Looming Water Crisis in Western U.S.

Scientists foresee a looming water crisis within the next two decades in the western United States due to human-caused global climate change.

The Rocky Mountains have warmed by 2 degrees Fahrenheit. The snowpack in the Sierras has dwindled by 20 percent and the temperatures there have heated up by 1.7 degrees Fahrenheit. All could lead to dire consequences for the water supply in the Western United States.

Led by a scientist at the Scripps Institution of Oceanography, researchers wrote in the journal Science that there has been a noticeable trend over the past half century of an intensifying decline in water which has already changed river flows, snow pack and air temperatures, accounting for 60 percent of changes.

Tim Barnett, a climate expert at Scripps Institution, part of the University of California at San Diego, told Reuters that this could cause a severe backlash for those living in the western U.S.

“It foretells of water shortages, lack of storage capability to meet seasonally changing river flow, transfers of water from agriculture to urban uses and other critical impacts,” he said.

The scientists claim that the issue has been determining whether the climate change was caused by natural variability or by human-produced greenhouse gases. Their conclusion hints that humans are to blame.

The researchers looked at water flows in three major western river systems — Columbia, Colorado and Sacramento/San Joaquin rivers and noted that over the past half century, changes have meant less snow pack and more rain in the mountains, rivers with greatly reduced flows by summer and overall drier summers in the region.

Barnett, who worked with experts at the U.S. government’s Lawrence Livermore National Laboratory, the University of Washington in Seattle and the National Institute for Environmental Studies in Japan, said that he doesn’t think that much can be done to change the trend at this time.

“We’re going to have to adapt our infrastructure and some of our societal needs to fit the way the world is changing,” Barnett told Reuters. “Water shortages throughout the west, hydroelectric power reductions, heat waves — the whole litany of things that go with global warming.”

The notion that historical water patterns could be relied on to continue normally has now changed due to the human-caused shifts in the Earth’s climate, Christopher Milly of the U.S. Geological Survey said.

“Our best current estimates are that water availability will increase substantially in northern Eurasia, Alaska, Canada and some tropical regions, and decrease substantially in southern Europe, the Middle East, southern Africa and southwestern North America,” Milly said.

Photo Caption: Computerized projections of western United States snowfall levels in 2050 compared to present day.

On the Net:

Scripps Institution of Oceanography

University of California at San Diego

Lawrence Livermore National Laboratory

Eric Raymond, CEO of Corporate Synergies, Joins The Board of The Center for Health Value Innovation

Corporate Synergies (CSG), a full-service independent employee benefits consultant and brokerage firm, and The Center for Health Value Innovation which fosters innovative strategy designs across all healthcare stakeholders, announced today that Mr. Eric Raymond, chief executive officer of Corporate Synergies, was elected to The Center for Health Value Innovation’s board of directors.

“Eric is obviously doing a terrific job as CEO of Corporate Synergies, and we look forward to his contributions as a member of The Center for Health Value Innovation’s board of directors,” said David Horn, The Center for Health Value Innovation’s Chairman of the Board. “Corporate Synergies is very focused on innovation and we think Eric’s insights and experience will be very valuable in helping to guide The Center for Health Value Innovation in the years ahead.”

“Within our industry, The Center for Health Value Innovation is one of the companies in the country that I most admire,” said Eric Raymond. “I’m really looking forward to working with David and the board to help with all of the amazing innovations that they are bringing to the marketplace.”

Eric Raymond brings the unique perspective of one who has represented insurance carriers, insurance brokers and health care providers. With 25 years of industry experience, he knows the issues inside and out, while others are seeking to accurately define the problem, Raymond has been dedicating his career to creating common sense, cost-effective solutions to America’s growing health care crisis which perfectly complements The Center for Health Value Innovation’s needs.

“The out-of-control upward spiral of healthcare costs has led too many employers to focus on short-term fixes for their immediate needs,” said Eric Raymond, CEO of Corporate Synergies. “In fact, these measures typically compound problems for the employer and the employee over the long term and end up costing more in medical dollars and lost productivity in the workplace.” Mr. Raymond continues, “I applaud the Center for Health Value Innovation for their commitment of improved health management and market leadership which mirrors Corporate Synergies market movement in value-based health designs.”

About Corporate Synergies Group, Inc.

Corporate Synergies is a full-service independent employee benefits consultant and brokerage firm based in Mt. Laurel, NJ. Founded in 2003, the company utilizes a unique suite of services combined with innovative technology to deliver cost-effective benefit solutions to employers and their employees. For further information about Corporate Synergies please visit www.CorpSyn.com or call 1-866-274-1719.

Cell Phones Get Spicy With Porn

The next frontier for erotica rapidly approaches, as it comes to tiny mobile phone screens.

According to Reuters, if the adult entertainment industry has its way, Americans may soon get a choice of free porn on cell phones, or at least some photographs of good-looking girls in bikinis.

Mobile porn has yet to take off in North America as carriers have been afraid of offending political and religious groups, not to mention parents concerned about children being exposed to adult content. 

That change may occur this year as phone companies plan to loosen control on their networks in a bid to allow a wider variety of gadgets and services, while introducing new tools to shield minors.

“It will be impossible to stop the adult business exploitation of mobile entertainment,” Gregory Piccionelli, a lawyer specializing in adult entertainment at law firm Piccionelli & Sarno told Reuters.

He predicted that U.S. consumers may soon be offered free porn on mobile phones alongside paid services such as live video or “adult dates,” a term for prearranged sex with strangers.

A conference being held in Miami this week is devoted to discussing mobile opportunities as the porn industry seeks to find a new driver of growth. A multitude of free online porn sites has cut into profits that have so far come mainly from DVDs, videotapes and pay-per-view or subscription-based Web sites.

In order to survive, adult entertainers need to be on top of phone trends, Jay Grdina, president of adult entertainment provider ClubJenna, Inc., which he co-founded with his wife, world-famous porn star Jenna Jameson told Reuters.

“If you don’t evolve you’re going to die. … We need to make sure we’re ready,” Grdina added in an interview before his keynote speech at this week’s Mobile Adult Content Congress, where adult entertainment and technology companies are brainstorming over how to make mobile porn a viable business.

Popular video-sharing site YouTube.com’s plan to expand to about 100 million advanced cell phones may help the cause.  Especially if it means some ClubJenna content, which includes everything from glamour photographs of scantily clad models to hardcore videos, is seen for free on phones. ClubJenna was sold to Playboy Enterprises Inc in 2006, Reuters reports.

“It’s a double-edged sword. On the one hand, it’s giving away content. … On the other hand, it’s expanding the brand,” Grdina continued, adding that ClubJenna needs a boost in the U.S. market, where it generates “pretty much zero” mobile revenue compared with “very healthy” revenue in Europe.

While he has had trouble winning deals with U.S. phone operators so far, Grdina hopes for a deal within 18 months to sell photographs of bikini-clad models without nudity.

The mobile porn industry in Europe is far more advanced than in North America. According to a Juniper Research report, pornography has made inroads on cell phones in Europe, where it was a $775 million industry in 2007 that will grow to $1.5 billion by 2012, with the global market reaching $3.5 billion in 2010.

While, in comparison, North America generated just $26 million last year as carriers shied away from porn sales. Canada’s second-largest phone company Telus Corp, for example, withdrew a mobile porn service last year after complaints from hundreds of customers and criticism from the Catholic Church, Reuters reports.

Gartner telecoms analyst Michael King told Reuters that he expects mobile porn to be more prevalent around 2009, when there will be more phones that can show high-quality graphics.

Porn is “one of the bigger pieces of Web revenue. You would assume the natural extension would be on mobile,” King added.

Piccionelli said that the iPhone, which Apple has forecast to sell 10 million units by the end of 2008, is ideal for viewing porn due to its graphics and Web browser that mimics computer browsers. Most phones have stripped-down browsers.

A new phone system being built by Google Inc may also boost consumer choice as the Internet company has pledged to support any type of mobile software, Reuters reports.

Alas, essential to development of mobile porn is the willingness by carriers to open their networks to more content. Even if they don’t sell porn they would benefit from additional fees paid by consumers if mobile Web-surfing increases.

Carriers in North America are unveiling new technologies that may assist in the porn industry moving to the forefront. Verizon Wireless, the second-largest U.S. mobile service, has promised to let customers use any device or software that can work on its network this year. Similarly, Sprint Nextel Corp said it will support a wide array of gadgets for a fast wireless Web service it kicks off in 2008.

Spokesman John Polivka told Reuters that customers of the service would be able to view anything they like. Sprint will also provide Web filters to help keep minors from adult sites.

NeuStar sells an age-verification system for which it aims to have both a U.S. carrier client and a content customer within six months.

“Two thousand eight is when the first people are going to be sticking their toes in the water,” John Ticer, a NeuStar marketing executive told Reuters.

Piccionelli added that mobile porn will always face uncertainties, such as a possible privacy backlash against age-verification systems as consumers need to give personal details.

“However, that does not mean that uncertainty will prohibit enormous profits from being made in this business,” he added.

On the Net:

Mobile Adult Content Congress

Celebrating America’s First Spacecraft

Explorer 1 was the first satellite launched by the United States when it was sent into space on January 31, 1958. Following the launch of the Soviet Union’s Sputnik 1 on October 4, 1957, the U.S. Army Ballistic Missile Agency was directed to launch a satellite using its Jupiter C rocket developed under the direction of Dr. Wernher von Braun.

The Jet Propulsion Laboratory received the assignment to design, build and operate the artificial satellite that would serve as the rocket’s payload. JPL completed this job in less than three months.

The primary science instrument on Explorer 1 was a cosmic ray detector designed to measure the radiation environment in Earth orbit. Once in space this experiment, provided by Dr. James Van Allen of the State University of Iowa, revealed a much lower cosmic ray count than expected.

Van Allen theorized that the instrument may have been saturated by very strong radiation from a belt of charged particles trapped in space by Earth’s magnetic field. The existence of these radiation belts was confirmed by another U.S. satellite launched two months later, and they became known as the Van Allen Belts in honor of their discoverer.

Explorer 1 revolved around Earth in a looping orbit that took it as close as 354 kilometers (220 miles) to Earth and as far as 2,515 kilometers (1,563 miles). It made one orbit every 114.8 minutes, or a total of 12.54 orbits per day. The satellite itself was 203 centimeters (80 inches) long and 15.9 centimeters (6.25 inches) in diameter.

Explorer 1 made its final transmission on May 23, 1958. It entered Earth’s atmosphere and burned up on March 31, 1970, after more than 58,000 orbits. The satellite weighed 14 kilograms (30.8 pounds).

A launch attempt of a similar satellite, Explorer 2, was made on March 5, 1958, but the fourth stage of the Jupiter-C rocket failed to ignite. Explorer 3 was successfully launched on March 26, 1958, and operated until June 16 of that year. Explorer 4 was launched July 26, 1958, and operated until October 6 of that year. Launch of Explorer 5 on August 24, 1958, failed when the rocket’s booster collided with its second stage after separation, causing the firing angle of the upper stage to be incorrect.

The craft’s mission

Explorer 1 carried instrumentation for the study of cosmic rays, micrometeorites, and for monitoring of the satellite’s temperature.

The instrumentation package, developed by a team at the University of Iowa under the direction of professor James A. Van Allen, was mounted inside the rocket’s body.

A single Geiger-Mueller detector was used for the detection of cosmic rays.

Micrometeorite detection was accomplished using both a wire grid and an acoustic detector. It was to detect hits from tiny meteorites.

Data from the instruments were transmitted continuously, but acquisition was limited to those times when the spacecraft passed over appropriately equipped receiving stations.

Its place in history

Van Allen’s realization that charged solar particles are trapped by the Earth’s magnetic field in concentric rings around the planet was the first major scientific discovery of the Space Age. They are now called the Van Allen radiation belts.

The mission revolutionized scientific understanding of the Earth and the solar system and created an entirely new field of research, called magnetospheric physics.

Later missions in both the Explorer and Pioneer series were to expand on the knowledge and extent of the zones of radiation and were the foundation of modern magnetospheric studies.

The impetus

The launch of Sputnik 1 by the USSR in late 1957 had shocked the American people, introducing the typical citizen to the Space Age in a crisis setting.

Not only had the Soviet Union been first in orbit, but Sputnik 1 weighed nearly 200 pounds, compared to the intended 3.5 pounds for the first satellite to be launched in Project Vanguard. In the Cold War environment of the late 1950s, this disparity of capability carried menacing implications.

The event created an illusion of a technological gap and provided the impetus for increased spending for aerospace endeavors, technical and scientific educational programs. It also led to the creation of NASA in 1958.

What happened to previous U.S. attempts to launch a rocket into space?

On Dec. 6, 1957, the Navy’s Vanguard, the first U.S. attempt to launch an Earth-orbiting satellite, rose a few feet above the ground, but then fell back to Earth and burst into flames.

On March 17, 1958, the Navy successfully launched Vanguard 1. It remains in orbit today as the oldest human-made object in space.

What were some of the next milestones in space?

A launch attempt of a second satellite, Explorer 2, was made on March 5, 1958, but the fourth stage of the Jupiter-C rocket failed to ignite.

Explorer 3 was successfully launched March 26, 1958, and operated until June 16 of that year.

Explorer 4 was launched July 26, 1958, and operated until Oct. 6 of that year. Launch of Explorer 5 on Aug. 24, 1958, failed when the rocket’s booster collided with its second stage after separation, causing the firing angle of the upper stage to be incorrect.

Where c an I see Explorer 1 now?

Full-scale replicas of Explorer 1 are in the Smithsonian National Air and Space Museum collection in Washington.

News researchers Jakon Hays, Kimberly R. Kent and Maureen Watts contributed to this report.

Sources: The Washington Post, NASA

How big was the satellite?

Spacecraft dimensions (not including rocket)

Length: 80 inches

Width: 6.25 inches in diameter

Weight: 30.8 pounds How big was the rocket?

Height: 68.6 feet – a four-stage rocket.

Weight (in pounds) loaded:

Overall (takeoff) 64,000

Stage 162,700

Stage 21,020

Stage 3280

Stage 480 Is it still up there?

The signal ended when batteries died on May 23, 1958.

The satellite burned up during re-entry over the Pacific Ocean on March 31, 1970. How high was it?

Altitudes ranged from 224 to 1,575 miles. How often did it circle Earth?

Approximately once every 115 minutes. Where was it launched?

Explorer 1 was launched at 10:48 p.m. on Jan. 31, 1958, from Cape Canaveral, Fla.

On the Net:

NASA

Super Bowl Parties Go High-Def

Just as Christmas is of the most important time of year for toy sales, the Super Bowl is prime time for sales of high-definition TV sets. Unfortunately, batteries are not included.

The Consumer Electronics Association (CEA) figures that this year’s Super Bowl will be the driving force behind the purchase of 2.4 million HD TVs, worth about $2.2 billion — and that’s not even counting the mounting brackets, the universal remote controls, the fancy speakers, or the popcorn.

Nor does it count the power the things consume. Electrical use starts at about 100 watts for a small unit (27 inches) and exceeds 600 watts for units in the 60-inch range—almost putting them in the realm of microwave ovens.

Wattages of other common household appliances:

  • Clock radio: 10
  • Computer and monitor: 270
  • Clothes dryer: 1800–5000

But people appear to be shrugging off the costs, since watching the Super Bowl on HD TV is turning into a high-tech tribal ritual, said CEA economist Shawn G. DuBravac.

CEA surveys show that about 35 percent of American adults plan to watch the game at home with a small group, DuBravac told LiveScience, and another 15 percent plan to watch at home with a large group. Fifteen percent plan to watch at a third-party location such as a club or hotel, and two percent plan to watch at a sports bars. The usual misfits — 11 percent — plan to watch it at home alone. Nineteen percent had made a decision not to watch for reasons best known to themselves, and the remaining three percent are presumably institutionalized.

“It doesn’t matter who is playing—the food is ordered, the TV is hung, and the invitations have gone out,” DuBravac added.

The fans have also gone on-line, as 18 percent of the people who said they plan to watch the game also plan to have a computer on hand to check statistics, compared notes with distant friends, or check betting lines. Thirteen percent said they plan to use a mobile phone for that purpose.

Of course, the Super Bowl is not the only sports event out there.

“We found that 40 percent of HD TV owners this year bought the set specifically to watch sports, up from 31 percent last year,” DuBravac said. “Among those who identify themselves as sports fans, 64 percent bought the sets to watch sports.”

Other events that HD buyers cited as reasons for getting a set were, in order, college bowl games, the World Series, the NBA finals, NCAA March Madness, and the summer Olympics, but the Super Bowl had them all beat, DuBravac said.

Incidentally, total sales for digital TVs in the US during 2007 amounted to 27.1 million, according to other CEA figures, and sales are expected to reach 31.8 million in 2008. Prices have fallen 39 percent since 2003.

African Fruits Could Help Alleviate Hunger

Environmental stability in Africa

WASHINGTON — Africa’s own fruits are a largely untapped resource that could combat malnutrition and boost environmental stability and rural development in Africa, says a new report from the National Research Council. African science institutes, policymakers, nongovernmental organizations, and individuals could all use modern horticultural knowledge and scientific research to bring these “lost crops” — such as baobab, marula, and butterfruit — to their full potential, said the panel that issued the report.

Today, tropical fruit production in Africa is dominated by species introduced from Asia and the Americas, such as bananas, pineapples, and papayas. Because these and other crops arrived on the continent centuries ago already improved through horticultural selection and breeding, they increasingly displaced the traditional species that had fed Africans for thousands of years. The imported species also received the support of colonial powers who wanted familiar crops that were profitable to grow, and indigenous fruits continued their downward spiral of dwindling cultivation and knowledge.

With renewed scientific and institutional support, however, Africa’s native fruits could make a much greater contribution to nutrition and economic development, the new report says. Fruit trees and shrubs also offer long-term benefits by improving the stability of the environment.

The report highlights 24 fruits that hold special promise; some are already being cultivated in parts of Africa, while others are harvested from the wild. Examples are:

AIZEN. Giving more people access to this wild fruit — which grows in extreme climates with few other food resources — could reduce malnutrition and mortality, the report says. The fruits are a good source of vitamins A and C, calcium, and some minerals, while the seeds are high in protein and zinc. This large, resilient Saharan shrub shows promise as a way to protect erodible slopes, stabilize dunes, and create windbreaks.

BALANITES. This small desert tree tolerates heat and aridity so well it thrives deep in the Sahara. It produces heavy yields of datelike fruits, as well as kernels that are one-half oil and one-third protein — similar to the makeup of soybeans and sesame seeds. These fruits and kernels already feed families in arid zones where few other food crops exist, but their full potential is scarcely tapped. The seeds supply a food-grade vegetable oil also used in local cosmetics and pharmaceuticals. The trees stabilize the natural environment, helping dry areas resist desertification.

BAOBAB. The fruits of the baobab tree contain a sticky pulp that can be dried into a nutritious powder high in protein, vitamins, and minerals. The powder is stirred into warm water or milk to create a healthy drink, and also beaten and dried into thin pancakes for use months or even years later, aiding food security. During the rainy season, villagers often store water in the tree’s trunk for later use. The sale of baobab fruits aids rural commerce, and the trees themselves — which also yield a popular leafy vegetable — are almost indestructible.

BUTTERFRUIT. This small tree produces fruit that is mainly used as a vegetable. High in calories and one of the best protein sources in the fruit world, butterfruit is especially promising for reducing child malnutrition. Even now, these fruits help many communities survive seasonal food shortages in the harshest hot, humid lowlands. Butterfruit also serves as a cash crop, pouring into cities and rural markets in large quantities. And the trees, which yield mahoganylike wood, may have potential for plantation forestry.

EBONY. The ebonies of Africa yield some of the world’s finest timber and also bear abundant, bright red fruits that are succulent and sweet. These can be dried for use when seasonal foods become scarce. The seeds of some ebonies are also edible, and the leaves are used as animal feed. Though the trees are known and valued on a local level, hardly anything scientific is known about managing them as food crops.

MARULA. This tree is a nutritional powerhouse, producing both fruits high in vitamin C and nuts similar to the macademia, high in protein and minerals. The fruits are popular in markets and even exported, while the kernels contribute to nutrition and food security. In addition, oils extracted from the nuts are also exported for high-priced skin care products. Harvesting the fruits and shelling the nuts provide work for thousands of rural women who have hardly any other source of income.

TAMARIND. These fruits are a strong source of B vitamins and calcium, and can be stored for months without refrigeration. In addition, tamarind’s sweet-sour pulp can be preserved in the form of sun-dried cakes — a simple procedure that perhaps millions throughout Africa could exploit for food security, the report says. Already widespread, the trees have great promise for restoring damaged lands to health and productivity, and likely for sequestering carbon, since they are treasured and seldom cut down.

The report is the third and final volume in a series that explored the benefits of reviving Africa’s indigenous crops. Previous reports included VOLUME 2, VEGETABLES (2006) and VOLUME 1, GRAINS (1996).

The study was sponsored by the Africa Bureau and the Office of Foreign Disaster Assistance of the U.S. Agency for International Development, with additional support from the Presidents Committee of the National Academies. The National Academy of Sciences, National Academy of Engineering, Institute of Medicine, and National Research Council make up the National Academies. They are private, nonprofit institutions that provide science, technology, and health policy advice under a congressional charter. The Research Council is the principal operating agency of the National Academy of Sciences and the National Academy of Engineering. A panel roster follows.

Copies of LOST CROPS OF AFRICA: VOL. 3, FRUITS are available from the National Academies Press; tel. 202-334-3313 or 1-800-624-6242 or on the Internet at HTTP://WWW.NAP.EDU.

On the Net:

The National Academies

Priority Health Adds Beaumont Hospitals and United Physicians to Its Provider Network

Priority Health, one of the largest health plans in Michigan, has reached agreements with Beaumont Hospitals and United Physicians to join its provider network.

“As we expand across the state of Michigan, we are committed to providing our members with access to affordable, high-quality care,” said Mike Koziara, vice president of the eastern region for Priority Health. “Partnering with Beaumont and United Physicians makes this possible.”

The Beaumont agreement, which was effective Jan. 1, 2008, gives Priority Health members access to Beaumont facilities across southeastern Michigan.

“Priority Health has a reputation of building strong partnerships with health care providers in local communities,” said Mark Johnson, senior vice president of Beaumont Hospitals. “That’s why we’re confident this agreement will benefit our patients as well as both of our organizations.”

United Physicians will become a part of the Priority Health network effective March 1, 2008.

“We are excited about Priority Health and its commitment to southeastern Michigan,” said Steven Grant, M.D., president and CEO of United Physicians. “Priority Health has been recognized as a leader among U.S. health plans. We are pleased to join the Priority Health network.”

About Beaumont Hospitals

Beaumont Hospitals is a three-hospital regional health care provider operating hospitals in Royal Oak, Troy and Grosse Pointe with 1,696 licensed beds. Beaumont Hospital in Royal Oak is a Level I trauma center. The Beaumont hospitals in Royal Oak and Troy are recognized as among “America’s Best Hospitals” by U.S. News & World Report.

About United Physicians

United Physicians is the largest physician organization in southeastern Michigan with 2,000 physicians. United Physicians’ providers have medical staff privileges at a number of the leading hospitals in southeast Michigan. It is among a select few physician organizations nationwide to earn certification in both Credentialing/Recredentialing and Utilization by the National Committee for Quality Assurance (NCQA).

About Priority Health

Priority Health is a nationally recognized health plan company based in Michigan. It serves more than a half-million members with a broad portfolio of products including commercial and government health plans. A nonprofit dedicated to providing all people access to affordable health care, Priority Health ranks 11th in the nation according to U.S. News & World Report and the National Committee for Quality Assurance. Priority Health employs 1,000 people throughout Michigan’s Lower Peninsula with offices in Farmington Hills, Holland, Jackson, Kalamazoo, Saginaw and Traverse City, as well as its headquarters in Grand Rapids. For more information about Priority Health, visit priorityhealth.com.

Artificial Lungs Coming Soon

When the lungs fail, doctors have woefully few tools in their arsenal to help people breathe.

That may change soon, say scientists who believe they are within sprinting distance of offering patients with acute lung failure an artificial lung — at least one that can be used short-term while they await transplants or for their damaged lungs to heal.

Researchers from academic institutions across the country who are developing and testing prototypes believe artificial lung clinical trials in humans, similar to studies already underway in Canada and Europe, may begin as early as this spring.

“We are doing extensive work with the Department of Defense,” says Brack Hattler, director of the Artificial Lung Program at the University of Pittsburgh. “They are very interested in support of soldiers in combat.” He expects human trials this spring for his group’s external device, the Hemolung.

Other artificial-lung researchers expect their models to be ready for human testing within one to five years. Food and Drug Administration approval for such devices could take years longer.

For suffering patients, five years may seem eons away, but in the research world it’s just around the bend, says Keith Cook, research assistant professor in the department of surgery and biomedical engineering at the University of Michigan.

Cook and colleague Robert Bartlett, a pioneer in the development of artificial organs, won a $5 million grant from the National Institutes of Health to fund animal studies that will accelerate the use of their Total Artificial Lung prototype in humans.

According to the National Heart, Lung, and Blood Institute, 150,000 Americans experience lung failure each year. A third do not survive, and those who do often suffer permanent respiratory damage. One thousand wait in line for lung transplants; 25% will die because their lungs fail them while they wait.

The purpose of an artificial lung is to help lung-failure patients survive the tenuous bridge of time between loss of respiratory function and a lung transplant, and to allow a patient whose lungs have undergone trauma, like severe smoke inhalation, to rest and heal, Cook says. “That time frame may be a few days or a few weeks.”

‘Iron lung’ memories persist

Early artificial-breathing devices include the tank respirator, or “iron lung,” introduced in the late 1920s and known for its role in treating polio victims.

Current treatment for lung failure is to hook patients up to an artificial respirator. It is costly, immobile and requires intubation, a process that can cause infection, says John Conte, a heart-and-lung transplant surgeon and associate professor at Johns Hopkins University School of Medicine. “You don’t want to take a patient who’s been flat on his back, with poor muscles and infection at the IV site, and do a transplant. That’s a recipe for disaster.”

Artificial lungs are small and portable, however, and are designed to allow patients to remain mobile and therefore stronger for surgery.

In healthy lungs, blood vessels absorb oxygen from the blood that’s pumped in from the heart, then release carbon dioxide through exhalation. An artificial lung basically imitates the way a normal lung works.

Scott Merz, a biomedical engineer and founder of MC3, a medical device company in Ann Arbor, Mich., says his company has a prototype of an artificial lung, Biolung, that may begin human testing in another year or two. MC3’s soda-can-sized device contains a bundle of polymer fibers that help exchange oxygen in the blood for carbon dioxide as blood washes over them.

Like other artificial-lung models, the Biolung is not implanted. It’s worn outside the body, attached with tubes to large blood vessels in the chest, arms or legs. It relies on a patient’s heart to pump the blood through the device, with blood flowing naturally between the high pressure in an artery to the lower pressure in a vein.

In Canada and Europe, Novalung, an artificial lung made by a German company of the same name, is in clinical trials. Doctors say they are having success with temporary use.

Shaf Keshavjee, professor and chairman of thoracic surgery at Toronto General Hospital and the University of Toronto, has performed five artificial-lung procedures in the past year using the Novalung. The CD-sized device has helped support patients for up to two weeks while they awaited a lung transplant.

Oxygen transfer is the key

Finding a surface — a membrane like the corporeal membrane in the chest — that transfers a significant amount of oxygen while not causing blood to clot or damaging blood cells as they pass across it has been a challenge for artificial-lung developers, Keshavjee says, but they have achieved success. “The technology that has developed now works well enough to use short-term,” he says. “It is a reality.”

Novalung was approved in October, not yet for lung failure, but for temporary use during heart surgery.

Down the road, researchers such as the University of Pittsburgh’s William Federspiel hope an implantable lung will be available to support patients with chronic diseases like asthma and cystic fibrosis.

Federspiel has been exploring an enzyme that, when used to coat the fibers in the artificial lung, accelerates the removal of carbon dioxide from the blood and may reduce the amount of blood that needs to be fed through the device, making it more efficient and safer for patients.

“The devices have come of age,” Keshavjee says. “There’s a real hope you can save lives with these devices. The long-term isn’t there yet, but it’s coming,”<>

High School Students’ Attitudes Toward Physical Education in Delaware

By Bibik, Janice M Goodwin, Stephen C; Orsega-Smith, Elizabeth M

Abstract It is important to understand high school students’ attitudes and perceptions toward physical education since they will be future members of the workforce who will need to use their knowledge to maintain a healthy lifestyle. Content standards are intended to assure that all students meet minimum curricular requirements, however, if students do not find physical education valuable, the content standards may have no meaning either. High school students’ attitudes toward their physical education programs in the state of Delaware were studied. These results provide a baseline for further examination of curriculum after implementation of state content standards. The students’ (N = 223) attitudes were measured using a 31-item survey. Results indicated approximately 45% of the students would enjoy having more sports or games in their physical education curriculum. The majority (74%) of the students indicated they preferred coeducational classes and 64% preferred working with other students of similar abilities. 43% of the students also indicated that physical education was important to their high school education, rating it just after math, english, and science. Correlation tests revealed that the majority of students who indicated they enjoyed physical education were more likely to enjoy school (p

Preparing our nation’s children to meet the demands of the 21st century by acquiring the knowledge and skills needed to be successful and productive citizens has been the focal point of the recent educational reform movement in the United States. Students in our nation’s schools are being held accountable to high academic standards. To this end, many states have initiated standards based education to improve academic achievement in each of the areas of the school curriculum. These standards indicate what a student should know and be able to do at specified points in their academic careers. In Delaware, for example, content standards were approved in 1995 by the Department of Education. At this writing, students are tested in english language arts, composed of reading and writing (grades 2-10); mathematics (grades 2-10); science (grades 4, 5, 6, 8 and 11); and social studies (grades 4, 5, 6, 8, and 11). As examples of standards in english language arts, by the end of grade 3 students must be able to write letters, summaries, messages, and reports while at the end of grade 5 students must be able to write these same texts using information from primary and secondary sources without plagiarism. In grade 6 mathematics, the students should be able to analyze real-world data to estimate the probability of future events and calculate the chances of winning or losing a simple game. In 8th grade mathematics, students should be able to construct displays of data and interpret trends in the graphs in order to make predictions (Delaware Department of Education, 1995).

Physical education has not been exempt from this reform at the national level. In 1995 the National Association for Sport and Physical Education (NASPE) defined a physically educated person as one who has “the knowledge, skills, and confidence to enjoy a lifetime of healthful physical activity” (p. 11) and subsequently developed content standards for physical education. Since that time, individual states have developed standards in health and physical education. This may be viewed as an attempt to combat the sedentary lifestyles plaguing many of our youth by providing knowledge and skills that will influence students’ decisions to pursue an active lifestyle. The development of the content standards may also suggest that physical education is being viewed as an important means in promoting health and wellness that may, in turn, influence students to lead physically active lifestyles. The State of Delaware is in the process of adopting content standards for physical education that have not been implemented statewide. Past practice in Delaware schools has been to offer a sport based curriculum. The new content standards are intended to shift the focus to more of a fitness based curriculum. Because of these efforts it is important to investigate the attitudes of Delaware high school students regarding their preference for a sport based model or a fitness based model.

It is important to examine student attitudes toward their curriculum as they can have a large impact on the success of a class. Attitudes develop at an early age and can be changed based on situational contexts such as a particular teacher or the class environment (Aicinena, 1991). In other words, a student’s attitude toward a particular subject in school can be shaped by his/her perception of the teacher or instructional setting. Attitudes toward physical activity and perceptions about physical education classes are important to understand as they can influence an individual’s decision to begin or to continue participation in an activity (Lee, Kang, and Hume, 1999; Silverman and Subramaniam, 1999).

Studies have examined attitudes and perceptions of students of all ages toward physical education (e.g., Barney, 2003; Bowyer, 1996; Stewart, Green, and Huelskamp, 1991; Tannehill and Zakrajsek, 1993). However, only a limited number of recent studies have been conducted that assess secondary students’ attitudes and their perceptions toward physical education (Carlson, 1995; Greenockle, Lee, and Lomax, 1990; Luke and Sinclair, 1991 ; Scantling, Strand, Lackey, and McAleese, 1995; Tannehill, Romar, O’Sullivan, England, and Rosenberg, 1994). There are several variables that influence high school students’ attitudes towards physical education. Carlson (1995) examined high school students’ negative attitudes toward physical education and found that some students did not feel physical education filled a need in their lives and consequently did not find it valuable. A lack of student input gave some students a feeling of powerlessness thereby making them feel as though they did not have any control over what happened in the gymnasium. This finding concurs with Aicinena (1991) who hypothesized teachers who allow some input into classroom decisions while maintaining control of instructional processes may foster positive attitudes toward physical education. Finally, Carlson (1995) concluded students who were less skilled felt isolated from their peers because they were not readily included in team activities or they were ridiculed for their lack of skill. Tannehill et al. (1994) also found students with negative attitudes felt uncomfortable or unsafe learning and practicing physical skills. These students did not participate in class or they used strategies to avoid conflict with the teacher. These attitudes were the same regardless of gender.

Luke and Sinclair (1991) examined potential determinants of male and female high school students’ attitudes toward physical education. They identified five main determinants of attitude: curriculum content, teacher behavior, class atmosphere, student self- perceptions, and facilities. Both male and female students identified these determinants in the same order. Scantling et al. (1995) and Greenockle et al. (1990) also identified related factors contributing to negative feelings toward physical education. These factors included boredom with activities, not wanting to get sweaty, not wanting to dress out, and the perception that athletes received preferential treatment.

Peer influence was another factor affecting attitudes toward high school physical education Greenockle et al. (1990). The students in their study appeared to engage in more active behavior in physical education classes when they received interest and positive reinforcement from their peers. Also noted was a negative influence of peers who did not dress for class and their direct impact on off- task behavior.

Despite research on high school students’ attitudes toward physical education, no studies were found which have a focus on student attitudes toward physical education in relation to a curriculum driven by state content standards. While content standards are intended to assure that all students meet minimum curricular requirements, if students do not find a need for physical education in their lives or do not find it valuable, the content standards possibly may have no meaning in their lives either. These attitudes may lead to avoidance behavior or disruptive behavior in the classroom. What may be one key to the relationships between student attitudes toward physical education and state content standards are the activities offered, the way in which these activities meet the standards, and the presentation of the activities to the students. For example, if one of the standards relates to developing aerobic fitness (NASPE Standard 4) it should be presented along with the concepts of the FITT (frequency, intensity, type, and time) principle, thereby giving the students a better understanding of why the activity is beneficial (NASPE Standard 2) and they will likely have a more positive attitude (NASPE Standard 6). Therefore, the specific research questions are:

1. What are high school student attitudes toward physical education?

2. How do other variables influence student attitudes towards physical education?

3. What is the perceived importance of physical education?

4. What activities are perceived to be most important to the physical education curriculum?

Method

Subjects

Students in 9th through 12th grades who were currently taking a physical education class in the state of Delaware were the subjects for this study. These students are required to take one 1/2 credit of physical education in 9th grade and in 10th grade. Any 11th and 12th grade students in a class were either transfer students from other states, taking the class to make up for a failing grade in a previous year, or taking physical education as an elective. All 223 students who were given the questionnaire completed it. Forty-five percent of the students were male and 55% were female. In addition, 39% of the students were in the 9th grade, 24% were in 10th grade, 16% were in 11th grade, and 21% were in 12th grade (Table 1).

Schools were selected to provide representation from each of the three counties in the state (New Castle, Kent, and Sussex). This was done to provide information from the different socioeconomic characteristics of the state. New Castle County, the northern most county, is the second largest county in area but the most densely populated. Sixteen percent of the population lives below the poverty line. Shipyards, auto manufacturing, machinery and chemical procedures, pharmaceutical companies, and banking and finance companies are the major employers. The dense neighborhoods juxtapose the poor with the affluent. There are 12 high schools, three vocational-technical high schools, and two charter high schools. Kent County is the smallest county in area and is the seat of the state capital. Eight percent of the population lives below the poverty line. The major employers for this county are the state government, Dover Air Force Base, and the paper products and rubber products industries. Kent County has six high schools and two charter high schools. In contrast to these two counties, Sussex County, the southern most county, is the largest county by area and is largely rural with seven high schools. Seven percent of the population lives below the poverty line. Fruit and vegetable fanning, dairy products, and fishing are the major industries along with broiler chicken farmers who supply the Eastern market.

The study was explained to physical education teachers from around the state who were in attendance at the state conference sponsored by the Delaware Association for Health, Physical Education, Recreation and Dance. This conference was a state wide in- service day. An equal number of teachers from each county were randomly selected. Therefore, the number of classes included in the study was dependent on the number of classes the teacher taught. Students from all three counties were represented in the survey.

Procedure

A 31-item survey was constructed that utilized items from the literature (Carlson, 1995 ; Luke and Sinclair, 1991; Scantling et al., 1995; Strand and Scantling, 1994; Tannehill and Zakrajsek, 1993) and was tailored to our specific interests. This survey took approximately 15 minutes to complete. Six physical educators, two from each county, and a faculty member from the University of Delaware whose expertise is survey design reviewed the survey. The six physical educators’ classes were not included in the final study. All agreed the survey was appropriate. The survey was pilot tested using similar groups of students to confirm the clarity of language and the meaning of the questions and some minor wording changes were necessary.

The University’s Institutional Review Board (IRB) approved this study. In compliance with the ERB’s policy, students were required to sign an assent form and those students under 18 were required to have a parent sign a consent form to permit them to participate. The physical education teacher administered the questionnaire during class. Students were told that no individual information would be reported to the teacher and that they could skip any item they did not wish to answer. To ensure student confidentiality, completed forms were placed directly into an envelope and sealed prior to being returned to the teacher. These unopened envelopes were then returned to the investigators.

Survey Instrument

The survey was organized in sections related to (a) demographics and personal information; (b) likes, dislikes, and perceived importance of physical education; (c) importance of other subject areas; and (d) most and least important activities in the physical education curriculum (Table 2).

Demographic and personal information included gender, grade level, and county of residence. Additional information included academic and career goals and participation in school sponsored activities (i.e., band, drama, clubs, sports). Students were asked to identify any activities (i.e. dance lessons and music lessons) in which they participated outside of school, and to indicate how they spent their free time. Finally, students were asked to identify their tobacco, alcohol, and drug use.

The second section addressed the likes, dislikes, and their perceived importance of physical education through open-ended questions such as what they liked/disliked most about physical education, what would make physical education more meaningful, and how frequently they should have physical education. A series of Likert-type scaled questions also asked students’ to indicate how safe they felt in the locker room, how comfortable they were in changing in the locker room, whether they preferred coeducational classes, and their preference for classmates in regard to skill ability. Reliability analysis was good with an alpha coefficient of 0.76. Comfort in the locker room was addressed because Ennis et al. (1997) and Strand and Scantling (1994) indicated that, for some students, in addition to not liking curricular content, the embarrassment of changing and showering in front of strangers, and the locker room environment itself produced a negative attitude toward physical education.

The third part of the questionnaire asked for information about the perceived importance of other school subjects to the students. Using a Likert-type scale the students were asked to respond ( 1 ) not important to (5) very important on how much they enjoyed certain school subjects and how important they thought those subjects were to their future. These subjects included art, english, foreign language, health, history, home economics, industrial arts, math, music, physical education, science, and social studies. Reliability was good with an alpha coefficient of 0.85. The final section of the questionnaire asked students to indicate the most and least important activities in their physical education curriculum. Using the Likert-type scale the students were asked to respond (1) not at all important to (5) very important on a list of 44 activities that included team sports, individual sports, aquatics, fitness, dance, self-defense, and outdoor recreation. Students could cross out any activities with which they were not familiar. Co-efficient alpha was 0.96.

Analyses

Descriptive statistics were used to determine students’ current enjoyment and importance of physical education and preferences in the curriculum. Correlations were conducted to examine the relationships between enjoyment and types of activities. Descriptive statistics were used to determine the students’ preferences for coeducational classes, playing with peers of different skill levels, their perceived safety level in the physical education environment, and individual negative health behaviors. Additional chi-square analyses were used to determine the impact of these variables on the enjoyment of physical education.

Results

Student’s attitudes towards physical education

When asked what they liked most about physical education, 31.4% mentioned specific sports or games (Figure 1). On the other hand, 18.8% of the students liked running the least. Approximately 45% of the students indicated that in order to make physical education more enjoyable more sports and games should be offered. Suggestions from the remaining 55% included allowing more personal choice and more strength and fitness opportunities.

Descriptive analyses revealed that 43.5% of both high school boys and girls rated physical activity to be important in their high school studies. On a scale of 1-5 (1= not important, 5= very important), math (4.20), english (4.23), and science (3.40) were the subjects ranked as most important to their education. However, physical education (3.24) and health education (3.64) were viewed as being more important than history/ social studies (3.06), home economics (2.90), foreign languages (3.14), industrial arts (2.36), art (2.18), and music (2.62).

Curriculum and enjoyment

In order to determine which activities had the greatest input on student enjoyment of physical education, correlation analyses were conducted. The students’ enjoyment of physical education was significantly correlated with attribution of team sports (such as basketball, baseball, floor hockey and volleyball; r =.25; p

Factors important to students’ enjoyment

It was found that the majority (74%) of subjects preferred coeducational classes. Chisquare tests revealed that a preference for coeducational classes was significantly related to enjoying physical education (X^sup 2^= .73, df= 4,193, p

There was a difference in feelings of safety in the locker room between counties. 46.4% of the students in Sussex felt very safe in the locker room while 25.9% in New Castle County felt safe. However, there was no relationship between feelings of safety and attitudes toward physical education. The majority (67%) stated that they felt very comfortable or pretty comfortable in the locker room. However, comfort in the locker room had a significant impact (p

Students who indicated that they enjoyed physical education were more likely to also enjoy school (X^sup 2^ = 27.01, df =8,214, p

It was found that those students who engage in negative health behaviors (defined as smoking, drinking alcohol, or using illegal drugs) were less likely to enjoy participating in physical education class (X^sup 2^ = 16.31, df = 4,215, p

Outside activities

Over fifty percent (50.7%) of the students participated in school sponsored extracurricular activities such as band, drama, chorus, clubs, sports, and yearbook. Among those who participated in extracurricular activities, the most frequently reported activity was sports (56.1%). In addition, 61.7% of all of the respondents reported that they participated in non- school the students participated in sedentary activities outside of school only one to two days per week, 42% of the students engaged in social activities three or more days per week, and approximately 45% participated in sports or exercised at least three to four days per week.

Discussion

Based on the results of this study it would appear that high school students in Delaware perceive physical education to be a positive and valuable experience. Results indicated that high school students believed physical education was an important part of their academic experience, rated just after math, english, and science. This was viewed as a very important finding as Delaware currently has approximately 24 % of their adult population classified as obese, ranking them tied for 15th in obesity rates of adults in the United States (webMD, n.d.). Additionally, recent data from the Centers for Disease Control (CDC) indicates approximately 14 % of the students who participated in the 2003 Youth Risk sponsored activities such as music lessons, dance lessons, and club sports. Once again, the category of sports was the most frequently reported activity (59%). It was found that approximately 93% of Behavior Survey (YRBS) are considered overweight while another 17% are at- risk for being overweight (http://www.cdc.gov/). Therefore, it is critical that steps be taken immediately to start to curtail these trends. According to the Surgeon General, physical activity is one of the key elements in attacking this problem (United States Department of Health and Human Resources, n.d.). Consequently, the fact that many of the high school students acknowledge the importance of physical activity may indicate that current public health efforts to reduce obesity rates in Delaware may be working.

As physical educators, we have to believe that we can have a major impact on this disturbing trend if we develop appropriate physical education programs. However, in order to maximize the success that physical education can have it is important that students perceive physical education in a positive manner and learn to enjoy being physically active. Enjoyment of physical activity has been identified as one of the crucial factors for our youth and adolescents to remain active (Motl, Dishman, Saunders, and Dowda, 2001; Sallis, Prochaska, Taylor, Hill, and Geracci, 1999; Wankel, 1993). This is seen as a critical concern as many of these students will become influential members of the community who will need to be supportive of our physical education programs for our efforts to continue.

To this end, it is important to consider that the students appeared to prefer a more traditional approach to physical education with a majority of students identifying team sports and games as the most enjoyable aspects of the curriculum. This was consistent with findings from previous studies (Tannehill and Zakraj sek, 1993 ; Tannehill et. al., 1994). It is thought that this may also be due to the fact that many students have not experienced anything other than traditional physical education programs as well as the large number of students who participate in sports either interscholastically, intramurally, or on club teams outside of school.

Another important variable in physical education is the use of coeducational classes. Prior to the 1970’s most physical education classes were single sex; however, with Title EX and other social changes coeducational classes became much more common. Now, almost all physical education classes are coeducational. The students in this study preferred coeducational classes, a finding which is also supported in the literature (Rice, 1988; Tannehill et al., 1994). When asked why they enjoyed coeducational classes the most typical response was “to look at the girls/boys”. This finding would appear to be influenced by the students’ developmental stage and their heightened awareness of the opposite gender. Unfortunately, it can also be detrimental to the educational process. Therefore, it is recommended that although coeducational classes may increase the enjoyment they may not be as educationally productive as having more homogeneous grouping of physical education opportunities for the students. This concept is supported by the findings that the majority of students (64%) preferred to participate with students of similar abilities while only 10% indicated they preferred to participate with students of lesser ability. This clearly indicates the grouping of students may be helpful in increasing enjoyment and possibly participation levels in our schools. This is likely to be of greatest importance at the secondary level as students are more likely to have more concern about peer response to their performance (Goodwin, 1997). Additionally, Kneer (1982) also states this type of grouping creates a much more effective teaching environment for the students. Those who have more skill can be provided additional challenge, while those who are not as skilled should have their needs addressed by adapting for their specific abilities and goals.

In order to address the issues of participating in team or individual sports and participating with classmates of similar ability, it is recommended that teachers incorporate team and individual sports into a fitness based curriculum. In other words, while the teachers should continue with the trend to teach students how to improve or maintain their health through being active, they may be well advised to structure their classes such that those who enjoy team or individual sports will have the opportunity to play small-sided games with classmates of similar ability (NASPE standard 3). This can be accomplished through a task style of teaching, grouping students of differing abilities so those with lesser abilities can play with a modified set of rules. For example, it is not necessary to require all students to play regulation basketball. There are many students who will never be able to develop the appropriate skill set necessary to play a basketball game properly. Therefore, it is good practice to place the players who do have those skills to participate in one activity while those who do not have those skills would be permitted to double dribble, travel, etc. A task style of teaching permits this to occur without emphasizing the different abilities. In other words, while the higher skilled students are working on a fitness or skill development task the less- skilled students may be playing the smallsided game. Regardless, it is important to focus on teaching the students why they are doing what they are doing, the benefits they are gaining by participating in these activities, while relating all of these activities to the state standards. This will also, hopefully, increase the students perception as to the importance of physical education while helping them experience greater enjoyment. Environmental variables, such as how one feels in the locker room, may also impact students’ attitudes towards physical education. Adolescence is a period in a student’s life that is marked by great physical and social developmental changes. The locker room is where there is generally less direct supervision of the students and where students with unsatisfactory body concepts are exposed to their peers. Examining student’s feelings in the locker room adds another dimension to the finding of Tannehill et al (1994) that students with negative attitudes felt uncomfortable or unsafe learning and practicing physical skills. It is also important to note that time spent in the locker room is part of the student’s total experience in physical education and may have a large impact on how they feel about physical education (Strand and Scantling, 1994; Ennis et al., 1997). Consequently, if students feel threatened or uncomfortable in the locker room, they may be less inclined to change for class and, if they do change, they may already have a negative attitude toward the class. It may, therefore, be important to examine the role of teacher supervision in the locker room as it affects student feelings of safety and comfort. It is recommended that teachers make their presence known in the locker room. This can be accomplished by simply having the teacher stand in the doorway during changing.

Another avenue we believe should be strongly considered is increasing the number of elective physical education offerings for juniors and seniors. Obviously, this becomes a resource issue for many schools. However, in those schools where there are sufficient facilities to handle the additional students, elective courses can be extremely beneficial. While many of these students may choose sports or games, others may choose fitness options. Regardless of the choice for activities, teachers will have more opportunities to help students remain active.

The proposed Delaware standards state that students should have knowledge of the following: physiology of exercise, biomechanics, motor learning, social psychology, self-management, physically active behaviors, and movement forms and proficiency. For example, under the physiology of exercise, standard one is that students will demonstrate the ability to apply the physiological concepts of exercise by participating in personalized, health-enhancing physical activity programs. By the end of kindergarten, students should demonstrate that physical activity causes the heart to beat faster and breathing rate to increase. However, by the end of grade eight, the student should be able to select an appropriate segment of F.I.T.T. to improve a specific aspect of personal fitness (Delaware Department of Education, 1995).

In order to continue to improve our physical education programs we must remember to listen to the students. We must then mesh their feedback with the state standards so that we can help students become healthy, active adults. Failure to accomplish these goals is likely to result in the continuation of the alarming increase in obesity rates. Our students must learn why physical activity is important to helping them become healthy and productive adults. We must also continue to monitor how the most and least active of our students are responding to the curricular changes that have been brought about by the development of state physical education standards. It is hoped that as the students become more familiar with a fitness-based curriculum that they will learn more about why physical activity is so important, as well has how to exercise safely. As these changes are made, developing programs that are more effective for all of our students may lead to students gaining an appreciation for the importance of healthy active lifestyles that may carry on into adulthood.

REFERENCES

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Greenockle, K.M., Lee, A.A., & Lomax, R. (1990). The relationship between selected student characteristics and activity patterns in a required high school physical education class. Research Quarterly for Exercise and Sport, 61, 59-69.

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Luke, M.D. & Sinclair, G.D. (1991). Gender differences in adolescents’ attitudes toward school physical education. Journal of Teaching in Physical Education, 11, 31-46.

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Drs. Janice M. Bibik, Stephen C. Goodwin, and Elizabeth M. Orsega- Smith are on the faculty at the University of Delaware.

Copyright Phi Epsilon Kappa Fraternity Winter 2007

(c) 2007 Physical Educator. Provided by ProQuest Information and Learning. All rights Reserved.

Massive Discharge of Untreated Sewage into the Ala Wai Canal (Oahu, Hawaii): A Threat to Waikiki’s Waters?

By Venzon, Nel C Jr

The world-famous Waikiki Beach, situated along Oahu’s picturesque south shore, may be in jeopardy. Considered the heart of Hawaii’s tourism industry, Waikiki and its surrounding environs host about 72,000 visitors per day, amounting to an estimated $3.6 billion total gross state product in 2002 (Department of Business, Economic Development & Tourism, 2003). Recent events affecting area waters, however, may have seriously compromised Waikiki’s future economic productivity and, as a result, undermined one of the state’s major economic driving forces. On March 24, 2006, Honolulu, Hawaii, witnessed one of its worst environmental crises when an estimated 48 million gallons of raw sewage were purposely diverted into the Ala Wai Canal over a five-day period (City and County of Honolulu, 2006). The Beachwalk Wastewater Pump Station (WWPS) Force Main, a 42- inch-diameter reinforced concrete pipe located on Kaiolu Street, had finally given way after servicing five Honolulu communities since its construction in 1964 and had ruptured after weeks of heavy rain (City and County of Honolulu).

Built in the early 1920s, the Ala Wai Canal is an approximately 2- mile-long waterway that receives drainage from Makiki (1,687 acres) and the Manoa-Palolo region (6,247 acres) (State of Hawaii Department of Land and Natural Resources, 2003; State of Hawaii Department of Land and Natural Resources Division of Water and Land Development, 1992). Also, serving as an estuary, the canal receives stormwater runoff from an additional 4,099-acre region comprising Ala Moana, Moili’ili, Kapahulu, and Waikiki (State of Hawaii Department of Land and Natural Resources, 2003). As a result of this heavy and widespread use, the canal has become polluted and has deteriorated over the years (De Carlo, Beltran, & Tomlinson, 2004; State of Hawaii Department of Land and Natural Resources, 2003). Since the flow from the canal and upstream vicinity empties into the near-shore marine waters, Waikiki waters and adjacent beaches are directly affected by any form of runoff.

A preliminary report indicated that a combination of heavy rainfall runoff into the sewage system, the rupturing of an aging sewer line on Kaiolu Street in Waikiki, area ground settlement, and near-by pile-driving activities appear to have contributed to the incident (City and County of Honolulu, 2006). In addition, all four pumps had to be turned on at the Beachwalk WWPS to accommodate the increased infiltration into the collection system, creating a pressure surge within the force main. Further inspection of the ruptured pipe revealed no sign of corrosion, suggesting that the break was recent (City and County of Honolulu, 2006).

The lack of a backup line forced local authorities to divert raw sewage into the Ala Wai Canal while the damaged pipe was being repaired. “Pumping sewage into the Ala Wai Canal prevented the waste from backing up into homes, hotels, and businesses located in Waikiki and nearby areas, which would eventually flow into the canal,” said Watson Okubo, supervisor of the Monitoring and Analysis Section Clean Water Branch (CWB) of the Hawaii State Department of Health (HSDOH). This strategy was part of a contingency plan established in 1996 for management of massive spills in Honolulu’s main metropolitan area (Perez, 2006). Another option was to haul wastewater away to the treatment plant; however, this inefficient approach was not a match for the magnitude of the spill (Takamura, 2006). Although the spill did not drastically affect residential areas, environmental and health concerns were nevertheless inevitable.

On the same day that the sewer main ruptured, officials from the City and County of Honolulu (CCH) Department of Environmental Services Monitoring and Compliance Branch immediately conducted water sampling from the canal and shoreline stations to evaluate contamination levels. Water quality was monitored at five canal stations, 18 shoreline sites, and 10 surf sites (Hawaii State Department of Health Clean Water Branch Monitoring and Analysis Section, 2006).

“Signs were posted thereafter along Ala Wai Canal to Magic Island, Ala Wai Yacht Harbor, and other areas to warn the public of sewage contaminated water and that exposure to water may cause illness,” Okubo said (see photo on page 26). CCH officials and crews also launched small boats and conducted daily monitoring of ocean currents and the flow of water from the Ala Wai drogues (City and County of Honolulu, 2006).

Although CCH did not conduct testing for pathogenic organisms, wastewater spill monitoring results revealed elevated levels of fecal coliform bacteria, enterococci, and Clostridium perfringens, which constituted a clear indicator that a potential health risk existed for individuals exposed to the contaminated water. Although fecal coliforms do not directly pose a danger to people or animals, they are generally associated with other organisms that cause typhoid, dysentery, hepatitis A, and cholera (U.S. Environmental Protection Agency, 2006a).

According to Terence Teruya, environmental health specialist for HSDOH’s Clean Water Branch, “These bacteria [fecal coliform, enterococci, and C. perfringens] are used as indicator organisms. Enterococcus in particular is used because of the ease of collection, identification, quantification, and correlation with gastrointestinal illnesses. These organisms reside in every human being, so consumption/contamination is not an issue.”

A study conducted by the U.S. Environmental Protection Agency (U.S. EPA) in 1986 serves as the basis for establishing enterococcus as the indicator organism (U.S. EPA, 1986). “In the study,” Teruya continued, “a correlation between enterococcus and gastrointestinal illnesses was identified, suggesting that the higher the enterococcus concentration, the greater the number of swimmers who reported gastrointestinal illnesses.”

According to HSDOH Administrative Rules Chapter 11-54, enterococci concentrations should not exceed a geometric mean of 33 colony-forming units (CFUs) per 100 mL for inland recreational waters and 7 CFUs per 100 mL for marine recreational waters (Hawaii State Department of Health, 2004). During the five days following the spill, increasingly high enterococci counts were observed at Ala Wai Canal sampling stations, reaching the alarming counts of an estimated 140,000 CFUs per 100 mL at the spill site on Kaiolu Street, 780,000 at the McCully Street Bridge, and 120,000 at the Ala Moana Boulevard Bridge] in water samples collected on March 29 (Figure 1).

A total of 729 records reflecting enterococci concentrations from September 1987 to December 1998 for the Ala Moana Bridge site and from April 1988 to December 1998 for the McCully Street Bridge site show geometric mean enterococci concentrations of 179.5 and 231.9 CFUs per 100 mL of water sample, respectively.

Although enterococci counts at five Ala Wai Canal sampling stations subsided thereafter, bacteria levels still exceeded the limit set by HSDOH for enterococci for 16 consecutive days following reconstruction of the ruptured pipe and cleanup of the reconstruction (Figure 2). As a result, the state health department closed affected beaches and posted additional warning signs urging the public to stay away from near-shore marine waters as well as several Waikiki shoreline stations because of high bacteria counts (Vorsino, 2006a).

The closure of the nearby beaches on March 25 and their re- opening on April 4 were also based on HSDOH’s analysis of C. perfringens concentrations resulting from environmental soil sources of enterococci (Fujioka, Betancourt, & Vithanage, 2006). During this period, results of environmental monitoring and beach water sampling for FRNA coliphages by culture and Bacteroides by PCR in Roger Fujioka’s laboratory at the Water Resources Research Center also showed that the beaches were contaminated for up to two days but not four days after the sewage spill had stopped (Fujioka, Betancourt, & Vithanage, 2006).

Despite such preventive measures, many beachgoers remained unaware of the extent to which sewage had contaminated shoreline waters and were disappointed that warning signs were not more conspicuously posted. “As soon as I got into the water [near Fort DeRussy and Duke Kahanamoku beaches], I noticed the foul smell, and it [the water] was brown. I could not stand it and left right away,” said Ursi Schmid. Schmid had to ask the lifeguard on duty for information because of the unavailability of warning signs. Although enterococci counts exceeding the limits were measured after the spill, warning signs were not posted in the vicinity until March 29 (Hawaii State Department of Health, Clean Water Branch Monitoring and Analysis Section, 2006). “I should have been properly warned, because it involved risking the health of the general public,” said Schmid, who came from Switzerland to live in Hawaii and has been swimming at the same beach for 16 years.

High enterococci levels were also detected in waters near the Waikiki Yacht Club and Magic Island, which sit on the ocean side end of the Ala Wai (City and County of Honolulu, 2006). These findings have left Hawaii residents skeptical and wary of the area. Corbin (last name not given) and Greg Terry, for instance, are longtime recreational fishermen who made use of the waters surrounding Waikiki Yacht Club and Magic Island before the incident. “We enjoyed fishing ulua [jack fish], papio, and ‘owama [goatfish], and sometimes we would catch fish that weighed 20 to 45 pounds. But because of the sewage spill, we are scared to even touch the water,” Terry said. Other major recreational activities, such as canoe paddling, whose practitioners normally practice on the Ala Wai Canal, have already relocated to other sites because of the massive spill. The Oahu Hawaiian Canoe Racing Association and Na Ohana O Na Hui Wa’a, Oahu’s two largest canoe-racing associations, representing about 5,000 paddlers of all ages, reported that practice would not be held at the canal in 2006 because of the incident (Leone, 2006a). In addition, 11 association canoe clubs were also displaced from the canal and from Magic Island, resulting in a decline in membership, because of the fear that members might become infected from the bacteria-contaminated water (Leone, 2006a; Advertiser Staff, 2006).

The state’s Department of Land and Natural Resources (DLNR) made efforts in collaboration with the Pacific Environmental Corporation (PEC) to clear the debris trap at the mouth of the Ala Wai Boat Harbor. The trap contained materials that had come down during heavy rains concurrently with the raw-sewage discharge (Antone, 2006). Located at the base of the Ala Moana Boulevard Bridge, the trap serves as the final catch point before the canal waters reach the open ocean. According to state officials, DLNR hired PEC to handle hazardous materials as a precautionary measure when it was working on waters from the canal.

Oliver Johnson, a 34-year-old Waikiki resident who fell into the Ala Wai Harbor, allegedly died one week after contracting a Vibrio vulnificus infection in his foot, a condition that was perhaps exacerbated by a preexisting history of alcoholic liver disease (Creamer, 2006). The Centers for Disease Control and Prevention (CDC) has reported other cases of V vulnificus infection, in which three of 14 people with wound-associated illnesses died; those incidents likely resulted from exposure to flood waters caused by Hurricane Katrina in the U.S. Gulf Coast (2005).

Additional concerns about the extent of possible contamination from the spill prompted further testing of the sand covering the resort-laden coastline of the south shore. Results indicated that bacteria levels on two Waikiki sites were within acceptable levels for bacteria in the water and did not pose a health risk (Aguiar, 2006). State Health Director Dr. Chiyome Fukino, however, commented that the results were inconclusive because three had been no previous testing of the sand; pre-contamination bacterial counts would be needed to provide a comparison with post-contamination samplings (Vorsino, 2006b). An independent analysis of beach sand for fecal indicator bacteria in Fujioka’s laboratory at the Water Resources Research Center showed that concentrations of these bacteria were higher in sand away from the water, suggesting that the source was not related to the sewage-contaminated beach water (Fujioka, Betancourt, & Vithanage, 2006).

In addition to routine maintenance and cleanup of the debris trapped in Ala Wai Harbor waters, Natural Systems, Inc. (NSI) is currently operating a 2,000-foot demonstration installation employing a bioremediation strategy to improve water quality in the Canal (see photo on page 29). The NSI project, which started in January of 2005, utilizes planted rafts that include the akulikuli plant (Sesuvium portulacastrum), an indigenous Hawaiian plant that bears small pink flowers and attracts waterfowl (Bornhorst, 2005). S. portulacastrum grows along the coastal regions and can survive various stress conditions such as salinity, drought, and heavy- metal contamination (M.S. Swaminathan Research Foundation, 2005).

According to Chad Durkin, Malama Aina Foundation science specialist, the effectiveness of the project depends on many uncontrollable variables: “Basically, the exponential growth of beneficial bacteria communities will have the greatest positive impact on the canal ecology. This is difficult to measure, so we measure water quality as an indicator of ecological change.” The photosynthetic system, which helps improve the quality of the water, is also associated with other microorganisms such as algae and bacteria, particularly the nitrosomonas and nitrobacter that interact with the hydroponic roots.

City officials claimed that the sewage discharge incident was the largest in Hawaii State’s history. Previous ruptures in the Beachwalk WWPS Force Main were not as serious as the one observed on March 24, according to Department of Environmental Services spill records. The first incident, a hairline fracture at the section of the Beachwalk WWPS Force Main that was detected on February 27, 1993, was believed to have caused a spill, lasting two days, of 510 gallons of wastewater into a nearby gravity collection systems manhole (City and County of Honolulu, 2006). Another incident, which took place on January 20, 2004, yielded zero spill volume as it was contained in the Force Main vault (City and County of Honolulu, 2006). Before the Ala Wai Canal incident on March 24, 2006, a 2- million-gallon spill into Marnala Bay near the city’s Sand Island Wastewater Treatment Plant on March 2, 2004, was the largest spill recorded as resulting from a sewer line break; it required three hours to repair (Leone, 2006b).

As an emergency plan, the city immediately activated the Beachwalk Wastewater Emergency Bypass (BWEB) project, which includes a 7,200-foot temporary bypass line to prevent future diversions of wastewater from the current force main (City and County of Honolulu News and Events, 2006). In addition, Governor Linda Lingle signed a proclamation on May 24, 2006, declaring Honolulu a disaster area, allowing the city to respond to the urgency of the situation and expedite pertinent administrative processes (Beachwalk Wastewater Emergency Bypass, 2006). The BWEB project is estimated to cost $20 million, including $2 million for the repair work of the March 24 break and $3 million for environmental restoration (The City and County of Honolulu News and Events, 2006).

At the time of this writing, HSDOH officials are establishing, as a civil-defense routine, an incident command system (ICS) that will delegate preparation, response, mitigation, and recovery should another massive spill occur. The ICS includes provision of public information via the local reporting system. A telephone hotline and Web site outlining pertinent details are being developed and updated daily to augment public awareness. A Wastewater Spill Response Committee, comprising government and private officials, surfers, and other individuals, has also been formed and meets on a weekly basis to address the improvement of Oahu’s water quality and reduction of the impact of future spills.

Another important challenge facing HS-DOH is the development of multiple indicator organisms. “A third indicator to improve the current detection methods is highly recommended to obtain immediate results,” Okubo said. “Escherichia coii and enterococci are not clearly representative of the number of fecal matter in the contaminated water.” In Hawaii, rain-related high enterococci levels may not clearly indicate the presence of sewer or fecal matter in the water because elevated counts in streams are due to runoff from soil, which are permissive microbiota that allow the in situ growth of these bacteria (Byappanahalli & Fujioka, 2004).

Indeed, the catastrophic nature of the recent Ala Wai Canal incident provides an important lesson to Hawaii’s state government with respect to issues that pose a profound effect on the economy and the community, as well as the environment. Pumping roughly 48 million gallons of untreated sewage into the canal was undoubtedly an incident with immeasurable consequences. A disaster of this magnitude is comparable to the largest spill in the history of the United States, the Exxon Valdez case, which spilled more than 11 million gallons of crude oil in Prince William Sound, Alaska. Ironically that incident occurred on the same date 17 years earlier (U.S. EPA, 2006b).

This environmental challenge is certainly an issue not to be ignored. If neglectedand worsened by expanding anthropogenic activities that contribute to the increasing deterioration of the canal-it potentially could have an irreversible negative effect on Oahu’s south shore beaches and marine ecosystem, the state’s tourism, and, most important, the future of Waikiki and those who live in paradise.

A warning sign is posted near the Ala Moana Boulevard Bridge and the Ala Wai Yacht Harbor, where water from the Ala Wai Canal empties into the open ocean. Although a floating device traps most of the debris, it is ineffective in eliminating other wastes and pollutants in the water.

The akulikuli plant (Sesuvium portulacastrum), anchored on rafts, is used in a bioremediation demonstration project to improve the water quality in the Ala Wai Canal.

REFERENCES

Advertiser Staff. (2006, May 5). Clubs staying out of Ala Wai for rest of year. Retrieved May 30, 2006, from http:// the.honoluluadvertiser.com/article/2006/May/05/sp/FP605050373.html.

Aguiar, E. (2006, April 22). Sand clean at four sites, test finds. Honolulu Advertiser, Hawaii Section, p. 1.

Antone, R. (2006, April 16). Ala Wai harbor cleanup costing extra. Honolulu Star Bulletin, p. A21.

Byappanahalli, M., & Fujioka, R. (2004). Indigenous soil bacteria and low moisture may limit but allow fecal bacteria to multiply and become a minor population in tropical soils. Water Science and Technology. 50(1): 27-32. Beachwalk Wastewater Emergency Bypass. (2006, May 26). Project update. Retrieved May 31, 2006, from http:// wwwbeachwalkby-pass.com/% 5Cproject.asp.

Bornhorst, H. (2005, September 30). Akulikuli blooms make lei, roots clean Ala Wai. The Honolulu Advertiser, Island Life Section p. 3.

Centers for Disease Control and Prevention. (2005). Vibrio illnesses after Hurricane Katrina-Multiple states, August-September 2005. Morbidity and Mortality Weekly Report. 54(37): 928-931.

City and County of Honolulu. (2006, April 25). Preliminary report beachwalk wastewater pump station force main rupture on March 24, 2006 (City and County of Honolulu Sand Island Wastewater Treatment Plant NPDES Permit HI0020117 April 24, 2006). Retrieved May 26, 2006, from http://the.honoluluadvertiser.com/dailypix/2006/Apr/25/ beachwalkreport.pdf.

City and County of Honolulu News and Events. (2006, May 18). City announces beachwalk emergency wastewater bypass plan. Retrieved May 31, 2006, from http://www.honolulu.gov/csd/publiccom/honnews06/ cityannouncesbeachwalkemergencywastewaterbypassplan.htm

Creamer, B. (2006, April 11). Bacteria draw attention of UH scientist. The Honolulu Advertiser, p. A2.

De Carlo, E.H., Beltran, V.L., & Tomlinson, M.S. (2004). Composition of water and suspended sediment in streams of urbanized subtropical watersheds in Hawaii. Applied Geochemistry. 19(7): 1011- 1037.

Department of Business, Economic Development & Tourism. (May 2003). The economic contribution of Waikiki. Retrieved May 26, 2006, from http://www.hawaii.gov/dlnr/occl/files/Waikiki/ econ_waikiki.pdf.

Fujioka, R., Betancourt, W., & Vithanage, G. (2006, October). Monitoring environmental and beach water samples for FRNA coliphages by FRNA coliphages by culture and bacteroides by PCR to assess closing and opening of beaches following a 48 million gallon sewage spill in Hawaii. Presentation given at the National Beaches Conference, Niagara Falls, NY. Retrieved September 25, 2007, from http://www.tetratech-ffx.com/beach_conf2006/agenda6.htm

Hawaii State Department of Health. (2004). Hawaii State Department of Health amendment and compilation of Chapter 11-54 Hawaii administrative rules. Honolulu, HI: Author.

Hawaii State Department of Health Clean Water Branch Monitoring and Analysis Section. (2006). Beachwalk force main spill to Ala Wai Canal: Partial interim chronology of event, sign postings, and bacteriological sampling. Honolulu, HI: Author.

Leone, D. (2006a, May 4). Paddling groups to steer clear of Ala Wai. Star Bulletin, pp. A1, A9.

Leone, D. (2006b, March 30). Sewage spill: Waikiki still nasty. Honolulu Star Bulletin, p. A1, A10.

M.S. Swaminathan Research Foundation. (2005). 2004-2005 Fifteenth annual report, Centre for Research on Sustainable Agricultural and Rural Development, Chennai. Retrieved May 26, 2006, from http:// wwwmssrf.org/ar/Fifteenth%20Annual%20Report%202004-2005.pdf.

Perez, R. (2006, April 9). Was dumping into the Ala Wai the only option? The Honolulu Advertiser, p. A1.

State of Hawaii Department of Land and Natural Resources. (2003). Ala Wai watershed analysis final report. Honolulu, HI: Author.

State of Hawaii Department of Land and Natural Resources, Division of Water and Land Development. (1992). A management plan for the Ala Wai Canal watershed. Honolulu, HI: Author.

Takamura, E.S. (2006, April 9). Ala Wai spill was city’s best option after main broke. The Honolulu Advertiser, Focus Section p. 1.

U.S. Environmental Protection Agency. (1986, January). Ambient Water Quality Criteria for Bacteria-1986. Retrieved May 26, 2006, from http://www.epa.gov/waterscience/beaches/1986crit.pdf.

U.S. Environmental Protection Agency, (n.d., updated March 2, 2006a). Fecai coliform. Retrieved May 26, 2006, from http:// www.epa.gov/maia/html/fecal.html.

U.S. Environmental Protection Agency, (n.d., updated March 8, 2006b). Exxon Valdez. Retrieved May 26, 2006, from http:// www.epa.gov/oilspill/exxon.htm.

Vorsino, M. (2006a, April 3). Waikiki beaches close. Honolulu Star Bulletin, pp. A1, A6.

Vorsino, M. (2006b, April 22). Sand tests show little risk of health threat. Honolulu Star Bulletin, p. A3.

Acknowledgements: The author expresses his appreciation to Watson Okubo for providing statistical and technical information throughout the investigation for this report. He also thanks Dean E McGinnis and Walter B. Igawa-Silva for providing tremendous assistance in the preparation of the manuscript.

Corresponding author: Nel C. Venzon, Jr., Mathematics Department, University Laboratory School, Curriculum Research & Development Group, University of Hawaii at Manoa, 1776 University Avenue, Honolulu, HI 96822. E-mail: [email protected].

Copyright National Environmental Health Association Dec 2007

(c) 2007 Journal of Environmental Health. Provided by ProQuest Information and Learning. All rights Reserved.

The Diagnosis of Late Life Hypogonadism

By Morley, John E

Abstract The diagnosis of late life hypogonadism is controversial. For the purposes of discussion, it is suggested that treatment of late life hypogonodism requires the presence of symptoms, a low level of circulating free or bioavailable testosterone level and a positive response to treatment. While this may appear to be a radical proposal, we believe it represents the most rigorous scientific approach to the diagnosis of late life hypogonadism at the present time.

Keywords: Hypogonadism, testosterone, ADAM, aging male survey, androgen deficiency

Introduction

Few areas have created as much controversy as the diagnosis of late life hypogonadism and its management. So while the condition was first mentioned in the Chinese Text of Internal Medicine and had a major, though controversial, role in the medicine of the late nineteenth and firsthalf of the twentieth century [1], it was considered an invention of the pharmaceutical industry in the beginning of the twenty-first century [2]. Over time it has had many names including male menopause (a truly inappropriate name), male climacteric, adrenopause, androgen deficiency of the aging male (ADAM), partial androgen deficiency of the aging male (PADAM) and late-onset hypogonadism. Recendy, a number of guidelines have been published in an attempt to define the condition and provide treatment guidelines [3,4], Despite this, much confusion still exists regarding the appropriate approach to diagnosing late life hypogonadism.

There would appear to be some consensus that the appropriate diagnosis of late life hypogonadism requires a complex of symptoms as well as an arbitrary testosterone level. The first problem arises in determining which constellation of symptoms determines that a male has late life hypogonadism. Part of the problem is many of the symptoms of late life hypogonadism are similar to those of depression, protein energy undernutrition, fatigue and frailty [5- 8] and some, such as muscle weakness (sarcopenia), are considered by some to be a characteristic of the aging process [9]. While attempts to create symptom complexes as questionnaires, such as the Saint Louis University Androgen Deficiency in Aging Males (ADAM) questionnaire and the Aging Male Survey are highly sensitive, they have suboptimal specificity [10-16]. There is also a pervasive viewpoint that a careful history and examination by a clinician would in some magical way perform better than either of these two questionnaires [17]. This viewpoint has not been tested, though an attempt to look at a variety of other symptoms failed to enhance the specificity [13, and unpublished observations].

A problem with symptoms is that recent studies have shown that there is marked inter-individual variation of the testosterone level at which symptoms occur, though within an individual the level appears to be relatively constant [18,19]. Using a single symptom, namely libido, as the gold standard for the diagnosis has also proved to be poorly associated with a given level of total or calculated bioavailable testosterone [20]. An attempt to improve the discriminate value of libido by using CAG repeats as a determinant of testosterone receptor efficacy also proved not to be successful [20]. Thus, while there is ample evidence that a low libido in the presence of some level of ‘low testosterone’ can be reversed by testosterone therapy [21], a low libido by itself is insufficient to allow the diagnosis of hypogonadism. Similar problems exist with determining the role of testosterone in producing poor quality erectile function [22-25]. There is even less ability to use other symptoms classically associated with hypogonadism as diagnostic markers. At a minimum it would appear that prior to using symptoms as a partial component of the diagnosis of late life hypogonadism, both depression and hypothyroidism should be excluded. Another conundrum is that many of the symptoms associated with hypogonadism are commonly seen in persons with illness and many of these diseases can produce low testosterone levels [26].

If symptoms perform poorly to diagnose late life hypogonadism then perhaps a biochemical measurement would be a better diagnostic tool? It is now well recognized that total testosterone, free testosterone and bioavailable testosterone all decline with aging [27-30]. Thus, a reasonable approach would be to create a normal range for young persons and use values below the normal range to make the diagnosis. This has stood endocrinologists in other conditions, e.g. hypothyroidism, in good stead over the years. Unfortunately, there are young persons with perfectiy normal libido and sexual function, who spend a significant portion of the day with testosterone levels well below any arbitrary normal range [31]. While, in part, this is due to the circadian rhythm, in some individuals these ultra low levels occur at times when testosterone levels would be expected to be well within the normal range [31- 33]. In addition, a significant week to week variation in testosterone levels occurs [34,35]. Further, classical testosterone measurements have been shown to be highly variable from assay to assay and often it appears that normal values for the assays have not been appropriately calculated [36-38]. Because most late-onset hypogonadism is due predominandy to hypothalamic-pituitary dysfunction, measurement of luteinizing hormone is not useful in aiding in the determination of gonadal status [39,40].

A second controversy in the measurement of testosterone in the diagnosis of hypogonadism revolves around whether total testosterone is sufficient or if some measure of unbound (free) or loosely bound (bioavailable) testosterone is a more appropriate measure [34,38,41- 44]. Endocrinology has championed the measurement of free hormones and it seems strange that this principle is not championed when it comes to testosterone. While there are sex hormone binding globulin (SHBG) receptors and in some cases cellular effects may be due to testosterone bound to SHBG, this would appear to be a limited situation [44]. When it has been looked at, bioavailable testosterone appears to correlate better with potential hypogonadal symptoms than does total testosterone [45]. Salivary testosterone, a proxy for unbound testosterone, may also perform better than total testosterone [46-48]. Because of the increase in SHBG with aging and a possible alteration in binding kinetics, men with total testosterone as high as 17 nmol/L may have low bioavailable testosterone levels [42, and unpublished observations].

Since the original studies by Tenover [49], Morley et al. [50] and Sih et al. [51] demonstrating positive effects of testosterone replacement in older males with biochemical hypogonadism a number of other placebo controlled studies have been published. While numbers are not large, there is sufficient data to allow rigorous meta- analyses to demonstrate positive effects of testosterone replacement on sexuality and muscle mass and strength [21,52-54]. In addition, a well conducted three year study showed that testosterone increased function in older men [55]. It should be recognized that there is a significant placebo effect, and replacement doses of testosterone may need to be relatively elevated to produce a measurable effect [56]. Finally, evidence for serious side effects in carefully monitored males is minimal [57-59].

Based on the above, we would like to suggest that a combination of symptoms and testosterone measurement is inadequate to make the diagnosis of late life hypogonadism. An appropriate diagnosis of hypogonadism can only be made when an older person has symptoms of low testosterone (or possibly sarcopenia or osteopenia), for which other common causes have been excluded and has a relatively low testosterone (

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35. Vermeulen A, Verdonck G. Representativeness of a single point plasma testosterone level for the long term hormonal milieu in men. J Clin Endocrinol Metab 1992;74:939-942.

36. Lazarou S, Reyes-Vallejo L, Morgentaler A. Wide variability in laboratory reference values for serum testosterone. J Sex Med 2006;3:1085-1089.

37. Wang C, Catlin DH, Demers LM, Starcevic B, Swerdloff RS. Measurement of total serum testosterone in adult men: comparison of current laboratory methods versus liquid chromatography-tandem mass spectrometry. J Clin Endocrinol Metab 2004;89:634-643.

38. Rosner W, Auchus RJ, Azziz R, Sluss PM, Raff H. Position statement: utility, limitations, and pitfalls in measuring testosterone: an Endocrine Society position statement. J Clin Endocrinol Metab 2007;92:405-413.

39. Matsumoto AM. Andropause: clinical implications of the decline in serum testosterone levels with aging in men. J Gerontol A Biol Sei Med Sci 2002;57:M76-M99.

40. Morley JE. Androgens and aging. Marmitas 2001;38:61-71.

41 Nankin HR, Calkins JH. Decreased bioavailable testosterone in aging normal and impotent men. J Clin Endocrinol Metab 1986;63:1418- 1420.

42. Vermeulin A, Kaufman JM. Diagnosis of hypogonadism in the aging male. Aging Male 2002;5:170-176.

43. Christ-Crain M, Meier C, Huber P, Zimmerli L, Trummler M, Muller B. Comparison of different methods for the measurement of serum testosterone in the aging male. Swiss Med WkIy 2004;134:193- 197.

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45. van den BeId AW, de Jong FH, Grobbee DE, Pols HA, Lamberts SW. Measures of bioavailable serum testosterone and estradiol and their relationships with muscle strength, bone density, and body composition in elderly men. J Clin Endocrinol Metab 2000;85:3276- 3282.

46. Wang C, Plymate S, Nieschlag E, Paulsen CA. Salivary testosterone in men: further evidence of a direct correlation with free serum testosterone. J Clin Endocrinol Metab 1981;53:1021-1024.

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49. Tenover JS. Effects of testosterone supplementation in the aging male. J Clin Endocrinol Metab 1992;75:1092-1098.

50. Morley JE, Perry HM III, Kaiser FE, Kraenzle D, Jensen J, Houston K, Mattammal M, Perry HM III. Effects of testosterone replacement therapy in old hypogonadal males: re preliminary study. J Am Geriatr Soc 1993;41:149-152.

51. Sih R, Morley JE, Kaiser FE, Perry HM III, Patrick P, Ross C. Testosterone replacement in older hypogonadal men: a 12-month randomized controlled trial. J Clin Endocrinol Metab 1997;82:1661- 1667.

52. Bolona ER, Uraga MV, Haddad RM, Tracz MJ, Sideras K, Kennedy CC, Capies SM, Erwin PJ, Montori VM. Testosterone use in men with sexual dysfunction: a systematic review and meta-analysis of randomized placebo-controlled trials. Mayo Clin Proc 2007;82:20-28.

53. Ottenbacher KJ, Ottenbacher ME, Ottenbacher AJ, Acha AA, Ostir GV. Androgen treatment and muscle strength in elderly men: a meta-analysis. J Am Geriatr Soc 2006;54:1666-1673.

54. Isidori AM, Giannetta E, Greco EA, Gianfrilli D, Bonifacio V, Isidori A, Lenzi A, Fabbri A. Effects of testosterone on body composition, bone metabolism and serum lipid profile in middle-aged men: a meta-analysis. Clin Endocrinol 2005; 63:280-293.

55. Page ST, Amory JK, Bowman FD, Anawalt BD, Matsumoto AM, Bremner WJ, Tenover JL. Exogenous testosterone (T) alone or with finasteride increases physical performance, grip strength, and lean body mass in older men with low serum T. J Clin Endocrinol Metab 2005;90:1502-1510.

56. Haren MT, Witten GA, Chapman IM, Coates P, Morley JE. Effect of oral testosterone undecanoatc on visuospatial cognition, mood and quality of life in elderly men with low-normal gonadal status. Maturitas 2005;50:124-133. 57. Hajjar RR, Kaiser FE, Morley JE. Outcomes of long-term testosterone replacement in older hypogonadal males: retrospective analysis. J Clin Endocrinol Metab 1997;82:3793- 3796.

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JOHN E. MORLEY

Division of Geriatric Medicine, Saint Louis University Medical Center, and VA Medical Center (GRECC), Saint Louis,

Missouri, USA

(Received 21 September 2007)

Correspondence: John E. Morley, MB, BCh, Division of Geriatric Medicine, Saint Louis University Medical Center, 1402 South Grand Boulevard, M238, Saint Louis, MO 63104, USA. Tel: (314) 977-8462. Fax: (314) 771-8575. E-mail: [email protected]

Copyright Taylor & Francis Ltd. Dec 2007

(c) 2007 Aging Male. Provided by ProQuest Information and Learning. All rights Reserved.

So-Called ‘Friendly’ Bacteria May Be Dangerous

By PETA BEE

WITH their promise to rid the body of the ‘bad bacteria’ that make us ill, it’s no wonder so many of us are buying probiotic dietary supplements.

Two million Britons now regularly consume these ‘friendly’ bacteria in the form of drinks, yoghurts, powders and capsules.

‘Friendly bacteria’ sound so harmless. So what then are we to make of the story last week that patients with pancreatic disease had died as a result of being given them? Doctors at the University Medical Centre in Utrecht, Holland, reported that 24 out of 296 patients died during a study to find out whether friendly bacteria known as probiotics affected inflammation of the pancreas.

The researchers said their results were proof that ‘extremely ill’ people should avoid probiotics, and the Dutch Food and Consumer Product Safety Authority has ruled that supplements should not be given to patients in intensive care, those with organ failure or anyone being fed through a drip. So should we be concerned about the new findings? In fact, when it comes to seriously ill patients, many UK hospitals already follow the approach being adopted by the Dutch, says probiotics, are treated as hostile Catherine Collins, chief dietician at St George’s Hospital in London.

In unhealthy people with weakened immunity the so-called friendly bacteria, such as lactobacillus casei or bifidobacteria, which make up probiotics, are treated as hostile invaders.

‘In some cases they can induce a potentially fatal condition called lactobacillus septicaemia,’ says Collins. ‘We’ve treated two cases recently at St George’s.

‘A lot of hospitals don’t embrace probiotics because the living bugs they contain have the potential to cause infection in vulnerable people.’ But what does this mean for the rest of us? Probiotic products aren’t dangerous for healthy people, says Claire Williamson, a nutrition scientist with the British Nutrition Foundation, but adds that manufacturers are often guilty of exaggerating their benefits.

PROBIOTICS are a relatively recent ‘invention’. Russian Nobel Prize winner and father of modern immunology Elie Metchnikoff was the first to discover beneficial bacteria at the beginning of the 20th-century.

He made his discovery after observing how Bulgarian peasants who consumed milk products containing fermenting bacteria appeared to enjoy extraordinary longevity and good health.

It’s now generally accepted that the human gut contains different strains of bacteria, some of which are beneficial, some that help with food digestion and some that are disease – causing.

But do supplements help maintain the ‘healthy’ balance of these bacteria, as proponents of probiotics suggest? Earlier this month, Professor Jeremy Nicholson, chair in biological chemistry at Imperial College London, revealed that lactobacillus probiotics seem to enhance digestion and may even assist weight loss by preventing the body from absorbing fat in food.

But Nicholson and his team were not sure how or why they work and say that, because the studies involved mice not humans, more investigations need to be carried out.

‘They can have an effect but we are still trying to understand what the changes might BLURRED headache eye to SITTING your of Interlace your your hands light eyes mean in terms of overall health,’ he says.

‘We have established that introducing friendly bacteria can change the dynamics of the population of microbes in the gut and could reduce the amount of fat digested by the body, but more work is needed in this area.’

Claire Williamson says: ‘There is some evidence that probiotics can help to stabilise gut flora that is disrupted when people take antibiotics, and also that the supplements can reduce symptoms of IBS.

‘But as yet the findings are inconclusive and should be treated with some caution.’ Critics doubt whether probiotic bacteria survive transit through the gut and suggest they are likely to be killed by acid in the stomach.

They also argue that a pot of probiotic yoghurt containing 1- 5million bacteria is unlikely to have any impact on the 100 trillion bacteria in gut microflora.

Indeed when Glenn Gibson, professor of microbiology at the University of Reading, analysed a range of probiotics on sale in the UK in 2006, he found up to half of them were useless and some contained types of bacteria that rendered them potentially harmful.

‘Around half the products don’t match up to what their label says and have either the wrong bacteria or the wrong numbers,’ he said.

However, better-known brands such as Actimel and Yakult were found by Gibson to contain at least tenmillion friendly bacteria from the lactobacillus or bifidobacteria families, which means they might be effective in aiding digestion.

Another pointer for the types of products to look for came from an earlier study Gibson conducted for the Food Standards Agency.

This showed that products containing high levels (ten million to several billion) of bifidobacterium and enterococcus faecium had the best survival rates in the upper intestine and that lactobacillus bacteria survived for up to five days in the lower intestine.

Drinks containing lactose or oligosaccharides (such as Yakult) or supplements that were enteric-coated so don’t dissolve until they reach the intestine (Multibionta) have the best survival rates. HOWEVER, Gibson’s tests showed that even if they did survive, probiotics did not necessarily lead to a beneficial increase in friendly gut flora. In other words, to some people they may be useless.

Furthermore, many nutritionists, such as Sue Baic, a spokeswoman for the British Dietetic Association, believe a better way to promote natural good gut bacteria is to consume prebiotics substances that support existing gut bacteria.

Found in human breast milk, prebiotics contain oligosaccharides, a type of carbohydrate that only our guts can feed upon and which are necessary for friendly gym necessary for friendly bacteria to multiply and flourish.

‘There are dietary sources such as onions, garlic, chicory and banana,’ she says.

‘But because we don’t eat enough of these, a supplement such as fructooligosaccharide may help friendly bacteria to grow in the gut.’

Black Holes Hungry for White Dwarf Stars

A strange and violent fate awaits a white dwarf star that wanders too close to a moderately massive black hole.

According to a new study, the black hole’s gravitational pull on the white dwarf would cause tidal forces sufficient to disrupt the stellar remnant and reignite nuclear burning in it, giving rise to a supernova explosion with an unusual appearance. Observations of such supernovae could confirm the existence of intermediate-mass black holes, currently the subject of much debate among astronomers.

“Our supercomputer simulations show a peculiar supernova that would be a unique signature of an intermediate-mass black hole,” said Enrico Ramirez-Ruiz, assistant professor of astronomy and astrophysics at the University of California, Santa Cruz.

Ramirez-Ruiz and his collaborators–Stephan Rosswog of Jacobs University in Bremen, Germany, and William Hix of Oak Ridge National Laboratory–used detailed computer simulations to follow the entire process of tidal disruption of a white dwarf by a black hole. Their simulations included gas dynamics, gravity, and nuclear physics, requiring weeks of computer time to simulate events that would take place in a fraction of a second. A paper describing their results has been accepted for publication in Astrophysical Journal Letters, and a preprint is currently available online.

“Every star that is not too massive ends up as a white dwarf, so they are very common. We were interested in whether tidal disruption can bring this stellar corpse to life again,” said Rosswog, the first author of the paper.

A white dwarf can explode as a “type Ia” supernova if it accumulates enough mass by siphoning matter away from a companion star. When it reaches a critical mass (about 1.4 times the mass of the Sun), the white dwarf collapses and explodes. Astronomers use these type Ia supernovae as “standard candles” for cosmic distance measurements because their brightness evolves over time in a predictable manner.

The new paper describes a distinctly different mechanism for igniting a white dwarf, in which tidal disruption by a black hole causes drastic compression of the stellar material.
The white dwarf is flattened into a pancake shape aligned in the plane of its orbit around the black hole. As each section of the star is squeezed through a point of maximum compression, the extreme pressure causes a sharp increase in temperatures, which triggers explosive burning.

The explosion ejects more than half of the debris from the disrupted star, while the rest of the stellar material falls into the black hole. The infalling material forms a luminous accretion disk that emits x-rays and should be detectable by the Chandra X-ray Observatory, the researchers said.

“This is a new mechanism for ignition of a white dwarf that results in a very different type of supernova than the standard type Ia, and it is followed by an x-ray source,” Ramirez-Ruiz said.

He estimated that this type of event would occur about 100 times less frequently than the standard type Ia supernovae, but should be detectable by future surveys designed to observe large numbers of supernovae. The Large Synoptic Survey Telescope (LSST), planned for completion in 2013, is expected to discover hundreds of thousands of type Ia supernovae per year.

“These exotic creatures will start showing up in the data from the LSST,” Ramirez-Ruiz said. “We want to predict the light curves so we can look for them in the survey data.”

The mechanism described in the paper requires a black hole that is neither too small nor too big. Such intermediate-mass black holes (500 to 1,000 times the mass of the Sun) may reside in some globular star clusters, but there is much less evidence for their existence than there is for the relatively small stellar black holes (tens of times the mass of the Sun) or for supermassive black holes (a few million times the mass of the Sun), found at the centers of galaxies.

The new paper describes in detail the disruption of a white dwarf with two-tenths the mass of the Sun by a black hole 1,000 times the mass of the Sun. The researchers also found that they can vary the mass of the white dwarf and still get the same outcome–tidal disruption and ignition of the white dwarf.

“We can ignite the whole mass range of white dwarfs if they get close enough to the black hole,” Rosswog said.
This research was supported by the Department of Energy’s Program for Scientific Discovery through Advanced Computing.

PHOTO CAPTION: This series of images shows the interaction of a white dwarf star with a black hole. As it passes the black hole, the white dwarf becomes strongly compressed and heated (top left), triggering an explosion. Most of the stellar mass is ejected into space (the “bubble” in the upper right part of the debris in the top right image), while the rest (the cusp-like part of the image) falls toward the black hole. While the ejected matter expands rapidly, the infalling matter builds a violent, thick accretion disk around the black hole. (Credit: University of California – Santa Cruz)

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University of California – Santa Cruz

Gender Differences In IQ Smaller Than Believed

In an interview with Newsweek’s Joan Raymond, British Researcher Adrian Furnham reveals that men are not necessarily more intelligent than their female counterparts; however they certainly believe that they are. Adrian Furnham is a professor of psychology at University College London who studies “perceived intelligence”, or how smart people think they are.

Furnham’s analysis of nearly 30 studies showed that in all actuality, men and women are fairly equal in terms of IQ. He claims that usually men tend to score higher on spatial tests, and women score a bit higher in language development and emotional intelligence. Neither of these things seems to make for a real difference when it comes to intelligence and gender.
The studies Furnham analyzed were international, and his findings show that across the globe, men show pride when it comes to their intelligence; they seem to over-inflate it. Women on the other hand, minimize their own.

When asked if most men think they’re Albert Einstein, Furnham replied, “There certainly is a greater male ego. It’s what we call the male hubris and female humility effect. Men are more confident about their IQ. These studies show that on average, women underestimate their IQ scores by about five points while men overestimate their own IQs. Since these studies were international in scope, the results were essentially the same whether women were from Argentina, America, Britain, Japan or Zimbabwe.” There may be even more factors affecting perceived intelligence, one of those being IQ distribution. In a university setting, especially, men tend to be at the top and the bottom of the bell curve, while women fall in the middle.

It isn’t just the men who think they are more intelligent, the women perceive them as smarter across generations as well. This could mean trouble for children, as parents frequently perceive their sons as smarter than their daughters, solely based on their gender. This is interesting since Great Britain’s school results show that girls are outshining the boys in nearly every subject.

As far as real-world application goes, this study does matter, according to Furnham. Because men perceive themselves as smarter, they are more confident about their abilities. A woman may be incredibly bright, but she may go into a job interview with low self-confidence, while a less intelligent or similarly intelligent man may enter into the interview being incredibly confident and showing self-belief. In a setting like this, self-esteem may be more important than ability.

Furnham does not necessarily want to advocate self-help training. He thinks many of the gurus in that field have incorrect arguments. In his opinion, “”¦it should be that increased performance and feedback on the causes of that performance, ability or effort raises self-esteem.”

On the Net:

University College London

University HealthSystem Consortium Hits 100-Member Milestone

The University HealthSystem Consortium (UHC) Board of Directors approved the membership request of Baylor Clinic and Hospital in Houston, Tex, increasing the size of UHC’s membership to 100 full members. The UHC board approved Jackson Health System in Miami, Fla, and University of Louisville Health Care in Louisville, Ky, as the 98th and 99th members, respectively, during the same meeting.

UHC, an alliance of 100 academic medical centers and 153 of their affiliated hospitals, offers its members specific programs and services to improve clinical, operational, and patient safety performance. In addition to accessing these services, new members Jackson Health System and Baylor Clinic and Hospital will use UHC’s Supply Chain Optimization services, accessing the contract portfolio through UHC’s contracting services company, Novation.

“We are pleased that these organizations understand the value of UHC membership, and we know that their unique contributions will enhance the UHC experience for all consortium members,” said Irene M. Cumming, president and chief executive officer of UHC.

In a unique situation, nonprofit Baylor Clinic and Hospital chose to join UHC while under construction. Operated by the Baylor College of Medicine, the hospital and outpatient clinic is slated to open 250-bed Phase I in 2010 and expand to 600 beds in Phase II.

“Being familiar with the value UHC affords its members, we believe that our relationship with the alliance and access to its services will provide solid footing as we create state-of-the-art care for the Houston community,” said Donna Sollenberger, chief executive officer of Baylor Clinic and Hospital. Sollenberger recently served as president and chief executive officer of University of Wisconsin Hospital & Clinics, a UHC member.

Jackson Health System, a 2,139-bed organization, operates 3 hospitals, 2 nursing homes, and 12 community clinics in Miami. The system has a physician education affiliation with the University of Miami and Florida International University. Jackson Memorial Hospital, one of the largest public teaching hospitals in the United States, is south Florida’s most complete health care provider.

University Medical Center comprises University Hospital and the James Graham Brown Cancer Center and works in partnership with the University of Louisville Health Sciences Center, which includes the Schools of Medicine, Dentistry, Nursing, and Public Health and Information Sciences. James H. Taylor, president and chief executive officer of University Medical Center, expects long-term benefits for University of Louisville Health Care through the new alliance with UHC.

“As the region’s leading academic medical center, we are committed to providing quality care to the people of western Kentucky and southern Indiana, as well as being the primary teaching medical facility for the University of Louisville Health Sciences Center,” said Taylor. “Collaboration with the country’s other top academic medical centers will only propel us to a new level of research and patient care.”

About UHC

Visit the About UHC section at www.uhc.edu for more information.

 UHC Media Contact: Linda Bosy 630/954-2808 or 312/301-6328 cell Email Contact

SOURCE: UHC

Are Germs Muscling in to Your Gym?

ALLENTOWN, Pa. — This is the time of year when health clubs are packed with well-intentioned people sweating and grunting their way back into shape.

While it was never very appealing to lie face down on a sweaty weight bench or grasp the handles of a cardio workout machine moistened by the previous user, it’s even less appealing, some might say foolhardy, in this new MRSA-conscious world.

Although the media’s attention was focused on preventing the new virulent strain of methicillin-resistant Staphylococcus aureus, or MRSA (pronounced mersa), in school gyms, some health club patrons wonder if it’s not so far-fetched to worry if they could pick up MRSA at their gyms.

Cathy Katzer, a social worker in Allentown, Pa., says anything’s possible, especially after she got plantar warts on her feet at a gym where she used to belong. Katzer praises the cleanliness at her new gym, but even so, she’s mindful to spray and wipe down the handrails on the treadmill after she works out on it.

“It’s not like I sweat and drip all over it,” Katzer emphasizes; it’s just good hygiene.

Parmita Rios of Fountain Hill, Pa., says everyone in her health club’s spinning class is required to spritz and wipe the bicycle handles and seats when class ends.

“Now I try to do it beforehand,” Rios says.

In an informal survey, the Morning Call looked at four gyms in Pennsylvania’s Lehigh Valley _ public and private, large and small _ to see whether they made cleaning agents readily available for members to wipe down equipment.

We found that all four gyms made available spray bottles filled with some sort of solution. Three gyms provided paper towels with the spray bottles; two offered the same cloth towel that was to be re-used many times by different people; two offered waterless, alcohol-based hand sanitizers and one included a dispenser of pre-moistened towelettes.

Most of the gyms provided one cleansing method. One made three of the methods available to its members and another club offered two cleaning options.

At least one of the clubs posted notices in the men’s and women’s locker rooms that stated patrons must wipe the equipment after each use.

Gym rats can rest easy, though. The Centers for Disease Control and Prevention say the chances are low of getting infected by MRSA at a health club. In addition, community-acquired MRSA is a less virulent strain of MRSA than the one found in hospitals and is easily treated, the CDC says.

Nevertheless, the Journal of American Medical Association found it important enough to publish a recent article that said public health officials are concerned about the growing number of cases of community-acquired MRSA in otherwise healthy people.

Reports vary on whether there have been any documented cases of MRSA acquired at health clubs. MRSA is not a reportable disease. Dr. Kent Aftergut, an assistant clinical instructor of dermatology at the University of Texas Southwestern Medical Center, says he has treated about a half dozen people who say they contracted staph at a gym.

The CDC and the International Health and Racquet and Sportsclub Association, a trade group with 8,800 members worldwide, say there have been no documented cases of people who contracted MRSA at a health club.

“Being healthy and being active in and of itself is a good way to fight off infection in general. We encourage people to go to clubs, as opposed to running away,” says Rosemary Lavery, a spokeswoman for IHRSA. The association has long had a standing list of health and sanitation guidelines its member clubs should follow.

But since the media coverage of community-acquired MRSA, concern has grown about contracting MRSA in health clubs and some health organizations have issued guidelines specifically aimed at public fitness centers.

“We have received many, many calls from people asking about how to protect themselves when they go to their health clubs,” says Betsy McCaughey, founder of the Committee to Reduce Infection Deaths, a not-for-profit organization dedicated to protecting patients and the public from infection.

The committee’s list of safeguards aimed at schools can also apply to public and private gyms, McCaughey says. For instance, people should not use bar soaps, whether at school gyms or private health clubs, because MRSA and other bacteria can live in soap dishes for up to 90 days, she says.

The committee also advises health clubs to do bacterial sampling from gym equipment, as MRSA and other bacteria can live up to 90 days on fabric and hard surfaces, she says.

McCaughey says equipment that has antimicrobial coatings embedded in the material may help “because it’s very difficult to constantly clean this equipment.” Liquid disinfectants have to remain on a surface for three minutes to kill bacteria, she says.

“You know most people spray something out of a Windex bottle, wipe and go. That won’t kill MRSA. You have to drench and wait,” McCaughey says.

A study of sports equipment at two fitness centers in a military community published in the Clinical Journal of Sports Medicine in 2006 showed benign bacteria and the rhinovirus, which causes the common cold, were on 63 percent of equipment surfaces that had contact with hands. Weight equipment was significantly more contaminated than aerobic equipment, the study said. Despite the presence of bacteria, the researchers concluded “there is little risk of exposure to pathogenic bacteria and that disinfecting the equipment will not offer significant protection against viruses.”

KarenBeth Bohan, an infectious disease specialist at the Nesbitt School of Pharmacy at Wilkes University, is intrigued with the question of MRSA in public fitness clubs and says it’s an area that warrants further study.

“I think the risk is pretty low, although there is some amount of risk,” she says.

Bohan is currently leading a research team studying MRSA strains in Wilkes-Barre, Pa., from people who visited hospitals or were in the community. The study does not look at specific locations in the community where people may have been infected with MRSA.

Public health officials advise the public to practice good hygiene anyway in exercise facilities, MRSA scare or not. One is far more likely to pick up cold or flu germs because they can be spread through a cough or sneeze.

That is little comfort when we know not everyone at the gym is as diligent about cleaning the equipment or themselves before and after they’ve exercised. And one would be hard-pressed to find a health club that had a cleaning crew at the ready to mop up the sweat on equipment each and every time someone used it.

“Good hygiene is very, very important and should not be underestimated,” emphasizes Dr. Jeffrey Jahre, chief of infectious diseases at St. Luke’s Hospital and Health Network.

“You need to disinfect all athletic equipment that is going to have skin contact. These are wiped down with a disinfectant cloth and that’s all you need to do,” Jahre says.

Don’t give MRSA or any other germ an opportunity to infect through an opening in the skin. Cover open sores, paper cuts, abrasions, wounds or other kinds of breaks in the skin with a clean, dry bandage, health experts say.

Other standard hygienic practices include washing your hands, your body and your clothing with soap and water after a workout.

“Staph is carried in the skin and handwashing is probably your most effective tool in preventing the acquisition of MRSA or spreading MRSA,” Jahre adds.

Haz-mat teams don’t need to come in and sterilize your gym, but facilities should regularly clean equipment that comes in contact with skin and make cleaning agents easily available for patrons.

“Most gyms should have procedures to wipe the kind of equipment that’s a likely source of contact (with skin), primarily mats. There are frequently abrasions when people are rubbing against mats. Mats are the one area that tend to be a source,” Jahre says.

Cleanliness should be standard operating procedure at all health clubs, such that members _ either through enforced rules or peer pressure _ wipe down equipment each time they use it, says Dr. Luther Rhodes, chairman of the infectious diseases department at Lehigh Valley Hospital.

“You can’t expect at the end of the day the cleaning crew is going to be sufficient. In the course of a day, 15 people may use the same workout equipment,” Rhodes says.

“Have the health club provide moist towelettes to wipe the equipment or antiseptic alcohol-based hand gel,” he says. Disinfectant sprays are effective but not ideal because they can get in the air and disturb some people, Rhodes says.

“Ideally, you should (wipe down) before you use the equipment and after you’re done. It’s a double obligation. It’s one thing if you’ve cleaned afterwards, but you can’t guarantee that the person before you cleaned it,” Rhodes says.

The disinfectants should be visible and easy to access at your gym, Rhodes advises. If they’re not provided, Rhodes says patrons should go to management and insist on them.

“This isn’t something people should have to bring (antiseptic cleaners) with them. They should ask for them and demand them or go somewhere else. I think it’s that serious a deal,” Rhodes says.

“I’m not the kind of person to badger an industry. This is new to everybody, the community spread of MRSA. It’s got everyone’s attention and people are afraid of it. Here’s something you can do, you being a business that wants to satisfy customers and make people feel safe. Their reputation is on the line with this issue.”

“Staph isn’t that hard to eradicate if some care is taken,” he adds.

McCaughey of the Comittee to Reduce Infection Deaths, says she’d like to see health clubs take “more effective precautions” than offering sprays bottles and paper towels because, she predicts, “there will be lawsuits at health clubs based on this.”

Bohan of Wilkes University says there’s no reason to panic. “Your skin is really a great barrier,” she says. “We do not live in a sterile world,” Bohan says, “but we’re not getting infected all the time. If you’re clean the risk is low.”

“The point is people need to be aware that you can get infected with MRSA. So maybe in the past you’d get a little sore on your arm or finger and it got infected. Maybe you tended not worry about it and put a topical antibiotic on it and did not see a doctor. In this age of MRSA, we probably need to be a little more cautious of things like that and not let them get real bad,” she says.

The important message is to focus on prevention, experts say.

“You have to balance reason and practicality with optimal effect. You’re not going to get this from casual contact,” says Jahre of St. Lukes Hospital.

Social Technology As a New Medium in the Classroom

By Yan, Jeffrey

New modes of everyday communication-textual, visual, audio and video-are already part of almost every high school and college student’s social life. But can such social networking principles be effective in an educational setting? At the Rhode Island School of Design (RISD) where I teach, students spend a lot of time on Facebook and other social networking sites. There is also an emerging interest in sharing academic achievements through social sites. RISD students have populated a rich repository of e- Portfolios in a directory (http://risd.digication.com/ portfolio/ directory.digi) which allows faculty, alumni, prospective students and prospective employers to browse through student work. Giving students the ability to share their work in this way transforms them into authors and publishers. Brian Hutcheson, who recently completed a master’s in teaching at RISD, created a program e-Portfolio as part of his degree requirement and an e-Portfolio showcasing a specific lesson on toy design he created while student teaching. (http://risd.digication.com/curvin mccabe6/Home/.) This e- Portfolio, which was shared publicly in RISD’s e-Portfolio directory, caught the attention of a highly regarded art textbook publishing company, Davis Publications, and was featured in their latest edition of School Arts magazine. Connections and opportunities like this arise often when the work of teachers and students is shared beyond the classroom through social technology.

In addition, schools and colleges increasingly employ new kinds of communications such as blogs and wilds.

Blogs. Blogs are simple online journals with entries organized chronologically-a structure many people find intuitive and easy to follow. New content is displayed prominently at the top, while older information gets archived.

Additionally, blogs offer RSS (real simple syndication) feeds that allow anyone to “subscribe” to be notified when new blog posts become available. Comments connected to individual postings on the blog give the author the opportunity to receive feedback from visitors.

Blogs are great tools for class interaction. Teachers can choose to have one blog to post teaching materials, in forms of images, files and links. Comments can be posted by teachers, classmates, parents or anyone who has been given access. Receiving feedback about coursework from not just a teacher, but also peers or possibly the outside world can be very empowering to students.

They are easy to set up and usually free of charge. Popular blogging platforms used in classrooms include Blogger (www.blogger.com) and EduBlogs (www.edublogs.org).

Blogs can be networked and created by teachers and students to form a community of blogs where students in a single class or even all students on a given campus can each present their own findings and discoveries. A colleague of mine, David Bogen, created a rich, active community with blogs at Emerson College (http://www. digital- culture.com). Students are publishing their work, thoughts and ideas on a regular basis. For example, students in the “Digital Culture” learning community post all their writing and multimedia work from several classes within the blog/portfolio environment, and use the course blogs for organizing collaborative projects.

Students are publishing their work, thoughts and ideas on a regular basis. Students are very capable of separating academic and social contexts. Emerson students use the blogs to collaborate academically, but Facebook to socialize.

Wikis. Teachers who want their students to be able to work together in an online publishing environment and need collaborative editing tools for students look to the wild.

Wikis are often used for group-based writing projects, collaborative notetaking or brainstorming. Teachers can set up wikis for groups of students, allowing them to give feedback with equal footing, make suggestions and changes and jot down ideas. Everyone is an author of the wild at the same time. Authors can start with very informal ideas and gradually edit and create drafts of their writing to be further edited and shaped by other authors of the wiki.

The best-known example is Wikipedia (www.wikipedia.com), the online encyclopedia written collaboratively by users around the world. Its global popularity is a testament to the strength that a collective has when united to communicate, share and build content together. At a much smaller and more controlled level, the capabilities of a wild in the classroom can broaden the learning experience, as student groups build rich, deep content over time. A great example can be found at Brown University’s wild site (https:// wiki. brown, edu/confluence/dashboard. action), topics from “Biomed” to “Men’s Club Soccer” can be found, with students collaborating across campus. In an interesting wiki created for a Chemistry Language course, students are building a collaborative reference of chemistry language terminology (https://wiki.brown.edu/ confluence/ display/CHEM/Chemistry +Language). Scrolling down the page, readers see a growing list of terms that students submitted with questions as well as instructor prompts, audio recordings of students using this terminology and chemistry equations.

Commercially available Wild software such as PBWiki (www.pbwiki.com) and WildSpaces (www.wildspaces.com) are very popular in the classroom today because of their ease of setup (usually 15 minutes or less) and their inherent flexibility and collaborative editing features. In Brown’s Chemistry Language wiki, the instructor creates the structure of the wild, invites students to join and then provides the students with guidelines on what kind of content should be submitted and how often (https:// wiki.brown.edu/ confluence/display/CHEM/About+Thi s+Site). Providing the students with information about the purpose and format of the wild leads to greater success within a course.

Online Learning Communities. Teachers looking for school- specific collaboration tools may be interested in established, educationally based social networks and online learning communities that can address schoolor district-wide communications. An example would be Elgg’s educational social network (www.elgg.net) that leverages blogs. Another example is Digication’s learning community (www.digication.com), which is based on e-Portfolios. These educationally based communities have safeguards in place to eliminate the dangers found in open social networks, like MySpace and Facebook. These networks are administrated by schools giving them the ability to control the level of openness, define permission settings and disallow outsiders who do not have passwords keeping the network safe and secure.

One unique feature that Elgg offers allows schools to run and host their own social network locally on their own servers. If a school has the necessary expertise in supporting such a network, staff can download the software free of charge and have complete control over the underlying code. Having access to the underlying code enables schools that prefer to be able to customize and manage software onsite using school owned hardware and IT resources to have that flexibility.

Digication’s e-Portfolio based online learning communities give teachers and students in K-12 and higher education institutions the ability to personalize and share their content. At RISD’s Art + Design Education Department, the students utilize e-Portfolio templates, which provide areas for syllabi, assignments, completed assignments with reflections by students and then evaluation comments by faculty. The e-Portfolio contains an archive of courses and assignments for each student for the entire degree program. From this documentation, faculty provide regularly scheduled critiques throughout the program. The student may then use the information to create a ‘job search’ e-Portfolio. An example of such an e- Portfolio, also referred to as a Program Portfolio can be seen at http://risd.digication.com/ mwall/Home.

Collaboration Motivates Participation. The new generation of Web 2.0 solutions are easier to use, more engaging and are making a larger impact upon collaboration and communication in the classroom than complex technologies of the past. Technologies adopted in schools today, including blogs, wikis, social networking and online learning communities, are keeping teachers and students connected in and out of class. They are creating opportunities for groups to share, collaborate, showcase and grow together. In addition, they allow exchange of information and ideas not only within the confines of a classroom, but across schools, districts, states and the world. Even 10th grade computer science classes are taking advantage of social technologies for crosscultural exchanges.

Teachers are amazed at how simple tools for sharing work and ideas can positively transform the classroom. Students who may avoid live class participation are leveraging new communication forms to become more active and “vocal” in a virtual class. The freedom to publish and share ideas creates a learning environment that empowers and motivates both teachers and students.

Jeffrey Yan is co-founder of Digication. He teaches a graduate course at Rhode Island School of Design on integrating technology into the classroom. [email protected].

Copyright New England Board of Higher Education Winter 2008

(c) 2008 Connection, New England’s Journal of Higher Education. Provided by ProQuest Information and Learning. All rights Reserved.

Thyroid Storm Induced By Blunt Thyroid Gland Trauma

By Delikoukos, Stylianos Mantzos, Fotios

Isolated thyroid gland injury due to blunt neck trauma is uncommon and rarely complicated by thyroid storm in patients without known hyperthyroidism. The aim of this study was to report our experience on blunt thyroid gland injury followed by massive gland hemorrhage, acute airway obstruction, and symptoms of thyroid storm. Among 231 patients with neck trauma, four patients appeared with isolated thyroid gland injury. In two of them, the diagnosis of simultaneous thyrotoxic crisis was made on the basis of clinical findings and confirmed on emergency laboratory tests. The diagnosis of thyroid gland injury was supposed by the history and physical examination and established after neck exploration. Therapy was directed at stabilizing the patients by correcting the hyperthyroid state, followed by operative treatment. Left lobectomy and total thyroidectomy were performed and, along with postoperative medical measures, led to uneventful recovery. This study demonstrates that thyroid gland injury due to blunt neck trauma, although uncommon, may result in potentially life-threatening thyroid storm due to rupture of acini and liberation of thyroid hormones into the bloodstream. This may occur in patients without known hyperthyroidism. BLUNT NECK TRAUMA is commonly encountered in cases of vehicle crashes, but isolated thyroid gland injury is rare. ‘ The frequency of thyroid gland injury due to blunt neck trauma is about one to two per cent.1-3 According to most of the reported cases, posttraumatic thyroid gland hematoma occurred in patients with a history of pre-existing goiter.2-4 Hemorrhage into a normal thyroid gland, caused by blunt neck trauma, is extremely rare.4 On the other hand, thyroid storm after trauma has rarely been reported and usually occurs in patients with known hyperthyroidism.5, 6 Thyroid storm induced by direct thyroid gland trauma has not been published in the literature. The aim of this study was to report our experience on isolated blunt thyroid gland injury followed by massive hemorrhage, acute airway obstruction, and symptoms of thyroid storm. The diagnosis of gland injury was proved by neck exploration. Thyrotoxic crisis was initially suspected on the basis of clinical findings and established by laboratory tests.

Patients and Methods

Between 1988 and 2005, 231 patients (175 men) presented to the emergency department complaining of blunt neck trauma due to traffic or other injury. Four appeared with isolated thyroid gland injury. In two patients, (women, 29- and 65-years-old) the trauma led to thyroid crisis. The two patients denied a previous history of goiter or symptoms of hyperthyroidism.

The first patient sustained neck trauma due to a motor vehicle accident. The patient, seated behind the driver without a fastened seat belt, struck her neck on the front seat. She arrived at the hospital 60 minutes after the crash. The patient was awake, normotensive, and free of respiratory problems. She manifested low grade fever (37.8[degrees] C), tachycardia (140 pulses/min), nervous system disorders (tremor and facial abrasions), and gastrointestinal dysfunction (nausea and vomiting). On physical examination, other than some smooth enlargement on the left anterior neck region, no signs of injury were visible.

The second patient fell in the bathroom due to a slippery floor and struck her neck on the wash-basin. She developed the sensation of having a lump in her throat and she had difficulties in swallowing. She was transferred to the hospital 12 hours after the accident because of increasing neck pain and worsening respiratory distress. She manifested high fever (39.2[degrees] C), supraventricular arrhythmias, central nervous system symptoms (tremor), and gastrointestinal dysfunction (vomiting and diarrhea).

The diagnosis of thyrotoxic crisis was supposed in both patients based on their clinical findings. Emergency laboratory tests were ordered (T^sub 3^, T^sub 4^, TSH) and initial medical and supportive therapies, directed at stabilizing the patients and correcting the hyperthyroid state, were applied. Cooling blanket, cold fluid infusion, flurbiprofen, diltiazem, and verapamil were used to decrease body temperature and heart rate. Radiological examinations (ultrasonography or computed tomography) were omitted due to the patients’ crucial condition. The laboratory test results, several hours later, revealed the total T^sub 4^ equaled 28 [mu]g and 26 [mu]g for the two patients respectively, [normal ranges (nr) 4-11 [mu]g/100mL], free T^sub 3^ equaled 330 mg and 325 mg, (nr = 160- 320 mg/100 mL), free T^sub 4^ equaled 4.3 mg and 4.1 mg, (nr = 0.8- 2.9 mg/100 mL), TSH equaled 0.2 ng and 0.3 ng, (nr = 1-10 ng/mL), and confirmed the diagnosis of acute thyroid storm.

Soon after the diagnosis of possible thyroid gland injury was confirmed in the first patient, the initial swelling in her left neck became extensive and congestion of the jugular veins developed. Acute respiratory distress prompted emergency operation. After a difficult intubation due to severe tracheal displacement, a neck exploration disclosed a ruptured left thyroid lobe. The left lobe was encased by a large expanding hematoma; the right lobe seemed normal. No larynx, trachea, or vascular injury was noted. A left thyroid lobectomy was performed.

The second patient was operated on due to deteriorated respiratory distress, soon after she was stabilized and the hyperthyroid state was partially corrected. A neck exploration confirmed the presence of a neck hematoma due to rupture of the upper thyroid artery. The right thyroid lobe seemed to be injured as well and a subtotal thyroidectomy was performed.

After operation, both patients were in agitated state for 4 and 6 hours respectively, along with hyperpyrexia and tachycardia. Thiamazole and propranorol were administrated for 1 week postoperatively, and thyrotoxic symptoms were declined with body temperature and heart rate of 36 to 36.7[degrees] C and 80 to 90 beats/minute respectively. Follow-up thyroid hormone studies at 1- day interval were gradually improved. Hormone values were lowered and became normal within 6 days. At 2-months and 1-year follow-up the patients were doing well.

Discussion

Neck trauma is common in motor vehicle accidents and may result in bony, muscular, nervous, vascular, and aerodigestive tract injuries.7, 8 Traumatic hemorrhage into a normal thyroid gland however, is rarely reported and therefore an unexpected finding. Few cases have been published, mostly in patients with pre-existing goiter or thyroid adenoma, and this may explain the isolated thyroid gland hemorrhage.1-4, 7 In our two patients there was no history of goiter, thyroid gland adenoma, or hyperthyroidism. Besides, no pathology other than hemorrhage was found in the examined gland specimens.

The diagnosis of isolated thyroid gland injury due to blunt neck trauma is difficult. An increasing paratracheal or pretracheal cervical swelling may be present in most patients after neck trauma. The onset of life-threatening symptoms and severe respiratory distress may require emergent airway management, including intubation or tracheostomy, usually before the diagnosis of thyroid gland injury is established. Most of the patients are operated urgently and neck exploration confirms the diagnosis of thyroid gland injury.4-9 Emergency investigations, such as computed tomography and/or ultrasonography of the neck, can establish the diagnosis of thyroid gland injury preoperatively.4, 7-10 In most cases however, radiological examinations are omitted due to patients’ crucial condition, and this happened in our patients as well.

Although Hsieh and Chou7 reported one case of conservative treatment of thyroid gland injury after blunt cervical trauma, almost all cases of traumatic thyroid gland hemorrhage were treated surgically by evacuation of the hematoma, debridement of the crushed thyroid tissue, and lobectomy or thyroidectomy. Most of these patients were operated on immediately after respiratory distress was encountered.1-4, 9 Few patients without respiratory symptoms required delayed operation after the diagnosis of thyroid trauma was established.8

Thyroid storm is a potentially life-threatening medical emergency caused by an exacerbation of the hyperthyroid state characterized by decompensation of one or more organ systems. It usually develops in patients with longstanding untreated hyperthyroidism. The crisis has an abrupt onset and is more often precipitated by an acute event such as surgery, trauma, or infection. Early recognition and aggressive treatment are fundamental in limiting the morbidity and mortality associated with this condition.11, 12 The clinical picture is characterized by four main features: fever, tachycardia or supraventricular arrhythmias, central nervous system symptoms, and finally gastrointestinal symptoms. The diagnosis of thyroid storm is often made on the basis of clinical findings alone, inasmuch as it is difficult in most emergency departments to obtain rapid confirmatory laboratory or nuclear medicine tests.12 Treatment of thyrotoxic crisis is multimodal. Initial medical and supportive therapies are directed at stabilizing the patient, correcting the hyperthyroid state, managing the systemic decompensation, and treating the underlying cause.5 Our two patients denied a previous history of goiter or symptoms of hyperthyroidism. Thyroid storm was due to blunt thyroid gland injury after direct neck trauma, as a consequence of rupture of acini and liberation of thyroid hormones into the bloodstream. The diagnosis of thyrotoxic crisis in both patients was based on clinical findings and established after emergency laboratory test results. Initial medical and supportive therapies were applied, followed by postoperative measures until symptoms resolved. REFERENCES

1. Lawton G. Traumatic hemorrhage into the thyroid simulating major-vessel damage from deceleration injury. Thorax 1974;29: 607- 8.

2. Grace RH, Shilling JS. Acute hemorrhage into the thyroid gland following trauma and causing respiratory distress. Br J Surg 1969;58:635-7.

3. Behrends RL, Low RB. Acute goiter hematoma following blunt neck trauma. Ann Emerg Med 1987;16:1300-1.

4. Rupprecht H, Rumanapf G, Braig H, Flesch R. Acute bleeding caused by rupture of the thyroid gland following blunt neck trauma: case report. J Trauma 1994;36:408-9.

5. Vora NM, Fedok F, Stack BC Jr. Report of a rare case of trauma- induced thyroid storm. Ear Nose Throat J 2002;81:570-2.

6. Waltman PA, Brewer JM, Lobert S. Thyroid storm during pregnancy. A medical emergency. Crit Care Nurse 2004;24:74-9.

7. Hsieh KC, Chou FF. Nonsurgical treatment of thyroid injury after blunt cervical trauma. Am J Emerg Med 2000;18:739-41.

8. Blaivas M, Horn DB, Younger JG Thyroid gland hematoma after blunt cervical trauma. Am J Emerg Med 1999;17:348-50.

9. Oertli D, Harder F. Complete traumatic transection of the thyroid gland. Surgery 1994;115:527-9.

10. Tomoda C, Uruno T, Takamura Y, et al. Ultrasonography as a method of screening for tracheal invasion by papillary thyroid cancer. Surg Today 2005;35:819-22.

11. Nakamura S, Nishmyama T, Hanaoka K. Perioperative thyroid storm in a patient with undiscovered hyperthyroidism. Masui 2005;54:418-9.

12. Migneco A, Ojetti V, Testa A, et al. Management of thyrotoxic crisis. Eur Rev Med Pharmacol Sci 2005;9:69-74.

STYLIANOS DELIKOUKOS, M.D., Ph.D., FOTIOS MANTZOS, M.D.

From the Department of Surgery, Halkis General Hospital, Halkis, Greece

Address correspondence and reprint requests to Stylianos Delikoukos, M.D., Ph.D., 9 Papakiriazi Street, Larissa 41 223, Greece. E-mail: [email protected].

Copyright Southeastern Surgical Congress Dec 2007

(c) 2007 American Surgeon, The. Provided by ProQuest Information and Learning. All rights Reserved.

The Use of a Computed Tomography Scan to Rule Out Appendicitis in Women

By Lopez, Peter P Cohn, Stephen M; Popkin, Charles A; Jackowski, Julie; Michalek, Joel E

Diagnosing appendicitis continues to be a difficult task for clinicians. The use of routine CT scan has been advocated to improve the accuracy of diagnosing appendicitis. When compared with the use of clinical examination alone, CT scan was not significantly different with regard to making the diagnosis of appendicitis in women of childbearing age. The use of computed tomography in making the diagnosis of appendicitis has become the current standard of practice in most emergency rooms. In women of childbearing age, with possible appendicitis, we prospectively compared clinical observation alone (OBS) to appendiceal CT scan with clinical observation (CT). Ninety women (OBS: 48, CT: 42) with questionable appendicitis and an Alvarado Score ranging from two to eight were prospectively randomized. A true positive study/exam resulted in a laparotomy that revealed a lesion requiring operation (confirmed by pathology). A true negative exam/study did not require operation. Hospital stay (OBS = 1.9 +- 1.6 vs CT = 1.3 +- 1.4 days) and charges (OBS = $9,459 +- 7,358 vs CT = $9,443 +- 8,773) were similar. The OBS group had an accuracy of 93 per cent, sensitivity of 100 per cent, and a specificity of 87.5 per cent. The CT group had an accuracy of 93 per cent, sensitivity of 89.5 per cent, and specificity of 95.6 per cent. Although this study is too small to statistically establish equivalence, the data suggest that a CT scan reliably identifies women who need an operation for appendicitis and seems to be as good as clinical examination. DIAGNOSING APPENDICITIS continues to be a difficult task for physicians. This is particularly true in women of childbearing age. Many female patients who are suspected of having appendicitis are found to have other conditions, such as pelvic inflammatory disease, acute cholecystitis, urinary tract infections, ovarian cysts, and gastroenteritis.1 Not surprisingly, negative laparotomy rates for women of childbearing age are reported to be as high as 34 to 45 per cent.2,3

The utility of computed tomography (CT) as a diagnostic examination for appendicitis has been described.4-9 The literature reports a 93 to 98 per cent accuracy in diagnosing appendicitis.4,10- 12 Rao et al.12 suggested that an appendiceal CT scan should be routinely used in all patients because of the high accuracy and cost savings. Despite the growing enthusiasm for routine CT, our group previously reported no added efficacy of CT use in a large prospective randomized trial in patients presenting to the emergency room with right lower quadrant pain comparing clinical assessment alone with clinical assessment and CT.13 Because women of childbearing age may have pain related to other etiologies such as gynecological disorders, we felt that these patients might benefit from the use of routine CT to confirm or rule-out appendicitis. Therefore, we designed a prospective trial focusing on women of childbearing age to determine the role of CT scans compared with clinical assessment alone in diagnosing appendicitis. We hypothesized that the use of an appendiceal CT would improve the accuracy for the diagnosis of acute appendicitis in women of childbearing age.

Patients and Methods

All female patients between the ages of 18 and 45 years presenting to the Surgical Emergency Room at Jackson Memorial Hospital with the possible diagnosis of acute appendicitis between November 1999 and February 2001 and from March 2003 to December 2004 were evaluated for inclusion in the study. The University of Miami institutional review board approved the experimental protocol for both times of the study. All patients gave informed consent. Patients were excluded if they were awaiting interval appendectomy, were unable to receive intravenous contrast for computed tomography, were HIV positive, had known inflammatory bowel disease, or were pregnant.

Experimental Design

Those included in the study were evaluated by the surgical team, consisting of a junior and senior surgical resident and an in-house surgical attending, before the diagnostic work-up. Each patient received an Alvarado clinical score using the following grading system:14 symptoms (migration) (1), anorexia (1), nausea/vomiting (1), signs (tenderness right lower quadrant (RLQ) (2), rebound (1), elevated temp (1), laboratory (leukocytosis) (2), and left shift in polymorphonuclear leukocyte (PMN) (1), for a total of 10.

Using the Alvarado score, we categorized patients in one of three groups. Group 1 had a score greater than eight with a very high probability of having appendicitis. These patients had no further work-up, but proceeded to surgery, with pathological confirmation of appendicitis. Group 2 had a score of less than two with a very low probability of having appendicitis. These patients had no further surgical evaluation except for telephone follow-up to confirm the absence of appendicitis. Group 3 had a score of two to eight with an intermediate probability of having appendicitis. Patients were randomized to either clinical assessment alone or clinical evaluation with appendiceal CT. Randomization was done using a computer and the results were placed in numbered envelopes, opened sequentially when a patient met entry criteria.

All the patients assigned to the clinical assessment (OBS) were admitted to the surgical service and monitored with serial physical examinations and laboratory studies until there was resolution of symptoms, another diagnosis was confirmed (e.g., Pelvic Inflammatory Disease, gastroenteritis, urinary tract infection), or the patient underwent appendectomy for high clinical suspicion. All patients were seen and examined by the surgical team, including an attending surgeon, before discharge. Those patients who were discharged or transferred without having an appendectomy were followed up at 1 week with a telephone call.

Similarly, the patients in the CT arm underwent a CT scan followed by surgery or were discharged after being admitted for a period of observation. All patients who were observed after having a negative CT scan were discharged after resolution of their symptoms without having an appendectomy. These patients were followed up with a 1-week telephone call.

CT Technique and Interpretation

These patients had CT of the abdomen and pelvis with a helical GE HI Speed Advantage Scanner (GE Medical Systems, Milwaukee, WI) after oral administration of 900 mL 2.1 per cent barium sulfate suspension at least 2 hours before scanning. No rectal contrast was administered and all patients received a 125 mL intravenous bolus of Optiray(R)320 (Mallinckrodt Ine, St. Louis, MO). Seven millimeter sections were obtained from the lower lungs through the pelvis at a pitch of 1.5.13 No complications were associated with this radiologic protocol. The scans were interpreted by a senior radiology resident and/or a radiology attending according to previously recorded CT criteria for confirming appendicitis.13

Outcome Measures and Statistical Analysis

The primary endpoint was the presence or absence of appendicitis (confirmed by pathology). We also recorded the presence or absence of gangrenous appendicitis, abscess, and/or perforation. The length of hospital stay and charges were noted in all patients. With 75 patients/group, this study would have a power of 83 per cent to detect a 20 per cent difference in the percentage of patients misclassified (CT: 10%, OBS: 30%), assuming two-sided testing with a significance level of five per cent. Means were contrasted with t tests; if the assumptions of the test were violated, then a Wilcoxon test was used. Percentages were contrasted with Fisher’s exact test. All statistical testing was 2-sided with a significance level of five per cent and SAS Version 9.1 for Windows (SAS Institute, Cary, NC) was used throughout.

Results

From November 1999 to February 2001 and again from March 2003 to December 2004, a total of 95 women of childbearing age were considered for inclusion in the study. None of the study patients presented with an Alvarado score >8 on initial evaluation. There were two patients with an Alvarado Score <2 who were excluded from the study. Additionally, three patients refused randomization during this study period and thus, 90 patients composed our study population.

Forty-eight patients were randomized to OBS group and 42 to the CT group. In the OBS arm, two patients were excluded for protocol violations leaving 46 patients for final analysis (Fig. 1). The two protocol violations were because these two patients received a CT scan after being randomized to the observation group.

There were no differences (Table 1) between the two groups with regard to mean age (OBS: 28.8 years, CT: 27.9 years, P = 0.62), mean Alvarado score (OBS: 5.8, CT: 5.9, P = 0.85), number of perforations (OBS: O, CT: 0,P= 1.0), median white blood cell count (OBS: 13.4, CT: 12, P = 0.5), median length of stay (OBS: 1 day, CT: 1 day, P = 0.22), and median hospital charges (OBS: $10,900, CT: $10,100, P = 0.3).

The number of patients, accuracy, sensitivity, specificity, positive predictive value, and negative predictive value are displayed in Table 2. The accuracy of the OBS and CT groups were 93 per cent and 93 per cent, respectively. The two groups were not significantly different with regard to accuracy (OBS: 93%, CT: 93%, P = 1.0), sensitivity (OBS: 100%, CT: 89.5%, P = 0.21), specificity (OBS: 87.5%, CT: 95.6%, 0.61), positive predictive value (OBS: 88%, CT: 94.4%, P = 0.63), or negative predictive value (OBS: 100%, CT: 91.7%, P = 0.49). Fig. 1. Cohort diagram.

TABLE 1. Patient Characteristics

One patient had a CT scan interpreted as negative. This patient went to the operating room based on clinical assessment and was found to have appendicitis, confirmed by pathology.

A follow-up phone call was attempted at 1 week in all patients who were discharged home without a diagnosis of appendicitis (true negative patients) in both the CT and OBS groups. There were 21 true negative patients in the OBS group, with seven patients who could not be reached. Thirteen were successfully contacted and reported no additional symptoms indicative of appendicitis. One patient did complain of new abdominal pain and was readmitted to our hospital for a hysterectomy. In the CT arm, 12 of the 22 patients could not be contacted. Ten patients in this group reported no further abdominal discomfort.

In the overall study population, there were no bowel perforations, abdominal abscesses, or gangrenous appendices. There was also no mortality.

Discussion

The use of routine CT scan has been advocated to improve the accuracy of diagnosing appendicitis.12, 15 Because an earlier prospective randomized study done by Hong et al.13 did not show any added benefit of routine CT use in all patients who presented with right lower quadrant pain, we hypothesized that routine CT scans might specifically benefit women of childbearing age, a patient group historically plagued by low diagnostic accuracy rates.1, 8 This study is the first randomized prospective trial examining the routine use of CT in diagnosing appendicitis specifically in women of childbearing age. Our results conclude that CT scanning was not significantly different from clinical assessment by a general surgeon and that both modalities accurately identified women who need an operation for acute appendicitis (OBS: 93%, CT: 93%). In addition, we found that hospital length of stay and hospital charges were similar with either the use of clinical examination alone or CT scanning.

The results of our CT scans were based on scanning the abdomen and pelvis after oral and intravenous contrast with a 7 mm slice thickness. The accuracy using this method to rule out or confirm appendicitis was 93 per cent, which compares favorably to other CT series.4, 8, 12, 15 We believe that the 7 mm thickness of the CT slice sufficiently covers the abdomen and pelvis, however the selection of a narrower slice collimation could enhance the detection of the appendix and therefore increase the sensitivity (89.5%) of the CT scans.16 In this study, patients had a complete CT of the abdomen and pelvis to rule out other etiologies for their pain. Noncontrast CT scans have been advocated by Malone et al.5 to expedite the patient’s work-up in the emergency room but with a slight sacrifice in accuracy. Our protocol does not use rectal contrast due to concerns of increased time and the technical assistance required. Other studies using rectal contrast report variable sensitivities, ranging from 84 to 96 per cent11, 17 and increased accuracy (98%).12

Patients who were found not to have appendicitis by CT scan or clinical observation had a follow-up phone call at 1 week postdischarge. These follow-up calls were made at 1 week to confirm the true negatives on patients that were discharged. However, our success rate for getting in touch with these patients after discharge at 1 week was less than ideal. Of the 43 true negative patients in the study, we were only able to contact 24 patients by phone for a follow-up of only 55 per cent. Based on the demographic pattern of our patients, those doing well after discharge rarely return to clinic for their follow-up appointments, thus it was not surprising that we could not get better follow-up by phone. It is possible that some of the 19 true negative patients that we were unable to contact after discharge had appendicitis, which was missed by OBS or CT. However, we believe that this number is zero or low because most of these patients use the county hospital exclusively to receive their medical care. We believe that these patients, if they became sick, would theoretically return to our hospital.

This trial was started in November 1999 and was accruing patients up until February of 2001 when the lead author was finishing his fellowship and leaving the institution. The data at that time was presented at the Southwestern Surgical Clinical Congress in San Diego in April 2001. The study at the time of the presentation was underpowered secondary to not having enough patients enrolled in the study. The lead author returned to the University of Miami in late 2002 and the study was restarted in March of 2003 to enroll enough patients. The protocol for the study was approved for both time periods by the institution’s institutional review board. The study was stopped the second time after entry of a total of 95 patients. The primary reason for halting the trial the second time in December of 2004 was our inability to accrue patients. This was due to the emergency medicine physicians routinely obtaining an abdominal CT scan before consulting the surgical service when evaluating patients with acute right lower quadrant abdominal pain during the last time period of our study. Thus, patients were not available to enter into our trial at the time of consultation, as they had already undergone CT radiologic imaging. It is often stated that “a head CT is worth a room full of neurologists.” In speaking to our emergency medicine colleagues, as well as general surgeons throughout the US, it seems that the current medical culture supports the notion that “an abdominal CT scan is worth a room full of general surgeons.” Surgeons have come to expect the CT results available at the time of consultation for evaluation of acute appendicitis. Abdominal examination by a qualified surgeon is no longer the initial phase in the definitive workup of a patient with right lower quadrant pain who presents to the emergency department.

As a result of not reaching our precalculated sample size, this study is too underpowered to detect a statistical difference. However, from the previous study by Hong et al.,13 a subgroup of women patients of childbearing age was shown to have no difference between CT scan and clinical exam when diagnosing appendicitis. Their results in this patient population are similar to our findings. In Hong’s study, a subset of 48 women of childbearing age were prospectively evaluated following the same protocol as our study and had similar patient characteristics. We believe that this reinforces our findings that either CT scanning or clinical assessment by a surgeon can be used successfully as a screening modality to rule in or out appendicitis in women of childbearing age. In our current study, the negative appendectomy rate was 12 per cent (3 false positives out of 25 clinically examined), which is lower than the negative appendectomy rate reported in the literature for female patients of childbearing age (19-40%).7, 8, 15 If clinicians are unavailable or unable to provide a low negative appendectomy rate with clinical assessment alone, then abdominal CT scans seem to be a valuable tool to aid in making the diagnosis of appendicitis.12, 15, 18, 19

A routine diagnostic test that can accurately and swiftly diagnose appendicitis in women of childbearing age has been desired by clinicians for some time. In the evaluation of right lower quadrant abdominal pain, CT scan seems to be equivalent to clinical examination by a general surgeon without increasing hospital charges or length of stay. This prospective randomized trial found that the use of computed tomography in women of childbearing age who presented with right lower quadrant was not significantly different from clinical assessment by an experienced clinician in accurately identifying patients who require an operation for appendicitis. Although this study is too small to statistically establish equivalence, these data suggest that a CT scan examination reliably identifies women who need an operation for appendicitis and seems to be as good as clinical examination.

REFERENCES

1. Rothrock SG, Green SM, Dobson M, et al. Misdiagnosis of appendicitis in nonpregnant women of childbearing age. J Emerg Med 1995;13:1-8.

2. Deutsch A, Zelikovsky A, Reiss R. Laparoscopy in the prevention of unnecessary appendectomies: A prospective study. Br J Surg 1982;69:336-7.

3. Bongard F, Landers DV, Lewis F. Differential diagnosis of appendicitis and pelvic inflammatory disease: A prospective analysis. Am J Surg 1985;150:90-6.

4. Balthazar EJ, Megibow AJ, Siegel SE, Birnbaum BA. Appendicitis: Prospective evaluation with high-resolution CT. Radiology 1991;180:21-4.

5. Malone AJ, Wolf CR, Maimed AS, Melliere BF. Diagnosis of acute appendicitis: Value of unenhanced CT. AJR Am J Roentgenol 1993;160:763-6.

6. Rhea JT, Rao PM, Novelline RA, McCabe CJ. A focused CT technique to reduce the cost of caring for patients with clinically suspected appendicitis. AJR Am J Roentgenol 1997; 169:113-8.

7. Schuler JG, Shortsleeve MJ, Goldenson RS, et al. Is there a role for abdominal computed tomographic scans in appendicitis? Arch Surg 1998;133:373-7.

8. Rao PM, Rhea JT, Novelline RA, et al. Helical CT technique for the diagnosis of appendicitis: Prospective evaluation of a focused CT examination. Radiology 1997;202:139-44.

9. Stroman DL, Bayouth CV, Kuhn JA, et al. The role of computed tomography in the diagnosis of acute appendicitis. Am J Surg 1999;178:485-9.

10. Choi YH, Fischer E, Hoda SA, et al. Appendiceal CT in 140 cases: Diagnostic criteria for acute and necrotizing appendicitis. Clin Imaging 1998;22:252-71. 11. Lane MJ, Liu DM, Huynh MD, et al. Suspected acute appendicitis: Nonenhanced helical CT in 300 consecutive patients. Radiology 1999;213:341-6.

12. Rao PM, Rhea JT, Novelline RA, et al. Effect of computed tomography of the appendix on treatment of patients and use of hospital resources. N Engl J Med 1998;338:141-6.

13. Hong JH, Cohn SM, Ekeh P, et al. A prospective randomized study of clinical assessment versus computed tomography in the diagnosis of acute appendicitis. Surg Infect (Larchmt) 2003 ;4: 231- 9.

14. Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 1986;15:557-64.

15. Walker S, Haun W, Clark J, et al. The value of limited computed tomography with rectal contrast in the diagnosis of acute appendicitis. Am J Surg 2000;180:450-5.

16. Weltman DI, Yu J, Krumenmacker J Jr, et al. Diagnosis of acute appendicitis: Comparison of 5- and 10-mm CT sections in the same patient. Radiology 2000;216:172-7.

17. Heaston DR, McClellan JS, Heaston DK. Community hospital experience in 600+ consecutive patients who underwent unenhanced helical CT for suspected appendicitis. AJR 2000; 174:53.

18. Balthazar EJ, Rofsky NM, Zucker R. Appendicitis: The impact of computed tomography imaging on negative appendectomy and perforation rates. Am J Gasstroenterol 1998;93:768-71.

19. Rao PM, Rhea JT, Rattner DW, et al. Introduction of appendiceal CT: Impact on negative appendectomy and perforation rates. Ann Surg 1999;229:344-9.

PETER P. LOPEZ, M.D., F.A.C.S.,* STEPHEN M. COHN, M.D.,* CHARLES A. POPKIN, M.D.,[dagger] JULIE JACKOWSKI, R.N.,[dagger] JOEL E. MICHALEK, Ph.D.,* THE APPENDICITIS DIAGNOSTIC GROUP[dagger]

From the * Department of Surgery, University of Texas Health Science Center, San Antonio, Texas and the

[dagger] DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine,

Miami, Florida

For the Appendicitis Diagnostic Group: Margaret Brown, MSN, Fahim Habib, M.D., Jeffrey Augenstein, M.D., Erik Barquist, M.D., Patricia Byers, M.D., Carl I. Schulman, M.D., Enrique Ginzburg, M.D., Mauricio Lynn, M.D., Mark McKenney, M.D., Nicholas Namias, M.D., David Shatz, M.D., Danny Sleeman, M.D., S. Morad Hameed, M.D., Robb R. Whinney, D.O., Louis Pizano, M.D., Peter Ekeh, M.D., Suzanne LeBlang, M.D., and Martin Newman, M.D.

Address correspondence and reprint requests to Peter P. Lopez, M.D., F.A.C.S., Assistant Professor of Surgery, Department of Surgery, University of Texas Health Science Center, 7703 Floyd Curl Drive, MC 7842, San Antonio, TX 78229. E-mail: Lopez @ uthscsa.edu.

Copyright Southeastern Surgical Congress Dec 2007

(c) 2007 American Surgeon, The. Provided by ProQuest Information and Learning. All rights Reserved.

Pancreatic Cancer: The Smaller the Tumor, the Better Your Chances

Findings are most definitive so far in linking tumor size and patient prognosis

The odds of surviving cancer of the pancreas increase dramatically for patients whose tumors are smallest, according to a new study by researchers at Saint Louis University and the M.D. Anderson Cancer Center in Houston ““ the first study to specifically evaluate the link between tumor size and survival rates for one of the most common and deadly cancers.

The findings ““ in the current edition of Pancreas (www.pancreasjournal.com) ““ vividly underscore the importance of early diagnosis of pancreatic cancer, the researchers said.

“Even though it seems intuitive and was supported by preliminary observations from earlier studies, for the first time we now have evidence that a progressive decrease in the size of a pancreatic tumor at the time of diagnosis improves patient outcomes rather dramatically,” said Banke Agarwal, M.D., Associate Professor of gastroenterology at the Saint Louis University School of Medicine and lead author of the study.

“These data emphasize the benefit and the need of finding and diagnosing tumors in the pancreas as early as possible,” Agarwal added. “In order to make progress against pancreatic cancer, we have to redouble our efforts to identify symptoms that are associated with the early stages of the disease.”

Pancreatic cancer is the fourth most common cancer in the United States and one of the most deadly, responsible for more than 33,000 deaths a year, according to the National Institutes of Health.

Despite many advances in the fight against other cancers in recent years, the prognosis for patients diagnosed with the pancreatic cancer has remained extremely poor. That’s largely because the cancer is frequently not suspected and is difficult to diagnose in its early stages, when most people are asymptomatic or have non-specific symptoms that are easily ignored or attributed to other diseases.

The study looked at 65 patients who were diagnosed with pancreatic cancer at the M.D. Anderson Cancer in Houston between December 2000 and December 2001. Their average age was 67 years old; 38 were men.

Researchers found a striking correlation between a patient’s prognosis and the size of their tumor at the time of diagnosis.

Of the 12 patients whose tumors were 20 millimeters or smaller, their median survival after diagnosis was 17.2 months. For those with tumors 21-25 mm, median survival was 12.3 months. For those with tumors 26-30 mm, median survival was 8.5 months. And for those with tumors larger than 30 mm, median survival was 7.6 months. Of those patients whose tumors were 20 mm or smaller, two were still alive after 48 months; none of the patients with tumors larger than 30 mm were alive after 36 months.

Unfortunately, while the patients with the smallest tumors had the highest rates of survival, they were relatively small in number. Only 12 patients ““ or 18 percent ““ had tumors 20 mm or smaller. By contrast, the largest group of patients ““ 27, or 42 percent ““ had tumors larger than 30 mm.

In addition, the average tumor size of patients in the study was 32.9 mm ““ well above the threshold at which survival rates are lowest. That figure is roughly comparable to an average tumor size of about 30 mm among pancreatic cancer patients in general, according to the study.

“These numbers illustrate why we’ve made so little progress in improving outcomes for people who are diagnosed with pancreatic cancer ““ we’re not finding their tumors until they’re too big and it’s too late,” Agarwal said. “We know we have a much better chance of helping someone survive pancreatic cancer if it’s caught early and their tumor is small.”

Major advances in imaging technology in recent years have greatly improved physicians’ ability to diagnose progressively smaller pancreatic tumors. This hasn’t led to earlier diagnosis, however, because patients generally don’t get to the doctor until symptoms appear ““ and by then it’s too late.

Agarwal said researchers will need to focus on finding ways to identify people who should be screened early for pancreatic cancer. Screening of the general population for the disease hasn’t proven effective ““ but screening of people with a family history of pancreatic cancer is under active investigation, he said.

In addition, preliminary data from other studies have shown that elderly people who’ve been recently diagnosed with diabetes or depression have a higher likelihood of pancreatic cancer ““ providing another avenue for researchers to explore, Agarwal said.

On the Net:

St. Louis University

Atkins Diet Can Help Cut Epileptic Seizures

High-fat, low-carb diet may be an option when other treatments fail

A modified version of a popular high-protein, low-carbohydrate diet can significantly cut the number of seizures in adults with epilepsy, a study led by Johns Hopkins researchers suggests. The Atkins-like diet, which has shown promise for seizure control in children, may offer a new lifeline for patients when drugs and other treatments fail or cause complications.

For almost a century, doctors have prescribed an eating plan called the ketogenic diet to treat children with epilepsy. This diet often consists of a short period of fasting, strictly limits fluids and drastically restricts carbohydrates. It appears to limit or even eliminate seizures, possibly by generating the build-up of ketones, compounds the body produces when it derives calories mostly from fat. Some of the largest studies to scientifically test this diet’s efficacy took place at Johns Hopkins in the mid-1990s, led by pediatric neurologists John Freeman, M.D., and Eileen Vining, M.D.

Why exactly the ketogenic diet works remains unknown, and it is notoriously difficult to follow, relying almost solely on fat and protein for calories. Consequently, doctors typically recommend it only for children, whose parents can strictly monitor their eating habits. The ketogenic diet is almost never prescribed to adults, who generally make their own food choices and often have difficulty complying with the diet’s strict guidelines.

In 2002, Johns Hopkins researchers began testing a modified version of the Atkins diet in children with epilepsy. The modified diet shares the high-fat focus of the ketogenic diet, prompting the body to generate ketones. However, it allows more carbohydrates and protein, doesn’t limit fluids and calories, and has no fasting period. When studies showed that the new diet prevented or curtailed seizures in children, the researchers began testing it for efficacy and ease of use in adults.

Reporting on the results in the February issue of Epilepsia, Eric H. Kossoff, M.D., an assistant professor of neurology and pediatrics at the Johns Hopkins University School of Medicine, said 30 adults with epilepsy, ages 18 to 53 years, who had tried at least two anticonvulsant drugs without success and had an average of 10 seizures per week, were placed on the modified Atkins diet. All patients were seen for free in the Johns Hopkins General Clinical Research Center.

The regimen restricted them to 15 grams of carbohydrates a day. “That’s a few strawberries, some vegetables, or a bit of bread,” says Kossoff. The diet offers most of its calories from fat-eggs, meats, oils and heavy cream-with as much protein and no-carb beverages as patients want.

Each day, patients kept diaries of what they ate and how many seizures they had. The researchers evaluated how each patient was doing at one, three and six months after starting the diet.

Results showed that about half the patients had experienced a 50 percent reduction in the frequency of their seizures by the first clinic visit. About a third of the patients halved the frequency of seizures by three months. Side effects linked with the diet, such as a rise in cholesterol or triglycerides, were mild. A third of the patients dropped out by the third month, unable to comply with the restrictions.

Fourteen patients who stuck with the diet until the six-month mark chose to continue, even after the study ended-a testament to how effective the diet worked to treat their epilepsy, Kossoff notes.

Though the modified Atkins diet won’t be a good fit for all patients, says Kossoff, “it opens up another therapeutic option for adults trying to decide between medication, surgery and electrical stimulation to treat intractable seizures.” A second study to examine the diet’s effects on adults with intractable seizures is under way.

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Johns Hopkins Medical Institutions

Factors Affecting Natural Resource Conservation Investments of Residents in the Lower Big Walnut Creek Watershed, Ohio

By Napier, T L McCutcheon, K; Fish, J

Abstract: Data were collected from adults living in households within the Lower Big Walnut Creek watershed in central Ohio to assess psychosocial orientations of local property owners toward natural resources issues within the watershed and to evaluate their willingness to allocate economic resources to implement soil and water conservation programs on their properties. Unlike adoption studies that have examined attitudes toward nonpoint source pollution issues using managers of agricultural land holdings, this study was designed to assess orientations of suburban residents who live adjacent to an environmentally sensitive stream in the largest metropolitan area of Ohio. Study participants were chosen using databases that contained descriptions of residential land holdings within the Big Walnut Watershed. All land owners with residential property equal to or greater than 2 ac (0.8 ha) within the watershed were defined as being eligible to participate in the study. A total of 386 single family residential land holdings were identified as meeting these criteria, and a structured questionnaire was mailed to all identified property owners during the fall of 2005 and early winter of 2006. Thirty-eight subjects could not be located, which reduced the sampling frame to 348. A total of 149 questionnaires were returned that were sufficiently completed for use in statistical modeling. This constitutes a response rate of 41.8%, which is considered good for mail questionnaire studies using contemporary social science research standards. Study findings revealed that watershed residents were positive toward natural resources conservation within the watershed. Multi-variate binary logistic regression analysis revealed that the theoretical model used to guide the investigation was useful for predicting which respondents would be willing to allocate personal resources to address natural resources conservation problems on their properties. Study findings are basically consistent with hypotheses derived from theoretical modeling based on the traditional diffusion model. Findings are discussed in the context of future natural resources conservation initiatives among watershed residents. Key words: adoption-nonpoint source pollution-soil erosion-suburban watershed- urban conservation-water resources

During the past 70 years, many factors have significantly influenced conservation planning and program implementation in the United States. Some of the most important factors are the formation of public policies that have legitimized government involvement in soil and water conservation, the establishment of agencies to implement state conservation policies, the authorization of public funding of conservation programs, the creation of social movements to advance conservation of natural resources, the emergence of societal concern for soil erosion and future productivity of land resources, and the development of conservation technologies/ techniques to reduce/eliminate environmental problems. Each of these factors contributed to soil and water conservation programs and policies by setting in motion processes of change that culminated in three policy/ planning outcomes that significantly altered the trajectory of conservation efforts in the United States. The first important outcome has been the importance placed on conservation planning and program implementation at the watershed level. The second outcome is the importance placed on nonpoint sources of pollution. The third outcome is the inclusion of urban residents in natural resources conservation planning and program implementation at the watershed level.

One significant shift in conservation planning and program implementation has been the emphasis placed on the watershed as the primary unit for natural resources conservation efforts (El-Swaify and Yakowitz 1998; Jansky et al. 2005; Napier et al. 2000, 1994, 1983; National Research Council 1999; Wayland 1993). While extensive soil and water conservation programs were implemented at the watershed level prior to the 1970s (Halcrow et al. 1982; Selznick 1949), the watershed assumed a much more important role during the past 30 years.

The watershed has become the central focus of conservation efforts because such hydrologic units provide planners and conservation field agents the opportunity to approach natural resources planning and conservation programs from a more holistic perspective (Brady 1996; Davenport et al. 1996; Diplas 2002; El- Swaify and Yakowitz 1998; Farrow and Bower 1993; Heaney 1993; Heathcote 1998; Lamy et al. 2002; National Research Council 1999; Ruhl 1999; Wayland 1993). Simultaneous consideration of a broader range of variables and the interactions among the various components of a watershed nearly always increase the probability that planning and subsequent program implementation efforts will achieve expected environmental outcomes.

Natural resources development at the watershed level also increases the probability that multiple stakeholder interests will be represented in the planning and program implementation stages. This approach to decision making is commonly termed participatory management (Holt 2001; Leach 2001, 2006; Sabatier et al. 2005). Focus on specific conservation issues within subsections of a watershed may exclude significant segments of watershed residents. Unless the interests of all watershed residents are represented in the decision-making process, conservation planning and program implementation efforts may not achieve anticipated outcomes.

Comprehensive planning and program implementation at the watershed level can also aid in the reduction of the inevitable conflict among competing stakeholders for the use of limited natural resources by facilitating a more efficient and equitable distribution (Leach 2001, 2006; Sabatier et al. 2005). Localized conservation efforts seldom consider the rights and needs of legitimate claimants in other areas of the watershed or in the larger society.

Another important shift in natural resources conservation efforts in recent years has been the importance placed on nonpoint source pollution. Nonpoint source pollution oftentimes is associated with agricultural sources of pollution because contributions of individual farmers are extremely difficult to identify and measure. However, any natural resource manager can contribute to environmental degradation via nonpoint source pollution.

Nonpoint source pollution from agricultural sources has been the focus of considerable research attention during the past three decades because soil erosion creates many environmental problems (Lai and Stewart 1995; Lambert et al. 2006). Wildlife habitat is often degraded due to deposition of sediments in streams, wetlands, lakes and oceans. Displaced farm chemicals contribute to eutrophication/hypoxia of lakes and oceans (Robinson and Napier 2002) which results in degraded habitat for fish and other wildlife. The aesthetic quality of land and water resources is often significantly reduced by soil erosion, which renders these resources less valuable for recreational purposes. The safety of drinking water supplies for humans and animals is often adversely affected by farm chemicals. Agricultural productivity can be significantl reduced by severe erosion, which can reduce the economic value of farmland and can threaten future food supplies.

The environmental, social and economic problems created by soil erosion of agricultural land have been observed for decades within the United States (Halcrow et al. 1982; Lovejoy and Napier 1986; Napier et al. 1983, 2004; Swanson and Clearfield 1994). Public policies have been created and billions of dollars have been allocated each year to reduce the environmental, social and economic costs associated with agricultural nonpoint source pollution.

While farming technologies and production techniques exist to prevent soil erosion and subsequent contamination of water resources, extensive research has demonstrated that many land owner- operators refuse to adopt and use conservation production systems (Halcrow et al. 1982; Lovejoy and Napier 1986; Napier et al. 1983, 1994; Swanson and Clearfield 1994). This is true despite the fact that research has demonstrated that farmers value the environment, perceive themselves to be stewards of the land, and often believe that farming contributes to environmental degradation and that pollution needs to be addressed as an environmental issue. While much is known about agricultural nonpoint source pollution, it is generally concluded that existing models developed to explain adoption of soil and water conservation production systems at the farm level are inadequate for that purpose. The only factor that has been shown to consistently motivate farmers to adopt and use conservation production systems is economic subsidies in the form of rents to set aside crop land from production (Cooper 2003; Lambert et al. 2006; Langpap 2004; Napier et al. 2004; Napier and Tucker 2001a, 2001b). Another important shift in natural resources conservation efforts in the United States has been the enhanced role of urban populations in natural resources planning and program implementation at the watershed level. While residents of urban areas have been recognized for many years as being significant contributors to water pollution via housing encroachment on environmentally sensitive waterways, soil erosion from residential and commercial construction sites, chemical run-off from lawns, storm sewer run-off, and a host of other contributions to environmental degradation, relatively little attention was directed toward involvement of urban populations in comprehensive watershed planning and program implementation. One explanation for the relative lack of involvement of urban populations in conservation efforts in the past was the emphasis placed on agricultural nonpoint source pollution.

While the research literature focused on how urban residents perceive and value natural resources is relatively scarce (Miller and Hobbs 2002), sufficient research exists to suggest that urban dwellers view conservation of natural resources in a different manner than their rural counterparts (DeStafano et al. 2005). Research by Bright et al. (2002) revealed that residents of Chicago, Illinois, valued protection of wildlife and trees. They also observed that perceptions of the outcomes of ecological restoration affected their attitudes toward natural resources conservation. Gobster (2001) reported that residents of Chicago often held different perceptions about what an urban park should possess in terms of natural resource attractions. A significant percentage of stakeholders wanted to impose human dominion over park resources while others wished to see a return to a more “natural setting.”

Human dominance of natural resources appears quite often in urban natural resources conservation/protection studies (Francis 1989; Nassauer 1997, 2004; Syme et al. 2001). Urbanites tend to favor imposition of human control on natural resources to create a physical environment they perceive to be pleasing and familiar. One of the most frequently mentioned human controls is cutting grass to create a more manicured area for the conduct of recreation activities and nature watching.

Other research reported that urban residents often value natural resources conservation and are concerned about environmental issues but are not willing to engage in behaviors to address environmental issues (Stern 1992). This research finding is consistent with a number of studies that have demonstrated that attitudes and values are often not highly consistent with actual behaviors (Kempton et al. 1995). The finding is also consistent with research conducted among agriculturalists that revealed high value placed on the environment by farmers but continued use of environmentally unfriendly farm production systems (Napier 2000).

The relative lack of in-depth research focused on urban populations in the context of environmental management is somewhat surprising and is an issue of concern for natural resources managers. Urbanization is a universal phenomenon and is particularly significant in high-scale societies such as the United States where the vast majority of people live in urban areas. As urban areas increase in size and as natural resources become further removed from city residents, the need to preserve remaining natural resources and to restore areas that can be converted back to more natural states in an economical and environmentally sustainable manner becomes critical for the future well-being of people. The retention and protection of natural resources within urban areas will provide ecosystem services and products to resident human populations that cannot be provided in any other manner (Daily 1997). To achieve the goal of improved environmental quality within urban communities, we need more information about how urban dwellers perceive natural resources and what they are willing to do to protect existing natural resources for future use (Miller and Hobbs 2002).

The purpose of the research reported here is to examine how residents of a suburb of Columbus, Ohio, view conservation issues that affect all of the people who live adjacent to the Lower Big Walnut Creek. The primary goal of the study is to produce a statistical model that will be useful for predicting willingness of local residents to allocate personal economic resources to adopt natural resource conservation practices and structures on their land holdings. Information derived from the study should be useful for future environmental planning and conservation program implementation within the watershed chosen for examination.

Theoretical Modeling

Selection of Theoretical Perspective. The theoretical model chosen to guide the study reported here is the traditional diffusion model (Rogers 1995). This model was selected because it is a perspective that has been effectively applied to investigations of adoption behaviors throughout the world. The diffusion model has been used extensively in social science research focused on the adoption of new technologies, techniques, behavioral practices and a host of other innovations.

Diffusion theory has been criticized by numerous scholars who argue that the model is biased toward adoption. While the model has been useful for predicting time of adoption once the decision has been made to adopt something, it has been shown not to be useful for predicting whether or not an individual will make the decision to adopt. Critics such as Buttel and Swanson (1986) and Pampel and van Es (1977) have argued that structural theories are probably more relevant to soil and water conservation issues than individual approaches advanced by diffusion theory. Also a number of scholars have raised serious questions about the relevance of. diffusion- type variables for predicting conservation adoption behaviors at the farm level (Halcrow et al. 1982; Lovejoy and Napier 1986; Swanson and Clearfield 1994). It is generally concluded that diffiision theory has limited utility for predicting adoption of conservation production systems at the farm level.

While critics of diffusion theory make good cases for selection of theories that emphasize structural explanations of conservation adoption behaviors, diffusion theory was adopted to guide this investigation because the pro-adoption bias was eliminated by selecting a random sample that included both adopters and non- adopters. Studies that are focused only on adopters will result in pro-adoption bias. However, random selection of subjects to assess participation in a hypothetical conservation initiative will include individuals who have a propensity to participate and others who will be less willing to participate.

Traditional Diffusion Model. The traditional diffusion model basically asserts that decision making about the adoption of anything is a function of exposure to relevant information about the innovation being assessed. Potential adopters must become aware that a problem exists and be aware of possible solutions. If potential adopters perceive that adoption of a specific innovation will contribute to the resolution of identified problems, then they should have a higher probability of adopting.

Diffusion theory asserts that acquisition of information about various aspects of the innovation being assessed will result in the formation of attitudes about the innovation being considered. Favorable attitudes toward the innovation being assessed will encourage adoption, while the evolution of unfavorable attitudes will increase the probability the innovation will be rejected.

The diffusion model states that barriers exist to impede adoption. One of the most common barriers to adoption is the lack of knowledge about how to implement the innovation being assessed. If the potential adopter does not possess technical skills to implement an innovation, adoption will not occur unless technical assistance is provided from some other source.

Another barrier to adoption is the lack of sufficient economic resources to implement what is being considered for adoption. If potential adopters do not possess adequate economic resources to invest in innovations, then adoption cannot occur unless some other source of financial support is available.

Adoption within the Big Walnut Watershed. In the context of adoption of conservation practices and structures within the Lower Big Walnut Creek watershed, diffusion theory argues that favorable attitudes toward conservation is a prerequisite for serious consideration of adoption of such innovations. If residents possess favorable attitudes toward conservation of natural resources within the watershed, they should be more highly motivated to participate in conservation programs by investing in conservation efforts on their property.

The diffusion model argues that subsidies will encourage adoption of conservation practices and structures for individuals who do not possess adequate technical skills and/ or economic resources to adopt. Individuals who do not possess relevant technical skills to implement conservation on their property will require technical assistance to adopt conservation practices or structures. Similarly, people who do not possess adequate economic resources to implement needed conservation practices or structures will require economic subsidies to effectively implement conservation programs.

Diffusion theory argues that potential adopters must be knowledgeable about the impacts of adoption before they will consider adopting anything. If watershed residents are knowledgeable that investment in conservation practices and structures on their property will have a positive impact on the quality of natural resources within the watershed, they should be more willing to invest in conservation efforts on their property.

The traditional diffusion model argues that residents must perceive that environmental problems exist before they will consider adopting conservation practices or structures. If potential adopters perceive that natural resources problems exist on their property, they should be more highly motivated to invest personal economic resources to adopt conservation practices or structures because such investments can increase property values and reduce the seriousness of environmental problems. Materials and Methods

Study Population. Data to examine the merits of the theoretical perspective used to guide the investigation were collected from selected property owners living within the Lower Big Walnut Creek watershed located in Franklin County, Ohio (see map presented in figure 1). The watershed traverses eastern suburbs of Columbus from the dam at Hoover Reservoir to its confluence with the Scioto River near the Franklin County border on the south. The watershed is approximately 37.6 mi (60.5 km) long in this section of die river and drains approximately 50,000 ac (20,235 ha). The area defined as the Lower Big Walnut Creek watershed for this study does not include the tributaries of Rocky Fork Creek and Black Lick Creek that are sometimes associated with the Lower Big Walnut Creek watershed.

The Ohio Environmental Protection Agency (OEPA 2005) and private conservation groups that are active within the watershed have documented a number of environmental problems within the watershed. Some of the most important environmental concerns are siltation, heavy metals, ammonia, E. coli, and physical habitat alterations. Several sources of environmental degradation that have been identified are as follows: Columbus water treatment facilities, sand and gravel extraction, agricultural production, private residential properties, the Rickenbacker Port Authority, and the Columbus International Airport. The airports contribute to water pollution primarily via ethylene glycol used to deice planes. Conservation groups have identified 26 illicit discharge sites and four illegal dumps that affect the environmental quality of the watershed.

One of the significant environmental problems identified within the watershed is fecal coliform. Identified sources of fecal coliform in the Lower Big Walnut Creek watershed are as follows: 12% from suburban runoff, 0.55% from home septic systems, and 87% from upstream sources. Upstream sources of the fecal coliform have been identified as follows: 92% from cattle in or near streams, 7% from other agricultural sources, and 1% from home septic systems (OEPA 2005).

Sedimentation remains a serious issue within the watershed due to upstream erosion from agricultural land. Conversion of land to intense residential use has also contributed to the problem (OEPA 2005).

The topography of the watershed is flat to slightly rolling. The soils are relatively deep and fertile but are susceptible to displacement via erosion (OEPA 2005). The study area is rapidly becoming a residential suburb of Columbus even though several areas within the watershed remain sparsely populated and a small minority of residents report agricultural land uses. The primary land use within the study area is residential housing.

The location of all land holdings within the Lower Big Walnut Creek watershed and the names and addresses of all property owners as of October 2005 were provided by the Franklin County Auditor’s Office. Subjects were selected for inclusion in the study using a series of sorting procedures (overlays). The two criteria used for selecting potential subjects were as follows: (1) land ownership and (2) owner of at least 2 ac (0.8 ha) within the designated study area.

The selection criterion of property ownership of equal to or greater than 2 ac (0.8 ha) was chosen because owners of properties with smaller land holdings usually do not have the types of natural resources problems assessed in this study, and the types of solutions offered for assessment would not have been relevant to their environmental problems. Much of the study area has been converted to residential housing with lots smaller than the 2-ac criterion used to select potential study participants. Therefore, a large portion of the residents of the study area were excluded from participating in the study. Nonresident property owners, business property owners, managers of public land holdings, managers of church and school properties, and all other nonresidential property owners were excluded from the study population.

A total of 386 property owner/residents were identified using these selection criteria. A modified Dillman (2000) mail survey approach was used to collect data. A structured questionnaire was mailed to all selected property owners during the late fall of 2005 with a cover letter explaining the purpose of the study. Two follow- up mailings were posted to nonrespondents during the early winter of 2006 to encourage participation in the study. The initial mailing revealed that 38 subjects could not be located due to transfer of property and were subsequently removed from the mailing list. The total number of possible subjects was reduced to 348 residential landowners. A total of 149 questionnaires were returned that were sufficiently completed for use in the statistical modeling. This constitutes a response rate of 41.8%, which is considered good by contemporary social science research standards for a mail questionnaire.

Study Variables. Respondents were asked to provide information about perceived environmental problems within the Lower Big Walnut Creek watershed and about specific actions they would be willing to take to address the issues identified. The factors assessed in the study were measured as follows:

Willingness to invest in conservation was designated as the dependent variable for the study and was measured by asking respondents to indicate the amount of money they would be willing to invest to resolve identified conservation issues on their property. The response categories included on the questionnaire are as follows: none (weighted 0), less than $100 (weighted 1), $100 to $299 (weighted 2), $300 to $499 (weighted 3), $500 to $999 (weighted 4), $1,000 to $4,999 (weighted 5), and more than $5,000 (weighted 6). Due to constrained variance in the distribution of responses to the dependent variable (see table 1 for the distribution of responses), categories 1 through 6 were combined into one category. This action produced a dichotomous dependent variable with 0 representing those not willing to invest money in conservation and 1 representing those who would be willing to invest in conservation on their properties.

The predictive variables used to represent the diffusion concepts discussed in the theory section are as follows: attitude toward conservation, orientation toward implementation of buffer systems, importance of subsidies, assistance to adopt, knowledge of impacts, concern for flooding, concern for nuisance wildlife, concern for stream erosion, concern for soil fertility/nutrient management, and location of residence. The predictive variables were measured as follows:

Attitude toward conservation was included in the study because diffiision theory places considerable emphasis on the role of attitudes in the adoption decision-making process. The variable was created to measure the value attached to natural resources conservation on respondents’ property and within the watershed. It was expected from theory that individuals who were more positive toward conservation would tend to be more willing to invest in conservation on their property. The variable was measured using seven Likert-type (Edwards 1957; Nunnally 1978) attitude scale items that assessed respondent orientations toward the importance of the following: natural areas, conservation at the local level, water and stream quality, improving wildlife habitat, controlling flooding, and learning about natural resources. The possible responses ranged from strongly disagree (weighted 1) to strongly agree (weighted 5). The reliability of the scale was assessed via the use of item analysis which produced an alpha coefficient of reliability (Cronbach 1951; Nunnally 1978) of 0.89. An alpha of this magnitude indicates the responses to the scale items are highly correlated and that the weighting values can be legitimately summed to form a composite scale score (see table 2 for scale items and the distribution of responses). Higher scale scores indicate more positive attitudes toward conservation.

Orientation toward implementing natural buffers was included in the study because diffusion theory argues that potential adopters must develop positive attitudes toward possible solutions to perceived problems before action options will be considered for adoption. The implementation of natural buffers on respondent properties near ditches and streams would be major contributors to resolution of environmental problems identified with residential housing within the study area. It was expected that individuals who were more positive toward implementing natural buffers on their land would be more willing to invest in conservation on their property. The variable was measured using two Likert-type attitude statements that assessed respondent orientations toward implementing natural buffers near streams and ditches. The possible responses ranged from strongly disagree (weighted 1) to strongly agree (weighted 5). The reliability of the scale was assessed via the use of item analysis which produced an alpha coefficient of 0.89. An alpha of this magnitude indicates the responses to the scale items are highly correlated and that the weighting values can be legitimately summed to form a composite scale score (see table 3 for scale items and responses). Higher scale scores indicate more positive attitudes toward implementing natural buffers.

Importance of subsidies was included in the study because diffusion theory argues that subsidies in the form of technical and economic subsidies can remove financial/knowledge barriers to adoption. It was expected that individuals who placed higher importance on subsidies would be less willing to invest their own resources in conservation on their property. The variable was measured using two Likert-type scale items that asked respondents to indicate the relative importance of technical assistance and financial assistance when making adoption decisions about conservation practices and structures. The possible responses ranged from strongly disagree (weighted 1) to strongly agree (weighted 5) that technical and financial assistance are important when making conservation adoption decisions. The alpha coefficient of reliability for the two-item scale was 0.82, which indicates the responses to the two items are highly correlated and that the weighting values can be legitimately summed to form a composite scale score (see table 4 for scale items and responses). Higher scale scores indicate higher levels of importance attached to subsidies. Assistance to adopt was included in the study as a second measure of the importance placed on incentives in the adoption decision making process. It was expected that individuals who desired assistance would be less willing to invest their own resources in conservation. The variable was measured by asking respondents to select the types of incentives that would encourage them to participate in conservation programs. Incentives assessed were as follows: technical assistance, tax credits, set-aside payments, financial assistance for vegetation improvements, and financial assistance for structural improvements. A checked response received value of 1 and a blank response received a 0. An alpha coefficient of reliability of 0.72 was computed using respondent responses (see table 5). Given the constrained variance in terms of the possible responses to the question, a value of 0.72 indicates the item responses are significantly correlated and that the weighting values can be legitimately summed to form a composite index. Higher index scores indicate the need for more numerous incentives to motivate potential adopters to adopt.

Knowledge of conservation impacts was included in the study because diffusion theory argues that knowledge about the impacts of innovations will facilitate adoption. It was expected that individuals who were more knowledgeable of impacts of conservation efforts on environmental problems would be more willing to invest in conservation. The variable was measured by asking respondents to indicate the types of knowledge that would encourage them to participate in conservation programs. Respondents were asked to check all of the types of knowledge that would increase the probability they would participate in conservation programs. The types of knowledge assessed were as follows: improvement in wildlife habitat, improvement in water quality, and maintenance of natural areas. All checked responses received a 1 and all blank responses received a 0. An alpha coefficient of reliability of 0.71 was computed from the responses to the three types of knowledge examined (see table 6). Given the constrained variance in terms of the possible responses to the question, a value of 0.71 indicates the item responses are significantly correlated and that the weighting values can be legitimately summed to form a composite index. Higher index scores indicate the need for a broader knowledge base for conservation decision making.

Diffusion theory argues that potential adopters must be aware of problems before they will consider adopting any innovation. Awareness of conservation problems on respondent properties was assessed by five variables and was measured as follows:

Concern for flooding was measured by asking respondents to indicate if flooding is a concern on their property. It was expected that individuals who were concerned about flooding on their property would tend to be more willing to invest in conservation efforts that could reduce the incidence of flooding. A positive response received a value of 1 and a blank response received a value of 0.

Concern for nuisance wildlife was measured by asking respondents if nuisance wildlife is a concern on their property. It was expected that individuals who were concerned about nuisance wildlife would be more willing to invest in conservation efforts that could reduce wildlife problems. A positive response received a value of 1 and a blank response received a value of 0.

Concern for stream erosion was measured by asking respondents if stream erosion is a concern on their property. It was expected that individuals who were concerned about stream erosion would be more willing to invest in conservation efforts that could reduce stream erosion on their property. A positive response received a value of 1 and a blank response received a value of 0.

Concern for soil fertility/nutrient management was measured by asking respondents if soil fertility/nutrient management is a concern on their property. It was expected that individuals who were concerned about soil fertility and nutrient management problems would be more willing to invest in conservation efforts that could reduce degradation of soil resources. A positive response received a value of 1 and a blank response received a value of 0.

Location of residence was included in the study as a general measure of awareness of conservation problems at the property site. It was reasoned that respondents who lived at the site of the property being assessed would be more aware of environmental problems than nonresident property owners. It was expected that residents would be more aware of environmental problems then absentee land owners and would be more willing to invest in conservation to improve the environment in which they were living. Residence was measure by asking respondents to indicate if they lived at the property being assessed. A positive response received a value of 1 and a blank response received a value of 0.

Statistical Analysis. Descriptive statistics were used to examine general trends in the data set, while binary logistical regression was employed to assess the merits of the theoretical perspective used to guide the investigation. Missing data were attributed the variable mean, which has been shown to be the best method for salvaging cases when the number of missing cases is small, the study group is relatively large, the strength of relationships is low to moderate, and the response rate is relatively high (Dormer 1982). (Note the amount of missing data was small within the data set. The only missing data were within the attitude scale items. To ensure that the use of mean substitution did not affect the findings, the statistics used to assess the reliability of the scales were computed using list-wise deletion of cases with missing data. The recalculated alpha coefficients for the three scales containing missing data were identical to the coefficients generated using mean substitution. The binary logit regression modeling was also computed using list-wise deletion of cases with missing data, and the findings are almost identical. The results of this modeling add considerable credibility for the use of mean substitution as the method for salvaging cases with missing data.) All of these conditions were satisfied in the data set.

Results and Discussion

Descriptive findings for willingness to invest economic resources for conservation are presented in table 1 and show that a large majority of study respondents were not willing to spend any money on natural resource conservation on their property. Over 60% of the study respondents indicated they would not spend one dollar on conservation efforts on their property. Only 21.5% indicated they would be willing to spend from $1 to $499 and 16.1% indicated they would spend more than $500. These findings are different from those produced by Blaine and Lichtkoppler (2004) in the Cleveland, Ohio area where they observed that respondents were willing to pay for conservation easements to improve water quality.

Descriptive findings for attitude toward natural resources conservation are presented in table 2 and demonstrate that study respondents were basically very positive toward natural resources conservation as assessed in the study. Respondents were most positive toward statements about encouraging the maintenance of water quality in local streams and improving wildlife habitat. However, all of the other attitude statements were perceived positively by respondents. These findings are consistent with many studies that have demonstrated that land managers are positive toward natural resources conservation (Bright et al. 2002; Napier et al. 2000, 1994).

Descriptive findings for willingness to consider implementing natural buffers are presented in table 3 and show that respondents were undecided about investing in such conservation efforts. Slightly less than 25% of respondents indicated a willingness to implement natural buffers.

Descriptive findings for the perceived importance of subsidies in the adoption of natural resources conservation practices and structures are presented in table 4 and demonstrate a high level of importance placed on subsidies in the adoption decision-making process. While technical assistance was ranked slightly higher than financial assistance, both types of assistance were perceived to be important when making conservation adoption decisions. Findings from many studies have demonstrated that subsidies significantly influence conservation adoption decisions for rural residents (Halcrow et al. 1982; Lambert et al. 2006; Napier et al. 2000, 1994; Swanson and Clearfield 1994).

Descriptive findings for types of assistance that would increase the probability of participating in natural resources conservation programs are presented in table 5. The most frequently selected assistance was a tax reduction on property. A total of 62.4% of the respondents indicated that a tax reduction would act as a motivator to participate in natural resources conservation programs. Other types of incentives were mentioned relatively infrequently. It is interesting to note that technical assistance and financial assistance were selected by a small minority of respondents. Such a finding is inconsistent with research focused on technology- intensive farm operators who tend to be motivated to participate in conservation programs by financial and technical assistance (Cooper 2003; Lambert et al. 2006; Langpap 2004).

The findings presented in table 5 strongly suggest that tax credits can act as a significant motivator for a large majority of study respondents to participate in natural resources conservation programs. This finding supports research by Schrader (1994) who noted that the preferred policy approach for watershed management was tax relief.

Descriptive findings for knowledge factors that would increase the probability respondents would participate in natural resources conservation programs are presented in table 6 and demonstrate that about one-third of the respondents would be influenced by the types of knowledge assessed in the study. These findings suggest that provision of knowledge in the areas assessed would have some effect on conservation program participation.

Descriptive findings for perceived natural resources concerns within the study area are presented in table 7. The findings demonstrate that the most frequently mentioned natural resource concern for study respondents was nuisance wildlife followed by flooding, stream erosion, and soil fertility/nutrient management. This finding is consistent with studies conducted among suburban residents which indicate that nuisance wildlife (especially deer) pose a significant environmental problem for residents (DeStafano et al. 2005; Harris et al. 1997; Raik et al. 2005).

The binary logistic regression findings are presented in table 8 and demonstrate that five variables were significant at the 0.05 level in predicting whether or not respondents were willing to invest economic resources in natural resources conservation on their property. The five significant variables are as follows: knowledge of conservation impacts, concern for nuisance wildlife, attitude toward conservation, concern for soil fertility/nutrient management and residence sums. As the number of categories of knowledge about conservation impacts increased, the probability increased that respondents would be willing to invest in conservation on their property. As concern for nuisance wildlife increased, as attitudes toward conservation became more positive, and as the concern for soil fertility/nutrient management increased, the probability increased that respondents would be willing to invest money in conservation on their property. As the probability increased that respondents were residents of the property being assessed, the probability decreased that they would be more willing to invest in conservation. None of the other predictive variables were significant at the 0.05 level.

The only finding that was not consistent with the theoretical perspective used to guide the investigation was for residence. Residents were less likely to invest in conservation than nonresident land owners. This may be due to greater awareness among residents that conservation problems are not problematic on the property being assessed. It may also be a function of nonresident respondents wishing to invest in property they intend to sell. Owners who intend to sell their properties may wish to invest in conservation improvements when they expect to be adequately compensated by an increase in property value. A number of studies have shown that farmers who do not expect to claim future benefit streams from conservation investments will not adopt conservation practices or structures (Batie 1986; Ervin 1981).

The computed Nagelkerke R-square is 0.394 which demonstrates substantial association among the predictive variables and willingness to invest in conservation. The percentage of correct classification of respondents into “willing to invest” and “not willing to invest” groups was 73.8%. (Note the percentage correct classification is somewhat misleading when study groups are uneven in size. Over 60% of the study participants could have been correctly classified, if all of the subjects had been classified as being in the “not willing to invest” group.)

Summary and Conclusions

The findings for Lower Big Walnut Creek residents are somewhat inconsistent with existing research literature focused on adoption of conservation production systems among agriculturalists. Theoretical perspectives developed using the traditional diffusion model to explain adoption of conservation production systems among farmers in central Ohio watersheds located in close proximity to the Lower Big Walnut Creek watershed have been consistendy shown to be inappropriate for that purpose (Napier 2000; Napier and Bridges 2002, 2003; Napier and Johnson 1998).

One possible explanation for the observed differences between farmers and suburban residents is that the costs and consequences of adopting conservation practices and structures for the two groups are substantially different. Adoption of conservation practices and structures by large-scale production agriculturalists often requires extensive investments of economic resources, modification of farming systems, permanent retirement of crop land, development of new farming skills, and a host of other modifications in the farm production system. Few of the costs associated with adoption of conservation production systems by large-scale agriculturalists are rewarded by significant increases in farm income. Failure of a newly adopted conservation farm production system to achieve anticipated production goals will result in loss of farm income and could result in the loss of the farm enterprise. Farmers are not willing to assume such risks unless they receive economic subsidies from the federal government to offset any economic risks they must assume to adopt new production systems.

On the other hand, urban residents are seldom required to invest large sums of money to resolve perceived environmental problems, and the amount of land involved is very small. Investment in natural resources conservation for urban residents does not threaten the economic well-being of the household because the economic viability of the family unit is not connected to the adoption of conservation practices and structures as it is for farmers. The benefits from very small economic investments in conservation are relatively high for urban dwellers with little risk of failure.

If this explanation of the differences in findings between farmers and nonfarm suburbanites is correct, holistic conservation planning and program implementation within watersheds containing similar population distributions as those examined in this study is certain to become more problematic and contentious over time. At the present time, urban residents in the Lower Big Walnut Creek watershed are not willing to invest in conservation which is also true for farmers, within surrounding watersheds (Napier 2000; Napier and Bridges 2002,2003; Napier and Johnson 1998) and probably in the Lower Big Walnut Creek watershed. If conservation programs are successful within the Lower Big Walnut Creek watershed study area in terms of increasing positive attitudes toward conservation and increasing the willingness of urban land owners to invest in conservation, it is highly likely that urbanites will expect upstream farmers to adopt conservation practices and structures to improve stream and water quality. Such a situation could result in urban residents demanding that farmers within the Upper Big Walnut Creek watershed (from Hoover Reservoir north through two counties) to comply with the environmental quality expectations held by urban residents. While agriculture is of little significance within Franklin County (Lower Big Walnut Creek watershed), the Upper Big Walnut Creek watershed located in Delaware and Morrow Counties contains a large number of large-scale production agriculturalists.

The potential conflict that could emerge between Columbus suburban residents and upstream farmers within the Upper Big Walnut Creek watershed adds credibility to the assertion made early in the paper for more holistic planning and conservation program implementation at the watershed level. If urban populations are to be involved in the decision making process at the watershed level, it must be recognized that the probability is high that urban residents will demand increased water and stream quality. Since the political power of urban residents will always be greater due to population size, it is almost certain that water and stream quality will be defined by urbanites. It is also highly likely that urban residents will be quite willing to support higher environmental standards for the watershed because they will be required to pay only a small portion of the costs to achieve those goals, assuming that the polluter will be required to pay for internalizing the problem. Urban people own little land that will require investment in conservation practices and structures, while farm owner- operators will be required to invest considerable amounts of money to comply with pollution standards. Such a situation reeks of potential conflict with rural farm operators set against rural nonfarm and urban conservation interests.

If the scenario outlined above is correct, the potential exists for extremely contentious decision making when urban, rural nonfarm and rural farm populations are involved in conservation planning and program implementation at the watershed level in the future. Unless some mechanism is maintained to subsidize farmers to adopt and use conservation production systems, conflict is almost certain to emerge.The outcome of the imposition of urban conservation expectations on upstream farmers in the Big Walnut watershed may be the migration of agriculture to areas outside of the watershed. The three outcomes of the changes in conservation policies and programs in the United States identified early in this paper clearly have introduced much higher levels of uncertainly into the conservation decision-making process at the watershed level. The desire to involve all publics in holistic watershed planning and program implementation combined with the concern for nonpoint source pollution have created a situation that will almost certainly set farmers and other large-scale land owners against all other interest groups within watersheds. It is highly likely that future watershed planning and program implementation in watersheds where urban and rural populations are located in close proximity to each other will be focused more on resolution of conflict than it is on achieving improved environment quality.

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Ted L. Napier is a professor of environmental policy in the Department of Human and Community Development in the Environmental Science Graduate Program and in the School of Natural Resources at the Ohio State University, Columbus, Ohio. Kelly McCutcheon and Jennifer Fish are members of the Franklin County Soil and Water Conservation District, Columbus, Ohio.

Copyright Soil and Water Conservation Society Jan/Feb 2008

(c) 2008 Journal of Soil and Water Conservation. Provided by ProQuest Information and Learning. All rights Reserved.

Infrared Helmet May Cure Alzheimer’s

Research at the University of Sunderland has shown that regular exposure to low level infra-red light can turn back the brain’s biological clock and reverse memory loss. Medical experts believe the discovery may be a key to providing treatment and potential cures for everything from dementia to learning disabilities and Alzheimer’s disease.

Neuroscientist Paul Chazot, who helped carry out the University of Sunderland research, told Britain’s Daily Mail, “The results are completely new – this has never been looked at before.”

Following the Sunderland research, Dr Gordon Dougal, a director of medical research at Virulite, a medical research company based in the U.K., developed an experimental helmet that transmits infra-red light into the brain, and is studying it’s effectiveness as a potential treatment or cure for dementia and Alzheimer’s disease.

The helmet would need to be worn for ten minutes a day, and would treat the brain with infra-red light, which would stimulate the growth of brain cells.   Dr. Dougal and his colleagues hope the new headgear might actually reverse the symptoms of dementia, including memory loss and anxiety, in as little as four weeks. 

Although the research is still in the early stages, medical experts are calling the new treatment a potentially life-changing development.

Dr Dougal claims that only ten minutes under the hat a day is enough to have an effect. 

“Currently all you can do with dementia is to slow down the rate of decay – this new process will not only stop that rate of decay but partially reverse it,” Dr. Dougal told Britain’s Daily Mail.

Low level infra-red red is able to penetrate the skin and the skull, and is thought to stimulate the growth of cells of all types of tissue and encourage their repair.  

“The implications of this research at Sunderland are enormous – so much so that in the future we could be able to affect and change the rate at which our bodies age,” Dr. Dougal said.

“We age because our cells lose the desire to regenerate and repair themselves. This ultimately results in cell death and decline of the organ functions – for the brain resulting in memory decay and deterioration in general intellectual performance.  But what if there was a technology that told the cells to repair themselves and that technology was something as simple as a specific wavelength of light?”

An Alzheimer’s Society spokesman told the Daily Mail,  “A treatment that reverses the effects of dementia rather than just temporarily halting its symptoms could change the lives of the hundreds of thousands of people. We look forward to further research to determine whether this technique could help improve cognition in humans.”

Image Caption: lead researcher at the University of Sunderland Dr Abdel Ennaceur and Durham University s Dr Paul Chazot are pictured with Dr Gordon Dougal and a prototype cognitive helmet

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‘Moderate’ Happiness May Be Healthier

Could the pursuit of happiness go too far? Most self-help books on the subject offer tips on how to maximize one’s bliss, but a new study suggests that moderate happiness may be preferable to full-fledged elation.

The researchers, from the University of Virginia, the University of Illinois and Michigan State University, looked at data from the World Values Survey, a large-scale analysis of economic, social, political and religious influences around the world. They also analyzed the behaviors and attitudes of 193 undergraduate students at Illinois.

Their findings, which appear in the December 2007 Perspectives on Psychological Science, challenge the common assumption that all measures of well-being go up as happiness increases. While many indicators of success and well-being do correspond to higher levels of happiness, the researchers report, those at the uppermost end of the happiness scale (people who report that they are 10s on a 10-point life satisfaction score) are in some measures worse off than their slightly less elated counterparts.

To put the findings in perspective, it is important to note that happiness generally correlates with all kinds of positive measures, said Illinois psychology professor Ed Diener, an author of the study. In general, the happier you are the more successful you are in terms of money, employment and relationships.

“Happy people are more likely (than unhappy people) to get married, are more likely to stay married, are more likely to think their marriage is good,” Diener said. “They’re more likely to volunteer. They’re more likely to be rated highly by their supervisor and they’re more likely to make more money.”

Happy people are also, on average, healthier than unhappy people and they live longer, Diener said. And, he said, some research indicates that happiness is a cause of these sources of good fortune, not just a result.

“But there is a caveat, and that is to say: Do you then have to be happier and happier” How happy is happy enough””

The research team began with the prediction that mildly happy people (those who classify themselves as eights and nines on the 10-point life satisfaction scale) may be more successful in some realms than those who consider themselves 10s. This prediction was based on the idea that profoundly happy people may be less inclined to alter their behavior or adjust to external changes even when such flexibility offers an advantage.

Their analysis of World Values Survey data affirmed that prediction.

“The highest levels of income, education and political participation were reported not by the most satisfied individuals (10 on the 10-point scale),” the authors wrote, “but by moderately satisfied individuals (8 or 9 on the 10-point scale).”

The 10s earned significantly less money than the eights and nines. Their educational achievements and political engagement were also significantly lower than their moderately happy and happy-but-not-blissful counterparts.

In the more social realms, however, the 10s were the most successful, engaging more often in volunteer activities and maintaining more stable relationships.

The student study revealed a similar pattern in measures of academic and social success. In this analysis, students were categorized as unhappy, slightly happy, moderately happy, happy or very happy. Success in the categories related to academic achievement (grade-point average, class attendance) and conscientiousness increased as happiness increased, but dropped a bit for the individuals classified as very happy. In other words, the happy group outperformed even the very happy in grade-point average, attendance and conscientiousness.

Those classified as very happy scored significantly higher on things like gregariousness, close friendships, self-confidence, energy and time spent dating.

The data indicate that happiness may need to be moderated for success in some areas of life, such as income, conscientiousness and career, Diener said.

“The people in our study who are the most successful in terms of things like income are mildly happy most of the time,” he said.

In an upcoming book on the science of well-being, Diener notes that being elated all the time is not always good for one’s success ““ or even for one’s health. Reviews of studies linking health and emotions show that for people who have been diagnosed with serious illnesses, being extremely happy doesn’t always improve survival rates, Diener said. This may be because the elated don’t worry enough about issues that can have profound implications for their ability to survive their illness, he said.

“Happy people tend to be optimistic and this might lead them to take their symptoms too lightly, seek treatment too slowly, or follow their physician’s orders in a half-hearted way,” he writes.

All in all, Diener said, the evidence indicates that happiness is a worthy goal for those who lack it, but the endless pursuit of even more happiness for the already happy may be counterproductive.

“If you’re worried about success in life, don’t be a 1, 2, 3 or 4 (on the 10-point scale),” Diener said. “If you are unhappy or only slightly happy, you may need to seek help or read those self-help books or do something to make yourself happier. But if you’re a 7 or 8, maybe you’re happy enough!”

On the Net:

http://www.uiuc.edu/

Leader of ProMedica to Leave Post Next Year

By Julie M. Mckinnon, The Blade, Toledo, Ohio

Jan. 24–Alan Brass plans to retire next year from ProMedica Health System, the Toledo hospital provider that expanded under his tutelage through investments — including the 2001 opening of Bay Park Community Hospital in Oregon — and the addition of hospitals throughout the region.

Under Mr. Brass’ leadership for 10 years, ProMedica is financially secure and committed to the community, as evidenced by projects such as the ongoing rebuilding of Toledo Hospital and Toledo Children’s Hospital, said Larry C. Peterson, chairman elect of the ProMedica board of trustees.

By the time that project is complete, ProMedica will have invested close to $400 million, said Mr. Peterson, who will help lead the search for Mr. Brass’ re-placement. The project’s second phase, a $156 million patient tower, is opening this month.

“He has certainly brought excellent leadership and put in place an outstanding management group,” said Mr. Peterson, who will become board chairman next year.

Yet, he added: “Certainly it’s a loss as far as we’re all concerned. He’s a friend.”

Mr. Brass plans to retire as chief executive on June 30, 2009, ProMedica announced yesterday. He was not available for comment.

The 59-year-old Youngstown native will become ProMedica’s chairman emeritus for six months after his retirement, helping the board and his successor as needed, Mr. Peterson said.

Mr. Peterson and Frank E. Duval, the current board chairman, will lead a search committee for Mr. Brass’ successor. A nationwide search will be conducted for ProMedica’s next top executive, and there are certain to be excellent candidates within existing management, Mr. Peterson said.

Mr. Brass was both president and chief executive of ProMedica until mid-2006, when Randy Oostra was named president and chief operating officer.

Long the highest-paid hospital executive in the Toledo area, Mr. Brass had nearly $1.9 million in total compensation in 2006, the most recent year for which financial information is available. His compensation package was more than $4.1 million the year before, including nearly $2.6 million deferred over several years.

When Mr. Brass was hired, ProMedica owned Toledo Hospital and Flower Hospital in Sylvania, as well as Paramount Health Care insurance company. It soon added hospitals in Defiance; Lima, Ohio; Adrian; Tecumseh, Mich., and Fostoria to its nonprofit organization.

ProMedica now has 15,000 employees and 2,900 physicians. It treats more than 2.5 million patients a year.

Through his tenure, Mr. Brass and ProMedica have not been immune to criticism.

Bay Park’s 2001 opening was seen as a direct competitive jab at chief rival Mercy Health System, owner of nearby St. Charles Mercy Hospital. So was starting an emergency helicopter service.

ProMedica also severed most medical education ties with the former Medical College of Ohio in 1999. The relationship began to mend three years later, but wounds publicly re-emerged last year.

Mr. Peterson, the board chairman-elect, said Mr. Brass intends to stay in the area after his retirement.

Mr. Brass’ non-ProMedica duties include serving on the board of trustees for Ohio State University, where he received a master of science degree in hospital and health services administration in 1973. His OSU board appointment runs until May, 2013.

Shortly before taking the helm at ProMedica on Jan. 19, 1998, Mr. Brass was executive vice president of operations of BJC Health System in St. Louis. He also headed both the Missouri Hospital Association and the board of the Children’s Miracle Network during his 10 years in Missouri.

Mr. Brass previously held administrative jobs at hospitals and health-care systems in Ann Arbor and Columbus.

Contact Julie M. McKinnon at: [email protected] or 419-724-6087.

—–

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Guelph General Hospital Demonstrates Benefits Of Automation With Omnicell Medication Use Systems

MOUNTAIN VIEW, Calif. and ONTARIO, Canada, Jan. 24 /PRNewswire-FirstCall/ — Omnicell, Inc. , a leading provider of system solutions to acute healthcare facilities, and Guelph General Hospital, a leading healthcare provider, today announced the results of a study demonstrating the benefits of installing Omnicell medication use systems.

With donations made to the Foundation of Guelph General Hospital from the Partners for Better Health campaign, Guelph General Hospital installed Omnicell’s Medication Specific Dispensing Systems to replace Guelph General Hospital’s existing manual, traditional mosaic drug distribution process. A comparative analysis was conducted prior to, and after, the Omnicell system implementation to identify patient care and staff efficiency improvements in the medication distribution system.

“Our comparative analysis demonstrated that the Omnicell systems substantially improved the quality and efficiency of our drug distribution process,” said Jane Martin, director of Pharmacy Services, Guelph General Hospital. “These improvements translate into less nurse and pharmacist time devoted to drug distribution, more time for direct patient care and less risk of medication errors for patients.”

Three-month study periods were analyzed prior to, and after, Omnicell implementation. There were 90 medication incidents reported pre-Omnicell implementation. Post-Omnicell implementation, this number decreased by 26.7% to 66 medication incidents reported. Of the incidents reported, pharmacy dispensing errors and errors where the nurses selected the incorrect medication due to look-alike, sound-alike names both decreased 60.0%.

Since approximately 98% of medications are now available on the Guelph General Hospital patient care units, medications are more quickly available for administration, reducing delays in patient care. Using a time-in-motion study, the time elapsed from the order written to the medication available on a nursing unit decreased 84% on average, from 263 minutes to 42 minutes, after the Omnicell implementation.

Nursing time needed to track down missing doses of medications, often through communications with a central pharmacy, was also reduced substantially. The telephone call volume to the central pharmacy decreased from 71 per day pre-Omnicell to 16.5 per day after Omnicell implementation, a 76.7% reduction. Of these phone calls, missing meds calls were reduced by 66.7% per day and out-of-stock medication calls were reduced by 70% per day. Likewise, the average number of communication forms needed was reduced by 90.7% per day. The Omnicell systems consolidate medication storage, and missing medication forms decreased by 95.5% and out of stock forms decreased by 89.7% per day.

Nursing time needed to access narcotic and controlled substances also decreased substantially post-Omnicell implementation due to the elimination of many manual steps, including documentation. Pre-Omnicell, the average narcotic and controlled substance transaction took 183 seconds. This decreased 85.2% post-Omnicell to 27 seconds.

“The pharmacy staff at Guelph General Hospital is to be applauded for the remarkable post Omnicell implementation results,” said Ed Albrough, senior product manager, at Omnicell. “Omnicell technology helps hospital staff reduce medication errors by reducing complexity, avoiding over-reliance on memory, simplifying key processes, and increasing efficiency. The less time required for nurses to wait for and to obtain medications translates into additional time to provide patient care.”

About Omnicell

Omnicell, Inc. is a leading provider of systems targeting patient safety and operational efficiency in healthcare facilities. Since 1992, Omnicell has worked to enhance patient safety and allow clinicians to spend more time with their patients.

Omnicell’s medication-use product line includes solutions for the central pharmacy, nursing unit, operating room, and patient bedside. Solutions range from complete automation systems for the central pharmacy to nursing unit and bedside dispensing cabinet systems. From the point at which a medication arrives at the receiving dock to the time it is administered, Omnicell systems store it, package it, bar code it, order it, issue it, and provide information and controls on its use and reorder.

Our supply product lines provide a healthcare institution with fast, effective control of costs, capture of charges for payer reimbursement, and timely reorder of supplies. Products range from high-security closed-cabinet systems and software to open-shelf and combination solutions in the nursing unit, cath lab and operating room. For more information, visit http://www.omnicell.com/.

About Guelph General Hospital

Guelph General Hospital is a dynamic, comprehensive acute care facility providing a full range of services to the residents of Guelph and Wellington County in Ontario, Canada. Services include 24-hour emergency coverage, advanced technology and diagnostic support, and specialty programs such as surgery, orthopedics, cardiac care, obstetrics, gynecology and pediatrics. For more information please visit http://www.gghorg.ca/.

Omnicell, Inc.

CONTACT: Perry Hagerman of Guelph General Hospital, +1-519-837-6440,ext. 2774, [email protected]; or Linda Capcara of LVA Communications,+1-480-229-7090, [email protected], for Omnicell Inc.

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

Children’s Mental Focus Foundation Announces a Scientific Breakthrough for Children Who Have Been Diagnosed With Autism, ADD and ADHD

HENDERSON, Nev., Jan. 24 /PRNewswire/ — Children’s Mental Focus Foundation (CMFF), a nonprofit organization located in Henderson, Nevada, has discovered a virus that may be linked to children with autism and other mental disorders. CMFF is a “Research Foundation” currently working with doctors that have patients afflicted with mental disorders. This new discovery may help children and adults cope with behavioral problems associated with mental disorders such as Autism, ADD and ADHD, says head of research at CMFF, Rick C. Hunt, PhD who discovered the virus. The virus is called the R1H2 virus. Further evaluations on some 200 children who had been diagnosed with Autism also revealed this same specific virus present in the brain of these children.

CMFF has already developed a natural technology approach, to prompt the child’s own immune system to respond correctly to this virus and support the elimination of this virus. The challenge facing the CMFF researchers and their affiliate physician offices across the USA is the task of creating a comprehensive brain healing therapy, so that these children can slowly recover from this disorder.

Another very real problem facing today’s parents is the journey back to recovery. CMFF will be developing and training healthcare practitioners and therapists in multiple support systems to make the recovery easier for everyone in the family. CMFF’s affiliates will be helping each member of the family as they go through difficult phases of recovery. These periods have been known to literally destroy marriages, cause embarrassing moments with friends and relatives, and cause a number of related problems that are associated with mental disorders.

“Our challenge at CMFF is to continue research on this important discovery,” says Rick C. Hunt, Ph.D. “With our own funds we have developed a new method of therapy for children and adults. It is in the form of an energetic patch that will deliver information to the child’s body, which will help boost their own immune system to eventually control the virus and encourage the body to begin healing itself.”

This new approach in therapy is called “Information Therapy.” As Dr. Hunt continues to describe his hypothesis it becomes apparent that this type of therapy USES NO DRUGS OR MEDICATION. This “Information Therapy” is classified as “complementary medicine,” which in the medical community is known to be used along with conventional medicine. CMFF research officials say this virus can be targeted by information programmed into the energetic patch to begin controlling the virus. The length of time that the child has to wear the patch depends on the severity of the disorder.

CMFF is in the process of conducting group studies for autistic children in Los Angeles, California; Henderson, Nevada; and Atlanta, Georgia, which so far has been showing positive results, but they say they do not have all the answers for these problems. CMFF believes this is an important breakthrough in discovering ways to control hyperactivity problems, and will begin asking for research funds for continued investigation.

According to some recent national concerns, experts estimate a child is being born with Autism in the USA every 20 minutes. Males are four times more likely to have autism than females. In most cases medical evaluations are sometimes misdiagnosed, and many children fall victim to harsh drugs and other treatments that are not necessary for a child or an adult who might show some autistic symptoms.

This type of therapy, according to CMFF officials, is a safe and non-toxic way to get control of the problem with no negative side-effects. The CMFF patch, with the help of the child’s own immune system, will attack the virus, and begin a healing process, thereby showing less evidence of symptoms associated with autism. Any donation to continue this research is appreciated. All donations received are 100% tax-deductible; CMFF can be reached at its web site at http://www.childrensmentalfocusfoundation.org/.

   For further information contact:   Children's Mental Focus Foundation, 1-866-390-9377   Website: http://www.childrensmentalfocusfoundation.org/    

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

Children’s Mental Focus Foundation

CONTACT: Children’s Mental Focus Foundation, +1-866-390-9377

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

Alsius Corporation Launches Thermogard XP(TM) Intravascular Temperature Management System

IRVINE, Calif., Jan. 24 /PRNewswire-FirstCall/ — Alsius Corporation , the worldwide leader in intravascular temperature management therapies, today launched the Thermogard XP(TM) Intravascular Temperature Management system designed to provide an enhanced level of therapeutic cooling power to clinicians serving critically ill and surgical patients that require central venous access.

Alsius’ Intravascular Temperature Management (IVTM(TM)) systems provide cooling and warming therapy via a computer-controlled temperature regulation system that connects to Alsius’ proprietary heat exchange catheters. The catheters are inserted into a major vein through a patient’s neck or groin, and circulate cool or warm saline in a closed-loop through balloons that surround the catheters. This approach decreases or increases core temperature from the inside of the body out toward the exterior, allowing for significantly more rapid control of a patient’s core body temperature, with greater efficiency and precision, compared to conventional external temperature management products such as cooling and warming blankets and ice packs.

The Thermogard XP represents the latest product introduction from Alsius and complements the CoolGard 3000(R) and Thermogard(TM) platforms by providing extra cooling power in situations where it is needed, including difficult-to-cool patients.

“We listened to the clinicians we work with and are pleased to offer the Thermogard XP as a solution for the most challenging temperature management scenarios,” said Bill Worthen, President and Chief Executive Officer of Alsius. “Alsius continues to serve the evolving needs of its neurosurgery, cardiac surgery, critical care, and emergency medicine customers and their patients with ongoing innovations and investment in research and development to improve heat exchange performance.”

The medical community continues to embrace the idea of body temperature as one of the four main vital signs and several major medical societies, including the American Heart Association and the American Stroke Association, support temperature management as the standard-of-care treatment for certain critically ill or surgical patients.

Quattro(TM) Catheter Introduced

Alsius also announced the introduction of the new Quattro(TM) catheter, a four-balloon heat exchange catheter that provides increased surface area and power with triple lumen central venous access. The Quattro allows clinicians to realize greater warming power on all Alsius IVTM systems and provides additional cooling power with the Thermogard XP.

“Every patient presents a unique set of characteristics and challenges calling for catheters of different lengths and insertion sites, as well as varying degrees of heat exchange power,” commented Suzanne Winter, Vice President, Worldwide Sales and Marketing. “The addition of Quattro to Alsius’ broad family of heat exchange catheters gives clinicians even greater flexibility to tailor cooling and warming therapies to those patients who might require enhanced cooling or warming power.”

Alsius IVTM(TM)

Alsius’ IVTM consists of the CoolGard 3000, Thermogard and Thermogard XP systems and a family of single-use catheters, including the Icy, Fortius or Quattro catheters, which are indicated in the United States for use: in cardiac surgery patients to achieve and/or maintain normothermia during surgery and recovery/intensive care; and to induce, maintain and reverse mild hypothermia in neurosurgery patients in surgery and recovery/intensive care. When used in conjunction with the Cool Line catheter, the Alsius systems are indicated in the U.S. for use in fever reduction, as an adjunct to other antipyretic therapy, in patients with cerebral infarction and intracerebral hemorrhage who require access to the central venous circulation and who are intubated and sedated.

About Alsius

Alsius, headquartered in Irvine, CA, is a commercial-stage medical device company that develops, manufactures and sells proprietary products to precisely control patient temperature in hospital critical care settings. Controlling body temperature, through cooling and warming, is becoming the standard of care for patients in select critical conditions and those undergoing a variety of surgical procedures. Alsius markets a comprehensive suite of catheter-based intravascular temperature management products that address the need for effective, accurate, easy-to-use and cost-effective control of body temperature in critical care patients. For more information, visit http://www.alsius.com/.

Safe Harbor

This press release may contain statements regarding plans and expectations for the future that constitute forward-looking statements within the meaning of the Private Securities Litigation Reform Act of 1995. All statements other than statements of historical fact are forward-looking. Such forward looking statements, based upon the current beliefs and expectations of Alsius’ management, are subject to risks and uncertainties, which could cause actual results to differ materially from those described in the forward-looking statements. The information set forth herein should be read in light of such risks. Additional information concerning such risks and uncertainties are contained in Alsius’ filings with the Securities and Exchange Commission, which can be accessed electronically on the Securities and Exchange Commission website at http://www.sec.gov/.

    Contact:     Suzanne Winter    Alsius Corporation    E-mail: [email protected]    Tel: (949) 453-0150 ext. 105     Kelli Kampanis    WeissComm Partners    E-mail: [email protected]    Tel: (212) 301-7172    Cell: (310) 625-3248  

Alsius Corporation

CONTACT: Suzanne Winter of Alsius Corporation, +1-949-453-0150, ext.105, [email protected]; or Kelli Kampanis of WeissComm Partners,+1-212-301-7172, cell, +1-310-625-3248, [email protected], for AlsiusCorporation

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

Advances in Hormone Replacement Therapy: Weight Benefits of Drospirenone, a 17[Alpha]-Spirolactone-Derived Progestogen

By Foidart, Jean-Michel Faustmann, Thomas

Abstract Hormone replacement therapy (HRT) remains the most effective treatment for menopausal symptom relief, and may provide cardiovascular benefits in younger women initiating treatment soon after menopause. However, large surveys indicate that many symptomatic women refuse or discontinue HRT prematurely owing to fear of weight gain. A continuous combined HRT containing 17beta- estradiol (E^sub 2^) 1 mg plus drospirenone (DRSP) 2 mg is effective in relieving menopausal symptoms and preventing postmenopausal osteoporosis. DRSP is a unique synthetic progestogen with a pharmacological profile similar to that of natural progesterone, including antialdosterone activity, a property not exhibited by other synthetic progestogens. DRSP can therefore reduce estrogen- related sodium and water retention in postmenopausal women receiving HRT via the renin-angiotensin-aldosterone system, which regulates sodium and water balance. This may translate into weight benefits. Pooled data from two placebo-controlled clinical trials (n = 333) indicated statistically significant weight loss of – 1.5 kg at 6 and 12 months in postmenopausal women receiving E^sub 2^/DRSP vs. placebo (p

Keywords: Drospirenone, hormone replacement therapy, progestogen, body weight, antialdosterone, renin-angiotensin-aldosterone system

Introduction

The menopause, the permanent cessation of menstruation, is experienced by the majority of women in their early fifties. As life expectancy continues to increase, women are likely to spend more than a third of their lives postmenopause. In 2000, there were an estimated 45.6 million postmenopausal women in the USA alone [1]. These demographic changes are expected to increase the number of menopausal and postmenopausal women to over 1 billion globally in 2030, with approximately 47 million women experiencing the menopause annually [2]. Approximately 80% of women have menopausal symptoms, of whom 45% find the symptoms distressing [3,4].

Hormone replacement therapy (HRT) remains the most effective treatment for the relief of menopausal symptoms [4-6]. Indeed, current European and US menopause society guidelines strongly recommend use of HRT for the relief of menopausal and urogenital symptoms, and for the prevention of bone loss [4,5,7-10]. Menopausal symptoms are varied, ranging from transient, inconvenient and distressing physical and psychological symptoms, such as hot flushes, insomnia and mood changes, to more serious long-term conditions, such as increased risk of fractures due to osteoporosis. Evidence from numerous studies has shown that HRT can relieve vasomotor symptoms, protect against osteoporosis and fractures [1,4- 9,11,12], provide a cardioprotective effect [13-18], preserve cognitive function [19,20] and, ultimately, lead to an improved quality of life for postmenopausal women [21].

Despite the overwhelming body of evidence for its benefits, some symptomatic postmenopausal women choose not to take HRT, or discontinue therapy at an early stage. Widespread media communication of the results of the Women’s Health Initiative (WHI) study and die Heart and Estrogen/progestin Replacement Study (HERS) has contributed to the concerns and uncertainties many women have about HRT [22-30]. Initial reports of data from these large-scale studies did not support the cardioprotective effects of HRT described previously in numerous observational studies of postmenopausal women [13,14], but instead suggested an increased risk for cardiovascular disease. However, recent publication of comprehensive analyses of the data from the WHI and HERS trials, and odier studies, suggest that HRT is cardioprotective in younger (

Unfortunately, since the initial reports of the WHI data in 2002, many postmenopausal women consider HRT to be associated with more risks and fewer benefits than they had previously thought [26-34]. Specific issues cited are increased risk of breast cancer and heart disease. With respect to menopause symptoms, many women cited bleeding disturbance with HRT as a significant issue. Lifestyle issues also affect women’s attitudes to HRT, and the potential for weight gain is a significant problem. Fear of gaining weight is frequently given as a reason why many postmenopausal women do not wish to take, or choose to discontinue, HRT [31,33-35].

The present paper reviews women’s attitudes to HRT post-WHI, and considers the reasons they choose not take HRT, with a focus on weight gain. The reasons why weight gain is frequently associated with menopause are discussed further, and the possibility that continuous combined HRT products containing new progestogens could contribute to the maintenance of body weight in postmenopausal women is explored.

Perceptions of hormone replacement therapy

Studies in Europe and the USA illustrate the different expectations women have of HRT, depending on their socioeconomic and cultural backgrounds [26,31-34,36-38]. Women questioned also demonstrated differences in their understanding of the changes they were likely to experience during the menopause. Their knowledge of the benefits and risks of HRT also varied considerably. One reason cited by women in all geographical groups for not wanting to use HRT, or for stopping their HRT treatment early, is the potential for weight gain.

In telephone surveys of postmenopausal women in Europe (n = 8012) and the USA (n = 5002), concerns regarding the increased risk of breast cancer and cardiovascular disease were cited as reasons for discontinuing HRT [31,33], but weight gain was also ranked surprisingly high as an unacceptable risk associated with therapy. A further US study found that a higher number of women discontinued HRT due to their worries about weight gain and monthly bleeding associated with initiating therapy than the number of women who actually experienced these side-effects while receiving treatment [39].

A retrospective pre-WHI study of new HRT users found that early treatment cessation was more frequent in younger women who did not have an obstetrician/gynecologist as their initial HRT prescriber [40]. This finding suggests that a significant number of women will not gain the additional long-term benefits of therapy. An initial consultation that includes a full explanation of the benefits of HRT may therefore encourage a woman to make a more informed choice about her treatment.

Weight gain during the menopause

A range of different factors might contribute to the weight gain often experienced at this time in a woman’s life [41-43]. A natural decrease in the basal metabolic rate reduces calorie use, leading to an increase in body weight [43]. Fat mass is typically redistributed, resulting in an increase in the waist-to-hip ratio in menopausal women [42,44,45]. In many cases, this increased adiposity and altered fat distribution appears to be a consequence of both reduced energy expenditure and the decline in endogenous estrogens [46]. Some clinical studies have shown that weight gain and change of fat distribution can be an estrogen-related effect of HRT treatment [47-49], although others report no significant effect of HRT on body weight [50-52]. As the fear of weight gain is often cited as a reason for not taking HRT, women who are confident that HRT will not cause a weight increase are more likely to be receptive to treatment.

Hormone replacement therapy and the renin-angiotensin- aldosterone system

The renin-angiotensin-aldosterone system (RAAS) plays a critical role in the regulation of body fluids, serum sodium, potassium and blood pressure via the angiotensin-mediated stimulation of aldosterone production [53,54] (Figure 1). Aldosterone acts on die kidney to conserve sodium and water, and eliminate potassium. Endogenous and synthetic estrogens increase the synthesis of angiotensinogen (the angiotensin precursor) by the liver. The consequent stimulation of the RAAS leads to increased production of aldosterone. Subsequent sodium and water retention leads to increased plasma volume, water retention symptoms, such as edema and weight gain, and, in susceptible women, to elevation of blood pressure. In premenopausal women, estrogen-induced stimulation of the RAAS is countered by progesterone, which competes with aldosterone at the mineralocorticoid receptor, thereby opposing any estrogen-mediated effects and preventing fluid retention [53,54]. Figure 1. Schematic of the renin-angiotensin-aldosterone system (DRSP, drospirenone).

Oral therapy with natural or synthetic estrogens, such as HRT, can affect the RAAS. Oral estrogens are rapidly absorbed in the gut and then undergo their first pass through the liver at high levels [55,56], excessively stimulating angiotensinogen and, consequently, aldosterone production. The conventional synthetic progestogens used in continuous combined HRT do not exhibit the antimineralocorticoid activity of natural progesterone [53,54]. Many of these progestogens are derived from testosterone, and their progestogenic effects are attributable to their androgenic properties and glucocorticoid effects. Therefore they are unable to block the aldosterone receptor and are consequently unable to counter the estrogen-induced increase in aldosterone levels, leading to fluid retention which is the key to HRT-associated weight gain [54].

Drospirenone: The ideal progestogen

A synthetic progestogen is primarily used in combined continuous HRT to counter the estrogen-mediated proliferation of the uterine endometrium in women with an intact uterus. The ideal synthetic progestogen would have properties that closely mimic the activity of endogenous progesterone and therefore potentially offer additional benefits. Drospirenone (DRSP), derived from 17alpha-spirolactone, is a novel synthetic progestogen which has activity closer to natural progesterone than other synthetic progestogens [54,57-59]. Indeed, DRSP is the only synthetic progestogen to have significant antialdosterone properties (Table I) [54,57-59]. As a potent aldosterone antagonist, DRSP acts on the mineralocorticoid receptor to prevent sodium retention, and thus reduces estrogen-related water retention associated with HRT. DRSP also has antiandrogenic properties that may counteract the negative effect of androgens on hair growth, lipid changes, insulin and, possibly, body composition in postmenopausal women [54]. Like natural progesterone, DRSP has no effect on either glucocorticoid or estrogen receptors.

Symptoms of premenstrual syndrome (PMS) can have a significant negative effect on quality of life, encompassing mood swings, irritability, water retention, and breast tenderness. In women suffering from premenstrual dysphoric disorder (PMDD), the severity of symptoms entirely disrupts normal functioning in daily life (e.g. relationships, work). The etiology of these disorders is unknown; however, treatment with the aldosterone antagonist, spironolactone, is effective in alleviating some of these symptoms and improving quality of life. As DRSP has antialdosterone activity, it is therefore likely to improve these quality-of-life-affecting somatic symptoms. Indeed, the combination of DRSP and ethinyl estradiol (EE) as an oral contraceptive has shown significant benefits on general well-being and PMS symptoms, especially physical symptoms, and improvements in health-related quality of life in several studies [60-62]. A combination containing DRSP 3 mg and EE 20 [mu]g in a new 24/4 regimen (24 active pills + 4 placebo pills) has demonstrated relief of emotional and physical symptoms of PMDD in large clinical trials [63,64]. The HRT combination of 17beta-estradiol (E^sub 2^) 1 mg plus DRSP 2 mg (Angeliq(R); Bayer Schering Pharma AG, Berlin, Germany) has also shown quality-of-life benefits in postmenopausal women [65].

In addition, contrary to the commonly held belief that HRT causes weight gain, clinical studies of E2 1 mg plus DRSP 2 mg demonstrated that this combination may actually help maintain or even slightly decrease body weight [65]. It is the unique pharmacological profile of DRSP (Figure 2) that translates into additional clinical benefits for postmenopausal women [53,54,66] and may contribute to improved HRT acceptance and compliance [65].

Table I. Comparison of drospirenone with other progestins [54,57- 59].

Figure 2. Pharmacological and clinical effects of aldosterone and antialdosterone action of drospirenone [53,54″66] (CNS, central nervous system; PARA, progestogen with aldosterone receptor antagonism).

Drospirenone: Benefits on body weight

Evidence for the benefits of E^sub 2^/DRSP with respect to body weight is increasing as further studies are carried out. A standardized weight measurement is taken as part of the safety assessment in all E^sub 2^/DRSP trials – analysis of these data has demonstrated that the unique pharmacological profile of DRSP translates into clinical benefits in terms of body weight maintenance, as summarized below.

Data from two placebo-controlled studies of E2 1 mg/DRSP 2 mg in postmenopausal women with an intact uterus were pooled to estimate weight change compared with placebo for up to 12 months. These two trials were selected for pooling because they are the only long- term (at least 12 months) placebo-controlled studies conducted with E^sub 2^/ DRSP; both trials used the same criteria for body weight measurement.

The first study was a double-blind, placebo-controlled, 2-year trial enrolling 240 postmenopausal women with an intact uterus, aged 45-65 years [67]. The study was designed to investigate the effects of treatment with different dosages of DRSP in combination with E^sub 2^ 1 mg on bone parameters. Weight measurements were standardized by using the same balance throughout the study: patients removed their shoes and were allowed to wear only light indoor clothing.

The second trial was a 1-year, double-blind, placebo-controlled, parallel-group study assessing die effects of E^sub 2^/DRSP on dermatological parameters (Bayer Schering Pharma AG, data on file). A total of 94 postmenopausal women with an intact uterus were enrolled. In all, 93 women (mean age 58.1 years) were evaluated over thirteen 28-day cycles. Treatment compliance was high throughout the study in both the E^sub 2^/DRSP (n = 47) and placebo groups (n = 46). Weight was measured routinely at every visit; again, the same balance was used throughout, and patients wore only light indoor clothing without shoes.

The pooled data showed a statistically significant weight loss of approximately -1.5 kg at both 6 and 12 months in women treated with E^sub 2^/DRSP vs. placebo (p

A beneficial effect on body weight was also observed in a 1- year, multicenter, double-blind, randomized, parallel-group study of postmenopausal women that was carried out to determine the effect of thirteen 28-day cycles of E^sub 2^/DRSP compared with E^sub 2^ monotherapy [65]. A total of 1147 postmenopausal women with an intact uterus were enrolled in the study, of whom 1142 were evaluated. Mean body weight at baseline was comparable for all treatment groups. Throughout the treatment period, women receiving E^sub 2^ 1 mg combined with DRSP 2 mg registered constant body weight or loss of weight, whereas increases in weight were recorded in those receiving E^sub 2^ 1 mg monotherapy (Figure 3; p

Table II. Estimated change in body weight: estradiol/ drospirenone vs. placebo (kg) in 333 women.

The effect of the E^sub 2^/DRSP combination on amount and distribution of body fat has also been studied in a randomized, double-blind, placebo-controlled trial [68]. A total of 240 healthy postmenopausal women (53-65 years old) were randomized to placebo or E2 plus DRSP for 2 years. Among the main outcome measures were the changes in central (CFM) and peripheral fat mass (PFM). Topographic distribution of body fat was measured using the CFM/PFM ratio. Women receiving E^sub 2^ 1 mg/DRSP 2 mg showed a decrease in CFM from baseline at months 6 (-0.37 kg) and 24 (-0.56 kg). PFM was decreased at 6 months (-0.33 kg) but increased at 24 months (+0.26 kg). At month 24, the CFM/PFM ratio was significandy lower than at baseline (-0.047 kg; p

DRSP in combination with EE as an oral contraceptive has also shown benefits with respect to body weight. A large, multicenter, open-label, randomized trial in Europe compared the efficacy, cycle control and tolerance of the monophasic oral contraceptive EE 30 [mu]g/DRSP 3 mg (Yasmin(R); Bayer Schering Pharma AG) with an oral contraceptive containing EE 30 [mu]g plus desogestrel (DSG) 150 [mu]g (Marvelon(R); Organon, The Netherlands) [69]. Overall, 887 women were randomized to receive treatment over 26 cycles with a 3- mondi follow-up. Body weight measurements without clothing were made at home in the morning, prior to breakfast, using the same scales each time. During the study weight was checked every cycle on the first day of taking the medication, then weekly, always on the same day of the week, including the tablet-free intervals. For the first 35 days of follow-up, weight was checked on the same day, each week.

Figure 3. Change in body weight in postmenopausal women: estradiol (E^sub 2^) 1 mg/drospirenone (DRSP) 2 mg (n = 227) compared with E^sub 2^ (n = 226). Adapted from [65] with permission from Lippincott Williams & Wilkins.

A significant difference in body weight was seen between the two treatment groups throughout the study. In the EE/DRSP group, mean body weight per cycle remained just under baseline throughout the study (range -0.22 to -0.68 kg), apart from cycles 25 and 26, whereas in the EE/DSG group the mean body weight was above baseline (range +0.02 to +0.89 kg) throughout the study except for cycles 1- 5 (range -0.01 to -0.15 kg). The differences between treatment groups were significant over cycles 1-13 (p = 0.0001) and 14-26 (p = 0.0009). Mean body weight was above baseline in both treatment groups during the follow-up phase [69]. Although overall a decrease was seen in the EE/ DRSP group and an increase was seen in the EE/ DSG group, the majority of women in both groups maintained a stable body weight (within 2 kg of baseline). However, the number of women gaining or losing more than 2 kg did differ between the treatment groups, with more women in the EE/ DRSP cohort losing > 2 kg and more women in the EE/DSG cohort gaining > 2 kg [69]. These findings indicated that overall the EE/DRSP combination has a favorable effect on body weight, and were consistent with another large-scale study comparing these two oral contraceptives over 13 cycles [70].

Discussion

HRT remains one of the most effective treatments for the management of vasomotor symptoms during the menopause [4-6]. Among the reasons why women decide against HRT, the fear of weight gain remains one of the most frequently cited [31,33-35]. Compliance with HRT is the result of a complex process that is influenced by perceptions and expectations of HRT, and attitude to the prevention of osteoporosis and cardiovascular disease when treatment is initiated. Individual women’s knowledge and expectations regarding HRT treatment should, therefore, be addressed by physicians when prescribing HRT.

Increased efforts are needed to improve HRT compliance through improved education and better treatment options. By helping to maintain or slightly decrease body weight, E2/DRSP may overcome one of the major hurdles to optimal treatment concerning many women with conventional HRT products. Studies in postmenopausal women indicate diat E2/ DRSP is an effective HRT regimen, not only providing quick and effective relief of vasomotor symptoms [71] and protecting against postmenopausal osteoporosis [67], but also having benefits regarding weight maintenance and a blood pressure-lowering effect in hypertensive menopausal women that has not been shown with other HRT options [72-74]. These additional beneficial effects are due to the antialdosterone antagonism activity of DRSP, the only synthetic progestogen to exhibit these properties [53,54,57-59,66].

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JEAN-MICHEL FOIDART1 & THOMAS FAUSTMANN2

1 Hopital de la Citadelle, Liege, Belgium, and 2 Bayer Schering Pharma AG, Berlin, Germany

(Received 19 June 2007; revised 16 July 2007; accepted 18 July 2007)

Correspondence: J.-M. Foidart, Hopital de la Citadelle, Bvd du 12eme de Ligne 1, B-4000 Liege, Belgium. Tel: 32 422 56582. Fax: 32 422 40005. E-mail: [email protected]

Copyright Taylor & Francis Ltd. Dec 2007

(c) 2007 Gynecological Endocrinology. Provided by ProQuest Information and Learning. All rights Reserved.

Scientists Produce Energy From Rain

Scientists at the atomic energy commission (CEA) in Grenoble, France, have developed a technique that takes the mechanical force produced by falling raindrops and converts this force into electricity that can be used to power various electronic devices and sensors.  

The system uses piezoelectric structures, which convert mechanical force to voltage, and can recover up to 12 milliwatts of power  from one of the larger “downpour” raindrops.

“We thought of raindrops because they are one of the still-unexploited energy sources in nature,” said Jean-Jacques Chaillout, who led the research, in an interview with the magazine New Scientist.

Chaillout’s team began their research by examining data on different types of rainfall.  Drizzle, they found, produces droplets of about 1 millimeter in diameter which have an impact energy of around 2 microjoules, while droplets from a downpour were typically 5 millimeters across and gave 1 millijoule of impact energy.

The researchers then used computer simulations to see how different-sized drops hit surfaces, concluding that a 25-micrometer-thick piezoelectric material would be the most efficient at harvesting energy from a range of raindrop sizes.

Finally, they mounted a 10-centimeter-long strip of a piezo plastic material called polyvinylidene fluoride on a rig and suspended a pipette above it that could be adjusted to create different size water droplets that fell at realistic rainfall velocities.

As the drops hit the piezo plastic, they found that it produced between 1 nanojoule and 25 microjoules of energy per raindrop, depending on the size of the raindrop. That equals about one microwatt of power for the smallest drops, enough to transmit a digital bit of information through 10 meters of air.

Although the output is tiny compared to that of solar panels, rain power has the advantage of working in the dark and could be used as a supplement to solar-powered devices.

The researchers said the first application could be inside the cooling towers of nuclear power stations, where a build-up of limescale reduces efficiency.

The team now plans to create a wireless limescale sensor that will be powered by the falling droplets that form when steam vented up the chimney condenses.

Other applications could include a self-powered rain detector for a car’s windshield wipers or wireless air-quality sensors that transmit pollution readings to a data center.   

Environmental sensors that “scavenge” their own energy make good sense, Peter Tavner, head of engineering at Britain’s Durham University, told New Scientist. “We use far too much energy in simply exchanging information between devices. I think self-powering them is the future.”

However, Stephen Roberts of Perpetuum, a company that builds devices, which capture energy from vibrating machinery and bridges, noted that rain-powered piezoelectric sensors provide only intermittent power and may wear out quickly.

On the Net:

New Scientist

Saints’ Relics on eBay Cause a Stir

On eBay on Jan. 3, a would-be seller posted a wheat-colored envelope, fastened with a red wax seal, said to contain remains of the Apostle Bartholomew.

Another posting showed a beveled glass reliquary inset with pieces of five saints’ earthly matter.

The sale of what the Catholic Church terms first-class relics — bits of bone, hair and flesh — outrages Tom Serafin, a Catholic activist and the president of the International Crusade for Holy Relics, a Los Angeles-based organization that maintains a traveling exhibit of venerated articles.

It’s not the prices that get Serafin hopping mad. It’s the fact that pitches appear on the site for the remains of saints and objects of worship, such as Eucharist wafers used in holy communion.

Church law forbids the buying and selling of the items.

“Just as you would not go around selling portions of one of your beloved deceased for money, for the church, these (saints) are our family members,” said Father Mark Weisner, spokesman for the Oakland Diocese.

On Tuesday, Weisner, stunned to learn of the online sales, ran an eBay search for “holy relics.” Up popped a posting for an authenticated piece of the papal collar of Pope Leo XIII (a second-class relic).

“If someone were to ask for my blessing, I wouldn’t say, ‘OK, that will be $10,'” said Father Michael Sweeney, president of the Dominican School for Philosophy and Theology. “It’s not to be treated as having profane value.”

EBay prohibits the sale of human remains.

Hate literature, body parts, babies, relics of executions and much more appear on eBay’s long list of barred items.

But Serafin and a handful of others, including a Russian archbishop and a retired FBI agent, have monitored the site and wrangled with the company for 10 years.

Their conclusion is that eBay does nothing to enforce its own rules.

“EBay is like a big monster,” he said. “You can’t even beat a conscience into them.”

A company spokeswoman rejected the allegations. The San Jose-based trading site continuously hunts down postings that violate its policies, said Kim Rubey.

But with users trading in more than 50,000 categories, some offenders slip through, she said.

“At any given time, there are 102 million items on the Web site worldwide, and 6 million are added every day,” Rubey said. “We do have a team of people working around the clock to remove listings that violate any policies.”

The company encourages visitors to report offenders, she said.

Prompted by Serafin’s http://www.boycottebay.net, Catholics barraged the company with angry e-mails when sellers posted Eucharist wafers. The company pulled the postings and vowed not to allow future sales of the Eucharist “and similar highly sacred items.”

Catholics believe that when they partake of the Eucharist wafer, it becomes the body, blood and soul of Christ, and the sacrament unites heaven and Earth. Its sale is a profound abomination, Sweeney said.

To transfer a relic from one entity to another requires the approval of the Holy See, Weisner said.

Along with the traffic in genuine relics comes the inevitable bogus trade, Serafin said. A counterfeit skull of Saint Thomas More and hand of Saint Stephen have made their way onto the site.

Serafin’s is not the first organization to do battle with eBay over its trade in items that offend faith groups. The Anti-Defamation League challenged the online auctioneer in 2000 over its sale of Nazi memorabilia, including Hitler’s monogrammed bedsheet and telephone book.

A year later, the company expanded its rules to ban anti-Semitic articles, but last week’s offerings included a Nazi armband.

“Catholics, all Christians, and those of African, Jewish or Asian ancestry should be outraged by the lax attitude that one of our nation’s biggest e-commerce sites shows to offensive items on their site,” Serafin said.

Yet even critics sympathize with the enormity of policing the site.

“How do you know the values of every faith?” Weisner asked. “It would be a huge undertaking. It would be an interesting challenge.”

Defective Sperm Cells Have Their Own Quality Control

COLUMBIA, Mo. — Defective sperm cells do not pass through the body unnoticed.

A new University of Missouri study provides evidence that the body recognizes and tags defective sperm cells while they undergo maturation in the epididymis, a sperm storage gland attached to the testis. According to researchers, only the best sperm that have the highest chance of succeeding in fertilization will survive the production process without a “tag.”

A small protein called ubiquitin marks abnormal sperm cells, including cells that have two heads, two tails or are otherwise misshaped. This “recycling tag” on the sperm cell tells the body which cells need to be broken back down into amino acids. This provides evidence that there is an active removal process or marking of defective sperm during the epididymal passage.

“Fertilization is, in a way, a numbers game,” said Peter Sutovsky, associate professor of animal sciences, clinical obstetrics and gynecology in the MU College of Agriculture, Food and Natural Resources. “You need a certain number of normal sperm cells to reach the egg. If too many are tagged with ubiquitin, there may be not enough to fertilize an egg.”

This study suggests that the male reproductive system must be able to evaluate and control the quality of the sperm to insure an optimal chance of fertilization. High levels of ubiquitin in the sperm can indicate low-sperm count or infertility. This process of quality control has been found in both humans and other mammals including bulls, boars and rats.

“In many cases, the cells that are tagged with ubiquitin are obviously abnormal with two tails or two heads, but many of them look like they don’t have defects,” Sutovsky said. “Oftentimes, these cells may look normal but lack proteins that are important to fertility.”

Once sperm cells are tagged as defective, it is unlikely that the process can be reversed. Sutovsky stresses the importance of a healthy lifestyle to reduce the likelihood of abnormal sperm cells. He suggests avoiding exposure to toxic chemicals, abstaining from smoking and maintaining a healthy diet. He suggests people who work with toxins on a daily basis should minimize their exposure by wearing protective clothing and respirators.

The study was published in the Journal of Cellular Physiology.

On the Net:

University of Missouri-Columbia

Dr. Schoch Joins SSM St. Charles Clinic Medical Group

By St Charles

SSM St. Charles Clinic Medical Group has added of Peter Schoch, MD, to the Medical Group’s adult primary care/internal medicine department.

Dr. Schoch (pronounced “Shuck”) is board certified and joins Dr. Ray Hu, Dr. Thomas Tyree and nurse practitioner Michele Marcus in the Medical Group’s office at SSM St. Joseph Medical Park, 1475 Kisker Road in St. Charles.

Dr. Schoch has over 10 years experience with Cornerstone Internal Medicine in High Point, N.C. He is a graduate of Central Methodist College in Fayette, Mo., where he had a double major in biology and chemistry and a minor in religion. Dr. Schoch completed medical school at the University of Missouri in Columbia.

He can be reached at the St. Charles Clinic Medical Group’s Kisker Road/Medical Park office at 636/498-5850.

The St. Charles Clinic Medical Group offers primary care and specialty services throughout St. Charles County, and in Troy and Warrenton. More information on physicians and specialists in the St. Charles Clinic Medical Group is available at www.ssmdrs.com.

Originally published by St. Charles Business Record Staff.

(c) 2008 St. Charles County Business Record. Provided by ProQuest Information and Learning. All rights Reserved.

Mental-Health Provider to Sue Wake, Durham

By Lynn Bonner, The News & Observer, Raleigh, N.C.

Jan. 23–Dominion Healthcare Services, a private mental-health company based in Raleigh, plans to sue two county mental-health offices and a private contractor for $1 billion, claiming they worked to drive the company out of business.

Willie Gary, a Florida lawyer and major Shaw University benefactor, is representing Dominion Healthcare. Joel Hopkins, a former Shaw basketball coach, is Dominion’s founder and CEO.

Gary’s firm said Tuesday that it would file the suit today against the Wake and Durham county mental-health offices and ValueOptions, a company the state hired to approve mental-health services for Medicaid patients. The law firm said it would hold a news conference this morning.

The suit would be another step in the legal back-and-forth between Dominion Healthcare and county mental-health offices.

Dominion is one of hundreds of companies in the state offering a mental-health service called community support. Dominion does business in the state’s biggest counties, including Wake, Durham and Mecklenburg.

State and local officials have investigated Dominion Healthcare several times in the past 15 months for alleged violations. County mental-health officials in Durham and Wake told Dominion late last year that they would take away the company’s licenses to bill Medicaid.

In administrative court hearings this month, Miki Jaeger, head of the quality management team for the Wake mental-health office, said the company altered medical documents to justify Medicaid payments. A manager from The Durham Center, the county’s mental-health office, testified she found patient medical records in an unsecured drop box outside a company office in Roxboro.

The company is appealing and won a ruling last week that forces the counties and ValueOptions to let Dominion Healthcare keep working and billing Medicaid while it seeks a final ruling.

In his ruling, Judge Joe Webster said the counties did not give the company a chance to correct its problems as the rules require.

There was no evidence to suggest the company was not meeting standards of care, Webster wrote. He was concerned that, in their review of company records, less-qualified government employees were second-guessing “licensed medical providers.”

ValueOptions was not part of the administrative case and was mentioned infrequently in testimony.

Kori Love, a spokeswoman for Gary’s firm, said the suit would cite ValueOptions for breach of contract. She provided no further details, saying they would be fully outlined today.

A spokesman for ValueOptions, Steve Anderson, said he knew nothing about the suit. Durham County Attorney Chuck Kitchen said he did not know whether his office would represent The Durham Center or whether the state Attorney General’s Office, which handled the administrative appeal, would pick up the case.

Noelle Talley, a spokeswoman for the Attorney General’s Office, said lawyers would have to review the complaint before they decided who would represent the county mental-health offices.

[email protected] or (919) 829-4821

—–

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

Distributed by McClatchy-Tribune Information Services.

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NASDAQ-NMS:HCSG,

Examine the Organ Transplant Immunosuppressive Markets

Reportlinker.com announces that a new market research report related to the Health Care industry is available in its catalogue.

Organ Transplant Immunosuppressive Markets

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Improved surgical techniques and organ preservation, understanding of immunologic barriers, and the development of newer and more potent immunosuppressives have combined to improve survival of transplant patients and grafts. Rejection remains the major barrier to long-term graft survival in patients, organ transplantation therapy is highly dependent on the success of immunosuppressants to suppress the recipient’s immune responses to the foreign organ. Most transplant patients require lifelong immunosuppressive therapy to prevent rejection, except when human leukocyte antigen (HLA)-identical transplants are used.

The number of organ transplants performed worldwide is approximately 70,000 annually. As medical science extends the life expectancy of patients with transplanted organs, demand continues to increase for safe, effective immunosuppressants to control transplant rejection.

Kalorama Information’s Organ Transplant Immunosuppressive Markets is focused on immunosuppressants utilized in solid organ transplantation. It provides an in depth look into the trends that have shaped today’s use of transplant immunosuppression regimens, and details the current and future global market. Included in this report:

Detailed statistics on Transplant Need, Organ Transplant Procedures, Costs, Patient Waiting Lists, and Patient Survival Rates

Immunosuppressive Current Market and Forecasts

Breakouts of Immunosuppressive Drugs by Drug Type and by Organ Transplanted

Regional Breakout of Immunosuppressive Sales (US, Europe, Asia/Pacific, Rest of World)

Market Share of Immunosuppressive Market

Review of Current Products and New Products in Development

Profiles of Immunosuppressive Market Competitors

As part of Kalorama Information’s information-gathering process, this report consists of primary research. An exhaustive search of medical and corporate literature was conducted. But interviews with executives in the market were used to build models and test assumptions in this report.

Pharmaceutical marketing directors, executives in the organ transplant market, as well as investors looking at this market are among those who will find this report a useful resource.

CHAPTER ONE: EXECUTIVE SUMMARY

# Overview

# Scope and Methodology

# Solid Organ Transplantation

# Long-Term Survival

# Shortage of Donor Organs

# Cost of Transplantation

# Organ Transplantation Trends in the U.S.

# Organ Waiting List

# Organ Transplant Trends in Europe

# Immunosuppression in Transplantation

# Immunosuppression Therapy

# Trends in Use of Immunosuppressants

# Trend from Calcineurin Inhibitors to Tacrolimus

# Trend From Use of Azathioprine to Mycophenolate Mofetil

# Immunosuppressant Market Analysis

# Immunosuppressive Market by Drug Classification

# Immunosuppressant Sales by Geographical Region

# CHAPTER TWO: SOLID ORGAN TRANSPLANTATION

# Introduction

# History of Organ Transplantation

# Progress and Limitations in Solid Organ Replacement

# Long-Term Survival

# Shortage of Donor Organs

# Cost of Transplantation

# Evolution of Organ Donation and Procurement

# National Transplant Act

# Organ Transplant Trends in the U.S.

# Organ Waiting List

# Organ Transplant Trends in Europe

# Number of Organs Transplanted in Europe

# Organ Transplantation Procedures

# Heart Transplantation

# History of Heart Transplantation

# Indications/Contraindications for Heart Transplant

# Status of Heart Transplantation

# Intestine Transplantation

# History of Intestine Transplantation

# Indications for Intestine Transplantation

# Status of Intestine Transplantation

# Kidney Transplantation

# History of Kidney Transplantation

# Indications/Contraindications for Kidney

# Transplantation

# Status of Kidney Transplantation

# Liver Transplantation

# History of Liver Transplantation

# Indications/Contraindications of Liver Transplantation

# Status of Liver Transplantation

# Lung Transplantation

# History of Lung Transplantation

# Indications/Contraindications of Lung Transplantation

# Status of Lung Transplantation

# Pancreas Transplantatiom

# Pancreatic Islet Cell Transplantation

# History of Pancreas Transplantation

# Indications/Contraindications Pancreas Transplantation

# Status of Pancreas Transplantation

# The Immune System and Organ Transplantation

# Posttransplantation Complications

# Organ Rejection

# Hyperacute Rejection

# Accelerated Rejectiom

# Acute Rejection

# Chronic Rejection

# Infection

# Renal Disorders

# Cancer

# Other Complications

# Future Directions in Organ Transplantation

# Stem Cells and Tissue Engineering

# Xenotransplantation

# CHAPTER THREE: TRANSPLANT IMMUNOSUPPRESSIVE THERAPIES

# Introduction

# The Immune System

# Functions of the Immune System

# Immunosuppression

# Immunosuppression Therapy

# Tolerance Induction

# History Of The Development Of Transplant Immunosuppressive

# Description Of Immunosuppressant Agents

# Corticosteroids

# Mechanism of Action

# Calcineurine Inhibitor Agents

# Cyclosporine

# Tacrolimus

# mTOR inhibitors

# Antiproliferative Agents

#

# Mycophenolate Mofetil

# Mycophenolic Acid

# Azathioprine

# Monoclonal Antibodies

# Muromonab-CD3

# Basiliximab

# Daclizumab

# Polyclonal Antibodies

# Antithymocyte globulin-equine and Antithymocyte globulin-rabbit

# Immunosuppressant Regimens

# Designing Immunosuppression Regimens

# Induction Therapy

# Maintenance Therapy

# Organ Rejection Therapy

# Hyperacute Rejection

# Accelerated Acute Rejection

# Acute Rejection

# Chronic Rejection

# Trends in Immunosuppressive Regimens

# Steroid Avoidance/Eliminating Regimens on Increase

# Minimizing Calcineurin inhibitor Regimens in Kidney

# Transplants

# Downside of Transplant Immunusuppressants

# Adverse Side Effects

# Cost of Transplant Medications

# Immunosuppressant Therapies in Research and Development

# Current Research and Development

# Circumventing the HAMA Reaction

# Selective blocker of T-cell Activation

# Selective Inhibitor of Janus Kinase

# Inhaled Formulation of Cyclosporine

# Utilizing Gene Expression Profiles to Measure the

# Efficacy of Immunosuppression

# CHAPTER FOUR: ORGAN TRANSPLANT IMMUNOSUPPRESSANT MARKET ANALYSIS

# Introduction

# Development and Expansion Immunosuppressants in Organ Transplants

#

# Trend from Calcineurin Inhibitors to Tacrolimus

# Trend From Use of Azathioprine to Mycophenolate Mofetil

# Trends in the Use of Immunosuppressives in Specific Organs

# Trends in Kidney Transplantation

# Maintenance Immunosuppression

# Immunosuppression Therapy for Acute Rejection

# Trends in Pancreas Transplantation

# Maintenance Immunosuppression

# Trends in Liver Transplantation

# Liver Maintenance Immunosuppression

# Immunosuppression Therapy for Rejection

# Trends in Intestine Transplantation

# Intestine Maintenance Immunosuppression

# Antirejection Treatment for Intestine Transplantation

# Trends in Lung Transplantation

# Lung Maintenance Immunosuppression

# Immunosuppression to Treat Acute Lung Rejection

# Trends in Heart Transplantation

# Immunosuppressant Usage One Year After Transplant

# Trends in Heart-Lung Transplantation

# Transplant Immunosuppressant Market

# Introduction

# Market and Forecasts

# Immunosuppressive Market by Drug Classification

# Immunosuppressant Sales by Geographical Region

# Top-Selling Immunosuppressant Brands

# Transplant Immunosuppressant Market Share

# Strategies to Gain Market Share or Market Entrance

# Genzyme Corporation Buys into the Transplant

# Immunosuppressant Market

# Pharmaceutical Lifecycle Management to Maintain or Gain Market Share

# CHAPTER FIVE: COMPANY PROFILES

# ASTELLAS PHARMA US, INC.

# History and Lines of Business

# Immunosuppressive Products

# Financial Information

# GENZYME CORPORATION

# History and Lines of Business

# Immunosuppressive Products

# Thymoglobulin

# Lymphoglobuline

# Financial Information

# NOVARTIS AG

# History and Lines of Business

# Immunosuppressive Products

# Neoral/Sandimmune

# Myfortic

# Certican

# Simulect

# Financial Information

# F. HOFFMANN-LA ROCHE LTD

# History and Lines of Business

# Immunosuppressant Products

# Financial Information

# Wyeth Pharmaceuticals

# History and Lines of Business

# Immunosuppressive Product

# Financial Information

# PROFESSIONAL ORGANIZATIONS

# COMPANY NAMES AND ADDRESSES

TABLE OF EXHIBITS

CHAPTER ONE: EXECUTIVE SUMMARY

* Table 1-1: Waiting List Candidates (Active and Inactive Combined), in U.S., 2004-2005

* Table 1-2: Current Organ Waiting List, Number of

* Transplant Procedures and Number of Donor Organs Recovered, in U.S., 2007

* Table 1-3: Growth in Number of Transplanted and Recovered Organs, in U.S., 2004-2005

* Table 1-4: Unadjusted One-and Five-Year Patient Survival by Organ, in the U.S.

* Table 1-5: Number of Deceased Donor’s Organs Used for Transplant, by Organ, as Reported by Eurotransplant, from 2002-2006

* Table 1-6: Current Waiting List for Solid Organs, as Reported by Eight European Countries, as of September 2007

* Table 1-7: Chronological Development of Transplant Immunosuppressive Therapies

* Table 1-8: Global Transplant Immunosuppressant Market, 2002-2012

* Figure 1-1: Market Share of Immunosuppressive Categories, 2006

* Figure 1-2: Immunosuppressant Sales by Geographical Region, 2006

* Figure 1-3: Immunosuppressant Market, by Organ Transplanted, 2006 (Kidney, Kidney/Pancreas, Liver, Lung, Heart)

* CHAPTER TWO: SOLID ORGAN TRANSPLANTATION

* Table 2-1: Landmarks in Organ Transplantation in the United States and Canada

* Table 2-2: Estimated US Average First-Year Billed Charges per Transplant, 2005

* Table 2-3: Waiting List Candidates (Active and Inactive Combined), in U.S., 2004-2005

* Table 2-4: Current Organ Waiting List, Number of Transplant Procedures

* Performed and Number of Donor Organs Recovered, in U.S., 2007

* Table 2-5: Growth in Number of Transplanted and Recovered Organs, in U.S., 2004-2005

* Table 2-6: Unadjusted One-and Five-Year Patient Survival by Organ, in U.S.

* Table 2-7: Unadjusted One-and Five-Year Graft Survival by Organ, in U.S.

* Table 2-8: Number of Deceased Donor’s Organs Used for Transplant, by Organ, as Reported by Eurotransplant, from 2002-2006

* Table 2-9: Number of Deceased Donor’s Organs Used for Transplant, by Organ and Country, as Reported by Eurotransplant, 2002-2006

* Table 2-10: Summary of Donor and Transplant Activity in the United Kingdom and the Republic of Ireland for 2005-2006

* Table 2-11: Current Waiting List for Solid Organs, as Reported by Eight European Countries, as of September 2007

* Table 2-12: Types of Transplant Rejection, by Organ

* CHAPTER THREE: TRANSPLANT IMMUNOSUPPRESSIVE THERAPIES

* Table 3-1: Chronological Development of Transplant Immunosuppressive Therapies

* Table 3-2: Most Commonly Prescribed Transplant Immunosuppressant Agents

* Table 3-3: Steroid Avoidance Rate at Discharge, 1996 to 2005 Recipients of Deceased Donor Kidneys

* Table 3-4: Steroid Avoidance Rate at Discharge, 1996-2005 Recipients of Deceased Donor Livers

* Table 3-5: Steroid Avoidance Rate at Discharge, 1996 to 2005 Recipients of Heart Transplants

* Table 3-7: Estimated Monthly Cost of Immunuosuppressant Drugs

* CHAPTER FOUR: MARKET ANALYSIS

* Figure 4-1: Comparative Calcineurin Inhibitor Use for Immunosuppressive Prior to Discharge, by Organ, 2003

* Figure 4-2: Comparative Use of Maintenance Antimetabolite and Sirolimus Immunosuppression Prior to Discharge, by Organ, 2003

* Figure 4-3: Immunosuppression Agents Used for Induction in Kidney Transplantation, 1996-2005

* Table 4-1: Immunosuppression Use for Kidney Transplant Maintenance Prior to Discharge, 1996 to 2005

* Table 4-2: Decrease in Acute Rejection Incidence Within a Year of Kidney Transplant, 1996-2003

* Table 4-3: Immunosuppression Use for PTA Maintenance Prior to Discharge, 1996 to 2005

* Table 4-4: Immunuosuppression Use: Liver Antirejection Treatment from Transplant to One Year Posttransplant, 1994-2003

* Table 4-5: Immunosupression Use for Maintenance Prior to Discharge for Intestine Transplants, 1995-2004

* Table 4-6: Immunosuppression Use for Induction in Lung Transplantation, 1996-2005

* Table 4-7: Immunosuppression Use of Maintenance Prior to Discharge for Lung Transplant Recipients, 1996-2005

* Table 4-8: Immunosuppression Use for Antirejection of Lung Transplant up to One Year Following Transplantation, 1995-2004

* Table 4-9: Immunosuppression Use for Induction for Recipients of Heart Transplants, 1996-2005

* Table 4-10: Immunosuppression Usage Rates from Discharge to One Year Post-Transplantation for Heart Recipients, 1994 & 1995

* Table 4-11: Immunusuppression use for Induction in Heart-Lung Transplantations, 1996-2005

* Table 4-12: Most Commonly Used Immunosuppressants, by Organ (Kidney, Kidney/Pancreas, Lung, Heart, Liver)

* Table 4-13: Global Transplant Immunosuppressant Market, 2002-2012

* Figure 4-5: Market Share of Immunosuppressive Categories, 2006 (Calcineurin Inhibitors, Corticosteroids, Polyclonal Antibodies, Monoclonal Antibodies, TOR Inhibitors, Antiproliferative Agents)

* Figure 4-6: Immunosuppressant Sales by Geographical Region, 2006

* Figure 4-7: Value of Immunosuppressant Market, by Transplanted Organ, 2006 (Kidney, Kidney/Pancreas, Lung, Heart, Liver)

* Figure 4-8: Immunosuppressant Market, by Transplanted Organ, by Percent (Kidney, Kidney/Pancreas, Lung, Heart, Liver)

* Figure 4-9: Top-Selling Transplant Immunosuppressants, by Brand Name, 2006

* Table 4-14: Transplant Immunosuppressant Market Share, by Manufacturer, 2006 ($billions)

Related companies :

Isotechnika Inc., Genzyme Corporation, Hartford Hospital, Islet Replacement Research Foundation, SangStat Medical Corporation, MicroIslet , Inc.

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Looking for a Nice House? Watanabe Mansion for Sale

By Christine Laue, Omaha World-Herald, Neb.

Jan. 23–The Watanabe mansion, one of Omaha’s largest and most notable homes, is for sale.

NP Dodge’s Jeff Rensch, the listing agent for the Regency mansion at 9800 Harney Parkway South, said Tuesday that he could disclose the sale price only to legitimate buyers.

“It’s priced to sell,” Rensch said. “It’s a great value for somebody.”

The home of philanthropist Terry Watanabe, former owner of Oriental Trading Co., has an assessed valuation of $4,989,600, according to the Douglas County assessor’s Web site.

Watanabe currently is living in the home and plans to maintain another residence in Omaha, Rensch said. Rensch declined to specify whether Watanabe has purchased another home.

Rensch said the mansion’s finished space is now 20,125 square feet, which is slightly more than the assessor’s site shows.

The brick, limestone and slate mansion sits on 4.05 acres and features nine bedrooms, 18 bathrooms, a gourmet kitchen, a custom wine cellar, a whole-house energy management system and a three-story elevator. The lower level features a modern exercise facility and health spa with sunken Jacuzzi, steam room, dry sauna and massage room.

The property also includes an indoor and outdoor pool and tennis courts.

“It’s an absolutely fabulous home in every way, and it’s been impeccably maintained,” Rensch said.

Because of the unusual scope of the home, it is not being listed in the multiple listing service — a routine way of advertising residential property, Rensch said. He said he has shown the home to “a couple families” in the past few weeks.

“We are right now in the process of marketing it privately and directly to families that we have targeted,” Rensch said.

He has, however, established a Web site –www.9800harney. com — with pictures and listed features.

Godfather’s Pizza founder Willy Theisen built the mansion in 1983. At that time, a contractor estimated that 4,000 pounds of copper went into the flashing, gutters and downspouts.

In April 1995, Theisen sold the property for $1.8 million to Watanabe, who ran Oriental Trading Co., which markets party supplies, toys, home decor items and giftware. On Halloween 2000, Watanabe retired from the company, which was founded by his late father, Harry.

The home has been part of a Halloween tradition in Omaha. Several thousand parents and children have flocked to the mansion each Halloween, when Watanabe would hand out trick-or-treat goodies.

A mansion expert hired in 2004 by the county to rank the desirability of Omaha-area mansions put the Watanabe house at the top of its list. At that time, its main living space was 12 times as large as the average Douglas County house.

—–

To see more of the Omaha World-Herald, or to subscribe to the newspaper, go to http://www.omaha.com.

Copyright (c) 2008, Omaha World-Herald, Neb.

Distributed by McClatchy-Tribune Information Services.

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

Ediacaran Biota on Bonavista Peninsula, Newfoundland, Canada

By Hofmann, H J O’Brien, S J; King, A F

ABSTRACT- Newly found fossils in the Conception and St. John’s groups of the Bonavista Peninsula considerably extend the known geographic distribution of the Ediacaran fossils in Newfoundland. They occur in deepwater sediments and are preserved as epireliefs, forming census populations underneath volcanic ash layers throughout a more than 1 km thick turbiditic sequence. The exposed fossiliferous units comprise the Mistaken Point, Trepassey, Fermeuse, and Renews Head formations. The remains are tectonically deformed, with long axes of elliptical discs aligned parallel to cleavage strike; shortening of originally circular bedding surface features is on the order of 30-50% (averaging ~35%).

The assemblage includes Aspidella, Blackbrookia, Bradgatia, Charnia, Charniodiscus, Fractofusus, Hiemalora, and Ivesheadia. These occur throughout the succession, with Aspidella being the most common genus, followed by Charnia and Charniodiscus. Four new taxa are described, with candelabra-like fossils with a Hiemalora-like base referred to Primocandelabrum hiemaloranum n. gen. and sp., bush- like fossils to Parviscopa bonavistensis n. gen. and sp., ladder- like fossils to Hadryniscala avalonica n. gen. and sp., and string- like fossils with basal disc to Hadrynichorde catalinensis n. gen. and sp. The remains also include dubiofossils. The stratigraphic ranges of some taxa on the Bonavista Peninsula are longer than previously reported from the Avalon Peninsula, with Fractofusus spindles present in the Trepassey Formation, Bradgatia, Charnia, Charniodiscus, and Ivesheadia reaching as high as the Fermeuse Formation, and Aspidella extending into the middle of the Renews Head Formation. The spindles in the Trepassey Formation are comparable to those found mainly in the stratigraphically older Briscal Formation on the Avalon Peninsula.

INTRODUCTION

THE DISTINCTIVE and problematic Ediacaran fossils of soft-bodied organisms constitute a prominent marker in the history of the Proterozoic biosphere, and a substantial biologic enigma as well. There is no unanimity as to their affinities. Early interpretations placed forms like those found in Newfoundland in the Kingdom Animalia, principally in the Phylum Cnidaria (e.g., Glaessner, 1959, 1984; Anderson, 1978; Fedonkin, 1981), Others have presented different interpretations. Included among these are attributions to a separate extinct Kingdom, Vendozoa (Seilacher, 1989; later Vendobionta, Seilacher, 1992), xenophyophorean protists (Zhuravlev, 1993, Seilacher et al., 2003), lichens (Retallack, 1994), photosynthetic “metacellular” organisms (McMenamin, 1998), colonies of Prokaryota (Steiner and Reitner, 2001), and fungus-like organisms (Peterson et al., 2003). Ediacaran fossils are now thought to be mostly metazoans. For a comprehensive recent review, see Narbonne (2005).

Discoidal remains of this biota were first recognized in the 19th century in the City of St. John’s, Newfoundland and described by Billings (1872) under the name Aspidella terranovica. The black shales in which they were found were subsequently designated the “Aspidella slates” (Murray and Howley, 1881), and the Fermeuse Formation in the more recently constituted St. John’s Group (Williams and King, 1979). Even earlier reports, as far back as 1858, treated somewhat similar ring-like structures from the Charnian of England as possible abiogenic concretions (Ford, 1999, p. 230). Aspidella itself remained controversial as a fossil for more than a century (Hofmann, 1971, p. 16). Modern integrative studies finally established its biogenicity convincingly, if not its biological affinities (Gehling et al., 2000). The Ediacaran biota comprises about ten dozen genera (Waggoner, 1999), exhibiting ample variation of morphology based on simple modes of growth that dominated for a period before becoming extinct at the end of the Proterozoic. Nearly three dozen localities are now known worldwide. The most prominent of these also exhibit the greatest diversity, and are situated in South Australia, Namibia, northern Russia, Ukraine, Newfoundland, and northwestern Canada. The age of the Ediacaran biota is constrained to ~635-542 Ma (Condon et al., 2005), and probably between 580-542 Ma.

The assemblages in the different areas are characterized by disparate sedimentary environments and different preservation styles, as well as distinctive biotic compositions (e.g., Narbonne, 1998; Waggoner, 1999; Grazhdankin, 2004). Ediacaran megafossils in northwestern Canada, Australia, and eastern Europe occur typically as hyporeliefs in shallow water siliciclastics, whereas those in Newfoundland, England, and Finnmark are preserved as epireliefs in deepwater sediments, and those in Namibia commonly are transported entities preserved as endoreliefs in storm-generated sandstone. Some forms such as discs are cosmopolitan, whereas others of more complex morphology have more restricted distribution. For analyses of Ediacaran assemblages, see the reviews by Waggoner (1999, 2003) and Grazhdankin (2004). The forms here described from the Bonavista Peninsula conform to what is known from the Avalon Peninsula- preserved on upper bedding surfaces in deep water turbiditic and shallowing-upward pro-deltaic sediments, below ashfall deposits.

Although the Avalon assemblage has received a great deal of study in recent years (Gehling et al., 2000, Narbonne et al., 2001, Clapham and Narbonne, 2002; Clapham et al., 2003, 2004; Narbonne and Gehling, 2003; Wood et al., 2003; Narbonne, 2004, 2005; Laflamme et al., 2004; Ichaso et al., 2007; Gehling and Narbonne, 2007; Laflamme et al., 2007), much sustained effort will be required to resolve major questions concerning the biological affinities of the elements of this biota. Studies by Narbonne and his associates are continuing to contribute substantially in this regard. Narbonne et al. (2001, p. 28 et seq.) provide a useful summary of the history of research on the Ediacaran biota in Newfoundland.

The objectives of the present study are the description and illustration of new material from the Bonavista Peninsula, now the third area in Newfoundland known to contain this remarkable assemblage (O’Brien and King, 2004a, 2004b, 2005), and, secondly, to relate these occurrences and their context to those on the Avalon Peninsula to the south. Some of the new localities have yielded exceptionally well preserved specimens of several taxa that improve our knowledge on the distribution, environmental setting, morphology, taphonomy, and taxonomic affiliation of specific Ediacaran taxa. One of the significant aspects of the ~570 Ma Avalon assemblage is that no unequivocal trace fossils have yet been recognized. Although here interpreted as body fossils, two of the new taxa in the Bonavista area (Parviscopa n. gen. and Hadrynichorde n. gen.) have some aspects in common with certain trace fossils normally found in rocks younger by 30 million years; these are suitable candidates for further studies to confirm their affinities.

GENERAL GEOLOGIC SETTING

The Bonavista Peninsula of Newfoundland lies within the Appalachian Avalon Zone, a complex and well-preserved Neoproterozoic to Early Paleozoic terrene that records the development of segments of a much larger Precambian orogenic system accreted to the Appalachians during Paleozoic orogenesis (cf. O’Brien et al., 1996). Integral parts of this belt are Ediacaran sedimentary rocks, which are spectacularly preserved along the deeply embayed coast of southeastern Newfoundland

Such Ediacaran rocks are well exposed on the Bonavista Peninsula, where the Spillars Cove-English Harbour fault zone (west of the present map area; see O’Brien et al., 2006, fig. 5) demarcates the boundary of two lithologically contrasting clastic sedimentary domains. Late Neoproterozoic sedimentary rocks west of this brittle structural zone are part of the Musgravetown Group (Hayes, 1948, p. 16-17; O’Brien and King, 2002), a major volcano-sedimentary succession that crops out over large parts of the western Avalon Zone. Similar aged sedimentary strata east of the fault zone, previously included in that group, have recently been remapped and subdivided by O’Brien and King (2002, 2004a, 2004b, 2005) and O’Brien et al. (2006). These rocks are now recognized as correlatives of the upper part of the Conception Group (post-570 Ma), the entire St. John’s Group, and the lower Signal Hill Group, which are major units mapped and defined by Williams and King (1979) and King (1988, 1990) in the Avalon Zone’s type area, Avalon Peninsula, approximately 180 km to the south-southeast. The formational nomenclature is applicable to the units in the Bonavista area, where formations are further subdivided into members as designated in O’Brien and King (2005, figs. 2 and 3). The units are well exposed in the Catalina Dome, a NNE trending elliptical outcrop area approximately 8 x 7 km centered on the towns of Catalina, Port Union, and Melrose (all three now incorporated in the municipality of Trinity Bay North); bedding dips radially around the dome at generally less than 25[degrees] (Fig. 1). Lithostratigraphic correlation of Bonavista and Avalon peninsula rocks is corroborated in a general way by fossil content, although the stratigraphic ranges of individual taxa are not identical in both areas (O’Brien and King, 2002, 2004a, 2005). The Ediacaran strata of eastern Bonavista Peninsula, like their correlatives on the Avalon Peninsula, represent a depositional transition from deepwater basin and slope (Conception Group) to shallowing-upwards basinal, pro- delta and delta front (St. John’s Group), and ultimately alluvial conditions (Signal Hill Group). Large quantities of volcanic ash were brought into this arc-adjacent marine basin throughout its depositional history and were important in the burial and preservation of the Ediacaran biota.

LITHOSTRATIGRAPHY AND PALEOENVIRONMENTS

CONCEPTION GROUP

Drook Formation.-The oldest exposed unit in the map area is the Shepherd Point Member of O’Brien and King (2005), part of the Drook Formation in the Conception Group. This member forms the core of the Catalina Dome (Fig. 1), and is characterized by evenly laminated gray-green siltstone interspersed with numerous thin laminae to thin beds of fine-grained, light gray weathering sandstone, and dark gray- green to black mudstone. Some black mudstones show minute irregular or wavy laminations several millimeters thick; preliminary studies suggest they may represent microbial mats on the sediment surface. Individual centimeter-scale sets of fine sand, silt, and mud are of constant thickness and laterally continuous for several meters, where they pinch out or are terminated by slightly irregular, very low-angle erosional discontinuities. Small scours, small-scale synsedimentary slump folds and faults, and mud rip-up clasts are common and indicate that erosive bottom currents flowed over an unstable slope. Interspersed throughout the member are medium beds of parallel-laminated, poorly sorted, structureless sandstone and rare beds of cross laminated sandstone. This unit has not yet yielded fossils in the study area, but is fossiliferous on the Avalon Peninsula (Narbonne and Gehling, 2003; Clapham et al., 2004).

Mistaken Point Formation.-The overlying Mistaken Point Formation was subdivided by O’Brien and King (2005) into a lower, siliceous Goodland Point Member and an upper, argillaceous Murphy’s Cove Member; both are fossiliferous throughout. The Goodland Point Member is a medium- to thick-bedded siliceous sequence composed of parallel- and cross-laminated sandstone, parallel-laminated siltstone, structureless mudstone and tuff, interpreted as representing Bouma turbidite subdivisions BCDE. The silt, mud, and ash may have been deposited as DE beds or as hemipelagic sediment associated with ash- fall material that was slowly deposited from suspension within the deep sea. Large-scale slump folds (up to several meters in height) are locally preserved and result from gravitational instability of sediment deposited on a slope. This member resembles, and may correlate with, the Middle Cove Member of the Mistaken Point Formation, eastern Avalon Peninsula (King, 1990). Like the soft- bodied Ediacaran fossils on the Avalon Peninsula, the impressions of the organisms on the Bonavista Peninsula are confined to turbiditic siliciclastics and are typically preserved on upper bedding surfaces of interturbidite mudstones, underneath thin water-laid tuffs.

The Murphy’s Cove Member is dominated by medium-bedded, gray and green sandstones and gray, green, and red mudstones. Variegated structureless and laminated mudstones are present at the top of the member and may correlate with the Hibbs Cove Member, uppermost Mistaken Point Formation, at its type locality on the Avalon Peninsula (King, 1990). Fine-grained, white, gray to light brown tuff forms thin beds and laminae throughout the member and commonly preserve Ediacaran fossils underneath.

ST. JOHN’S GROUP

Conception Group strata in the core of the Catalina Dome pass conformably into fossiliferous marine mudrocks and interbedded sandstones of the St. John’s Group (Williams and King, 1979), which consists of, in ascending stratigraphic order, the Trepassey, Fermeuse, and Renews Head formations. These sediments formed initially in a deep basinal slope environment, which, in response to a combination of sea-level changes and to seaward advances of a large prograding delta, shallowed over time and in two major cycles (King, 1980, 1990; O’Brien and King, 2005).

Trepassey Formation.-The Trepassey Formation lies conformably above the Mistaken Point Formation and shows a coarsening- and thickening-upward succession. It is divided into a lower, mud- and silt-rich Catalina Member and an upper, sand-rich Port Union Member (O’Brien and King, 2005). The Catalina Member is a succession of repetitive, thin-to medium-bedded, greenish-gray mudstone, siltstone, and pyritiferous sandstone. The beds are tabular with a sharp base, laterally persistent, and commonly graded, with a basal laminated silty sandstone passing upwards into structureless mudstone and tuff; they are interpreted as Bouma DE turbidites. Ripple cross-lamination and sole marks are rare in these beds. In the upper part of the member, medium beds of cross-stratified sandstone are locally developed. Ediacaran fossils occur below distinctive brown ash layers at several stratigraphic levels in the upper part of the member. The Catalina Member correlates with most of the Trepassey Formation at its type locality in the southern Avalon Peninsula. The upper part of the Catalina Member coarsens and thickens upward and passes transitionally into the Port Union Member. Thick to very thick, 1-3 m tabular beds of fine- to very coarse-grained gray quartzofeldspathic sandstone and granule conglomerate, and interbeds of mudstone, siltstone, agglomerate, and tuff characterize this member. The coarse beds are immature, volcanogenic, and formed under combined rapid downslope subaqueous flow of pre-existing sediment mixed with new pyroclastic debris, which might explain why no fossils have been found within these units. A comparable coarse sandstone facies forms a unit only 5 to 10 m thick at the very top of the Trepassey Formation on the Avalon Peninsula. Other extensive facies within the Port Union Member include thick-bedded fine- to medium-grained sandstone with distinct parallel lamination, associated thick beds of fine- to medium- grained sandstone with a massive or structureless appearance, and intercalated fossiliferous units of thin-bedded mudstones and very fine-grained sandstones that are comparable with those of the underlying Catalina Member.

FIGURE 1-Geologic map of Catalina area, with fossil localities (after O’Brien and King, 2005). Locality 32 is outside map area, near Maberly, 7 km NNE of northeast corner of area, at 48.608[degrees]N 53.009[degrees]W. SHG = Signal Hill Group.

Large-scale slumps and disrupted beds are present throughout the Trepassey Formation, representing periodic rapid burial of the habitat that sustained the organisms in this deep-marine setting. The slumps are of the same composition as their respective members and indicate the presence of a slope on which original sediment deposits became unstable, either because of sediment load or seismic shock; the mass movement was probably slight as the slumped material is near slump scars from which they were derived. The increasing influx up-section of laminated, fine- to medium-grained sand indicates high-energy downslope processes and may reflect shoaling of the basin or sea-level changes.

Fermeuse Formation.-The black-shale-dominated Fermeuse Formation lies in sharp and conformable stratigraphic contact above the Trepassey Formation. The succession studied to date consists primarily of three principal, interbedded lithofacies. Following the terminology of O’Brien et al. (2006), the prominent facies (A-f), seen in the lowermost part of the formation, is dark gray to black shale and mudstone with laminae, and thin to medium interbeds of gray siltstone, fine grained, brown-weathering gray sandstone, and minor tuff. Impoverished current ripples and cross-lamination are locally present but are usually indistinct; rhythmically alternating sand-mud graded units are common. A second, characteristically remobilized facies (B-f) consists of slumped folds of sandstone resedimented in a mud matrix that occur with debris flows. The latter consist of a mixture of sand, mud, and coarse angular to rounded cobble-size fragments of siltstone and sandstone. A third facies (C-f), developed in the upper part of the succession, includes black shales with rare or widely spaced laminae or thin beds of silty sandstone. In general, the proportion of sand increases upwards through the formation. Tuff beds are most common in the lower 300 m of the section and are associated with Ediacaran fossils.

The remobilized facies (B-f) occurs throughout several hundred meters of stratigraphic section and contains repetitive and spectacularly preserved tabular units of synsedimentary folds and disrupted beds of sandstone, each unit commonly several meters thick, interbedded with black shale and silty sandstone. The slumped units are locally capped by sand-rich sedimentary breccias overlain by shale. Thin beds of ash within the shales within facies A-f and B- f preserve a variety of Ediacaran fossils at several stratigraphic levels.

The slumped and disrupted units are attributed to gravitational sliding of poorly consolidated beds of sand and mud on a sloping paleosurface during normal pelagic sedimentation. Huge masses of mixed sand, mud, and coarse clastic debris were transported as debris and other mass flows into deeper parts of a submarine slope and basin. The presence of sharp bedding planes directly above truncated folds of sandstone and coarse breccias at the top of the disrupted unit indicate periods of erosion by intense bottom currents.

Renews Head Formation.-The Renews Head Formation gradationally and conformably overlies the Fermeuse Formation. It differs from the latter by its greater silt and sand content, its pyritic, rusty- weathering lenticular bedding, and the presence of impoverished or starved current ripples, pseudonodules, waterescape structures, and small sand dykes. This formation records another coarsening- and thickening-upward succession. It represents a second major cycle within the group, but one of prograding deltaic sedimentation that passes upward and laterally (above the deep basin and slope) into terrestrial conditions represented by the Gibbett Hill Formation (Signal Hill Group). The Renews Head Formation is divisible into three main lithofacies: (A-r) black shale with numerous laminae of rusty brown-weathering gray silty sandstone, (B-r) thin- to medium- bedded lenticular sandstone intercalated with black shale, and (C- r) distinctive, very thick to extremely thick (>3 m) beds of cross- bedded, laminated, and structureless gray sandstone units interbedded with black shales and thin sandstones. The coarse- grained sandstones are, in places, associated with granule and small pebble layers. Facies (C-r) is commonly incised or present in facies (A-r) and (B-r) and is interpreted as major channelized sand lobes and sheets, which are possible deltafront deposits related to delta- top sedimentation recorded in the overlying Gibbett Hill Formation that crops out beyond the map area (see O’Brien and King, 2004a). Shale-rich units in the formation bear Aspidella terranovica.

PALEONTOLOGY

Fossil assemblage and localities.-In a 1978 reconnaissance mapping and paleontological investigation of eastern Bonavista Peninsula, one of the authors (King) noted that 1) the siliceous rocks of Goodland Point, Catalina, resembled the Mistaken Point Formation, 2) the mudstones of Catalina were comparable with the Trepassey Formation, and 3) the shale sequence of Melrose matched the Fermeuse Formation. At that time, only the shales were found to be fossiliferous, yielding very poorly preserved sphaeromorph acritarchs and nonseptate filamentous microfossils near Port Union (Hofmann et al., 1979). As a result of more recent work, Ediacaran fossils were discovered in this area (O’Brien and King, 2004a).

The main occurrence of the Ediacaran biota on the Bonavista Peninsula is limited to the Catalina Dome (Fig. 1). Discoidal fossils have also been observed at English Harbour, 20 km south of Catalina, and at Maberly, 10 km to the north. The exposed units belong to the Conception and St. John’s groups, with fossiliferous horizons in the Mistaken Point, Trepassey, Fermeuse, and Renews Head Formations.

The general geographic and stratigraphic distributions of the fossiliferous localities were given by O’Brien and King (2004a), as was a summary of their morphologic diversity. The same authors have since provided a more detailed inventory of their occurrence (O’Brien and King, 2005), but the present paper is the first to more fully describe and illustrate the Ediacaran fossils on the Bonavista Peninsula. Figure 2 presents a graphic summary of the more than a dozen constituent elements of this assemblage.

The fossils are best observed on dip slopes of shoreline outcrops. The discovery site, also the one showing the greatest diversity of fossils in the new assemblage, is located in the Murphy’s Cove Member of the Mistaken Point Formation (Locality 5), and is illustrated in Figure 3. The fossils are protected under provincial legislation, but remain exposed to the elements (wave and ice action, cliff collapse, algal and bacterial growth, human activity).

Like the soft-bodied Ediacaran fossils on the Avalon Peninsula, the impressions of the organisms are confined to turbiditic siliciclastics and are typically preserved on upper bedding surfaces of interturbidite mudstones, underneath thin water-laid tuffs (Narbonne et al., 2001, 2005).

Figure 2-Main components of Ediacaran biota on the Bonavista Peninsula. Basal portion of large Charnia Ford, 1958 is conjectural.

All fossils show the effect of Early Paleozoic tectonic deformation and pervasive cleavage development related to the formation of the Appalachian orogenic belt. Originally circular features such as the Aspidella organism were deformed into NNE trending ellipses, in effect constituting built-in strain gauges that provide a quantitative measure of the amount of tectonic shortening, which is on the order of ~35% on average in the study area, but can attain 50% or slightly more locally. This allows for the retrodeformation of not only their images, but also those of associated frondose, bush-like, and other fossils, to reconstruct their morphologies and felling directions at the time of burial (Wood et al., 2003, fig. 5). Most of the illustrations in the plates of the present paper are retrodeformed images of the fossils.

The fossils were studied in situ during the summers of 2004 to 2006, and photographed with digital cameras. Selected important specimens were molded with low viscosity (~7000 cps) black latex which then served to make casts using a dental stone compound, both of which aided the study in the laboratory. Very few actual samples were collected to respect legislation regarding the preservation of the fossil sites. Specimens and casts are deposited at the Newfoundland Museum (NFM) in St. John’s, bearing consecutive numbers from NFM F-457 to NFM F-656. Catalogue numbers of illustrated material are cited in the captions of the respective figures.

We here provide an interim overview of 40 localities while more detailed studies are continuing. The fossils comprise more than a dozen taxa, most of which are also represented on the Avalon Peninsula. The most common and longest-ranging is Aspidella terranovica. Other long-ranging and widespread forms are Bradgatia Boynton and Ford, 1995, Charnia Ford, 1958, Charniodiscus Ford, 1958, Hiemalora Fedonkin, 1982, and Ivesheadia Boynton and Ford, 1996, all of which (excepting Hiemalora) are also characteristic of the Charnwood Forest area in England, from where, in fact, they were first described. Fractofusus is rare in the Mistaken Point and Fermeuse Formations, but abundant at some levels in the Trepassey Formation, and unknown in the Renews Head Formation and in the Charnian of England. Fossils not previously encountered are also described and assigned to four new species and genera.

The fossiliferous exposures extend stratigraphically from near the base of the Mistaken Point Formation in the Conception Group to the middle of the Renews Head Formation in the St. John’s Group (Fig. 4), and thus the range is limited by lack of strata in the lower part of the stratigraphic section as compared to the much more completely exposed sequence on the Avalon Peninsula, where the section also includes the fossiliferous Briscal and Drook Formations below the Mistaken Point Formation. On the other hand, many of the taxa reach stratigraphic levels appreciably higher on the Bonavista Peninsula than on the Avalon (Fig. 5).

The frondose forms Charnia and Chamiodiscus show strong preferred alignment on individual bedding planes, which is attributed to downcurrent felling by bottom currents (Wood et al., 2003). An overall bimodal pattern emerges, with a main mode in a NNE direction, and an opposing secondary mode (Fig. 6); the mean vector show a slight clockwise rotation in ascending the stratigraphic section. The preferred orientation and tripartite organization of basal holdfast disc, stem, and frond indicate that the organisms were erect sessile benthos anchored on the mud, rather than endobenthic (Seilacher, 1992).

DESCRIPTIONS AND DISCUSSIONS OF FOSSILS

Various schemes have been devised to accommodate Ediacaran fossils in a systematic way, but the goal of finding a suitable scheme acceptable to all who work with such remains is still elusive. The most comprehensive and elaborate attempt has been by Fedonkin (in Sokolov and Ivanovskiy, 1985, and Sokolov and Iwanowski, 1990), who arranged the taxa under two main headings, Radialia and Bilateria, with further groupings based on the underlying symmetry of the taxa. Radialia encompass various classes of discoidal coelenterates, whereas the Bilateria comprise various phyla of worm- and arthropod-like fossils, as well as the extinct phylum Petalonamae of frondose forms, some of which, strictly speaking, are not bilateral (e.g., Pteridinium Giirich, 1933). Forms such as Bradgatia, Ivesheadia, Fractofusus, and others do not readily fit into this scheme. Another attempt to classify the Ediacaran biota is that presented in Runnegar and Fedonkin (1992, p. 373).

Inasmuch as the systematic position and phylogeny of many of the forms still need to be worked out (e.g., see Runnegar, 1995 for arguments generally still current), we here use an informal order of presentation that groups the genus-level taxa based on the following broad informal geometric categories and their postulated affinities (Table 1); one kind of dubiofossil is also described. The scheme has its drawbacks. For instance, the discoid forms have traditionally been classified as cnidarians. However, they may be holdfasts of fronds that were not preserved, and they thus could or should be classed as Petalonamae.

Genus ASPIDELLA Billings, 1872

ASPIDELLA TERRANOVICA Billings, 1872

Figure 7.1-7.6

Aspidella terranovica Billings, 1872, p. 478, fig. 14.

FIGURE 3-Discovery locality (Locality 5) in Mistaken Point Formation. 1, Section, looking east. Co-author A. King standing near origin of baseline (0.0 m) on main fossiliferous layer (F7), which extends to white arrow at left. Meter-stick near middle resting on layer F4 with numerous Aspidella Billings, 1872 specimens (see Fig. 7.5). Lighter layers are tuffaceous horizons. Principal fossil levels indicated by F1-F8 in drawn section at right. 2, Composite photo of main bedding surface F7 of eastern part of main ledge at Locality 5, showing location of specimens that provided latex molds. Numbers represent distances in meters east of origin of baseline, and are cited in captions in relevant subsequent figures. Meter scale at center graduated in decimeters. Discoid forms, Spriggia morphs O’BRIEN AND KING, 2004a, fig. 3 D, E; pl. 3A, 3C partim.

For comprehensive synonymy, see GEHLING ET AL., 2000.

Description.-Centimetric elliptical discs on bedding surfaces, with several preservational morphotypes, including small concave epireliefs and larger flat discs, both with distinct narrow raised rim, and others with few to numerous concentric ridges and depressions of low to moderate relief. Dimensions of 84 specimens (long axes) measured at various localities ranging from 0.48 to 12.5 cm (mean 3.72 cm), with a positively skewed, polymodal pattern (Fig. 7); two main modes between 1 and 3 cm and 4 and 5.5 cm.

Occurrence.-Mistaken Point Formation, Localities 1-6, 11, 12, 37, 39; Trepassey Formation, Localities 10, 15, 20, 33, 37, 40, 41; Fermeuse Formation, Localities 16-19, 21-30, 38; Renews Head Formation, Locality 32.

Discussion.-Aspidella terranovica is the taxon with the longest stratigraphic range in the area, and also the most widespread, occurring at 33 of the 41 localities. Despite the basic simple discoid shape, it represents taphonomically quite variable remains, as is the case on the Avalon Peninsula. The polymodal pattern in Figure 7 reflects differences to be expected from measurements on different bedding surfaces and localities. In a comprehensive analysis of discoidal Ediacaran genera worldwide, Gehling et al. (2000) synonymized numerous forms, treated them as preservational variants of Aspidella, and interpreted the discs as casts of the basal impressions of collapsible or hollow bulb-shaped organisms. This action was questioned by Serezhnikova (2005, p. 392), who regarded Ediacaria Sprigg, 1947 and Cyclomedusa Sprigg, 1947 as distinct from Aspidella, and the synonymization as premature, but for our material, we accept the synonymization. Gehling et al. (2000) recognized several morphotypes, including invaginate, flat, and convex types, which are also represented in our area (Fig. 7.1- 7.6). The remains are hardly distinguishable from the basal attachment discs of the frondose taxa such as Charniodiscus, with which they frequently co-occur, and from which they are separated only by the absence of any evidence of an attached frond. In addition, discs in the Catalina Dome area hint at a further relationship to Hiemalora, as non-annulate discs with faint radial processes are associated with close-by Hiemalora (Fig. 7.4).

Figure 4-Simplified stratigraphic section with approximate position of fossil localities. Thicknesses are dip-based estimates. Full circle indicates presence of taxon; empty circle signifies uncertain identification. SHG = Signal Hill Group. Basal portion of taxon 6 (Charnia grandisl) is conjectural.

FIGURE 5-Comparison of stratigraphic ranges of major Ediacaran taxa in eastern Newfoundland. Thicknesses of formations are not to scale. Note the higher ranges on the Bonavista Peninsula (rectangles). Inset map: A-Mistaken Point area on Avalon Peninsula; B-Catalina area on Bonavista Peninsula.

GENUS HIEMALORA Fedonkin, 1982

HIEMALORA STELLARIS (Fedonkin), 1980

Figure 9.1-9.10

Star-shaped forms, ANDERSON AND CONWAY MORRIS, 1982, p. 7-8, text- fig. 3.

Stellate organism, CONWAY MORRIS, 1990, fig. 1c.

Tentaculate discs with possible affinities to Hiemalora, O’BRIEN AND KING, 2004a, p. 209-210, pl. 5b.

?Medusina filamentus [filamentis] SPRIGG, 1949, p. 90, pi. 13, fig. 1, text-fig. 7D.

Pinegia stellaris FEDONKIN, 1980, p. 9, pl. 1, figs. 3-5.

Pinegia stellaris FEDONKIN, 1981, p. 61, pl. 30, figs. 1-3.

Hiemalora stellaris FEDONKIN, 1982, p. 137.

Pinegia cf. stellaris FEDONKIN, 1983, p. 129, 134, pl. 29, fig. 3.

Hiemalora stellaris FEDONKIN, 1984, p. 42-43, pl. 5, fig. 3.

Hiemalora cf. stellaris FEDONKIN, 1984, pl. 5, fig. 5.

Hiemalora stellaris FEDONKIN IN SOKOLOV AND IVANOVSKIY, 1985, v. 1, p. 84, pl. 7, figs. 1, 6, fig. 7A.

Hiemalora stellaris GUREEV, 1988, p. 69, pl. 13, figs. 2, 3.

Hiemalora stellaris FEDONKIN IN SOKOLOV AND IVANOWSKIY, 1990, v. 1, p. 90-91, pl. 7, figs. 1, 6.

?Hiemalora sp. FARMER, VIDAL, MOCZYDLOWSKA, STRAUSS, AHLBERG, AND SIEDLECKA, 1992, p. 189, fig. 5a-b.

Hiemalora stellaris FEDONKIN, 1992, figs. 15-17.

Hiemalora pleiomorphus RUNNEGAR AND FEDONKIN, 1992, p. 387, fig. 7.7.5C.

Hiemalora aff. H. pleiomorphus NARBONNE, 1994, p. 412, fig. 3.1.

Hiemalora stellaris FEDONKIN, 1994, fig. 1A.

Hiemalora cf. stellaris FEDONKIN, 1994, fig. 1C

Hiemalora stellaris SOKOLOV, 1997, p. 134-135, pl. 18, fig. 3.

Hiemalora MARTIN, GRAZHDANKIN, BOWRING, EVANS, FEDONKIN, AND KIRSCHVINK, 2000, p. 843-844, fig. 4D.

Hiemalora NARBONNE, DALRYMPLE, AND GEHLING, 2001, p. 33, 60, 65, 67.

Hiemalora pleiomorpha DZIK, 2003, p. 124, fig. 10B (only).

Description.-Discs on upper bedding surfaces, 0.3-4.8 cm wide (mean = 2.25 cm, n = 27), outlined by a distinct narrow raised rim ~0.5-1 mm wide surrounding a mostly flat disc with or without concentric ring. Attached to rim are numerous outwardly radiating, densely packed to moderately spaced narrow rays or appendages of variable length, generally of the order of the disc diameter or less, but in some specimens attaining double that (maximum observed length 5.2 cm, with average maximum of 3.15 cm for 27 specimens). Rays rectilinear to slightly sinuous, usually unbranched, but bifid and occasional trifid branching observed; rays rarely crossing over one another; 2 mm or less in width, slightly tapering distally to a point (as if descending obliquely into the sediment) or to a bulbous terminus (Fig. 9.1). In Figure 9.6, small specimen sitting on ray of larger specimen. In specimens illustrated in Figure 9.1-9.3, and 9.6, rays exhibiting shallow axial trough with curved semi- elliptical cross sections between narrow, levee-like lateral ridges; possible fusion of two filaments. Central disc bearing faint round outlines 3-5 mm across. Measurements of more complete specimens given in Figure 10.

Occurrence.-Mistaken Point Formation, Localities 2, 3, 5, 11, 35; Fermeuse Formation, Localities 16-18, 21, 24, 26, 29?, 38.

Discussion.-Inasmuch as the terms “tentacles” and “roots” used in the literature for the slender radiating appendages convey quite different anatomical features and functions, depending on one’s interpretation of the body, it seems more appropriate to use the more neutral descriptive labels “rays” or “appendages” until meir function has been more convincingly demonstrated. While appendages in most specimens are unbranched, a few clearly exhibit branching.

FIGURE 6-Circular histograms (radius of wedge) showing azimuths of frond alignments of Charnia and Chamiodiscus Ford, 1958 specimens on Bonavista Peninsula by formation, using 30[degrees] bins for retrodeformed data; mean vector and 95% confidence interval superimposed.

TABLE 1-Postulated affinities of Ediacaran taxa on Bonavista Peninsula.

The affinities of Hiemalora have been problematic. Their shape is not unlike that of the modern colonial cnidarian Obelia Peron and Lesueur, 1810. Fossils of this type from the Vendian (Ediacaran) of the White Sea region were originally referred to Pinegia and compared to solitary polyps of the lower Hydrozoa (Fedonkin, 1980). As the name Pinegia was preoccupied, the fossils were subsequently renamed Hiemalora (Fedonkin, 1982). Without being aware of these publications, Anderson and Conway Morris (1982) considered 3 alternatives for identical fossils in the Mistaken Point Formation- a basal attachment organ, a star-like trace fossil like Heliochone Seilacher and Hemleben, 1966, and a body fossil of unknown affinity. They favored the body fossil interpretation. An attachment organ was discounted, because the smooth ring was viewed as surrounding empty space, and no upward projections were observed. The trace fossil possibility was discarded because of the relationship between the structure and sediment and the mode of preservation. However, while most workers have considered them as cnidarians, the trace fossil interpretation was revisited by Martin et al. (2000). More recently, Dzik (2003, p. 125) regarded the structures as “basal discs of petalonamaeans or related organisms with finger-like protrusions functioning as roots, or possibly, as penetrating organs releasing sulfide from the microbial mat.”

Two species have been formally designated: H. stellaris, originally described from siliciclastics in the northern part of the Russian Platform (Fedonkin, 1980, 1982), and H. pleiomorpha, first recognized in laminated black, bituminous limestone from the Olenek Uplift in Siberia (Vodanyuk, 1989). The latter has a distinguishing presence of an ornamentation on the disc, a pattern of parallel to slightly divergent sets of fine, essentially rectilinear striations on the disc, reminiscent of a delicately folded or stretched membrane. These features may be taphonomic, but may also be related to the presence of appendages that pulled on the membrane under external stress. The distinction between the two species is not always clearcut, as a fair amount of morphologic variability can be observed on a given bedding plane (e.g., Vodanyuk, 1989, fig. 3). Moreover, other specimens from the same formation in the Olenek Uplift seem to lack these features (e.g., Fedonkin, 1984, pl. 4, fig. 6; 1985, pl. 7, fig. 4; Dzik, 2003, fig. 10c; unillustrated specimen in the collection of the Paleontological Institute in Moscow, PIN 3995/252). At least one specimen of undoubted H. stellaris from the Ukraine also bears fine parallel striations on the disc (Fedonkin, 1984, pl. 5, fig.3, PIN 3993/309). Fedonkin (1992, fig. 15), the author of H. stellaris, also has attributed a large specimen with H. pleiomorpha aspect to H. stellaris. The two species may be the end members of biologic and/ or taphonomic spectra. Well preserved Siberian material of Hiemalora is presently under study by Russian colleagues (Serezhnikova and others), so more robust criteria for differentiating the species may be generated. Because of the lack of evidence for the delicate striations in any of our material, and the absence of any distinct multiple clustering of data points (Fig. 10), we assign all our specimens to H. stellaris. FIGURE 7-Outcrop photos of Aspidella terranovica Billings, 1872 (1-6), and Aspidella-like Dubiofossil A (7), from Bonavista Peninsula. All scale bars graduated in cm, except for 5 and 7, which are in dm. Photos in 1-4 are retrodeformed. 1, Multi- ringed, Spriggia-like morph of A. terranovica, Trepassey Formation, Locality 15. 2, Moderately-ringed morph in Fermeuse Formation, Locality 21. 3, Aggregation of small specimens of A. terranovica, some with radial markings (type morph of Gehling et al., 2000). Renews Head Formation, Locality 32. 4, A. terranovica specimens, and discs with faint, Hiemalora-like radial markings extending from raised peripheral rim (a, c). Compare with H. pleiomorpha Vodanyuk, 1989 specimen in Serezhnikova (2005, pl. 4, fig. 3). Gently depressed interiors of discs still retain fine-grained, dark gray tuff covering. The specimens occur on the same bedding surface as the fine Hiemalora (Fedonkin, 1985) specimen illustrated in Figure 9.1. Mistaken Point Formation, Locality 3. NFM catalog numbers: a: NFM F-471; b: NFM F-472; c: NFM F-473; d: NFM F-474; e: NFM F-475; f: NFM F-476; g: NFM F-477. 5, Cluster of A. terranovica specimens of variable size in Mistaken Point Formation Level F4 at Locality 5 (see Fig. 3.1). 6, Large, flat, relatively smooth Spriggia-line morph. Light colored area at center is covering ash layer. Mistaken Point Formation, Level F1 at Locality 4 (see Fig. 3.1). 7, Dubiofossil Type A, a very large ovate structure with concentric rings and very low relief. Mistaken Point Formation, Locality 8.

Figure 8-Size distribution of Aspidella specimens in Bonavista area, based on long diameter of ellipse coincident with cleavage/ bedding lineation. Polymodal pattern reflects different size values for different stratigraphic levels and localities.

Fossils attributed to either species with different degrees of certainty are now known from the Ediacaran in other parts of the world (e.g., Ukraine, Norway, NW and E Canada, Australia; refer to synonymy) (Fig. 11). An early illustration of a disc with branching processes that has caused some workers to compare it to Hiemalora is “Medusina filamentus” from the Rawnsley Quartzite (Sprigg, 1949, p. 90, pi. 30, fig. 1, text-fig. 7d). Sprigg interpreted the form as a medusoid. The illustration of the holotype shows a partial narrow concentric rim surrounding the central disc and the field with the radial processes, at a distance of about 3Vi times the radius of the central disc. This is unlike Hiemalora. The specimen was subsequently ascribed to Pseudorhizostomites Sprigg, 1949, to which it is connected by transitional forms, according to Glaessner and Wade (1966, p. 605).

Specimens of H. stellaris from siliciclastic rocks in the Mogilev Formation of the Ukraine (Gureev, 1988, pi. 13, figs. 2, 3) are comparable to specimens from the White Sea area.

Relatively well preserved specimens from Wales (Gehling et al., 2000, p. 450; J. Gehling photo, personal commun., 2005) closely resemble specimens from Locality 3 in the Catalina area, particularly the processes with levee-like borders and the rounded outlines on the disc.

Farmer et al. (1992, fig. 5a, 5b) illustrated, along with other body fossils, some low epireliefs from the Stappogiedde Formation in Finnmark, northern Norway, and attributed them to Hiemalora sp., but provided no further description. The specimens have a poorly defined central disc ~1 cm across, surrounded by a dense fringe of somewhat ragged-looking, radial appendages.

Narbonne (1994, fig. 3.1) classified a solitary, fragmentary specimen from the Sheepbed Formation in NW Canada as Hiemalora aff. H. pleiomorpha. The specimen is relatively large, has somewhat more relief than typical H. pleiomorpha, has densely packed appendages, some fine striations of uncertain significance on one edge of the central disc, and is preserved in positive hyporelief in turbiditic siliciclastics. It was interpreted as a semiinfaunal polyp impression.

Martin et al. (2000, fig. 4d) illustrated a specimen of Hiemalora from the White Sea coast that very clearly portrays multiple branching, with one or more short branches diverging at angles of 300 -60[degrees] from the main strand. As already stated, the form was interpreted as a trace fossil.

Lastly, De (2003) reported on two questionable Hiemalora specimens from the Upper Vindhyan Bhander Group northwest of Satna, central India. The illustrated specimens are not distinct enough to have confidence in their attribution to this genus, and they are not included in the synonymy.

Material from the Catalina area illustrated in this paper contributes new information on two aspects of the Hiemalora enigma: function and original morphology. It bears on the long-standing question of whether the radiating structures are tentacles, roots, or traces. At least two specimens on the same bedding plane in the Mistaken Point Formation at Locality 5, and another two in the Fermeuse Formation at Localities 21 and 26, show a tripartite arrangement (Fig. 12): a disc with radial appendages that is indistinguishable from Hiemalora, with an attached stalk, which in turn merges distally with an abraded, partially preserved frond. Unfortunately, the detail of the fronds is insufficient to allow their attribution to any of the frondose forms known from Newfoundland or elsewhere. These candelabra-like fossils with a Hiemalora base are next described separately under Primocandelabrum hiemaloranum n. gen. and sp.

It should be noted that Hiemalora individuals without fronds in the Catalina area are, in places, closely associated with, and seem to intergrade with, identical discs that are relatively quite smooth and that bear only a few faint, or no, ray-like radial markings (Fig. 7.4). These structures could be regarded as simple, atypical, unornamented Aspidella.

The second aspect to which the new material contributes is original morphology. Specimens in the Mistaken Point Formation at Locality 3 are remarkably well preserved due to a thin covering layer of black, fine-grained tuffaceous sediment (Fig. 9.1, 9.3). Some specimens suggest that the central organ had significant relief (Fig. 9.10). Others appear to have been flatter, their softbodied parts compacted vertically in such a way that the central organ was compressed without developing a noticeable concentric pattern typically found in Aspidella, which was interpreted as a bulb-like organism or organ by Gehling et al. (2000). The radiating cylindrical appendices or rays were molded in such a way as to suggest collapse of their axial portions, whereas the lateral portions remained elevated and assumed a levee-like aspect. While branching of rays is observed, it is not common. The apparent confluence or fusion of two radial elements in one specimen is intriguing (Fig. 9.1). While it could be due to molding of collapsed tubes, fusion of hyphae is a feature found amongst the fungi, and one may consider whether these fossils could belong to this group. This would support the earlier interpretation by Peterson et al. (2003) that a fungal model may be applicable to particular Ediacaran taxa such as Aspidella, Charnia, and Charniodiscus, although they may not necessarily have been members of the Kingdom Fungi. Additionally, in one instance, a small specimen seems to he over the ray of a larger specimen or be connected with it (Fig. 9.6), while in a second example a round body forms a terminus of fused rays (Fig. 9.1). These juxtapositions may be coincidence, but it is worth considering the possibility that asexual reproduction is represented and search for more examples to strengthen such an interpretation.

Figure 9-Epireliefs of Hiemalora stellaris (Fedonkin), 1980 from Catalina area. All photos retrodeformed; bar scales in cm. 1, Specimen with shallow concave disc filled with fine-grained ash and numerous radiating tubular appendages preserved as rectilinear to curvilinear rays with axial depressions and levee-like margins. Some rays apparently terminating in subcircular structure, and showing confluence (middle right). Mistaken Point Formation, Locality 3. NFM F-478. 2, Specimen with numerous appendages, several exhibiting branching; trifid branch at arrow. Mistaken Point Formation, Locality 3. 3. Specimen with few appendages on same bedding plane as that in 1, located 25.4 cm away. NFM F-479. 4, Specimen with concentrically patterned disc and some relief. Mistaken Point Formation, Locality 5, at 12.2 m E (see Fig. 3.1). NFM F-480. 5, H. stellaris. Mistaken Point Formation, Locality 5 at 32.6 m. 6, Specimen from layer 5.7 cm above layer bearing specimens illustrated in parts 1 and 3 (see also Fig. 15.1). Specimen is cut by small soft- sediment fault scarp (light diagonal band). Note small specimen in upper right (arrow), positioned on ray of larger specimen, possibly representing a case of vegetative reproduction. Mistaken Point Formation, Locality 3. NFM F-467. 7, Small specimen of H. stellaris (NFM F-466) and nearby small Aspidella terranovica (NFM F-465; see also Fig. 15.1). Same slab as part 6. 8, Specimen from Fermeuse Formation, Locality 21, at 23.0 m E, 7.7 m N. NFM F-481. 9, Specimen in Fermeuse Formation, Locality 17. NFM F-482. 10, H. stellaris specimen with high relief and branching appendages. Fermeuse Formation, Locality 24. NFM F-483.

Figure 10-Morphometry data of retrodeformed specimens of Hiemalora in Catalina area. 1, Scatter plot of mean ray length (d) vs. disc diameter (D), and selected ratios of D/d. 2, Scatter plot of number of rays vs. disc diameter. 3, Frequency histogram of D/d ratio; compare with fig. 5 of Serezhnikova (2005).

GENUS PRIMOCANDELABRUM NEW GENUS Type species.-Primocandelabrum hiemaloranum new genus and species (by monotypy).

Diagnosis.-Tripartite, candelabrum-like fossils comprised of basal disc, stem, and variable and incompletely preserved bushlike frond of overall triangular shape, containing coarse, distally diverging branches.

Etymology.-Named for the candelabrum-like shape and its early appearance in the geologic record; primus = L. first.

Discussion.-Hiemalora has not previously been reported as having an attached frond. We here recognize a new genus that is distinct from Hiemalora only by the presence of an attached stem and frondose superstructure. The situation is analogous to the practice of regarding Aspidella and Charniodiscus as separate taxa, depending on the basis of the presence or absence of an identifiable frond, as the genus of frond cannot be guessed from the preservation of only the holdfast; both Aspidella and Hiemalora are viewed as form or organ taxa.

PRIMOCANDELABRUM HIEMALORANUM NEW SPECIES

Figure 12.1-12.4

Diagnosis.-As for genus; basal disc with prominent external radiating processes.

Description.-Tripartite epireliefs characterized by basal discoidal or globular structure attached to a distinct stem that develops distally into an incompletely preserved, bush-like or candelabra-like frond with a general, overall triangular shape. Basal globular or discoidal structure outlined by a narrow raised marginal rim enclosing shallow depression with or without faint concentric markings; numerous (8-30) narrow, straight to slightly sinuous or bent ray-like appendages radiating from disc rim. Diameters of four discs observed 2.5, 3.2, 4.2, and 7.8 cm, length of processes about equal to disc diameter. Stem length (distance between disc center and frond) 3.7, 5.3, 6.0, and 12.4 cm, similar to disc diameter, width uniform, respectively 0.5, 1.6, 0.8, and 3 cm. Fronds incomplete, proximal portion forming acute to approximately right angles, preserved length about double the stem length (minima respectively 8.5, 10.5, 15.0, and 23.5 cm), widths 4.7, 7.0, 7.2, and 20 cm. Frond with poorly defined, coarse, distally diverging ridges and intervening depressions; two depressions in one specimen with faint transverse markings 3 mm wide (Fig. 12.3).

Figure 11-Reported world occurrences of Hiemalora. 1, Sekwi Brook; 2, Avalon; 3, Bonavista; 4, Wales; 5, Tanafjord; 6, White Sea; 7, Podolia; 8, Olenek Uplift; 9, Ediacara; 10, questionable Hiemalora in Vindhyan Supergroup. For references, see synonymy.

Etymology.-Named for its Hiemalora-like base.

Types.-Holotype NFM F-484; paratypes NFM F-485, NFM F-486.

Occurrence.-Mistaken Point Formation at Locality 5, and Trepassey Formation at Localities 21 and 26.

Type locality.-Trinity Bay North, Locality 5, at 37.5 m E (see Fig. 3.2).

Type horizon.-Lower part of Murphy’s Cove Member of Mistaken Point Formation.

Discussion.-The morphology of the basal disc with radiating processes coincides with that of Hiemalora, and the two would be indistinguishable were it not for the presence of an attached stem and frond. The candelabra-like form with the radiating processes on the basal disc thus may have an important bearing on the interpretation of Hiemalora insofar as the radiating appendages in the latter have been explained alternatively as tentacles and as rooting structures. The new Bonavista material supports the case for the latter interpretation, if, indeed the two taxa represent different degrees of preservation of one type of organism. If so, one should look for evidence for the presence of an attached stem in specimens previously referred to Hiemalora. On the other hand, the two taxa may be distinct despite the morphologic resemblance of the ray-bearing discs. The candelabra-like organisms were attached to the seafloor, and were felled in the same direction as nearby Charnia and Charniodiscus specimens. As with specimens of uiese latter frondose genera on the Avalon Peninsula, preservation quality is best for the basal disc and progressively deteriorates towards the distal portion, a taphonomic effect due to diachronous burial of an erect frondose organism (Laflamme et al., 2004, p. 829).

Preservation of local detail in the frond of one specimen, more clearly seen in the latex mold than the specimen in outcrop, shows several oblique divisions spaced equally about 4 mm apart (Fig. 12.3). The pattern is reminiscent of secondary branches in Charnia and Charniodiscus. The shape of the preserved frond portion of this specimen also resembles a stalked specimen of Bradgatia from the Trepassey Formation, but which is without a clearly recognizable Hiemalora-like base (see Fig. 19.4 under Bradgatia).

PRIMOCANDELABRUM sp.

Figure 12.5

“Dusters”, “Feather dusters”, “Tree fronds”, NARBONNE, DALRYMPLE, LAFLAMME, GEHLING, AND BOYCE, 2005, p. 58, 60, 65, 68, figs. 6.3, 6.5, 6.6, 7.3, 7.6.

Description.-Tripartite epireliefs characterized by basal discoidal structure attached to a distinct stem that develops distally into an incompletely preserved, bush-like frond with coarse, distally diverging branching ridges and intervening irregular depressions. Basal disc with or without faint concentric markings. Fronds with overall inverted triangular shape apparently without distinct geometric pattern. Diameters of four discs observed 2.0, 2.2, 3.1, and 5.0 cm. Respective stem length (distance between disc center and frond) 1.9, 2.7, 2.7, and 5.5 cm, similar to disc diameter, stem width respectively 0.3, 0.6, 0.4, and 1.0 cm. Fronds incomplete, proximal portion forming acute to approximately right angles, preserved length respectively 2.4, 4.8, 12.3, and 13 cm, widths approximately 4.0, 5.8, 10, and 10.5 cm. One specimen with faint radial markings on basal disc.

Occurrence.-Mistaken Point Formation, Localities 5, 6; Trepassey Formation, Locality 20: Fermeuse Formation, Localities 21, 26, 29?. Also present in the Mistaken Point Formation on the Avalon Peninsula.

Discussion.-The dimensions and the shape of the bushy superstructure are very similar to those of specimens of P. hiemaloranum, but the ratio of frond width to frond length is slightly higher for Primocandelabrum sp. than for P. hiemaloranum, and the basal discs lack the diagnostic radiating appendices. If originally present, the rays were not preserved, or the attachment disc is preserved at a higher level in the sediment, in which case the form may be a taphomorph of P. hiemaloranum. The fronds of most of these structures show no clear geometric patterns that would allow them to be referred to Charnia, Charniodiscus, or bifoliate rangeomorphs, and thus their affinities are undetermined.

Fronds with rayless discs occur in the Mistaken Point Formation on the Avalon Peninsula, where they have been variably referred to as “dusters”, “feather dusters”, and “tree-fronds.” These are presently under study at Queen’s University.

GENUS CHARNIA FORD, 1958

The Catalina area has yielded fronds of several apparently intergrading morphologic varieties equipped with a short stem emanating from an attachment disc, all broadly attributable to Charnia. The frond patterns range from ones with symmetrical, alternating, acutely diverging primary branches with regular transverse secondary partitions, to ones with a rhomboidal surface pattern, to ones with more asymmetrical and more irregular branches with few or no preserved secondary divisions and presence of rangeomorph elements, allowing for the differentiation of at least 3 morphotypes.

FIGURE 12-Outcrop views of Primocandelabrum hiemaloranum n. gen. and sp. (1-4) and Primocandelabrum sp. (5). All photos retrodeformed; bar scale divisions in cm. 1, Partial frond with well developed rays on basal disc. Mistaken Point Formation, Level F7 at Locality 5 at 37.5 m E (see Fig. 3.2). Holotype NFM F-484. 2, Large partial specimen. Fermeuse Formation, Locality 26. Lighting from right Paratype NFM F-485. 3, Detail view of latex mold made from frond of specimen of Primocandelabrum hiemaloranum n. gen. and sp. in part 2, showing rhythmically spaced transverse markings, probably representing secondary branches. Photo is printed as mirror image to show same orientation as in part 2. Paratype NFM F-485. 4, Abraded frond with faint Hiemalora-like base. Fermeuse Formation, Locality 21. Lighting from right Paratype NFM F-486. 5, Partial frond with Aspidella-like base. Trepassey Formation, Locality 20.

The appreciable morphologic diversity in the Catalina area presents somewhat of a taxonomic dilemma, that is, whether one should assign the forms to different species, or whether the variability represents taphonomic factors or different orientations during burial. For our material, we rely on the regularity of the lobe pattern and transverse divisions, as well as the smaller acute angle at which lobes diverge from the main axis, to assign specimens to C. masoni, and mis includes those with rhomboidal patterns. We distinguish these from specimens with more irregular branching and with higher divergence angles, which we ascribe to Charnia antecedens. Bedding surfaces with numerous individuals of either species show strong preferred orientation, indicating felling from an erect, anchored living position in response to a passing current. A fourth species chacterized by decimetric length is attributed to C. grandis?

The biological affinities of these fossils are uncertain. Charnia has been variously interpreted as algal (Ford, 1958), an octocoral of the extinct order Rangeomorpha (Jenkins, 1985), a pennatulacean cnidarian (Fedonkin, 1992; Jenkins, 1992, 1996; Nedin and Jenkins, 1998), a vendobiont (Seilacher, 1989, 1992), or a fungus (Petersen et al., 2003). Our new material includes fronds with distinct rangeomorph elements within the primary branches of Charnia antecedens, placing them firmly within the Rangeomorpha of the extinct Phylum Petalonamae Pflug, 1972. Glaessner (1979) erected the Family Charniidae based on this genus. CHARNIA MASONI FORD, 1958

Figure 13.1-13.6

Charnia masoni FORD, 1958, p. 212, pl. 13, fig. 1.

Charnia masoni FEDONKIN, 1981, p. 66, pl. 3, figs, 5, 6; pl. 29, fig. 1.

Charnia masoni FEDONKIN, 1985, p. 110, pl. 12, fig. 4; pl. 13, figs. 2-4.

Charnia masoni NEDIN AND JENKINS, 1998, p. 315, fig. 1.

Charnia masoni NARBONNE, DALRYMPLE, AND GEHLING, 2001, p. 32, pl. 1C.

Charnia masoni NARBONNE, DALRYMPLE, LAFLAMME, GEHLING, AND BOYCE, 2005, p. 28, pl. 1I.

Description.-Centimetric to decimetric remains preserved in epirelief, organized in three parts when complete, comprising a basal disc connected by a short stem to a moderately long, bifoliate frond outlined by pattern of narrow vein-like ridges and intervening broader depressions, forming a leaf-like structure that constitutes its most distinctive feature. Frond composed of two opposing series of up to 10 or more contiguous, uniform, parallel, straight to slightly sigmoidal oblique primary branches, diverging at a uniform angle of 150 -50[degrees], in alternate fashion, along zigzag frond axis, with opposing branches offset by half a branch width. Branches in lateral contact or overlapping, divided uniformly into secondary modules of obliquely transverse subrectangular segments generally of uniform orientation, size and shape, and usually numbering between 5 and 12. Some specimens with pattern of regularly spaced and equally distinct, parallel ribs that intersect obliquely with a second set of equally distinct ribs to produce a rhomboidal signature (Fig. 13.5, 13.6). Most specimens incomplete; five specimens yielding partial measurements: where present, basal discs small, 0.5-1.5 cm across; stems 0.5-5.0 cm long, 0.3-0.9 mm wide; fronds 5.7-26.5 cm long, 1.6-5.4 cm wide.

Occurrence.-Mistaken Point Formation, Localities 4-7, 9, 11, and on the Avalon Peninsula (Narbonne et al., 2001); Trepassey Formation, Locality 20; Fermeuse Formation, Localities 17, 18, 26. The species is also found in England (Ford, 1958), the White Sea area (Fedonkin, 1985), Northern Siberia (Fedonkin, 1985), and South Australia (Nedin and Jenkins, 1998).

Discussion.-This species is abundant at several localities, but complete specimens are rare, making it difficult to obtain morphometric data on the overall dimensions and number of branches of the organisms. However, the partial preservation allows the recognition of the systematic, uniform, and symmetrical branching characteristics and uniform secondary modules of C. masoni. Specimens with rhomboidal patterns lack a prominent zigzag axis, and could be interpreted as individuals in an orientation different from the normal felling position, one which resulted in the branches becoming superimposed and concomitantly obscuring the zigzag axis underneath the branches. This kind of preservation has not heretofore been described, and brings up the possibility of the presence of “ventral” and “dorsal” sides of the organisms, elements that need to be explored further. Specimens with apparent long stem (e.g., Fig. 13.3) may represent individuals whose proximal branches were lost due to recent erosion, although another small specimen (Fig. 13.8) has a parallel-sided ridge between the frond and basal disc, indicating that a robust stem is a real biologic feature.

CHARNIA GRANDIS? (Glaessner and Wade, 1966)

Fig. 14

?Charnia sp. GLAESSNER, 1959, p. 1472, text-fig. 1b.

?Rangea? sp. GLAESSNER, IN GLAESSNER AND DAILY, 1959, p. 397, pl. 46, fig. 2.

?Charnia sp. GLAESSNER, 1961, p. 75, text-fig.

?Charnia sp. a GLAESSNER, 1962, p. 484-485, pl. 1, fig. 4.

?Rangea grandis GLAESSNER AND WADE, 1966, p. 616, pl. 100, fig. 5.

?Glaessnerina grandis GERMS, 1973, p. 5, fig. 1D.

Charnia grandis BOYNTON AND FORD, 1995, p. 168, fig. 1.

?Glaessnerina grandis JENKINS, 1996, p. 35, fig. 4.1.

Charnia grandis FORD, 1999, p. 231, fig. 3.

Description.-Incomplete frond preserved as negative epirelief, proximal portion missing; dimensions of retrodeformed specimen approximately 66.5 x 21.1 cm. Single preserved frond portion composed of two series of about 21 partially preserved, upward (forward) curving and distally tapering, parallel primary branches emerging in alternating fashion on each side of medial zigzag axis that is well marked only in the lower portion. Branching angle near 90[degrees] for larger proximal branches, with angles gradually becoming more acute for distal branches, trending towards ~40[degrees]. Width of primary branches (measured near medial axis) gradually decreasing from ~9 mm for branches in proximal region to 3.2 mm for those near apex of frond, and also decreasing distally along branch. Primary branches divided into numerous (up to 13) secondary branches or partitions disposed obliquely at 40- 60[degrees] to primary branches, widths gradually diminishing (in concordance with decrease in primary branch size) from ~10 mm in large proximal branches, to ~3 mm in branches near frond apex, and also distally in individual branches. Lateral inclination of secondary branches with respect to frond axis gradually flattening distally from ~45[degrees] in large proximal primary branches to ~5[degrees] in branches near apex.

Occurrence.-Mistaken Point Formation, Locality 4; Bradgate Formation, Charnwood Forest, England; Ediacara Member, Ediacara, Australia.

Discussion.-Our specimen most closely resembles a 60-cm long specimen from the Bradgate Formation of Charnwood Forest, England, identified as Charnia grandis (Boynton and Ford, 1995, fig. 1; Ford, 1999, fig. 3). Both specimens are more nearly complete than the holotype from the Rawnsley Quartzite in Australia (Glaessner and Wade, 1966, pl. 100, fig. 5), a fragment with dimensions of 16.0 x 7.5 cm showing preservation of five primary branches on one side and seven on the opposing side, and bearing up to 13 se

This Mother of Twins Tried Everything to Cure Her Crippling Back Pain, but Paying for a MRI Scan Was the Turning Point …

By LAURA CUMMING

THERE are relatively few fatalities on the table,” the surgeon cheerily announced, “though you obviously have to be careful with the carotid artery. We go in through the front of the neck, whip out the discs and replace them with filigree metal.” At the time I thought he said something about gold but perhaps I was just flustered with amazement. For this was a revelation. Nobody had yet suggested that whatever was wrong with me might warrant actual surgery.

Nine months before, writing on my laptop with the usual aching shoulders and neck, I felt fizzing in the fingers of my left hand. My left scapula began to burn with pain and within days my forearm felt as if had been flayed. The slightest pressure to the skin was as searing as acid and the only way to escape further torment, it seemed, was to avoid all human contact.

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My earliest acupuncturist was an amiable hippy who burned what smelled like pot and told me approvingly of Richard Nixon’s conversion to acupuncture after watching open-heart surgery performed without anaesthetic in China. I was pregnant when I first went for treatment and remember weeping at the thought that I might not be able to cradle my child because I had pretty much lost the use of my arm. The acupuncturist was convinced he could reverse my fortunes. He tried hard.

Some weeks later I lost the baby.

I pressed further along this route, foolishly making an appointment with an acupuncturist to the stars (Chelsea, but I’m naming no names). She couldn’t even commence until I agreed to stew all my food and give up garlic.

The second chiropractor (Wimpole Street, also nameless) boasted that what distinguished him from the third osteopath (Lambeth, still learning) was that he took X-rays of his patients. I have it still, the meagre little image he took of completely the wrong vertebrae.

Good kind people sent Rescue Remedy, lavender oil, books of calm thoughts, that pain pen that supposedly baffles pain signals to the brain but which is about as effective as an ordinary Biro.

You try to be properly grateful even though it feels as thoughtless as telling an infertile woman to do yoga or just relax the same advice casually meted out by all and sundry to those with back pain.

By the time my 35th appointment came round I approached it with glumness and rancour, for it seemed as though my life was nearing collapse and nothing was going to prevent it. I could no longer work or rest without pain. I couldn’t write the book HarperCollins had just commissioned. I couldn’t sit, and stood instead all the way through meetings, dinners and journeys by train or plane.

There came a point where I thought I might never sit comfortably again. I avoided my husband’s gentlest embrace.

People in pain become sombre and withdrawn. You start to live inside your own head more and more, paired off with your constant companion. You seek out biographies of those who have endured infinitely worse: John F Kennedy, never far from a doctor, surviving on 40 different kinds of painkiller, corseted, injected, trussed.

Frida Kahlo, her spine shattered by a bus accident; I can’t stand the art, but her fortitude truly inspires.

BUT PAIN must have a narrative, otherwise how are you to respond to your friends’ ever-patient inquiries? There came a day when the various diagnoses, all of which agreed pretty well with Google’s interpretations of my symptoms, no longer held any truth for me.

So I did what anyone can now do: I went out and paid Pounds 600 for an MRI scan at the Lister Hospital. Which is how I came to be sitting in the office of an orthopaedic surgeon. Until that day I didn’t know what was wrong with me.

But one look at the scan and Damian Fahy heroes will be named changed my future.

I had, I have, fairly pronounced cervical spondylosis with a couple of extra spanners thrown in for free. Spondylosis itself is so common it’s almost universal.

The discs between one or more vertebrae wear thin, producing soreness and stiffness but most usually no symptoms at all. If you play a lot of sport or have made it beyond 40 you probably have a bit of spondylosis without even knowing it.

In my case three discs are pretty much shot and some vicious little bone fishhooks have formed on the rims of the cushionless vertebrae. Nerves were being impinged upon and the exits for those nerves from the spinal column on the left were narrowing dangerously as the vertebrae got closer together.

The glory, and horror, of the MRI scan is its irrefutable clarity of vision.

Unlike the X-ray, everything becomes visible. So the narrowing around the nerves was there for all to see and me to fear, which was much how I felt at first: that inside me the fine threads of existence were being sawn up by sharpened bones. One false move! I imagined it as somewhere between The Pit and the Pendulum and Tom and Jerry.

But the relief of diagnosis surged simultaneously. Now I knew where I stood. Now I understood, in fact, why standing was the only position I could endure for long. Radiculopathy, as it’s called, was the real problem: pain at the roots of the nerves trying to exit between those vertebrae was radiating out through the system.

And almost everything I had been advised to do had merely sustained it: sleeping on a hard inflexible bed, resting instead of walking about, sitting for hours on end, which only tightened the nerves, letting a chiropractor crack the wrong bones.

Fahy sent me to James Bird, a brilliant physiotherapist who loosened my nerves and raised my spirits with his quirky humour. I still do his exercises, including the handy technique for self- traction that can be performed surreptitiously on a crowded Tube.

Fahy referred me to Glyn Towlerton, a twinklingly deft and sympathetic pain consultant. He performed a cervical epidural, in which cortisone and anaesthetic are injected directly into the spine while the patient is awake under continuous X-ray.

The epidural didn’t help so we progressed through various drugs: Neurontin, created for epilepsy, which regulates the electric signals between nerve and brain, and Amitriptylin, antidepressant. In the end, we hit upon Tramadol, an opioid analgesic which eases the pain whenever I get it badly; which is rare these days because Fahy also introduced me to Clive Lathey.

Lathey is an osteopath who broke his back 20 years ago and has experienced everything you are suffering times 10.

He is the most intelligent and gifted practitioner imaginable. His massage is superb, his manipulations so effective that the sense of deadlock very soon vanishes. By easing the vertebrae he has kept my radiculopathy at bay for three years; I go to him every six months, more if the worst pain returns.

Dennis, my husband, did everything he could at the time took dictation for my articles, wrote my emails, fielded calls, drove me everywhere, sat up with me through the darkest hours. And then he gave me something unmaginably greater: our twins, Hilla and Thea.

They, too, have helped in a most unexpectedly effective way. The best thing you can do for spondylosis is to strengthen your back muscles as much as possible; the twins between them, at two and a half, already weigh more than five stone.

As for the operation, Fahy was against cutting my throat, not just because it can change the voice or damage the nerves but also because, for all its immense upheaval, it doesn’t necessarily work. A fellow orthopaedic surgeon suffering the same condition told Fahy he would never undergo the operation he himself regularly performed.

His answer? Osteopathy, exercise, wellchosen wine and painkillers.

Laura Cumming is art critic of The Observer..

MRI scan Get a letter of referral from your GP and shop around for a machine with capacity. Expect to pay around Pounds 600 for a full back scan (www.vistadiagnostics.co.uk).

Clive Lathey registered osteopath, The Putney Clinic, SW15 , www.putneyclinic.co.uk) 45-minute consultations start from Pounds 60.

Damian Fahy spinal and orthopaedic surgeon, West London Spine Clinic, SW1 (i www.westlondon spineclinic.com). Consultations start at Pounds 250 for 30 minutes.

Glyn Towlerton consultant in pain medicine, Chelsea and Westminster Hospital, SW3 02070604362

Half-hour consultations from Pounds 180.

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

Warning: Folk Remedies Could Contain Lead

Health departments around the U.S. say traditional medicines used by immigrants from Latin America, India and other parts of Asia are the second most common source of lead poisoning in the country, surpassed only by lead paint. In fact, these medicines may account for tens of thousands of cases of lead poisoning in children each year, according to an AP investigation.

Dozens of adults and children have become gravely ill or died during the past eight years after taking these dangerous medicines, which are manufactured outside the country and often sold here by folk healers and in ethnic grocery stores.

Lead is added to many of the remedies because of its supposed curative properties. In other cases, it’s simply a matter of powders and pills becoming contaminated with lead during the manufacturing process.

Doctors say the lead has no proven medical benefits whatsoever.

In Harris County, Texas, which includes Houston, traditional medicines are responsible for nearly 20% of all cases in which children were found to have high levels of lead. In Arizona, the rate is 25%.  

Children’s lead poisoning in Texas, California and Arizona has been traced to Mexican remedies such as greta, azarcon and rueda, powders that contain 90% lead and are used to treat constipation in children.

In New York City and Rhode Island, high lead levels in the blood have been tied to litargirio, a powder containing up to 79 percent lead. It is used by Dominican immigrants for foot fungus and body odor.

In New York, Chicago and Houston, dangerous amounts of lead have also been found in ayurvedic medicines, which are used in India and commonly found in South Asian immigrant communities. These medicines include ghasard, a brown powder given to relieve constipation in babies, and mahayogaraj gugullu, to treat high blood pressure.

“No one’s testing these medications,” said Dr. Stefanos Kales, an assistant professor of environmental health at the Harvard School of Public Health who researched the problem, to the AP. “There’s no guarantee it doesn’t have dangerous levels of lead.”

A woman named Maria said she took her grandmother’s advice and gave her two daughters and a niece a dose of a bright orange powder called “greta”, a Mexican folk medicine used to treat stomach aches in children.  She had no idea that greta was 90% lead.

“Instead of doing something good for them, I did them more harm,” said Maria, who requested her last name not be used. “I was so afraid of all the things that could happen to them. It was a terrible experience.”

Fortunately, doctors detected the dangerously high lead levels in the little girls’ blood during a routine checkup a week later. The children have shown no ill effects.

According to Centers for Disease Control and Prevention statistics, folk medicines account for up to 30 percent of all childhood lead poisoning cases in the United States.  The Environmental Protection Agency estimates 240,000 U.S. children were diagnosed with high blood lead levels in 2004 to 2006.

“I don’t think anyone has a good handle on the exact prevalence of use,” Kales said. “I’m sure it’s underreported because doctors don’t generally ask about this and patients don’t report it.”

Only 14 percent of children are tested for lead nationwide. Many more cases are almost certainly going unreported. Often, the source of lead cannot be traced in cases where paint is not the underlying cause.

The use of folk medicine is rooted in generations-old cultural traditions. Ayurvedic medicine, for example, originated more than 2,000 years ago in India, where 80 percent of the population uses it.

“People think, well, my grandmother did it, so it’s not a problem. It’s extremely hard to change cultures and beliefs,” Brenda Reyes with the Houston Health Department told AP.

In Houston, where a quarter of residents are foreign-born, Health Department officials routinely pay undercover visits to herbalist stores and try to buy remedies known to contain lead. However, storekeepers often don’t admit they carry the medicine unless they personally know the customer, Reyes said.  

On the Net:

Centers for Disease Control and Prevention

UPMC Health Plan Expands Medicare and Special Needs Plan Into Additional Western Pennsylvania Counties

PITTSBURGH, Jan. 22 /PRNewswire/ — UPMC Health Plan announced it has expanded both its UPMC for Life Medicare HMO (Health Maintenance Organization) and its UPMC for Life Specialty Plan into Cameron, Clarion, Elk, Forest, and McKean counties. The Health Plan also announced the expansion of its Medicare PPO (Preferred Provider Organization) into Clearfield and Greene counties.

“Expanding our footprint in Western Pennsylvania helps us continue to meet the health needs of our aging population,” said Catherine Batteer, UPMC Health Plan’s vice president for Medicare. “We are pleased to now serve seven additional counties, which brings the current service area for our Medicare and Special Needs plans to 25 counties in Western Pennsylvania.”

UPMC for Life offers a variety of Medicare plans with and without prescription drug coverage. The $0 monthly premium plan option, which offers members richer benefits for no cost beyond traditional Medicare payments, is a popular choice.

The UPMC for Life Specialty Plan is for individuals with complex health issues who carry both Medicare Parts A and B and Medical Assistance. Combining the coverage and protection offered by both programs, UPMC Health Plan provides coordinated care designed to meet the unique needs of this dual- eligible population. UPMC for Life Specialty Plan members receive Medicare Part D prescription drug benefits, including a $0 copayment for generic prescriptions.

“By offering the UPMC for Life Specialty Plan in additional counties, we are now able to better serve those with special needs in Western Pennsylvania,” said John Lovelace, UPMC Health Plan’s vice president for Medicaid Services and Special Needs Plans.

The UPMC for Life Medicare and Specialty Plan service area includes Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Clearfield, Crawford, Erie, Fayette, Greene, Indiana, Jefferson, Lawrence, Mercer, Somerset, Venango, Washington, and Westmoreland counties, as well as Cameron, Clarion, Elk, Forest, and McKean counties.

UPMC for Life Medicare and Special Needs Plan members are assigned a personal Health Care Concierge to provide ongoing assistance regarding their benefits. The member’s assigned concierge welcomes the member by phone, is available when the member calls him or her, and calls to “check in” regularly.

Members can enroll in UPMC for Life Medicare plans up to March 31, 2008. For more information, call the UPMC for Life Medicare Sales Department at 1- 877-381-3765 Monday through Friday from 8 a.m. to 8 p.m. TTY users should call 1-800-361-2629.

Applications for enrollment in the UPMC for Life Special Needs Plan are accepted at all times. For more information, call 1-866-405-8762 Monday through Friday from 8 a.m. to 8 p.m. TTY users should call 1-800-407-8762.

Information regarding Medicare and Special Needs Plans is also available at the Health Plan’s website at upmchealthplan.com.

About UPMC Health Plan

UPMC Health Plan, the second-largest health insurer in Western Pennsylvania, is owned by the University of Pittsburgh Medical Center (UPMC), one of the nation’s top-ranked health systems. The integrated partner companies of the UPMC Insurance Services Division – which includes UPMC Health Plan, Work Partners, EAP Solutions, UPMC for You (Medical Assistance), and Community Care Behavioral Health — offer a full range of group health insurance, Medicare, CHIP, Medical Assistance, behavioral health, employee assistance, and workers’ compensation products and services to nearly 1 million members. Our local provider network includes UPMC as well as community providers, totaling more than 80 hospitals and more than 7,500 physicians in a 29-county region. For more information, visit http://www.upmchealthplan.com/.

UPMC Health Plan

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

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

Food Poisoning Causes Serious Long-Term Consequences

Scientists are beginning to take note of a troubling pattern of long-term health consequences for those who suffer food borne illnesses.  Considering the high number of food recalls taking place in recent months, understanding these consequences has taken on a new sense of urgency.

In interviews with the Associated Press, people who had suffered food poisoning from E. coli infections as children described high blood pressure, kidney damage, and even full kidney failure as much as 10 to 20 years later.   Some who suffered a case of salmonella or shigella went on to develop arthritis, and a mysterious paralysis was seen that could attack people who had only mild symptoms of campylobacter.

While these long-term effects are believed to make up only a small fraction of the 76  million who suffer food poisonings each year in the U.S., no one can say for sure how many people are truly at risk.   An even more important question may be what other illnesses have yet to be linked to food poisoning.  

Food borne illnesses cause 325,000 hospitalizations and 5,000 deaths a year, according to the Centers for Disease Control (CDC).  Some of the survivors’ long-term consequences are obvious from the outset. Some required kidney transplants, or have scarred intestines that promise lasting digestive difficulty.  However, many of the long-term effects are still not completely understood.

“Folks often assume once you’re over the acute illness, that’s it, you’re back to normal and that’s the end of it,” said Dr. Robert Tauxe of the Centers for Disease Control and Prevention, in an AP article. The long-term consequences are “an important but relatively poorly documented, poorly studied area of food borne illness.”

Donna Rosenbaum heads the consumer advocacy group STOP, Safe Tables Our Priority. “We’re drastically underestimating the burden on society that food borne illnesses represent,” Ms. Rosenbaum said in an AP interview.

Every week, STOP hears from patients with health complaints they suspect or have been told are related to food poisoning years earlier.  Rosenbaum spoke of a woman who survived severe E. coli at age 8. Years later while in her 20s, the woman had to have her colon removed. Others have developed diabetes after food poisoning inflamed their pancreas.

She also spoke of parents who wonder if a child’s learning problems might stem from food poisoning that required dialysis as a toddler.

“There’s nobody to refer them to for an answer,” says Rosenbaum.

So starting this month Rosenbaum’s group is initiating the first national registry of food-poisoning survivors with long-term health problems.  STOP hopes by sharing these stories with scientists it will drive much-needed research in this area.

In the case of Alyssa Chrobuck, who 15 years ago at age 5 was hospitalized as part of the Jack-in-the-Box hamburger outbreak that made a deadly E. coli strain notorious, she now suffers a host of health problems unusual for a 20-year-old.  These include high blood pressure, recurring hospitalizations for colon inflammation, a hiatal hernia, thyroid removal, and endometriosis.

“I can’t eat fatty foods. I can’t eat things that are fried, never been able to eat ice cream or milkshakes,” Chrobuck told AP.

“Would I have this many medical problems if I hadn’t had the E. coli? Definitely not. But there’s no way to tie it definitely back.”

But when people appear to recover, it is difficult to prove that later problems are related to a previous food poisoning and not something else. It may be that people prone to certain gastrointestinal conditions, for instance, also are genetically more vulnerable to germs that cause food borne illness.

For now, some of the best evidence comes from the University of Utah, which has long tracked children with E. coli.   The research found that about 10 percent of E. coli sufferers develop a life-threatening complication called hemolytic uremic syndrome, or HUS, where the kidneys and other organs fail.

Ten to 20 years after these children recover, between 30 percent and half of HUS survivors will have some kidney-caused problem, said Dr. Andrew Pavia, the university’s pediatric infectious diseases chief, in an AP article. That includes high blood pressure caused by scarred kidneys, slowly failing kidneys, even end-stage kidney failure that requires dialysis.

Additionally, HUS might trigger a variety of other organ problems because it causes blood clots all over the body that could leave a trail of damage, said Pavia.

“I don’t want to leave the message that everyone who had symptoms … is in trouble,” stresses Pavia.  E. coli doesn’t seem to trigger long-term problems unless it started shutting down the kidneys the first time around, he said. “People with uncomplicated diarrhea, by and large we don’t have evidence yet that they have complications,” he said.  

Although research is scarce, there are some proven long-term consequences of various food borne illnesses.

About 1 in 1,000 who suffer of campylobacter, an infection spread by raw poultry, develop far more serious Guillain-Barre syndrome a month or so later. Their body attacks their nerves, causing paralysis that usually requires intensive care and a ventilator to breathe.  

Over 30% of the nation’s Guillain-Barre cases have been linked to previous campylobacter, even if the diarrhea was very mild, and they typically suffer a more severe case than patients who never had food poisoning.

While they eventually recover, “We don’t know a great deal about what happens to those people five years later. What does ‘normal’ look like?” Tauxe says.

In the case of salmonella, a small number of people with the illness will go on to develop something called reactive arthritis six months or longer after the acute illness. Reactive arthritis causes joint pain, eye inflammation, sometimes painful urination, and can lead to chronic arthritis. Certain strains of shigella and yersinia bacteria trigger this reactive arthritis too, according to Tauxe.

Among his most pressing questions is whether HUS can increase the risk of diabetes later in life, since  HUS patients often suffer pancreatitis.  However, he said proving a direct connection will require tracking a lot of patients who can provide very good medical records documenting their initial food borne illness.

On the Net:

Centers for Disease Control

Seawater Spray Cures Kids Colds

New research shows simple salt water may be the best cure for a child’s cold symptoms. 

In a recent European study, rinsing with a nasal spray made from Atlantic Ocean seawater improved cold and cough symptoms faster and prevented recurrence in children 6-10 years old.

The study, funded by Goemar Laboratories La Madeleine, Saint-Malo, France, which makes Physiomer, the seawater nasal spray used in the analysis, was published in this month’s issue of the Archives of Otolaryngology.

The report was published days after the U.S. Food and Drug Administration (FDA) issued a warning on nonprescription cold remedies for children under 2.  

The FDA warning said the medicines were too dangerous due to potential side effects such as convulsions and rapid heart rates, which in rare cases had caused deaths. The FDA hopes to rule later this year on whether or not these cold remedies are safe for children ages 2-11 years old. 

The American Academy of Pediatrics has stated these cold and cough products are not effective for children under age 6, and may also be risky.

It may be that the salt water has a simple mechanical effect of clearing mucus, or it could be that trace elements in the water play some more significant role, though the exact reason why such a solution works is not known, said Dr. Ivo Slapak and colleagues at the Teaching Hospital of Brno in the Czech Republic, in a Reuters interview.

The authors added that while saline washes have long been mentioned as a treatment for colds, scientific evidence about whether they work is lacking.

During the study, the researchers examined 390 children with uncomplicated cold or flu symptoms over the course of 12 weeks.  The children were randomly assigned to receive either standard treatment, such as nasal decongestants, or those same medications plus the saline nasal wash.

Children given the salt water spray got it six times a day initially and three times a day in the latter part of the study, when the investigators were determining whether the spray would prevent symptoms from redeveloping.

The researchers found the noses of children given the spray were less stuffy and runny the second time they were checked. And eight weeks after the study began, those in the saline group had significantly fewer severe sore throats, coughs, nasal obstructions and secretions than those given standard treatments.

Additionally, fewer children in the saline group had to use fever-reducing drugs, nasal decongestants and mucus-dissolving medications or antibiotics.  Finally, the researchers found these children were  sick less often and missed fewer school days.

“We brush our teeth every day, however, we do not pay attention to our noses ““ a potential gate for infection,” said study co-author Dr. Jana Skoupa, of Pharma Projects in Prague, Czech Republic, in an interview with Forbes.  “Nasal wash should be used, based on our findings, immediately.”

Physiomer, the nasal spray used in the study, is the leading brand in Europe.  However, it is not currently available in the United States. 

Senior Healthcare Consultants and Subsidiary Companies Announce Election of Officers & Distribution Managers

DALLAS, Jan. 21 /PRNewswire/ — Senior Healthcare Consultants (SHC), owned by RJR Insurance Services, Inc., one of the largest captive-distribution senior insurance marketing firm’s in the Nation, announces its officers & distribution managers for 2008.

   Officers of Senior Healthcare Consultants are:    --  Richard P. Dale, Jr. -- President and Chief Executive Officer, RJR       Insurance Services, Inc.   --  Brian M. Corder -- Chief Financial Officer   --  Robert A. Douglas -- Chief Marketing Officer   --  L. Keith Farnsworth -- Chief Operations Officer   --  Fritz E. Simonson -- Chief Recruiting Officer   --  Jerry W. McCreight -- 1st Vice President Accounting and Cost       Distribution   --  Billy Medina -- Director Internal SHC CallCenter Operations     Distribution Managers for the core marketing divisions are:    --  Robert A. Douglas, 1st Vice President Senior Market Sales -- Senior       Healthcare Consultants   --  David C. Croom, Vice President Regional Sales -- Senior Healthcare       Consultants   --  George A. Alexiades, Vice President Division Sales -- Senior       Healthcare Consultants   --  Glenn J. Virga, Vice President Policy Persistency -- Senior Healthcare       Consultants   --  Stefan J. King, Vice President Team Leadership -- Senior Healthcare       Consultants   --  Richard L. Van Dyke, Vice President Part-Time Divisions -- Senior       Healthcare Consultants   --  Summer L. Banks, Head Recruiting Division Manager -- Senior Healthcare       Consultants   --  Amanda C. Allen, Head Internal Administration -- RJR Insurance       Services, Inc.   --  Beckie N. Tran, New Business Head Administrator -- RJR Insurance       Services, Inc.   --  Michelle A. Rutlidge, SHP Head Administrator -- Senior Healthcare       Partners, Inc.   --  Zach M. Lorenzini, Information Technology Head Administrator -- RJR       Insurance Services, Inc.   --  Michael W. Thompson , SHC Lodge and Ranch Foreman -- Southland       Securities, Inc.    

“Leadership is the capacity to translate vision into reality. The individuals we have selected as our 2008 Officers and Distribution Managers have proven to epitomize this,” said Richard P. Dale, Jr., President and CEO. “They are highly conversant of the culture of our company and can achieve the goals we have set forth in the mass distribution of our product lines. Having unlocked the potential inside of them conducive to exponential growth, I expect a very abounding 2008 and further record-breaking distribution.”

   SHC markets 4 primary products:    --  Senior Health Insurance -- Medicare Supplement ("Medi-Gap")   --  Private Fee For Service -- Medicare Advantage & Medicare Part D   --  Final Expense Life Insurance   --  Non-Insurance Reduced-Cost Benefit Programs     About SHC  

Senior Healthcare Consultants (SHC) markets senior insurance, Private Fee For Service (PFFS), and non-insurance benefit plans through their captive distribution channels. The primary divisions of SHC provide its producers 4-5 daily preset appointments (no cold-calling/prospecting) in a true career environment in which they can develop a strong profession for themselves while protecting our senior population. SHC is skilled in neophyte (previously non-licensed) agent/consultant recruiting and training. It currently has active business in 44 states. SHC believes in strong adherence to market conduct, market compliance, agent/consultant training, and building large and profitable blocks of business through high-rated, top insurance carriers. Over the last 5 years, through their captive-distribution alone, they have generated over $60,000,000 in new sales premiums.

For further information on this company view its primary corporate websites at http://www.shcsales.com/ and http://www.shcmarketing.com/.

Senior Healthcare Consultants

CONTACT: Keith Farnsworth, +1-214-389-7020,[email protected], or SHC Operations, [email protected], both ofSenior Healthcare Consultants

Web site: http://www.shcmarketing.com/http://www.shcsales.com/

Magnets Improve Coronary Stents

PHILADELPHIA — When cardiologists prop open blocked arteries with the lifesaving metal cylinders known as stents, inevitably there is some damage to the cells that line the blood vessel walls _ damage that may not heal properly on its own.

A team of Philadelphia researchers now thinks it can address the problem by borrowing a trusty concept from Physics 101: magnets.

The scientists implanted stents in the carotid arteries of rats, then placed the animals between two large electromagnets, temporarily magnetizing the stents. The rats were then injected with healthy repair cells that had been loaded with tiny magnetic particles, which were simply drawn through the bloodstream to the right location.

The procedure, reported this month online and in the print issue of Proceedings of the National Academy of Sciences, is just one way researchers are exploring the use of magnets as medical tour guides through the byways of the human body.

The authors of the paper, from Children’s Hospital of Philadelphia and Drexel and Duke Universities, also envision using magnets to deliver drugs and even designer genes _ and not just to the insides of arteries. Stents used in the bile duct, urinary tract, esophagus and lungs also could be targeted _ as could other kinds of metal implants that are used in orthopedic procedures.

Biomedical engineer Robert S. Langer, a Massachusetts Institute of Technology professor who was not involved with the paper, praised the new research for its “cleverness.”

“It seems to me that could be universally applicable,” Langer said.

In blood vessels, the goal of the magnet-based therapy is to help prevent stented arteries from becoming reobstructed, whether by blood clots or abnormal cell growth. Further study is needed, and the procedure is a few years from being tried in humans.

There’s a big market for it. Bare-metal stents were approved for use in 1994, followed by the advent of the drug-coated variety in 2003. They’ve become so popular for use in heart patients _ more than 600,000 were implanted in 2004 nationwide _ that coronary bypass operations have declined as a result.

But both kinds of stents can have unwanted consequences, such as damage to the clot-resistant endothelial cells that line arteries, said cardiologist Robert J. Levy, senior author of the new paper.

When bare-metal stents are implanted, sometimes abnormal smooth-muscle cells will grow before the endothelial cells can heal, reobstructing the artery. Drug-coated stents help prevent this abnormal growth, but they also inhibit the regrowth of healthy endothelial cells, so blood clots are a concern.

Solution: Deliver healthy endothelial cells to the proper location.

That’s where the magnets come in, said Levy, who directs the cardiology research laboratories at Children’s Hospital.

First, the team loaded the endothelial cells with magnetic nanoparticles _ tiny spheres of a biodegradable polymer that had been impregnated with iron oxide. These cells were then injected into five stented rats that sat between the magnets.

The cells had been engineered to have a luminescent “reporter gene,” so once they stuck to the stents, they could readily be seen with the proper imaging equipment, Levy said. Sure enough, the glowing particles were visible in the very diamond-shaped pattern of the mesh stents to which they adhered.

Drexel’s Boris Polyak, the co-lead author of the paper, said further study was needed to see if such cells would grow permanently into the surrounding tissue.

“We expect them to adhere, to proliferate, and to grow,” Polyak said.

When the stents were examined soon after the injections, the cells already had begun to attach to the artery wall, Levy said. (The researchers used cells from a cow because they were readily available, but they plan to follow up with a rat’s own endothelial cells.)

The polymer used to make the particles is of the same kind already used for biodegradable sutures, and it is easily broken down by the body. The iron oxide was at low enough levels that it was cleared by the rats’ cells with no ill effects.

But Levy said in the future, his team hopes to make nanoparticles with even lower levels of iron oxide.

That would be possible if physicians made use of the much stronger magnetic field in a device that is already widely found in hospitals: the MRI machine.

The magnetic field in an MRI is about 10 times stronger than what was used with the rats; as a result, physicians could use magnetic particles with much less iron oxide, he said.

MIT’s Langer said he wasn’t sure that an MRI machine could be used for this purpose without modification. So testing the machines is among the next projects in Levy’s lab.

Hospital Use of Diluted Meds Unsure

By Bob Stiles

A registered nurse at Mercy Jeannette Hospital was uncertain how many vials of painkilling medicine that he had diluted with saline solution may have been used to treat patients, if any, according to investigators.

Frank C. Glomb, 33, of 834 Kiski Park Drive, Washington Township, was charged this week with three felony drug offenses related to illegal acquisition of narcotics and recklessly endangering another person.

The state Attorney General’s office accused Glomb of diverting morphine, Demerol and other powerful narcotics from the Jeannette hospital’s pharmacy for his own use from August through September, according to charges filed before Jeannette District Judge Joseph DeMarchis.

Investigators said they determined that Glomb would cut open boxes of liquid pain medication, remove some of the drugs, then replace the missing liquid with saline solution. He then would glue the boxes back together and return the altered medicine to the cabinets, authorities said.

Investigators questioned Glomb Nov. 9, at which time he admitted diverting the drugs, according to a probable cause affidavit.

“Glomb could not put a definitive number on the amount of narcotics he had tampered with and what was ultimately returned to stock or administered to patients through the hospital,” the affidavit said of the interview.

The reckless endangerment charge stemmed from the replacement of pain medicine “with saline and/or unknown substances” and their placement “back into use for patient care at Mercy Jeannette Hospital,” the complaint said.

Attorney general spokesman Nils Frederiksen said Thursday that investigators have no evidence to indicate that diluted pain medicine reached patients, or additional charges would be filed.

He said the investigation showed that Glomb, who worked in the medical surgical ward, would remove about half of the painkiller from a vial, then replace the missing amount with the saline solution.

“It was about a 50-50 mix … a diluted mix,” Frederiksen said.

He surmised a diluted painkiller would not supply the relief expected by the patient or the physician.

Calls made to Julie Hester, the hospital’s administrator, were not returned yesterday.

Hospital spokeswoman Patti Buhl said yesterday that the facility cooperated with investigators and notified them when the diluted medicine was discovered.

“To the best of our knowledge, none our patients were put at risk, and we’ve done a thorough investigation,” she said.

Buhl said patient charts were examined and no patients complained about uncontrolled pain.

Despite the allegations, Buhl claimed the hospital had stringent regulations in place about how medicines are obtained and administered.

According to court papers, nurses had access to the medicine cabinets.

Stacy Kriedeman, state health department spokeswoman, said her agency typically reviews procedures used by a hospital when claims of medicine tampering are reported.

Hospital personnel used records to link Glomb to at least four boxes of painkillers that were in the pharmacy Sept. 30, investigators said. At that point, they had become suspicious after he suffered a seizure while working the 3-11 p.m. shift, court papers said.

“An examination of the contents (by a pharmacy technician) revealed that several of the vials of injectables appeared to have been opened and glued back together,” the affidavit said. “The fourth box had already been dispensed to the ICU (intensive care unit), which was immediately recovered.”

The technician “found that one of the carpujects (vials) from that box had already been administered to a patient, but the remaining nine carpujects were recovered,” the affidavit said.

A further check of the entire hospital turned up 409 carpujects that were either obviously tampered with or were in boxes that had been opened and resealed, investigators said. All of the recovered carpujects were found in the unit where Glomb worked, investigators said.

The affidavit said that when Glomb suffered the seizure, empty syringes, partial bottles of unknown liquids and a razor blade fell out of his sock and smock.

“When Glomb was taken to the emergency room, a nurse … found that Glomb had an IV port in his arm,” the affidavit said.

At that point, with suspicions raised, authorities said Glomb indicated to hospital employees that he had been diverting narcotics from the hospital for several months. He allegedly signed a statement saying such. Hospital officials then contacted authorities.

Buhl declined to discuss Glomb’s employment history or status.

In November, Glomb told investigators he first acquired the narcotics at the hospital by injecting himself with pain medicine left in syringes already used for patients. At this point, Glomb said, he was using painkillers two or three times per week, according to court papers.

But as his demand for drugs increased to two or three times per day, Glomb said he needed to find a new way to get drugs, investigators said.

Glomb allegedly tampered with the solutions in a bathroom. He also would take home some of the drugs, disposing of the used paraphernalia when he returned to work, court papers alleged.

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

Abbott’s HUMIRA(R) (Adalimumab) Receives FDA Approval For Moderate to Severe Chronic Plaque Psoriasis

ABBOTT PARK, Ill., Jan. 18 /PRNewswire-FirstCall/ — Abbott announced today it has received U.S. Food and Drug Administration (FDA) approval to market HUMIRA(R) (adalimumab) as a treatment for adult patients with moderate to severe chronic plaque psoriasis, an autoimmune disease characterized by skin lesions that are sometimes painful and itchy. HUMIRA has been approved for the treatment of adult patients with moderate to severe chronic plaque psoriasis who are candidates for systemic therapy or phototherapy, and when other systemic therapies are medically less appropriate. HUMIRA should only be administered to patients who will be closely monitored and have regular follow-up visits with a physician.

The approval is based on two pivotal trials, REVEAL and CHAMPION, showing that nearly 3 in 4 patients achieved 75 percent clearance or better at week 16 of treatment versus placebo. HUMIRA has 10 years of clinical trial experience beginning with rheumatoid arthritis patients. It was approved for moderate to severe rheumatoid arthritis in 2002, psoriatic arthritis in 2005, ankylosing spondylitis in 2006, and moderate to severe Crohn’s disease in 2007.

“The approval of HUMIRA for psoriasis is welcome news for people living with this challenging, lifelong disease,” said Pam Field, acting president and CEO, National Psoriasis Foundation. “We are pleased to let people with plaque psoriasis know they now have a new treatment option available to them.”

Psoriasis affects an estimated 125 million people worldwide, with approximately 25 percent of patients experiencing moderate to severe disease. Psoriasis is a serious, sometimes painful autoimmune disease resulting in inflamed, scaly, red skin lesions known as plaques, which may crack and bleed. In addition to visible symptoms, people with psoriasis may suffer from poor self-image and social isolation, and even feelings of depression, such as sadness and despair. Recent research also suggests psoriasis may be associated with other serious health risks. Up to 30 percent of psoriasis patients develop psoriatic arthritis, which combines skin symptoms with arthritis symptoms, including joint pain and inflammation.

“The approval of HUMIRA is excellent news for patients suffering from psoriasis, which can have a profound physical and emotional impact on a person’s life,” said Alan Menter, M.D., chairman, division of dermatology, Baylor University Medical Center, Dallas. “HUMIRA offers dermatologists an important new therapeutic option that has been shown to help alleviate a range of psoriasis signs and symptoms, including redness, scaling and itching, in many psoriasis patients.”

HUMIRA for Plaque Psoriasis

The approval of HUMIRA is based on data from more than 1,400 adult patients in two pivotal trials — REVEAL and CHAMPION. Both studies evaluated the efficacy and safety of HUMIRA in clearing skin in moderate to severe adult plaque psoriasis patients versus placebo. In addition, CHAMPION compared a biologic medication to methotrexate, a standard systemic treatment for psoriasis. REVEAL results were published in the Journal of the American Academy of Dermatology in January 2008 and CHAMPION results were published online in the British Journal of Dermatology.

In each trial, reduction in disease activity was determined by the Psoriasis Area and Severity Index (PASI) and Physician’s Global Assessment (PGA). The PASI score measures the extent and severity of psoriasis. PASI may be calculated before and after a treatment period to determine efficacy; for example, a PASI 75 correlates to a 75 percent improvement in signs and symptoms of psoriasis. PGA also measures efficacy of therapy. On a six-point scale, a zero score means no signs, one means minimal and a five means signs of very severe psoriasis.

Key Data

In REVEAL, a pivotal 52-week trial, the short-term and sustained clinical efficacy and safety of HUMIRA were evaluated in more than 1,200 patients from the United States and Canada with moderate to severe chronic plaque psoriasis. Patients experienced a significant reduction in the signs and symptoms of their disease at 16 weeks when treated with HUMIRA. Specifically,

   --  Almost 3 out of 4 patients (71%) receiving HUMIRA achieved PASI       75 compared to 7 percent of patients receiving placebo at week 16.   --  At week 16, 62 percent of HUMIRA-treated patients achieved a PGA score       of clear or minimal (0 or 1) compared to 4 percent of placebo-treated       patients.    

In CHAMPION, a pivotal 16-week study evaluating 271 psoriasis patients from eight European countries and Canada, HUMIRA-treated patients experienced a significant reduction in the signs and symptoms of their disease compared with methotrexate or placebo-treated patients.

   --  Nearly 80 percent (78%) of patients treated with HUMIRA (n=99)       achieved a PASI 75 response, compared to 19 percent of patients       treated with placebo (n=48).   --  More than 70 percent (71%) of patients treated with HUMIRA achieved a       PGA score of clear or minimal at 16 weeks of treatment, compared with       only 10 percent of placebo-treated patients.    

The safety profile of HUMIRA in the plaque psoriasis clinical trials was similar to that seen in HUMIRA clinical trials for rheumatoid arthritis (RA). The most commonly reported adverse events in HUMIRA psoriasis trials were upper respiratory tract infection, nasopharyngitis (inflammation of the nose and pharynx), headache, sinusitis and arthralgia. HUMIRA is self-administered as an injection. Patients are treated with an initial 80 mg dose of HUMIRA (two 40 mg injections) followed by one HUMIRA injection (40 mg) one week later. After that, a maintenance dose of 40 mg is administered every other week.

“HUMIRA has demonstrated its versatility in effectively treating multiple autoimmune diseases, and this approval expands the therapeutic resources available to dermatologists and other physicians who take care of patients with psoriasis and psoriatic arthritis,” said Eugene Sun, M.D., vice president, Global Pharmaceutical Clinical Development, Abbott.

In April 2007, Abbott simultaneously submitted a supplemental Biologics License Application (sBLA) with the FDA and a Type II Variation to the European Medicines Agency (EMEA) seeking approval to market HUMIRA (adalimumab) as a treatment for chronic plaque psoriasis. EMEA approval was received in December 2007, and the U.S. approval makes psoriasis the fifth autoimmune disease indication for HUMIRA.

More Information on Psoriasis

While psoriasis can occur in people of all ages, it typically appears in patients between the ages of 15 and 35, and currently has no cure. In a recent survey from the National Psoriasis Foundation, nearly 40 percent of psoriasis respondents reported feelings of helplessness and self-consciousness as a result of their disease.

Psoriasis varies from person to person and treatment depends largely on type, location, severity, age and medical history, and the primary treatment goals are to reduce the thickness, redness, scaling and itching of the skin. Treatment may include topical agents, phototherapy or medication taken by pill or injection.

Important Safety Information

Serious infections, sepsis, tuberculosis (TB) and opportunistic infections, including fatalities, have been reported with the use of TNF-blocking agents, including HUMIRA.

Many of these serious infections have occurred in patients also taking other immunosuppressive agents that in addition to their underlying disease could predispose them to infections.

Infections have also been reported in patients receiving HUMIRA alone. Treatment with HUMIRA should not be initiated in patients with active infections. TNF-blocking agents, including HUMIRA, have been associated with reactivation of hepatitis B (HBV) in patients who are chronic carriers of this virus. Some cases have been fatal. Patients at risk for HBV infections should be evaluated for prior evidence of HBV infections before initiating HUMIRA. The combination of HUMIRA and anakinra is not recommended and patients using HUMIRA should not receive live vaccines.

More cases of malignancies have been observed among patients receiving TNF blockers, including HUMIRA, compared to control patients in clinical trials. These malignancies, other than lymphoma and non-melanoma skin cancer, were similar in type and number to what would be expected in the general population. There was an approximately 3.0 fold higher rate of lymphoma in combined controlled and uncontrolled open-label portions of HUMIRA clinical trials. The potential role of TNF-blocking therapy in the development of malignancies is not known. TNF-blocking agents, including HUMIRA, have been associated in rare cases with demyelinating disease and severe allergic reactions. Infrequent reports of serious blood disorders have been reported with TNF-blocking agents.

Worsening congestive heart failure (CHF) has been observed with TNF-blocking agents, including HUMIRA, and new onset CHF has been reported with TNF-blocking agents. Treatment with HUMIRA may result in the formation of autoantibodies and rarely, in development of a lupus-like syndrome.

The most frequent adverse events seen in the placebo-controlled clinical trials in adults with rheumatoid arthritis (HUMIRA vs. placebo) were injection site reactions (20 percent vs. 14 percent), upper respiratory infection (17 percent vs. 13 percent), injection site pain (12 percent vs. 12 percent), headache (12 percent vs. 8 percent), rash (12 percent vs. 6 percent) and sinusitis (11 percent vs. 9 percent). Discontinuations due to adverse events were 7 percent for HUMIRA and 4 percent for placebo. As with any treatment program, the benefits and risks of HUMIRA should be carefully considered before initiating therapy.

In HUMIRA clinical trials for ankylosing spondylitis, psoriatic arthritis, Crohn’s disease and plaque psoriasis, the safety profile for adult patients treated with HUMIRA was similar to the safety profile seen in adult patients with rheumatoid arthritis. In placebo-controlled clinical trials in plaque psoriasis, the incidence of arthralgia was 3 percent in HUMIRA-treated patients versus 1 percent in controls.

About HUMIRA

In addition to its approval for chronic plaque psoriasis, HUMIRA is approved by the FDA for reducing signs and symptoms, inducing major clinical response, inhibiting the progression of joint structural damage, and improving physical function in adult patients with moderately to severely active RA. HUMIRA is indicated for reducing the signs and symptoms of active arthritis, inhibiting the progression of structural damage and improving physical function in patients with psoriatic arthritis. HUMIRA resembles antibodies normally found in the body. It works by blocking tumor necrosis factor alpha (TNF-alpha), an inflammatory protein that, when produced in excess, plays a key role in the inflammatory responses of some autoimmune diseases.

To date, HUMIRA has been approved in 72 countries and more than 250,000 people worldwide are currently being treated with HUMIRA. Clinical trials are currently under way evaluating the potential of HUMIRA in other immune-mediated diseases.

In May 2007, Abbott announced it had also submitted an FDA regulatory application for HUMIRA to treat juvenile rheumatoid arthritis and an EMEA regulatory application for HUMIRA to treat juvenile idiopathic arthritis. Clinical trials are currently underway evaluating the potential of HUMIRA in ulcerative colitis. HUMIRA is also approved for reducing signs and symptoms in patients with active AS. HUMIRA is approved for reducing the signs and symptoms and inducing and maintaining clinical remission in adults with moderately to severely active Crohn’s disease who have had an inadequate response to conventional therapy and reducing signs and symptoms and inducing clinical remission in these patients if they have also lost response to or are intolerant to infliximab.

Abbott’s Commitment to Immunology

Abbott is focused on the discovery and development of innovative treatments for immunologic diseases.

More information about HUMIRA, including full prescribing information and Medication Guide, is available on the Web site http://www.rxabbott.com/ or in the United States by calling Abbott Medical Information at 1-800-633-9110.

About Abbott

Abbott is a global, broad-based health care company devoted to the discovery, development, manufacture and marketing of pharmaceuticals and medical products, including nutritionals and devices. The company employs 65,000 people and markets its products in more than 130 countries. Abbott’s news releases and other information are available on the company’s Web site at http://www.abbott.com/.

Abbott

CONTACT: Media, Liz Shea, +1-847-935-2211, or International, TracySorrentino, +1-847-937-8712, or Financial, Larry Peepo, +1-847-935-6722, allof Abbott

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

Stem Cell Researchers Take On Parkinson’s Disease

New ways to grow brain cells in the laboratory could eventually provide a way to treat Parkinson’s disease

Scientists in Sweden are developing new ways to grow brain cells in the laboratory that could one day be used to treat patients with Parkinson’s disease, an international conference of biologists organized by the European Science Foundation (ESF) was told last week.

Professor Ernest Arenas of the Karolinska Institute in Stockholm presented his research to the EuroSTELLS “Stem Cell Niches” conference in Barcelona on January 11. Stem cell therapy hold the promise of treating disease by growing new tissues and organs from stem cells ““ “Ëœblank’ cells that have the potential to develop into fully mature or “Ëœdifferentiated’ cells. The EuroSTELLS is an ESF EURCORES program, managed by the European Medical Research Councils (EMRC), that aims to develop a stem cell “Ëœtoolbox’ by generating fundamental knowledge on stem cell biology.

Parkinson’s disease affects around three in a hundred of people aged over 65. The condition can cause muscles to become rigid and limbs to tremble uncontrollably. Parkinson’s disease results from the loss of a particular type of brain cell called dopaminergic (DA) neurons in the part of the brain called the substantia nigra.

Among the various approaches that are currently being discussed from an ethical perspective, is the possible approach of taking stem cells, growing them into new brain cells and transplanting these into the patient. “The idea is to start with stem cells and induce them to become neurons,” said Professor Arenas, whose research is carried out as part of a EuroSTELLS collaboration. “These could then be transplanted into the brain of the patient. Also, such cells could be ideal for developing and testing new drugs to treat brain disease.”

However, to create such cells that function efficiently and safely is a major challenge. Early efforts at growing DA neurons from embryonic stem cells produced cells which, when transplanted into animal models, had a tendency to form tumors or clumps, or die without an obvious reason.

Professor Arenas’s team studied the development of DA neurons in animals to determine the important biological molecules in the brain that were necessary for the cells to grow and function efficiently. The scientists identified one particular molecule that seemed to be key, a protein called Wnt5a. They showed that when this molecule, together with a second protein called noggin, was included in cultures of stem cells, far more DA neurons were produced than when these ingredients were not present.

The team then carried out a series of molecular, chemical and electrophysiological tests on the newly grown neurons to check their proficiency, which was shown to be good.

Crucially the team also moved away from embryonic stem cells ““ which can be induced to grow into a wide variety of different cells. Instead they used neural stem cells ““ which are programmed to develop only into nerve cells.

When the researchers transplanted the cells into laboratory animals whose substantia nigra region of the brain was damaged, the results were promising. “We reversed almost completely the behavioral abnormalities, and neurons differentiated, survived and re-innervated the relevant part of the brain better” Professor Arenas said. “Furthermore we do not see the kind of proliferation of the cells that has occurred in the past and we get very little clustering when the cells are treated with Wnt5a. The cells are safer than embryonic stem cells and more efficient than fetal tissue.”

Verification of this approach with human cells is ongoing and if the study is successful, it may lead to a clinical trial. Experts in the field have recently identified this approach as the next step in cell replacement therapy for Parkinson’s disease and the hope is that this may, ultimately, lead to cells suitable for transplant into human patients.

On the Net:

European Science Foundation

AmberWave Systems and University of New Hampshire Receive Technology Innovation Grant From the New Hampshire Innovation Research Center

AmberWave Systems, a leader in the research, development and licensing of advanced technologies for semiconductor manufacturing, will be partnering with the University of New Hampshire (UNH), after the two institutions were named as recipients of the “Granite State Technology Innovation Grant” by the New Hampshire Innovation Research Center (NHIRC).

The NHIRC’s Granite State Technology Innovation Grant leverages an investment by the state of New Hampshire with federal dollars from the National Science Foundation’s EPSCoR program (Experimental Program to Stimulate Competitive Research). Companies receiving the grant provide matching funds and services, thereby increasing the value of the project, the return on investment, and the likelihood of success.

The grant will help support the project “Cost Effective Nano-Patterning for Aspect Ratio Trapping Technology.” Aspect Ratio Trapping (ART), a technique developed and nurtured by AmberWave Systems. ART is a technology that focuses on integrating silicon and compound semiconductors. It could allow manufacturers to capitalize on investments in current manufacturing technologies, and improve the speed and functionality of many of the technology devices and gadgets used everyday by consumers, while at the same time, considerably reducing costs.

“One of the fundamental and critical issues to this ART technology is the cost of patterning the silicon substrate suitable for ART material growth,” said Dr. Anthony Lochtefeld, AmberWave’s vice president of research. “We chose to work with Dr. Glen Miller because he has developed several methods for the high-rate directed assembly of nanoelements at UNH. We believe that his innovative and cost-effective approaches may help us to achieve a more efficient ART technology.”

Dr. Glen P. Miller, a professor in the department of chemistry and materials science program at UNH, will lead the grant project at the university. Dr. Miller also serves as the associate director of the Center for High-rate Nanomanufacturing at UNH. The project will allow him, as well as his students, to transition from cutting-edge research to real world applications.

“Our partnership with AmberWave represents an opportunity to apply fundamental research that originated at UNH to real problems in the semiconductor industry,” said Dr. Miller. “This is a marriage between research excellence at UNH and semiconductor experience and expertise at AmberWave. It’s a win-win.”

The NHIRC hopes that AmberWave, with the assistance of UNH, can better expand their product line, in addition to their bottom line. Companies that grow are better able to hire employees who are more than likely to spend their money in their home communities, and that, they said, is sustainable economic impact.

“The AmberWave project with Dr. Miller’s lab at UNH exemplifies the intent and purpose of the Granite State Technology Innovation Grant program: To assist New Hampshire companies in the advancement of new technologies by making the expertise and facilities of our research institutions available to them,” said Robert Dalton, director of the NHIRC.

About AmberWave Systems

Founded in 1998, AmberWave Systems has become a leader in the research, development and licensing of advanced technologies for semiconductor manufacturing. By funding and guiding university research, AmberWave Systems is bringing new technology developments to fruition through patents and technology licensing. In conjunction with its university research projects, AmberWave Systems conducts its own research, development and limited manufacturing in its semiconductor fabrication facility in Salem, New Hampshire. In addition, AmberWave Systems collaborates with other technology focused companies to further expand and develop its research. For more information about the company, please visit its Web site at http://www.amberwave.com.

Cleveland Clinic Recruits World Renowned Heart Rhythm Specialist to Direct Electrophysiology

CLEVELAND, Jan. 17 /PRNewswire/ — Bruce D. Lindsay, M.D., currently Professor of Medicine and Director of Cardiac Electrophysiology at Washington University in St. Louis, has been appointed Director of Electrophysiology at the Cleveland Clinic Heart and Vascular Institute.

“We are pleased to have such an established leader in the field of electrophysiology join our team and continue to develop this talented department of physicians who have deep skills in treating delicate and complex diseases,” said Bruce Lytle, M.D., Chairman of Cleveland Clinic Heart and Vascular Institute.

“Dr. Lindsay is one of the world’s most prominent experts in heart rhythm disorders and will bring great energy and leadership to this vital area of cardiology,” said Dr. Steven Nissen, Chairman of Cardiovascular Medicine.

Dr. Lindsay, an established leader in the field, is the President of the Heart Rhythm Society, a member of the Board of Trustees for the American College of Cardiology and former chair of the College’s Board of Governors. He also works with the American Board of Internal Medicine writing examinations that certify knowledge and skills in the field of cardiac electrophysiology.

“My decision to accept this position was strongly influenced by the Clinic’s mission to provide compassionate health care of the highest quality,” said Dr. Lindsay. “This embodies a goal I have set throughout my career, and I look forward to working with this internationally acclaimed institution.”

Dr. Lindsay is a graduate of Jefferson Medical College and completed a residency in internal medicine at the University of Michigan. He served in the National Health Service Corps from 1980-83 at a rural health initiative project in East Jordan, Michigan. While practicing in this rural community, he became interested in heart rhythm disorders because little was known about the causes and optimal treatment of these problems.

Dr. Lindsay completed a cardiology fellowship at Washington University where he undertook additional training in the treatment of heart rhythm disorders. He joined the faculty in 1985 and became director of the electrophysiology program in 1994.

His clinical research and publications have focused on identification of patients at increased risk for cardiac arrest, improved technology for implantable defibrillators, malfunctions of implantable cardiac devices and advances in ablation of heart rhythm abnormalities. He is an author for the Heart Rhythm Society’s recent state of the art consensus document for ablation of atrial fibrillation. Through his commitment to education he has served on the faculty at meetings throughout the United States, Europe, Japan, Taiwan and China.

About Cleveland Clinic

Cleveland Clinic, located in Cleveland, Ohio, is a not-for-profit multispecialty academic medical center that integrates clinical and hospital care with research and education. Cleveland Clinic was founded in 1921 by four renowned physicians with a vision of providing outstanding patient care based upon the principles of cooperation, compassion and innovation. U.S. News & World Report consistently names Cleveland Clinic as one of the nation’s best hospitals in its annual “America’s Best Hospitals” survey. Approximately 1,800 full-time salaried physicians and researchers at Cleveland Clinic and Cleveland Clinic Florida represent more than 100 medical specialties and subspecialties. In 2006, there were 3.1 million outpatient visits to Cleveland Clinic. Patients came for treatment from every state and from more than 80 countries. There were more than 53,000 hospital admissions to Cleveland Clinic in 2006. Cleveland Clinic’s Web site address is http://www.clevelandclinic.org/.

Cleveland Clinic

CONTACT: Eileen Sheil, +1-216-444-8927, [email protected], or Erinne Dyer,+1-216-444-8168, [email protected], both of Cleveland Clinic

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

Aetna Signs Contract With Central Georgia Health Network

Aetna (NYSE: AET) announced today it has reached agreement with Central Georgia Health Network (CGHN) on a multi-year contract that adds the Medical Center of Central Georgia and its affiliated physicians to Aetna’s provider network in the Macon area. The agreement provides current and new Aetna enrollees with access to the CGHN provider network.

“We’re very pleased to announce this new agreement,” said Ramzy ElGomayel, Aetna’s head of network operations in Georgia. “This is very good news for Aetna members and prospective future customers in the Macon area. We’ve greatly expanded access to hospitals, facilities and physicians in Central Georgia.”

“This agreement extends access to the Medical Center of Central Georgia and our physicians for a significant number of Aetna members in and around the Macon area,” said Don Faulk, president and CEO of Central Georgia Health System. “We welcome them to the Central Georgia Health Network and look forward to serving them with world-class care.”

Under the agreement, members of Aetna network-based plans will be able to receive covered in-patient and out-patient services, at in-network rates, from the Medical Center of Central Georgia, the children’s hospital in Macon, home health, home infusion, three urgent care centers, radiology centers, a rehab hospital, an ambulatory surgery center, and approximately 180 physicians who previously had not participated with Aetna. These physicians include hospital-based doctors and community physicians. Aetna members will continue to have access to about 220 of CGHN’s affiliated physicians who had previously established contractual arrangements with Aetna.

Aetna provides and administers health benefits to more than 500,000 members in Georgia. Those members currently have access to a contracted network of 153 hospitals, 4,360 primary care physicians and 8,790 specialists.

About Central Georgia Health System

Central Georgia Health System is a private, not-for-profit corporation that includes The Medical Center of Central Georgia and Central Georgia Health Network and other health related companies. CGHN is a physician-hospital organization, which includes more than 400 primary-care and specialty physicians.

About Aetna

Aetna is one of the nation’s leading diversified health care benefits companies, serving approximately 36.4 million people with information and resources to help them make better informed decisions about their health care. Aetna offers a broad range of traditional and consumer-directed health insurance products and related services, including medical, pharmacy, dental, behavioral health, group life and disability plans, and medical management capabilities and health care management services for Medicaid plans. Our customers include employer groups, individuals, college students, part-time and hourly workers, health plans, government-sponsored plans and expatriates www.aetna.com