political, and economic contexts in which criminal justice systems operate (e.g., Dixon 1995). Furthermore, sentencing policies are typically framed with a “community standard” in mind (e.g., Rossi & Berk 1997). It is therefore important to first establish what this community standard is. Finally, because hostile and benevolent sexism are believed to stem from people’s socialization within their culture, and are not particular to members of a particular profession (e.g., Glick, Fiske, et al. 2000), an investigation of judgments among the general public can offer a direct assessment of the public’s role in the formation of crime seriousness judgments. Accordingly, in the present study respondents from a national sample were asked to evaluate the seriousness of hypothetical crime scenarios and to propose the appropriate punishment for these crimes as committed by (traditional and nontraditional) women and men. Our goal was to assess the relationship between the offender’s gender and gender- role “traditionality” and the crime seriousness judgments assigned as a function of respondents’ sexist attitudes toward women. As a first step, to test chivalry theory we wanted to see if positive attitudes toward women-such as those manifested in benevolent sexism- are associated with a lenient approach toward female offenders, and if negative attitudes toward women-such as those manifested in hostile sexism-are associated with a lack of leniency or with an even harsher approach toward female offenders than toward their male counterparts. If paternalistic sexist attitudes are indeed responsible for the differential treatment of men and women, the absence of sexist attitudes would be expected, at the very least, to reduce such differential treatment. We thus posit our first two hypotheses:

Hypothesis 1: Crimes committed by women will be judged as less serious, and will be assigned a lighter sentence, than the same crimes committed by men, for respondents with high, but not low, benevolent sexism scores.

Hypothesis 2: Crimes commuted by women will be judged as more serious, and will be assigned a harsher sentence, than the same crimes commuted by men, for respondents with high, but not low, hostile sexism scores.

Note that these hypotheses do not take into consideration the extent to which these women conform to stereotypical traditional gender roles, as selective chivalry theory suggests. Even if our first two hypotheses are supported, the question still remains whether all female offenders receive differential treatment, or whether it depends on the “type” of woman the offender is. In line with the extensions proposed by selective chivalry theory, our next two hypotheses refer to the differential reactions that traditional and nontraditional female offenders elicit, compared with those toward male offenders. We expect positive attitudes toward women (i.e., among individuals with high benevolent sexism scores) to be associated with a particularly lenient approach toward traditional female offenders, but not toward nontraditional female offenders. Correspondingly, we expect negative attitudes toward women (i.e., among those with high hostile sexism scores) to be associated with a notably harsher approach to nontraditional female offenders, but not toward traditional female offenders. Hence:

Hypothesis 3a: Crimes committed by traditional women will be judged as less serious, and will be assigned a more lenient sentence, than the same crimes committed by men, for respondents with high, but not low, benevolent sexism scores.

Hypothesis 3b: Differences between the seriousness judgments of nontraditional women’s and men’s crimes will not be moderated by benevolent sexism.

Hypothesis 4a: Crimes committed by nontraditional women will be judged as more serious, and will be assigned a harsher sentence, than the same crimes committed by men, for respondents with high, but not low, hostile sexism scores.

Hypothesis 4b: Differences between the seriousness judgments of traditional women’s and men’s crimes will not be moderated by hostile sexism.

Method

Data were collected from a random sample of the adult Israeli population (n = 840). Although the majority of studies in the field have been conducted on U.S. samples, several studies of crime seriousness (e.g., Herzog 2003a, 2003b), sexism (e.g., lieblich & Friedman 1985; Seginer et al. 1990), and judicial treatment of female offenders (e.g., Erez & Hassin 1997) with Israeli samples have produced findings comparable with those of U.S. studies. Furthermore, our guiding theoretical framework suggests that chivalry effects occur because of sexist attitudes toward women. We therefore expect our findings to be relevant for other societies besides the U.S., where sexist attitudes may be prevalent.

The most recent Israeli home telephone directories (2003), covering all geographical regions, provided the study’s sampling pool. Official data from the Ministry of Communications indicate that 98 percent of Israeli households are hooked up to the phone system and are listed in the telephone directories. To boost response rates, respondents who could not be initially reached were contacted again. This ultimately led to a high response rate of 62 percent. Overall, the sample presents a close fit to the official data on the Israeli population on a large variety of demographic and social variables (CBS 2005).

Data were collected through personal questionnaires, administered by means of a telephone survey,4 between January and March 2004. A content analysis of Israel’s major national newspapers was conducted in this period and revealed no outstanding crimes that were liable to affect responses to our questionnaire. Terrorist, military, and criminal acts directly related to the IsraeliPalestinian conflict were excluded from the scenarios used in the study. The study focused solely on criminal acts typically committed in Israel and abroad, thereby enhancing the potential to generalize our findings to other national contexts. Although ideally we would like to have gathered as much information as possible from each respondent, in order to obtain respondents’ willingness to participate in the phone surveys and to maintain their focus throughout the interview we limited each questionnaire to five crime scenarios (see more details in the next section), one sexism scale (i.e., benevolent or hostile), and a small number of demographic variables. Each telephone interview lasted approximately five minutes. The wording in the questionnaire was kept as simple as possible, and the students who served as surveyors were carefully trained by the researchers to minimize potential biases. Furthermore, the questionnaire was pretested with a small number of respondents (n = 80) to provide an initial test of the measures’ reliability and to reveal unexpected response patterns (none were found). The questionnaire was originally written in Hebrew; however, because the Israeli population includes many Arabic- and Russian-speaking individuals, questionnaires were translated to Arabic and Russian through a translation-back-translation process. A comparison of the original questionnaire with the back-translated versions revealed very close similarity between versions.

Because of limitations involving survey length, each respondent answered either benevolent sexism or hostile sexism questions, but not both. The assignment of sexism scale was conducted randomly, and differences between the two groups in respondent demographics were negligible. Those who were assigned the hos tile sexism scale comprised a slightly greater number of women (55 percent, compared with 47 percent among those assigned the benevolent sexism scale), and a slightly younger age (mean age of 35.2, compared with 36.6 among those assigned the benevolent sexism scale). No other significant differences were found in respondent demographics across the two groups.

Research Scenarios

Previous studies of crime seriousness judgments regarding a variety of offenses have often used the scenario methodology, in which respondents are presented with an evaluative task that approximates real-life situations and leaves less room for interpretative variation than do standard poll surveys (e.g., Herzog 2003a, 2003b; O’Connell & Whelan 1996; Rossi et al. 1974; Sellin & Wolfgang 1964). However, a main weakness of the simple scenario approach is that it does not allow for the systematic and simultaneous examination of the effects of multiple contextual factors on respondents’judgments (e.g., Cochran et al. 2003; Jacoby & Cullen 1999; Rossi & Berk 1997). We employed factorial design methodology, which overcomes this weakness while retaining the advantages of the simple scenario approach.

The factorial design method uses short multidimensional scenarios presented in a form that combines the benefits of controlled and randomized experimental designs and conventional surveys (e.g., Rossi & Anderson 1982; Rossi & Berk 1997). Accordingly, our crime scenarios were created by the random selection of values from each of several variables (one value per variable per scenario) until each variable was represented and a complete scenario was devised (see sample scenarios at the end of the Appendix). In each scenario, the type of crime and the offender’s and victim’s characteristics (gender, family status, etc.) were randomly assigned.5 As a result, the scenarios created represented a random sample of all possible scenarios, employing all possible values of the selected variables.6

Dependent Variables

Respondents were asked to provide two judgments for each scenario. First, in line with the majority of studies on judgments of crime seriousness, respondents were asked to evaluate the perceived seriousness (on a Likert scale from 1 = “Not serious at all” to 11 = “Very serious”) of each of the crimes described in the scenarios. To supplement the seriousness judgments, respondents were also asked to determine “the most appropriate punishment” for each of the crimes (punishment options were life sentence, any chosen number of years in prison, a monetary fine, community service, or probation: see Appendix).7 Research has consistently reported a high correspondence between subjective evaluations of seriousness and judgments of appropriate sentences, such that higher evaluations of seriousness are generally associated with more severe punishment recommendations (see Blumstein & Cohen 1980; Jacoby & Cullen 1999; O’Connell & Whelan 1996). To increase the uniformity of the evaluative task, respondents were instructed to base their responses on their subjective evaluation of the scenarios rather than on any personal legal knowledge they may have had (e.g., Rossi et al. 1974).

Independent Variables

In line with the study’s hypotheses, hostile and benevolent sexism were two of the study’s independent variables. To keep surveys brief, rather than using Click and Fiske’s (1996) full 22- item ambivalent sexism scales, we used one of their benevolent sexism subscales to measure benevolent sexism: the Complementary Gender Differentiation (CGD) dimension (“Many women have a quality of purity that few men possess”; “Women, compared to men, tend to have a superior moral sensibility”; and “Women, as compared to men, tend to have a more refined sense of culture and good taste”). Because our hypotheses regarding benevolent sexism suggest that those who are high on this scale are likely to hold a more positive view of (traditional) women, we focused on this subscale, which directly addresses women’s perceived advantages over men.8 Furthermore, the three benevolent sexism subscales have consistently yielded high intercorrelations (e.g., Click & Fiske 1996, 1997). Indeed, a pretest of the benevolent sexism scale with a sample of 205 undergraduate students yielded correlations of r = 0.62 and r = 0.55 between the CGD dimension and the two remaining benevolent sexism subscales. The correlation between the CGD subscale and the full benevolent sexism scale was r = 0.79, which further suggests that the essence of this construct can be captured by the single dimension. As for the hostile sexism component, an alternative sexism scale with fewer items-the five-item Old Fashioned Sexism Scale (OFSS; Swim et al. 1995)-was employed. Previous studies have demonstrated high correlations between this and the hostile sexism scale, suggesting that these two scales essentially measure the same construct (e.g., Click & Fiske 1996, 1997; Click, Fiske, et al. 2000). Sample items of the OFSS scale include “Women are generally not as smart as men,” and “It would be just as comfortable having a woman versus a man as a boss” (reverse-coded; see Click, Fiske, et al. 2000). Both the OFSS and the CGD benevolent sexism subscale yielded marginally acceptable reliability coefficient alphas (0.68 for both).9

Another set of independent variables involved the gender and traditionality of the offender, which incorporated the offender’s family and work statuses.10 These variables were derived from the randomly assigned factorial dimensions within the crime scenarios (see Appendix). Although judgments regarding women’s conformity to stereotypical gender roles rely on a variety of variables, two of the main factors that have been shown to determine whether a woman is perceived as “traditional” are family and occupational status. Conservative gender roles typically emphasize women’s role in the family and at home as stay-at-home mothers (e.g., Daly 1987, 1989; Spohn 1999). Thus in the present study, in the various scenarios presented in the questionnaire, traditional women were operationalized as being married with children and as not working in a full-time job. Nontraditional women were operationalized as those who were single and held full-time jobs.

This kind of operationalization of traditionality adheres to arguments and findings in studies of selective chivalry (e.g., Crew 1991; Kruttschnitt & Green 1984; Steffensmeier 1980). Overall, these studies have argued that the sentencing of women is often influenced by economic dependency and motherhood, attributes associated with the traditional female role. Although by definition female offenders do not represent the ideal stereotypical traditional woman, selective chivalry findings nevertheless demonstrate that there could be degrees of traditionality. Despite not being entirely “traditional,” offenders who are married with children have been shown to be judged more leniently than single female offenders without children (e.g., DaIy 1987, 1989; Kruttschmitt & Green 1984; O’Neil 1999).

Control Variables

Our study centered on the differential treatment of offenders based on gender and adherence to normative sex roles; however, studies in the United States have found crime seriousness judgments to be influenced by the offender’s race as well. The majority of these studies found a main effect, as well as an interaction effect, with race (Chesney-Lind & Shelden 2004; Steffensmeier, Ulmer, et al. 1998; Stolzenberg & D’Alessio 2004). Nevertheless, the effect of gender is generally not conditioned by race, and more-lenient treatment of women is found for both racial minorities and whites (Spohn & Beichner 2000). The effects of race exceed the scope of this article, but we still wished to control for it in our analyses. Because our data were collected in Israel, where race does not constitute a meaningful divider, we used ethnicity (i.e., Jews and Arabs) as the Israeli equivalent to race in the United States. Israeli Arab society has often been described as a nonassimilating, disadvantaged minority (18 percent of the general population), separated from the Jewish majority in almost every aspect of social life. Given that the Jewish-Arab divide constitutes one of the central political, social, and class conflicts in Israel, the social dynamics of ethnicity are often equivalent to the dynamics of race in countries where race constitutes a central defining variable (e.g., Herzog 2003b). We therefore controlled for offenders’ ethnicity in our analyses. In addition, we controlled for several other variables that could potentially influence respondents’ crime seriousness judgments: the offender’s criminal record (yes/not stated), the victim’s gender (male/female), and the respondent’s gender (male/female), age (interval: in years), income (five categories, ranging from less than 5,000 NIS to more than 9,000 NIS), education level (interval: years of education), family status (eight categories: single, married, divorced, widowed, each of the former four categories with/without children), and employment status (four categories: unemployed, limited number of hours per week, part- time [50 percent] job, and full-time job).

Analyses

Each of our hypotheses involves a two-way interaction effect. Accordingly, we used the OLS regression procedures indicated by Aiken and West (1991). To test each of the hypotheses, we regressed the two independent variables (in line with Aiken and West, continuous variables were centered around their mean before including them in the analysis) and their interaction term on respondents’ seriousness judgments. For example, to test Hypothesis 1-that respondents with high, but not low, benevolent sexism scores would judge crime scenarios to be less serious when the perpetrators were women-we regressed offenders’ gender, respondents’ benevolent sexism scores, and the interaction between gender and benevolent sexism on respondents’ seriousness judgments. Similarly, to test Hypothesis 3a-that respondents with high, but not low, benevolent sexism scores would judge crime scenarios when committed by traditional women as less serious than when committed by men-we regressed the traditional (married and not employed) female versus male offender contrast, as well as respondents’ benevolent sexism scores, and the interaction between the contrast variable and benevolent sexism, on respondents’ crime seriousness judgments.11 Corresponding analyses were applied for each of the hypotheses, with control variables included in all of the analyses.

Results

We started by testing a baseline model in which only the control variables were regressed on crime seriousness judgment scores (Table 1, first column). As expected, offenders with a criminal record received harsher seriousness judgments than offenders with no stated record. Similarly, in line with previous works on offender’s race and ethnicity (Daly & Tonry 1997; Sampson & Lauritsen 1997), crimes where the offender was a member of the minority group (i.e., Arab) received harsher seriousness judgments. Also in line with previous works (e.g., Ruback et al. 1999; seelau et al. 2003), the victim’s gender had a significant effect on seriousness judgments, with crimes against female victims receiving harsher judgments. In addition, a number of respondent characteristics had significant effects on crime seriousness judgments. Consistent with previous findings (e.g., O’Connell & Whelan 1996), women tended to report higher seriousness judgments than men. Furthermore, harsher judgments were provided by respondents with a higher employment status (e.g., full-time rather than part-time employees) and by respondents who are married with children. A possible explanation for these findings is that individuals who lead a more conservative form of life, with full-time jobs and families, may also exhibit more conservative views toward crime. A deeper understanding of these findings would require a separate study, with these variables as its focus.

Sexism and Chivalry

Before testing our hypotheses, we wanted to examine the relationships among benevolent sexism, hostile sexism, and respondents’ demographics. In line with previous findings (e.g., Click, Lameiras, et al. 2002), both benevolent sexism and hostile sexism correlated negatively with level of education (- 0.38 and – 0.06, respectively). Similarly, both sexism scales correlated negatively with income (-0.21 and -0.06, respectively). Benevolent sexism also correlated significantly and positively with respondents’ age (0.19).

Because each subject received only one sexism scale (either benevolent or hostile), this sample cannot provide information about the relationship between benevolent sexism and hostile sexism. However, in an independent representative sample of 3,149 Israeli respondents (these data were collected for a different study), where both benevolent sexism and hostile sexism data were collected from all respondents, the correlation between benevolent sexism and hostile sexism was 0.32 (p

Analyses of variance (ANOVAs) were used to compare the two sexism scales in this study across values of the respondents’ demographic variables. Men proved significantly higher (p

To interpret the significant interaction effect, we dichotomized the benevolent sexism variable into high- and low-benevolent-sexism groups (one standard deviation above or below the scale’s mean) and plotted the interaction effect (see Figure Ia). All the interaction effects in the following analyses were plotted using the same procedure. As can be seen, the relationship outlined supports Hypothesis 1. While among respondents who were low on benevolent sexism, crimes when committed by women were judged as only slightly less serious than when committed by men, highbenevolent-sexism respondents judged crimes committed by women as substantially less serious than the same crimes committed by men.

In testing Hypothesis 2-that respondents with high, but not low, hostile sexism scores would judge crime scenarios to be more serious when the perpetrators were women than when they were men-beyond the significant interaction term (beta = 221, p

Sexism and Selective Chivalry

Our primary hypotheses concerned the interaction between sexist attitudes and selective chivalrous judgments. Results of the analyses testing Hypothesis 3a-that respondents with high, but not low, benevolent sexism scores would judge crime scenarios when committed by traditional women as less serious than when committed by men-are presented in the fourth column of Table 1. In addition to the expected significant interaction effect (beta = – 0.279, p

Results of the analyses testing Hypothesis 4a-that respondents with high, but not low, hostile sexism scores would judge crime scenarios when committed by nontraditional women more harshly than when committed by men-are presented in the fifth column in Table 1. The interaction term (beta = 0.120, p

To test our hypotheses another way, we reran the analyses using the respondents’ choice of punishment as the dependent variable instead of seriousness judgments. With the exception of Hypothesis 4a, where the finding using the punishment variable was in the predicted direction but was not significant (p = 0.079), all the hypotheses were reconfirmed.

Discussion

We set out to examine the role of individuals’ attitudes toward women in explaining chivalry phenomena. Previous studies demonstrated the existence of differential treatment of male and traditional female offenders, and assumed that such differences can be explained in terms of chivalrous attitudes. Our study, by contrast, addresses the process by which such effects are likely to arise. In line with the formulations of chivalry theories, we demonstrated empirically that paternalistic attitudes toward women are one likely source of chivalry effects. But beyond this, our study challenges underlying implications of such theories-namely, that paternalistic attitudes are uniform across individuals, and in particular across men.

In keeping with chivalry theories, we found that female offenders tended to receive more lenient seriousness judgments than men and that judgments were contingent on the extent to which female offenders assumed traditional gender roles. However, the further complexity of the chivalry phenomenon is only revealed when the evaluators’ underlying attitudes are considered. Our findings suggest that the extent to which crime evaluators hold benevolent or hostile attitudes toward women is a key factor in forming crime seriousness judgments. Chivalry effects were substantial among respondents who held benevolent attitudes toward women but were negligible among those who did not. Conversely, the disfavor in judgments of women was offered only by respondents who held hostile attitudes toward women.

Our findings were particularly substantial for the benevolent component of sexism. While nonsexist respondents (i.e., those scoring particularly low on the benevolent sexism scale) did not exhibit any difference in the crime seriousness judgments of female versus male offenders, individuals with high benevolent sexism scores judged traditional female offenders qualitatively differently than male offenders; male offenders received extremely high seriousness scores, while traditional female offenders received only moderate seriousness scores. The fact that the effect for hostile sexism was somewhat weaker than the effect for benevolent sexism was likely due to the smaller variance and non-normal distribution in hostile sexism. The lower variance may reflect extant social pressures against the expression of overt hostility toward women. Research on sexism has in fact suggested that paternalistic and sexist attitudes toward women have become less overt (as in die case of hostile sexism) since the early 1970s, and that odier constructs, such as modern sexism or benevolent sexism, may better reflect sexist attitudes toward women today (e.g., Click & Fiske 1996, 1997; Swim et al. 1995).

In line with studies that link socioeconomic variables with liberalism (e.g., Adorno et al. 1950; Rice & Coates 1995), higher levels of education and income were generally negatively associated with sexist attitudes. Sexism also varied across some of the other demographic categories. For example, men tended to exhibit more hostile sexism than women; in particular, single men tended to score higher on the hostile sexism scale than married women with children. Although our findings indicate that some of these sociodemographic variables are related to crime seriousness judgments, the support for our hypotheses was established after controlling for the effects of these variables. Beyond any effect that social characteristics such as age, education, and family status may have on people’s crime seriousness judgments, individual differences in benevolent and hostile sexism appear to be quite meaningful for understanding differences in judgments of male versus female offenders.

Such individual differences may also be related to the type of crime prototypes dial people embody (Smith 1991, 1993). According to Smith (e.g., 1991, 1993), certain crime categories appear more typical than odiers. For example, robberies with an armed perpetrator are perceived as more typical than those with an unarmed perpetrator. Similarly, robberies of homes are more typical than robberies of workplaces. In her studies, Smith has shown that individuals’ crime judgments are influenced by the extent to which die crime is similar to their crime prototypes. Ahhough not previously tested, it is plausible that the perpetrator’s gender, and gender traditionality, may also be part of people’s crime prototypes. Furthermore, our findings raise the possibility that crime prototypes may also be a function of individuals’ overall attitude toward women. Thus a crime committed by a nontraditional woman may be perceived as more typical, and thus judged more harshly, by individuals who are high, rather than low, on hostile sexism. Overall, our findings reveal a much more complex picture than has been previously portrayed in theories of differential judicial treatment. Chivalry theses rest on the assumption that chivalrous treatment results from society’s paternalistic view of women. Rather than using gender as a proxy for the evaluator’s view of women, we focused on what seems to be the actual source of chivalry-the particular benevolent or hostile attitudes toward women. This new focus gains additional support from the fact that respondents’ gender was not significant and did not alter the results of our analyses (see Table 1).

Furthermore, in the light of our results, it is less surprising that previous chivalry studies, which have not addressed individuals’ attitudes toward women, failed to produce consistent support for the theories. It is possible that in studies where chivalry was revealed, samples comprised a majority of individuals who were high on benevolent sexism. On the other hand, where chivalry was not found, and in particular where the “evil women thesis” (i.e., harsher judgments of nontraditional women) was observed, samples may have had a majority of decision makers who were low on benevolent sexism, or even high on hostile sexism.

Although our findings shed light on the phenomenon of the differential treatment of men and women, because our sample comprised members of the general public rather than judicial practitioners, they cannot be conclusively applied to judicial personnel, whose training and experience on the job distinguishes them from the average respondent. Nevertheless, the aim in this article was to test the central premise on which chivalry theories are based, whereby chivalrous treatment is based on a paternalistic approach in society at large. That said, the next step in this line of research could be to directly examine the relationship between sexist attitudes and chivalry effects among judicial practitioners in order to consolidate our conclusions here.

Future studies should consider additional variables for conceptualizing nontraditional women and additional social divides, such as race or ethnicity, and their interplay with gender and social position. Effects were found in the present study even with nontraditional women being conceptualized simply as being unmarried and fully employed. It may very well be that differential treatment across the various gender/traditionality categories will be even more extreme when race is added to the equation. In line with our current perspective, we suggest that individual differences in racist attitudes may help explain when and why differential treatment is observed across racial groups.

It is somewhat ironic that the literature on chivalry theories, which highlights the role of stereotypical views of women, appears to have adopted a somewhat simplistic and stereotypical view of men. Although one’s gender may be somewhat associated with one’s attitudes toward women (see, for example, social identity, selfcategorization, and defensive attribution theories), the assumption that men in general hold paternalistic and sexist attitudes toward women is just as sexist as the assumption that women are weak and helpless. While such a view may have been better founded years ago, there is sufficient evidence today to suggest that gender-based attitudes have experienced substantial shifts in recent decades, and that men’s and women’s views of society are now far more heterogeneous, and far less based on the observer’s gender, than they were in the past (Click & Fiske 1996, 1997; Swim et al. 1995).

Although the present study focused on differential judgments of crime seriousness, our findings could explain similar patterns of discrimination in other contexts as well. Our main argument is that instead of using social categories as proxies for people’s judgments, whenever possible researchers should focus on the actual attitudes that people hold in the context of the phenomenon studied.

1 Additional explanations provided for the chivalry theory are: (1) naivete, i.e., that women are less capable than men of committing criminal acts; (2) the protective association that male judicial personnel tend to make between female offenders and other personally significant women; and (3) the practicality argument, which focuses on the social costs to society due to the need to care for the remaining family members while punishing female offenders (see Bickle & Peterson 1991; Steffensmeier 1980; Steffensmeier, Ulmer, et al. 1998; also Daly 1987, 1989).

2 It has also been argued that preferential treatment is accorded to women who perpetrate offenses that are “typically female,” such as petty theft and shoplifting (e.g., Farnworth & Teske 1995; Johnson & Scheuble 1991; Scheider 2000).

3 This situation is consistently found for both lesbians and prostitutes; females who have committed serious, “masculine” crimes (murder, assault, robbery); and especially females in juvenile courts, where harsher punishments are usually applied to girls rather than to boys who commit status and moral-order offenses. The rationale for this last difference is that these girls are seen as being at greater moral danger and as needing to be protected from themselves or from external immoral influences (see Chesney-Lind & Shelden 2004; Farr 2000; Kempf-Leonard & Sample 2000).

4 Among the advantages of this survey method are the access to a large number of respondents in a relatively short period of time; the relative ease of obtaining a broad, nationally representative sample; its fairly low cost; its ease of standardizing responses for comparison; the minimal danger of the researcher biasing the respondents; and the high level of anonymity. This latter factor was particularly important for the current study due to the sensitive content of the questionnaires (i.e., permissiveness regarding criminal acts).

5 The offenses evaluated in this study included intimate murder, acquaintance murder, domestic violence, acquaintance violence, rape, vehicular homicide, apartment burglary, shoplifting, robbery, tax evasion, drug selling, drug use, bribery, and sexual harassment. Note that based on repeated criticism concerning the over- representation of violent offenses in some seriousness studies (e.g., Cullen et al. 1985; Miethe 1982), the offenses described in this study were highly diverse, ranging from very grave (e.g., murder) to very minor (theft of a watch), and included offenses of many kinds: violent, property, economic, white-collar, and victimless. These offenses were randomly chosen from a large pool of offenses representing the population of criminal offenses in Israel. To avoid unnecessary complexity, some variables were kept uniform across scenarios. First, the offenders were responsible for their acts, which had criminal consequences. second, the scenarios all involved a single offender and a single victim.

6 Rossi and Andersen (1982) note that allowing multiple variables of a crime scenario to vary randomly across scenarios, and controlling for the respondents’ personal characteristics, permits the simultaneous exploration of the effects of several independent variables while still providing unbiased estimates of each variable’s contribution to the respondent’s overall judgment. Moreover, due to their randomization, the variables in the scenarios do not co-vary either with the respondents’ characteristics or among themselves.

7 In coding the punishment variable, the more lenient punishments of “fine,””community service,” and “probation” were coded as the most lenient imprisonment sentence offered in the sample. The “life sentence” option was coded as the harshest imprisonment sentence suggested (i.e., 65 years). Because the distribution of this variable was highly skewed, we transformed the data before conducting any analyses with it. An inverse function (1/X) appeared to offer the best transformation, which brought the variable’s distribution much closer to being normal.

8 Due to limitations on survey length, we limited our questions regarding benevolent sexism to the CGD subscale. Given the context of our study, it is possible that the Protective Paternalism factor would also be a relevant construct to consider.

9 Because each respondent answered questions about benevolent sexism or hostile sexism, we cannot report the extent of overlap for the scales among the respondents within our main study.

10 In addition to the impact of gender, previous research has addressed the possibility that offenders’ race/ethnicity, either directly or jointly with race, may further explain differences in reactions to crime (e.g., Langan et al. 2001). However, evidence for the role of race is mixed (e.g., Mastrofski et al. 1995), and it has been further argued that it is very difficult to tease out how stereotypes of race/ethnicity interact with gender within the vignette (Rossi & Berk 1997; Seron et al. 2004). Therefore, we did not test for the interactive effect of race/ethnicity in the present study. Nevertheless, we did control for race/ethnicity in our analyses, as indicated in the section on control variables.

11 When scenarios are taken as the unit of analysis, there is the potential for a response bias, because the responses of each rater are not independent (since each rater responds to a number of scenarios; Hox et al. 1991). We used Bryk, Raudenbush, and Congdon’s (1996) Hierarchical Linear Models (HLM) software (version 5.05), which considers such nonindependence of responses, to conduct the equivalent multilevel analyses of our data. The findings were equivalent to our OLS regression results, thus reconfirming our hypotheses. 12 Because associations exist between each of the sexism scales and several of the control variables (e.g., respondent income, respondent family status), the effects of these controls on crime seriousness judgments were not consistent across the different hypotheses, in which different sexism scales were included. A discussion of these variations in the effects of controls is beyond the focus of our article. Nevertheless, the first column of Table 1 presents baseline effects of these controls, which were consistent with previous findings.

References

Adorno, Theodore W., et al. (1950) The Authoritarian Personality. New York: Harper & Row.

Aiken, Leona S., & Stephen G. West (1991) Multiple Regression: Testing and Interpreting Interactions. Newbury Park, CA: Sage Publications.

Alien, David W., & Diane E. Wall (1993) “Role Orientations and Women State Supreme Court Justices,” 77 Judicature 156-65.

Bickle, Gayle, & Ruth D. Peterson (1991) “The Impact of Gender- Based Family Roles on Criminal Sentencing,” 38 Social Problems 372- 94.

Blumstein, Alfred, & Jacqueline Cohen (1980) “Sentencing of Convicted Offenders: An Analysis of the Public’s View,” 14 Law & Society Rev. 223-61.

Bryk, Anthony S., et al. (1996) HLM: Hierarchical Linear and Non- Linear Modeling with the HLM/2L and HLM/3L Programs. Chicago: Scientific Software International.

Butler, Judith (1990) Gender Trouble. New York: Routledge.

Campbell, Bernadette, et al. (1997) “Evaluating Measures of Contemporary Sexism,” 21 Psychology of Women Q. 89-102.

CBS [Central Bureau of Statistics] (2005) Statistical Abstract of Israel. Jerusalem: Central Bureau of Statistics.

Chesney-Lind, Meda, & Randall Shelden (2004) Girls, Delinquency, and Juvenile Justice. Los Angeles: West/Wadsworth.

Cochran, John K., et al. (2003) “Attribution Styles and Attitudes Toward Capital Punishment for Juveniles, the Mentally Incompetent, and the Mentally Retarded,” 20 Justice Q 65-93.

Coontz, Phyllis (2000) “Gender and Judicial Decisions: Do Female Judges Decide cases Differently than Male Judges?,” 18 Gender Issues 59-73.

Corbett, Claire, & Frances Simon (1991) “Police and Public Perceptions of the Seriousness of Traffic Offenses,” 31 British J. of Criminology 153-64.

Corley, Charles J., et al. (1989) “Sex and the Likelihood of Sanction,” 80/ of Criminal Law ana Criminology 540-56.

Crew, B. Keith (1991) “Sex Differences in Criminal Sentencing: Chivalry or Patriarchy?,” 8 Justice Q, 59-84.

Cullen, Francis, et al. (1985) “Consensus in Crime Seriousness: Empirical Reality or Methodological Artifact?,” 23 Criminology 99- 118.

Daly, Kathleen (1987) “Discrimination in the Criminal Courts: Family, Gender, and the Problem of Equal Treatment,” 66 Social Forces 152-75.

_____ (1989) “Neither Conflict nor Labeling nor Paternalism Will Suffice: Intersections of Race, Ethnicity, Gender, and Family in Criminal Court Decisions,” 35 Crime &? Delinquency 136-68.

Daly, Kathleen, & Michael Tonry (1997) “Gender, Race and Sentencing,” in M. Tonry, ed., Crime and Justice: A Review of Research, Vol. 22. Chicago: Univ. of Chicago Press.

Demuth, Stephen, & Darrell Steffensmeier (2004) “The Impact of Gender and RaceEthnicity in the Pretrial Release Process,” 51 Social Problems 222.

Dixon, Jo (1995) “The Organizational Context of Criminal Sentencing,” 100 American J. of Sociology 1157-98.

Edwards, Anne R. (1989) “Sex/Gender, Sexism and Criminal Justice: Some Theoretical Considerations,” 17 International J’. of the Sociology of Law 165-84.

Erez, Edna, & Yael Hassin (1997) “Women in Crime and Justice: The case of Israel,” 9 Women fc? Criminal Justice 61-85.

Farnworth, Margaret, & Raymond H. C. Teske Jr. (1995) “Gender Differences in Felony Court Processing: Three Hypotheses of Disparity,” 6 Women and Criminal Justice 23-44.

Fair, Kathryn Ann (2000) “Defeminizing and Dehumanizing Female Murderers: Depictions of Lesbians on Death Row,” 11 Women and Criminal Justice 49-66.

Glick, Peter, & Susan T. Fiske (1996) “The Ambivalent Sexism Inventory: Differentiating Hostile and Benevolent Sexism,” 70/. of Personality and Social Psychology 491-512.

_____ (1997) “Hostile and Benevolent Sexism: Measuring Ambivalent Sexist Attitudes Toward Women,” 21 Psychology of Women Q 119-35.

Glick, Peter, & Susan T. Fiske, et al. (2000) “Beyond Prejudice as Simple Antipathy: Hostile and Benevolent Sexism Across Cultures,” 79 /. of Personality and Social Psychology 763-75.

Glick, Peter, & Maria Lameiras, et al. (2002) “Education and Catholic Religiosity as Predictors of Hostile and Benevolent Sexism Toward Women and Men,” 47 Sex Roles 433-41.

Herzog, Sergio (2003a) “Religiosity and Perceptions of Crime Seriousness by Jewish and Muslim Respondents in Israel,” 24 Deviant Behavior 153-74.

_____ (2003b) “Does the Ethnicity of Offenders in Crime Scenarios Affect Public Perceptions of Crime Seriousness?,” 8 Social Forces 757-81.

Hox, Joop J., et al. (1991) “The Analysis of Factorial Surveys,” 19 Sociological Methods and Research 493-510.

Jacoby, Joseph, & Francis Cullen (1999) “The Structure of Punishment Norms: Applying the Rossi-Berk Model,” 89 The J. of Criminal Law and Criminology 245-307.

Johnson, David R., & Laune K. Scheuble (1991) “Gender Bias in the Disposition of Juvenile Court Referrals: The Effects of Time and Location,” 29 Criminology 677-99.

Kempf-Leonard, K., & Lisa Sample (2000) “Disparity Based on Sex: Is Gender-Specific Treatment Warranted?,” 7 Justice Q. 89-128.

Krullschnitt, Candace, & Donald Green (1984) “The Sex- Sanctioning Issue: Is It History?,” 49 American Sociological Rev. 541-51.

Kulik, Carol T., et al. (1996) “Understanding Gender Differences in Distributive and Procedural Justice,” 9 Social Justice Research 351-69.

Langan, Patrick A., et al. (2001) Contacts between the Police and the Public: Findings from the 1999 National Survey. Washington, DC: U.S. Departmen

Cutaneous Metastases in Patients With Rectal Cancer: A Report of Six Cases

By Gazoni, Leo M Hedrick, Traci L; Smith, Philip W; Friel, Charles M; Swenson, Brian R; Adams, Joshua D; Lisle, Turner C; Foley, Eugene F; Ledesma, Elihu J

Cutaneous metastases from rectal cancer are rare manifestations of disseminated disease and uniformly represent dismal survival. A retrospective review of six patients with rectal cancer metastatic to the dermis was performed. The diagnosis of rectal cancer was made concurrently with the diagnosis of the dermal metastases in all six patients. A 100 per cent histopathologic concordance existed between the tissue of the dermal metastases and primary rectal tumor. The progression of systemic metastatic disease was the cause of death in 83.3 per cent of patients (5/6). No patient survived more than 7 months from the time of diagnosis. Recognition of suspicious skin lesions as possible harbingers of undiagnosed visceral malignancy is important in managing patients both with and without a history of previous cancer. RECTAL CANCER METASTASES to the skin, although uncommon, represent disseminated disease and portend a poor prognosis. Cutaneous metastases are most commonly small 1- to 2- centimeter nodules that often coalesce and resemble epidermal cysts, keratoacanthomas, or pyogenic granulomas.1-3 This finding is characteristic of most cutaneous metastases regardless of the origin of the primary tumor. Ulceration occurs in approximately 10 per cent of nodules.2 In this study, we present our series of six patients who were diagnosed with rectal cancer concurrently with metastatic lesions to the skin.

Case Series

Patient Information

Of six patients, one patient was female and five patients were male. The mean age at diagnosis was 67.3 years. Patients commonly presented with constipation, bloating, bloody and thin stools, weight loss, and scrotal edema. All patients had a palpable mass on digital rectal examination.

Cutaneous Manifestations

Cutaneous metastases varied in location and number (Figs. 1-3 & Table 1). Some patients had multiple sites of dermal involvement, but the lower abdomen/back was not involved in any patient.

FIG. 1. Arm metastases.

Management

Anoscopy and rigid sigmoidoscopy were performed on all patients. Complete colonoscopy was performed in all but one patient (the scope was unable to pass the lesion). All tumors were found less than 10 centimeters from the anal verge. A 100 per cent histopathologic concordance existed between the tissue of the cutaneous metastases and primary rectal tumor.

At the time of diagnosis, liver metastases were found in two patients. Two patients had radiologic evidence of metastatic disease; one patient with a lung mass and the other with a retroperitoneal mass. Tumor fixation (frozen pelvis) was present in four patients. The operations performed in all six patients were palliative. Diverting loop colostomies were performed on three patients, one of which was emergent as the patient presented with an acute obstruction. Two patients received end colostomies. A stent was successfully placed with good early functional result in one patient; however, no conclusion to its long-term functionality and consequences could be made as the patient soon died secondary to a myocardial infarction. One patient presented with a severe Enterococcus faecalis soft tissue infection at the site of cutaneous metastasis requiring massive resection of the perineum, scrotum, and lower abdomen. The patient survived this insult and was discharged after skin grafting but then died 3 months later of liver and lung metastases.

FIG. 2. Groin metastases.

FIG. 3. Penile metastases.

All patients underwent radiation and chemotherapy. In three patients, radiation was performed before chemotherapy. Two patients underwent concurrent radiation and chemotherapy and one patient had chemotherapy followed by radiation. The radiation dose varied from 4500 Gy to 5000 Gy. All patients received 5-fluorouracil. All patients received leucovorin except for one who did not tolerate therapy. Subjective improvement of the skin lesions was reported in all but one patient. Progression of systemic metastatic disease was the cause of death in five patients and myocardial infarction in one patient. The skin metastases themselves were not the cause of death although they caused a significant morbidity as the lesions were disfiguring, bleeding, suppurative, and foul-smelling. Notably, the lesions were not painful.

TABLE 1. Patient Information

Discussion

Colorectal cancer accounted for approximately 148,610 cases of newly diagnosed cancer and 55,170 deaths in the United States in 2005 according to the American Cancer Society. Approximately four to six per cent of colorectal cancer cases are metastatic to the skin.2,4-6 Although liver, lung, bone, and brain metastases are more common manifestations of disseminated colorectal cancer, cutaneous metastases of colorectal cancer do occur and will potentially affect up to 6,000 of the 148,610 patients with newly diagnosed colorectal cancer in the United States.

Autopsy series have reported an incidence of 0.7 per cent to 10.4 per cent of cutaneous metastases in all patients with cancer of any cause.7-9 Excluding primary skin cancers, gastrointestinal malignancies account for 15 per cent of cutaneous metastases.10, n In one series of 4,020 cancer patients with metastatic disease, cutaneous metastases were found in 10.4 per cent of patients.2 All tumors were adenocarcinomas. Colorectal cancer was the third most common cause of cutaneous metastases in men behind melanoma and lung cancer and the seventh most common cause in women. Breast cancer and melanoma were the top two primary tumors in 70.7 per cent and 12.0 per cent, respectively, of women with cutaneous metastases. In this series, the mean time of death from diagnosis was 18 months.

In most case reports of metastatic colorectal cancer to the skin, the metastatic lesion was found after re section of the primary lesion. Dermal invasion, which is postulated to occur via intravascular and intralymphatic spread,12 usually occurs within 2 years of the primary resection and represents poor prognosis with mean survival ranging between 3 and 20 months.1-9 Whereas our series, the largest nonautopsy series to our knowledge, mirrors the findings of poor patient survival, all of our patients were diagnosed with cutaneous metastases at or before the time of the diagnosis of the primary rectal cancer. One series of 7316 cancer patients found that only one per cent of patients had dermal metastases at the time of the diagnosis of the primary tumor and 0.6 per cent of patients had dermal metastases as the first sign of visceral malignancy.10 The skin of the lower abdomen/trunk and previous abdominal incisions have been reported as the most common site of dermal metastases.13,14 In contrast, no patient in our series had involvement of the lower abdomen/trunk.

Rectal cancer metastatic to the dermis is a welldescribed, although uncommon manifestation of advanced disease. It should be considered in patients with risk factors or symptoms consistent with colorectal cancer who present with suspicious skin lesions including foul-smelling, suppurative skin lesions. Biopsy of concerning lesions in patients with a history of malignancy is also recommended. Our series also demonstrates that cutaneous metastasis may sometimes be the first sign that leads to diagnosis of a primary rectal cancer.

REFERENCES

1. Adani GL, Marcello D, Anania G, et al. Subcutaneous right leg metastasis from rectal adenocarcinoma without visceral involvement. Chir Ital 2001;53:405-7.

2. Lookingbill DP, Spangler N, Helm KF. Cutaneous metastases in patients with metastatic carcinoma: A retrospective study of 4020 patients. J Am Acad Dermatol 1993;29:228-36.

3. Sarid D, Wigler N, Gutkin Z, et al. Cutaneous and subcutaneous metastases of rectal cancer. Int J Clin Oncol 2004;9:202-5.

4. Stavrianos SD, McLean NR, Kelly CG, Fellows S. Cutaneous metastasis to the head and neck from colonic carcinoma. Eur J Surg Oncol 2000;26:518-9.

5. Wong NS, Chang BM, Toh HC, Koo WH. Inflammatory metastatic carcinoma of the colon: A case report and review of the literature. Tumori 2004;90:253-5.

6. Krathen RA, Orengo IF, Rosen T. Cutaneous metastasis: A meta- analysis of data. South Med J 2003;96:164-7.

7. Spencer PS, Helm TN. Skin metastases in cancer patients. Cutis 1987;39:119-21.

8. Reingold IM. Cutaneous metastases from internal carcinoma. Cancer 1966;19:162-8.

9. Abrams HL, Spiro R, Goldstein N. Metastases in carcinoma; analysis of 1000 autopsied cases. Cancer 1950;3:74-85.

10. Lookingbill DP, Spangler N, Sexton FM. Skin involvement as the presenting sign of internal carcinoma. A retrospective study of 7316 cancer patients. J Am Acad Dermatol 1990;22:19-26.

11. Brownstein MH, Helwig EB. Metastatic tumors of the skin. Cancer 1972;29:1298-307.

12. Kauffman LC, Sina B. Metastatic inflammatory carcinoma of the rectum: Tumor spread by three routes. Am J Dermatopath. 1997;19:528- 32.

13. Iwase K, Takenaka H, Oshima S, et al. The solitary cutaneous metastasis of asymptomatic colon cancer to an operative scar. Surg Today 1993;23:164-6.

14. Gmitter TL, Dhawan SS, Phillips MG, Wiszniak J. Cutaneous metastases of colonic adenocarcinoma. Cutis 1990;46:66-8.

LEO M. GAZONI, M.D., TRACI L. HEDRICK, M.D., PHILIP W. SMITH, M.D., CHARLES M. FRIEL, M.D., BRIAN R. SWENSON, M.D., IOSHUA D. ADAMS, M.D., TURNER C. LISLE, M.D., EUGENE F. FOLEY, M.D.,

ELIHU J. LEDESMA, M.D.

From the Department of Surgery, University of Virginia, Charlottesville, Virginia

Address correspondence and reprint requests to Leo M. Gazoni, M.D., MR4 Building, Room 3116,409 Lane Road, Charlottesville, VA 22908. E-mail: [email protected].

Copyright Southeastern Surgical Congress Feb 2008

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

Hepatic Malignant Epithelioid Hemangioendothelioma: A Case Report and Review of the Literature

By Woodall, Charles E Scoggins, Charles R; Lewis, Angela M; McMasters, Kelly M; Martin, Robert C G

Malignant epithelioid hemangioendothelioma is a rare hepatic tumor of vascular origin. It is most commonly found in young to middle aged women, and the tumors vary in reported malignant potential. Compounds such as oral contraceptive pills, poly vinyl chloride, and Thorotrast have been identified as risk factors for subsequent disease development. Radiologic (“lollipop” sign, capsular flattening) and pathologic (Factor-VIII antigen staining positive) evaluation aids in the diagnosis. As with most mesenchymal tumors, surgical resection is the most effective means of controlling local disease and preventing distant metastasis, though adjuvant therapies have been offered for those that are unresectable or not transplant candidates. We present our case of a hepatic malignant epithelioid hemangioendothelioma and a review of the English-language literature. Case Presentation

A 69-YEAR-OLD WHITE female complained of vague abdominal pain with some generalized fatigue and a 10 pound weight gain. The clinical evaluation was otherwise negative. Specifically, she had no history of hepatitis or cirrhosis, and no history of exposure to environmental agents potentially associated with malignant epithelioid hemangioendothelioma (EHE).

Computed tomography of the abdomen demonstrating a 4.0 x 5.0 x 3.0 cm mass confined to the right lobe of the liver in segments 7 and 8, suggested a malignancy, rather than focal nodular hyperplasia or hepatic adenoma given its morphology, hypervascularity, and absence of significant fat content. Liver function tests, carcinoembryonic antigen, and alpha fetal protein, were all within normal limits, and a viral hepatitis panel was negative. Upper and lower endoscopy were normal. A percutaneous core needle biopsy of the mass suggested a tumor of vascular origin likely a malignant epithelioid hemangioendothelioma because immunohistochemical stains for Factor VIII antigen, cluster of differentiation molecule (CD) 31, and CD 34 were positive.

An arteriogram confirmed the vascular nature of the mass and defined normal vascular anatomy. She underwent cholecystectomy and right hepatic lobectomy. Malignant EHE was confirmed (Figs. 1, 2). The patient tolerated the procedure well; she received no adjuvant therapy and remains well without evidence of disease at 7 years postoperatively.

Discussion

Malignant EHE represents a rare (

FIG. 1. High power photomicrograph showing the vascular channels of the tumor.

FIG. 2. Midpower photomicrograph of the tumor demonstrating the vascularity next to normal liver parenchyma.

The relative obscurity and heterogeneity of this tumor makes diagnosis via imaging difficult, though some recent reports have expanded the knowledge base in regards to radiologic findings. The lesions are most frequently peripheral in location. Malignant EHE may manifest as a single nodule or diffuse bilobar disease, which can coalesce into a larger dominant mass. This coalescence was first described by Fumi et al.18 when they proposed a two tiered classification system based on nodular or diffuse disease status. Plain abdominal x-rays frequently show right upper quadrant calcifications (Table 1 ).7 The tumors are heterogeneous by ultrasound; they may be hyper-, hypo-, or isoechoic.19 Cross sectional modalities such as computed tomography and magnetic resonance imaging can reveal the recently described “lollipop sign,” with a hepatic or portal vein terminating at the periphery of the mass giving rise to a unique imaging characteristic not commonly seen with other hepatic malignancies.20 Capsular retraction from peritumoral fibrosis may also cause “flattening” of the surface of the liver. Computed tomography may note a hypervascular periphery; additionally, the MR technique of administering superparamagnetic iron oxide has been proposed as a test to furthermore delineate these tumors because of their avid uptake of this contrast medium.21

TABLE 1 Useful Adjuncts in Diagnosing Epithelioid Hemangioendothelioma

Laboratory data is usually nondiagnostic. Tumor markers, such as carcinoembryonic antigen and afetoprotein are generally normal. A recent case series identified serum thyrotropin elevation in seven patients, apparently from a thyrotropin analogue secreted from the tumor.22 This was also reported in a separate case report of a woman before she was treated with transplantation, and was suggested as a postoperative tumor marker to follow patients for early evidence of recurrence.23 Liver function tests may be mildly abnormal, including gamma-GTP (glutamyl transpeptidase).24 Patients may also have an elevated plasma Factor VIII level.

TABLE 2. Review of Cases and Outcomes of Malignant Epithelioid Hemangioendothelioma

Pathologically, the tumors have vascular invasion, a finding that is not surprising given their vascular origins, with the endothelial cells being “epithelioid” or “histiocytoid” in nature.2 Immunohistochemical staining for epithelial markers such as factor VHI-related antigen, CD-31, and CD-34 aid in the diagnosis and confirm its endothelial origin, a pathognomonic feature. Like many mesenchymal tumors, the determination of malignancy is indirect, by such factors as mitotic index and cellularity, as well as clinical behavior.7

Because the hepatic variant of the tumor is more aggressive, up to 60 per cent of patients get metastatic disease, most commonly in the lungs as is the case with most sarcomatous tumors.5 Advanced local dis ease can be problematic as well. Complications such as spontaneous rupture25 and adult Kasabach-Merritt syndrome (a vascular lesion that triggers platelet trapping and subsequent consumptive thrombocytopenia)26 have been reported. In advanced disease, Budd-Chiari may be encountered.27

Similar to other mesenchymal neoplasms, operative therapy remains the mainstay of treatment for patients with malignant EHE.28 Though one case report does identify spontaneous regression in an elderly female with biopsy proven disease,29 most authors recommend definitive operative intervention. As with other hepatic malignancies, the type of operative therapy being recommended is shifting. Resection for localized disease is the generally accepted modality, though some papers report a more fulminant course complicated by recurrence after curative resection.30 Orthotopic liver transplantation for diffuse disease has shown durable success, with survival rates of 75 per cent at 5 years and 60 per cent disease free rates,1 similar to that of patients who undergo transplantation for other hepatic tumors.31 The disease can return in the allograft.5 Despite this, some authors have even recommended it for patients with extrahepatic disease,32 followed by chemotherapy, usually doxorubicin or 5-fluorouracil. Adjuvant therapies, such as arterial chemo-embolization have been reported as a viable bridge to transplantation.33 Radio-frequency ablation, commonly used in the liver for other malignancies, has been used successfully in bone disease34 and would likely serve some purpose in hepatic manifestations of disease. Antineoplastic drugs such as thalidomide have shown benefit as adjuvant therapies or primary treatment for unresectable disease35 and interferon alpha-2B has been used in combination with bilobar hepatic resection with success in case reports.36 Therapeutic devascularization has been attempted in patients with nonresectable disease, with poor results.15 Because of the rarity of the tumor and nonuniform treatment of patients, as well as the varied nature of the disease, predicting prognosis is somewhat challenging. Most publications seem to suggest somewhere between 40 and 75 per cent 5-year survival,15 though there are certainly case reports of patients at both extremes of this spectrum. Whereas some may succumb early, many reports suggest long survival after resection, and a successful term pregnancy has even been described after extirpation of widespread metastatic disease.37 Less is known about truly long-term (greater than 5 year) outcomes. Malignant hepatic epithelioid hemangioendothelioma remains a rare entity, addressed in the literature mostly by case reports (Table T). Its variable nature and clinical course make standardized staging, therapy, and prognosis difficult. While multiple causative factors have been suggested, these remain little more than loose associations. Most authors recommend surgical therapy as standard of care, and this seems appropriate given that most other mesenchymal tumors are best treated operatively. Transplantation has been effective, with survivals in line with other hepatic malignancies treated by this therapy. A large clinical series seems unlikely given the infrequency with which this tumor is encountered; case series and reports such as this one will likely remain as the sole source of reported clinical literature for this malignancy.

REFERENCES

1. Hertl M, Cosimi AB. Liver transplantation for malignancy. Oncologist 2005;10:269-81.

2. Weiss SW, Enzinger FM. Epithelioid hemangioendothelioma: A vascular tumor often mistaken for a carcinoma. Cancer 1982;50:970- 81.

3. Pokharna RK, Garg PK, Gupta SD, et al. Primary epithelioid haemangioendothelioma of the liver: Case report and review of the literature. J Clin Pathol 1997;50:1029-31.

4. Matsushita M, Shimizu S, Nagasawa M, et al. Epithelioid hemangioendothelioma of the liver: Imaging diagnosis of a rare hepatic tumor. Dig Surg 2005;22:416-8.

5. Mani H, Van Thiel DH. Mesenchymal tumors of the liver. Clin Liver Dis 2001;5:219-57.

6. Uchimura K, Nakamuta M, Osoegawa M, et al. Hepatic epithelioid hemangioendothelioma. J Clin Gastroenterol 2001 ;32: 431-4.

7. Makhlouf HR, Ishak KG, Goodman ZD. Epithelioid hemangioendothelioma of the liver: A clinicopathologic study of 137 cases. Cancer 1999;85:562-82.

8. Emre S, McKenna GJ. Liver tumors in children. Pediatr Transplant 2004;8:632-8.

9. Meirowitz NB, Guzman ER, Underberg-Davis SJ, et al. Hepatic hemangioendothelioma: Prenatal sonographic findings and evolution of the lesion. J Clin Ultrasound 2000;28:258-63.

10. Garcia-Botella A, Diez-Valladares L, Martin-Antona E, et al. Epithelioid hemangioendothelioma of the liver. J Hepatobiliary Pancreat Surg 2006;13:167-71.

11. Dean PJ, Haggitt RC, O’Hara CJ. Malignant epithelioid hemangioendothelioma of the liver in young women. Relationship to oral contraceptive use. Dean Am J Surg Pathol. 1985;9: 695-704.

12. Ishak KG, Sesterhenn IA, Goodman ZD, et al. Epithelioid hemangioendothelioma of the liver: A clinicopathologic and follow- up study of 32 cases. Hum Pathol 1984;15:839-52.

13. Shin MS, Carpenter JT Jr, Ho KJ. Epithelioid hemangioendothelioma: CT manifestations and possible linkage to vinyl chloride exposure. J Comput Assist Tomogr 1991;15:505-7.

14. Gelin M, Van de Stadt J, Rickaert F, et al. Epithelioid hemangioendothelioma of the liver following contact with vinyl chloride. Recurrence after orthotopic liver transplantation. J Hepatol 1989;8:99-106.

15. Lauffer JM, Zimmermann A, Krahenbuhl L, et al. Epithelioid hemangioendothelioma of the liver. A rare hepatic tumor. Cancer 1996;78:2318-27.

16. Dail DH, Liebow AA, Gmelich JT, et al. Intravascular, bronchiolar, and alveolar tumor of the lung (IVBAT). An analysis of twenty cases of a peculiar sclerosing endothelial tumor. Cancer 1983;51:452-64.

17. Terada T, Nakanuma Y, Hoso M, et al. Hepatic epithelioid hemangioendothelioma in primary biliary cirrhosis. Gastroenterology 1989;97:810-1.

18. Furui S, Itai Y, Ohtomo K, et al. Hepatic epithelioid hemangioendothelioma: Report of five cases. Radiology 1989;171: 63- 8.

19. Levy AD. Malignant liver tumors. Clin Liver Dis 2002;6: 147- 64.

20. Alomari AI. The lollipop sign: A new cross-sectional sign of hepatic epithelioid hemangioendothelioma. Eur J Radiol 2006;59:460- 4.

21. Kehagias DT, Moulopoulos LA, Antoniou A, et al. Hepatic epithelioid hemangioendothelioma: MR imaging findings. Hepatogastroenterology 2000;47:1711-3.

22. Ayling RM, Davenport M, Hadzic N, et al. Hepatic hemangioendothelioma associated with production of humoral thyrotropin-like factor. J Pediatr 2001;138:932-5.

23. Mucha K, Foroncewicz B, Zieniewicz K, et al. Patient with liver epithelioid hemangioendothelioma treated by transplantation: 3 years’ observation. Transplant Proc 2006;38:231-3.

24. Furuta K, Sodeyama T, Usuda S, et al. Epithelioid hemangioendothelioma of the liver diagnosed by liver biopsy under laparoscopy. Am J Gastroenterol 1992;87:797-800.

25. Lau WY, Dewar GA, Li AK. Spontaneous rupture of hepatic epithelioid haemangio-endothelioma. Aust N Z J Surg 1989; 59:972-4.

26. Frider B, Bruno A, Selser J, et al. Kasabach-Merrit syndrome and adult hepatic epithelioid hemangioendothelioma an unusual association. J Hepatol 2005;42:282-3.

27. Clements D, Hubscher S, West R, et al. Epithelioid haemangioendothelioma. A case report. J Hepatol 1986;2:441-9.

28. Mehrabi A, Kashfi A, Schemmer P, et al. Surgical treatment of primary hepatic epithelioid hemangioendothelioma. Transplantation 2005;80(1 Suppl):S109-12.

29. Otrock ZK, Al-Kutoubi A, Kattar MM, et al. Spontaneous complete regression of hepatic epithelioid haemangioendothelioma. Lancet Oncol 2006;7:439-41.

30. Ben-Haim M, Roayaie S, Ye MQ, et al. Hepatic epithelioid hemangioendothelioma: Resection or transplantation, which and when? Liver Transpl Surg 1999;5:526-31.

31. Nissen NN, Cavazzoni E, Tran TT, Poordad FP. Emerging role of transplantation for primary liver cancers. Cancer J 2004; 10:88-96.

32. O’Grady JG. Treatment options for other hepatic malignancies. Liver Transpl 2000;6(Suppl 2):S23-9.

33. St Peter SD, Moss AA, Huettl EA, et al. Chemoembolization followed by orthotopic liver transplant for epithelioid hemangioendothelioma. Clin Transplant 2003;17:549-53.

34. Rosenthal DI, Treat ME, Mankin HJ, et al. Treatment of epithelioid hemangioendothelioma of bone using a novel combined approach. Skeletal Radiol 2001;30:219-22.

35. Mascarenhas RC, Sanghvi AN, Friedlander L, et al. Thalidomide inhibits the growth and progression of hepatic epithelioid hemangioendothelioma. Oncology 2004;67:471-5.

36. Galvao FH, Bakonyi-Neto A, Machado MA, et al. Interferon alpha-2B and liver resection to treat multifocal hepatic epithelioid hemangioendothelioma: A relevant approach to avoid liver transplantation. Transplant Proc 2005;37:4354-8.

37. Myles TD, Strassner HT, Wong DJ. Pregnancy after treatment of epithelioid hemangioendothelioma. A case report. J Reprod Med 1994;39:52-4.

CHARLES E. WOODALL, M.D., CHARLES R. SCOGGINS, M.D., ANGELA M. LEWIS, M.D.,

KELLY M. MCMASTERS, M.D., PH.D., ROBERT C.G. MARTIN, M.D.

From the Department of Surgery, Division of Surgical Oncology, James Graham Brown Cancer Center,

University of Louisville School of Medicine, Louisville, Kentucky

Address correspondence and reprint requests to Robert C.G. Martin, M.D., University of Louisville School of Medicine, 315 East Broadway Suite 312, Louisville, KY 40202. E-mail: [email protected].

Copyright Southeastern Surgical Congress Jan 2008

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

Recurrent Pure Mucinous Carcinoma of the Breast With Mediastinal Great Vessel Invasion: HER-2/Neu Confers Aggressiveness

By Adair, Jamie D Harvey, Kyle P; Mahmood, Ali; Caralis, James; Gordon, William; Yanish, Gregory

Mucinous carcinoma of the breast, also known as colloid carcinoma, is a less common variant of breast cancer constituting less than five per cent of breast cancers. We report the case of a 42-year-old premenopausal female who presented with a palpable chest wall recurrence 4 years after simple mastectomy, axillary node dissection, and TRAM flap reconstruction for pure mucinous carcinoma. The recurrent neoplasm was a pure mucinous carcinoma and was found to be invading the mediastinum into the great vessels. The tumor was estrogen receptor positive, progesterone receptor negative, and HER-2/neu positive, which is an unusual finding for mucinous carcinoma. The fact that this tumor demonstrated HER-2/neu positivity may explain the uncharacteristic aggressive nature of this normally indolent type of breast tumor. To our knowledge, this is the first reported case of any mucinous breast cancer invading the mediastinal great vessels and its subsequent en-bloc resection. Mucinous breast cancer has classically been known as a less aggressive type of tumor, which tends to have a better prognosis than other breast malignancies. These tumors occur in two forms, as either pure or mixed type, the latter being more common. The treatment of this type of breast cancer is similar to invasive ductal carcinoma. Current genetic techniques allow us to determine receptor status and predict how a tumor may behave. We are able to predict certain features and behaviors of breast cancer that we were unable to predict in the past. This has led to new and exciting treatment options for all types of breast cancer. In recent years, there has been a great deal of interest in HER-2/neu receptor status and the aggressive nature that tumors possessing mis receptor exhibit. In this case report, we present a recurrent pure mucinous tumor that demonstrated angiolymphatic invasion microscopically and grossly was found to be invading the mediastinal great vessels. The recurrent tumor was ER+/PR- and HER-2/neu positive.

Case Report

The patient is a 42-year-old premenopausal female who was diagnosed with a pure mucinous carcinoma of the right breast in 2001. A core-needle biopsy at that time revealed a pure mucinous tumor. The patient underwent simple mastectomy, axillary node dissection, and immediate TRAM flap reconstruction. The primary tumor was 3.5 centimeters in size with two positive lymph nodes (out of 20). Sentinel lymph node biopsy was not performed because there were clinically positive nodes in the axilla. A metastatic work-up consisting of routine lab work and a CT scan of the thorax did not reveal any metastases. The tumor was ER+/PR- and exhibited HER-2/ neu overexpression. Postoperative therapy included FAC (5- Fluoracil, Adriamycin [Pharmacia Inc., Kalamazoo, MI], and Cytoxan [Bristol-Myers Squibb Company, Princeton, NJ]) followed by radiation and tamoxifen citrate. The patient had been asymptomatic for almost 4 years. She had follow-ups every 6 months for the first 3 years and was then scheduled for annual visits. Shortly before her first annual visit, she noticed an enlarging chest wall mass over a period of 3 months. A metastatic work-up was initiated. CT scan of the abdomen and pelvis were negative for metastases. CT scan of the thorax revealed a large anterior chest wall mass measuring 4 x 4 x 7 centimeters causing local destruction of the sternum and mediastinal invasion (Fig. 1). CT guided needle biopsy was then performed and several specimens sent to pathology. The specimen consisted of connective tissue heavily infiltrated by a malignant neoplasm that was consistent with a pure mucinous carcinoma (Fig. 2). A whole body bone scan after intravenous injection of technetium- 99 showed only focal uptake in the right manubrium, which corresponded to the palpable sternal mass.

The patient was experiencing significant pain and emotional distress over this rapidly enlarging cosmetically disfiguring chest wall mass. She was young, extremely motivated, and had no comorbid conditions. The case was presented at a multidisciplinary tumor conference for possible treatment options. Thoracic surgery was consulted for management of the chest wall tumor for possible excision. After a long discussion with the patient, and the limited treatment options, decision was made to proceed with surgery for excision of the chest wall mass with the understanding that this may be only palliative.

FIG. 1. Preoperative CT scan of the thorax revealing a large anterior chest wall mass invading the mediastinum, (t = tumor, a = aorta, S = sternum)

FIG. 2. Neoplastic hyperchromatic cells varying in size with some areas showing clusters and nests of neoplastic cells surrounded by pools of mucin. The tumor also demonstrates bony erosion. [H&E stain]

En-bloc chest wall resection was done through a transverse incision directly over the tumor anterior to the manubrium. Dissection of the mass circumferentially revealed a fingerlike projection on the inferior aspect of the tumor projecting deeper into the mediastinum. There appeared to be direct invasion at the junction of the superior vena cava (SVC) and innominate vein (Fig. 3). The vascular invasion was not seen on the preoperative CT scan. Ballottable palpation verified the intravascular nature of the tumor. The decision at that time was to gain vascular control with inflow occlusion technique and remove the tumor. The area of the vein at the junction of the SVC and innominate vein where the tumor was infiltrating was resected and the tumor removed. The SVC was then closed primarily. The patient recovered uneventfully from the surgery with no complications.

FIG. 3. Dissection of the tumor in the mediastinum ultimately revealed it to be invading the junction of SVC and innominate vein.

Postoperatively the case was again presented at a multidisciplinary breast tumor conference for possible treatment options. The characteristics of the tumor, which included hormone receptor status, type of mucinous carcinoma, and vascular invasion were all considered. The past treatment of her primary breast cancer was also considered. The patient was offered and consented to the chemotherapeutic regimen consisting of Herceptin(R) (Genentech Inc., South San Francisco, CA) and Taxotere(R) (Sanofi-Aventis, US, LLC, Bridgewater, NJ). Radiation was contraindicated because the patient had received prior radiation to the breast.

Discussion

Mucinous carcinoma, also known as colloid carcinoma, is a less common variant of breast cancer constituting less than five per cent of all breast cancers. These tumors tend to be in multiple series, less aggressive in nature than other more common types of breast cancer, and are also more likely to occur in older patients with a mean age of sixty- seven. These tumors have substantially less nodal involvement, exhibit ER+/PR+, and are HER-2/neu negative compared with other common breast carcinomas.1^ One study reported that the survival of patients with mucinous carcinoma is not significantly different from that of the general population and that systemic adjuvant therapy and node dissection may be avoided in many patients with these types of carcinoma.5, 6 However, over 30 years ago, Silverberg et al.7 concluded there was insufficient evidence that treatment should be conservative. We agree with this statement and recommend taking into account the HER-2/neu status when deciding on treatment options.

There is sparse information in the literature regarding the more aggressive variant of mucinous carcinoma with very few case reports.8 To our knowledge, mere are no reported cases of mediastinal vascular invasion of either pure or mixed type mucinous carcinoma of the breast. Pure mucinous carcinomas tend to have a less aggressive growth pattern and have less lymph node metastases.9 These tumors’ recurrence rates tend to be late and few, with no increase in mortality compared with other breast cancer types.10

Our case illustrates a patient with a recurrent tumor hormonal receptor status of ER+/PR- with HER-2/neu overexpression. ER+/PR+ tumors are known to have a better prognosis than ER+/PR- tumors. ER+/ PR- tumors express higher levels of HER-2/neu. HER-2/neu is seen in 20 to 30 per cent of all breast cancers and is well known to be a negative prognostic factor. These tumors also have increased disease recurrence and metastases. Signaling through HER-2/neu receptors reduces progesterone receptor expression in experimental models, thus ER+/PR- receptors with HER-2/neu overexpression are more likely to have a higher recurrence.11-14 This seems to be consistent with our recurrent tumor as HER-2/neu was positive by fluorescence in situ hybridization (FISH) analysis. This emphasizes the importance of HER-2/neu status regarding all breast cancer including the mucinous type.

Diagnostic work-up of mucinous tumors may be approached by fine needle aspiration (FNA) or core biopsies. Core biopsy can achieve 100 per cent sensitivity and accuracy in the diagnosis of malignant lesions including mucinous carcinoma.15 Diagnosis is confirmed with histology revealing the mucoid component consisting of ribbons, small tubules, cribiform areas, and deposits of mucin surrounding isolated islands of cells with hyperchromatic nuclei. The Stanford School of Medicine Surgical Pathology Criteria defines pure mucinous carcinoma of the breast as a breast carcinoma of which at least one mird of the volume of the tumor is extracellular mucin throughout. Furthermore, if a tumor has focal areas that are not at least 33 per cent mucinous, then the designation is mixed mucinous/ductal carcinoma.16 The recurrent mucinous carcinoma in our case was found to be invading the junction of the superior vena cava and innominate vein. The veins were resected and the tumor completely removed. Vessel reconstruction after resection can be approached with several different variations and have been described primarily for lung cancer invading the great vessels. To our knowledge, resection of a great vessel has never been done for vascular invasion of a mucinous breast cancer. The tumor and vein were resected and a direct running suture repair was performed.

Postoperatively the patient recovered without complication. She was placed on Herceptin(R) with chemotherapy because it has been shown to benefit patients with HER-2/neu positive metastatic breast cancer.17 After en-bloc resection of the tumor and adjuvant chemotherapy, the patient has had follow-ups with periodic CT scans of the chest and abdomen and most recently with a PET scan. Nearly 2 years after surgery for recurrent disease, the patient remains asymptomatic and does not have any evidence of metastases on imaging.

Although the literature generally confers a mucinous type of breast cancer as being a less aggressive tumor of the breast, it may behave uncharacteristically, especially when HER-2/neu receptor positive. When the patient presented to us 4 years after her initial surgery with a disfiguring recurrent breast cancer involving the chest wall, it presented a challenge. Due to the nature of the local recurrence, the patient’s age, good health status, and motivation, en-bloc resection of the chest was performed. The patient received adjuvant therapy after recovering from surgery. We are pleased to report that after 2 years, the patient is alive and well with no evidence of recurrent disease.

REFERENCES

1. Li C, Moe R, Daling J. Risk of mortality by histologic type of breast cancer among women aged 50 to 79 years. Arch Intern Med 2003;163:2149-53.

2. Northridge ME, Rhoads GG, Wartenberg D, et al. The importance of histologic type on breast cancer survival. J Clin Epidemiol 1997;50:283-90.

3. Norris HJ, Taylor HB. Prognosis of mucinous (gelatinous) carcinoma of the breast. Cancer 1965;18:879-85.

4. Rosen PP, Wang TY. Colloid carcinoma of the breast: Analysis of 64 patients with long term follow up. Am J Clin Pathol 1980;73:304.

5. Diab S, Clark G, Osborne K, et al. Tumor characteristics and clinical outcome of tubular and mucinous breast carcinomas. J Clin Oncol 1999; 17:1442.

6. Fentiman IS, Millis RR, Smith P, et al. Mucoid breast carcinomas: Histology and prognosis. Br J Cancer 1997;75:1061-5.

7. Silverberg SG, Kay S, Chitale AR, Levitt SH. Colloid carcinoma of the breast. Am J Clin Path. 1971;55:355-63.

8. Ishikawa T, Hamaguchi Y, Ichikawa Y, et al. Local advanced mucinous carcinoma of the breast with sudden growth acceleration: A case report. Jpn J Clin Oncol 2002;32:64-7.

9. Rasmussen BB, Rose C, Christensen IB. Prognostic factors in primary mucinous breast carcinoma. Am J Clin Path 1987;87: 155-60.

10. Toikkanen S, Kujari H. Pure and mixed mucinous carcinomas of the breast: A clinicopathologic analysis of 61 cases with long-term follow-up. Hum Pathol 1989;20:758-64.

11. Arpino G, Weiss H, Lee AV, et al. Estrogen receptorpositive, progesterone receptor-negative breast cancer: Association with growth factor receptor expression and tamoxifen resistance. J Natl Cancer Inst 2005;97:1238-9.

12. Menard S, Fortis S, Castiglioni F, et al. HER-2 as a prognostic factor in breast cancer. Oncology 2001;61(suppl 2):67- 72.

13. Ross JS, Fletcher JA. The HER-2/neu oncogene in breast cancer: Prognostic factor, predictive factor, and target for therapy. Stem Cells 1998;16:413-28.

14. Slamon DJ, Clark GM, Wong SG, et al. Human breast cancer: Correlation of relapse and survival with amplification of the HER-2/ neu oncogene. Science 1987;235:177-82.

15. Lam WW, Chu WC, Tse GM, et al. Role of fine needle aspiration and tru cut biopsy in diagnosis of mucinous carcinoma of the breast- from a radiologist’s perspective. Clin Imaging 2006;30:6-10.

16. Stanford School of Medicine Surgical Pathology Criteria. Pure mucinous carcinoma of the breast. 2007 Stanford University School of Medicine; available at http://surgpathcriteria.stanford.edu/breast/ mucincabr/index.html.

17. Slamon DJ, Leyland-Jones B, Shak S, et al. Concurrent administration of anti-HER-2 monoclonal antibody and first line chemotherapy for HER-2 overexpressing metastatic breast cancer: A phase III, multinational, randomized control trial. N Engl J Med 2001;783:792.

IAMIE D. ADAIR, M.D., KYLE P. HARVEY, M.D., ALI MAHMOOD, M.D., IAMES CARALIS, D.O.,

WILLIAM GORDON, M.D., GREGORY YANISH, M.D.

From the St. Joseph Mercy Oakland Hospital, Pontiac, Michigan

Address correspondence and reprint requests to Kyle P. Harvey, M.D., St. Joseph Mercy Oakland Hospital, 44405 Woodward Avenue, Pontiac, MI 48341.

Copyright Southeastern Surgical Congress Feb 2008

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

"ËœNear Perfect’ Dinosaur Found in North Dakota

Researchers at North Dakota’s state museum are scrupulously chipping away at a giant greenish-black 65-million-year-old rock, using tiny brushes and chisels to uncover a nearly complete dinosaur fossil, with skin and all. 

Named Dakota, the fossil is unlike almost any other ever found, and was unearthed in 2004 in southwestern North Dakota. The Edmontosaurus is covered by fossilized skin that is hard as a rock, and among only a few mummified dinosaurs ever discovered.

“This is the closest many people will ever get to seeing what large parts of a dinosaur actually looked like, in the flesh,” said paleontologist Phillip Manning, of Manchester University in England, a member of the international team researching Dakota.

“This is not the usual disjointed sentence or fragment of a word that the fossil records offer up as evidence of past life. This is a full chapter,” he told the Associated Press.

Typically, animal tissue decomposes shortly after death. But researchers said Dakota must have been swiftly buried under just the right circumstances for the texture of the skin to be preserved.

“The process of decay was overtaken by that of fossilization, preserving many of the soft-tissue structures,” Manning said.

The dinosaur was discovered by 25-year-old Tyler Lyson, a doctoral paleontology student at Yale University, on his uncle’s ranch in the Badlands in 1999.  Just weeks after he began unearthing the fossil in 2004, he knew he had found something special.

“Usually all we have is bones,” Lyson said in a telephone interview with the Associated Press. “In this special case, we’re not just after the bones; we’re after the whole carcass.”

Using the world’s largest CT scanner, operated by the Boeing Co. and used to examine space shuttle parts, the researchers got a better look at the contents encased in the ragged sandstone mass.

According to Stephen Begin, a Michigan consultant on the project, Dakota is only the fifth dinosaur mummy ever found that is “of any significance.”

“It may turn out to be one of the best mummies, because of the quality of the skin that we’re finding and the extent of the skin that’s on the specimen,” he said.

Begin said although several dinosaurs with fossilized skin have been unearthed around the world, only a handful had enough skin to be of use for research and education, and in most of the previous fossils the skin was considered to be of lesser significance. “The goal was to get bones to put on display,” he said.

Researchers moved Dakota to the museum early last month. John Hoganson, a paleontologist at the North Dakota Geological Survey, said it would take a year or move to completely uncover it.

Amy Sakariassen, part of the team working on the project, joined Begin in chipping away at the rock. At one point, she was toiling away with a brush whose bristles had been ground down to practically nothing.

“It really is wonderful to work on it,” Sakariassen said. “Nobody’s seen that particular scale in 67 million years. It’s quite thrilling.”

Manning said his involvement has called for 18-hour days and seven-day weeks and “more work than I could have ever imagined. But I would not change a single second of the past few years.”

Hoganson said the fossil’s main part weights nearly 5 tons, and consists of two parts.

“The skeleton itself is kind of curled up,” he said. “The actual length would be about 30 feet, from about the tip of its tail to the tip of its nose.”

The fossil has inspired both a children’s book and an adult book, as well as National Geographic television programs. The research is being funded in large part by the National Geographic Society.

“We are looking forward to seeing what emerges from the huge dinosaur body block now housed in North Dakota,” said John Francis, a society vice president.

Many prehistoric fossils have been found in the western North Dakota Badlands, where the weather has heavily eroded the terrain over time. Hoganson believes other treasures like Dakota are likely waiting to be unearthed.

“It’s one of the few places in the world where you can actually see the boundary line where the dinosaurs became extinct, the time boundary,” he said. “In the Badlands, this layer is exposed in certain places.”

Lyson eventually hopes to send Dakota on a worldwide tour before returning it back to his hometown of Marmarth, where he is creating a museum. Until then, the North Dakota Heritage Center on the state Capitol grounds plans to display part of Dakota this summer.

On the Net:

Manchester University

North Dakota Heritage Center

Teleflex Medical Exhibits Arrow Pressure Injectable Acute Central Venous Catheters

Teleflex Medical, a leading global supplier of disposable products for critical care and surgical applications, will exhibit its new pressure injectable central venous catheters at the Society of Interventional Radiology Meeting in Washington, D.C. from March 15 – 20. The FDA provided clearance to commercialize Arrow multi-lumen central venous catheters with the additional indication of pressure injection. Arrow is the only manufacturer of acute central venous catheters indicated for pressure injection up to 10ml/second.

Teleflex Medical estimates that nearly 20 percent of patients in acute care settings who are CVC recipients will need a CT scan. The additional indication gives clinicians who perform CT scans more options for scanning patients. CT technicians will now have the option of using an indwelling pressure injectable Arrow CVC without having to insert another catheter just for the scan. Arrow’s additional indication will reduce the stress on patients who up to now have had to endure another catheter insertion.

The Arrow Pressure Injectable CVC is available in Maximal Barrier trays. Arrow’s Maximal Barrier Precautions Tray with ARROWg+ard Blue PLUS® is an integrated kit for combating five sources of catheter-related bloodstream infection (CRBSI): environmental contamination, skin flora, post-placement subcutaneous tract infection, intraluminal contamination, and hematogenous seeding. The Arrow Maximal Barrier Precautions Tray also helps reduce risk by including protective apparel and upgraded sharps safety devices. And its components help ensure compliance with the latest guidelines from the Centers for Disease Control (CDC), the Occupational Safety & Health Administration (OSHA) and the Institute for Healthcare Improvement (IHI).

Additionally, the Pressure Injectable CVC products include a new echogenic introducer needle, also recently cleared by the FDA. The echogenic needle is designed to enhance visibility of the needle tip under ultrasound guidance. Ultrasound guidance has been shown to substantially reduce venous access complications compared with the more common landmark techniques. The CDC, IHI, and Agency for Healthcare Research and Quality (AHRQ) support the use of ultrasound guidance for the placement of central venous catheters. The new Arrow echogenic needle, when used with ultrasound guidance, can improve success rates for venous access on the first attempt. The combination can eliminate multiple punctures while significantly improving the rate of first time accuracy, significantly reducing venous access procedural times and the potential for malpositioning of catheters. The new echogenic needle, along with the Arrow InView™ Ultrasound System, will complement Arrow’s broadening range of products designed to reduce the risk and complications of venous access.

“Pressure injection involves pushing specific volumes of contrast into the patient’s bloodstream very quickly. The bolus of contrast is seen by the CT scanner and helps clinicians collect images from inside the patient with ever-increasing clarity. Access to scanning equipment continues to grow as do the scanners’ capabilities; this means that more and more patients can benefit from this technology. Fortunately, Arrow’s new capability will reduce the need for the 20 or so percent of patients who already have a CVC from needing to receive another needle insertion,” said Tim Hopper, Vice President, Marketing, Teleflex Medical North America. “This will benefit patients and also hospitals by saving the CT department time and other resources.”

About Teleflex Medical

Headquartered in Research Triangle Park, North Carolina, Teleflex Medical is a global leader in disposable medical products for critical care and surgical applications and a business segment of Teleflex Incorporated (NYSE:TFX). The company also produces surgical instruments and devices, cardiac devices and other specialty products for device manufacturers. The Teleflex Medical family of brands includes the trusted names of Arrow®, Beere, Deknatel®, Gibeck®, HudsonRCI®, KMedic®, Pilling®, Pleur-Evac®, Rsch®, Sheridan®, SMD, SSI™, Taut®, TFX Medical OEM and Weck®.

The Arrow brand product line offers a broad range of clinically advanced, disposable catheters and related products for critical and cardiac care. Arrow products are used primarily by anesthesiologists, critical care specialists, surgeons, emergency and trauma physicians, cardiologists, interventional radiologists and other healthcare providers. More information about Arrow products can be found at www.teleflexmedical.com.

Safeway Offers Immunization to Help Prevent Against Shingles

Safeway Inc. announced that it is offering vaccination to prevent against shingles in over 700 pharmacies in the states of AK, CA, CO, DE, HI, ID, IL, MT, NE, NV, OR, PA, TX, VA and WA administered by Safeway pharmacists. The vaccine will be provided on a walk-in basis at in-store pharmacies; patients should call their Safeway pharmacy or go to www.safeway.com/rx to find a location near them.

“The only way to prevent against contracting this debilitating disease is to get a single shot. By administering vaccines on site, Safeway is making it easy for anyone to protect themselves,” said Dave Fong, Safeway Senior Vice President, Pharmacy. “Receiving a shingles vaccination is as easy as stopping at the pharmacy during your regular shopping trip.”

Shingles is a disease caused by the same virus that causes chickenpox. Anyone who has ever had chickenpox is at risk for shingles. Shingles most commonly occurs in people 50 years old or older, people who have medical conditions that keep the immune system from working properly, or people who receive immunosuppressive drugs. The first sign of shingles is usually an itching, tingling, burning, or painful feeling which progresses to fluid-filled blisters that can last for two to four weeks. In almost every case, shingles causes pain even after the blisters heal that can last for months or even years. The Centers for Disease Control and Prevention (CDC) recommends shingles vaccination for all people over the age of 60.

Safeway also offers full-service adult and adolescent immunization services for the prevention of such ailments as tetanus, hepatitis, pneumococcal, meningococcal and more. Safeway owns and operates stores under the Vons, Dominick’s, Genuardi’s, Carrs, Randalls, Tom Thumb, Pak ‘n Save, Pavilions and Safeway banners.

ABOUT SAFEWAY www.Safeway.com

Safeway Inc. is a Fortune 100 company and one of the largest food and drug retailers in North America, based on sales. The company operates 1,743 stores in the United States and western Canada and had annual sales of $42 billion in 2007.

Average Hospital Stay Costs Nearly $7,000 Per Patient in Canada: Report

By Anne-Marie Tobin, THE CANADIAN PRESS

TORONTO – A new report on health care estimates that, on average, each stay in a Canadian hospital by a patient costs almost $7,000.

The Canadian Institute for Health Information report, released Tuesday, offers a breakdown on costs by medical condition, and finds that diseases of the circulatory system – for example, heart attack and stroke – cost the most to treat in acute-care facilities.

It’s the first report of its kind to examine what hospitals spend by patient stay and by medical condition, the institute said. The report did not include Quebec but examined 2.4 million hospital stays throughout the rest of Canada.

“Knowing exactly where the money is spent, you’re then able to focus your strategy around the planning of your expense around health,” Francine Anne Roy, director of Health Resources Information at CIHI, said from Ottawa.

Hospital stays for patients with circulatory diseases ring in at an average cost of $11,260, and they accounted for 19 per cent of in-patient costs in 2004-2005 when volume of patients and the cost per patient were tallied. There were 292,000 hospital stays for this condition, Roy said.

Injuries from external causes – such as falls, accidents and poisonings – accounted for 10 per cent of total in-patient costs, and each of those hospital stays cost on average an estimated $9,400.

Diseases of the respiratory system, cancer and diseases of the digestive system rounded out the top five in terms of the most expensive medical conditions to treat. Together, the five conditions accounted for 58 per cent of the cost of in-patient hospital stays.

Mental or behavioural disorders represented 6.6 per cent of the cost of acute-care hospital stays, the report said.

The statisticians looked at the cost of treating patients admitted to hospital for at least one night. This included, for instance, the cost of nursing, meals and drugs but didn’t include the cost of emergency care, day surgery, long-term care, clinics or fee-for-service payments to doctors.

“It will help planners think about some of their preventive programs, and also how to manage their budget,” Roy explained.

“For example, if they are creating a new hospital with different types of units, let’s say heart-cardiac unit, they will have a better understanding of the cost to run such a unit.”

Childbirth costs came out to just under $3,000 per stay, said Roy, and more than 314,000 patients were admitted.

The researchers also did a comparison of costs by gender, excluding childbirth, and found that it costs more, on average, to treat male patients in a hospital than it does to treat female patients.

The average cost to treat male patients was $7,964 per hospital stay, compared to $6,236 per stay for females.

Roy said the researchers were surprised by the finding, and noted that females tend to live longer.

“We have not investigated that piece to be able to have an answer, but it is certainly something we would like to investigate further,” she said.

One possibility, she speculated, is that women might be using more preventive programs and going to the hospital less.

MTM Study Reports Improved Quality and Economic Outcomes Using Medication Management Systems’ Assurance Pharmaceutical Care System(TM)

MINNEAPOLIS, March 18 /PRNewswire/ — A landmark study published in the Journal of the American Pharmacists Association documents how medication therapy management (MTM) services, provided by experienced pharmacists using the Assurance Pharmaceutical Care System(TM), produced both improved clinical outcomes and lower total health care expenditures. Entitled Clinical and Economic Outcomes of Medication Therapy Management Services: The Minnesota Experience (Isetts, et al. J Am Pharm Assoc. 2008;48(2):203-211), the Journal’s Special Feature reports on the effects of face-to-face MTM services in 285 patients with multiple medical conditions and complex drug therapies compared against a similar group of 252 patients who did not receive MTM services. In this collaborative study between Fairview Health Services, Blue Cross and Blue Shield of Minnesota and the University of Minnesota, Fairview’s pharmacists provided MTM services using a consistent pharmaceutical care process that was guided by and documented in Medication Management Systems’ (MMS) Assurance Pharmaceutical Care System(TM).

Patients receiving MTM services demonstrated significant improvement in drug therapy goals achieved, drug problems resolved, and selected Healthcare Effectiveness Data and Information Set (HEDIS) measures improved. In addition, total annual health expenditures were significantly decreased in the MTM patients when measured against the pre-MTM service baseline. The decreased health expenditures resulted in a 12:1 return on investment (ROI) for MTM services. In the study, pharmacist usage of Assurance Pharmaceutical Care System(TM) was cited as a key contributor to attainment and documentation of improved clinical outcomes and lower total health expenditures.

“MMS is proud of the role of our proprietary Assurance Pharmaceutical Care System(TM) in supporting pharmaceutical care delivered by MTM pharmacists and in documenting the positive results reported in this landmark study,” said Nathan Schultz, Pharm.D., President of MMS. “This important work clearly demonstrates the value of MTM services provided by well-trained pharmacists using a consistent care process.”

According to Amanda Brummel, Pharm.D., MTM Operations Manager, Fairview Pharmacy Services, “Our pharmacists worked directly with patients and their providers using the systematic clinical approach of the pharmaceutical care model. Supported by the Assurance Pharmaceutical Care System(TM), they were able to provide robust MTM services that improved quality indicators and lowered healthcare expenditures for our patients. The 12:1 ROI achieved provides dramatic evidence of the value of medication therapy management services.”

About Medication Management Systems

Medication Management Systems (MMS) is a leader in designing, delivering and implementing, successful, standards-driven medication therapy management (MTM) programs. MMS employs a proven patient-centered pharmaceutical care approach supported by the Assurance Pharmaceutical Care System(TM) to improve medication efficacy, safety, and adherence for patients with complex drug therapies. Visit http://www.medsmanagement.com/.

Medication Management Systems

CONTACT: Tom Albers, R.Ph., Chief Marketing Officer of MedicationManagement Systems, +1-952-746-8185, [email protected]

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

Envisat Observes Elevated CO2 From Manmade Emissions

Using data from the SCIAMACHY instrument aboard ESA’s Envisat environmental satellite, scientists have for the first time detected regionally elevated atmospheric carbon dioxide ““ the most important greenhouse gas that contributes to global warming ““ originating from manmade emissions.

More than 30 billion tons of extra carbon dioxide (CO2) is released into the atmosphere annually by human activities, mainly through the burning of fossil fuels.

According to the latest report by the Intergovernmental Panel on Climate Change (IPCC), this increase is predicted to result in a warmer climate with rising sea levels and an increase of extreme weather conditions. Predicting future atmospheric CO2 levels requires an increase in our understanding of carbon fluxes.

Dr Michael Buchwitz from the Institute of Environmental Physics (IUP) at the University of Bremen in Germany and his colleagues detected the relatively weak atmospheric CO2 signal arising from regional “Ëœanthropogenic’, or manmade, CO2 emissions over Europe by processing and analyzing SCIAMACHY data from 2003 to 2005.

As illustrated in Image 2, the findings show an extended plume over Europe’s most populated area, the region from Amsterdam in the Netherlands to Frankfurt, Germany.

Carbon dioxide emissions occur naturally as well as being created through human activities, like the burning of fossil fuels (oil, coal, gas) for power generation, industry and traffic.

“The natural CO2 fluxes between the atmosphere and the Earth’s surface are typically much larger than the CO2 fluxes arising from manmade CO2 emissions, making the detection of regional anthropogenic CO2 emission signals quite difficult,” Buchwitz explained.

“This does not mean, however, that the anthropogenic fluxes are of minor importance. In fact, the opposite is true because the manmade fluxes are only going in one direction whereas the natural fluxes operate in both directions, taking up atmospheric CO2 when plants grow, but releasing most or all of it again later when the plants decay. This results in higher atmospheric CO2 concentrations in the first half of a year followed by lower CO2 during the second half of a year with a minimum around August.

“That we are able to detect regionally elevated CO2 over Europe shows the high quality of the SCIAMACHY CO2 measurements.”

Buchwitz says further analysis is required in order to draw quantitative conclusions in terms of CO2 emissions. “We verified that the CO2 spatial pattern that we measure correlates well with current CO2 emission databases and population density but more studies are needed before definitive quantitative conclusions concerning CO2 emissions can be drawn.”

Significant gaps remain in the knowledge of carbon dioxide’s sources, such as fires, volcanic activity and the respiration of living organisms, and its natural sinks, such as the land and ocean.

“We know that about half of the CO2 emitted by mankind each year is taken up by natural sinks on land and in the oceans. We do not know, however, where exactly these important sinks are and to what extent they take up the CO2 we are emitting, i.e., how strong they are.

“We also don’t know how these sinks will respond to a changing climate. It is even possible that some of these sinks will saturate or turn into a CO2 source in the future. With our satellite measurements we hope to be able to provide answers to questions like this in order to make reliable predictions,” Buchwitz said.

By better understanding all of the parameters involved in the carbon cycle, scientists can better predict climate change as well as better monitor international treaties aimed at reducing greenhouse gas emissions, such as the Kyoto Protocol which addresses the reduction of six greenhouse gases.

Last year, European Union leaders highlighted the importance of cutting emissions from these manmade gases by endorsing binding targets to cut greenhouse gases by at least 20 percent from 1990 levels by 2020.

Image 1 Caption: More than 30 billion tonnes of extra carbon dioxide (CO2) is released into the atmosphere annually by human activities, mainly through the burning of fossil fuels (oil, coal, gas) for power generation, industry and traffic.

Image 2 Caption: Using data acquired from 2003-2005 by the SCIAMACHY instrument aboard ESA’s Envisat environmental satellite, scientists have for the first time detected regionally elevated atmospheric carbon dioxide ““ the most important greenhouse gas that contributes to global warming ““ originating from manmade emissions. the findings show an extended plume over Europe’s most populated area, the region from Amsterdam in the Netherlands to Frankfurt, Germany. Credits: ESA – DLR – IUP, Univ.Bremen

Image 2 Caption: CO2 measurements over the Northern Hemisphere obtained at the Earth’s surface (thin lines) from Envisat’s SCIAMACHY instrument (thick yellow line and two northern hemispheric maps). This figure highlights the natural fluxes of CO2 which, unlike manmade CO2 fluxes, operate in both directions ““ taking up atmospheric CO2 during spring and summer when plants grow, but releasing most or all of it again later in the year, when the plants decay. This results in higher atmospheric CO2 concentrations in the first half of a year followed by lower CO2 during the second half of a year with a minimum around August. Credits: ESA – DLR – IUP, Univ.Bremen

On the Net:

ESA

University of Bremen – SCIAMACHY page

Envisat at a glance

Kimberly-Clark Launches KIMVENT* 24-Hour Oral Care Kit

Kimberly-Clark Health Care announced today the launch of the Kimberly-Clark* KIMVENT* 24-Hour Oral Care Kit, a systematic and flexible oral care system developed to assist caregivers in meeting the Centers for Disease Control and Prevention’s recommendations for an oral hygiene program for patients at risk for ventilator-associated pneumonia (VAP).

For ventilator-dependent patients, it is well-documented that proper oral care is critical in the prevention of VAP; however, it is a step that is often overlooked.

“In our research with critical care nurses, we found that oral care is considered very important; however, nurses are looking for a better way to get the job done,” said Kimberly-Clark Health Care Vice President of Global Sales and Marketing John Amat. “We worked closely with nurses to understand what features would help make oral care compliance one less worry. We feel that our new system addresses each of the areas where nurses told us improvements could be made.”

Designed by nurses for nurses to address the challenges associated with oral care products, the KIMVENT* 24-Hour Oral Care Kit has a convenient and portable design as well as ergonomic and user-friendly tools. The kit can be kept at the patient’s bedside and includes the following features:

Easy-access carton with individual packs, which allows caregivers to choose the right tool at the right time based on patient need and hospital protocol

No-leak, easy-peel procedure packs that serve as a workstation and include everything needed to clean, debride, suction and moisturize the oral cavity

Unique, patent-pending, self-cleaning, covered Yankauer that has a high-flow tip with multiple holes to quickly and effectively remove secretions and a rigid, clear, curved shaft that makes the oral cavity more visible and easy to maneuver

Portable, no-mess, easy-to-use cups that contain extra cleaning solution

Flexible suction toothbrush that has soft, gentle bristles to remove dental plaque, debris and secretions

Suction swabs that have an angled tip design, providing easy access to surfaces, and a soft sponge tip that stimulates, cleans and freshens the mouth

Pliable suction catheter that helps remove oral secretions

Clear mouth moisturizer that contains aloe vera gel

The Yankauer features a self-cleaning mechanism and cover

Traditional Yankauers are often stored in a plastic cover or bag, where they can remain wet and covered in secretions. The KIMVENT* Yankauer has an innovative, self-cleaning mechanism that uses Kimberly-Clark’s patent-pending “peep-seal” technology to “squeegee” secretions and debris from the shaft after suctioning, leaving the Yankauer drier and cleaner between uses.

“Nurses told us that a self-cleaning mechanism was important, so we leveraged technology used in our Ballard* Trach Care* product to make that possible,” said Amat. “KIMVENT* Oral Care Kit complements our line of closed endotracheal suction catheters and is a perfect complement to the products that we offer to address risk factors for VAP.”

Because there are multiple risk factors leading to VAP, Kimberly-Clark is committed to providing clinicians with a range of innovative, effective clinical solutions and best practice education to address VAP. Kimberly-Clark’s product bundle includes its market leading BALLARD* TRACH CARE* Closed Suction Systems for suctioning secretions from the airway without disconnecting the ventilator circuit; MICROCUFF* Endotracheal Tube to reduce the leakage of potentially infectious secretions into the lungs; BAL-CATH* System, a simple, effective bedside bronchoalveolar lavage for improved diagnostic yield; and a variety of additional oral care products.

To learn more about the Kimberly-Clark* KIMVENT* 24-Hour Oral Care Kit or for more information about any of the solutions in the VAP bundle, please visit http://www.kchealthcare.com/kimvent.

Kimberly-Clark in the Health Care Environment

Around the world, medical professionals turn to Kimberly-Clark for a wide portfolio of solutions that improve the health, hygiene and well-being of their patients and staff. As part of their healing mission, caregivers rely on Kimberly-Clark to deliver clinical solutions and educational resources that are used to prevent, diagnose and manage a wide variety of health care-associated infections. With more than $1 billion in annual revenue in its health care business, Kimberly-Clark holds the No. 1 or No. 2 market share positions in several categories, including infection control solutions, surgical solutions, pain management and digestive health. Throughout the care continuum, patients and staff alike trust Kimberly-Clark* medical supplies and devices. For more information, please visit http://www.kchealthcare.com.

Parents of Baby with Rare Aging Disease Search for a Cure

For many families like that of 13-month-old Zach Pickard finding a cure for Hutchinson-Gilford Progeria has become a race against time.

Hutchinson-Gilford Progeria is a rare disease that speeds up the aging process and usually begins when a child is 18-24 months old. Because they age at a rate of six to eight times faster than most children, those with Progeria typically die of heart disease at an average age of 13.

When he was 2 months old, Zach’s parents, Bill and Tina Pickard, noticed bumps on his skin, and began a 9-month journey to find a doctor who could explain his condition.

It was then that they met Dr. Ann Lucky, a pediatric dermatologist in Cincinnati who had never diagnosed the rare disease before, but was able to notice the correlation of Zach’s symptoms to those of Progeria.

Six weeks later, Zach was diagnosed with the disease.

“At first we didn’t believe this was possible because of the rarity of the syndrome,” Tina Pickard said. “But I knew by the end of the day, after looking at information on the Internet, that this is what he had.”

In 2002, researchers discovered that a mutation in the gene called LMNA, which makes the Lamin A protein is the cause of Progeria. The altered protein makes the nuclear envelope unstable and progressively damages the nucleus, making cells more likely to die prematurely.

Hutchinson-Gilford Progeria is an extremely rare disorder only reported in 1 in 4 million newborns worldwide. People with progeria usually develop specific facial appearances including prominent eyes, thin nose and lips, a small chin and protruding ears.

Additionally, the syndrome causes hair loss, aged skin, and a loss of fat under the skin, while development of motor skills is not affected.

The severe hardening of the arteries in childhood adds to the risk of young heart attack or stroke in those with progeria.

As for now, Zach is like any other baby. He is too young to be showing many physical traits of the syndrome.

“He yaks with strangers when we’re in restaurants and he draws people to him,” Tina Pickard said. “If you meet him you love him.”

The Pickards are trying to collect money and raise awareness of the extremely rare disease.

“Honestly, at the end of the day we have to be able to look at ourselves in the mirror and say that we’ve made a difference,” Tina Pickard said. “We want to educate people and create awareness within the community that this foundation needs money.”

Photo Caption: Hutchinson-Gilford Progeria Syndrome. HGPS is a childhood disorder caused by mutations in one of the major architectural proteins of the cell nucleus. In HGPS patients the cell nucleus has dramatically aberrant morphology (bottom, right) rather than the uniform shape typically found in healthy individuals (top, right). Source: The Cell Nucleus and Aging: Tantalizing Clues and Hopeful Promises. Scaffidi P, Gordon L, Misteli T. PLoS Biology Vol. 3/11/2005, e395

On the Net:

Genetics Home Reference – Hutchinson-Gilford progeria syndrome

Growth Hormone Adds Bulk, Not Strength

Use of human growth hormone among athletes may add muscle, but it doesn’t necessarily actually improve strength, according to new research.

Dr. Hau Liu and his colleagues at the Santa Clara Valley Medical Center in San Jose, Calif. wrote the report on the banned “wonder drug” that has raised controversy in the past with many Major League Baseball players.

In their studies of 440 participants, researchers noticed an additional 5 pounds more of muscle, and lost about 2 pounds more of fat in those using HGH. They also noted that some of the extra body mass could just be fluid buildup.

However, this addition of body mass in HGH users did not account for an increase in strength or stamina.

“What we saw is that while there was a change in body composition, we didn’t find evidence that growth hormone improves athletic performance,” said Liu.

Furthermore, they even noted that people who took growth hormone reported more fatigue than those who were not taking the drug. This may have been due to the increase of lactate, a byproduct of exercise that can result in pain and fatigue.

Human growth hormone is made in the pituitary gland and it promotes growth. Its synthetic use began in the 1980s and has only been approved for those who have specific conditions.

In those who have a condition that prompts the use of HGH, an increase of strength and exercise capability is seen, but there is none in normal healthy human beings, they said.

The research was unable to make a long-term prognosis, as the longest conducted study lasted only 3 months.

“The key takeaway is that we don’t have any good scientific evidence that growth hormone improves athletic performance,” Dr. Andrew Hoffman, a professor of endocrinology, gerontology and metabolism who worked on the study, said.

He added that many hormones, such as testosterone, actually contribute more to overall strength than HGH.

The review also added that the does used in their tests were probably less than those used by professional athletes looking for an added boost.

“Athletes probably take much more hormone than the investigators felt that they could ethically try to give to healthy people; in addition, some athletes combine growth hormone with other anabolic hormones like testosterone.”

On the Net:

Santa Clara Valley Medical Center

‘Stevia’ May Help Us Break Our Sugar Addiction

Sugar, sorry to say, can make us sick. The most popular alternative — artificial sweeteners — have long posed health concerns and may lead to weight gain.

Enter stevia, a calorie-free herb said to be up to 300 times sweeter than sugar.

In what will surely spice up the decades-long debate over sugar substitutes, companies as large as Coca-Cola and as obscure as Seattle-based Zevia say stevia’s time has come. But the U.S. Food and Drug Administration isn’t about to make things easy for consumers worried about sugar intake and often confused by the options.

Stevia has been used as a sweetener for hundreds of years in Paraguay and Brazil and has been added to soft drinks, ice cream, pickles, candies and breads in Japan since the 1970s.

But the FDA has not approved it as a food additive, citing safety concerns. The European Union and Canada also don’t allow food companies to add stevia to products.

“Reports have raised concerns about control of blood sugar and the effects on the reproductive, cardiovascular and renal systems,” the FDA wrote in a warning letter to Hain Celestial, which included stevia as an ingredient in one of its teas.

But stevia, also called stevioside, is widely available _ and perfectly legal _ in the United States when it’s purchased as a dietary supplement. It often can be found just a few aisles away from Equal, tucked among the vitamins, minerals and herbs. The sweet-leafed herb, derived from the bushy South American stevia rebaudiana plant, also is easily obtained via the Internet.

Stevia proponents believe this nonsensical situation _ stevia is acceptable as a dietary supplement but not as an ingredient _ has kept Americans in the dark about the herb’s candy-like leaves, which can have a menthol-like bitter aftertaste. When used in low amounts for sweetening, stevia has zero calories, is not carcinogenic _ on the contrary, it has been shown to reduce breast cancer in rats _ and does not accumulate in the body, proponents say.

The lethal dose is very high, according to Belgian researcher Jan Geuns, author of “Stevioside: A safe sweetener and possible new drug for treatment of the metabolic syndrome,” a paper he presented at the 2006 American Chemical Society national meeting.

“Stevia is completely safe,” he said.

What worries stevia critics is that Americans tend to have a problem with moderation. Stevia might be fine if it’s used twice a day in a cup of tea. But “if stevia were marketed widely and used in diet sodas, it would be consumed by millions of people and that might pose a public health threat,” said the consumer watchdog group Center for Science in the Public Interest.

Regardless, Americans want a natural alternative. Nearly 7 of 10 U.S. adults say they want to cut down or avoid sugar completely, according to the market research firm The NPD Group, a concern that has driven up the use of artificial sweeteners. But two-thirds are concerned about the safety of sweeteners, according to another report.

The two leading chemical sweeteners, aspartame (NutraSweet, Equal) and sucralose (Splenda), have been approved by the FDA, but are still highly controversial.

Whole Foods says it won’t carry products containing sucralose, which is made by chlorinating sugar, because it believes many of the safety studies were commissioned by those who had a financial interest in its approval. And the granddaddy of the group, saccharin (Sweet’n Low), is a petroleum derivative that has been banned in Germany and France for almost a century.

“I’ve seen a shift in consciousness” about sugar substitutes, said Ann Louise Gittleman, author of “Get the Sugar Out” (Random House, $13.95). Gittleman recently updated her 1996 book to include more information on high-fructose corn syrup as well as sugar’s effect on aging and cancer.

“It’s part of people becoming more aware of toxins in the environment on all levels,” she said. “Try as we might, you can’t trick the body or Mother Nature.”

When we do try, by using no- or low-calorie artificial sweeteners, for example, it often backfires. A recent study by Purdue University researchers showed that artificial sweeteners can make you fat because the body is programmed to associate sweet tastes with calories consumed. When the natural connection is broken _ false sweetness isn’t followed by lots of calories _ the metabolic system is confused and people may eat more, or expend less energy than they normally would, said study co-author Susan Swithers.

Cue stevia. For Jessica Newman, 37, the intensely sweet leaf that can be dropped in tea, coffee or oatmeal was exactly what she needed to break her daily habit of five Diet Cokes.

An attorney, mother of three and marathon runner in Seattle, she fueled herself on diet soda and Powerbars, but longed for a healthy alternative to artificial sweeteners.

When she found stevia, she became such a proponent that she, along with her husband, Derek, and their friend Ian Eisenberg, developed a stevia-based dietary supplement called Zevia. The five-calorie sugar-free beverage, which is essentially a soft drink but can’t be labeled as such, has no artificial flavors, food dyes or phosphoric acid.

Demand has been brisk; Zevia is in a dozen states and within a month is expected to available at Sunset Foods stores in Chicago’s north and northwest suburbs. Newman says they’ve received e-mail orders from every state and currently are offering a free six-pack to those willing to pay the shipping charges.

“Many of the people who are responding to Zevia already know about stevia and the dangers of artificial sweeteners,” Newman said. “We think we’re offering a choice to kick the diet soda habit. We call it `nature’s answer to diet soda.'”

Coke, meanwhile, has filed several dozen patent applications for the ingredient and teamed up with Cargill to develop its own stevia product called Rebiana. It plans to introduce Rebiana in countries where the ingredient is already approved and petition the FDA to allow stevia to be used as a food additive.

“Stevia is wonderful; it has no glycemic properties, actually enhances blood sugar balance, is high in soluble fiber, and full of antioxidants,” said Chicago nutritionist Bonnie Minsky of Nutritional Concepts.

But not everyone wants to give up an occasional Diet Coke. Fifteen-year-old Christine Elizabeth Cauthen started a Facebook group called “I Drink Artificial Sweeteners and I’m Proud of It” after a friend planned to swear them off because studies have linked them to cancer.

“If you think about it, a lot of things in life cause cancer,” Cauthen said in an e-mail. “I don’t see anything wrong with having (Diet Coke) every once in a while.”

___

Stop! Don’t reach for that diet soda!

Although we all would be healthier if we cut sugar and sweeteners out of our diet, it’s a tall order. Humans are hard-wired for sweetness.

But since 1985, the annual per-person consumption of all added sugars _ everything from beet sugar to high-fructose corn syrup _ has climbed 30 pounds, from 128 pounds to 158 pounds. The result of this national sugar rush is an epidemic of inflammatory-related disorders, obesity and Type 2 diabetes.

“Most Americans’ taste buds are so completely out of whack that we don’t know what tastes sweet,” said Connie Bennett, author of “Sugar Shock” (Penguin, $14.95) “When you kick artificial sweeteners or sugar, your taste buds begin to change. Vegetables such as celery, jicama and sweet potatoes taste much better and more interesting.”

Tapering down is your best bet, because stopping “cold turkey” may cause withdrawal symptoms, sometimes severe. Here are a few ways to get started.

_”Unless there’s an overwhelming reason (such as diabetes) to cut sugar consumption quickly, begin by avoiding sugary snacks, foods and drinks until dinner,” said nutritionist Bonnie Minsky of Nutritional Concepts in Chicago. “Eating protein three times daily and substituting sugary snacks with nuts/seeds/dried fruits will prevent blood-sugar lows. Look forward to one sugary `treat’ (dark chocolate) after a balanced dinner. Keep cookies, cakes, and candies out of the house.”

_To wean yourself off diet soda, stick to two a day and don’t drink it between meals to satisfy thirst, said Ann Louse Gittleman, whose book “Get the Sugar Out” (Random House, $13.95) contains 501 ways to reduce sugar consumption. “If you drink it with food, you might be tempted to have something more nutritious. But don’t use (soda) as a stimulant to keep you going.”

_Drink half your body weight in ounces of water; when you crave something sweet, eat something sour, such as a pickle. Also, suck on cinnamon sticks or cloves, Gittleman said.

_If you’re a real sugarholic, substitute two pieces of dried fruit, a fig or date. “Eat a little of everything and a lot of nothing,” Gittleman said. “And eat it after a full meal where you have fat and protein to prevent your blood sugar from dipping.”

_Delay, distance and decode your craving, Bennett advised. “If you want diet soda, first get a glass of water. Then distance yourself from the tempting soda machine.”

_Find an acceptable alternative. Gittleman recommends Celestial Seasonings Bengal Spice tea and carbonated or regular water with a slice of lemon or orange.

___

MORE CHOICES TO HELP YOU MOVE AWAY FROM SUGAR:

Although sugar is still sugar, the following can be used in small amounts in place of artificial sweeteners until you’re ready to give it up altogether. The products below are available at most health food stores and gourmet or specialty food stores. Online, visit localharvest.org. Check Asian or Mediterranean grocery stores for ground date sugar. Prices listed are approximate.

BROWN RICE SYRUP

Amber colored, with a mild butterscotch or caramel-like flavor; it’s about half as sweet as sugar and is gluten free, according to Connie Bennett, author of “Sugar Shock.” The syrup is made by fermenting cooked brown rice with enzymes. After straining off the liquid, the process converts the rice starches into about 50 percent soluble complex carbohydrates, 45 percent maltose and 3 percent glucose.

Cost: $5 to $6 for 16 ounces.

REAL MAPLE SYRUP

A little drop goes a long way. It’s made by boiling down maple sap and contains a full complement of minerals and is particularly rich in potassium and calcium, said Ann Louse Gittleman, author of “Get the Sugar Out.”

Cost: $7 to $10 per pint.

HONEY

Although it has more calories and raises the blood sugar even more than white sugar, Jonny Bowden lists raw, unfiltered honey in his book “The 150 Healthiest Foods on Earth” (Fair Winds Press, $24.99) because it contains enzymes and phytonutrients and has some reported medicinal benefits. But it could cause allergic reactions to pollen-sensitive individuals.

Cost: $3.50 and up _ way up _ for 16 ounces.

BLACKSTRAP MOLASSES

Another Bowden favorite, molasses is the thick syrup that’s left after sugar beets or cane is processed for table sugar. Blackstrap contains the lowest sugar content of the molasseses and has a bitter-tart flavor. It has good-for-you ingredients, but few consume enough of the strong-flavored syrup to benefit.

Cost: $5 to $6 for 16 ounces.

SORGHUM SYRUP

The National Sweet Sorghum Producers and Processors Association makes this very clear: Sorghum syrup is not the same as molasses, a byproduct of the sugar-making process. Sorghum syrup comes from sorghum cane: Juices are extracted and then concentrated through evaporation. Genuine sorghum contains nutrients such as iron, calcium and potassium. The association recommends substituting sorghum cup for cup in any recipe or dish that calls for molasses, honey, corn syrup or maple syrup.

Cost: $8 to $12 for 16 ounces.

DATE SUGAR

If you simply can’t do without sugar, this is Gittleman’s favorite stand-in. It’s made from pulverized dried dates; although it has the consistency of sugar, it isn’t refined like sugar. It also contains fiber and is high in many minerals. One tablespoon of date “sugar” is counted as one fruit exchange in the diabetic exchange system. Because it has an intense flavor, you might be inclined to use less.

Cost: $6 to $8 for 12 ounces.

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Artificial sweeteners have been hailed as an effective way to cut calories and control weight, help manage chronic conditions such as diabetes and potentially prevent cavities.

But some contend that the ubiquitous pink, blue and yellow packets can be just as harmful as sugar.

Mounting research, meanwhile, shows they can actually trigger carbohydrate cravings and lead to weight gain.

Here’s a quick look at three common sweeteners approved by the Food and Drug Administration.

_ Aspartame (NutraSweet and Equal)

Aspartame, a general all-purpose sweetener in foods and drinks, is 200 times sweeter than sugar. Despite concerns that aspartame is linked to a host of ailments, including cancer, autoimmune disorders, digestive distress, mood swings and joint pain _ and efforts by two states to ban it _ the FDA says the sweetener is safe unless you have a genetic disorder of metabolism known as phenylketonuria.

_ Saccharin (Sweet’N Low, Sweet Twin)

Saccharin is 200 to 700 times sweeter than sugar. A petroleum derivative, it is found in gum, cosmetics, baked goods, tabletop sweeteners, soft drinks and jams.

In 1977, the FDA proposed a ban on saccharin because of concerns about rats that developed bladder cancer after receiving high doses of it.

The National Cancer Institute cleared saccharin of the charge, but it’s banned in foods in Germany and France.

_ Sucralose (Splenda)

Sucralose is 600 times sweeter than sugar on average and is marketed as a “no-calorie sweetener” even though it contains 96 calories a cup, said Ann Louise Gittleman, author of “Get the Sugar Out (Random House, $13.95) Made from table sugar, sucralose adds no calories because it isn’t digested in the body.

Although some report digestive distress, especially constipation and headaches, concerns also have surfaced over long-term safety. Whole Foods won’t carry products containing sucralose because the company doesn’t believe there’s enough balanced information. But in 1999, the FDA allowed sucralose as a general-purpose sweetener in all foods.

Cocaine Symptoms Similar to Those of Heart Attacks

The American Heart Association is warning young ER patients about the risks of misidentifying the symptoms of cocaine use as heart attack symptoms. The results of some heart attack treatments in addition to cocaine can be fatal.

In an article published on Monday in The American Heart Association’s journal Circulation, Dr. James McCord and his colleagues confronted the issue of cocaine-related chest pain.

Cocaine is the second most popular illicit substance in the U.S. Its symptoms can be similar to those of a heart attack including shortness of breath, anxiety, chest pain, palpitations, nausea, dizziness and heavy sweating.

“Not knowing what you are dealing with and giving the wrong therapies could mean death rather than benefit,” said Dr. James Reiffel, professor of clinical medicine at Columbia University Medical Center/New York Presbyterian Hospital.

Some drugs used for heart attack patients can cause bleeding into the brain in patients whose blood pressure is high due to cocaine use.

Also, betablockers, that can lower blood pressure, have the opposite effect in cocaine users, raising blood pressure and squeezing cocaine-narrowed arteries.

Cocaine users visited the ER at an increase of 47 percent between 1995 and 2004 up from 135,711 to 199,198 according to the government’s Substance Abuse and Mental Health Services Administration.

According to the report, chest discomfort was reported in 40 percent of patients who appeared in the ER after using cocaine.

“The symptoms that they get with the cocaine are very similar to a heart attack,” said Dr. James McCord, who chaired the statement writing committee.

It is possible for cocaine to actually cause a heart attack. “By increasing heart rate, blood pressure, and contractility, cocaine leads to increased myocardial demand,” according to the article.

“Your heart rate goes up because your heart needs more oxygen, then it shrinks the arteries to the heart,” McCord said.

However, only 1 percent to 6 percent of patients with cocaine-associated chest pain actually have a heart attack, according to the guidelines.

The article suggests that all chest pain should be reported to physicians, but patients who use cocaine should be honest so they can be monitored using an electrocardiogram and other tests to rule out a heart attack.

“I think an ideal scenario would be someone whose job is to talk to them about this – explain the extent of the health problems, give them information about resources to help them quit cocaine,” McCord said.

On the Net:

American Heart Association

The full article can be acccessed here.

Columbia University Medical Center

New York Presbyterian Hospital

Substance Abuse and Mental Health Services Administration

Organic Vineyards Recycle Grape Skins and Scraps

For more than two years the massive piles of dried grape skins have been mixed with landscapers’ leaves and grass clippings and waste fish from the local fish distributor and left to cook like a giant organic stew in a back lot of a Peconic vineyard.

As the buds begin to break on the vines of Pindar Vineyards in Peconic, N.Y., this spring, the product of that composting process will be spread on up to 60 acres of grape vines. It’s an important first step by the region’s largest grape grower to move away from the commercial herbicides and fertilizers that growers in the region have long relied on to limit weed growth and keep their grape crop stable and healthy.

Now, with concerns about chemical runoff spoiling groundwater and with rising costs of industrial mixtures, even the largest commercial operations are coming to understand the benefit of what is termed sustainable agriculture.

The compost, dark and rich in nutrients and essential microbes, will be spread in 6- to 8-inch-thick layers along scores of long rows of Chardonnay and cabernet sauvignon vines at Pindar, to both enrich the soil and provide a thick mulch to inhibit weed growth. If all goes as planned, said vineyard manager Pindar Damianos, the composting operation will be expanded. That would help the vineyard save potentially hundreds of thousands of dollars in costs for herbicides and chemical fertilizers.

The vineyard has been amassing grape skins from the winemaking operation since the 2005 harvest and grape pressing – which has left 300 tons of the leathery flakes. It also has been allowing local landscapers to drop off leaves and grass clippings on the property, adding manure from local horse farms, and trucking in free fish waste from Braun Seafood in Cutchogue, the latter to provide a vital nitrogen boost to cook the compost. The heaps must heat to an internal temperature of more than 200 degrees to break down the grape seeds.

Pindar isn’t the first local grape grower, or East End farmer, to turn to the methods. Macari Vineyards of Mattituck is recognized as one of the most committed organic farming pioneers in the region. It maintains a herd of 25 longhorn cattle to provide both manure and a horn additive as part of its adherence to so-called biodynamic farming methods.

Joe Macari Jr., co-owner and manager of the vineyard, said his combination of composting, biodynamic sprays and compost-tea applications are not only good for the ground he grows on, but also show in his wines. “I believe you have to put back into the soil,” he said.

“The proof is in the bottle of wine,” Macari said. “It shows in my wine.”

Macari said he still sprays fungicide and pesticide once a year, but he has managed to avoid applying chemical nitrogen and herbicide for the past 10.

Joseph Gergela, executive director of the Long Island Farm Bureau, an agriculture advocacy group, said Macari’s long history in sustainable farming and efforts by others such as Jamesport Vineyards provide ample evidence for larger operations like Pindar’s that the system can work.

Gergela said farmers in general on Long Island have been increasing their use of sustainable farming techniques, though he acknowledged, “Certainly when an outfit like Pindar does it, it’s significant because they are so large.”

Numerous farms, he said, have worked out partnerships with Long Island Compost, the large regional compost provider, in a program to host compost windrows on their properties in exchange for a share of the material.

Damianos of Pindar said placement of his compost heaps on a remote corner of the vineyard away from neighborhoods has helped him avoid complaints about odors that sometimes hound composting operations.

While he’s certain the composting will prove beneficial to the health of the vineyard, Damianos said the first year’s application will probably break even financially. That’s because he bought a new machine called a side-dresser to apply the thick layer of new black compost to the rows. In future years he expects to see savings by reducing chemical purchases. Beyond that there’s the aesthetic value.

“I like seeing all the rows of vines covered with black compost,” he said.

Sun Pharma Receives FDA Approval for Amifostine Injection

Sun Pharmaceutical Industries has announced that the FDA has granted approval for the abbreviated new drug application to market amifostine for injection 500mg.

Amifostine is used as an adjuvant in cancer treatment. Sun Pharma’s amifostine for injection will be indicated for the reduction of kidney damage in patients who have advanced ovarian cancer and are being given repeat doses of cisplatin.

This generic amifostine for injection is therapeutically equivalent to MedImmune’s Ethyol amifostine for injection 500mg. Sun Pharma, being the first-to-file an abbreviated new drug application (ANDA) for generic Ethyol with a para IV certification, has a 180-day marketing exclusivity. Ethyol is covered under three patents. This ANDA was filed with para IV certification against all the patents. Medimmune has filed a suit in the District Court of Maryland and the case is under litigation.

What’s a Diabetes Patient to Do?

By Kathleen Fackelmann

Donald McEwen was driving on I-480 when he saw an ad on the back of a bus recruiting people for a study on diabetes.

He picked up his cellphone almost immediately.

“I was scared to death,” he says now about the pain, fatigue and vision problems caused by his diabetes. “My health was so bad that I thought I would be not long for this world.”

McEwen, a salesman from Parma, Ohio, got into the study, took his medication and pushed his blood sugar from dangerously high levels to near normal. The health problems he had suffered for years all but disappeared.

“For me, the program was near-miraculous.”

But on Feb. 6, the federal government stopped one part of the study, saying it posed a risk to patients such as McEwen. An independent panel of experts had discovered an elevated risk of death in diabetics who were being aggressively treated to drive blood sugar down to near-normal levels.

The news shocked diabetes experts and patients alike because it challenged the conventional wisdom: Diabetes patients who kept blood sugar close to normal levels were thought to be better off. But that shock quickly turned to confusion a week later when an international team doing a similar study said it could find no such added risk.

The conflicting information has left about 20 million Americans with type 2 diabetes in limbo. No one knows whether the risk of death is real. No one knows whom it might affect. And for now, there’s no pat answer about how low to push blood sugar levels.

The truth is, the experts don’t have the answers yet, and it could be months before they do. More findings are expected to be released at a major meeting on diabetes in June.

“There’s a lot of information we just don’t have,” says Denise Simons-Morton of the National Heart, Lung, and Blood Institute, the federal agency that sponsored the study that uncovered the death risk. She says U.S. and international researchers have gone back to assess the data and hope to have more information soon.

Clarification is vital, and not just for McEwen and the millions of others who have the disease today. Experts say the number of type 2 diabetics is growing rapidly, fueled by rising obesity among Americans. Researchers at the Centers for Disease Control and Prevention project that by 2050, the number of people who have diabetes will increase 200% from 16 million in 2005 to about 48 million. And of those, 95% will have type 2 diabetes, which is more common in people who are overweight.

The U.S./Canada study

Action to Control Cardiovascular Risk in Diabetes, or ACCORD, was the first large-scale study to try to figure out whether controlling blood sugar levels could reduce the risk of heart disease in people who have diabetes. Cardiovascular disease is the leading cause of death for people with type 2 diabetes.

The ACCORD researchers recruited 10,251 diabetics in the USA and Canada. All were diabetics for at least a decade, and they were at high risk of having a heart attack or stroke.

Patients such as McEwen were assigned to an intensive management program with the goal of driving blood sugars down to less than 6% on the A1C test. The A1C is a measure of how much sugar is in the blood. People without diabetes have an A1C of 4% to 6%. People with diabetes have elevated blood sugar levels, and that is thought to damage blood vessels, the heart and other body systems.

Others were assigned to a usual care group, and they were supposed to get sugars to the standard range of 7% to 7.9%.

Researchers saw patients in the intensive-management group frequently. After four years, the people in that group reduced sugar values to about 6.4%. People assigned to the usual-care group didn’t get checked as much, but they still got sugars down to an average of 7.5%

Then the 10-member panel discovered the fatal flaw in the study: They found that 257 people in the intensive-care group had died, compared with 203 people getting the standard treatment.

Previous studies had shown lowering blood sugar could reduce the risk that diabetics would suffer from complications such as vision loss. But John Buse, chief of endocrinology at the University of North Carolina, and others had hoped the ACCORD study would show that near-normal blood sugars could also protect diabetics from heart disease and stroke.

That’s why Buse and others were shocked when the study appeared to show the opposite.

“No one expected this,” says Buse, who also is the vice chairman of the ACCORD steering committee.

That difference of 54 deaths suggested that for some unknown reason, people in the intensive-treatment group had an increased risk of dying of heart attacks, strokes and other causes. The panel concluded that the potential risk of the intensive strategy outweighed any possible gain, and the federal government halted the study to warn people such as McEwen and Caroyln Gibbons, 65, of Fayetteville, N.C.

Gibbons had taken her diabetes drugs religiously since joining the study. She had lowered her sugars to a 5.3% on the A1C.

“I thought I was doing really well, and then the study’s findings came out,” she says. Now researchers have told Gibbons to err on the safe side and let sugars rise to 7% to 7.9%.

“I am going up to 7%, but I’m not thrilled about it,” she says. She worries that the findings are a fluke and that her health could go downhill. Gibbons says that with an A1C of 5.3% she had fewer problems, such as intense pain in her foot caused by nerve damage.

Different study, different result

Misgivings such as those voiced by Gibbons were heightened when an international team of researchers announced on Feb. 13 that they could not confirm the risk of death. That international study, called ADVANCE, involved 11,140 high-risk diabetics. One group in that study also kept sugars to the normal range by intense treatment.

When the international team went in and examined the number of deaths in their study, they could find no added risk for people who kept sugars close to normal.

Buse says the American researchers now are searching intently for the cause of the high death rate. “It’s a little like looking for a needle in a haystack,” he says.

The researchers have ruled out some factors that might have been behind the extra deaths. For example, they found no link between the death risk and the drugs used by the participants, including Avandia, which has been linked to heart attacks in people with diabetes.

The ACCORD and ADVANCE researchers will present more complete findings in June at the American Diabetes Association annual meeting. Scientists from a third study, the VA Diabetes Trial, also are expected to weigh in on the question.

“My hope is that the results will sort out then,” says Richard Kahn, chief scientific and medical officer for the American Diabetes Association. The ADA plans to assemble a panel of experts to analyze the findings and, if necessary, revise blood sugar guidelines.

Until then, the ADA and other experts urge people with diabetes to stick with the current standards for blood sugar control. The ADA recommends that most diabetics should get sugars down to less than 7% on the A1C.

How low should they go? The jury’s still out on that question.

Richard Hellman, president of the American Association of Clinical Endocrinologists, says many younger, relatively healthy diabetics do just fine when they keep their A1C to about 6.5%.

But older diabetics might need to go higher than 7%, Hellman says. Keeping blood sugar close to normal levels can, in some cases, trigger dangerous attacks of low blood sugar, he says.

“You can’t write one prescription for everyone,” says Faramarz Ismail-Beigi, an investigator in the ACCORD study at University Hospitals Case Medical Center in Cleveland. Until the death risk is explained, patients in the intensive-management group will be counseled to let their sugars rise slightly to the target of 7% to 7.9%.

McEwen says he’ll ease up slightly on his medication, but he has no plans to go back to the out-of-control blood sugar levels that led to his health problems.

So while researchers haggle over the scientific questions, McEwen will take the practical approach to his disease. He plans to go out and walk a mile every day. “My weight is 260, and I am 5 feet 8 inches tall,” he says, and he knows obesity can make diabetes worse.

He’s working with the ACCORD team to cut down on the high-fat comfort foods such as french fries that have contributed to his weight gain. And he says he’ll still keep a tight lid on his blood sugar levels.

McEwen had an A1C of 11% when he joined the study in 2005. He has lowered his levels to the normal range, and that effort gave him the miracle he was hoping for the day he picked up his cellphone.

“For a long time I thought I was going blind,” he says. “Having my vision back is just wonderful.”

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Zoo Nutritionists Keep Animals Healthy and Happy

The next time you visit the zoo, the animals may be in better health than ever. Zoo nutritionists are changing the diets of gorillas, polar bears, monkeys, and elephants all over the country.

This new trend of a nutritious diet is not much of a contrast from the recent fitness craze of people. Avoiding obesity plays a large part in the animal nutrition program. So does keeping the animals as happy as they were when they were eating their favorite treats.

Zoo animals and humans are similar; they both enjoy eating unhealthy, fatty, sugary foods. Jennifer Watts, staff nutritionist at Brookfield Zoo, west of Chicago, says that the animals are “not moving as much as they are genetically programmed to.” This is true due to the fact that they are caged, and not out in the open to run as they please. This presents a challenge in keeping the animals fit. Food is also often used for training ““ too many treats can add rolls to the stomach of even the best gorilla.

To keep the animals healthy, Watts is launching a Weight Watchers-esque program to track the animals’ diets with points. The animals have a certain number of points they can eat per day, as well as a few extra points a week for those goodies that motivate them.

Watts said of the diet, “We’re trying to keep calorie intake within a limit…We are very vigilant about monitoring the animals’ weight, because, like humans, it can lead to other health problems.”

Under Watts’ new plan, molasses, which is a favorite food of the bears, might be one point per cup, and granola bars might be worth one point as well. These foods are motivators for the creatures to get up and move around, as well as to learn tricks. And in the right quantity, they can be very helpful and healthy.

Various zoos are catching on to the fad, but some are doing things a little differently. The Indianapolis Zookeepers feed their animals sugar free treats instead of fattening ones. One of their tricks is to hide sugar-free Jell-O around the polar bears’ habitat so that they are forced to forage for their food.

The Toledo Zoo’s Chris Hanley claims low-salt crackers and alfalfa biscuits are excellent snacks. This particular zoo even schedules an annual “Big Feed” day where visitors feed animals veggies as well as other healthy snacks. That particular zoo also feeds their lions, tigers, and wolves real carcasses to provide a more natural diet, which requires expending energy to obtain.

Zoo nutrition is not a new fad. Animal nutritionists first began to appear in the 1970s; there are currently full time nutritionists at about 20 of the nation’s 216 accredited zoos, as well as consultants for the zoos that do not have full time nutritionists.

Prior to zoo nutrition becoming a science, many animals were overfed but malnourished ““ not receiving the appropriate supplements to their diets. The diets of animals still can’t be replicated perfectly, due to the fact that elements from their diets are difficult to obtain. As Watts said, “We can’t go to South America and collect the figs or the branches or the beetles that an animal eats there.” Instead, researchers obtain samples after careful observation of what items the animals consume and bring this information back to nutritionists so that the diets can be analyzed. Mimicking the nutrients is the best thing nutritionists can do.

An excellent example of a specimen that has been sustained with the help of proper nutrition is Cookie the Cockatoo at Brookfield Zoo. The bird is 74 years old, and most of its life, he subsisted entirely on seeds. These seeds have little calcium and are high in fats. Cookie eventually was diagnosed with osteoporosis, a bone-thinning condition. Presently Cookie gets the discovered missing minerals in his water every day to prevent his bones from weakening further.

Zoo nutritionists definitely have their work cut out for them. Designing animal diets is not an easy task. Unlike the one-species-focus of human nutrition, zoo nutrition must cover the diets of many animals. There are so many different feeding strategies and dietary needs for the huge variety of animals at the zoo that all have to be addressed properly.

On the Net:

Brookfield Zoo

Toledo Zoo

Pinto Takes Parting Shots at Lawyer

By Michael P. Mayko, Connecticut Post, Bridgeport

Mar. 15–WATERBURY — Paul Pinto concluded his testimony in the Steel Point trial Friday with a flourish. He claimed Alfred Lenoci Sr. provided an all-expense paid trip to Atlantic City for former Bridgeport Mayor Joseph P. Ganim and several of his supporters.

Pinto also denied arranging a meeting at the former Rusty Scupper restaurant in New Haven with Charles Willinger Jr., a Bridgeport-based land use lawyer, or demanding $200,000 under a threat “to shade” his testimony.

And then he ripped Willinger, calling him “unethical, deceptive and a liar.”

Pinto said he developed that opinion over the past 17 years while knowing, socializing and working with Willinger.

“You realize Mr. Pinto has admitted he was the mayor’s bagman and is a convicted felon,” Willinger said in an interview after court in response to Pinto’s testimony. “He has further admitted in the past that he has lied under oath. By the conclusion of this trial, we’ll all see who’s telling the truth.”

Unlike Pinto, Ganim and the two Lenocis (Alfred Sr. and Alfred Jr.), Willinger was not convicted in the Bridgeport corruption probe.

Pinto did testify Willinger was unaware of the $1 per square foot payment to the Lenocis for projects they developed in Bridgeport.

If that wasn’t enough, Pinto was asked if he was upset about the 8-foot stockade fence the elder Lenoci constructed around his home on The Circle in Easton last summer. The two live next door to each other, and Lenoci said he constructed the fence to avoid seeing Pinto, who he once employed.

Pinto also served as the best man at the younger Lenoci’s wedding, only to later wear an FBI recording device to try to record Alfred Jr. in December 2000.

“Was there a problem in your mind regarding the fence,” Pinto was asked by Ira Grudberg, the elder Lenoci’s lawyer.

“Not a problem in my mind,” Pinto replied.

“Does Mr. Lenoci have a relative — a brother-in-law, Stephen Grens — who lives across the street,” Grudberg asked. “Did you tell him if the Lenocis messed with you, you would fix them at the Conroy trial?”

“No, I did not,” Pinto said.

So ended another trial day in Superior Court Judge Barry K. Stevens’ courtroom as the second week of Alex Conroy’s lawsuit concluded.

The case will pick up Tuesday with testimony from Louis Ceruzzi, a principal in Ceruzzi Development and Starwood Ceruzzi, both in Fairfield. Ceruzzi, who has partnered in real estate deals with the Lenocis, is expected to be questioned by Conroy’s lawyers about attempts to help United Properties obtain the Steel Point project from Conroy. The public trial is being conducted on the third floor of the Superior Courthouse at 400 Grand St.Conroy is suing Ganim; the city of Bridgeport; Lenoci; his son, Alfred Jr.; and his cousin, Willinger; and Joseph Kasper Jr., the former owner of Kasper Group and HNTB, a Rocky Hill-based architectural and engineering project management company.

Pinto had been a defendant but, with his lawyer, H. James Pickerstein, constructed a deal that removed him.

So for the past three days, Pinto testified as a witness for Conroy. Sometimes it appeared he contradicted himself.

Early in his testimony, he claimed Ganim took action to stonewall and impede Conroy’s project in order to slide United Properties into it.

On Friday, Pinto admitted that he testified in a Feb. 22, 2007, deposition that “there was no specific plan to eliminate Conroy” and that the expectation was that Conroy’s proposal would fail “naturally.”

That came during questioning by Christian Young, who represents Alfred Lenoci Jr.

But when questioned by R. Bartley Halloran, one of Conroy’s lawyers, Pinto said his opinion was developed through conversations and newspaper articles, not marketing or demographic studies.

As to his admitted lying under oath, Pinto explained that came during the Ganim trial. At that time, he was asked about a Fairfield zoning meeting involving a beach house he owned and rented to college students.

“I don’t recall being there,” Pinto said.

Pinto did recall “bad blood” between Conroy and the elder Lenoci stemming from a West Hartford development deal involving the construction of a B.J.’s warehouse and a Home Depot.

“Conroy had to be bought out of that deal,” Pinto said.

“Did he tell you that the other partners put up the money they had to but Conroy did not?” Grudberg asked.

“No,” Pinto said.

Still Pinto claimed Lenoci flew Ganim, members of his family and several campaign contributors on a private jet to Atlantic City.

The witness said Lenoci footed the bill for “dinner, lunch, an enormous suite, massages, drinks “

“Were there any other bribes or gratuities?” asked Halloran, Conroy’s lawyer.

“Al Sr. paid for all masonry work at the house the mayor was building, all site work, all clearing of the property, building a chimney and a fireplace,” Pinto said. “He told me to make sure the mayor knew how much and to what degree he paid for the work.”

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