Dreams of Steam: Locomotive From China Evokes U.S. Rail History

By Jim Warren, The Lexington Herald-Leader, Ky.

Jan. 17–It’s been roughly 50 years since a steam locomotive operated on the railroad tracks around Lexington.

But that’s about to change.

The R.J. Corman Railroad Co. has taken delivery on a Chinese-built steam locomotive, which it plans to park on a siding just off Cox Street, both as a piece of historic preservation and for actual use on as-yet-unspecified “special occasions.” Company owner Rick Corman says he expects to fire up the engine and try it out on the track within a few weeks, as soon as it’s inspected and spruced up from its long trip from China.

That day can’t come soon enough for local rail fans, several of whom braved 30-degree weather Wednesday morning for a rare glimpse of a real, working steam locomotive. They watched and snapped pictures for more than two hours, as work crews from the Corman company carefully unloaded the 140-ton steam engine from two railroad flatcars that brought it and its tender car to Lexington over the weekend.

“You know it can’t be a cost-efficient project, but I’m just glad that there is someone who has the resources to preserve something like this,” said Lexington’s Way Thompson, one of those watching the unloading. “I’ve always loved trains and steam engines.”

Corman actually bought the engine from Railroad Development Corp., a Pittsburgh firm that had acquired three of the Chinese locomotives. Corman’s engine traveled to the U.S. by ship, arrived in New Orleans last month, and then was shipped to Lexington by rail. Though built in China, the engine is based on a U.S. design from the 1920s.

Why buy a Chinese locomotive rather than an American one?

The few steam locomotives seen in this country today typically are museum pieces rescued from the scrap heap.

But Corman’s engine is no antique. It was built in 1986 and was in use on Chinese railroads as recently as 2005, hauling coal and passengers. According to Corman, Chinese railroads continued to rely on steam power until recently, and only now are replacing their outmoded steam engines with modern diesels. So, steam engines now available in China are only a few years old and require little restoration, compared with old U.S. engines that must be rebuilt.

American railroads abandoned steam for diesel power decades ago. But for many rail fans, no diesel ever built can match the romance and appeal of a smoking, snorting steam locomotive.

The Bluegrass Railroad Museum in Versailles at one time owned a steam engine, but sold it because of high operating costs. Steam excursion trains pass through Lexington occasionally. But there is no steam locomotive regularly operating in Central Kentucky today.

Which is why the prospect of having one in Lexington is such a thrill for fans like Way Thompson — and for Matt Schwerin, 30, who didn’t know much about steam engines until lately, but has had to learn a lot about them very quickly. Schwerin, who works for the Corman Railroad Co., will be the person mainly responsible for operating the locomotive.

“It started in June when Mr. Corman told me, ‘I need you to go to China,'” Schwerin said.

He ultimately made two trips to Jinzhou, China, to see the locomotive, watch it being refurbished, and learn to operate it. Schwerin’s regular job at the Corman company is as manager of operation practices. And while he’s a certified railroad engineer, he had never before run a steam engine.

Indeed, until recently, Schwerin had never even seen a steam locomotive except in a museum. At age 30, he was born too late to experience the steam era on American railroads. Now, he’s getting a second chance to learn what it was like.

“I sort of put myself through a crash course on steam once Mr. Corman told me I’d be involved in this project,” Schwerin said. “Operating a steam locomotive is a totally different experience from a diesel. I think it’s really exciting that a for-profit railroad company would make this kind of investment and commitment.”

Rick Corman said he sees the engine as a door into history.

“How do you know where you’re going if you don’t know where you’ve been?” he said. “We’re going to maintain it and operate it some two or three times a year, just for special occasions.

“Steam engines aren’t very efficient, but they do have character and people love them. I think it will be a nice addition to our company.”

—–

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

Distributed by McClatchy-Tribune Information Services.

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200 Babies Born Per Hour in Philippines

200 babies born per hour in Philippines

MANILA– The population in the Philippines will be increasing at the rate of 200 babies for every hour this year, making the archipelago the most populated in Southeast Asia,local media said on Tuesday.

Filipinos now number around 84 million, the Manila Time reported, citing the Philippine National Statistical Coordination Board.

The population growth rate of the Philippines is above the Association of Southeast Asian Nations (ASEAN) average of 1.5 percent and is higher than that of Thailand, Indonesia and Vietnam,said Romulo Virola, the board’s secretary-general.

The Philippines is lower than that of the six other ASEAN countries, including Singapore, which is promoting childbirth among couples. Brunei, Cambodia, Laos, Malaysia and Myanmar are the other members of the regional association.

Virola cited at least three reasons for the country’s rising population, including the poor’s lack of access to modern family- planning methods, their need for more children to do household chores or help in economic activities of the family, and their reliance on guidance from the Catholic Church on such methods, which the Vatican forbids.

In the latest population survey conducted in 2000, the population growth was 193 persons for every hour or three persons a minute.

Available data from the 1990, 1995 and 2000 censuses show that the Philippine population grew annually by 2.32 percent between 1990 and 1995, 2.36 percent between 1995 and 2000, and 2.34 percent between 1990 and 2000.

Based on the 2000 census, population projections put the country’s growth rate at 1.97 percent between 2006 and 2007, and at 1.95 percent between 2007 and 2008.

The mid-year 2008 population growth is projected at 90.45 million, or equivalent to a population density of 266 per square kilometer and an average population size of 2,154 for every barangay or village.

USC and EMA Award James De La Torre, M.D. The 2008 EMA/USC Administrative Fellowship in Emergency Medicine

Emergent Medical Associates (“EMA”) and the Department of Emergency Medicine of the Keck School of Medicine are proud to announce that they have awarded the Administrative Fellowship in Emergency Medicine for 2008 to Dr. James de la Torre. Dr. de la Torre is currently completing his residency in Emergency Medicine at Los Angeles County-USC Medical Center in Los Angeles, CA.

“We are very excited to name Dr. de la Torre as the second EMA-USC Fellow. This year’s group of candidates was outstanding. However, Dr. de la Torre was a clear stand out,” said Dr. Scott Brewster, Medical Director at EMA. “He is an exceptional physician with the essential tools to be a future leader in Emergency Medicine.”

“I am honored to be selected for the EMA-USC Administrative Fellowship,” said Dr. de la Torre. “The fellowship will complement my clinical experience, give me an opportunity to gain more administrative and business experience and prepare me for an increasingly complex emergency medicine practice environment. I am looking forward to learning from the leadership team at EMA and exploring all the unique aspects of the fellowship.”

Dr. de la Torre graduated from UCLA with a BS in Biochemistry and received his medical doctorate from Harvard University. He was awarded the SAEM excellence in EM for medical students. After completing medical school, Dr. de la Torre completed an internship in internal medicine at UCLA-Olive View Medical Center. Currently, he is completing his residency in EM at Los Angeles County-USC Medical Center. During residency he published a review article on coccidiomycosis for emedicine, presented and reviewed a trauma case on EM:RAP and is doing research on occult pneumothoraces. He is also an ACLS instructor and coordinates the journal club at L.A. County.

About the Department of Emergency Medicine of the Keck School of Medicine

The department is located at the LAC+USC Medical Center. This historic hospital, formerly known as County General Hospital, is home to one of the US’ oldest and largest residency training programs for Emergency Physicians, dating back to 1971. It is now a PGII-IV program training 54 residents. The department is responsible for 400-500 patient visits daily.

About Emergent Medical Associates

EMA, headquartered in Manhattan Beach, CA, is a premier provider of physician staffing and practice management services for 14 Emergency Departments with an annual census of over 385,000 visits throughout Southern and Central California. Through its consulting division e-MSO, EMA exports best practices and innovative management techniques to hospitals and other ED groups, helping improve patient care and ensure contract security. EMA’s proprietary techniques are patient-focused and targeted on improving the daily operations of Emergency Departments.

For more information on:

The ED Administrative Management Fellowship, visit http://www.ema.us/fellowship

EMA, visit http://www.ema.us

The Keck School of Medicine, visit http://www.usc.edu/schools/medicine/ksom.html

The USC Marshall School of Business and the Degree in Medical Management, visit http://www.marshall.usc.edu/mmm

 Company Contact: James B. Edwards EMA (310)-379-2134 Email Contact

SOURCE: Emergent Medical Associates

Molecular Diagnostic Testing in Malignant Gliomas: A Practical Update on Predictive Markers

By Yip, Stephen Iafrate, A John; Louis, David N

Abstract Advances in understanding the molecular underpinnings of cancer and in molecular diagnostic technologies have changed the clinical practice of oncologic pathology. The development of targeted therapies against specific molecular alterations in cancer further portends changes in the role of the pathology laboratory to guide such custom therapies. To reconcile the flood of scientific discoveries in this area, the promises of highly touted novel therapeutics, and the practicality of applying this knowledge to the day-to-day practice of clinical neuropathology, the present review highlights the operative differences between diagnostic, predictive, and prognostic markers, and discusses issues surrounding the transition of prospective biomarkers to routine laboratory implementation. This review focuses on 3 predictive molecular markers that are either in clinical use or are contemplated for use in the evaluation of malignant gliomas: assessment of 1p/19q loss in oligodendroglial tumors, examination of O^sub 6^-methylguanine DNA methyltransferase promoter methylation status in glioblastomas, and molecular dissection of the epidermal growth factor receptor- phosphatidylinositol 3-kinase pathway in glioblastomas. Implementation of such predictive markers is not straightforward and requires critical review of the available literature and attention to practical laboratory, compliance, financial, and clinical management issues.

Key Words: Biomarkers, Glioblastoma, Glioma, Molecular diagnostics, Neuropathology, Oligodendroglioma.

INTRODUCTION

Advances in understanding the molecular basis of disease and identification of disease biomarkers have heralded the era of molecular diagnostics in pathology. This development, however, comes with unique sets of challenges that will confront the pathologist. Indeed, the pathologist will be essential to evaluate scientific evidence critically and to determine whether a candidate molecular marker can provide information to alter disease management. The pathologist will also have to consider the practicality of adopting a new test in the clinical setting. Such considerations are now typically undertaken under increasing pressure from clinicians to incorporate testing for newly discovered markers. In this regard, the pathologist must balance the desire to bring the latest research findings to the bedside with the need to observe numerous checks and balances that ensure that newly incorporated markers are ready for clinical testing.

NOVEL MARKERS: BASIC CONSIDERATIONS

Biomarkers are important diagnostics tools in oncology; they also aid in monitoring disease progression and assist in determining prognosis and predicting therapeutic response (1, 2). Biomarkers vary from specific proteins and antigens to unique genetic, epigenetic, and proteomic profiles, but common to all markers is that they provide information specific to a disease process. They function to supplement, and rarely to supplant, the histopathologic examination of tissues that is the mainstay of traditional oncologic pathology.

Diagnostic, Prognostic, and/or Predictive

Before the laboratory implementation of a novel biomarker, there must be a clear definition of whether its use lies in the diagnostic, prognostic, or predictive realm. A diagnostic marker aids in the initial recognition of cancer or its relapse (3). A prognostic marker presents information pertaining to the natural history of disease and, therefore, the probability of disease relapse and durability of remission. A predictive marker identifies probability of response to a specific therapeutic agent or modality (4). Differentiating between these different types of markers is important so that one can make informed clinical decisions (5, 6). A single marker, however, may provide various combinations of diagnostic, prognostic, and predictive information. For example, expression of the estrogen receptor by immunohistochemistry is relevant in the diagnostic workup of metastatic lesions suspicious to be derived from a breast carcinoma primary, but it is also relevant to survival (prognostic) and potential response to hormonal interventional therapies (predictive) (7).

The clinical use of a potential marker is based on the magnitude of its diagnostic, prognostic, or predictive abilities and on the reliability of such changes. The former reflects the degree of clinical benefit that results from decisions based on information provided by the marker. For example, a candidate molecule that identifies tumors with a significantly enhanced response to a therapeutic agent can have dramatic impact on patient care. This applies not only to the identification of patients who may benefit from the agent but also to the exclusion of predicted nonresponders from unnecessary treatment, sparing them the untoward side effects and the expense of the agent. The second feature is marker reliability, that is, consistent association of the marker with specific clinical behavior and outcome. Implementation of markers into the clinical laboratory must be based on proper validation of assays to ensure that the results are reliable. When markers are both reliable and relevant to clinical care, they serve an important role in identifying clinically relevant of patient subgroups. However, when these 2 parameters are not met, the use of a new marker can complicate patient management and have deleterious consequences.

Issues Surrounding the Development of Novel Biomarkers

The development of biomarkers for early screening of malignancies has been divided into 5 phases, analogous to the development of therapeutics. Although the glioma markers discussed below are not screening markers per se, but rather function in patients already diagnosed with gliomas, the same systematic approach of evaluating markers certainly can be modified and adopted for tumor markers. The 5 phases range from preclinical evaluation to validation in retrospective studies, followed by prospective studies, and the realization of its impact on cancer management (8). Phase 1 consists of preclinical exploratory studies comparing diseased with nondiseased tissues with the aim of identifying unique markers or specific patterns. This can be achieved using immunohistochemistry, enzyme-linked immunosorbent assay, or, more commonly nowadays, data from one of the “-omics” technology such as gene expression microarray analysis or proteomic studies. Phase 2, which is clinical assay validation, attempts to confirm expression of the biomarker in small numbers of patients known to have the disease, in comparison to a normal cohort, thus establishing the true-positive and false- positive rates. Phase 3 consists of retrospective longitudinal repository studies that evaluate the ability of the biomarker to detect preclinical disease. Phase 4 moves the study to prospective screening in a relevant population. Population-based cancer control studies constitute the goal of Phase 5. Substandard performance of the biomarker in this phase, which assesses the “practicality” of the candidate marker, can potentially derail its adaptation for widespread clinical use. Certainly, Phases 1 and 2 are identical for markers that are used for cancer screening and for evaluating existing tumors, and the next 3 phases can be modified accordingly for tumor markers. In fact, the same general principles apply for the evaluation of real-world applicability of both screening and tumor markers (Table 1). For example, similar systematic approaches for the evaluation and implementation of tumor markers have been proposed by breast cancer researchers (9).

TABLE 1. Factors That Can Affect the Widespread Implementation of a Candidate Biomarker

Many molecules that are initially touted to have great promise do not make it to the final stages of acceptance as clinically validated markers (Fig. 1). In addition, the initial optimism associated with the discovery and characterization of such molecules is generally dampened by the time of widespread laboratory use. This is frequently associated with the publications of follow-up reports examining and reexamining the use of the putative marker in real- world studies with large numbers of clinical specimens. As a result, the eventual adaptation of a biomarker in daily pathology practice is dependent on many factors but hinges on its ease of use and standardization, as well as robustness when facing an inherently heterogenous pool of clinical pathologic specimens and the vagaries of daily routine laboratory practice (10, 11).

Compliance, Billing, and Reimbursement

Medical laboratory testing in the United States, including molecular diagnostics, is regulated under the Clinical Laboratory Improvement Amendments (12). Established in 1988, this set of legislations set out operating guidelines of excellence for the diagnostic laboratory that include specific regulations on quality control and assurance, method validation, personnel, and proficiency testing. Adherence to these regulations depends on the complexity of the individual tests. To ensure maintenance of quality assurance in the often-changing field of molecular diagnostics, an expert panel has made recommendations that include establishment of laboratory- focused consortia and databases to facilitate collaboration and reporting of test results, development of positive controls for test validation, improved performance evaluation program, and strengthening of existing molecular pathology training programs (13). Compliance with an established standard of excellence requires ongoing evaluation and reevaluation of testing procedures and outcomes, a cycle of activity that is especially important in a rapidly changing field (14, 15). In the clinical laboratory, this is best served by having a dedicated molecular diagnostic division that can maintain the necessary volume for the different assays for both cost-efficiency and for maintenance of competency. FIGURE 1. Typical sequence of events after the discovery of a biomarker; initial excitement is often tempered by real-world performance of the marker (see text).

Financial considerations are an important issue in integrating molecular testing into clinical pathology. The rapidity of assay development and the demand for new diagnostic procedures put significant pressure on realigning existing billing and reimbursement policies and contracts with the novel tests (16, 17). In addition, many of these molecular diagnostic methods require expensive capital expenditure for specialized equipment, reagents, and dedicated technical training. These factors also argue for the creation of a dedicated service that can handle molecular diagnostic needs from the different subspecialized areas of pathology. It is intended that the initial outlay in expenditure and the cost of maintenance of molecular diagnostics will prove to be economical in the long run by integration of molecular tests into the rest of traditional disease management (17). In an era of increasingly sophisticated and “personalized” (not to mention expensive) therapeutics, similarly personalized molecular diagnostics assays are essential in ensuring that only those patients with the appropriate molecular profiles receive the targeted therapeutic agent. Molecular diagnostics should help reduce or prevent the escalation of costs in a market that is becoming increasingly permeated with potent, molecularly targeted therapies (18). Currently, however, the number of molecular assays is expanding rapidly, and this already has major financial implications. For example, at our institution, test codes for molecular diagnostics have increased from 18 in 1998 to 134 in 2002 to 360 in 2006. This has brought about major increases in the total reference laboratory budget for our hospital, with molecular diagnostic expenses approximately doubling from $1 to $2 million (19).

Cost/benefit issues and the perceived extent of benefits to the population at large also determine the eventual adaptation of the marker for clinical use. On a practical note, widespread acceptance and clinical adaptation of the marker by the scientific and medical community are usually followed by acceptance from the various financial payers such as Medicare and private insurers. In reality, payers are often slow to reimburse testing associated with new technological advances. For example, with the current procedural (CPT) codes, there are no appropriate codes for large-scale microarray-type gene expression or genomic surveys (there are 3 new codes for small-scale arrays, not for arrays interrogating thousands or hundreds of thousands of targets). Introduction and acceptance of these assays in clinical service is just a matter of time; therefore, all parties should anticipate technological trends to ensure appropriate coding and, therefore, fair financial compensations for novel molecular diagnostic procedures. Acceptance of even more standard molecular assays, however, may vary from payer to payer and from state to state; for example, in our experience in Massachusetts, the combination of brain tumor diagnosis (International Classification of Diseases, 9th Revision) codes and molecular procedural (CPT) codes are interpreted by current local Medicare coding rules as medically unnecessary, and this often results in nonpayment from Medicare, whereas payment is allowed when the same CPT codes are aligned with International Classification of Diseases, 9th Revision codes for other cancer sites. These agencies will demand proof of cost-effectiveness and accountability. Abuse and misuse of these novel tests (many of which remain relatively costly), especially in billing, can have significant financial/ legal consequences. It is the responsibility of the practicing pathologist to be up-to-date with the recommended guidelines to order these tests appropriately (20, 21). In this regard, a recent analysis proposed a hierarchic approach to the implementation of biomarker development with coevolvement of therapeutic options; they also placed special emphasis on the education of patients and clinicians on various aspects of the biomarker assay, including evidence gaps and available and pending therapeutic options (9). Similar to therapeutics, there should be collaborative postmarketing surveillance of approved biomarker assays. Equally importantly, issues of privacy and protection against discrimination based on biomarker information must be addressed (9). Such practical demands often affect biomarker adoption and sometimes necessitate more complex marker measurements being restricted to large medical centers or private national laboratories.

PREDICTIVE MOLECULAR MARKERS IN DIAGNOSTIC NEUROONCOLOGY

Improvement in our understanding of the molecular basis of brain neoplasia and advances in technology are slowly transforming the field of brain tumor diagnostics (22). There now exist several examples of molecular markers in neuropathology that serve essential roles in the evaluation of tumors with ambiguous/difficult histologic features. A particularly compelling example is INI1 testing in atypical teratoid/rhabdoid tumor, which also illustrates the continuous adaptation to evolving technology in the life of a biomarker, having shifted from fluorescent in situ hybridization (FISH) assays to gene sequencing to immunohistochemistry in a matter of a decade (23, 24, 25). In addition, the same obstacles that stand in the way of integration of molecular diagnostics into traditional pathology service (discussed above) also apply to neuropathology (26). The issues of initial capital outlay and maintenance of programs, as well as the capability to recover these costs through billing and reimbursement, will continue to present challenges to the practicing neuropathologist.

The remainder of this review summarizes the data on the 3 sets of predictive markers that have been most recommended for the clinical evaluation of malignant gliomas: 1p/19q loss, O^sub 6^- methylguanine DNA methyltransferase (MGMT) inactivation, and epidermal growth factor receptor (EGFR)-phosphatidylinositol 3- kinase (PI3K) pathway activation. We have restricted the review to predictive markers because such markers, given their potential use in directing therapies, are often rapidly requested by clinicians once their roles have been suggested. Prognostic markers, on the other hand, are far more numerous-as can be seen by a quick perusal of most pathology and oncology journals-but are not as often demanded by either oncologists or patients.

For each of these markers, consideration is given to existing evidence to support use of the marker, the current status of assays for measuring the marker, use of the marker in clinical trials, and use of the marker in routine clinical practice. By working through these parameters, a report card can be issued for each marker, which in turn enables the pathologist to appreciate at what stage the marker stands in its development.

Chromosome 1p and 19q Analysis in Oligodendroglial Tumors

Rationale and Evidence for Marker Relevance

The biologic basis of why deletions of chromosomal arms 1p and 19q are associated with markedly improved clinical courses in patients with oligodendroglial tumors is unclear; the rationale for undertaking such analysis is based solely on empirical observations published in the literature. In 1998, Cairncross et al (27) reported the clinical implications of allelic loss of 1p and 19q in patients with histologically defined anaplastic oligodendroglioma. They found that loss of 1p was a predictor of chemosensitivity to the procarbazine-lomustine-vincristine (PCV) chemotherapy regimen. Furthermore, combined 1p/19q loss was associated with enhanced chemosensitivity and longer overall survival. Although this proved to be a reproducible observation that spawned widespread use of 1p/ 19q analysis in clinical neuro-oncology, the underlying biologic reason for these associations has thwarted explanation. For example, the putative tumor suppressor genes on 1p and 19q have not been identified despite extensive work (28-32), and recent evidence suggests the deletions may reflect whole-chromosome arm loss as a result of a centromeric translocation of 1 and 19 (33, 34). Moreover, 1p/19q loss is inversely related to TP53 mutations and 2 genomic abnormalities frequently found in astrocytomas: 10q deletions and amplification of the EGFR gene (35). In addition, 1p/ 19q genotype seems related to tumor location in the brain and, therefore, possibly to cell of origin (36, 37). Thus, the favorable phenotype can result from a combination of molecular factors for which 1p/19q loss is simply a convenient marker. However, to date, genetic profiling at the DNA and RNA levels has not defined such a combination of molecular factors (32, 38). Despite the lack of a biologic mechanism, clinical 1p/19q testing is the most mature molecular diagnostic test in the evaluation of malignant gliomas.

The 1p/19q story has already generated a couple of hundred scientific articles that have ranged from analyses of individual candidate genes to moderately large clinical correlation studies. The clinical correlations have definitively shown that those anaplastic oligodendrogliomas with 1p and 19q deletions are clinically distinct from those histologically similar tumors that lack deletions (39, 40). The observations have also generated substantial discussion and debate that has centered on 2 major open questions: (1) In which clinicopathologic setting is 1p/19q testing useful? For example, should testing be extended to low-grade oligodendrogliomas and to oligoastrocytomas in addition to the anaplastic oligodendrogliomas? (2) Is the test really predictive or simply prognostic, or a combination of predictive and prognostic? Can the test also be used diagnostically, that is, to define oligodendroglioma? The answer to the initial question is emerging through published studies and clinical use in multiple large institutions: 1p/19q testing may prove useful in the setting of any “oligodendroglial” tumor, whether high-grade or low-grade, whether pure or mixed with astrocytoma. For instance, in addition to the clear situation for anaplastic oligodendrogliomas, 2 articles have suggested that the slow but steady radiologic responses of low- grade oligodendroglial tumors to temozolomide correlate with loss of 1p (41, 42). Another has demonstrated that prognosis in oligoastrocytomas relates to 1p/19q status, with those patients whose oligoastrocytomas had 1p/19q deletion having better prognoses than those with p53 expression; this article, however, did not look at therapeutic response as a parameter, and, therefore, the predictive power of 1p/19q was not assessed (43).

The answer to the second question is less clear, but is likely to involve a group of biologic features that affect both natural history (i.e. prognosis) and overall therapeutic sensitivity (i.e. prediction, although possibly not response to a few specific therapies). For example, although the initial studies addressed response to PCV chemotherapy, more recent studies have shown that 1p/ 19q status can predict response to temozolomide as well (41, 44). Furthermore, 2 recent prospective randomized Phase 3 trials validated 1p/ 19q status prediction with regard to PCV chemoresponsiveness but also showed that patients with 1p/19q- deleted tumors fared better when treated with radiation alone (45, 46). A prior study had also demonstrated that patients whose oligodendrogliomas had 1p/19q loss had longer times to progression after radiation therapy with or without chemotherapy (47). In combination, such data suggest that the predictive value of 1p/19q testing is not strictly related to chemosensitivity, but may reflect a broader therapeutic sensitivity. Finally, given the interrelated nature of patient survival with therapeutic intervention, it remains possible that 1p/19q status is also related to natural history of the disease, with 1p/19q-deleted tumors being more slowly growing lesions, but that assessment of natural history is not possible given the overwhelming likelihood of therapeutic intervention.

At the same time, it is important to realize that the 1p/ 19q story is not the whole story. For example, a small number of patients with intact 1p/19q might benefit from PCV therapy (48). Clearly, in this regard, further identification and characterization of molecularly distinct subsets of patients within the 1p/19q- defined groups-either with regard to current therapeutics (PCV, temozolomide, radiation) or future targeted therapy-are necessary.

Status of Assays

1p/19q status can be assessed by loss of heterozygosity (LOH) assays, FISH, array comparative genomic hybridization (aCGH) and an assortment of less commonly used methods (49, 50). The 3 major techniques are listed in Table 2 along with their positive and negative attributes. The first 2 methods are relatively common clinical molecular diagnostic techniques that have their unique advantages and disadvantages. In general, the choice of one over the other depends primarily on local expertise, existing laboratory capabilities, and pathologist preferences. Other techniques such as quantitative polymerase chain reaction (PCR) have also been used but have not proven to be popular for clinical use (51).

Polymerase chain reaction-based LOH assays detect allelic losses by comparing polymorphisms between tumor and normal DNA (which is most commonly isolated from peripheral blood leukocytes). In tumors with 1p or 19q loss, there is loss of 1 of the normal heterozygous alleles (if the maternal and paternal copies can be distinguished, the polymorphism is said to be heterozygous or informative) (Fig. 2A). Polymerase chain reaction primers are designed against unique microsatellite sequences at each chromosomal region of interest. Because not all patients are heterozygous at all test loci, multiple (often 3) microsatellite loci are assessed to ensure that enough informative loci will be available to detect loss. Because the technique is allele based, rather than chromosomal number based (see below), an advantage of an LOH assay is that it can detect mitotic recombination events in which there are 2 copies of a single allele in tumor cells; however, mitotic recombination is a common mechanism for TP53/17p loss in malignant gliomas but not for 1p or 19q loss (53). A significant logistic limitation to LOH assays is the requirement for constitutive DNA, typically from blood, because this requires obtaining blood from patients (sometimes after they have left the hospital) and coordination of 2 specimens and their corresponding DNA. Typically, the pathologist selects a paraffin block of formalin-fixed tissue that adequately represents the tumor, that is, preferentially containing an abundance of viable neoplastic oligodendroglial cells with minimal contamination from other tissue type and tumor necrosis. Usually, multiple scrolls of the block are collected, followed by DNA extraction. The subsequent PCR step can be automated and batched, and reading of the subsequent electrophoretic tracings is generally straightforward and can be quantitated. Polymerase chain reaction assays are easy to develop and are moderately scaleable, allowing the possibility for growth of molecular diagnostic assays in the future.

TABLE 2. Comparison of 3 Common Molecular Assays for 1p/19q Status Determination

FIGURE 2. (A) 1p and 19q loss of heterozygosity (LOH) PCR. Capillary electrophoresis chromatogram generated after PCR amplification of DNA isolated from peripheral blood (bottom) and tumor (top) from a patient with oligodendroglioma. Loss of heterozygosity is noted for 2 markers in the tumor. The normal DNA shows heterozygous peaks for both markers (blue peaks), with marker 1 (chromosome 1p) showing 112- and 114-bp alleles and marker 2 (chromosome 19q) showing 158- and 170-bp alleles. Size markers are represented as red peaks. (B) 1p fluorescence in situ hybridization (FISH). FISH Dual-color FISH of an oligodendroglioma specimen showing loss of chromosome 1p as illustrated by the single red (1p probe) in comparison to 2 green signals (1q probe) per cell. (C) Array CGH of anaplastic oligodendroglioma. Array CCH performed using DNA from an anaplastic oligodendroglioma demonstrated loss of 1p and 19q with concordance to locations of markers used for LOH PCR analysis (red arrows) and relative to bacterial artificial chromosomes used as FISH probes (green arrows). Sex chromosomes were mismatched as internal hybridization control. Figure courtesy of Dr. Gayatry Mohapatra, Massachusetts General Hospital, Boston, MA.

Fluorescent in situ hybridization uses unique fluorescent probes that are hybridized directly to tissue sections, permitting direct microscopic evaluation of chromosomal copy number in tumor cells (Fig. 2B). Fluorescent in situ hybridization can be performed on formalin-fixed, paraffin-embedded tissue (as tissue sections or as dissociated cells from thick tissue slices) and can be used in conjunction with tissue microarray to maximize efficiency (54, 55). Importantly, FISH obviates the need for constitutive DNA and is a familiar technique in most pathology departments. Another advantage of this technique is the relative preservation of histologic detail and, therefore, the ability to study cells with obvious histologic abnormalities or cells from a specific population. The disadvantages of FISH include its relatively low scalability in the setting of multiple assays, and it is relatively labor-intensive. In addition, FISH lacks the ability to detect mitotic recombination events (because 2 copies of the same allele are present); fortunately for testing of oligodendrogliomas, mitotic recombination does not underlie allelic loss in these tumors (56). On the whole, FISH seems to be the most popular technique in current use in the United States for 1p/ 19q evaluation.

Array CGH uses genome-wide differential labeling of tumor and normal DNA for a comparative hybridization to arrays of DNA (57). The comparative hybridization of the differentially labeled tumor and normal DNA provides an estimate of copy number at every chromosomal locus on the array (Fig. 2C). A variety of arrays have been used: some feature genome-wide representation with chromosomal loci as either large bacterial artificial chromosomes, cDNAs, or relatively short oligonucleotides; others feature genomic regions specific to a certain disease process or group of processes (58). Array CGH is a powerful method primarily because it provides the capability to screen the entire genome and is, thus, the ultimate in scaleable assays. Although aCGH lacks the ability to detect mitotic recombination events with standard arrays, the use of single nucleotide polymorphism arrays allows detection of such events (59, 60). At the present time, aCGH remains a predominantly experimental technology, and the current cost of implementation for widespread diagnostic use may be prohibitive for many pathology departments. However, in the future, aCGH may be the most commonly used assay for assessing chromosomal copy number changes at all different genomic sites and in all different human tumors. Recommendations for Routine and Clinical Trial Testing: Diagnostic Use

The strong association of 1p/19q loss with oligodendroglioma histology has raised the question of whether oligodendrogliomas should be defined by this genetic signature, much in the same way as some sarcomas and hematologic malignancies are now defined by specific genetic abnormalities. Although 1p/19q loss is very common in oligodendrogliomas, being found in approximately 60% to 80% of cases in most series, this genetic combination is not present in all histologically defined oligodendrogliomas (49, 61). This begs the question of what to call those tumors that microscopically qualify as oligodendrogliomas but that do not harbor 1p/19q loss-a question that cannot be answered at the present time. Furthermore, there seem to be correlations between histologic features and genotype in that oligodendrogliomas with classic histologic features are preferentially associated with 1p/19q loss (62). Such associations complicate any simplistic assessment of how to define these tumors.

One approach has been to perform 1p/19q analysis in those tumors that are difficult to classify histologically as either oligodendroglioma or oligoastrocytoma. In most neuropathology practices, such diagnostically challenging cases are not uncommon. Furthermore, in our experience reviewing tumors called oligodendroglioma by general pathologists, we have found that knowledge of 1p/19q status can provide a method for training one’s eye to recognize more classical oligodendrogliomas and, therefore, to homogenize the diagnosis of oligodendroglioma somewhat (63); setting such standards can be useful and can counter the more indiscriminate use of the term “oligodendroglioma” by pathologists who do not want to miss a potentially chemosensitive tumor. In these diagnostic settings, it has been tempting to conclude that the presence of 1p/19q loss means that the tumor is an oligodendroglial neoplasm, and that the absence of 1p/19q loss means that it is not. Although we agree that assessment of 1p/19q status in such cases may provide information on prognosis and possibly on response to therapy, we do not advocate using the genetic information to change a histologic diagnosis. This may become the practice in the future if additional data supporting this approach were published, but there are no sufficient published data at the present time to do so.

Practically, if the goal of diagnosis is to stratify tumors for prognostic and predictive reasons, then one should place combined emphasis on both tumor histology and 1p/19q status. Indeed, this was the conclusion of the most recent World Health Organization Classification of Tumours of the Central Nervous System consensus meeting, which defined oligodendroglioma as “a diffusely infiltrating, well-differentiated glioma of adults, typically located in the cerebral hemispheres, composed of neoplastic cells morphologically resembling oligodendroglia and often harbouring deletions of chromosomal arms 1p and 19q.” (64).

Recommendations for Routine and Clinical Trial Testing: Prognostic Significance and Prediction of Therapeutic Sensitivity

The central issue with regard to 1p/19q testing in glioma patients is how results influence clinical decision making. Because analysis of 1p/19q has only been adopted within the past 10 years, many questions remain unanswered, and practice varies from institution to institution and from neuro-oncologist to neuro- oncologist. Nonetheless, there are data on usage from a recent survey of practicing neurooncologists, primarily in North America, who treat patients with anaplastic oligodendroglioma (65). Of the 93 respondents, 75.3% reported ordering 1p/19q testing on anaplastic oligodendroglioma patients 76% to 100% of the time; only 5.4% of the respondents never ordered 1p/19q testing. Thus, the test is widely and frequently used, and it is possible that the few neuro- oncologists not ordering the test may not have ready access to testing. This survey also cataloged therapeutic choices based on 1p/ 19q status in the same cohort of patients: either temozolomide, followed by radiation therapy; concurrent temozolomide/radiation therapy, followed by temozolomide; radiation, followed by temozolomide; or temozolomide only. In those patients whose anaplastic oligodendrogliomas had intact (i.e. no loss) 1p/19q, the most common treatment regimen from the respondents was concurrent temozolomide/ radiation, followed by temozolomide. On the other hand, in those patients whose anaplastic oligodendrogliomas had 1p/ 19q loss, the most common treatment regimen from the respondents was temozolomide alone. The specific reasons behind this therapeutic shift away from early radiation were not defined in the survey, but most neuro-oncologists have rationalized this shift by citing the potential neurotoxic effects of radiation, particularly in the setting of patients who have large tumors and/or are expected to have long survivals. Interestingly, for patients with loss of 1p but intact 19q, the therapeutic choices were intermediate between the 1p/ 19q loss and 1p/19q intact cases, perhaps as a result of the data showing that tumors with 1p loss/19q intact were sensitive to PCV chemotherapy but did not have as long survival rates as combined 1p/ 19q loss cases (27, 40). Therefore, although the optimal therapeutic courses for different genetic subsets of anaplastic oligodendroglioma have not been defined, the survey demonstrates that the results of 1p/19q testing are influencing therapeutic decisions in patients with anaplastic oligodendroglioma.

For low-grade oligodendrogliomas, the situation is even less defined. In our experience, we have seen the results of 1p/ 19q testing used for both prognostic and predictive purposes in different patient settings. For example, in the setting of a patient with a Grade II oligodendroglioma in which signs and symptoms (e.g. seizures) are well controlled, the finding of 1p/ 19q loss can be used as a rationale to watch such a patient carefully over time under the assumption that a low-grade oligodendroglioma with 1p/19q loss will be a very slowly growing tumor. On the other hand, in the setting of a symptomatic Grade II oligodendroglioma, the finding of 1p/19q loss can be used as a rationale for early treatment with temozolomide under the assumption that the tumor will likely display chemosensitivity. In such scenarios, therefore, use of the test is highly dependent on individual patient issues.

For oligoastrocytic tumors, the situation is also poorly defined. Many would argue, as shown in some articles (43), that those oligoastrocytic tumors with 1p/19q loss are more likely to behave like oligodendrogliomas, and that those with p53 alterations and 1p/ 19q intact are more likely to behave like astrocytomas. The corollary for treatment would be to take a more aggressive therapeutic approach for patients whose tumors have a more astrocytoma-like genotype than those that have a more oligodendroglioma-like genotype, but the issue has not been studied in any definitive manner. Again, in such settings, use of the test is highly dependent on individual neuro-oncologists’ practices and on individual patient issues.

For clinical trials of oligodendroglial tumors, 1p/19q testing is mandatory. An open question, however, is whether such testing should be used up front to guide placement into 1 treatment arm versus another or if such testing should be a retrospective analysis parameter. Clearly, stratification in any trial of oligodendroglioma needs to take into account 1p/19q status.

In summary, 1p/19q LOH testing plays a common role in the management of patients with oligodendroglial neoplasms, primarily by fine-tuning prognostic or predictive estimates. Current assays are robust, and the resulting information complements, but does not replace, histologic diagnosis. In our opinion, 1p/19q testing should be performed on all glial tumors suspected to have an oligodendroglial component, and the results linked to tumor histologic findings. Ongoing diagnostic issues include further molecular dissection of subgroups and the eventual development of consensus treatment paradigms.

MGMT Testing in Glioblastomas

Rationale and Evidence for Marker Relevance

Many chemotherapeutic agents used in the treatment of glioblastoma are alkylating agents. Although nitrosoureas such as lomustine and carmustine were the most common agents used in the past (66), there has been a marked shift in recent years to the oral imidazotetrazine derivative temozolomide. The primary mechanism of action of temozolomide is the addition of methyl groups to the O^sub 6^ position of guanine to produce lethal methylguanine adducts. The DNA repair enzyme MGMT reverses this process by repairing methylguanine adducts; MGMT effects a stoichiometric and irreversible transfer of the methyl group at the O^sub 6^ position of the modified guanine to a cysteine residue of MGMT, with restoration of the normal configuration of the nucleotide. Concurrently, the finite pool of cellular MGMT enzyme is gradually depleted in the presence of large amounts of O^sub 6^-modified guanine. As a result, inactivation of MGMT leads to a decreased ability to repair DNA and a corresponding increase in cytotoxicity. It has therefore been logically hypothesized that a decrease in MGMT expression would correlate with an increased sensitivity to such alkylating agents. In fact, O^sub 6^-benzylguanine, an irreversible inhibitor of MGMT that depletes tumor of MGMT activity, has been shown to enhance in vitro and in vivo cytotoxicity of alkylating agents against tumors (67), and this agent has been tested as a chemosensitizer in glioma patients (68, 69). Most significantly for this review, a body of literature supports the hypothesis that the level of tumor MGMT correlates with survival (70, 71) and with alkylating agent sensitivity in gliomas (72, 73). The latter predictive correlation is discussed below. In gliomas and other tumors, epigenetic silencing of MGMT gene transcription secondary to promoter hypermethylation, rather than gene mutation or deletion, has been observed as the major mechanism for MGMT inactivation (74, 75). At the protein level, however, MGMT protein expression is heterogeneous within tumors and within small regions of tumors, suggesting molecular heterogeneity as well. As discussed below, this heterogeneity complicates in situ interpretations of MGMT expression.

In 2005, a multinational collaborative trial reported that MGMT gene silencing predicted enhanced benefits in glioblastoma patients treated concurrently with radiotherapy and temozolomide (76). Conversely, patients with tumors not methylated at the MGMT promoter did not benefit as much from this therapy and showed only marginal improvement in median overall survival compared with radiotherapy alone. The authors concluded that knowledge of MGMT promoter methylation status could help guide decision making: adjuvant temozolomide would be incorporated into the standard treatment regimen for patients whose glioblastomas had methylated MGMT promoters, but potentially withheld from patients whose glioblastomas did not have methylated MGMT promoters. This would help to minimize unnecessary hematopoietic toxicity in the patient population least likely to derive therapeutic benefit from temozolomide (76). Another recent study suggested that MGMT promoter methylation status was useful in predicting temozolomide responsiveness in low-grade gliomas and highlighted the possibility of applying MGMT testing in patients with lower-grade gliomas (77).

Status of Assays

O^sub 6^-Methylguanine DNA methyltransferase promoter methylation status has been evaluated primarily via methylation-specific PCR (MSP) of sequences within the CpG-rich MGMT promoter region. Methylation-specific PCR relies on the differential susceptibility of methylated versus unmethylated cytosines to sodium bisulfite modification, which leads to selective amplification with primers specific to either the originally methylated or unmethylated sequence (Fig. 3A) (78). Methylation-specific PCR lends itself to routine laboratory testing, and can be used on DNA from formalin- fixed paraffin-embedded tissue. Nevertheless, the technique remains highly dependent on tissue quality and quantity, the specificity of the primers selected, the adequacy of bisulfite treatment, and PCR conditions. In addition, the inherent heterogeneity of glioblastomas also makes interpretation problematic; it is not uncommon to see amplification of both methylated and unmethylated MGMT promoter sequences in the same specimen, which may represent tumor cell heterogeneity or the presence of nonneoplastic cells.

For the above reasons, laboratory testing for MGMT promoter methylation is not straightforward. Nonetheless, given the use of MSP to evaluate other disease loci such as promoter hypermethylation of the mismatch repair gene MLH1 in patients with sporadic colorectal cancer (79), optimization and standardization of MGMT MSP assays should be possible (80). There are also several other bisulfite-based analytic techniques, including quantitative MSP, bisulfite sequencing, methylation-sensitive single-strand conformation analysis, and mass spectrometric-based quantitative analysis, and some have been used to analyze MGMT (78, 81, 82).

Because transcriptional silencing is the end result of promoter methylation, examination of MGMT protein expression by immunohistochemistry would seem a logical approach to MGMT analysis (Fig. 3B). This has the further advantages of being relatively inexpensive and able to be performed in any clinical diagnostic laboratory (83-85). Unfortunately, there is marked intratumoral heterogeneity for MGMT immunoreactivity in a substantial number of malignant gliomas that complicates interpretation. Although it is possible to issue a report citing the percentage of positive cells in a given area, the significance of such numeric indices is not clear. Moreover, the immunohistochemical assays for MGMT are not necessarily robust or consistent, and some laboratories have not been successful in optimizing these assays for clinical use. Finally, although one would expect concordance between MGMT promoter methylation status and MGMT protein expression, discrepancies have been reported in gliomas (80, 86) and in other tumors as well (87, 88). In fact, other variables such as methylation dosage and methylation status of other regions of the MGMT gene also seem to contribute to transcriptional control (89, 90).

FIGURE 3. (A) O^sub 6^-Methylguanine DNA methyltransferase (MGMT). Methylation-specific PCR (MSP) of primary glioblastoma cases illustrating promoter hypermethylation (Case 1) and absence of methylation (Cases 2 and 3). In Case 1, PCR reaction using methylation-specific primers for the MGMT promoter generated amplification product equivalent in size to that of the positive control (+CON). Interestingly, primers specific to the unmethylated MGMT promoter sequence generated a faint band of amplification product in Case 1. This highlights the inherent heterogeneity of the cellular material used for MGMT MSP testing with mixtures of hypermethylated and unmethylated MGMT promoters. On the other hand, Cases 2 and 3 showed clearly the absence of MGMT promoter hypermethylation by the absence of products using methylation- specific primers but generation of PCR product identical in size to that of the negative control (-CON). (B) O^sub 6^-Methylguanine DNA methyltransferase immunohistochemistry. Tissue section from a glioblastoma specimen unmethylated at the MGMT promoter (by MGMT MSP) demonstrated concordant nuclear expression of the MGMT protein in tumor cells. However, MGMT immunoreactivity is heterogeneous in the tumor tissue. O^sub 6^-Methylguanine DNA methyltransferase immunoreactivity of the vascular cells act as internal positive control (magnification x200).

Recommendations for Routine and Clinical Trial Testing

As discussed above, MSP is currently the most established technique to assess MGMT and is the technique for which the most convincing clinical correlations have been reported (76). Going forward, a better understanding of the clinical impact of abrogation of MGMT expression via promoter hypermethylation will help to accelerate adoption of this test and immunohistochemical assessment in clinical practice.

Despite concerns about assay quality and significance, MGMT status at both the gene methylation and protein levels has been correlated with prognosis in patients with glioblastoma. However, because prognostic assessments in glioblastoma are typically not of major use (i.e. only implying modest differences in survival), MGMT testing is not typically undertaken for prognostic purposes. We would further argue that predictive testing for MGMT is also not ready for routine clinical implementation at the present time. Although the data have demonstrated differences in significance between the survival benefits conferred by temozolomide in patients whose glioblastomas have MGMT methylation versus those whose tumors lack MGMT methylation, there was a trend that nearly achieved significance (p = 0.06) for temozolomide benefit in patients whose tumors lacked methylation (76). Given that temozolomide is a well- tolerated oral agent and the only agent in the last 2 decades to show a definite survival benefit (91), it seems highly unlikely that temozolomide would be withheld from a patient whose glioblastoma lacked MGMT promoter methylation. One can argue that negative testing might enable a decision to stop temozolomide therapy in a patient whose tumor demonstrated radiologic progression during therapy, but that same decision might be reached as well on the basis of clinical and radiologic data. Therefore, it seems unlikely that MGMT promoter methylation assays will play an important predictive role until the time that an alternative chemotherapy to temozolomide exists. However, for clinical trials, particularly those that involve alkylating agents such as temozolomide, MGMT testing will be an important analysis parameter.

EGFR-PI3K Pathway Evaluation in Glioblastoma

Rationale and Evidence for Marker Relevance

Aberrant expression of proteins implicated in growth pathways is common in glioblastomas. Because many of these proteins are also potential targets for therapeutic intervention using specific molecular inhibitors, their detection may have significant predictive potential. Indeed, there have been dramatic successes using this approach in systemic cancers in recent years, as shown by the use of imatinib mesylate (Gleevec; Novartis, Basel, Switzerland), a small molecule tyrosine kinase inhibitor that preferentially targets the BCR-ABL fusion protein in chronic myelogenous leukemia and the C-KIT oncogene in gastrointestinal stromal tumor (92, 93), and the use the small molecule EGFR inhibitors gefitinib (Iressa; AstraZeneca, London, UK) and erlotinib (Tarceva; Genentech/OSIP, San Francisco, CA) nonsmall cell lung cancer (NSCLC) (94, 95). In NSCLC patients, EGFR inhibitors have marked effects in those tumors that harbor specific activating mutations in the EGFR gene (96, 97). The role of identifying such key translocations and mutations increasingly resides in the molecular diagnostics laboratory, and the rapid surge in the identification and validation of molecular targets with therapeutic and diagnostic potentials will increasingly act as the impetus to adopt these markers and to develop diagnostic assays in the clinical setting (98, 99). For glioblastoma, as discussed below, EGFR represents a logical target for such inhibitors, and, therefore, molecular evaluation of the EGFR pathway correspondingly represents a logical focal point for developing predictive markers in the setting of such inhibitors. Epidermal growth factor receptor has long been implicated in glioblastoma (100-103). Up-regulation of EGFR signaling through amplification of the gene or activating mutations is common in glioblastomas, occurring in approximately one third of cases (104). The unique EGFRvIII mutant, which is identified in half of those glioblastomas with EGFR amplification, seems to be a constitutively active receptor (105). Missense mutations may also be common within the exons encoding the extracellular domains of EGFR (106). Although such genetic changes seem frequent, most studies of both wild-type EGFR and the vIII mutant have not identified a clear prognostic role for EGFR status in the setting of glioblastoma. Nonetheless, as discussed below, there may be a predictive role for assessing EGFR at the genetic or protein level.

Epidermal growth factor receptor represents an attractive target for molecular inhibition for a number of reasons. One, the EGFRvIII mutant receptor is nearly unique to glioma cells, which makes it an ideal target (107). Two, EGFR amplification and overexpression, when present in glioblastomas, are often found in extremely high levels. Three, the recently described mutations in the extracellular domains of EGFR have been demonstrated in vitro to have oncogenic effects and also to convey sensitivity to a small molecule EGFR tyrosine kinase inhibitor (106). These features suggest that analysis of EGFR, at either a genetic or protein expression level, can provide information relevant to therapeutic response.

Complicating this simplistic assessment, however, is a complex and somewhat redundant signal transduction network that bridges EGFR at the cell surface to its eventual oncogenic effects in the nucleus. At least 1 key effector cascade is the PI3K pathway that involves a variety of key molecules known to be dysregulated in glioblastoma, notably AKT, mammalian target of rapamycin (mTOR), and phosphatase and tensin homolog (PTEN) (108). The complex interplay among these molecules and the extent of pathway redundancy may confound decision making based on simple molecular assays, especially with regard to which patient population might derive benefit from small molecule tyrosine kinase inhibitors. Nonetheless, 2 studies have identified relatively similar molecular changes that may correlate with response to EGFR inhibition in glioblastomas.

In 1 study, analysis of 41 glioblastomas showed 7 of 13 patients with tumors with diffuse EGFR immunopositivity and p-AKT immunonegativity (EGFR+/p-AKT-) responded clinically to erlotinib, whereas only 1 in 5 from the EGFR-/p-AKT- group responded (109). Epidermal growth factor receptor gene amplification or EGFR expression predicted responsiveness. However, AKT activation status as measured by phosphorylation (p-AKT) seemed to be a very powerful predictor of erlotinib response. In another report on 49 glioblastoma patients, tumors with coexpression of both the mutant EGFRvIII and PTEN showed statistically significant response to the kinase inhibitors erlotinib and gefitinib (110). Interestingly, this group did not demonstrate a significant relationship between EGFR gene amplification and clinical response. The assumption underlying these studies is that expression of these molecules equates with receptor activation. However, it is not clear if overexpression of wild-type EGFR has identical effects to overexpression of the vIII mutant, and the selection pressures that facilitate vIII mutation would suggest that vIII conveys an oncogenic advantage and that, as a result, these should not be biologically identical. Both articles additionally suggest that an intact PTEN-AKT pathway is necessary for clinical response to the inhibitors; erlotinib and gefitinib seem to be beneficial primarily in patients with low levels of activated AKT (p-AKT) and preserved expression of PTEN, both indicative of an intact PTEN-AKT pathway. Of note, tumors with PTEN loss are significantly more susceptible to targeted inhibition of mTOR, a downstream signal effector that is negatively regulated by PTEN (111).

The above data suggest that glioblastoma response to EGFR inhibitors is related to overexpression of wild-type or mutant EGFRvIII and to an intact PI3K-PTEN pathway. However, other reports fail to document therapeutic benefit from EGFR inhibitors in glioblastoma patients. Several gefitinib trials have demonstrated partial responses but no change in overall survival in glioblastoma patients (104, 112), and 1 Phase 2 erlotinib trial resulted in median progression-free survival of only 12 weeks (113). In addition, little diminution of EGFR phosphorylation, a marker of receptor activation determined by Western blotting, was noted in glioblastoma tissues obtained from patients treated with erlotinib and gefitinib (114). Thus, the role of predictive markers may be minimal unless clear responses to these therapies are observed in at least a small subset of glioblastoma patients.

It is also important to note that amplification and overexpression of EGFR as demonstrated by FISH or immunohistochemistry, expression of the vIII mutant of EGFR as shown by immunohistochemistry, and increased phosphorylation of EGFR and its downstream signaling partners as shown by protein analysis do not automatically equate to sensitivity to specific small molecule kinase inhibitors such as gefitinib, erlotinib, and newer generations of these compounds. Spatial filling into the tertiary kinase domain as determined by the unique activating mutations and interplay by the various downstream signal transducers may play equally important roles in predicting clinical response.

Status of Assays

At present, immunohistochemistry is the most convenient method for examining expression of EGFR and its signaling partners (Fig. 4B) (115, 116). For most pathology laboratories, immunohistochemistry is quick and can be incorporated into the normal clinical laboratory workflow. Notably, however, a survey of 5 commercially available EGFR antibodies on a panel of soft tissue sarcomas found that variations in the frequency of EGFR immunopositivity were dependent on the type of antibody and on the scoring scheme (117). In addition, although phospho-specific antibodies are capable of detecting phosphorylated and activated isoforms of the protein, as demonstrated by their use in p-AKT detection (109), immunohistochemistry based on phospho-specific antibodies require a high degree of optimization and careful interpretation (118). Clearly, ongoing clinical trials that incorporate immunohistochemistry testing of EGFR and its signaling partners should fully disclose the pertinent details of the experimental protocols to allow replication and standardization of the assays. At this time, clinical testing of components of the EGFR signaling pathway is not mature.

FIGURE 4. (A) Epidermal growth factor receptor (EGFR) fluorescence in situ hybridation (FISH). Dual-color FISH of a glioblastoma specimen showing amplification of the EGFR gene locus (numerous green signals per cell) in comparison to normal diploid control chromosome 7p copy number control probe (2 red signals per cell). (B) Epidermal growth factor receptor immunohistochemistry. A glioblastoma with amplification of the EGFR gene demonstrating strong immunoreactivity for cell surface as well as expression of EGFR protein. Endothelial cells function as internal negative controls (magnification x 400). Tissue used for photographs courtesy of Dr. Cathy Nutt, Massachusetts General Hospital, Boston, MA.

Fluorescence in situ hybridization remains the most widely used method for assessment of EGFR gene copy number, with most laboratories scoring cases as amplified or nonamplified (115). In addition, the assay is robust and straightforward to develop and perform in any laboratory familiar with FISH (Fig. 4A). In comparison to immunohistochemistry, as outlined previously and in Table 2, FISH places greater demand on the resources of the pathology laboratory, and there are discrepancies between EGFR gene amplification as determined by FISH and increased EGFR expression by immunohistochemistry (119, 120). Reconciliation of the differential findings and further in-depth exploration of the mechanisms underlying EGFR gene amplification should help to clarify the use of both techniques. It is not inconceivable, as is current practice, to rely on results of both techniques for making treatment decisions.

Recommendations for Routine and Clinical Trial Testing

The paradigm illustrated by the EGFR story-in the setting of NSCLC response to molecular inhibitors in the presence of EGFR gene mutation and in the possible setting of glioblastoma response to molecular inhibitors in the presence of EGFR overexpression and intact downstream pathways-is perhaps the most exciting in current neurooncology. The paradigm elegantly combines a known biologic mechanism with a specific molecular inhibitor and a reasonable laboratory technique for evaluation of the relevant marker. Indeed, such studies should be a routine component of all clinical trials using molecular inhibitors. However, the marker assays evaluated as part of these trials must be as comprehensive as possible and must be as clearly reported as possible to derive the most useful translational information from such trials.

For current diagnostic applications, it is hard to recommend such testing in a routine predictive situation because practical problems prevent widespread adoption of these assays. These include availability of antibodies, interpretation of results, reproducibility of the assay, and, most importantly, how much actual therapeutic benefit can be realized from identification of these molecules in subsets of glioblastoma patients. Practically, the high cost of many of the novel therapeutics demand the accurate and precise identification of responsive patient populations, and this should propel continual development of novel and better diagnostic techniques and the search for biomarkers in these biologically important pathways. However, at the present time, evaluation of these markers should be reserved for the trial situation. SUMMARY

The potential clinical significances of 1p/19q loss, MGMT promoter hypermethylation, and aberrations in EGFR signaling pathways have raised the possibility of molecular tailoring of glioma therapy (121). We summarize our recommendations in Table 3. Briefly, 1p/19q testing is widely used to assess prognosis and manage patients, to guide clinical trials, and, less accurately, to establish diagnoses; 1p/19q assays are robust but not based on biologic knowledge of distinct pathways or molecules. Testing for MGMT promoter hypermethylation is based on a sensible hypothesis and should be incorporated into clinical trials, but optimal assays are uncertain and not standardized among different laboratories. Finally, evaluation of the EGFR-PI3K-PTEN signaling cascade is based on an elegant biologic rationale, but the inherent complexity of the signaling pathway makes it difficult to expect a single assay to serve as a simple readout, and practical issues prevent robust testing at the present time. Moreover, such approaches may only be relevant in the context of specific molecular inhibitors of this pathway. The most important feature of this latter observation, however, is that it established an important paradigm for how particular molecular parameters may reflect the likely effects of particular molecular inhibitors. In this regard, ongoing drug discovery and the rollout of new designer compounds will place additional pressure on designing new diagnostic assay to identify patient subsets who might respond to the new therapies. Nonetheless, this approach represents the future of personalized targeted medicine.

There will clearly be increasing pressure on the neuropathologist to adopt novel molecular tests. However, the neuropathologist has a duty to be the practical and critical decision point for assay implementation. The neuropathologist must be familiar with the issues surrounding molecular assays, as well as the clinical, financial, and societal ramifications if new assays are instituted. Indeed, the era of personalized molecular medicine places the neuropathologist in an exciting role, but one that demands a considerable degree of responsibility.

TABLE 3. Recommendations for Molecular Markers in Malignant Gliomas

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Effect of Liquid Pancreatic Enzymes on the Assimilation of Fat in Different Liquid Formula Diets

By Hauenschild, Annette Ewald, Nils; Klauke, Thorsten; Liebchen, Ariane; Bretzel, Reinhard Georg; Kloer, Hans-Ulrich; Hardt, Philip Daniel

ABSTRACT. Background: In some diseases, patients require high- calorie tube feeding with standard enteral formulas usually administered via temporal feeding tubes. One frequent pathophysiological condition in a relevant number of these patients is exocrine pancreatic insufficiency. Patients unable to swallow capsules might benefit from a liquid pancreatic enzyme (LPE) preparation. Methods: LPEs were prepared and mixed with different commercially available formula diets produced for enteral feeding. Lipolysis was then measured by fatty acid titration. Results: Complete lipolysis by liquid enzyme preparations was observed in diverse formula diets. Fat assimilation was even complete when LPE had been prepared 3.5 hours before the experiments, showing that the enzymes had been stable up to that time. Conclusions: The use of LPEs seems to be a good therapeutic option in patients with exocrine pancreatic insufficiency and the need for permanent high-calorie enteral feeding. Pharmaceutical companies should therefore be further encouraged to develop and distribute liquid enzyme preparations. (Journal of Parenteral and Enteral Nutrition 32:98- 100, 2008) The therapy of patients with short bowel syndrome, cystic fibrosis, several neurologic diseases, and acute and chronic pancreatitis, as well as the therapy of intensive care patients include high-calorie tube feeding with standard enteral formulas. These diets are usually administered via feeding tubes, specifically percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic jejunostomy (PEJ).

However, a frequent pathophysiological condition that can be found in a number of these patients is exocrine pancreatic insufficiency, which leads to a relevant malassimilation of the fat contents in these diets. Especially in cystic fibrosis and chronic pancreatitis, exocrine insufficiency is a frequent finding, which is treated by pancreatic enzyme replacement therapy.1-3 Different forms of enzyme-containing drugs are currently commercially available. Yet all of them are packed in the form of capsules, which cannot be administered via feeding tubes. Therefore, the enzymes have to be swallowed, which can only be achieved in conscious and awake patients. However, some of the patients requiring enzyme replacement therapy are unable to swallow, and many of them even require continuous overnight feeding. These patients might benefit from a liquid pancreatic enzyme (LPE) preparation.

Several years ago, we reported the successful use of an LPE preparation for a patient with short bowel syndrome and exocrine pancreatic insufficiency.4 Thus, we investigated the assimilation of fat-containing standard liquid formula diets in vitro by LPE preparation.

MATERIALS AND METHODS

LPEs were prepared dissolving 1 g of pancreatin powder in 100 mL of 0.2% NaCl. The solution was then filtered through sterile gauze swabs (Fuhrmann GmbH, Much, Germany) to remove undissolved proteins. The pancreatin powder (Pankreon; Solvay Pharmaceuticals, Hannover, Germany) contained different amounts of lipase (312 U/g, 625 U/g, 1250 U/g, 2500 U/g, 5000 U/g). Then 2 mL of LPE were mixed with 10 mL of different commercially available formula diets produced for enteral feeding. Lipolysis was measured by fatty acid titration5: the pH was kept stable at pH 7 by neutralizing emerging fatty acids with NaOH titration. Lipolysis was calculated according to NaOH consumption (molar equivalent, mE) and fat content of the formula diets as declared by the manufacturers.

The following formulas were investigated (Table I):

* Fresubin Survimed OPD 2.4 g fat per 100 mL

* Fresubin Flussig 3.4 g fat per 100 mL

* Fresubin Supportan 7.2 g fat per 100 mL

* Fresubin Plussonde 3.4 g fat per 100 mL

* Pulmocare 9.2 g fat per 100 mL

* Nutricomp Immun 3.7 g fat per 100 mL

The experiments were performed at 37[degrees]C with or without the addition of bile acids (“Galle dispert”; KaliChemie Pharma GmbH, Hannover, Germany; 2 mL/2 minutes up to 16 mL) and with or without addition of calcium chloride (2 mol/L; 2 mL). Each titration experiment was performed for up to 20 minutes.

TABLE I

Fat content, protein:fat:carbohydrate relation, and manufacturer of the used formula diets

RESULTS

Pulmocare

Ten milliliters of Pulmocare containing 9.2 g of fat per 100 mL was used. For 100% lipolysis, 1.95 mE of NaOH was calculated to be needed. Sixteen milliliters of bile (15 mmol/L) and 2 mL of CaCl (2 mol/L) were added. Complete lipolysis was observed using 5000 U, 2500 U, and 1250 U of lipase at different time points (Table II).

Pulmocare Using LPE After 3.5 Hours

Ten milliliters of Pulmocare containing 9.2 g of fat per 100 mL was used. For 100% lipolysis, 1.95 mE of NaOH was calculated to be needed. Sixteen milliliters of bile (15 mmol/L) and 2 mL of CaCl (2 mol/L) were added. LPEs had been prepared 3.5 hours before the experiment using 5000 U of lipase. Complete lipolysis was observed after 5 minutes.

Fresubin Flussig

Ten milliliters of Fresubin Flussig containing 3.4 g of fat per 100 mL was used. For 100% lipolysis, 0.75 mE of NaOH was calculated to be needed. Sixteen milliliters of bile (15 mmol/L) and 2 mL of CaCl (2 mol/L) were added. Complete lipolysis was observed in all LPEs but 312 U of lipase (Table II).

Fresubin Survimed

Ten milliliters of Fresubin Survimed containing 2.4 g of fat per 100 mL was used. For 100% lipolysis, 0.692 mE of NaOH was calculated to be needed. Sixteen milliliters of bile (15 mmol/L) and 2 mL of CaCl (2 mol/L) were added. Complete lipolysis was observed in all LPEs used (Table II).

TABLE II

Lipolysis of fat in different formula diets using different amounts of lipase

Fresubin Supportan

Ten milliliters of Fresubin Suppotan containing 7.2 g of fat per 100 mL was used. For 100% lipolysis, 1.6 mE of NaOH was calculated to be needed. Sixteen milliliters of bile (15 mmol/L) and 2 mL of CaCl (2 mol/L) were added. Complete lipolysis was observed using 5000 E and 2500 E of lipase (Table II).

Fresubin Plus Sonde

Ten milliliters of Fresubin plus Sonde containing 3.4 g of fat per 100 mL was used. For 100% lipolysis, 0.75 mE of NaOH was calculated to be needed. Sixteen milliliters of bile (15 mmol/L) and 2 mL of CaCl (2 mol/L) were added. Complete lipolysis was observed in all LPEs used (Table II).

Nutricomp Immun

Ten milliliters of Nutricomp Immun containing 3.7 g of fat per 100 mL was used. For 100% lipolysis, 0.94 mE of NaOH was calculated to be needed. Sixteen milliliters of bile (15 mmol/L) and 2 mL of CaCl (2 mol/L) were added. Complete lipolysis was observed in all LPEs used except for 321 U of lipase (Table II).

DISCUSSION

Pancreatic enzyme replacement therapy is a well-accepted treatment that is necessary in a number of diseases accompanied by exocrine pancreatic insufficiency. To date, it has been well established in chronic pancreatitis and cystic fibrosis.1-3 However, it has been difficult to supply pancreatic enzymes with the formula diets in patients needing high-calorie enteral feeding because patients have to swallow the pancreatin preparations in the form of capsules. In many situations (eg, need of permanent continuous [24 hours] tube feeding or enteral nutrition via jejunal tube in pancreatitis), patients cannot therefore be supplied with adequate doses of enzymes.

Some time ago, we reported the successful use of an LPE preparation in a single case of short bowel syndrome in Crohn’s disease, with consequent exocrine insufficiency.4 Clinical results were promising. In order to investigate how long the enzymes are working and whether complete lipolysis of the fat contents in standard formula diets can be achieved, we performed the present in vitro experiments.

In this study, we could demonstrate complete lipolysis by liquid enzyme preparations in diverse formula diets. Fat assimilation was even complete when LPE had been prepared 3.5 hours before the experiments, showing that the enzymes were stable up to this time. Our experience using this technique in single patients suggests no adverse events or side effects.4 Thus, the use of LPE seems to be a good therapeutic option in patients with exocrine pancreatic insufficiency and need of permanent high-calorie enteral feeding.

Patients with severe acute pancreatitis are another subgroup of patients in definite need of high-calorie enteral feeding administered distal to the pancreas.6 Formula diets administered via jejunal feeding tubes, together with LPE solutions, could ensure high-calorie enteral feeding in this special group of patients.

Generally speaking, the suggested route of administration is jejunal feeding because intragastric administration might in all likelihood result in digestion of the used enzymes. According to our results, it seems reasonable to adjust the dosing of LPEs to the fat content and composition of the used formula diet. Concerning the timing of lipolysis, we recommend administration of the enzymes together with the formula diet as a freshly prepared premixed solution, yet a simultaneous administration of the formula diet and the LPE solution seems possible as well.

In the meantime, it has even become possible to prepare LPEs that are stable for several months (M. Galle, Solvay, oral communication, March 2006). Yet one must remember that long-term stability and sterility have not been adequately studied, and further research in this field is necessary to establish appropriate guidelines for LPE storage and use. Pharmaceutical companies are further encouraged to develop and distribute LPEs for use in this special group of patients.

ACKNOWLEDGMENTS

The authors thank Solvay Pharmaceuticals, Hannover, Germany, for providing the Pankreatin powder.

REFERENCES

1. Baker SS, Borowitz D, Duffy L, Fitzpatrick L, Gyamfi J, Baker RD. Pancreatic enzyme therapy and clinical outcomes in patients with cystic fibrosis. Pediatrics. 2005;146:189-193.

2. Anthony H, Collins CE, Davidson G, et al. Pancreatic enzyme replacement therapy in cystic fibrosis: Australien guidelines. Paediatr Child Health. 1999;35:125-129.

3. Layer P, Keller J, Lankisch P. Pancreatic enzyme replacement therapy. Curr Gastroenterol Rep. 2001;3:101-108.

4. Hardt PD, Helfrich C, Klauke T, Kloer HU. Liquid pancreatic enzyme therapy for a patient with short bowel syndrome and chronic pancreatitis in a complicated case of Crohn’s disease. Eur J Med Res. 1999;4:345-346.

5. Nilsson NO, Belfrage P. Continuous monitoring of free fatty acid release from adipocytes by pH-stat titration. J Lipid Res. 1979; 20:557-560.

6. Meier R, Ockenga J, Pertkiewicz M, et al. ESPEN guidelines on enteral nutrition: pancreas. Clin Nutr. 2006;25:275-284.

Annette Hauenschild, PhD; Nils Ewald, MD; Thorsten Klauke, MD; Ariane Liebchen, PhD; Reinhard Georg Bretzel, MD; Hans-Ulrich Kloer, MD; and Philip Daniel Hardt, MD

From the Third Medical Department, University Hospital Giessen und Marburg, Giessen, Germany

Received for publication April 3, 2007.

Accepted for publication June 15, 2007.

Correspondence: Nils Ewald, MD, Third Medical Department, University Hospital Giessen and Marburg, Giessen Site, Rodthohl 6, D- 35392 Giessen, Germany. Electronic mail may be sent to [email protected].

Copyright American Society for Parenteral and Enteral Nutrition Jan/ Feb 2008

(c) 2008 JPEN, Journal of Parenteral and Enteral Nutrition. Provided by ProQuest Information and Learning. All rights Reserved.

New Thermometer Reduces Foot Ulcers in Diabetics

New research indicates an increase in temperature on the foot of a diabetic can be a sign of a developing ulcer that could lead to amputation.  However, diabetics can prevent foot ulcers and their complications by monitoring the temperature of their feet with a special, user-friendly thermometer.

The thermometer, called TempTouch and developed by Xilas Medical, costs about $150, and uses an infrared tip that digitally measures skin temperature on contact.

In a government-funded study of 225 diabetic veterans, the thermometer reduced by two-thirds the number of high-risk patients who developed foot ulcers.

The thermometer works by measuring the small variations in temperature between different parts of the foot, between the right middle toe and the left, for example.   These small temperature differentiations occur days before the skin breaks with an ulcer.  

To monitor foot temperature, diabetics would measure several spots on each foot.  When the thermometer finds a hot spot, the patient would elevate their feet for about a day until the temperature returns to normal.  This reduces pressure and allows the body to heal more easily that it otherwise would if the skin had cracked.

Over half a million diabetics are stricken with foot ulcers each year, but some fail to even notice the ulcers because the diabetes has numbed their feet.  Once they develop, foot ulcers heal slowly, and are susceptible to infections.   These complications are responsible for approximately 80,000 amputations of toes, feet and lower legs each year.

With the TempTouch, diabetics can detect hot spots in both feet and allow the temperature to normalize before the skin cracks and become a full-blown wound.

 “A wound really will heat up before it breaks down,” said Dr. David Armstrong of Chicago’s Rosalind Franklin University of Medicine and Science, a diabetic foot specialist, in an Associated Press article.  “Heat is one of the most sensitive things, one of the first things that happens when we begin to have tissue breakdown,”

In addition to developing the handheld TempTouch thermometer,  Xilas Medical has received a National Institutes of Health grant to make a new version of the thermometer that would resemble a bathroom scale.  The new thermometer would automatically measure skin temperature on the bottom of patients’ feet and immediately alert the patient of any trouble spots.   

However, availability of the scale-like thermometer is still a few years out, and for now the TempTouch can only be obtained with a prescription.

An estimated 21 million people have diabetes.  Complications include damaged blood vessels and nerves from years of uncontrolled, high glucose levels.  This damage often leads to poor lower body circulation and loss of sensation in the feet, both of which contribute to the development of foot ulcers.

Prevention has traditionally been difficult, with patients using visual inspection and wearing proper fitting shoes in an attempt to avert foot ulcers.  

Dr. Theresa Jones, who leads research on diabetes complications at the National Institutes of Health, told Associated Press that while the study results are compelling, larger studies should be included to prove the long-term benefit.  

The study was funded by the Department of Veterans Affairs and published in last month’s American Journal of Medicine.   

On the Net:

Xilas Medical

Radiation Therapy Oncology Group (RTOG) Selects VisionTree Optimal Care(TM) to Collect Quality of Life Patient Outcomes Data

VisionTree®, the leader in Web-based patient-centered health record management and provider communication systems, announced today that the Radiation Therapy Oncology Group (RTOG) through the American College of Radiology selected its VisionTree Optimal Care™ (VTOC) platform for collecting quality of life patient outcomes data for a pilot study conducted by the RTOG. RTOG will use the system at a select number of member institutions for a prostate cancer study in order to improve the compliance of the data collection, validation and reporting processes.

“Clinical research typically has its greatest challenges in collecting patient-completed information, since it is usually done through a paper or phone survey,” said Benjamin Movsas, M.D., Chair of Radiation Oncology at Detroit’s Henry Ford Hospital and Principal Investigator of an RTOG pilot study testing the VTOC system. “VTOC offers us the ability to move this process to an electronic format through a secure Web portal to collect data in a faster and more compliant manner. The platform also allows us to deliver relevant information to the patient including reminders, education material and study information more effectively in order to manage their treatment. VTOC is a system whose time has come.”

VTOC’s user-friendly, HIPAA-secure, Web-based platform allows consenting patients to fill out their quality of life forms in real-time from any location that has Internet access, including their home. The system can also send patients reminders via e-mail or text messaging to increase the likelihood of their on-going participation.

“VTOC will be an important part of our analysis of prostate cancer patients, and will be used by 15 sites to pilot the use of a Web-based data collection and communication in clinical trials, including the Mayo Clinic in Rochester, Minnesota and Washington University at St. Louis,” said Deborah Bruner, Ph.D., RTOG Outcomes Committee Chair and Quality of Life co-chair of the study as well as Director, Recruitment, Retention and Outreach Core Facility, Abramson Cancer Center of the University of Pennsylvania. “Since many people are familiar and comfortable with Internet applications, we estimate that the system will provide us an increase in patient participation over the ‘pad and pencil’ survey program that’s in place now. That means the quality of our data will be even more credible and usable.”

VTOC is fully compliant with Title 21, Part 11 of the Code of Federal Regulations (CFR) statistical process control system pertaining to electronic records and signatures. The platform can collect outcomes data by exporting Microsoft® Excel® with PDF™ reports, and can “push” the survey to patients for completion at timed intervals with reminders and education material, if desired.

“VTOC is a win-win for both healthcare consumers and providers,” said Martin Pellinat, CEO of VisionTree. “The system empowers patients to provide important feedback directly with their physician electronically, as well as build their own personal health record to help make the best decisions at the most critical times. VTOC will also serve as the vehicle to transform the medical industry into a true paperless environment, increasing staff’s productivity and data gathering capabilities to effectively measure patient satisfaction. With more than 100,000 users, VTOC is improving the way healthcare is offered.”

About the RTOG and ACR:

The Radiation Therapy Oncology Group (RTOG) is a clinical research enterprise of the American College of Radiology (ACR), located in the ACR Philadelphia, PA office. RTOG is a multi-institutional clinical cooperative group funded by the National Cancer Institute. RTOG has over 35 years of experience in conducting clinical trials and is comprised of over 290 major research institutions in the United States and Canada. The group currently is conducting more than 30 active studies that involve radiation therapy alone or in conjunction with surgery and/or chemotherapeutic drugs or which investigate quality of life issues and their effects on the cancer patient.

The American College of Radiology (ACR) is a national professional organization serving more than 32,000 radiologists, radiation oncologists, interventional radiologists and medical physicists with programs focusing on the practice of radiology and the delivery of comprehensive health care services.

About VisionTree®:

VisionTree Software, Inc. is the leader in Web-based patient-centered health record management, communication and data collection systems. VisionTree’s Healthcare Solutions consist of VisionTree Optimal Care™ or VTOC, VisionTree Outcomes Online™ and VisionTree Clinical Trials™ for Web-based data collection, efficient workflow, as well as improved communication, documentation and quality of care. VisionTree’s customer base consists of leading academic and community healthcare organizations across the country. For more information, visit www.visiontree.com.

© 2008 by VisionTree, Inc. All rights reserved.

CNS Response, Inc Completes Neuro-Therapy Clinic Acquisition; Names Daniel A. Hoffman, MD Chief Medical Officer

COSTA MESA, Calif., Jan. 15 /PRNewswire-FirstCall/ — CNS Response, Inc. (BULLETIN BOARD: CNSO) announced today that it has completed the previously announced acquisition of Neuro-Therapy Clinic, P.C., a neuropsychiatric clinic in Denver, Colorado. The Company also announced that Daniel A. Hoffman, MD has been appointed Chief Medical Officer. Dr. Hoffman, a neuropsychiatrist with more than 25 years experience, was previously National Medical Director of Neuro-Therapy Clinic.

Len Brandt, Chairman and CEO of CNS Response, reported, “Our close relationship with Dr. Hoffman and the Neurotherapy Clinic has already played a significant role in establishing the value of rEEG(R) guidance in medication management.”

George Carpenter, President of CNS Response, commenting on the future, said, “We expect Neuro-Therapy Clinic to further define the opportunity to use technology in general, and rEEG in particular, to vastly improve clinic performance in patient outcomes, costs, and convenience and to best communicate this to all — patient, physician, payer. In this way, the Neuro-Therapy Clinic is something of a dynamic laboratory discovering how to integrate technology and be a true center of excellence on all of these measures. Put to practice, this knowledge presents CNS Response with an opportunity to further our relationship with other clinics and physicians using rEEG.”

“Dr. Hoffman is a leader and a true partner in the development of rEEG so we are particularly pleased to have him join our team,” Mr. Brandt continued. “Dr. Hoffman will play a critical role in implementing our strategy for the validation and commercialization of our core rEEG platform.”

Established in 1993, Neuro-Therapy Clinic, P.C. is a center for highly-advanced testing and treatment of neuropsychiatric problems, including learning, attentional and behavioral challenges, mild head injuries, as well as depression, anxiety, bipolar and all other common psychiatric disorders.

Dr. Hoffman served as Medical Director for Neuro-Therapy Clinic from 1993-2007. He also served as National Medical Director for CNS Response from 2004-2007 and has maintained a private practice in neuropsychiatry since 1977. He served as an Assistant Clinical Professor at the University of Colorado from 1977 to 1996.

Dr. Hoffman has lectured extensively throughout the country on leading-edge testing and treatment for Psychiatric Medication Selection and other brain related topics and has been published in more than 30 peer-reviewed articles. He is on the editorial boards of the Journal of Neurotherapy, the Journal of Applied Psychophysiology and Self Regulation and the Journal of Neuropsychiatry and Clinical Neurosciences.

About CNS Response

CNS Response is a life-sciences data company focused on the commercialization of the first patented commercial system that guides psychiatrists and other physicians to determine proper treatments for patients with behavioral (mental or addictive) disorders. This technology allows CNS Response to create and provide simple reports (“rEEG(R) Reports”) that specifically guide physicians to treatment strategies based on the patient’s own physiology.

rEEG(R) utilizes traditional electroencephalography (EEG) in conjunction with a normative database and a proprietary clinical (symptomatic) database to identify the following: (1) medication classes most likely to be needed; and (2) medications within these classes with the most probable treatment potential for each patient. Reports are provided to physicians in a relationship analogous to that of a reference laboratory. Prospective, retrospective and field studies of treatment-resistant patients have reported treatment success of 70% or greater in managed care, outpatient psychiatric and residential substance abuse clinical settings.

In addition to providing analytical support to physicians, CNS Response is also an aide to pharmaceutical developers, who can use rEEG to (1) stratify study populations to improve the success of FDA clinical trials; (2) provide insight on effective therapeutic dosing of investigational drugs; (3) identify additional indications for psychiatric medications; (4) provide insight into effective drug combinations; and (5) discover opportunities for decision analytics and support. In addition to these applications, CNS Response continues to investigate the use of rEEG analysis for development of proprietary pharmaceutical opportunities.

Safe Harbor Statement Under the Private Securities Litigation Reform Act of 1995

Except for the historical information contained herein, the matters discussed are forward-looking statements made pursuant to the safe harbor provisions of the Private Securities Litigation Reform Act of 1995, as amended. These statements involve risks and uncertainties as set forth in the Company’s filings with the Securities and Exchange Commission. These risks and uncertainties could cause actual results to differ materially from any forward-looking statements made herein.

   Contacts:    Investor Relations:   Sara Ephraim   (646) 536-7002   [email protected]    Media:   Jason Rando / Jennifer Saunders   (646) 536-7033 / 7011   [email protected]   [email protected]  

CNS Response, Inc.

CONTACT: Investor Relations: Sara Ephraim, +1-646-536-7002,[email protected], or Media: Jason Rando, +1-646-536-7033,[email protected], or Jennifer Saunders, +1-646-536-7011,[email protected], all of The Ruth Group, for CNS Response, Inc.

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

Cummins Opens New Health Center for Employees, Families

Cummins (NYSE:CMI) is opening a new onsite Health Center at its Cummins Filtration facility in Cookeville, Tenn. where employees and their families will have convenient access to primary medical care.

The Cummins Health Center opens Wednesday, Jan. 16 with a ribbon-cutting ceremony and an open house so that employees can meet the staff and tour the facility. The center, which will be staffed with health professionals from 8:30 a.m. to 4:30 p.m. week days, will offer routine primary medical care including annual physical examinations, vaccinations for children and adults, and blood pressure and cholesterol screenings.

Cummins contracted with CHD Meridian, a national onsite medical provider of occupational and primary medical care services based in Nashville, Tenn. CHD Meridian will staff and manage the facility and to ensure quality of care. Employees will pay a discounted fee for services at the center, which is located on the plant campus.

“We’re very excited about providing high-quality, convenient and affordable care to our employees and their families,” said Raymond Higgs, Health and Safety Manager at the Cummins Filtration Cookeville location. “It encourages our people to get the care they need when they need it.”

The opening of the Cummins Health Center is one example of the Company’s commitment to providing employees with high-quality health care.

“Having easy access to quality health care benefits our employees and Cummins,” said Pamela Carter, President of Cummins Filtration. “We are proud to offer this benefit to our employees so that they can receive necessary preventive and routine care through this high-quality health center.”

Cookeville is the first location within Cummins to offer a health center providing primary care. Cummins expects to open additional health centers with primary care services in the future.

About Cummins

Cummins Inc., a global power leader, is a corporation of complementary business units that design, manufacture, distribute and service engines and related technologies, including fuel systems, controls, air handling, filtration, emission solutions and electrical power generation systems. Headquartered in Columbus, Indiana, (USA) Cummins serves customers in more than 160 countries through its network of 550 Company-owned and independent distributor facilities and more than 5,000 dealer locations. Cummins reported net income of $715 million on sales of $11.4 billion in 2006. Press releases can be found on the Web at www.cummins.com.

About Cummins Filtration

Cummins Filtration Inc. is a wholly owned business unit of Cummins Inc. and the world’s leading designer and manufacturer of air, fuel, hydraulic and lube filtration, chemicals and exhaust system technology products for all engine-powered equipment. Cummins Filtration cares about maintaining a cleaner, healthier, and safer environment. Going beyond compliance, Cummins Filtration proactively seeks improvements to products and processes and offers environmentally friendlier product choices for all major engine systems. The company’s homepage can be found at cumminsfiltration.com. In North America, customers can call Cummins Filtration Customer Assistance at 1-800-22FILTER (1-800-223-4583) for more information.

Many Blacks Remain Wary of Clinical Trials

Many African-American patients refuse to join medical studies because they fear they will be lied to and harmed by scientists who view them as human guinea pigs, according to a study by Johns Hopkins researchers.

Confirming the observations of many researchers, the study might explain why clinical trials of new therapies fail to enroll enough black participants — and why trials might fail to predict how blacks will react to new drugs and medical devices.

Incidents such as the Tuskegee study — the infamous 40-year experiment in which researchers withheld treatment from black men with syphilis — have left many blacks wary of doctors and medical research, the Hopkins researchers concluded.

“African-Americans are twice as likely to perceive harm in clinical trials than whites,” said Dr. Neil R. Powe, a professor of medicine at Johns Hopkins and lead author of the study, “and that accounts for their unwillingness to participate in medical research.”

Other experts agreed that some African-Americans fear exploitation and urged researchers to allay those concerns by doing a better job of communicating the risks and benefits of medical research.

“While distrust is an issue, you have to ask yourself why is there still distrust,” said Dr. Claudia R. Baquet, director of the University of Maryland’s Center for Health Disparities. “One of the problems is physicians don’t discuss clinical trials with their patients. People don’t feel like they can make an informed decision about participating.”

One recent study of 14 million cancer patients in the United States, for instance, found that while 3 percent to 4 percent of all patients participated in a clinical trial, only 0.5 percent of African-Americans patients participated.

Although researchers often cite distrust of the medical establishment as the reason blacks avoid studies, until now that opinion has been based mostly on anecdotal reports by doctors and researchers, Powe said.

“We thought we knew, but no one had made that direct link,” he said.

To test whether African-Americans were indeed more fearful of medical research than whites, Powe and his colleagues surveyed 717 outpatients at 14 Maryland clinics. Of the respondents, 36 percent were black and the rest white.

When asked if they would participate in a mock study of a heart disease drug, black men and women were only 60 percent as likely as whites to agree to participate.

Blacks were also more distrustful of doctors than whites were. For instance, 58 percent of black patients felt their physicians would willingly give them experimental drugs without their consent, compared with 28 percent of whites.

Similarly, 25 percent of blacks but only 15 percent of whites said their doctors would ask them to participate in a risky study.

This distrust means that fewer blacks participate in research, Powe said, and as a result, studies might miss important biological differences in how people of different races respond to new medical therapies.

“If we don’t test therapies in certain populations, how can we expect to know anything about whether they work in those populations?” Powe said. The results of his study were published online yesterday in the journal Medicine.

Wayne Bridge, 52, a retired African-American state trooper who lives in Baltimore, traced the origins of his general wariness to slavery. “After that little Carnival Cruise we enjoyed from Africa, maybe that plays a role in the attitude,” he said.

Harriet A. Washington, the author of Medical Apartheid, a book published last year on the history of medical experimentation on African-Americans, said that the medical establishment’s reputation for misleading blacks is deserved.

Among Washington’s assertions: Sick black slaves in the 1800s were sold to doctors for experimentation, doctors sterilized blacks without their consent after the Civil War, and African-American patients were subjected to deadly, experimental doses of radiation in the 1950s.

“There is a long, unhappy and unfortunately consistent history of exploitation of blacks by the medical system,” she said. “Many, many African-Americans have preserved the memory of these abuses.”

Theodore Hunter, 60, an African-American resident of West Baltimore who works at Baltimore-Washington International Thurgood Marshall Airport, cited the Tuskegee study as a reason he would refuse to join a clinical trial. During the study, which ran from 1932 to 1972, white doctors allowed 400 black men, most of whom were illiterate, to suffer for decades without treatment.

Hunter sees Tuskegee as a cautionary tale. “We don’t know what’s going on at Johns Hopkins University or the University of Maryland,” he said. “It might be run by white doctors, and you don’t know if they’re giving you something to make you better or worse.”

Dr. Ezekiel Emanuel, the chair of the Department of Bioethics at the National Institutes of Health, acknowledged that racism existed — and might still exist — among doctors performing research.

But the exploitative research of the past, he said, was less directed at a certain race than at vulnerable populations in general — the poor, prisoners and institutionalized children, for instance.

“The question you have to ask is whether race was the determining factor — there were plenty of abuses of whites as well,” he said. Researchers operate under much stricter ethical guidelines nowadays, he said, and clinical trials on the whole are safer.

“The practice of clinical research in the past was very different to what’s been put in place now,” he said. “It’s usually in people’s interest to participate now, but nothing is risk free.”

Genetically-modified Carrots Help Calcium Absorption

COLLEGE STATION ““ A specially developed carrot has been produced to help people absorb more calcium.

Researchers at Texas A&M AgriLife’s Vegetable and Fruit Improvement Center studied the calcium intake of humans who ate the carrot and found a net increase in calcium absorption. The research, which was done in collaboration with Baylor College of Medicine, means adding this carrot to the diet can help prevent such diseases as osteoporosis.

“If you eat a serving of the modified carrot, you’d absorb 41 percent more calcium than from a regular carrot,” said Dr. Jay Morris, lead author on the paper, a post doctorate researcher at Baylor College of Medicine in Houston.

The finding will be reported in the Proceedings of the National Academy of Sciences online edition Jan. 14.

“The primary goal was to increase the calcium in fruit and vegetables to benefit human health and nutrition,” Morris said. “Fruit and vegetables are good for you for many reasons, but they have not been a good source of calcium in the past.”

Morris, who worked on the study while earning a doctorate at Texas A&M University, said fruits and vegetables play a role in good bone health for other reasons.

“We believe that if this technology is applied to a large number of different fruits and vegetables, that would have an even greater impact on preventing osteoporosis,” he said.

For this study, the researchers provided the carrots to a group of 15 men and 15 women. The people were fed either the modified carrots, called sCAX1, or regular carrots in the week one. On a second visit two weeks later, they were fed the other type of carrot.

Urine samples were collected 24 hours after each feeding study to determine the amount of specially marked calcium absorbed, Morris explained.

The study group also was evaluated for their normal absorption rate to compare with the rate of absorption from the calcium-enhanced carrots, he said.

He said both men and women absorbed higher amounts of calcium from the modified carrots. But the technology needs to be available in a wide range of fruits and vegetables so that people can get the calcium benefit.

“The daily requirement for calcium is 1,000 milligrams, and a 100 gram serving of these carrots provides only 60 milligrams, about 42 percent of which is absorbable,” he noted. “A person could not eat enough of them to get the daily requirement.”

But if vegetables and fruits could be bred to contain more calcium, then a diet that includes a variety of these produce might come closer to providing necessary calcium, Morris said.

“Increased fruits and vegetables (in the diet) are better for a myriad of reasons,” he said.

On the Net:

Texas A&M University

Study Helps Explain How Allergic Reactions Are Triggered

Findings point to calcium channels as essential regulators of mast cell activation.

BOSTON ““In demonstrating that a group of calcium ion channels play a crucial role in triggering inflammatory responses, researchers at Beth Israel Deaconess Medical Center (BIDMC) have not only solved a longstanding molecular mystery regarding the onset of asthma and allergy symptoms, but have also provided a fundamental discovery regarding the functioning of mast cells. Their findings appear in the January 2008 issue of Nature Immunology.

A group of immune cells found in tissues throughout the body, mast cells were once exclusively known for their role in allergic reactions, according to the study’s lead author Monika Vig, PhD, an investigator in the Department of Pathology at BIDMC and Instructor of Medicine at Harvard Medical School. “Mast cells store inflammatory cytokines and compounds [including histamine and heparin] in sacs called granules,” she explains. “When the mast cells encounter an allergen ““ pollen, for example ““ they “Ëœdegranuate,’ releasing their contents and triggering allergic reactions.”

But, she adds, in recent years, scientists have uncovered numerous other roles for mast cells, suggesting they are key to a number of biological processes and are involved in diseases ranging from multiple sclerosis and rheumatoid arthritis to cancer and atherosclerosis.

In order for mast cells to function, they require a biological signal ““ specifically, calcium. Calcium moves in and out of the cells by way of ion channels known as CRAC (calcium-release-activated calcium) currents. Last year, several research groups, including Vig’s, identified CRACM1 as being the exact gene that was encoding for this calcium channel.

“With the identification of this long-elusive gene, we were able to create a knockout mouse that lacked CRACM1, and [as predicted] these animals proved to be resistant to various stimuli that usually cause severe allergic reactions,” she explains. Further experiments demonstrated that mast cells removed from the CRACM1 knockouts were not able to take in calcium, and therefore, were unable to provoke allergic responses when they were exposed to allergens.

“These findings provide the genetic demonstration that CRAC channels are essential in mast-cell activation,” notes senior author Jean-Pierre Kinet, MD, BIDMC Professor of Pathology at Harvard Medical School. “This provides the proof of concept that an inhibitor of the CRAC channel should be able to impact mast-cell related diseases, including asthma and allergic diseases.”

Adds Vig, “Since mast cells are also known to contribute to the progression of several other debilitating diseases, including multiple sclerosis, rheumatoid arthritis and cancer, an inhibitor of the CRAC channel could, in the future, help in slowing the progression of these diseases as well as alleviate disease symptoms.”

This study was funded by grants from the National Institutes of Health, the Irvington Institute and the intramural program of the National Institutes of Health, National Institute of Environmental Health Sciences.

In addition to Vig and Kinet, study coauthors include BIDMC investigators James Billingsley, Huiyun Wang and Marie-Helene Jouvin; Wayne DeHaven, Gary Bird and James Putney of the National Institute of Environmental Health Sciences; and Patricia Rao and Amy Hutchings of Synta Pharmaceuticals, Lexington, Mass.

On the Net:

Beth Israel Deaconess Medical Center

Fallon Community Health Plan Selects TriZetto’s QNXT(TM) System and Application Hosting Services to Provide Greater Administrative Efficiency

The TriZetto Group Inc. (NASDAQ: TZIX) announced today that Fallon Community Health Plan (FCHP) has selected TriZetto’s QNXT™ enterprise administration system and QNXT Application Hosting Services. TriZetto’s hosted application will complement FCHP’s strategic goals to improve productivity, enhance service and grow membership, while continuing to deliver on FCHP’s national reputation for providing superior quality of care.

“After a thorough review of the leading products in the industry, TriZetto’s QNXT core administration system and QNXT Application Hosting Services proved to be the solutions we were looking for. The ease of use, flexibility in plan design and service-oriented architecture of the QNXT product make it a natural fit for our business needs in an increasingly complex and competitive environment,” said Mark Fisher, senior vice president and chief operating officer at Fallon Community Health Plan. “We will now have a core infrastructure that was developed by an industry leader in payer technology providing us the flexibility needed to meet the challenges that lie ahead.”

The QNXT enterprise administration system is part of TriZetto’s suite of leading enterprise applications, providing comprehensive health care payer administrative functionality and consumer-directed health capabilities, including HSA/HRA functionality. Combined with TriZetto’s QNXT Application Hosting Services, customers like FCHP are empowered with an advanced solution to meet the rapidly changing administrative and care management requirements in the healthcare market while assisting them to more efficiently service their members and providers.

“The combination of TriZetto’s QNXT platform with TriZetto’s new QNXT application hosting services, offer payers the ability to leverage superior system functionality, along with application expertise, effective application management, and IT operations expertise to improve time to market and meet the demands of a continuously changing industry–all on a predictable and scalable, monthly subscription basis,” said Rob Scavo, president of TriZetto’s Core Administration Solutions.

About FCHP

Founded in 1977, Fallon Community Health Plan provides health care services designed to meet the unique and changing needs of all they serve. Headquartered in Worcester, Massachusetts, FCHP is the only health plan in Massachusetts that is both an insurer and provider of care. Their product portfolio includes a variety of group and individual health plan options (HMO, POS, PPO, Commonwealth Care, Commonwealth Choice, MassHealth and Medicare Advantage plans) featuring flexible and innovative benefit designs. FCHP administers fully- self-insured funding arrangements with customized services for employers. Their uniquely developed provider networks offer high-quality, cost-effective, coordinated care and give members access to doctors and hospitals throughout Massachusetts. They also offer a broad spectrum of services and programs to ensure members, at every stage of life, remain as healthy and productive as possible. As a provider of care, FCHP operates Summit ElderCareSM, an advanced and completely integrated PACE (Program of All-inclusive Care for the Elderly) program that offers seniors and their caregivers an alternative to nursing home care. Their continued commitment to deliver high-quality health care and exceptional customer service has earned FCHP consistent ratings as one of the nation’s top health plans, and in 2007, placed their Medicare and Medicaid health plans as the #1 health plans in America. FCHP is the only health plan in Massachusetts to have been awarded “Excellent” Accreditation by the National Committee for Quality Assurance for their HMO, Medicare Advantage and Medicaid products. For more information, visit www.fchp.org.

About QNXT™

QNXT is part of TriZetto’s suite of core administration enterprise application systems. It supports medical and dental claim processing and offers comprehensive consumer-directed health capabilities with advanced HSA/HRA functionality. System capabilities also include a full range of functionality geared to support the administrative demands for single and multi-line of business payers, including group contracting, benefits management, eligibility and enrollment, premium billing/accounts receivable, provider network management and contracting, utilization and case management, claim processing and customer service. Designed to encompass an “n-tier” environment and service-oriented architecture, QNXT offers the flexibility and functionality that payers need in order to achieve optimal growth and efficiency-with a low total cost of ownership. QNXT enables customers to span the chain of healthcare decision-making ensuring that the right people have the right information in real time.

About TriZetto

TriZetto is Powering Integrated Healthcare Management™. With its technology touching nearly half of the U.S. insured population, TriZetto is uniquely positioned to drive the convergence of health benefit administration, care management and constituent engagement. The company provides premier information technology solutions that enable payers and other constituents in the healthcare supply chain to improve the coordination of benefits and care for healthcare consumers. Healthcare payers include national and regional health insurance plans, and benefits administrators that provide transaction services to self-insured employer groups. The company’s payer-focused information technology offerings include enterprise and component software, hosting and business process outsourcing services, and consulting. Headquartered in Newport Beach, Calif., TriZetto can be reached at 949-719-2200 or at www.trizetto.com.

Patients Caught in Centinela Hospital Shake-Up

By Melissa Evans

With some of its most renowned doctors departing and more than 300 staff members facing layoffs, Centinela Hospital Medical Center is in the midst of a tense shake-up after the sale of the struggling hospital three months ago.

Some patients scheduled for elective surgeries are even being moved to other facilities because the hospital’s new owner canceled contracts with their HMO insurance carriers.

“This is a terrible situation for people who have surgeries scheduled and then suddenly canceled,” said Vance Polish, who underwent hip replacement surgery last week. “I couldn’t have waited another week. I was up every night with pain.”

Polish was able to receive his surgery at Centinela, but only because he is old enough to qualify for Medicare. He spent several hours on the phone with insurance agents after learning that the hospital had canceled its contract with his private carrier, Blue Cross.

It is all part of the business plan engineered by Prem Reddy, a cardiologist who bought the 369-bed hospital – critical to the communities of Inglewood, Gardena, Hawthorne and surrounding areas – with promises to turn it around financially. To do that, the hospital can no longer afford to let insurance companies undercut the cost of expensive procedures, said officials with Reddy’s company, Prime Healthcare Services.

Centinela was losing about

$36 million a year from poorly negotiated insurance contracts, low Medi-Cal and Medicare reimbursement rates and uninsured patients, said Von Crockett, Centinela’s chief executive officer.

Because Centinela serves one of the poorest regions of Los Angeles County, it doesn’t have the fundraising power of other hospitals to remain solvent, Crockett said.

Instead, Reddy and other officials put the onus on insurance companies. After the sale was announced in November, hospital officials sent notices to Blue Cross, Blue Shield, Aetna, PacifiCare and Health Net that they wanted to renegotiate rates.

The companies refused, hospital officials said, and as a result, HMO contracts were canceled as of Dec. 31. Centinela still accepts patients covered by PPO plans, and takes Medicare and Medi-Cal.

Emergency room patients aren’t affected at all – they are, in fact, welcomed. Insurance companies are obligated to cover emergency care, and the hospital can charge insurers vastly higher rates without contracts.

This business strategy has proved successful for Reddy, who owns eight other medical facilities from Victorville to Chino. He acquired most of them while they were facing bankruptcy.

The downside to this business strategy is that doctors who provide non-emergency care, including elective surgeries, are being squeezed out of the hospital because HMO insurance won’t cover these procedures. Many say quality will suffer as more doctors leave.

“What we’re seeing is the change of a hospital from a classic community hospital to a downsized hospital with a giant emergency room,” said Dr. Lawrence Dorr, a nationally known orthopedic surgeon who will likely move the bulk of his practice elsewhere.

The Arthritis Institute at Centinela, which draws thousands of patients a year, may close completely. The hospital sent layoff notices to 150 nurses, tech workers, staff and others, but Crockett said talks are under way that may salvage some services before the layoffs take effect at the end of February.

“It just seems unreal to me,” said Geri Ward, director of the institute who was given notice. “People come here from all over the country for training. We’re one of the highest-ranking institutes for joint replacement in the U.S.”

Layoff notices were also sent to

30 workers in the hospital’s rehabilitation center, which is closing, and about

200 nurses and others who worked at Daniel Freeman Memorial Medical Center, which housed an oncology and rehabilitation ward.

Prime Healthcare bought the main hospital in Inglewood for an undisclosed sum, but the soon-to-be vacant Daniel Freeman, along with the Marina Campus in Marina del Rey, remain under the ownership of Centinela Freeman Health System.

Dorr said he will likely move his practice to the Marina Campus, which has plans to expand its facility over the next few years to accommodate more physicians.

Centinela still touts its orthopedic, cardiovascular and sports medicine departments on its Web site – it is widely known as the hospital of the Los Angeles Lakers and Dodgers – but doctors say they are unsure of what the future holds.

“I think the jury’s still out right now as to whether the hospital will be able to continue to provide the kind of care that the community is used to,” said Dr. Larry Paletz, a urologist who served as the hospital’s chairman of the board until the recent sale.

His practice has not yet been affected, “but there’s a lot of worry, a lot of anxiety about what may happen,” he said. “These are my friends, people I’ve practiced with for many years.”

Staff members and physicians, some of whom didn’t want their names used, said morale is extremely low. Talk on the elevators and in hallways has centered around who is leaving, and where people are going, some said.

Patients seem confused. Virgil Davis, a longtime Inglewood resident and Centinela patient, said his doctor’s office got him in quickly for heart surgery this fall because of the anticipated changes.

His wife is scheduled to have heart surgery later this month, and her procedure was unexpectedly moved to the Marina Campus.

“They told us our insurance wasn’t accepted (in Inglewood) anymore,” said Davis, who is covered by PacifiCare. “I wish somebody would tell us what’s going on.”

Doctors agree that the financial situation at Centinela is dire; the hospital loses thousands of dollars every time they perform a surgery. A single pacemaker can cost upward of $27,000, hospital officials say – and the insurance companies don’t even foot the bill for the equipment, much less the staffing costs and supplies needed for surgery.

“This is a tough change, but some of the change may be for the better,” said Dr. Bob Chesney, who runs the Tommy Lasorda Heart Institute, one of Centinela’s premier programs. “I think every hospital CEO is watching to see if this is going to work.”

Reddy places the blame squarely on the shoulders of insurance companies, which have wrangled with him in the past over his tactics.

Ultimately, patients get put in the middle – and in many cases, end up paying higher costs, said Nicole Evans, spokeswoman for the California Association of Health Care Plans, a trade association that represents 40 HMO insurance carriers.

What often happens, she said, is the insurance company pays the contractual rate for emergency care – even if they don’t have a contract in place – and the hospital sends the patient a bill for the difference. The patient should call the insurance company to dispute the cost, she said, but many wind up just paying it.

“They’re already going through a stressful time,” she said. “The hospital shouldn’t be adding to that.”

Evans said insurance companies have an obligation to negotiate fair rates with hospitals as medical costs soar. If they don’t, higher insurance premiums could be passed on to patients, she said.

Crockett, however, said the insurance companies were unbending in their negotiations, and that the hospital would have had to eventually close without drastic measures.

Most agree that would have been devastating to an area of Los Angeles that has lost four hospitals to financial failure in the Past five years, creating a domino effect that has put pressure on fewer hospitals.

Reddy’s approach “isn’t going to satisfy everyone, but what’s the alternative?” said Jim Lott, executive director of the Hospital Association of Southern California, a trade group. “Prime Healthcare selectively chooses hospitals they think they can turn around, and they’ve so far managed to keep hospitals open.”

[email protected]

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

This Week It Was Revealed How This Married Teacher Seduced a 16- Year-Old Boy

By Helen Weathers

FOR a school which prides itself on the high quality of its pastoral care and commitment to the emotional, physical and sexual health of its pupils, it would be hard to imagine a more embarrassing scandal.

Award-winning Paignton Community College in Devon, lauded for its pioneering sexual health advice service for students, has found its nemesis in the form of its now disgraced English teacher, a 28-year- old married woman called Jo Gorman, herself once a star pupil at the college.

This week it emerged that Mrs Gorman had been sacked from the school following a disciplinary hearing, having been suspended last November over the ‘sexual touching’ of a 16-year-old male pupil for which she also received a police caution.

Photos of the pair were seemingly taken on mobile phones which reportedly rapidly spread after being sent to other pupils.

What a nightmare for the college which became the first school in the South West to be singled out by the National Society for the Protection of Cruelty to Children as a ‘Listening School’ a status only achieved once a designated standard has been reached relating to four aspects of health education promoting the welfare of its pupils.

And what will the mandarins in the Department of Education think? For the college has been held up as a shining example to the rest of Britain after it set up its controversial Tic Tac centre, offering advice to students on all manner of issues including sexual health.

Indeed, the college’s own policy document on safeguarding children reads: ‘All staff believe that our school should provide a caring, positive, safe and stimulating environment that promotes the social, physical and moral development of the individual child.’ One member of staff, however, was clearly not singing from the same songsheet. Indeed, Jo Gorman’s actions, which have shocked and angered parents, might well have been stimulating but there was certainly nothing moral about them.

Coming hot on the heels of headlines last year about teenage pregnancies at the school ex-pupil Kizzy Neal fell pregnant at 13 and is now the 15-year-old mother of an eightmonth-old son, while pupil Charlotte Maddox became a teen mum at 13 almost two years ago it means parents are at their wits’ end.

One 43-year-old parent, whose 15-year-old daughter was taught by Mrs Gorman, said last night: ‘I feel absolutely disgusted at what’s happened. When my daughter came home and told me, I just couldn’t believe it.

What on earth was this teacher thinking of? ‘When I met her, she seemed the most normal person in the world. Not tarty, nothing over the top, just normal. That’s what makes it so hard to believe.

‘I was told the boy had managed to keep the back. A friend of the couple say that relationship secret but a friend of his found a compromising picture of Mrs Gorman on his phone and word got out.

‘What responsible teacher would allow this to happen? She’d only been married a year and her husband worked at the school, too. If it had been a male teacher sexually touching a female student, all hell would have broken loose, but it seems to me the whole episode has been smoothed over.

‘At least she’ll never be able to work with children again, but it’s outrageous. I feel so angry I’ve persuaded my daughter not to stay on in the sixth-form. She’s going to college instead. I’m not happy with the school, not happy at all.’ Last night Mrs Gorman and her husband Craig, 28, who works at the school as the head of the IT department, were not answering the door at their Pounds 200,000 seafront home. She is not expected to appeal against the result of the disciplinary hearing.

The former rising star, who won the college’s Linden Challenge Cup as its best A-level student 11 years ago, must be wondering how she allowed herself to throw away her career on a relationship with a teenage pupil, albeit a seemingly willing one.

Yesterday a car was on the drive of the Gormans’ home with a ‘Mum- to-be’ sticker in the back. A friend of the couple say that Mrs Gorman is due to give birth to her first baby in March.

The friend said: ‘They’ve been trying for a baby for a long time. Jo is very upset and angry over what’s happened. She said there was no sexual relationship with the pupil and that she was set up by a troublesome pupil because she was strict with the students.’ The caution means she had to sign the Sex Offenders’ Register and was added to the Department of Education blacklist, known as List 99. As for the state of her marriage, that remains unknown. The family of the boy, who cannot be named for legal reasons, has asked for privacy.

While the college principal Jane English and all the other teachers were in the dark about what was going on between Mrs Gorman and the teenager, pupils last night revealed that it had been the talk of the school for months.

And the picture which emerged was of a young, newly married teacher who Gormans’ home with a ‘Mum-to-be’ sticker in

She smacked the bottom of a boy who winked at her ‘

despite her ‘prim and proper’ manner with parents was regarded by her pupils as ‘very flirtatious’ with the boys.

One 15-year-old female pupil who was in Mrs Gorman’s English class said: ‘She was the type of teacher who was very strict with the girls but favoured the boys. She was very giggly around them.

‘When the girls played up and were naughty, they’d be ordered from the class while the boys were sent out and allowed back in after just five minutes. None of the girls thought she was very pretty. We all thought she was plain and that no one would fancy her.

‘She used to try too hard. She was always trying to act younger than her years, to try and fit in with her pupils.

Well, the boys anyway.’ According to one male ex-pupil, now aged 18, Mrs Gorman once playfully patted a pupil’s bottom as he left the room an educational technique which can be found nowhere in the college’s many policy documents on safeguarding children.

The pupil, who was in Mrs Gorman’s English class for three years, said: ‘I was one of her favourites and we became quite close friends. It wasn’t like talking to a teacher, she was more of an equal.

‘She would ask me to stay behind after class and really praise me. She’d tell me I’d go far if I kept my head down and worked. She was quite flirtatious, although not in an over the top way.

‘A lot of the boys fancied her because although she wasn’t conventionally pretty, there was something about her. I remember once a boy in my class said something cheeky to her as he left class, winked at her and she came over and smacked his bottom.

‘Another time she gave me a cuddle, after I’d done something well. There wasn’t anything sexual about it, but I suppose, looking back, it’s not the kind of thing a teacher should do.’ He added that the teenager involved in ‘

the scandal with Mrs Gorman was considered a bit of a ‘geek’ by the other boys and had, in the past, been bullied.

‘Mrs Gorman liked to take the more vulnerable boys under her wing. When I heard what had happened I was surprised, but the more I thought about it, I wasn’t, really.

‘When I was there, I would say there was quite a bit of flirtation going in that school between pupils and teachers. Some of the girls had huge crushes on male teachers and as Mrs Gorman was one of the younger female teachers some of the boys fancied her.’ The boy Mrs Gorman threw her career away for was, according to various accounts, good-looking, outgoing and bright, with a girlfriend in the year below him. Pupils say he never bragged about his special relationship with his teacher and tried to keep it quiet.

But when Mrs Gorman appeared to take a shine to the boy, word got round pretty quickly.

‘Everyone thought it was a bit of a giggle because she didn’t seem the type. She was married as well.

Her husband worked in the IT department and he was really nice.

Quite good-looking and very helpful. He’s the one I feel sorry for,’ said one pupil.

The infatuation might have fizzled out without incident had, according to pupils, one of the boy’s friends not found pictures of Mrs Gorman on his phone. These apparently then spread like wildfire via mobile phone and internet and the secret was out.

And so Mrs Gorman’s career came to an abrupt end and it would appear that the scandal is the final straw for some parents, who are less than happy with the pastoral care on offer at Paignton Community College.

Those parents the Mail spoke to believe it embodies everything that is wrong about the current thinking on sex education in Britain’s secondary schools, encouraging an acceptance of sexual activity among pupils.

In 1998 Paignton a mixed sports college with 1,860 pupils set up the controversial Tic Tac (Teenage Information Centre Teenage Advice Centre) in a bungalow in its grounds, open each lunchtime and staffed by health professionals including GPs, nurses and youth workers.

This was the same year that the college sent out 700 letters to the parents of male pupils warning them of the dangers of hepatitis B after a local woman, drug addict Michelle Brindham, 22, who has since died, contracted the disease.

It had been discovered that several boys from the school had slept with her. It was reported that up to 15 boys at a time would queue up outside her flat for sex.

So perhaps the Tic Tac centre could be regarded as an enlightened response to the issue of under-age sex and how dangerous it can be.

There are now two such centres on each of the school’s two sites, providing confidential advice on all manner of subjects from bullying to homework worries, from alcohol and drugs to stress. And, of course, safe sex and contraception.

Despite its being held up as model of good practice to other schools in promoting sexual health awareness and described as exemplary by the Department for Education, some parents are dubious about the Tic Tac centre fearing it promotes sexual activity among under-age pupils.

One parent, who asked not to be named because her child is still at the school, said: ‘What the school should be saying to pupils is “you are too young to be having sex”.

But it seems to me the message they are receiving is “we know you are having sex so here are a few condoms”.

‘My daughter’s friend went to the Tic Tac centre because she was pregnant. She was under 16 and they arranged an abortion for her because she didn’t want to keep the baby. Her mother still doesn’t know to this day.

‘Other people may say that it is respecting the wishes and confidentiality of the child, but to me it’s unacceptable.’ And while the school’s Ofsted report, published last year, praises the Tic Tac initiative, underlining that it has won local and national recognition, it described the college’s provision for spiritual, moral, social and cultural development as merely ‘satisfactory’ with ‘opportunities for spiritual reflection less well developed’.

And what of those under-age mothers? Kizzy Neal’s parents, Kerry and Kevin Neal, who help their daughter bring up her son while she continues her studies at college, have been shocked by this latest and unwanted development in the school’s history.

Mrs Neal, who still has a 14-yearold son at the school, said: ‘A lot of parents are very angry and I’ve been told that some are threatening to take their children out and have written letters of complaint.

It seems to me that many of the pupils knew about this before any of the authorities.

‘I was shocked when I read about it in the papers because Mrs Gorman always seemed quite prim and proper, but when you speak to the kids you find out they’ve known about it for months.’ Mr Neal added: ‘It seems to me that the school preaches that the Tic Tac initiative is a model of excellence, but you need to look at what’s actually happening. I think it just encourages pupils, when they are still too young, to think that it’s OK to have sex.’ Paignton Community College principal Jane English said in a statement: ‘The college undertook its own inquiry under its grievance and disciplinary procedures.

‘The outcome of the investigation resulted in Mrs Gorman being dismissed from the college.’ She declined to comment further when contacted by the Mail yesterday.

No doubt Mrs Gorman’s pastoral care of her pupil is not the kind she would want to be repeated..

(c) 2008 Daily Mail; London (UK). Provided by ProQuest Information and Learning. All rights Reserved.

Swimming: the Perfect Cardiovascular Exercise

So you want to start a regular exercise program. You’re looking for something easy on the joints, easy to do.

C’mon — you’re all wet.

In a good way, that is.

Swimming as a form of cardiovascular exercise might not be your first idea for breaking a sweat, losing weight or working out those muscles, but guess what? It just so happens, it’s the perfect way to do just that.

All you need is a suit, a towel and a pool. You don’t even have to be a member of a health club, although it’s more economical if you are.

“I recommend swimming for anyone,” said Drew Miller, a trainer at Gold’s Gym. “You can get some of the best workouts you can find in the pool.”

Swimming is an excellent choice for people who haven’t done much exercise in awhile (the technical term is “de-conditioned”), or for pregnant women and seniors, Miller said. But don’t turn your back on swimming if you don’t fall into one of those categories.

“It’s not just for people who haven’t been in the gym for a long time. It’s for anyone.”

Because the act of swimming isn’t one that most are used to doing, “you’re not conditioned to it,” Miller says. “You don’t swim from your car to the gym — you walk. So, you’re going to burn more calories in the pool than on the treadmill.”

Other benefits, Miller says, include learning how to breathe and how to control your breath. It’s also less stressful on your joints and muscles.

“It’s the most aerobic exercise you can do.”

So, why don’t more folks dive in?

“People are very self-conscious of their body,” Miller says. “They think, ‘I don’t want to get in the pool, not yet. Let me drop 10 to 15 pounds first.’ “

Jad Mahnken, director of aquatics at the Downtown YMCA , agrees that how-I-look-in-a-swimsuit is a big swimming deal breaker, although he’s seen an increase in high school swimmers.

Mahnken says water jogging — jogging in the water with a weight belt on — is taking off nationally in a big way. “But it hasn’t caught up locally, yet.”

Swimming is especially good on joints, and respiration-wise, “you can’t get a better workout — you’re practicing breath control.”

Mahnken says the very young and the older-than-30 crowd take to the water best. That includes kids in swimming lessons, women in water aerobics classes (although he sees more and more men in those classes) and triathletes in training.

“For the most part, once a child can swim across the pool and back, most parents take them out of swimming lessons, so after the age of 9, the numbers sink down,” he said.

You can get your feet wet by starting with a water aerobics class. Ask your club or gym which one is best geared toward your current fitness level. You can start easy, but there are advanced, high-intensity classes and combo-classes, such as water Pilates, that are more challenging.

For some water aerobics class participants, getting wet together has built community.

“It has one of the most empowering community dynamics. What really defines a good class is a good instructor building a community of their class,” Mahnken says.

Another swimming benefit: You can forget about no-pain-no-gain.

“With swimming you have none of the pain that running or lifting weights every day can bring you,” says Megan Quann Jendrick. Jendrick, a two-time Olympic gold medalist, and her husband, Nathan Jendrick, wrote “Get Well, Get Fit: The Complete Guide to Getting a Swimmer’s Body.”

If you want to go it on your own with a basic swimming strategy, this book can get you there. It includes training regimens, workouts, drills, a diet plan and tips. The book focuses on perfecting each swimming stroke — freestyle, breaststroke, backstroke and butterfly — and takes you from beginning to advanced for each stroke.

There also are tips and quotes from other swimming experts and these four essentials to getting started:

1. Understand what your goals are, what you’re doing, why you’re doing it and the result you’re going for.

2. Think long-term.

3. Have the right tools. Have your water bottles, swimsuit, cap, goggles and whatever else you’ll need in hand and ready to go.

4. Ignore criticism.

Development of Anti-MUC1 Di-scFvs for Molecular Targeting of Epithelial Cancers, Such As Breast and Prostate Cancers

By Albrecht, H Denardo, G L; Denardo, S J

Pretargeted radioimmunotherapy (RIT) is a promising approach to increase the therapeutic index of RIT for malignant solid tumors. For pretargeted RIT of epithelial cancers, such as breast and prostate, mucin 1 (MUC1), the epithelial mucin, was chosen as a target antigen (Ag). Overexpression, hypoglycosylation and loss of apical distribution on the cellular membrane distinguish the tumor associated MUC1 from normal MUC1. These characteristics of MUC1, best known in breast cancer, were validated in prostate cancer. The multivalent bispecific MUC1 pretargeting molecule under development consists of a tumor binding module and a radioactive hapten capturing module. The building blocks of each module were chosen as single chain antibody fragments (scFv) to be covalently attached to a multifunctional polyethylene glycol (PEG) scaffold. PEGylation studies with scFvs selected from anti-MUC1 libraries and engineered with a free thiol for site-specific conjugation showed that highest reaction yields were obtained with short monofunctional PEG molecules. To accommodate the use of a bifunctional PEG for covalent assembly of binding and capturing modules, the MUC1 binding module was developed into a di-scFv-SH format and optimized for linker length and location of the free thiol in respect to Ag binding and site-specific conjugation. Approaches under study to improve PEGylation yields with bifunctional PEG molecules include alkyne- azide cycloaddition. Assembly efficiencies, through PEGylation, of the binding and capturing modules and pharmacokinetics will influence the final valency of the MUC1 pretargeting molecule: anti- MUC1 di-scFv-PEG- anti-radioactive hapten scFv or di-scFv-PEG-anti- radioactive hapten di-scFv. KEY WORDS: Drug labelling – Breast neoplasms – Prostatic neoplasms.

Although the first radioimmunotherapy (BIT) experiment was conducted in the early 1950’s with ^sup 131^I-labeled rabbit antiserum in rats bearing osteosarcoma xenografts,1 clinical interest in the use of antibodies increased with the development of the hybridoma technique by Kohler etal. in 1975.2 The ability to produce gram amounts of pure murine monoclonal antibodies (MAbs), that target a single epitope, greatly facilitated the use of antibodies and contributed to the identification of tumor associated antigens (TAA). The targeted delivery of cytotoxic radioactive doses to tumor tissues, using systemically delivered MAbs, known as RIT, appeared as a novel and promising cancer therapy in the 1980’s. Following the early clinical use of radiolabeled MAbs in imaging studies,3 the efficacy of RIT in the treatment of cancer has been widely investigated in animal models and patients.4-5 Such trials brought forward two major limitations of RIT: 1) development of an immune response, in some patients, against MAbs of mouse origin, known as human anti-mouse antibodies; and 2) normal tissue radiation toxicity, particularly bone marrow, as a consequence of the long circulation time of radiolabeled MAbs.

The immune response triggered by MAbs of mouse origin was bypassed by their substitution with chimeric, humanized and fully human antibodies, as well as recombinant antibody fragments. This was made possible through advances in molecular immunology and the development and adaptation of a plethora of molecular biology techniques to genetically engineer antibodies. The adaptation of the peptide phage display technique to display single chain (sc)Fva6 was a major breakthrough in recombinant antibody technology. The power of phage display, and subsequently developed display techniques, resides in the fact that they provide a direct link between phenotype and genotype. This greatly facilitates the selection and cloning of an antibody fragment against a given antigen (Ag). Two routes are currently used for the production of human antibodies: cloning of human Fv fragments onto human constant regions of immunoglobulins (Ig) and immunization of transgenic mice engineered to express human IgGs.7

The efficacy of RTT in the treatment of non-Hodgkin’s lymphoma has led to approval by the Food and Drug Administration of two radiolabeled anti-CD20 MAbs: Zevalin ([90Y]ibritumomab) (Idee Pharmaceuticals, San Diego, CA, USA) and Bexxar ([^Ijtositumomab) (Corixa, Seattle, WA, USA). In contrast to solid tumors, where radiolabeled antibodies have to penetrate into tissue, hematological malignancies provide better access of the radiolabeled antibodies to tumor cells and are more radiosensitive. Therefore, the radioactive dose delivered to the tumor is greater than that received by normal tissues/organs and results in a high therapeutic index (TO, defined as radioactivity to tumor divided by radioactivity to normal tissues. Therefore, successful RIT of solid tumors requires a higher TI. A number of strategies, including the optimization of the pharmacokinetics of targeting antibodies,8 cleavable linkers 9 and combined modality RIT10 have been devised to achieve this goal. One of the most promising approaches is pretargeting, in which the pharmacokinetics of the targeting antibody are dissociated from those of the radionuclide through separate injections.11 Greatly enhanced TI has been shown in animal models and in patients for two extensively studied pretargeting systems: 1) antibody fragment- streptavidin (SA) fusion protein with radiolabeled biotin; and 2) bispecific anti-target Ag and antiradioactive hapten antibodies.12, 13 The advantages of the SA/biotin based system are twofold: 1) high functional affinity for the target Ag is achieved through SA tetramerization; and 2) high affinity of biotin for SA provides an efficient capture of the radionuclide. However, SA and its analogues are immunogenic. Bispecific antibodies, on the other hand, humanized or human, have been developed in various formats, sizes and valencies,14-15 that contribute to the optimization of their pharmacokinetics.

Modular designs appear as a good strategy to overcome low production yields of multivalent bispecific antibodies. Here, we report the experimental path followed for the development of modular multivalent bispecific pretargeting molecules for RIT of metastatic breast and prostate cancers.

MUC1 as a target antigen

Mucin 1 (MUC1), also known as polymorphic epithelial mucin, polymorphic urinary mucin, episialin, DF3 Ag, epithelial membrane antigen and CA15-3, is a member of the mucin family that is represented by large molecular weight (MW) glycoproteins. According to their gene sequences, mucins fall into one of two groups: secreted or transmembrane mucins. The MUC1 gene encodes a transmembrane mucin characterized by the presence of 3 domains: extracellular, transmembrane and cytoplasmic.16 Beside genetic, MUC1 polymorphism is created at the messenger ribonucleic acid (mRNA) level through alternative splicing and at the protein level through glycosylation.

MUC1, initially synthesized as a single polypeptide, functions as a non-covalent heterodimer.17 The N terminal subunit consists of the extracellular domain, composed of a variable number (20-100) of 20 aa tandem repeats (VNTR).18 The VNTR motif, GVTSAPDTRPAPGSTAPDAH, can carry up to 5 Oglycosyl chains since serine and threonine residues are the targets of O-glycosylation.19 The MUC1 C terminal subunit consists of a short extracellular segment followed by a transmembrane domain and cytoplasmic tail.16 Dimerization of the MUC1 N and C terminal subunits leads to tethering to the cell membrane of the large MUC1 extracellular domain 17 (Figure 1). Its rodlike structure extends over 100-200 nm above the cell surface which exceeds by 5 to 10 fold the length of most membrane proteins.19 In normal glandular tissues, MUC1 is expressed, as a heavily glycosylated protein, on the apical borders of normal secretory epithelial cells.20 By contrast in neoplastic tissue, MUC1 is overexpressed and underglycosylated and, as a consequence of the loss of gland structure, MUC1 expression is no longer restricted to the apical borders of epithelial cells 21 (Figure 1).

The tumor associated MUC1 fulfills many characteristics of an ideal TAA:22 it is expressed on almost all human epithelial cell adenocarcinomas (breast, pancreas, ovary, lung, urinary bladder, prostate and endometrium), thus in nearly 80% of all human tumors; TAA MUC1 is distinct from MUC1 present on normal cells; TAA MUC1 is more abundant than normal MUC1.

Assessment of target antigen in prostate cancer

Expression of hypoglycosylated MUC1 epitopes (less O-glycans) is best documented in breast cancer, where in comparison to normal tissue, more staining was observed with anti-MUC1 MAbs recognizing hypoglycosylated forms of MUC1.23-24 Not all cancers express high levels of hypoglycosylated MUC1 epitopes and cancer progression is not always associated with this MUC1 form.25, 26

In primary prostate cancer, gene expression profiling showed that 3 cancer subtypes can be distinguished and that MUC1 is expressed in the two most aggressive subtypes.27 No differential expression of the MUC1 gene was reported upon comparison of gene expression in primary and metastatic prostate cancer tissues.28 The detection of MUC1 in normal and malignant prostate epithelia with a MAb recognizing a cytoplasmic epitope led to the conclusion that MUC1 expression is heterogeneous in both tissues.29 However, a correlation between the levels of sialylated MUC1 and the histological grade and clinical stage of the prostate cancer was observed by using a MAb specific for sialylated MUC1.3[degrees] In a study comparing the reactivity of normal, primary and metastatic prostate cancer tissues with a MAb binding to hypoglycosylated MUC1, an increase of MUC1 epitopes and hypoglycosylated MUC1 forms was found on higher grade prostate cancer.31 In order to obtain a better insight on MUC1 expression in prostate cancer, epitope mapping of the MUC1 extracellular domain was carried out, but unlike previous studies that used one or two MAbs, 7 well characterized anti-MUC1 MAbs were used. Immunohistochemistry (IHC), performed on normal and prostate cancer tissues with increasing Gleason grades present on a microarray, showed an increase of MUC1 epitopes and hypoglycosylated forms of MUC1 with increasing Gleason grade (Figure 2).32 IHC data also showed that most, but not all, prostate cancer samples were positive for MUC1, in agreement with previous findings.27- 3i Thus, according to our data and that of others,*1 the targeting of hypoglycosylated forms of MUC1 for imaging and pretargeted RIT of aggressive prostate cancer is appropriate. Figure 1.- Characteristics of normal and aberrant mucin 1 (MUC1). Schematic representation of MUC1 protein expressed on normal and malignant cells of epithelial origin. 1: extracellular domain of MUC1 protein with O-glycosylations on serine (S) and threonine (T) residues of the variable number tandem repeats motif. Note hypoglycosylation on aberrant MUC1; 2: transmembrane domain of MUC1 protein; and 3: cytoplasmic domain of MUC1 protein.

Figure 2.-Immunohistochemistry (IHC) on prostate tissue with antimucin 1 (MUC1) single chain antibody fragments (scFvs). Reactivity of two anti-MUC1 scFvs and two well characterized anti- MUC1 murine monoclonal antibodies (MAbs) (BrE3 recognizes the TRP epitope on moderately and hypoglycosylated MUC1 and B27.29 reacts preferentially with hyperglycosylated/normal MUC1) tested by EHC on normal to benign (A), prostatic intraepithelial and Gleason grade 1 to 2 (B) and Gleason grade 3 to 5 (C) prostate tissue cores (0.6 mm).

Selection of anti-MUC1 scFvs

Numerous anti-MUC1 MAbs have been generated against Ags, including human milk fat globule (HMFG), membranes of tumor cells, peptides and oligosaccharides. The investigation of the reactivity and specificity of 56 MAbs against the MUC1 glycoprotein led to the following conclusions: 34 MAbs defined epitopes located within the VNTR motif; 16 MAbs showed evidence for involvement of carbohydrate residues in their epitopes; no obvious relationship was found between the type of immunogen and the specificity of each antibody; the hydrophilic sequence of PDTRPAP was always present either in part or full in epitopes within the MUC protein core.33 The presence of the PDTRPAP sequence in peptidic epitopes is in agreement with the immunodominant peptide region in each MUC1 VNTR motif that was identified by nuclear magnetic resonance and referred to as the “PDTR” knob.34 Another anti-MUCl MAb, BrE3, raised against HMFG and reactive with the TRP epitope 35 has been used in breast cancer patients for imaging and RIT.36

Based on this information, a MUC1 peptide containing 4 VNTR was chosen as an Ag for the preparation of hyperimmune anti-MUCl scFv phage display libraries. The choice of the scFv format for the phage display library was guided by the fact that a monovalent 25-30 KD scFv appeared as a suitable module for engineering multivalent targeting molecules and that the technology to construct such a library was available.37

Two anti-MUC1 scFv phage display libraries were constructed by using the RPAS mouse scFv module (Amersham Biosciences Corp., Piscataway, NJ, USA) and mRNAs extracted from the spleens of BALB/c or NZB immunized mice (cell membrane enriched lysates from MUC1 expressing MCF7 and HBT 3344 tumor cells at a ratio of 10:1 followed by 3 injections at 3 week intervals of the 80 mer MUC1 peptide conjugated to KLH). The initial BALB/c scFv phage library contained 107 clones with an estimated diversity of 105.38

Cloning of VH and VL domains of Igs with the RPAS mouse scFv module results in the insertion of DNA sequences corresponding to scFvs in the VH-VL orientation with a (G^sub 4^S)^sub 3^ peptide linker into the pCANTAB 5E expression vector (Figure 3). ScFvs expressed from this vector carry a N terminal signal peptide for periplasmic export and a C terminal E Tag for purification by immunoaffinity chromatography.

Anti-MUC1 scFvs were selected by 3 rounds of affinity selection with decreasing amounts (100, 50 and 10 nM) of MUC1 peptide conjugated to biotinylated bovine serum albumin and captured with magnetic SA coated beads. Further selection was carried out in ELISA assays with scFv containing periplasmic extracts of individual clones. ScFvs that bound to the MUC1 synthetic peptide and lysates of MCF7 (human breast cancer) and DU145 (human prostate cancer) cells were subjected to DNA sequencing. Sequence analyses showed that the selected anti-MUC1 scFvs share 70% or more sequence homology at the amino acid level. Production yields of soluble scFvs purified from periplasmic extracts varied from 0.1 mg/L to 1.5 mg/ L. Affinity constants of these scFvs, for binding to the MUC1 peptide, determined by Scatchard and linear regression ranged between 1.7 x 10^sup 8^ and 8.2 x 10^sup 8^ M^sup -1^.39 Such scFv binding affinities are satisfactory for targeting Ags associated with solid tumors knowing that threshold affinities of 10^sup 7^- 10^sup 8^ M^sup -1^ are required for visualization of ^sup 125^I- scFv tumor uptake and that no gain in tumor accumulation is observed with affinities above 10^sup 9^ M^sup -1^.40

Insertion of a cysteine for site-specific PEGylation

The attachment of scFv modules to a scaffold like PEG can be random or site-specific. Conjugation by random targeting of primary amines of lysine residues or free thiols introduced via the use of 2 iminothiolane has been satisfactory with large molecules, such as antibodies. For smaller proteins and peptides, random conjugation often results in reduction or loss of biological activity.41 Furthermore, random conjugation also generates a heterogeneous final product, an undesirable quality for a pharmaceutical. On the other hand, conjugation at a specific site, remote from the molecule’s active site, limits interferences with biological activity and leads to homogeneous conjugates. Site-specific conjugation based on thiol chemistry appeared applicable to scFvs for the following reasons: most scFvs are devoid of free thiols and the intradomain disulfide bridges formed between the 2 cysteines present in each VH and VL domains are fully buried 42 and a free thiol can be provided through insertion of a cysteine at any chosen location by insertinal DNA mutagenesis. Because we were interested in adding a free thiol to more than 1 scFv, a modification of the expression vector seemed more appropriate. Thus, N and C termini of a scFv remained as the only two possible locations for the insertion of an extra-cysteine. The presence in a scFv of unstructured hydrophilic N and C termini, as confirmed by 3D modeling,39 supported accessibility to the free SH at either scFv end. However, the scFv C terminus appeared as the better choice since it already contains an additional E Tag sequence and other scFvs with a C terminal cysteine insertion have retained activity.43-45 A cysteine specifying codon (TGT) was added by PCR directed mutagenesis to the pCANTAB 5E vector backbone, downstream of the Sfil/NotI restriction sites used for scFv cloning and upstream of the E tag sequence used for scFv purification by affinity chromatography (Figure 3); this version of pCANTAB 5E, engineered for the addition of a C terminal cysteine to any scFv expressed from it, was named pCANTAB 5E Cys.46 In comparison to non modified scFvs, production yields in shake flasks of soluble scFv cys purified from bacterial periplasmic extracts were usually decreased by one half, whereas their Ag binding activities were increased twofold. The tendency of scFv cys to leak into the culture medium accounts for their yield reductions and their improved Ag binding activities reflect the increased functional affinity resulting from the formation of covalent scFv homodimers or (scFv’)^sub 2^. In the absence of a reducing agent, such as tris(2- carboxyethy)phosphine (TCEP), monomers and dimers of scFv cys coexist at approximately similar ratios.45, 46 Each of the dual forms of scFv cys has an application. In the absence of a reducing agent, scFv-S-S-scFv dimers with enhanced Ag binding activity provide higher sensitivity to Ag binding assays; this is particularly useful for immunohistochemistry.46 For site-specific conjugation, 100% of the free thiols are made available through conversion of dimers to scFv-SH monomers by addition of a reducing agent.46

Figure 3.-Schematic illustration of the steps involved in the development of multivalent pretargeting molecules.

Format of MUC1 binding modules: covalent and bivalent di-scFvs

Initial attempts for site-specific conjugation of scFv cys modules onto a bifunctional PEG scaffold were met with 45% of (scFv)^sub 2^-PEG product. Site-specific PEGylation yields with monofunctional PEG up to 80% have also been reported by others.48 In addition to PEGylation yield decrease with increased numbers of functional groups per PEG molecule, the synthesis of homogeneous multifunctional PEG is also difficult. Thus, although attractive in theory, the multimerization of 3 or 4 scFv cys modules through PEGylation remains elusive in practice. Since pharmacokinetic and optimal tumor Ag binding considerations contributed to the original design of the MUC1 pretargeting molecule, its design could only change in terms of building blocks, but not of mode of action. In other words, the MUC1 pretargeting molecule should retain a MW >70 KD to circumvent glomerular filtration and provide bivalent binding to gain functional affinity for the targeted tumor Ag. Hence, instead of scFv cys modules and trior tetra-functionalized PEG, the format of the tumor binding module was revised to accommodate the use of a bifunctional PEG (Figure 3). The most popular bivalent scFv format is the diabody, a non-covalent dimer obtained by shortening the length (

Figure 4.-Immunoreactivity of anti-mucin 1 (MUC1) di-single chain antibody fragments (scFv)-SH and di-scFv-PEG. A) Immunoreactivity of anti-MUC1 di-scFv-SH (D5c5D5) tested by immunohistochemistry (IHC) on MUC1 expressing breast (MCF7) and prostate (DU145) cancer cells. B) Immunoreactivity of anti-MUC1 di-scFv-PEG conjugate (D5c5D5-PEG) tested by IHC on MUC1 expressing breast (MCF7) and prostate (DU145) cancer cells in comparison to that of a MUC1 negative control MAb (Lym-1 reacts with HLA-DR determinants). Bars represent 20 mm.

Immunoreactivity of anti-MUC1 di-scFvs

Immunoreactivity of an anti-MUC1 scFv in the selected format (scFv-G^sub 4^S-C-(G^sub 4^S)^sub 3^-scFv) for the di-scFv-SH module was assessed in vitro and in vivo. In vitro binding to MUC1 peptide and lysates of MUC1 expressing cells was demonstrated in ELISA and IHC experiments showed that the di-scFv-SH (D5c5D5) bound to membranes of MUC1 expressing tumor cells (Figure 4A). For in vivo tumor binding evaluation, the di-scFv-SH (D5c5D5) was conjugated to [niIn]DOTA-maleimide and the purified [111In]DOTA-D5c5D5 conjugate, with an apparent MW of 52 KD, was injected into a mouse carrying bilateral subcutaneous DU145 tumor xenografts on its abdominal wall. Tumor targeting was visualized by y camera imaging (Figure 5).

Immunoreactivity of PEGylated MUC1 binding module was assessed in vitro. The anti-MUCl di-scFv-SH (D5c5D5) was PEGylated with a 5 KD linear bifunctional (methoxy and maleimide active groups) PEG and the di-scFv-PEG product, purified by gel exclusion chromatography, was tested for its MUC1 binding activity. ELISA assays, with MUC1 peptide, MCF7 and DU145 cell lysates as Ags, showed that the immunoreactivity of the di-scFv-PEG was comparable to that of di- scFv-SH, the non-PEGylated counterpart. This result was substantiated by IHC on MUC1 expressing tumor cells (Figures 4A, B).

Figure 5.-In vivo tumor imaging with an anti-mucin 1 (MUC1) di- single chain antibody fragment (scFv). DU145 tumor xenograft gamma camera image. The arrows point to [111n]DOTA-anti-MUC1 di-scFv-SH (D5c5D5) uptake by tumors bilaterally implanted in the abdominal wall of a nude mouse, as visualized 1 day after tail vein injection. The DU145 tumor xenograft best visualized was smaller (about 250 mg) in size than the larger (about 450 mg) necrotic tumor, nearly undetected at 24 h postinjection. Strong kidney and bladder uptakes are also visualized.

Discussion

The choice to target a MUC1 peptidic epitope, carried by the VNTRs of the MUC1 extracellular domain, is justified by the presence of abundant hypoglycosylated MUC1 forms on epithelial cancers, such as breast and prostate cancers.32,56

Assembly of the MUC1 pretargeting molecule for imaging and pretargeted RIT of metastatic breast and prostate cancers requires three major components: a tumor Ag binding module, a radioactive hapten capturing module and a bifunctional PEG for covalent attachment of the binding and catching modules.

The MUC1 binding module, developed as a di-scFv-SH and optimized to scFv-G^sub 4^S-C-(G^sub 4^S)^sub 3^-scFv, has an apparent MW of 52 KD and is ready for use. The radioactive hapten capturing module, consisting of an anti-DOTA (radioactive metal) scFv, has been developed in two formats: scFv-SH and di-scFv-SH. While the design of the MUC1 pretargeting molecule is definitively set for bivalent binding to tumor Ags, capture of the radioactive hapten will be either mono or bivalent. The choice between a scFv-SH or di-scFv-SH capturing module will ideally be based on in vivo performances of bispecific (scFv)^sub 2^-PEG-scFv and (scFv)^sub 2^-PEG-(scFv)^sub 2^ MUC1 pretargeting molecules. Steric hindrance, created by the hydrophilic bulky PEG, that accounts for the well known benefits of PEG conjugates, such as reduced immunogenicity, increased half-life and solubility and protease resistance, also limits PEGylation yields by reducing protein accessibility.57 Because steric hindrance should be reduced by the use of shorter PEG molecules,57 the PEG scaffold in the MUC1 pretargeting molecule should not exceed 10 KD in size. Therefore, the MW of such a molecule will be 75-85 KD for (scFv)^sub 2^-PEG-scFv and 100-110 KD for (scFv)^sub 2^-PEG- (scFv)^sub 2^ and in either case large enough to prevent rapid elimination from the circulation through glomerular filtration.

Various approaches to increase PEGylation efficiencies of scFv- SH and di-scFv-SH modules are under investigation. One such approach, consists of using 1, 2, 3 trizole ligation (“click chemistry”) for covalent attachment to a bifunctional (azide/tri- alkyne) PEG scaffold of the binding and capturing modules. This approach has yielded up to 74% scFv-PEG-scFv molecules and provides control over the composition of the product.58 Because attachment of smaller molecules to a bifunctional and small size PEG is more efficient, the likelihood to increase the assembly yield of (scFv)^sub 2^-PEG-scFv molecules is higher than that of (scFv)^sub 2^-PEG-(scFv)^sub 2^ molecules. On the other hand, a significant yield improvement for (scFv)^sub 2^-PEG-(scFv)^sub 2^ might be achieved by using a bifunctional short PEG, such as a 2 KD PEG- Mal^sub 2^, with bispecific, anti-MUC1 and anti-radioactive hapten, di-scFv-SH.

The fact that valency prevails over MW for superior tumor retention 59 might not be critical for the radionuclide capture module of the MUC1 pretargeting molecule, suggesting that the goal to be reached, TI improvement of RIT, can be achieved with bispecific tri- or tetravalent pretargeting molecules. Recently, a carcinoembryonic antigen pretargeting molecule, as a bispecific trivalent Fab construct assembled through the dock and lock method, showed high tumor localization in a human colonic carcinoma model.60

In summary, the preclinical development of MUC1 pretargeting molecules for RIT of metastatic breast and prostate cancers is in its final stages. PEGylation efficiencies of the binding and capturing modules will influence the final valency of these molecules: bispecific, tri- or tetravalent scFvs. Presentation at the 18th IRIST meeting, London, July 12-14, 2006.

Funding.-This research was supported by National Cancer Institute Grant PO1 CA47829, U.S. Department of Energy Grant DE-FG01- 00NE22944 and Department of Defense Grant DAMD17-01-0177.

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H. ALBRECHT, G. L. DENARDO, S. J. DENARDO

Davis Medical Center

University of California, Sacramento, CA, USA

Address reprint requests to: S. DeNardo, MD, Radiodiagnosis and Therapy, University of California, Davis Medical Center, 1508 Alhambra Boulevard, Room 3100, Sacramento, CA 95816, USA.

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Candlelight Vigil Planned for San Jose Teen Killed in Car Crash

By Mark Gomez, San Jose Mercury News, Calif.

Jan. 11–A candlelight vigil will be held tonight for the San Jose teenage girl who was killed in a car crash earlier this week.

Family and friends of Jessica Stephens, 16, will gather at 7 p.m. at the intersection of San Tomas Expressway and Hamilton Avenue, the site of the fatal accident. Jessica was killed early Wednesday morning when the Honda CRX she was riding in drove through a red light, while traveling 30 mph above the posted speed limit, and collided with a minivan, according to the California Highway Patrol. Jessica was riding illegally in the back of the two-seat vehicle.

The driver of the Honda, 19-year-old Eduardo Perez, suffered major injuries and remains in critical condition at Santa Clara Valley Medical Center, according to hospital spokeswoman Joy Alexiou. Todd Thibodeau, a spokesman for the CHP, said Perez will be arrested on suspicion of vehicular manslaughter with gross negligence.

On Thursday, hours after the death of the Prospect student, friends set up a large memorial at the northeast corner of the expressway and Hamilton Avenue. By evening, flowers, stuffed animals, balloons and photos sparkled in the light of numerous candles while students and parents quietly huddled at the scene before somberly walking away.

Funeral services will be held Tuesday at 1 p.m. at Hope Church, located at 1975 Pollard Road in Los Gatos.

Staff writer Gary Richards contributed to this report. Contact Mark Gomez at [email protected] or (408) 920-5869.

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Adventist Bolingbrook Hospital Opens to the Public

BOLINGBROOK, Ill., Jan. 11 /PRNewswire/ — The first new hospital in Illinois in more than 25 years will officially open its doors on Monday, January 14. After three years of construction, Adventist Bolingbrook Hospital received glowing clinical and facility reviews from the Illinois Department of Public Health and is set to begin providing much-needed medical care to residents of the Will County region and beyond.

The new 138-bed hospital will include 106 medical/surgical beds, 20 obstetric beds and 12 intensive care beds, along with a Level II trauma center. Patient rooms will include the latest amenities such as sleeper sofas for overnight family stays, flat screen TVs, wireless Internet access and room service. The 300,000 square-foot hospital will be one of the area’s largest employers and is intended to meet the growing healthcare needs of the communities in and around Will County.

“We are looking forward to treating our very first patient on Monday,” said Isaac Palmer, Chief Executive Officer of Adventist Bolingbrook Hospital. “We are excited for the community to finally get a chance to see what we have to offer from the state-of-the-art medical equipment to the amenities in the private patient rooms.”

Nearly 2,000 area residents took advantage of a sneak peak inside the state-of the-art facility at a community celebration on Sunday, November 18, 2007.

The hospital will employ approximately 600 area residents including management positions, nurses and other clinical and support staff. The architectural design combined with the latest medical advances and the soothing patient amenities reflect the whole-person mission for which Adventist Midwest Health is known.

“It is a privilege for Adventist Bolingbrook Hospital to be providing the communities we serve needed medical care, close to home. Our spectacular team of physicians, nurses and caregivers is focused on providing better healing and wellness for the region,” said Palmer. “By defining healthcare from the viewpoint of the patient, we hope to change the way people think about hospitals.” For more information on the new Adventist Bolingbrook Hospital, please visit http://www.keepingyouwell.com/.

Adventist Bolingbrook Hospital

CONTACT: Julie Busch, +1-630-312-7559, [email protected], forAdventist Bolingbrook Hospital

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

The Beginning of a New Invasive Plant

By Culley, Theresa M Hardiman, Nicole A

The Callery pear (Pyrus calleryana Dcne. [Rosales: Rosaceae]), an ornamental tree from China, has begun appearing in disturbed areas throughout the United States. To understand the relatively recent spread of this species into natural areas, we review its horticultural history, the traits promoting its invasiveness, and its current invasive status. Cultivated varieties (cultivars) of this species sold in the United States originate from different areas in China and represent genotypes that have been planted in high densities in residential and commercial areas in the introduced range. The species cannot self-pollinate because of a self- incompatibility system, but recent fruit set is due to crossing between different cultivars or between the scion and rootstock of cultivated individuals. Consequently, individual cultivars themselves are not invasive, but the combination of cultivars within an area creates a situation in which invasive plants can be produced. Because of the established nature of this species in urban areas, the spread of wild P. calleryana will most likely continue, especially as new cultivars continue to be introduced into the mixture of cultivars already present. Keywords: Callery pear, cultivar, intraspecific hybridization, invasiveness, Pyrus calleryana

Invasive plant species can inflict tremendous economic and ecological costs on agriculture and on natural ecosystems (Pimentel et al. 2000,2005), but scientists still do not fully understand why some species become invasive and others do not. Successful invasions involve introduction and establishment in a new area, followed by a lag phase and then by spread, which can lead to major ecological and human impacts (Sakai et al. 2001). Most studies have focused on invasive plant species that have already had substantial ecological or human impacts, such as purple loosestrife (Lythrum salicaria; Brown et al. 2002) and spotted knapweed (Centaurea maculosa; Suding et al. 2004). In contrast, species beginning their spread have received relatively little attention, largely because of the difficulty in locating them before they are well established as invasives. If these species could be identified at the initial spreading phase, the eventual high cost of their control and eradication (Pimentel et al. 2005) could be reduced.

A species can be introduced to a new locality in many ways, either accidentally (e.g., as contaminants in shipping) or deliberately (e.g., for medicinal use). One source of deliberate introduction is through horticulture (Burt et al. 2007), in which plant species are imported by plant explorers, various botanical gardens and arboreta, garden club seed exchanges, some plant nurseries, and the seed trade industry (Reichard and White 2001). Although most species introduced for horticulture are not invasive, a small portion have escaped from cultivation and spread into natural areas (Reichard and White 2001). Given the high cost of controlling invasive species (Pimentel et al. 2005), it is imperative to revisit the role of horticultural introductions in plant invasions today.

An introduced species that is in the early stages of spread in the United States is Pyrus calleryana Dene. (Rosales: Rosaceae), an ornamental tree frequently planted in urban residential and commercial areas. This species is native to China, Taiwan, Korea, Vietnam, and Japan, where it has a broad ecological range, inhabiting slopes, plains, mixed valley forests, and thickets (Cuizhi and Spongberg 2003). Commonly known as the Callery pear, this species is sold primarily in the form of various cultivated varieties (cultivars). Each cultivar is a collection of identical plants propagated clonally from a single individual selected for one or more unique and desirable characteristics (e.g., abundant flowering, vibrant fall color). As such, cultivars are variants of the same species that are maintained in cultivation. Wild populations off! calleryana can now be found throughout the United States (figure 1; Vincent 2005) in disturbed sites with high light, including transportation corridors, park boundaries, and restored wetland prairies. The latitudinal range of wild individuals in the United States corresponds to the range of the species in China (figure 2; Qian and Ricklefs 1999). Wild individuals grow rapidly, flower at a young age, and often generate fruit that is dispersed by birds such as introduced European starlings. The importance of P. calleryana in the horticultural industry over past decades has made it possible to document its history and spread. In this article we (a) review the horticultural history off! calleryana to understand how it has affected the species’ present distribution, (b) examine the biological traits promoting its invasiveness, and (c) document the current invasive status of the Callery pear. These are necessary first steps to control the species as it begins to exert substantial ecological and economic effects within its introduced range.

Figure 1. Typical invasive Pyrus calleryana individual flowering in southwestern Ohio, in early spring. Photograph: Theresa M. Culley.

Historical overview

Although today P. calleryana is grown primarily for ornamental use, it was initially brought to the United States to combat fire blight in the common pear (Pyrus communis). This potentially fatal disease is caused by the bacterium Erwinia amylovora, which is spread by pollinators. In the early 1900s, the cultivated pear industry in the western United States was being decimated by fire blight, which caused the loss of more than 86% of the annual crop (Meyer 1918). Frank Reimer, at the Southern Oregon Experiment Station, began searching for resistant Pyrus species to use in breeding programs and as rootstock for P. communis. He found that P. calleryana was mostly resistant, but few individual plants were available. At Reimer’s request, US Department of Agriculture (USDA) plant explorer Frank Meyer agreed to collect at least 100 pounds (45 kilograms [kg]) of P. calleryana seed in China so that enough genotypes could be examined to develop the much-needed resistant strain of P. communis (Cunningham 1984).

During his last trip to China, from 1916 to 1918, Meyer collected P. calleryana seed primarily in and near JTngmPounds n and also in Yichang, where a resistant genotype had once before been collected (Meyer 1918). It was difficult to collect an adequate number of seeds because trees with substantial fruit were hard to locate, seed processing was very tedious, and contamination with Pyrus betulifolia (whose fruit is similar in appearance) was initially common. Small batches of seed were periodically sent to the USDA, including 18.5 pounds (8.4 kg) of a locally cultivated form of P. calleryana (USDA accession number SPI 45586) as well as wild seeds collected on Meyer’s behalf by an American missionary in Henan Province (SPI 45594). Meyer’s inability to quickly collect a substantial amount of seed was disappointing to those who hoped to begin surveying new genotypes for fire blight resistance. Consequently, Reimer traveled to Asia in 1917, first locating P. calleryana in southern Japan and then in southern and central Korea. He eventually joined Meyer in jTngmen, in China’s Hubei Province, where they collected P. calleryana fruits together before traveling to Yichang. During their weeks together, Meyer dispatched several batches of P. calleryana seed back to the USDA (all recorded as SPI 45592). Reimer also collected over a hundred kilograms of fruit in the mountainous Jmgang shan area (northwest of Yichang).

After Meyer’s death in China in 1918, additional collections of P. calleryana continued to be imported into the United States for fire blight testing. Most significant among these was an accession of seeds purchased in Nanjing, China, in 1919 (SPI 47261), from which the popular ornamental cultivar ‘Bradford’ originated. Reimer also returned to China in 1919, making a second collection of P. calleryana in Shandong Province, much farther north than he had been in his previous visit (Westwood 1980). Unfortunately, he did not maintain his 1917 and 1919 collections separately, so the exact Chinese origin of individual seedlings from these collections (one of which became the Autumn Blaze’ cultivar) is unknown. P. calleryana seeds continued to be collected several decades after these initial explorations and eventually became commercially available for plant breeders and nurseries.

The screening of P. calleryana for fire blight-resistant genotypes in the United States involved planting large numbers of seeds and inoculating the resulting seedlings to determine their susceptibility to the disease. Many hectares of land were seeded with P. calleryana in Medford, Oregon, where Reimer was conducting his experiments, and in Glenn Dale, Maryland, at the USDA Plant Introduction Station. Although these initial studies focused on fire blight resistance and on overall vigor and scion-rootstock compatibility (Whitehouse et al. 1963a, 1963b), P. caileryanas tolerance to a wide variety of detrimental environmental conditions, such as drought, soon became apparent. The Callery pear’s hardiness eventually led to the use of the species as a common rootstock for a variety of cultivated Pyrus species. It was in one of these outplantings of P. calleryana, in Glenn Dale, Maryland, that the ornamental potential of the species was first recognized. By 1950, there were still a few P. calleryana trees remaining at the USDA Plant Introduction Station that originated from the planting of seed from Meyer’s SPI 47261 collection decades earlier (Santamour and McArdle 1983). In 1952, the ornamental possibilities of one particular vigorous, thornless tree were recognized, and cuttings of it were grafted onto P. calleryana seedlings at the USDA station (Creech 1973). These clones were then planted in a nearby treeless residential subdivision for testing as an ornamental street tree (Whitehouse et al. 1963a, 1963b). After eight years, the success of these carefully pruned test trees was apparent, and the cultivar was given the name “Bradford” in honor of a horticulturalist at the station (Whitehouse et al. 1963a, 1963b). By 1962, the tree was available commercially, and it eventually became one of the most widely planted boulevard trees in urban areas in the United States. Prized for its white spring flowers, rapid growth, compact form, and glossy, dark green leaves, ‘Bradford’ continues to be propagated today by grafting cuttings (scions) onto P. calleryana rootstock.

Figure 2. The United States and China are located at similar latitudes. Provinces in China where Pyrus calleryana are found (shown in black) are at the same latitude as areas in the southeastern United States where the species is already invasive. Source: Adapted from Qian and Ricklefs (1999).

The Glenn Dale station was also the origin of other Callery pear cultivars (see <>. edu/faculty/culley/Pyrus. htm). For example,’Whitehouse’ was selected in 1969 and released in 1977 after it was found growing near the vicinity of the station in a population of 2500 pear seedlings that were offspring from the original set of trees planted at the station decades earlier. The original tree was an open-pollinated, thornless seedling, presumably resulting from a cross between two of the many P. calleryana individuals growing at the site (Cunningham 1984). The National Arboretum is credited with introducing the ‘Capital’ cultivar, of unknown parentage, which was developed in 1981. This cultivar has an even narrower shape than ‘Whitehouse’, making it ideal for use as an ornamental screening tree or in locations where space is limited (Cunningham 1984). Both the ‘Capital’ and the ‘Whitehouse’ cultivars produce more blooms than other Callery pear cultivars (Kuser et al. 2001). />

Several P. calleryana cultivars originated in the western United States, primarily in Oregon, near Reimer’s original outplantings. For example, a seedling with striking fall leaf coloration was found growing at the Lewis-Brown Horticultural Farm in Corvallis, Oregon (Westwood 1980). The seedling originated from P. calleryana trees introduced to the area by Reimer, who grew them from seed obtained from his Chinese expeditions (Westwood 1980). The tree was cloned by grafting onto seedling P. calleryana rootstock and later by budding onto P. communis or Pyrus fauriei seedlings; in the latter case, the clone exhibited a dwarf phenotype. In 1978, the cultivar was patented as ‘Autumn Blaze’, and it is still sold today.

As Callery pears grew in popularity, many nurseries began developing and releasing their own cultivars. For example, ‘Aristocrat’ was selected in 1969 from a large number of P. calleryana seedlings growing at a nursery near Independence, Kentucky. These seedlings originated from Chinese seed originally collected by Meyer. The selected tree had a strong central leader with horizontal branches and an early pyramidal form (Storey 1996). One of the most popular Callery pear cultivars today is’Chanticleer’, named the 2005 Urban Tree of the Year by the Society of Municipal Arborists (Phillips 2004). ‘Chanticleer’ was cloned from a street tree in Cleveland, Ohio (Santamour and McArdle 1983), which was originally derived from commercial seed purchased in 1946. This tree proved so remarkable that it was cloned several times, resulting in the independent development of several cultivars (‘Cleveland Select’, ‘Stone Hill’, ‘Select’, and ‘Glenn’s Form’), all of which are genetically identical to ‘Chanticleer’.

As Callery pear cultivars were being developed and released, the original and highly popular ‘Bradford’ cultivar was found to have a major structural flaw. The narrow crotch angles of the branches eventually caused individual trees to split under their own weight after approximately 15 to 20 years of growth. Consequently, urban arborists began to promote other Callery pear cultivars with improved branching patterns, such as ‘Aristocrat’ (Kuser et al. 2001) and ‘Chanticleer’. ‘Bradford’, however, is still preferred in many areas of the United States because it has better resistance to fire blight than other cultivars (Gilman and Watson 1994). All commercially available trees continue to be formed by grafting the desired scion onto different P. calleryana rootstock or by budding. Ornamental pear trees planted in urban areas are now a mix of different cultivars, in which ‘Bradford’ still retains a significant role. Consequently, many of the cultivars sold today in the United States contain genotypes, whether scion or rootstock, that represent different parts of the native Chinese range of P. calleryana.

Species biology

Pyrus calleryana possesses many traits that contribute to its ability to spread into a variety of environments. These includes reproductive characters, a self-incompatibility system that promotes outcrossing, resistance to disease and herbivory, and tolerance of different environmental conditions. These biological attributes are found in the native range of the species and enhance P. calleryana’s ability to spread and persist in new locations.

Reproduction. Pyrus calleryana is a perennial tree that begins flowering at approximately three years of age. It is one of the first trees to leaf out in the early spring and one of the last to retain its leaves in late autumn. Flower buds of this species are produced in early spring before leaf formation, and typically appear grouped together in approximately 6 to 12 flowers per inflorescence (Cuizhi and Spongberg 2003). Individual flowers are protandrous, about 2 to 2.5 centimeters (cm) in diameter, and consist of five sepals, five petals, two sets of 10 anthers each that differentially dehisce, and two to five carpels (Cuizhi and Spongberg 2003) with two ovules per locule. This produces a maximum seed number of 10, although the actual number is usually between 2 and 6. The flowers are strongly malodiferous and are highly attractive to insect pollinators, including generalist honeybees (Apis mellifera L.), bumblebees (Bombus terrestris L.), other introduced bees, and hoverflies (Syrphidae) (Farkas et al. 2002). Fruits take several months to develop and remain on the tree until they mature in early to late autumn (August to October). The fruits are consumed and the seeds dispersed in late fall by a variety of animals, such as European starlings and American robins (Gilman and Watson 1994, Swearingen et al. 2002). A prominent seed bank is likely for P. calleryana because its seeds possess secondary dormancy if exposed to warm temperatures in late winter (Huxley 1999). The species is diploid (In – 34; Zielinski and Thompson 1967, Cuizhi and Spongberg 2003).

Self-incompatibility. Like other members of the Rosaceae, P. calleryana is self-incompatible (Zielinski 1965) and thus cannot produce fruits through self-pollination. Such selfincompatibility is due to the genetically controlled system in P. calleryana, known as gametophytic self-incompatibility. In this system, pollen tubes begin to grow down the styles of both compatible and incompatible mates, but if the haploid pollen grain shares the same self- incompatibility allele as the diploid maternal tissue, the pollen tube is prevented from reaching the ovule (de Nettancourt 2001). Compatible crosses can occur only between haploid pollen and diploid maternal tissue with no self-incompatibility allele in common, but fruit set can still occur in crosses between parents that share one self-incompatibility allele (a semicompatible cross). The gametophytic self-incompatibility system is present in fruit species such as apple, cherry, almond, and some plum and apricot cultivars, as well as other Pyrus species (Tomimoto et al. 1996, Zuccherelli et al. 2002).

The occurrence of self-incompatibility in P. calleryana is consistent with the observation decades ago that Callery pear trees (originally composed primarily of the ‘Bradford’ cultivar) only rarely produced viable fruit (Zielinksi 1965, Swearingen et al. 2002) and that these fruit were very small, with few seeds. More recently, however, abundant fruit set has been detected in many cultivars growing in urban areas (Swearington et al. 2002). Furthermore, fruits almost always form after hand pollinations between cultivars. This increase in P. calleryana fruit formation probably reflects the diversity of different cultivars planted today within crossing distance of one another. Because individual trees within each cultivar are clones, all individuals of a cultivar contain the same selfincompatibility genotype, thereby causing incompatibility in self-crosses and within-cultivar crosses. There is an exception: if the rootstock of a cultivated tree is allowed to sprout, it may cross with a scion that is genetically different. Fruits are often produced by crosses between cultivars that differ by at least one self-incompatibility allele; this may explain recent fruit set in urban areas where a mix of cultivar types typically occur, especially those that have different Chinese ancestry and are therefore more likely to contain different self-incompatibility genotypes. Disease and herbivory. One reason the Callery pear is so popular is that it is more resistant to disease and pests than many other ornamental trees. Although all P. calleryana cultivars have some degree of resistance to fire blight, ‘Bradford’ has consistendy higher resistance (Gilman and Watson 1994), whereas ‘Whitehouse’ is more susceptible to the disease (Gerhold 2000), especially in warm and humid southern states where fire blight is more common. ‘Bradford’ is highly resistant to the Japanese beetle (Popillia japonica; Keathley et al. 1999) but is susceptible to the pearleaf blister mite (Eriophyes pyri)-a species that also feeds on leaves of ‘Chanticleer’, ‘Redspire’, and ‘Whitehouse’, causing significant foliar injury (Gill 1997). P. calleryana resists wood-boring beetles (Anoplophora glabripennis), apparently by producing chemical compounds that interfere with normal beetle growth and development (Morewood et al. 2004).

The Callery pear is susceptible to several herbivores. Damage from white-tailed deer has been observed in cultivated varieties of P. calleryana (e.g.,’Bradford’,’Chanticleer’, and ‘Aristocrat’) and in other ornamental Pyrus cultivars (Kays et al. 2003). The susceptibility of wild trees to deer damage remains unknown, although herbivory may be deterred in some wild plants by the production of thorns along stems and branches, a condition often seen within P. calleryana s native range in Asia. The thorns are not typically lost in mature shoots of wild P. calleryana, as they are in several other Pyrus species that also possess this phenotype. In me case of wild P. calleryana, protective thorns may enhance individual fitness by reducing herbivory.

Environmental tolerance. Callery pear cultivars are known for their ability to tolerate a wide range of environmental conditions, including moisture, disease, and pollution. Consequently, these cultivars are ideal street trees for urban locations, where such conditions often prevail. Such tolerance reflects the wide habitat variation of the species in its native range, as Meyer (1918) noted while in Yichang:

Pyrus calleryana is simply a marvel. One finds it growing under all sorts of conditions; one time on dry, sterile mountain slopes; then again with its roots in standing water at the edge of a pond; sometimes in open pine forest, then again among scrub on blue-stone ledges in the burning sun; sometimes in low bamboo-junglc.and then again along the course of a fast flowing mountain stream or on the occasionally burned-over slope of a pebbly hill. The tree is nowhere found in groves; always as scattered specimens, and but very few large trees were seen. (p. 91)

The ability of P. calleryana to persist in variable and adverse soil conditions is also a reason for its success as rootstock for Pyrus species that are cultivated for fruit consumption (e.g., P. communis) or ornamental use. In China, young P. calleryana saplings are commonly used for rootstock if they are found naturally growing in a suitable location, where they could be grafted in situ.

Callery pears in general adapt well to different soils (including clay) of variable pH and also tolerate restricted root zones, pollution, drought, and heat. Consequently, many cultivars grow well in tree islands located in paved parking lots or planted along residential streets, often under utility wires (e.g., Gerhold 2000, Kuser et al. 2001). Despite these harsh and constricted environments, Callery pear cultivars exhibit rapid growth and establishment and, if pruned properly, can eventually become established shade trees.

Despite their general tolerance, Callery pear cultivars are limited in two respects. First, P. calleryana cannot tolerate extreme cold and will not survive where temperatures fall lower than -28 degrees Celsius (Phillips 2004). Consequently, cultivars do not perform well in the northern United States, where very cold winter temperatures predominate. The species is currently recommended for planting only in USDA Plant Hardiness Zones 5-9 (Gilman and Watson 1994), but its ability to invade new habitats, and therefore its potential invasive range, may expand northward as a result of global warming. second, P. calleryana and its cultivars do not tolerate shade well, preferring instead high-light environments. Wild P. calleryana are rarely found in the understory of larger trees; they prefer open or disturbed habitats where they may form dense, monocultural stands.

Current spread and invasion

In recent years, Callery pear seedlings have begun to appear in many natural areas in the eastern United States (Stewart 1999, Swearingen et al. 2002, Haldeman 2003, Vincent 2005). As documented by herbarium records (Vincent 2005), the earliest escaped plants were identified in 1964 in eastern Arkansas and in 1965 in Talbot County, Maryland. Collections of wild P. calleryana increased over time, with 2% of herbarium specimens dated 1964-1979, 17% dated 1980- 1989, 31% dated 1990-1999, and 50% dated 2000-2003 (Vincent 2005). In 1994, ‘Bradford’ and related cultivars were considered to have little invasive potential (Gilman and Watson 1994), but more than 10 years later, wild P. calleryana is found in natural areas in at least 26 states (figure 3; Vincent 2005). The ‘Bradford’ cultivar is currently listed by the US Fish and Wildlife Service as a plant invader of mid-Atlantic natural areas (Swearingen et al. 2002). P. calleryana itself or the cultivar ‘Bradford’ is listed as invasive on plant lists in six states (Alabama, Georgia, North Carolina, Maryland, New Jersey, and Pennsylvania) and is on watch lists in four others (Tennessee, New York, South Carolina, and Oklahoma). Callery pears are also spreading from cultivation in Delaware and Arkansas, and in southwestern Ohio, Callery pear saplings and trees have been found in several urban parks that adjoin residential areas where cultivated ornamental pears are widely planted. In Australia, Callery pear is considered a potential environmental weed (Csurhes and Edwards 1998).

Figure 3. The recommended planting range of the ‘Bradford’ Callerypear (shown in gray) in the United States. The “x” denotes the 26 states in which wild Pyrus calleryana has been collected or observed. This consists of the 23 states found by Vincent (2005) and the states of Virginia (M. Becus, voucher #103031 and n0306b, CINC), Oklahoma (Taylor etal 1996), and Connecticut (L.J. Mehrhoff, #124627 CONN). Source: Adapted from Fact Sheet ST-537 from the University of Florida, Institute of Food and Agricultural Sciences (November 1993).

Reasons for the spread. The ornamental use of P. calleryana in the United States and certain life history traits have been instrumental in affecting the species’ expansion within its introduced range. Because of the popularity of Callery pear cultivars, the species has been planted at high densities in many urban areas across the United States, where the trees are cultivated to maximize growth. In contrast, Meyer (1918) wrote that trees in China “are often quite small,” and “altho’ not rare in the hills around here, the trees are very widely scattered.” Because cultivars commonly planted in the United States typically originate from different regions of China, they represent genotypes that would normally never encounter one another within the native range. By transporting these genotypes to another country, cloning them in large quantities, and planting them together in mixed combinations supplied with resources, a situation has been created in which cultivars with different self-incompatibility genotypes can now readily cross with one another and produce fruit. Such intraspecific hybridization between cultivars, and possibly interspecific hybridization with other escaped Pyrus species, has been suggested as an explanation for the recent expansion of the Callery pear (Stewart 1999, Vincent 2005).

Propagation of the Callery pear by grafting cultivar scions onto P. calleryana rootstock could also contribute to the spread of the species in the United States when trees are not properly maintained. There are cases of Callery pear infestations at abandoned nurseries (e.g., Taylor et al. 1996) where the rootstock has sprouted and flowered, potentially allowing it to cross with the genetically distinct scion. Thus a single cultivated tree can produce fruit under the proper conditions. Rootstock sprouting may occur at random or when roots near the soil surface are nicked by lawn machinery.

Many life history traits of P. calleryana have also contributed to its ability to spread, especially in disturbed sites associated with human settlement. These include a generalist pollination system which, along with self-incompatibility, promotes outcross fertilization and thereby maximizes reproductive output and genetic variation in founding populations. seed dispersal into natural areas is promoted by indiscriminant and abundant birds, and a seed bank enables the species to persist in areas after adults have been removed. Furthermore, some traits of the Callery pear that were specifically selected during its development as an ornamental tree could also promote invasiveness. These include rapid growth, abundant flowering, and wide environmental tolerance. Many of these characteristics of P. calleryana are typical of an ideal weed (Baker 1974, Newsome and Noble 1986, Roy 1990, Shiftman 1997, Sakai et al. 2001).

Impact on the environment. The environmental and ecological effects of P. calleryana have yet to be thoroughly examined, but evidence thus far points to several detrimental impacts. Because of its rapid growth and preference for highlight environments, P. calleryana can potentially impede the establishment of late- to middle-stage successional species in disturbed sites. P. calleryana can also form dense, thorny thickets, especially from the root sprouts of abandoned trees. These thickets, which are impenetrable to humans, may provide cover for birds and small mammals. Pyrus calleryana fruit is also consumed by birds, albeit mostly by introduced European starlings. Wild pears are an unwanted addition in newly restored wetland prairies, where they sprout readily and compete with planted native species. The removal of wild P. calleryana is often hampered by the thorny phenotype of some individuals. From a horticultural standpoint, P. calleryana also exhibits some undesirable traits that offset its widespread popularity. The susceptibility of certain Callery pear cultivars to breakage has led some towns and cities to stop planting them, or even to remove them along streets, to avoid liability from falling limbs (Fulcher 2002). Callery pears can also drop soft fruits on the ground in some areas, causing unsightly litter and posing a danger to foot traffic (Fulcher 2002). The widespread planting of Callery pears in some areas also results in unpleasing aesthetic effects because of their overuse in the urban landscape (Dirr 1998).

Removal and control. There are few documented management strategies for the Callery pear. The most effective control practice for wild trees is complete removal (Swearingen et al. 2002). For large trees that have been cut down, an appropriate systemic herbicide, such as concentrated glyphosate or triclopyr, must be applied immediately to all parts of the freshly cut trunk to prevent regrowth (Swearingen et al. 2002). Trees can also be girdled about 15 cm above the ground during spring and summer, if complete removal is not possible. Mowing of saplings and small trees is ineffective, because the species readily sprouts from any existing trunk or root system. Seedlings and shallow-rooted plants can be pulled up with care if the soil is moist (Swearingen et al. 2002).

To prevent the formation of wild P. calleryana plants, homeowners and landscape designers should consider alternative tree species (Jones 2004, Burrell 2006). These include the Allegheny serviceberry (Amelanchier laevis), fringe tree (Chionanthus virginicus), green hawthorn (Crataegus viridis), and two-winged silverbell (Halesia diptera var. magniflora). If landowners wish to retain established cultivated Callery pear trees, a control method to prevent fruit production is to spray the tree during full bloom with the chemical ethephon, which is 95% effective at preventing fruit set while preventing premature blossom drop (Perry and Lagarbo 1994). Sucker growth at the base of the tree trunk should also be removed promptly to prevent possible growth, flowering, and cross-pollination with the scion. Additional research is needed on the effectiveness of different herbicides and control treatments.

Implications of invasion

Pyrus calleryana demonstrates the importance of the horticultural pathway in the invasion process. Consumer demand for unique and novel plant species facilitates the introduction of nonnative species, which are then mass-produced, transported, and distributed locally to gardeners and landscapers. This greatly accelerates the natural process of introduction, especially given increased global commerce and the availability of plants for purchase over the Internet. Although most plant species introduced for horticulture, agriculture, or forestry are not invasive, a small proportion of introduced species do spread into natural areas (Reichard and White 2001). Most woody invasive plant species, such as P. calleryana, were originally introduced into the United States for horticultural or agricultural purposes. For example, Reichard (1997) reported that 82% of 235 woody invasive species were originally used for landscaping, 14% were used for agriculture, 3% were introduced as ornamentals but used primarily for soil erosion control, and 1% were introduced accidentally.

Horticultural introductions of plant species have the potential to promote invasiveness in several different but not mutually exclusive ways. First, cultivars themselves may escape and form invasive populations. For example, invasive populations of fountain grass (Pennisetum setaceum) contain a single genotype identical to that found in commercially available seed (Poulin et al. 2005). Invasive populations of ivy (Hedera spp.) also contain commercial cultivars in addition to putative hybrids (Clarke et al. 2006). second, cultivars may cross-fertilize with related native or introduced species nearby, as is already documented for different taxa (Ellstrand and Schierenbeck 2000). Third, genetically distinct cultivars may cross-fertilize with one another, resulting in viable offspring in which genetic recombination creates novel genotypes (intraspecific hybridization). This occurs not only in P. calleryana but also in L. salicaria, in which self-sterile cultivars can successfully cross-fertilize with one another (Anderson and Ascher 1993; James Amon, Department of Biological Sciences, Wright State University, Dayton, Ohio, personal communication, 29 August 2007). Fourth, the rootstock of grafted individuals can potentially sprout and reproduce by crossing with the upper scion (as described for P. calleryana) or related species. Alternatively, the rootstock itself can become invasive, as is the case for the multiflora rose (Rosa multiflora), which was originally used as rootstock for cultivated roses and planted as a living fence. Finally, some cultivars may be preadapted for invasion because of horticulturally desirable traits selected during their development (e.g., abundant flowering, environmental tolerance) as well as innate traits developed in their native habitat (e.g., allelopathy). In the evergreen shrub Ardisia crenata, for example, selection for showy appearance and dense foliage has resulted in slower growth but greater competitive ability in invasive populations (Kitajimaetal.2006).

Reducing the number of invasive or potentially invasive plant introductions will require participation at all levels of the horticultural pathway. Plant breeders and growers need to identify potentially invasive species and cultivars before they are released. To this end, scientists must develop accurate predictive models (e.g., Reichard 1997) to pinpoint informative traits with which breeders can screen their stock for invasiveness. In some cases, cultivars are already being assessed in trials for invasive traits such as abundant seed set and high seed germination (Lehrer et al. 2006, Wilson and Knox 2006).

Future tests should measure competitive ability (Anderson et al. 2006), incorporate environments that mimic conditions where spread could occur, and include pollinations between cultivars to determine compatibility and relative fecundity. Ideally, breeders would develop suitable and profitable alternatives to potential invaders, such as completely sterile cultivars of highly popular species (Li et al. 2004). Voluntary initiatives should also be encouraged for the horticultural industry, including growers, local plant nurseries, and home improvement stores, to encourage self- regulation to minimize plant invasions (Burt et al. 2007). Finally, because consumer demand drives much of horticultural development, it is crucial to educate the general public about the impacts of invasive plants and to offer examples of noninvasive alternatives. Ultimately, scientists, plant breeders, nursery personnel, land managers, and the general public all must work together to prevent the introduction of invasive plant species through the horticultural pathway.

Conclusions

In the United States, P. calleryana’s status is that of an early invader that is spreading across many areas of the country. As such, individual cultivars themselves are not invasive, but the combination of cultivars within an area can create a situation in which invasive plants are produced. There is an urgent need to monitor the impact of P. calleryana on ecosystems and to determine effective methods of control. Because Callery pear cultivars are already established as landscaping trees in the urban environment, it is unlikely that the species will decline; in fact, the spread of wild P. calleryana will most likely continue in the next few decades, especially as new cultivars continue to be introduced. It remains to be seen whether the species will ultimately subsist as a minor nonnative component of the ecosystem or whether it will become an economically costly problem (Pimentel et al. 2005). By monitoring P. calleryana over the next decade, scientists may better understand certain plant traits as well as the role of intraspecific hybridization in promoting invasiveness (Ellstrand and Schierenbeck 2000). Ultimately, the Callery pear system may provide valuable insight into the evolution of invasiveness, particularly as it is influenced by the widespread popularity of ornamental plant species introduced into the United States.

Acknowledgments

We wish to thank Brian Baumgartner, Marjie Becus, Bob Fulcher, Keith Manbeck, James Mundy, and Michael Vincent for contributing information or field assistance. Chris Carr provided help in preparing the maps for figure 2, Richard Stokes and Jessica Gottmann contributed comments, and Ruby Culley assisted with earlier versions. The manuscript was also improved by comments from three anonymous reviewers. This research was supported by a grant from the US Department of Agriculture, Cooperative State Research, Education, and Extension Service, to T. M. C. (USDA CREES 06-35320-16565).

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Theresa M. Culley (e-mail: [email protected]) and Nicole A. Hardiman (e-mail: [email protected]) are with the Department of Biological Sciences at the University of Cincinnati in Ohio.

Potential Impacts of Climate Change on the Distribution of North American Trees

By McKenney, Daniel W Pedlar, John H; Lawrence, Kevin; Campbell, Kathy; Hutchinson, Michael F

Currently predicted change in climate could strongly affect plant distributions during the next century. Here we determine the present- day climatic niches for 130 North American tree species. We then locate the climatic conditions of these niches on maps of predicted future climate, indicating where each species could potentially occur by the end of the century. A major unknown in this work is the extent to which populations of trees will actually track climate shifts through migration. We therefore present two extreme scenarios in which species either move entirely into future climatic niches or do not move out of their current niches. In the full-dispersal scenario, future potential ranges show decreases and increases in size, with an average decrease of 12% and a northward shift of 700 kilometers (km). In the no-dispersal scenario, potential ranges decrease in size by 58% and shift northward by 330 km. Major redistribution pressures appear to be in order under both dispersal scenarios. Keywords: climate change, climate envelopes, North American trees, distribution, dispersal

There is strong evidence of a pending and profound change in global climate as a result of human activities (Karl and Trenberth 2003, IPCC 2007). Recent estimates predict an increase in global mean temperature of 2.4 to 6.4 degrees Celsius ([degrees]C) (IPCC 2007) and significant changes in the hydrologic cycle (Trenberth et al. 2003) by the end of this century.

Climate has long been identified as a primary control on the geographic distribution of plants (Forman 1964, Box 1981). Therefore, plant species may be expected to exhibit marked redistributions in response to climate change. Fossil pollen records from the Holocene period document such responses for a variety of plant species (e.g., Delcourt and Delcourt 1988, Malanson 1993, Williams et al. 2004). In addition, species are expected to be redistributed independently, forming new forest types with unique species combinations (Webb 1992, Williams et al. 2004).

To better understand the potential impacts of the current warming trend, considerable effort has gone into predicting the effect of future climate scenarios on various flora and fauna (Walther et al. 2002, Chambers et al. 2005, Shi et al. 2006). Iverson and colleagues (forthcoming) examined the potential redistribution of 134 tree species in the United States that would result from a doubling of current atmospheric levels of carbon dioxide (C02). They reported that, depending on the climate-change scenario, more than a quarter of those species could experience a northward range shift of more than 400 kilometers (km). A marked reorganization of major forest ecosystems has also been predicted for British Columbia, Canada (Hamann and Wang 2006), and Europe (Sykes et al. 1996). A more extensive, though considerably coarser-scaled, study was undertaken to examine the effects of a 3[degrees]C change on 15,000 native North American vascular plants (Morse et al. 1993). In this case, researchers reported a potential loss of 7% to 11% of continental plant diversity, with rare species with small geographic ranges being affected the most.

In this article, we report on the potential impacts of climate change on the climatic ranges of 130 species of North American trees- the most extensive, detailed study to date of tree species over the continent. Including both Canada and the United States in the analysis allows valuable insights into the extent of potential range shifts, which a more regional approach cannot accomplish (e.g., Shafer et al. 2001, Iverson and Prasad 2002). Furthermore, our tree species occurrence data have been generated from an extensive data- gathering effort and thus are more comprehensive than extractions from published range maps, a commonly used practice in climatechange studies. We hope these findings will provide policymakers and planners with broader contextual information on the potential impacts of climate change and help them develop adaptation strategies.

The climate-envelope approach

To predict plant response to possible climate change, climatic controls on current plant distributions must be quantified. In recent years, there has been a proliferation of methods developed for modeling species-environment relationships (Segurado and Araujo 2004, Guisan and Thuiller 2005, Elith et al. 2006, Heikkinen et al. 2006, Pearson et al. 2006). Here, we use the climate envelope (CE) approach, as implemented in the climate-envelope software ANUCLIM (Nix 1986, Houlder et al. 2000), to summarize the climatic niche of the tree species under study. This approach was used because it is conceptually straightforward, transparent, and well suited to presence-only data. CEs have been used extensively for investigating plant and animal responses to climate change (Bartlein et al.1986, Busby 1988, Brereton et al. 1995, Huntley et al. 1995, Eeley et al. 1999, Box et al. 1999, Berry et al. 2002, Pearson et al. 2002).

Critics have questioned the validity of the CE approach because it does not take into account nonclimatic factors that play important roles in determining species distributions and the dynamics of distribution change. These factors include competition and predation (Davis et al. 1998, Hampe 2004), edaphic and land-use controls (Iverson and Prasad 1998), dispersal ability (Lawton 2000, Hampe 2004), and the rate of genetic adaptation in response to environmental change (Etterson and Shaw 2001, Hampe 2004). In a response to these criticisms, Pearson and Dawson (2003,2004) pointed out that most of these concerns are minimized when CEs are employed and interpreted at broad spatial scales, where climatic factors tend to be the primary controls on species distributions. Although the continental-level scope of the present work should minimize the influence of nonclimatic factors, we recognize that there is still considerable uncertainty around actual range shifts. Therefore, we present findings for two extreme scenarios; a “full dispersal” situation, in which populations are able to migrate entirely into their future climate habitat, and a “no dispersal” situation, in which they are unable to migrate quickly enough and thus survive only in areas that overlap with their current climatic range (Peterson et al. 2002, Thuiller et al. 2006). The actual future distribution of a given tree species will most likely be somewhere between these extremes, but this approach helps to bound the problem.

A CE was generated for each tree species. ANUCLIM works by first generating an estimate of the value of each climate variable of interest at each location where a species was observed. The climatic extents of the species’ range are then defined by obtaining the minimum and maximum values for each of the climate variables in the analysis. ANUCLIM generates 19 biodimatic variables by default. However, because there may be differences in the size and shape of the predicted CE, depending on the variables used (Beaumont et al. 2005), it is important to select appropriate variables for analysis. In choosing a set of climate variables, one looks for the smallest set that defines important climatic constraints on tree survival and growth-larger sets can unnecessarily constrain potential ranges with superfluous climatic requirements (Box 1981, Beaumont et al. 2005). For the current work, we made use of variables that summarized two important climatic gradients for plants-heat and moisture (e.g., Woodward 1987, Shao and Halpin 1995, Stephenson 1998). For heat we chose annual mean temperature, minimum temperature of the coldest month, and maximum temperature of the warmest month. These variables represent the mean and extreme values of temperature at a given location and are highly correlated (r > 0.90) with other familiar climatic controls on tree distribution, such as extreme minimum temperature, growing season length, and degree days. Moisture gradients were similarly summarized using annual precipitation, precipitation in the warmest quarter, and precipitation in the coldest quarter. We note that it is not precipitation per se that plants respond to, but rather available moisture in the soil, which is typically calculated using a water-budget model. However, we found high levels of correlation (i.e., r values of 0.7 to 0.8) between the precipitation variables we used and coarse-scale, global water-budget variables (Willmott et al. 2007). Work to develop and incorporate high-resolution water-budget data into our models is ongoing, but progress is hampered by limited soils data across much of Canada. Basic climate variables such as those we used have been shown to be highly correlated with North American tree distributions at the continental scale (Thompson et al. 1999).

Tree and climate information

Continent-wide, georeferenced observations of tree occurrence are available (see http://planthardiness.gc.ca/; McKenney et al. 2007). The gathering of georeferenced data is ongoing, but to date more than 1,071,000 observations have been obtained for 286 tree species. In Canada, we obtained such data from the Ministries of Natural Resources within each province, Conservation Data Centres, botanical gardens, herbaria, and experts such as master gardeners and community horticultural society members. In the United States, our main source of information was the US Forest Service, which maintains an extensive tree-distribution database (Alerich et al. 2005).The accuracy of the location data we used varies, but should be within 3 km in the United States and 5 km in Canada. Each species was screened by comparing its distribution data to its natural range, as provided by a digitized Little’s (1971,1977) range map. Using this approach, we judged that data on 130 species (box 1) were suitable for producing reliable CEs for the problem at hand-that is, the observations comprehensively sampled the natural range with no obvious gaps. In fact, all species chosen for analysis had occurrence locations that fell outside the range of Little’s maps (15% of locations, on average), suggesting that incorporating this type of distribution data allows a more complete quantification of climatic tolerances than is possible from range maps alone. Baseline climate data were taken from 30-year climate station averages for the period 1971-2000 from both Canada and the United States (McKenney et al. 2006a). Thin-plate smoothing splines were used to create spatially continuous models of monthly mean minimum and maximum temperatures and total precipitation as a function of latitude, longitude, and elevation (see Hutchinson [2004] and references therein for details). Bioclimatic summary variables were then derived from these basic surfaces. These spatially continuous models can estimate climate variables at each plant occurrence location. Errors estimated from withheld data tests are in the range of 10% to 20% for precipitation and less than 0.5[degrees]C for temperature.

Box 1. Scientific and common names of the 130 tree species included in the analysis.

From the extent of the current CE for each tree species, areas of suitable climate habitat were delineated on maps for each of three future periods (2011-2040,2041-2070,2071-2100). The climate projections were generated by several general circulation models (GCMs), which model the complex relationship between atmospheric flow and radiative energy (Hayhoe et al. 2006). Given the great uncertainty in predicting future climate, we used projections from three internationally recognized GCMs-the Canadian GCM (Boer et al. 2000), the UK-based Hadley GCM (Gordon et al. 2000), and the Australian-based Commonwealth Scientific and Industrial Research Organisation GCM (Gordon and O’Farrell 1997).

We used two emissions scenarios (A2 and B2, as described in Nakicenovic and Swart 2000) for each of the GCMs (figure 1). The scenarios differ in that scenario A2 assumes a higher human population, less-forested land, greater pollution, and higher C02 emissions; scenario B2 assumes an acceleration of energy and resource conservation efforts during the early decades of this century, such that C02 emissions will decline by midcentury. These two emissions scenarios were selected to assess plausible futures, given a range in human choices over the next few decades.

To generate the future climate grids, average change surfaces were generated for each time period by interpolating the changes predicted by each GCM and emission scenario (McKenney et al. 2006b). These change estimates were then added to the 1971-2000 climate station normals, and these adjusted station values were used to generate the bioclimate models for the future periods. Thus, the results represent Canadian and US climatology as provided by the existing network of climate stations in combination with the broadscale average changes predicted by the climate-change scenarios. This method of adding the model-generated anomalies to current climate values has the advantage of eliminating bias in the control run of the GCM model (Overpeck et al. 1991).

In the full-dispersal scenario, each species is assumed to move fully into its future CE. Changes in latitude were calculated by subtracting the mean center of the current CE from the mean center of the CE under each GCM and emission scenario. Similarly, changes in CE area were calculated by expressing the future CE area as a percentage of the current CE area. For the no-dispersal scenario, future maps were overlaid on current maps and only the area of overlap was taken as the future distribution. Once the future CE was defined in this way, change metrics were calculated in the same way as for the fulldispersal scenario.

Change in climate-envelope size

Under the full-dispersal scenario, some CEs increased in size and others decreased, with an overall average of about a 12% decrease (figure la). Of the 130 species under study, 72 were predicted to show a decrease in future CE size. Of particular concern are 11 species whose future CEs decrease more than 60% in size (table 1). Most of these species have very limited distributions in the southeastern region of the United States, but Lawson cedar (Chamaecyparis lawsoniana) and California red fir (Abies magnifica) are found on the western coast of the United States. Examination of the CE parameters for these 11 species suggests that they all have very specific climatic requirements, particularly for precipitation conditions that are rarely found under the future climate scenarios. The future CEs of 58 species were predicted to increase in CE size from 0.4% to 43%. With a few exceptions, species showing the greatest predicted increases in future CE size are currently found in the eastern United States and along the western coast.

In contrast, under the no-dispersal scenario in which tree species persist only in areas of overlap with their current climatic range, future CEs decrease sharply in size-by 58% on average over the course of this century (figure lb). Of the 25 tree species showing the greatest decrease in CE size (table 1), most have limited distributions along either the eastern or western coast. Specific results for all of the 130 tree species that we analyzed can be viewed at http://planthardiness.gc.ca/.

Changes in CE size were clearly related to the region in which species were located. Many species showing the largest predicted size reductions have distributions that extend into the far southeast region of the United States (table 1). We note that many of these species may have climatic tolerances that would extend farther south but, because of the presence of the Gulf of Mexico, CEs based on empirical distribution data may be truncated at the Gulf Coast (see Thuiller et al. [2004] for a similar example in Europe). Consequently, these species may be more tolerant to climate changes in this region than our models suggest. To get a sense of how much these species affected our overall results, we recalculated size shifts after removing from the analysis 34 species with southeastern distributions that ran up against the Gulf of Mexico. As a result, size shifts decreased by about 10% (i.e., mean shifts were 2% and 50% reductions under the full- and nodispersal strategies, respectively). Of the species examined here, there were no comparable examples on the West Coast in which species’ climatic tolerances appear truncated by the US-Mexico border.

For the species listed in table 1, under the no-dispersal scenario, future CEs have shifted northward or decreased in size to the point at which there is very little overlap with their current CEs. Unless these species have broader climatic tolerances than currently quantified, can adapt rapidly, or make the shift into their new CEs, their prospects for persistence in natural settings are poor. Neilson and colleagues (2005) review the literature and conclude that the rate of future climate change is likely to exceed the migration rates of most plant species. For example, on the basis of generally accepted migration rates of 50 km per century, Iverson and colleagues (2004a) reported that, for five tree species in the eastern United States, less than 15% of new potential habitat would have even a small probability of being colonized within 100 years. This problem is exacerbated in rarer species because of low source strength (Iverson et al. 2004b), making them more prone to extinction (Schwartz et al. 2006). For such species, future survival may rely more on human activities (e.g., planting programs) than on natural dispersal mechanisms (Pitelka 1997). This raises important policy challenges regarding assisted migration and forest regeneration (McLachlan et al. 2007). Our maps, which show species- specific future CEs, provide insight into potential planting areas for species of concern. Furthermore, these models will be updated regularly with new distribution data, thus providing ongoing insights into species’ climatic tolerances.

Figure 1. Change predicted by six climate-change models in the size of climate envelopes of 130 North American trees from a 1971- 2000 baseline to three future time periods. (a) Scenario in which species move entirely into future climatic niches, (b) Scenario in which species move only within current niches. Box plots show median, 25th and 75th percentiles, and 10th and 90th percentiles. The “A” and “B” refer to the different scenarios used for each model; the scenario signified by CGCM-A, CSIRO-A, and HAD-A assumed a higher human population, less-forested land, greater pollution, and higher carbon dioxide emissions. The scenarios with “B” assumed an acceleration of energy and resource conservation efforts during the early decades of this century, such that carbon dioxide emissions would decline by midcentury. Abbreviations: CGCM, Canadian general circulation model (GCM); CSIRO, Commonwealth Scientific and Industrial Research Organisation GCM; HAD, Hadley GCM.

Change in climate-envelope latitude

The mean centers of future CEs are predicted to shift northward by 6.4 and 3.0 degrees latitude (i.e., roughly 700 km and 330 km) on average under the full-dispersal and no-dispersal scenarios, respectively (figure 2). The smaller northward shift shown by the nodispersal scenario is not surprising given that, for this scenario, northward shifts are constrained by the northern edge of the current CE. However, the shifts predicted under the full- dispersal scenario are indeed drastic. The 25 tree species showing the greatest latitudinal shifts are listed in table 2. With the exception of white alder (Alnus rhombifolia)y a western species, all of these species exhibit an extensive distribution in the southeastern quadrant of the continent, generally ranging north to the Great Lakes region. By the end of this century, the CE for most of these species is predicted to shift into northern Ontario and Quebec-in many cases to Hudson Bay. Results for the entire 130 tree species (and others) can be viewed at http://planthardiness.gc.ca/. Table 1. The 25 North American tree species with the largest projected reductions in climate-envelope area under the no- dispersal scenario.

Table 2. The 25 North American tree species with the largest projected shifts in latitude under the full-dispersal scenario.

We also examined the potential effect of CE truncation due to the Gulf of Mexico. Generally speaking, the effect of including the far southeastern species in the analysis had a smaller effect on latitudinal shifts than on size shifts, as discussed above. Of the 25 species showing the greatest latitudinal shifts, only 3 were from the far southeast (table 2), and there was essentially no change in overall shift statistics when the 34 species from the far southeast were removed from the analysis (i.e., mean northward shifts were 6.4 and 3.2 degrees of latitude under the full-dispersal and no- dispersal scenarios, respectively).

The magnitude of the latitudinal shifts reported here is comparable to that found by Hamann and Wang (2006), who predicted a potential shift of 1000 km for tree species in British Columbia-but this magnitude is generally at the high end of that reported in the literature. For example, Overpeck and colleagues (1991) examined the potential response to climate change of seven vegetation groups in eastern North America and predicted northward shifts of 100 to 500 km per century. Similarly, Shafer and colleagues (2001) reported on predicted CE shifts for 15 North American tree species on the order of “hundreds of kilometres.” More modest estimates are provided by Iverson and colleagues (forthcoming), who used random-forest methodology (Prasad et al. 2006) to estimate potential changes in suitable habitat. They reported an average mean center shift of about 112 km for 111 northward-tending species under a cool, energy- conserving scenario, and a shift of about 270 km for 99 species (up to 850 km) under a warm, nonconserving scenario. There are a few reasons for their relatively lower estimates. First, because of a lack of Canadian data, they tracked northward migrations of suitable habitat only as far as the US-Canada border, thus greatly limiting the potential size of latitudinal shifts. second, their suitability model ineluded not only climate but also soil and land-use considerations, which would further reduce the amount of suitable future habitat-particularly in northern areas where soil conditions can be poor for many tree species. Finally, they tracked changes in the centroid of maximum abundance of the species, which need not change as much as the absolute range. We reiterate that our findings are aimed at indicating where the suitable CE for a species could be by the end of the century, not necessarily where the species will be.

Figure 2. Change in the latitude of climate envelopes of North American trees for three future time periods and six climate-change scenarios based on (a) full-dispersal and (b) no-dispersal scenarios. Box plots show median, 25th and 75th percentiles, and 10th and 90th percentiles. The “A” and “B” refer to the different scenarios used for each model; the scenario signified by CGCM-A, CSIRO-A, and HAD-A assumed a higher human population, less-forested land, greater pollution, and higher carbon dioxide emissions. The scenarios with “B” assumed an acceleration of energy and resource conservation efforts during the early decades of this century, such that carbon dioxide emissions would decline by midcentury. Abbreviations: CGCM, Canadian general circulation model (GCM); CSIRO, Commonwealth Scientific and Industrial Research Organisation GCM; HAD, Hadley GCM.

To visually summarize the potential reorganization of the tree species under study, we generated CE richness maps for the current time period (figure 3a) and the 2071-2100 time period under the B2 (figure 3b) and A2 (figure 3c) emissions scenarios. To do this, we overlaid the CEs for all species, counted the number of CEs that fell in any given grid cell, then averaged the results across the three GCMs. The maps indicate drastic changes in patterns of CE richness as a result of the northward migration of suitable climate habitat. Alaska, the northern Prairie provinces, Ontario, Quebec, and the Maritimes are predicted to experience future climate that is favorable for a wide variety of tree species-with potential increases of more than 60 CEs in some areas. This general trend toward greater species richness in northern areas is supported by the work of Currie (2001), who predicted increases in tree richness of 25% to 50% in the northern United States associated with a doubling of atmospheric CO2.

Conversely, by the end of the century, the climate in much of the southern United States will not be within the current known climatic tolerances for most of the 130 tree species in this study. This pattern is consistent for both emissions scenarios, although shifts are more drastic under the A2 scenario (figure 3), particularly in the east. In fact, much of the southern United States is predicted to have future climate conditions that fall within the current tolerances of only one of the species we examine here-white fir (Abies concolor). This species is currently found in the southwest, where some locations currently experience average monthly maximum temperature values of up to 42[degrees]C; such conditions are predicted to be more widespread in the southern United States by the end of the century. Notably, both emissions scenarios identify the Appalachians as a potential zone of climatic refuge, an arm of higher CE richness extending into the southeastern region. Such refugia were thought to be important for maintaining biodiversity in the face of the climatic and landcover changes during the last glacial period (Williams et al. 2004).

There are important qualifications to these findings. First, our study examines only a sample of the approximately 700 tree species in North America, so we do not imply that the south will be devoid of trees. Furthermore, it is possible that novel climate habitats created in the southeast will be at least partially filled by species that are not currently part of the natural vegetation of the United States; exotic species expansions have been predicted for other regions and species groups under climate change (e.g., Kriticos et al. 2003, dimming and Van Vuuren 2006). Williams and colleagues (2007) explored the projected future distribution of novel and disappearing habitats on a global scale and predicted a high degree of climatic novelty for the southeastern United States. Finally, as noted above, species bordering a barrier such as the Gulf of Mexico cannot be easily assayed for their true climate tolerances and thus may persist in the southeast for longer than our models suggest. To further explore this situation, we generated CE richness maps with 34 species, which were bounded to the south by the Gulf of Mexico, removed from the analysis. However, the maps differed very little from those shown in figure 3.

Figure 3. Climate-envelope (CE) richness for 130 North American tree species under (a) current climate conditions; (b) future climate (2071-2100) based on the B2 emissions scenario, in which atmospheric carbon dioxide increases; and (c) future climate (2071- 2100) based on the A2 emissions scenario, in which atmospheric carbon dioxide decreases. Maps (b) and (c) are averaged over three general circulation model outputs.

Climate-change scenarios

The various climate-change models were qualitatively consistent in predicting effects on tree species distribution (figures 1,2). However, the Australian GCM consistently predicted more extreme changes in size and latitude-about 15% greater than either the Canadian GCM or Hadley GCM. Also, under the A2 emissions scenario, predicted CEs were smaller and more northerly than CEs predicted under the B2 scenario. This is not surprising, given that in the A2 scenario, the human population is larger and greenhouse gas emissions are higher than in the B2 scenario (Nakicenovic and Swart 2000).

Conclusions

One of the major unknowns in climate-change work is the extent to which species will be able to disperse into their new suitable habitats. Future distributions will be determined not only by climate but also by a hierarchy of factors such as dispersal ability, biotic interactions (i.e., competition and predation), genetic adaptation, and abiotic factors (e.g., soil conditions). Also influencing future outcomes is the role of humans. What path will actual greenhouse gas emissions take over the next 10 to 50 years? Will we purposely or accidentally redistribute species as habitats change? It is critical that humans decide, in the next decade or two, which path they wish to follow with regard to greenhouse gas emissions. Models with varying levels of complexity have been, or are being, constructed to predict where tree species could end up under future climates. There will always be a significant level of uncertainty around this topic, however, because of the complex and stochastic nature of both plant migration and climate change. All exercises of this type are predicated on GCMs. Improvements in global climate modeling will clearly have downstream effects in spatial predictions of biological responses to climate change and human adaptation strategies. We endorse multiple modeling approaches to increase confidence in predictions of climate change. This study uses currently quantified climatic tolerances to explore two extreme responses by trees to climate change: species moving entirely into future CEs and species not moving at all, and thus persisting only in areas of overlap with their current CE. The most likely outcome is probably somewhere between these bounding scenarios, particularly for latitudinal shifts where the lack of fertile soil in northern Canada is likely to limit the northward migration of many tree species. Under the full-dispersal scenario, average CE sizes for the 130 tree species were predicted to decrease in size by 12% (ranging from a decrease of 93% to an increase of 44%) and shift northward, on average, by 700 km (ranging from 230 km to 1100 km) by the end of this century. Eleven tree species showed declines of less than 60% in the size of their future potential ranges. Under the no-dispersal scenario, future potential ranges were predicted to be, on average, 58% smaller (ranging from 13% to 98%) and shifted northward by 330 km (ranging from 0 to 880 km); the climate habitats of 17 species were predicted to be 80% smaller. These results fall generally in line with other studies that also show potentially large impacts on vegetation as a result of climate change. However, the degree to which tree species can robustly persist in areas that appear destined for rapid change beyond species’ current climatic tolerances will be critically important. Hence, these analyses will be updated regularly with new observations on climate tolerances as they become available.

Acknowledgments

Funding for this work was provided by Natural Resources Canada. We thank Pia Papadopal for assistance in generating current and future climate surfaces, and Bill Meades, Lisa Venier, Denys Yemshanov, Louis Iverson, and three anonymous referees for valuable comments on the manuscript. We are also indebted to the many individuals and agencies that provided the plant-distribution data used in this work.

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doi:10.1641/B571106

Daniel W. McKenney (e-mail: [email protected]), John H. Pedlar, Kevin Lawrence, and Kathy Campbell are with the Landscape Analysis and Applications section of the Canadian Forest Service. Michael F. Hutchinson is with the Fenner School of Environment and Society at the Australian National University in Canberra.

Cranberries: True Miracle Cure for Women

Research reveals two glasses a day keep bladder infections, ulcers, cavities, and viruses away

Cranberry juice, long dissed as a mere folk remedy for relieving urinary tract infections in women, is finally getting some respect.

Thanks to Prof. Itzhak Ofek, a researcher at Tel Aviv University’s Sackler Faculty of Medicine, the world now knows that science supports the folklore.  Prof. Ofek’s research on the tart berry over the past two decades shows that its juice indeed combats urinary tract infections.

And, he’s discovered, the refreshing red beverage has additional medicinal qualities as well.  Prof. Ofek has found that cranberry juice exhibits anti-viral properties against the flu, can prevent cavities, and lessens the reoccurrence of gastric ulcers. Unhappily for half the human race, however, new research published this year in the journal Molecular Nutrition & Food Research on ulcers, suggests that, like urinary tract infections, the healing power of cranberries apply only to women.

Medicinal “Teflon”

The remarkable healing property in cranberries stems from a heavy molecule known as non-dialyzable material or NDM. This molecule, isolated by Prof. Ofek and his colleagues, seems to coat some bodily surfaces with Teflon-like efficiency, preventing infection-causing agents from taking root.

Surprisingly, NDM appears to have no effect on some of the good bacteria in our bodies, says Prof. Ofek.  His seminal research on the subject, in collaboration with Prof. Nathan Sharon from the Weizmann Institute, appeared in the world’s leading medical journal, the New England Journal of Medicine, in 1991. “We understood that there was something in cranberry juice that doesn’t let infections adhere to a woman’s bladder,” Prof. Ofek says. “We figured it was a specific inhibitor and proved this to be the case.”

A Unique Mouthwash

After the 1991 study, Prof. Ofek conjectured that if cranberries could protect against bacterial invasion in the bladder, “Could they work wonders elsewhere?” He took the question Tel Aviv University’s School of Dental Medicine, and together with Prof Ervin Weiss, produced positive results.

“We found that NDM inhibits adhesion of oral bacteria to tooth surfaces and as a consequence reduced the bacterial load that causes cavities in the mouth,” says Prof. Ofek. “And after a clinical trial, we formulated a mouthwash based on cranberries which was patented by Tel Aviv University.”

From Mouth to Midsection

But Prof. Ofek wasn’t content to stop at cavities. Working with Prof. Ervin Weiss and Prof. Zichria Rones at Hadassah Medical and Dental School, he found that NDM inhibits the flu virus from attaching to cells and prevented experimental flu infections in animal models.

Most recently, Prof. Ofek collaborated with Dr. Haim Shmuely, a resident physician at the Beilinson Hospital and lecturer at Tel Aviv University, to find that cranberry also inhibits two-thirds of the “unhealthy” bacteria that clings to gastric cells, which lead to ulcers.

“The results were very interesting,” says Prof. Ofek. “Cranberry helped reduce the load of this bacteria, Helicobacter pylori, in the gut. In combination with antibiotics, it reduced repeat ulcers from approximately 15 percent to about 5 percent.”

Ladies Only

The one drawback to this research is that it only holds true for women, showing once again cranberry’s affinity for the female. “The whole thing with cranberries seems to be female-oriented,” admits Prof. Ofek.

He continues, “The take-home message is that God created this fruit with a polyphenolic material. We still don’t know its chemical formula, but it seems to target a fraction of bacteria and viruses.”

Today, a cranberry research team comprised of scientists from across Israel, and headed by Professors Ofek and Weiss, are investigating the berry’s healing powers. Recently, it was found that cranberry NDM may also act as an anti-cancer agent. The scientific research methods behind the research have been patented by Tel Aviv University.

Prof. Ofek’s recommendation is that women drink two glasses a day to treat certain infections. And because “there is still so much we don’t know about cranberries, I would suggest that men also drink two glasses a day,” he concludes.

The American cranberry juice company Ocean Spray funded a majority of Prof. Ofek’s early research and his later research on ulcers. He is currently on sabbatical at the University of Tennessee in Memphis.

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Tel Aviv University

Microbial Mannanases: An Overview of Production and Applications

By Dhawan, Samriti Kaur, Jagdeep

ABSTRACT Microbial mannanases have become biotechnologically important since they target the hydrolysis of complex polysaccharides of plant tissues into simple molecules like manno- oligosaccharides and mannoses. The role of mannanases in the paper and pulp industry is well established and recently they have found application in the food and feed technology, coffee extraction, oil drilling and detergent industry. Mannanses are enzymes produced mainly from microorganisms but mannanases produced from plants and animals have also been reported. Bacterial mannanases are mostly extracellular and can act in a wide range of pH and temperature, though acidic and neutral mannanases are more common. This review will focus on complex mannan structure and the microbial enzyme complex involved in its complete breakdown, mannanase sources, production conditions and their applications in the commercial sector. The reference to plant and animal mannanases has been made to complete the overview. However, the major emphasis of the review is on the microbial mannanases. KEYWORDS hemicellulases, mannanase, mannooligosaccharides, mannose, locust bean gum, konjac glucomannan

INTRODUCTION

Enzymes are the catalytic keystone of metabolism and are the hub of concentrated worldwide research. The advent of enzymology represents an important breakthrough in the biotechnology industry, with the worldwide increase in usage of enzymes. The latter half of the twentieth century saw an unparalleled expansion in our knowledge of the use of microorganisms, their metabolic products, and enzymes in a broad area of basic research and their potential industrial applications. Hydrolases such as proteases, amylases, amidases, esterases and carbohydrolases such as cellulases, hemicellulases and pectinases occupy the major share of the industrial enzyme market. Cellulases and hemicellulases have numerous applications and biotechnological potential (Bhat, 2000; Sun and Cheng, 2002; Wong and Saddler, 1992; Beauchemin et al, 2001). It is estimated that approximately 20% of the more than one billion US dollars of the world’s sale of industrial enzymes consist of cellulases, hemicellulases and pectinases (Bhat, 2000).

Mannan and heteromannans are a part of the hemicellulose fraction in plant cell walls. Structural analysis of plant cell wall polysaccharides has revealed that the cell wall of a dicot sp. contains three major classes of polysaccharides viz. cellulose, hemicellulose and lignin (Dekker et al., 1985). Hemicelluloses are defined as those plant cell wall polysaccharides that are not solubilized by water or chelating agents but are solubilized by aqueous alkali (Selvendran and O’Neill, 1985). According to this definition, hemicelluloses include mannan, xylan, galactan and arabinan. Hemicelluloses are also defined chemically as cell wall polysaccharides that are structurally homologous to cellulose because they have a backbone composed of 1,4-linked beta-D- pyranosyl residues (O’Neill and York, 2003). Hemicellulose is abundant in primary walls but is also found in secondary walls (Puls, 1997).

In recent years, hemicellulases have emerged as key enzymes in the rapidly growing biotechnology industry, owing to their multifaceted properties, which find usage in a wide array of industrial applications (Hongpattarkere et al., 2002). Most studies on hemicellulases have focused until now on enzymes that hydrolyse xylan, the primary constituent of hemicellulose in grasses. Enzymes that hydrolyse mannan have been largely neglected, even though it is an abundant hemicellulose, therefore the application of mannanase for catalyzing the random hydrolysis of beta-D-1,4 mannopyranoside linkages in beta-1,4 mannans is as important as the application of xylanases.

The use of mannanases in the paper and pulp industry increased significantly with the discovery of Gubitz et al. (1997). Since then researchers worldwide have focused their attention toward newer microbial isolates for mannanases. Despite the availability of several reports on mannolytic microorganisms, there are only a few reviews available on mannanases. These reviews emphasize mainly production and properties of mannanases and not their biotechnological potential. Thus there is a need to assemble information available on these enzymes from different sources in order to bring to light their importance and direct research into the probable application of these enzymes. The present review will encompass the microbial sources, production, properties and potential industrial applications of mannanases.

MANNAN: OCCURRENCE AND STRUCTURE

Mannans and heteromannans are widely distributed in nature as part of the hemicellulose fraction in hardwoods and softwoods (Capoe et al., 2000), seeds of leguminous plants (Handford et al., 2003; Buckeridge et al, 2000) and in beans (Lundqvist et al., 2002). Hemicelluloses are copolymers of both hexose and pentose sugars. The branched structure allows hemicellulose to exist in an amorphous form that is more susceptible to hydrolysis. Within biomass, mannans or the hemicelluloses are situated between the lignin and the collection of cellulose fibres underneath. Consistent with their structure and side group substitutions, mannans seem to be interspersed and covalently linked with lignins at various points while producing a coat around underlying cellulose strands via hydrogen bonds, but as few H-bonds are involved they are much more easily broken down than cellulose. The mannan layer with its covalent linkage to lignin and its non-covalent interaction with cellulose may be important in maintaining the integrity of the cellulose in situ and in helping protect the fibers against degradation to cellulases (Puls and Schuseil, 1993).

Mannan is the predominant hemicellulosic polysaccharide in softwoods from gymnosperms, but is the minor hemicellulose in hardwood from angiosperms (Puls, 1997). Unsubstituted beta-1,4- mannan, composed of a main chain of beta-mannopyranose residues, is an important structural component of some marine algae (Yamasaki etal., 1998) and terrestrial plants such as ivory nut (Chanzy etal., 2004) and coffee bean (Nunes etal., 2006). It resembles cellulose in the conformation of the individual polysaccharide chains, and is water insoluble.

Hardwood mannans are composed of beta-1,4-linked mannopyranose and glucopyranose units, whereas softwood contains two different types of acetylated galactoglucomannans. These consist of glucose, mannose and galactose in the ratio 1:3:1 and 1:4:0.1 respectively (Lundqvist etal., 2002). In leguminous seeds, water soluble galactomannan is the main storage carbohydrate, comprising up to 20% of the total dry weight (McCleary, 1988). It has a a-galactose linked at the O-6 position of some mannose residues and may also have some beta-D-glucose residues incorporated in the backbone. Furthermore, the mannose residues can be acetylated to various degrees at the C-2 and C-3 positions (Figure 1). The galactomannans from different leguminous taxonomic groupings differ in their degrees of galactose substitution and M:G ratios between 1.1:1 (high galactose) and 3.5:1 (low galactose) are encountered. The high degree of galactose substitution of the (1-4) beta-D-mannan in galactomannans is clearly sufficient to prevent the chain aggregation that leads to insolubility and crystalline order in the mannans and glucomannans. The mannose: galactose ratio (M:G) is key in determining the amount of intermolecular association called hyperentanglements. Without any galactose side chains, mannan backbone will aggregate due to intermolecular interaction between the unbranched parts of heteromannans.

FIGURE 1 General structure of mannan and heteromannans. A) A typical mannan structure, a main chain of beta-1,4 linked mannose (Man) residues; B) A typical galactomannan structure, a main chain of beta-1,4 linked mannose residues with alpha-1,6 linked galactose (Gal) residues attached to some (Man) residues; C) A typical glucomannan structure, a main chain of beta-1,4 linked mannose (Man) and glucose (Glc) residues; D) A typical galactoglucomannan structure, a main chain of beta-1,4 linked mannose (Man) and glucose (Glc) residues, with alpha-1,6 linked galactose (Gal) residues attached to some (Man) residues.

The substrate used routinely for the study of mannanases is galactomannan from locust bean gum (Ceratonia siliqua) with a mannose: galactose ratio of 4:1 (De Nicolas-Santiago et al., 2006). In addition, ivory nut (Phytelephas macrocarpa) mannan, an unbranched beta-1,4-linked mannan homopolymer and manno- oligosaccharides (mannobiose, mannotriose, mannotetraose and mannopentoase), can also be used as substrates in the hydrolysis (Stoll et al., 2005).

TABLE 1 The major mannanases and their classification

ENZYMATIC HYDROLYSIS OF MANNAN

The main component of mannan is D-mannose, a six carbon sugar, but due to the heterogeneity and complex chemical nature of plant mannans, its complete breakdown into simple sugars that can be readily used as energy sources by particular microorganisms, the synergistic action of endo-1,4-beta-mannanases (E.C 3.2.1.78, mannan endo-1,4-beta-mannosidase) and exoacting beta-mannosidases (E.C 3.2.1.25) is required (Table 1). Additional enzymes, such as beta- glucosidases (EC 3.2.1.21), alpha-galactosidases (EC 3.2.1.22) and acetyl mannan esterases (Tenkanen, 1998) are required to remove side chain sugars that are attached at various points on mannans. A galactomannan structure whose glycosidic bonds are hydrolyzed by two enzymes viz. endo-1,4-beta-mannanases and alpha-galactosidases is shown in Figure 2. FIGURE 2 Scheme of Enzymatic Action on Galactomannan. The beta-(1-4) linked polymannose chain is substituted with alpha-(1-6) linked galactose (GAL) residues. The arrows represents the glycoside links recognized by beta-mannanase and alpha-galactosidase.

beta-1,4-mannanases are endohydrolases that cleave randomly within the 1,4-beta-D mannan main chain of galactomannan, glucomannan, galactoglucomannan, and mannan (McCleary and Matheson, 1986). Apart from their ability to hydrolyze different mannans, some beta-D-mannanases have also been reported to transglycosylate manno- oligosaccharide substrates (Harjunpaa etal., 1995; Schroder etal., 2004).

Hydrolysis of these polysaccharides is affected by the degree and pattern of substitution of the main chain by beta-D-galactosyl residues in galactomannan and galactoglucomannan (McCleary, 1979) and by the pattern of distribution of D-glucosyl residues within the main chain in glucomannan and galactoglucomannan. In glucomannan, the pattern of distribution of O-acetyl groups may also affect the susceptibility of the polysaccharide to hydrolysis. Like beta- glucosidases in the cellulase system, beta-mannosidases are essential for the complete hydrolysis of plant heteromannans. They convert the manno-oligosaccharides produced by beta-mannanases to mannose (Franco etal., 2004). The galactose release from softwood pulp is enhanced by the presence of mannanase in combination with alpha-galactosidase (Clark etal., 2000). The main products obtained during the hydrolysis of mannan by beta-mannanases are mannobiose and mannotriose. beta-mannanases from Aspergillus tamarii(Civas etal., 1984), Trichoderma reesei (Stalbrand et al., 1993) and Aspergillus niger (Ademark et al., 1998) all produced mainly mannobiose and mannotriose and traces of higher oligosaccharides.

The pattern of galactomannan hydrolysis and the apparent subsite- binding requirements have been interpreted from structural analysis by NMR of isolated hydrolysis products from glucomannan and galactomannan incubated with Aspergillus niger beta-mannanase. It is suggested that the enzyme has five substrate binding subsites- alpha, beta, gamma, delta and epsilon, which is equivalent to -3, – 2, -1, +1, and +2, according to the nomenclature given by Davies et al. (1998). Binding to at least four subsites is required for efficient hydrolysis. Substitution of the substrate monomers at two of the subsite positions restricted hydrolysis, most likely by preventing binding (McCleary and Matheson, 1986). The hydrolysis of the pine craft pulp by the Trichoderma reesei beta-mannanase was also studied (Tenkanen etal, 1997). Judging from this study, Trichoderma reesei enzyme also appears to be restricted by galactosyl residues in a similar way to the Aspergillus niger enzyme.

SOURCES OF MANNANASES

Mannanases are ubiquitous in nature and are elaborated by a compendia of microorganisms largely isolated from natural environments. A vast variety of bacteria, actinomycetes, yeasts and fungi are known to be mannan degraders (Talbot and Sygusch, 1990; Puchart et al., 2004). The important degraders are listed in Table 2.

Among bacteria, degradation is mostly confined to gram- positives, including various Bacillus species (Yanhe et al, 2004; Sun et al., 2003) and Clostridia species (Kataoka et al., 1998; Perret et al., 2004; Nakajima and Matsuura, 1997). However, a few strains of gramnegative bacteria, viz. Vibrio (Tamaru etal., 1997, Pseudomonas (Braithwaite et al., 1995) and Bacteroides (Gherardini and Salyers, 1987) have also been reported. In addition, a few thermophiles and extremophiles belonging to genera Bacillus, Caldocellum, Caldibacillus, Rhodothermus, have also been described (Hatada et al., 2005; Morris et al., 1995; Sunna et al., 2000; Politz et al., 2000). Besides these, actinomycetes from the streptomycetes group, viz. Streptomyces galbus (Kansoh and Nagieb, 2004), Streptomyces lividans (Arcand et al., 1993), actinobacteria group, viz. Cellulomonas fimi (Stoll et al., 1999) and the actinoplanetes group viz. Thermomonospora fusca KW3 (Hilge et al., 1996) are described as mannan degraders with an ability to act on a wide variety of mannan substrates. The most mannolytic group among fungi belongs to genera Aspergillus, Agaricus, Trichoderma, Sclerotium (Huang et al., 2007; Chen et al., 2007; Tang et al., 2001; Franco et al., 2004; Sachslehner et al., 2000). Thus the property of mannolysis is widespread in the microbial world. Mannanases of microbial origin have been reported to be both induced as well as constitutive enzymes and are usually being secreted extracellularly into the medium in which the microorganism is cultured. The bacterial mannanases produced by Sporocytophaga coccoids and Aerobacter mannolyticus were found to be intracellular (Dekker and Richards, 1976). Extracellular mannanases are of considerable commercial importance, as their bulk production is much easier. Mannanases are also produced in higher plants (Shimahara et al., 1975; Marraccini et al., 2001) and animals (Yamaura et al., 1993, 1996) Although a number of mannanase-producing bacterial sources are available, only a few are commercially exploited as wild or recombinant strains, of these, the important ones are: Bacillus sp., Streptomyces, Caldibacillus cellulovorans, Caldicellulosiruptor Rt8B, Caldocellum saccharolyticum. (Zhang et al., 2006; Hatada et al., 2005; Morris et al., 1995; Sunna et al., 2000).

TABLE 2 Sources of mannanases

ASSAY METHODS

Numerous screening methods exist for detecting mannanase activity in microorganisms. A solid medium providing rapid assays is useful for the direct measurement and isolation of mannanase-producing organisms from natural substrates and for the isolation of mutants. Common screening techniques devised for the detection of mannan degrading enzymes by microorganisms involve plate assays where the respective polymer, or its derivative, is incorporated into the basal growth medium. The production of corresponding hydrolases is indicated by the clearing of the opaque medium as the substrate is dissolved by the enzymes produced by the growing colonies. In such procedures, the results are often difficult to interpret in case of fungal isolates, because the zones of clearing are not always easy to distinguish from the unaffected medium and activity might not be detected because of the masking effect of the mycelial mass when the rate of fungal growth exceeds enzyme diffusion. A gel-diffusion assay for the quantification of endo-beta-mannanase activity has been developed (Downie et al., 1994). The assay is specific and detects activity as low as 0.07 pkatal. The assay was equally effective at acidic and neutral pH. One per cent (w/v) Congo Red dye resulted in fast staining times (15 min) and good contrast. The diameter of the clearing zones decreased linearly with increasing substrate concentration in the range of 0.1-1.0% w/v galactomannan. The assay was specific for this endoenzyme, with no zone of clearing developing for alpha-galactosidase, and only a slight decrease in dye intensity with beta-mannosidase. The clearing zone diameter was greater in the gel-diffusion assay using Congo Red than using Remazol Brilliant Blue colored Carob substrate at identical concentrations, enzyme activities and assay conditions. This problem was further overcome by inoculating a polycarbonate membrane 0.2 [mu]m, 90 mm diameter, Nucleopore Co (Chang et al., 1992), or a circle of sweet cellophane 400 (De Nicolas-Santiago et al., 2006) with the test fungus. After incubation, the membrane is removed and the enzyme activity recorded. The membranes, which can resist penetration by fungi, are placed between moistened filter papers and sterilized by autoclaving before use.

Solid media are also used to screen cell-free extracts from microorganisms for mannan degrading enzyme activity. Generally, the enzyme solution is placed in a well (cup) cut in an agar medium containing a mannan/heteromannan substrate. The agar surface usually needs to be flooded with a reagent to develop the zones of enzyme activity around the cup. The diameter of the cleared zone is measured with calipers and recorded. Diameters are converted to enzyme activity by running a dilution of the enzyme and plotting zone diameter against the log of the enzyme concentration (Dingle et al., 1953).

An assay based on the quantification of hydrolysis products has been described by McCleary (1988). Dyed polysaccharide substrates (AZO-carob galactomannan, Megazyme) can also be used as a substrate and incubated with enzyme for ten minutes; ethanol is added to stop the reaction and to precipitate high molecular-weight galactomannan. Low molecular-weight fragments stay soluble and can be spectrophotometrically quantified at 590 nm, due to the attached dye (Stalbrand, 2003). To relate to enzyme activity units, a standard curve (supplied by Megazyme for each batch of substrate) with known enzyme amounts can be prepared.

PRODUCTION CONDITIONS

Microbial mannanases are mostly extracellular and are greatly influenced by nutritional and physicochemical factors, such as temperature, pH, nitrogen and carbon sources, inorganic salts, agitation and dissolved oxygen concentration (Mabyalwa and Setati, 2006; Li et al., 2006; Lin et al., 2007).

However their production is significantly influenced by using different mannan substrates such as glucomannan, galactomannan, galactoglucomannan. Galactomannans of guar gum (mannose:galactose) ratio of 2:1 and locust bean gum (mannose:galactose) ratio of 4:1 and glucomannan of konjac (mannose:glucose) ratio of 1.6:1 induced their production (Dong et al., 1991; Yague et al., 1997). Besides carbon source, the type of nitrogen source in the medium also influences the mannanase titers in production broth (Kataoka and Tokiwa, 1998). Generally, organic nitrogen is preferred, such as peptone and yeast autolysate (Puchart et al., 2004), which have been used as a nitrogen source for mannanase production by various Bacillus strain viz. Bacillus polymyxa, Bacillus subtilis, Bacillus brevis (Zhang et al., 2006; Cui et al., 1999) while beef extract and peptone have been used in the case of Clostridium tertium (Kataoka and Tokiwa, 1998). Inorganic nitrogen sources such as ammonium sulfate, diammonium hydrogen phosphate, ammonium dihydrogen phosphate and sodium nitrate have also been reported to be effective in some microbes (Zakaria et al., 1998; Perret et al., 2004; Araujo and Ward, 1990). Divalent cations stimulate or inhibit enzyme production in microorganisms. Nakajima and Matsuura (1997) observed stimulation in mannanase production from Clostridium sp. in the presence of Ca^sup 2+^ and Mg^sup 2+^. However, most other metal ion salts Fe^sup 3+^, Al^sup 3+^, EDTA, Hg^sup 2+^ were inhibitory to mannanase production (Chen et al., 2000; Sun et al., 2003). Iron was found to play a critical role in the production of mannanase by most of the microorganisms. In addition to the various chemical constituents of a production medium, physiological parameters such as pH, temperature, agitation, aeration and incubation period also play an important role in influencing production by different microorganisms. The initial pH of the growth medium is important for mannanase production. Largely, bacteria prefer pH around 7.0 for best growth and mannanase production, such as in the case of Bacillus sp., Clostridium sp. (Helow and Khattab, 1997; Talbot and Sygusch, 1990) However, maximum activity at higher pH (>7.0) has been observed in some cases (Hatada et al, 2005). The optimum temperature for mannanase production corresponds with the growth temperature of the respective microorganism, for example, the best temperature for growth and mannanase production in the case of Bacillus sp. M50 was 50[degrees]C (Chen et al., 2000). It has been observed that, in general, mannanases are produced in the temperature range 4-85[degrees]C (Politz and Borriss, 2000; Kansoh and Nagieb, 2004). Incubation periods ranging from a few hours to several days have been found to be best suited for maximum mannanase production by bacteria. An incubation period of 24 h was optimum for mannanase production by Bacillus subtilis 168 (Helow and Khattab, 1996), and 36 h for Bacillus subtilis BM 9602 (Cui etal., 1999), maximum mannanase was produced after 72 h and 96 h of incubation. Mannanases are often secreted into the culture liquid as multiple enzyme forms as observed for some bacteria (Stoll etal., 1999; Akino et al., 1989), and several fungi including Schkrotium rolfsii (Gubitz etal., 1996), Aspergillus fumigatus (Puchart et al., 2004) and Trichoderma reesei (Stalbrand etal., 1993). The multiplicity of these mannanases is thought to be due to their ability to bind and degrade different substrates (Johnson et al., 1990). These beta-1,4- mannanase isoforms may be secreted as products of the same gene differing only in their post-translational modification, such as with A. fumigatus (Puchart et al., 2004) or their production may be regulated differently such as Sclerotium rolfii isoforms that exhibited different functions on substrates of varying sizes (Grosswindhager etal., 1999). Kinetics of mannan depolymerization, i.e. Michaelis-Menten constant (K^sub m^) and the maximal reaction velocity (V^sub max^) values, are reported for different fungal and bacterial beta-mannanases. K^sub m^, and V^sub max^ values reported for Aspergillus Jumigatus are 3.07 mg/ml and 1935 [mu]mol min^sup – 1^ mg^sup -1^ for Man I and 3.12 mg/ml and 2139 [mu]mol min^sup -1^ mg ^sup -1^ for Man II on locust bean gum (Puchart et al., 2004). For Aspergillus tamarii V^sub max^ and K^sub m^, reported are 43.5 [mu]mol min^sup -1^ mg^sup -1^ and 2 x 10^sup -2^ g/100 ml (Civas et al., 1984) on locust bean gum. Franco et al (2004) reported V^sub max^ and K^sub m^ values as 20.1 units /ml and 6.0 mg/ml, respectively, for Trichoderma barzanium strain T4 on wheat bran. Among bacterial beta-mannanases (Talbot and Sygusch, 1990) reported for Bacillus stearothermophilus a V^sub max^ value of 455 +- 60 U/ mg and the estimated Km value of 1.5 +- 0.3 mg/ml on locust bean gum. In Bacillus subtilis SA-22 the Michaelis constants (K^sub m^) were measured as 11.30 mg/ml for locust bean gum and 4.76 mg/ml for konjac powder, while V^sub max^ for these two polysaccharides were 188.68 [mu]mol min^sup -1^ ml^sup -1^ and 114.94 [mu]mol min-1 ml^sup -1^ respectively (Sun etal., 2003).

Thus, microbial mannanases are generally produced in the presence of different mannan substrates, viz. guar gum (Cyamopsis tetragonobola), locust bean gum (Ceratonia siliqua), and konjac glucomannan (Amorphophallus konjac) in the presence of any complex nitrogen source. Dye-based substrate ostazin brilliant red mannan and azo-carob galactomannan can also be used for easy screening of mannanase producing microorganisms. The requirement for metal ions varies with the organism. However, physical parameters such as pH, temperature, agitation and aeration influence mannanase production via modulating the growth of the bacterium. Mannanases are produced throughout bacterial growth, with peak production being obtained by the late logarithimic phase. The production period for mannanases varies from a few hours to a few days. A list of various production conditions used with different microorganisms is presented in Table 3.

FAMILY CLASSIFICATION AND MODULARITY OF MANNANASES

Mannanases are glycoside hydrolases that degrade mannans and heteromannans. Glycoside hydrolases (EC 3.2.1.-) are a widespread group of enzymes that hydrolyze the glycosidic bonds in oligo- and polysaccharides. Due to the complicated structures of the carbohydrates with different combinations in nature, a large number of enzymes with different substrate specificities are required. Glycoside hydrolases from various sources were classified into different families based on their amino acid sequence similarities (Henrissat and Bairoch, 1993, 1996). The basic principle behind the family classification is that the family membership of a particular enzyme can be defined from its sequence alone and there is a direct relationship between sequence and folding similarities. Structure conservation was shown to be much stronger than amino acid conservation. Families can thus be grouped into “clans” according to their three-dimensional structure (Henrissat, 1990). So far there are a total of 110 families and some of them are well studied. The beta-mannanase sequence comparison studies permit assignment of these enzymes to either glycoside hydrolase family 5 or 26. Family 5 comprises several bacterial mannanases including Caldocellum saccharolyticum, Caldibacillus, Vibrio species, fungal mannanases from Aspergillus aculeatus, Trichoderma reesei and Agaricus bisporus and eukaryotic mannanase from Lycopersicon esculentum and Mytilus edulis. Family 26 comprises mannanases from Bacilli sp., Cellvibrio japonicus, Pseudomonas fluorescens and Rhodothermus marinus. Thus both bacterial and eukaryotic mannanases have been annotated to family 5. With the exception of a few anaerobic fungi, the mannanases in family 26 are of bacterial origin. In some cases, mannanases from the same genus have been classified in different families; beta-mannanases from different strains of Caldocellulosiruptor saccharolyticus have been classified in both families 5 and 26 (Gibbs et al., 1996), and multiple beta- mannanases in Cellvibrio japonicus have been classified in both families 5 and 26 (Hogg et al., 2003). Besides this, beta- mannanases from different Bacilli species are also found in both families (Sygusch et al., 1998; Hatada et al., 2005). Some glycoside hydrolases are multifunctional enzymes that contain catalytic domains that belong to different GH families like Paenibacillus polymyxa. A cel44C-man26A gene was cloned from this endophytic strain. This gene encodes for a protein that contains a glycoside hydrolase family 44 (GH44) catalytic domain and a glycoside hydrolase family 26 (GH26) catalytic domain. The multifunctional enzyme domain GH44 possesses cellulase, xylanase, and lichenase activities, while the enzyme domain GH26 possesses mannanase activity (Han et al., 2006).

TABLE 3 Overview of various production conditions (molecular weight, optimum pH, optimum temperature, carbon source, and pl values) of mannanase producing microorganisms

Most mannanases often display a modular organization and usually consist of two-domain proteins (Henrissat etal., 1995; Perret et al., 2004). These proteins generally contain structurally discrete catalytic and non-catalytic modules (Warren et al., 1996).

beta-mannanases in both families belong to the 3-D structure group (beta/alpha)z fold catalytic module characteristic of clan Glycoside hydrolase-A (Stoll et al., 2005). The most important non- catalytic module consist of carbohydrate binding module (CBM) which facilitate the targeting of the enzyme to the polysaccharide, By analogy to the glycoside hydrolases, CBMs are classified into families based on sequence similarities and three dimensional structures (Boraston et al., 2004). Presently, 49 families of CBMs have been reported and a number of these families are closely related and consequently grouped into superfamilies or clans. A comprehensive classification of mannanases and other hydrolases is available at http://afmb.cnrs-mrs.fr/CAZY. Amongst beta-mannanases from aerobic fungi, the enzymes from T. reesei and A. bisporus are composed of a family 5 catalytic module linked to a family 1 CBM (Tang et al., 2001; Yague etal., 1997). Some bacterial beta- mannanases from families 5 and 26 have more complex structures: the C. fimi beta-mannanase Man26A contains both a mannan binding family 23 CBM, a putative SLH-module and a module of unknown function (Stoll et al., 1999, 2000; Stalbrand et al., 2006). The family 5 beta-mannanase from Thermoanaerobacteriumpolysaccharolyticum also contain a SLH-module and, in addition, two internal family 16 CBMs (Cann et al., 1999). Several beta-mannanases from anaerobic bacteria and fungi contain dockerin modules, which attach the beta- mannanases either to the microbial cell surface or to multienzyme complexes such as the cellulosome (Shallom and Shoham, 2003; Halstead et al., 1999; Tamaru and Doi, 2000; Perret et al., 2004). The family 26 beta-mannanases from Caldocellulosiruptor saccharolyticus contains two family 27 mannan-binding modules (Sunna et al., 2001) and from Paenibacillus pofymyxa contain a fibronectin domain type 3, CBM family 3 in addition to two catalytic domains (Han et al., 2006). A comparison of the modular structure of different mannanases reveals CBMs have been predicted for several beta-mannanases from family 5 and family 26. However, only in a few cases has the binding been experimentally confirmed. In addition to Man5A, family 1 CBMs have been indicated in die fungal beta- mannanases from Agaricus bisporus (Tang et al., 2001; Yague et al., 1997). However, the beta-mannanases from Aspergillus aculeatus and Aspergillus niger appear to lack CBMs (Ademark et al., 1998; Christgau et al., 1994). Some other family 5 beta-mannanases have CBMs that have been classified into family 3, 16 and family 35. Moreover, some family 26 beta-mannanases have family 23, 27 and 35 CBMs, which have been shown to bind to mannan (Stoll et al., 2000; Sunna et al., 2001). However, many beta-mannanases from both families 5 and 26 appear to be sole catalytic modules. Thus, at present, it is difficult to establish any obvious patterns in modularity among beta-mannanases. It clearly appears as if several different strategies in mannan-hydrolysis subsist. Henrissat et al. (1998) proposed a scheme for designating enzymes that hydrolyze the polysaccharides in cell walls of plants. A written designation of the module organization of recendy studied beta-mannanases is depicted in Table 4. CLONING AND EXPRESSION OF THE MANNANASE GENE

Gene cloning is a rapidly progressing technology that has been instrumental in improving our understanding of the structure- function relationship of genetic systems. It provides an excellent method for the manipulation and control of genes. More than 50% of the industrially important enzymes are now produced from genetically engineered microorganisms. Recombinant DNA techniques offer a plethora of opportunities for construction of genetically modified microbial strains with selected enzyme machinery. To ensure the commercial utilization of hemicellulosic residues in paper and pulp industries, the production of higher mannanase yields at low capital cost is required. Microbial genes encoding proteins associated with sugar metabolism are clustered which indicates that their expression is coordinated. The sequence of some of the genes encoding beta-1,4- mannanases have been determined and analyzed to deduce the primary structure of mannanase enzymes. In this respect, isolation and cloning of the mannanse gene represents an essential step in the engineering of the most efficient microorganism. Several reports have been published in the past decade (Table 4) on the isolation and manipulation of microbial mannanase genes with the aim of enzyme overproduction, studying the primary structure of the protein, its role in the secreting microorganism, and protein engineering to locate the activesite residues and/or to alter the enzyme properties to suit its commercial applications. Henrissat (1990) recognized two families encoding beta-mannanases on the basis of amino acid sequence similarities. Only two beta-mannanases genes were available for comparison at the time his enzyme classification was made. ManA from Caldicellulosiruptor saccharolyticus (Luthi et al., 1991) and ManA from a Bacillus sp. (Akino et al., 1989) were compared with 301 glycosyl hydrolases and classified respectively as type 5 and type 26 glycosyl hydrolases. A number of mannanase genes had been sequenced since the classification of mannanases by Henrissat (1990) and all share homology with either manA from Caldicellulosiruptor saccharolyticus or the Bacillus mannanase gene (Gibbs et al., 1999). Attempts have been made to clone and express mannanase from bacteria such as Bacillus stearothermophilus, Caldibacillus cellulovorans, Caldicellulosiruptor Rt8B, Caldocellum saccharolyticum (Sygusch et al., 1998; Morris et al., 1995; Sunna et al., 2000) into a non mannanase producing strain of Escherichia coli. As alkaline beta- mannanases provide obvious advantage for the application in the manufacture of kraft pulp and in the detergent industry, where high pH processes are common. Few reports describe the molecular cloning, sequencing and expression of mannanase genes from alkaliphilic Bacillus sp. (Takeda et al., 2004a; Takeda et al., 2004b; Hatada et al., 2005), Bacillus subtilis B36 (Li et al., 2006), Bacillus N16-5 (Yanhe Ma et al., 2004), Bacillus agaradhaerens (Bettiol and Showell, 2002), Bacillus sp. 1633 (Kauppinen et al., 2003) and Thermoanaerobacterium polysaccbarolyticum (Cann et al., 1999). The sizes of mannanase genes and their protein products are highly divergent (Table 4). This indicates that mannanases form a group of proteins that possess similar enzyme activities even though they have highly different primary protein structure. Amino acid sequence alignments of members of family 5 rarely reveal levels of sequence identity greater than 20%, As the amino acid sequence of members of family 5 were divergent, members of family 5 have been classified in eight subfamilies, subfamilies A1-A8 (Hilge et al., 1998). Subfamilies A7 (eukaryotic mannanases) and A8 (bacterial mannanases) have recendy been included. Members of subfamily A8 exhibit levels of sequence identity greater than 43%, while the levels of sequence identity for members of subfamily A7 and members of subfamily A8 are less than 20%. Three dimensional structures of two /5-1,4- mannanases from family 5 in complex with oligosaccharide products have been determined by Xray crystallography (Hilge etal, 1998; Sabini etal., 2000). Recendy, the preliminary structure determination of a bacterial family 5 /3-l,4-mannanase (Akita et al., 2004) has been reported. Eight conserved residues of all family 5 enzymes were demonstrated to be responsible for the catalytic activity of the enzyme including two catalytic glutamates (Sakon etal., 1996).

Yanhe et al. (2004) reported the eight essential conserved active site residues of /3-mannanase in strain Bacillus N16-5 as Arg-83, His-119, Asn-157, Glu-158, His-224, Tyr-226, Glu-254, and Trp-283. Computer analysis of the deduced amino acid sequence of ManA from Bacillus sp. N16-5 with sequences in the GenBank and UniProt databases showed that ManA consists of a single catalytic domain. The amino acid sequence of ManA showed high homology to family 5 mannanases: 96.8% sequence similarity to ManA of B. agaradhaerens (GenBank accession number: AAN27517), 58.2% to ManG of B. circulans (BAA25878), 52.3% to ManA of Bacillus sp. I633 (AAQ31835), 39.4% to ManA of Thermobifida fusca (CAA06924), 34.4% to ManA of Vibrio sp. MA-138 (BAA25188), and 33.1% to ManA of Streptomyces lividans 66 (S30386).

TABLE 4 Occurrence of the main mannanase genes and their products

Yanhe et al. (2004) compared the sequences of mannanases from Bacillus sp. N16-5 and Bacillus sp. AM001, the only two mannanases extensively characterized among alkaline mannanases reported to date. A higher level of similarity (48%) was observed for the C terminal region (about 150 amino acid residues long) of these two enzymes. Hatada et al. (2005) reported a novel alkaline mannanase Man26A in the culture of an alkaliphilic Bacillus sp. strain JAMB- 750. The N-terminal half (Glu27-Val486) of the enzyme exhibited moderate similarities to other mannanases belonging to glycoside hydrolase family 26, such as the enzymes from Cellvibrio japonicus (37% identity), Cellulomonas fimi (33% identity), and Bacillus sp. strain AM-001 (28% identity).

Another family 26 beta-mannanase Man A of D. thermophilum Rt46B.1 on alignment with related enzymes shows that it shares considerable sequence similarity (58% sequence identity) with the catalytic domain of ManA from Caldicellulosiruptor sp. strain Rt8B.4 (Gibbs et al., 1996), and at least 25% sequence identity with the other family 26 mannanases listed in Table 2. Matsushita et al. (1991) published a sequence coding for a beta-1,4-endoglucanase from Bacteroides ruminicola. However, comparison with the mannanase domains from D. thermophilum Rt46B.1 and Caldicellulosiruptor Rt8B.4 ManA suggests that the B. ruminicola enzyme is a multidomain enzyme possessing both a mannanase and an endoglucanase domain. Currently, the reported three-dimensional structures for GH26 members are for the Cellvibrio japonicus mannanase CjMan26A, and for the Cellulomonas fimi mannanase CfMan26A. These enzymes possess a conserved motif in which two glutamates have been identified as the putative catalytic residues; at least two additional residues are conserved (Bolam et al., 1996; Le Nours et al., 2005). Notably, the location of the catalytic apparatus is completely conserved, with the catalytic residues positioned on strands beta-4 and beta-7 (Jenkins et al., 1995).

Amongst the fungal mannanases, The T. reesei man 1 gene was the first fungal mannanase gene characterized (Stalbrand et al., 1995). Tang et al. (2001) demonstrated that the catalytic domain of CEL4 from Agaricus bisporus had the most amino acid sequence similarity with Ascomycete mannanases from Aspergillus aculeatus and Trichoderma reesei, which belong to glycosyl hydrolase family 5 (43 and 42%, respectively). The availability of a number of family 26 mannanase sequences provides the opportunity for the design of PCR primers to highly conserved regions. It has allowed the identification of strains that carry mannanase genes from this family as well as providing the necessary sequence information for the isolation of the entire genes by genomic walking. These consensus primers have been successfully tested against the genes known to be present in genomic DNA from D. thermophilum Rt46B.1 and Caldicellulosiruptor Rt8B.4 and have revealed several other family 26 mannanases present in culturable and unculturable hemicellulolytic thermophilic bacteria (Bergquist et al., 1996). Further sequence information on family 5 mannanases is required before consensus primers can be designed to allow the identification and isolation of these genes.

APPLICATIONS

There are many applications for mannanases in the industrial processes. The worldwide requirement for enzymes for individual applications varies considerably. Mannanases are used mainly for improving the quality of food, feed and aiding in enzymatic bleaching of softwood pulps in the paper and pulp industries. There is a paucity of knowledge about the roles that govern the diverse specificity of these enzymes. Deciphering these secrets would enable us to exploit mannanases for their applications in biotechnology. The following section will discuss details of some of the most promising applications of mannanases (Howard et al., 2003; Galbe et al., 2002; Comfort et al., 2004).

Paper and Pulp Industry

The most potent application of mannanase is consistent with its potential use in enzymatic bleaching of softwood pulps. The extraction of lignin from wood fibers is an essential step in bleaching of dissolving pulps. Pulp pretreatment under alkaline conditions hydrolyzes hemicelluloses covalently bound to lignin and thus facilitates subsequent removal of lignin. There is a drawback to alkaline treatment of wood pulps, however, in that it creates an environmental pollution problem (Hongpattarakere, 2002). The alternate use of mannanases equally facilitates lignin removal in pulp bleaching and yields results comparable to alkaline pretreatment (Cuevas et al., 1996). Consequently, to substitute within a pulp-bleaching sequence an enzymatic pretreatment for the ultrahot alkaline extraction stage (Clarke et al., 2000) offers the possibility of significant reduction in environmental pollution and thus is of considerable interest to the pulp and paper industry. To be feasible, however, enzymatic bleaching requires that hemicellulase treatment not impair pulp quality by attacking cellulose fibers. Softwoods from which the majority of pulps are derived contain as much as 15 to 20% hemicellulose in the form of galactomannan (Suurnakki et al., 1996). Mannanases having substrate specificities for galactomannan constituents would make excellent candidates for use in enzymatic bleaching of softwood pulps (Gubitz et al., 1997). Moreover, pulping is best carried out at elevated temperatures, thermophilic mannanases could offer significant advantages over mesophilic mannanases in terms of their higher intrinsic stability and catalytic efficiencies at such elevated temperatures (Yanhe et al., 2004). Mannanase is useful in chlorine- free bleaching processes for paper pulp (chemical pulps, semichemical pulps, mechanical pulps or kraft pulps) in order to increase the brightness, thus decreasing or eliminating the need for hydrogen peroxide in the bleaching process (Tenkanen et al., 1997).

Hydrolysis of Coffee Extract

Different mannanase preparations are used for the hydrolysis of coffee mannan, thus reducing significantly the viscosity of coffee extracts. Mannan is the main polysaccharide component of these extracts and is responsible for their high viscosity, which negatively affects the technological processing of instant coffee. Mannanase may also be used for hydrolyzing galactomannans present in a liquid coffee extract, preferably in order to inhibit gel formation during freeze drying of the (instant) coffee. Coffee mannan is isolated from green defatted beans by delignification, acid wash and subsequent alkali extraction with a yield of 12.8%. Additionally, coffee extract polysaccharides are separated by alcohol precipitation and are found to form nearly half of the coffee extract dry weight. These isolated mannans as well as the mannans in the coffee extract are efficiently hydrolyzed by the mannanase, which resulted in significant viscosity reductions (Sachslehner et al., 2000; Nicolas et al., 1998). Concurrently, the reducing sugar content increased continuously due to the release of various mannooligosaccharides including mannotetraose, mannotriose, and mannobiose. Both a partially purified, immobilized and a soluble, crude mannanase preparation are successfully employed for the degradation of coffee mannan (Nunes et al., 1998, 2006).

Use in Detergent Industry

Application of carbohydrases in detergents is well known. Amylases and cellulases being the most common enzymes. Recently, alkaline mannanases stable to constituents of detergents have found application in certain laundry segments as stain removal boosters. Mannanases hydrolyze mannan containing materials like gums (galactomannans, glucomannans and guar gum). These gums are used worldwide as a thickener or stabiliser in many types of household products and foods including ice-creams, BBQ sauces, hair styling gels, shampoos, conditioners and toothpaste (Wong and Saddler, 1992). Stains containing mannan are generally difficult to remove because mannans have a tendency to adsorb to cellulose fibers and therefore bind to cotton textiles. Further, mannan also has a “glue effect.” This gluing effect means that particulate soils released during the wash cycle or from subsequent wear can bind to invisible residual mannan. In other words, not only many mannan stains reappear, but mannan can also be transferred to otherwise clean fabrics during washing and result in fabric greying. Mannanases cleave the beta-1,4-linkages of mannans through hydrolysis, thus breaking down the gum polymer into smaller carbohydrate fragments. These smaller, more water-soluble polysaccharide fragments remain free from the fabric and are siphoned out of the wash. Mannanases can thus prevent redeposition of soil released during washing.

The cleaning compositions must contain at least one additional detergent component. These compositions can also be formulated as sanitization products, contact lens cleansers, dishwashing, hard surface cleaner, and health and beauty care products (Bettiol et al., 2000). Such additive products are intended to supplement the performance of conventional compositions and can be added at any stage of the cleaning process (McCoy, 2001). Treatment with cleaning or detergent compositions comprising the mannanase can improve whiteness as well as prevent binding of certain soils to the cellulosic material. Accordingly, mannanase are used in cleaning compositions, including laundry, personal cleansing and oral/dental compositions, Such cleaning compositions comprising a mannanase and an enzyme selected from cellulases, proteases, lipases, amylases, pectin degrading enzymes and xyloglucanases, are prepared to provide superior cleaning performance.

To Improve the Nutritional Value of Poultry Feeds

Reduction in weight gain and feed conversion efficiency in poultry birds has been associated with intestinal viscosity due to different feeds. beta-Mannan is a polysaccharide commonly found in feed ingredients such as soybean meal (SBM), palm kernel meal (PKM), copra meal (CM), guar gum meal and sesame meal. There is almost universal use of soybean meal and full fat soy as protein sources in poultry feeds, PKM and CM as ruminant feed (Moss and Givens, 1994; Chandrasekariah et al., 2001) pig diets (Pettey et al., 2002) and rabbit diets (Aganga et al., 1991). All these meals have some common properties: high fiber content, low palatability, lack of several essential amino acids and high viscosity coupled with several anti- nutritional properties such as mannan, galactomannan, xylan and arabinoxylan, their utilization in the intestine is very limited. beta-Mannans have been found to be highly deleterious to animal performance, severely compromising weight gain and feed conversion as well as glucose and water absorption. Incorporation of beta- mannanase into these diets results in decreased intestinal viscosity, thus improving both the weight gain of chicks and their feed conversion efficiency. More recently, the beneficial effect of enzymatic degradation of beta-mannan by addition of beta-mannanase to diets containing SBM has been documented in broilers (Jackson et al., 2004; Daskiran et al., 2004; Lee et al., 2003), layers (Wu et al., 2005), turkeys (Odetallah et al., 2002) and swine (Pettey et al., 2002). Using endo-mannanase alone may only produce a small proportion of mannose and thus only a small amount of mannan is likely to be absorbed in the intestine of broilers (Saki et al., 2005). A combination of endo-mannanase from different strains may have a complementary ability to cleave sugars, the use of a combination of endo-mannanase from different strains of organisms may be helpful and that is more possible in the poultry industry. A study of endo-mannanases has been done by Tamaru et al. (1997), who found that endo-mannanase from Vibrio sp. could not hydrolyse mannotriose but produced mannotriose, while endo-mannanase from Streptomyces could hydrolyse mannotriose to form mannose and mannobiose (Kusakabe and Takashi, 1988). Due to the fact that most of mannanase in the market is in form of endo beta-mannanase (e.g. gamanase and hemicell mannanase), it can be speculated that manno- oligosaccharides, mannotriose and mannobiose as well as a small amount of mannose are generated when this type of enzyme is included in the diet. Since only mannose can be absorbed in the intestine, the production of mannobiose and mannooligosaccharides are, to some extent, useless. So these components of carbohydrates may not be absorbed and are therefore unable to supply energy to the host. However, in the sense of the health of the poultry, the production of mannooligosaccharides can improve a chicken’s health (Laere et al., 1999), either by increasing the population of specific bacteria such as Bifidiobacteria because the supply of these types of carbohydrates are a source of feed for bacteria in the caeca and thus suppressing the pathogenic ones, or by flushing out the pathogenic bacteria which attach to the mannooligosaccharides. In fact, mannooligosaccharides are added to the poultry diets for this effect (Lyons and Jacques, 2002). The use of mannanase in poultry research has been widespread and proven to be successful (Sundu et al., 2006). Use in Oil Drilling

Mannanases can also be used to enhance the flow of oil or gas in drilling operations. Practically, product flow to the well bore is stimulated by forcing out open crevices in the surrounding bedrock, which is done by flooding the well with a natural polymer (guar gum) solution and sand particles, capping the well and then pressurizing the bedrock until it fractures. The viscous polymer solution carries the sand through the fractures, propping open cracks for oil and gas flow. To facilitate product flow, the polymer solution is thinned (Adams et al., 1995; Christoffersen, 2004). As mannanases are able to hydrolyze guar gum at elevated temperatures (Politz etal., 2000), so implementation of oil production by these enzymes could be feasible.

In oil Extraction of Coconut Meats

Mannanases can be used in enzymatic oil extraction of coconut meat. The main components of the structural cell wall of coconut meat are mannan and galactomannan (Saittagaroon et al., 1983). A high oil yield is achieved in this process. In the traditional method of oil extraction by expeller, unsanitary handling, drastic processing of copra for oil extraction, refining of the product, the presence of polycylic aromatic hydrocarbons (PAH) retained in the coconut oil not only lessen the quality of the by-product like protein but also render the product susceptible to aflatoxin contamination and oxidative rancidity. The enzymatic oil extraction process not only eliminates such problems but also improves the sensory qualities of the products. In addition, the improvement of the quality of coconut oil minimizes the need for refining the oil as it is already comparable to the semi-refined coconut oil. This enzymatic process gives three valuable products: coconut oil, an aromatic protein containing liquid that may be used as a beverage base and a coconut protein isolate (Chen et al., 2003).

In the Textile and Cellulosic Fiber Processing Industries

The mannanase can be used for preparation of fibers or for cleaning of fibers in combination with detergents in the textile and cellulosic processing industry. The processing of cellulosic material for the textile industry into a material ready for garment manufacture involves several steps: spinning of the fiber into a yarn, construction of woven or knit fabric from the yarn and subsequent preparation, dyeing and finishing operations. Woven goods are constructed by weaving a filling yam between a series of warp yarns; the yarns could be of two different types. Mannanase is useful in an enzymatic scouring process and in desizing (removal of mannan size) during the preparation of cellulosic material for proper response in subsequent dyeing operations (Palackal et al., 2006).

For Degradation of Thickening Agents

Galactomannans such as guar gum and locust bean gum are widely used as thickening agents, e.g. in food and print paste for textile printing such as prints on T-shirts. Mannanase can be used for reducing the viscosity of residual food in processing equipment and thereby facilitate cleaning after processing. The enzyme or enzyme preparation is useful for reducing viscosity of print paste, thereby facilitating wash out of surplus print paste after textile printings (Ademark et al., 1998).

As Non-Nutritional Food Additives

Mannanases also contribute to the human health as they degrade mannans, which otherwise are resistant to mammalian digestive enzymes in the small intestine but are readily fermented in the large intestine, particularly by probiotic bacteria belonging to the genera Bifidobacteria and Lactobacillus. Prebiotic oligosaccharides including mannooligosaccharides, i.e. hydrolysis products of mannan degradation, are believed to promote the selective growth and proliferation of human beneficial intestinal microflora (Kobayashi et al., 1984, 1987).

Thus, mannanases only recendy attracted increased scientific and commercial attention due to potential applications in several industries. A few commercial products have been launched successfully worldwide in the past few years (Table 5).

CONCLUSION

The benefit of employing novel enzymes for specific industrial processes is well recognized with the discovery of beta-mannanases. beta-Mannanases (3.2.1.78) hydrolyze mannan based hemicelluloses and liberate short beta-1,4 manno-oligomers, which can be further hydrolyzed to mannose by beta-mannosidases (EC 3.2.1.25). There are currently about 50 beta-mannanase gene sequences in GH families 5 and 26. The increasing number of new microbial genomes is revealing new mannolytic systems. Major challenges in this field include the design of efficient enzyme system for commercial applications. Mannanases occur ubiquitously in animals, plants, and microbes. However, microbes are most potent producers of mannanases and represent the preferred source of enzymes in view of their rapid growth, limited space required for cultivation, and ready accessibility to genetic manipulation. Microbial mannanases have been used recently in the food, feed and detergent industries. Advances in genetic manipulation of microorganisms have opened new possibilities for the introduction of predesigned changes, resulting in the production of tailor-made mannanases with novel and desirable properties. The development of recombinant mannanases and their commercialization by P&G, ChemGen and Genencor is an excellent example of the successful application of modem biology to biotechnology.

TABLE 5 List of commercial mannanases and their suppliers

Industrial applications of mannanases have posed several problems and challenges for their further improvements. The biodiversity represents an invaluable resource for biotechnological innovations and plays an important role in the search for improved strains of microorganisms used in the industry. A recent trend has involved conducting industrial reactions with enzymes reaped from exotic microorganisms that inhabit hot waters, freezing Arctic waters, saline waters, or extremely acidic or alkaline habitats. The mannanases isolated from extremophilic organisms are likely to mimic some of the unnatural properties of the enzymes that are desirable for their commercial applications. Exploitation of biodiversity to provide microorganisms that produce mannanases well suited for their diverse applications is considered to be one of the most promising future alternatives. The existing knowledge about the structure- function relationship of mannanases, coupled with novel techniques, promises a fair chance of success, in the near future, in evolving mannanases that were never made in nature and that would meet the requirements of the multitude of mannanase applications.

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Christgau, S., Kauppinen, S., Vind, J., Kofod, L. V., and Dalboge, H. 1994. Expression, cloning, purification and characterization of a beta-1,4-mannanase from Aspergillus aculeatus. Biochem. Mol. Biol. Int. 33: 917-925.

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Comfort, D. A., Chhabra, S. R., Conners, S. B., Chou, C.-J., Epting, K. L., Johnson, M.R., Jones, K.L., Sehgal, A.C., and Kelly, R.M. 2004. Strategic biocatalysis with hyperthermophilic enzymes. Green Chemistry 6: 459-465.

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Cui, F., Shi, J., and Lu, Z. 1999. Production of neutral beta- mannanase by Bacillus subtilis and its properties. Wei Sheng Wu Xue Bao. 39(1): 60-63.

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Quiet Time Babies in Neonatal Intensive Care Unit Benefit From Controlled Light and Sound

By Story by LIBBY KEELING, Courier & Press staff writer 464-7450 or [email protected]

Although rousing games of Red Light, Green Light are a few years off, the neonatal intensive care unit at Deaconess Women’s Hospital is equipped with three-tiered, red-yellow-green signals that issue noise-traffic alerts from the ceiling.

The electronic SONICU Sound System, referred to as “The Light Show” by staff, was installed as part of renovations completed in August.

“This is one quarter later, and it really has dramatically changed the behavior of everyone in the NICU,” said Dr. Kenneth Herrmann, medical director for newborn services at the Deaconess- Riley NICU located at The Women’s Hospital on the Gateway campus.

Each of six areas in the NICU has its own independent sound sensor and signal light. A green light indicates the sound level is appropriate (below 50 decibels). Yellow lights (50-55 decibels) serve as a caution.

When sound levels exceed 55 decibels, signal lights glow red and overhead lighting in the affected area automatically dims, providing a second visual cue to staff, parents and visitors.

Decreasing sound levels and input in the NICU improves brain development, explained Anne Marie Nelson, Deaconess developmental specialist.

“The babies rest better,” she said. “If they’re resting better, they’re using that energy to grow,

which is the name of the game.”

Marie Elliott didn’t see a single red light during the first four days her daughter, Loyal, born Dec. 10, was in the NICU.

“It’s really quiet and calm. I actually get sleepy in there,” said Elliott, who lives in Evansville. “I think it’s more relaxing for the babies as well as the nurses.”

The calm atmosphere in the NICU helps reduce stress, Elliott said, and her NICU experience with Loyal has been different from her newborn nursery experience with her son, Royal, who is nearly 2.

“I think that it’s better that it’s quiet, instead of a whole lot of crying babies,” she said. “It gives you time to bond with your baby.”

Yellow alerts are triggered with relative frequency, Herr-mann said, especially during shift changes and when certain ventilators are in use.

Sometimes the beeping of monitors, the sounding of their alarms or crying babies, “screaming bloody murder,” will push noise levels into the red zone, said Misty Dilback, whose twins, Anna and Adelyn, were born 11 weeks premature Oct. 23.

“I do like it. The girls like it, too. They’re always looking up trying to figure out what’s going on,” said Dilback, who lives in Henderson, Ky.

“I think it makes it nice, too, if people come in and don’t realize that they have to be quiet, then that little system will catch them. Like my dad, sometimes he’ll come in and he’ll be talking and I’ll be like, ‘Dad, shh.’ And I’ll look up and I’ll say, ‘Do you see those lights up there?'”

Research indicates loud sounds, bright lights and other painful stimuli cause changes in premature babies’ developing brains, Herrmann said.

“There’s evidence that if we would treat them differently, better, in a kinder, more gentle fashion, that you can actually see changes in brain structure on the MRI examinations,” he said.

A similar sound control system in the NICU at Riley Hospital for Children in Indianapolis inspired the local “light show.”

Herrmann said the Women’s Hospital worked with Chris Smith, the Indianapolis-based engineer who developed the Riley system, to enhance his original design by adding the dimming of overhead lights when sound levels are excessive and in the red.

“Now the most difficult sound to control is a healthy baby cry,” he said. “Those naughty babies are sent home.”

The system also tracks and logs yellow and red alerts. In a 24- hour period, Dec. 10 to 11, Herrmann said, it recorded one red/ dimming light combination occurring in one area of the NICU at 2 a.m.

“It’s fabulous,” he said. “It’s a change in the care, but it’s a change in the culture, where people are coming in without anybody saying they’re too loud. They are just never loud anymore, which we think is good for the babies.”

Kaci Miller, who has been a registered nurse in the NICU for four years, said that when the red/dimming light combo occurs it’s typically triggered by a sudden loud noise, such as something being dropped.

“You can tell when a sudden noise does occur, the babies will jump or startle. Their vital signs will change,” she said.

“This kind of helps. We do have a lot lower noise level most of the time, and it just helps the babies stay calm and relaxed.”

Another feature built into the NICU’s electronic light system includes an artificial sunrise and sunset, allowing for diurnal variation. Overall, lights in the NICU are brighter during the day, gradually dim in the evening, and gradually brighten in the morning.

“It’s just a natural thing that occurs, and it’s good for the babies,” Miller said. “It helps when they go home. This is what it’s going to be like.”

(c) 2007 Evansville Courier & Press. Provided by ProQuest Information and Learning. All rights Reserved.

Piedmont Hospital Rated Best in Atlanta for Overall Cardiac Care and Cardiac Surgery

ATLANTA, Jan. 8 /PRNewswire/ — Piedmont Hospital has been recognized as Best in Atlanta for Overall Cardiac Care and Cardiac Surgery for 2008, according to The Tenth Annual HealthGrades Hospital Quality in America Study.

The HealthGrades(R) study identifies key trends in the quality of care provided by approximately 5,000 hospitals nationwide. HealthGrades researchers analyzed Medicare discharges from every U.S. hospital between 2004 and 2006. Risk-adjusted mortality and complication rates were calculated, and hospitals were assigned a one-star (poor), three-star (as expected), or five- star (best) quality rating for 28 diagnoses and procedures from heart failure to hip replacement to pneumonia.

Patients admitted to the nation’s top-performing hospitals — five-star hospitals like Piedmont — have better outcomes and lower mortality rates than those treated at one-star hospitals, across 18 procedures and conditions, according to the study released recently by HealthGrades. HealthGrades is the nation’s leading independent healthcare ratings company.

“We are extremely proud of this recognition earned by a dedicated team of professionals, who aim tirelessly to attain the greatest clinical outcomes and patient safety standards. To win such high honors by an independent study is a testament to the physicians, nurses and entire team of cardiac professionals at Piedmont,” said Robert W. Maynard, president and CEO of Piedmont Hospital.

Piedmont Hospital is the only metro Atlanta hospital to attain both the Cardiac Care and the Cardiac Surgery Excellence Awards and one of only 108 hospitals in the country to earn the distinction. Overall cardiac care includes performance in numerous cardiovascular services, including care for patients with heart attack, atrial fibrillation, coronary artery bypass graft surgery (CABG), valve surgery, interventional cardiology, and heart failure. Earlier in the year, Piedmont Hospital was the recipient of HealthGrades 2007 Distinguished Hospital for Patient Safety Award(TM), for the second consecutive year. The award ranked Piedmont among the top five percent nationally for patient safety outcomes.

According to The Tenth Annual HealthGrades Hospital Quality in America Study, Piedmont Hospital also received the following recognitions:

        * Recipient of the HealthGrades Cardiac Care Excellence Award(TM) --          2008        * Recipient of the HealthGrades Cardiac Surgery Excellence Award(TM)          -- 2008        * Ranked Among the Top 5% in the Nation for Cardiac Surgery -- 2008        * Ranked Among the Top 10% in the Nation for Overall Cardiac Services          -- 2008        * Best in Atlanta for Overall Cardiac Services, 2008        * Best in Atlanta for Cardiac Surgery, 2008        * Ranked Among the Top 5 in Georgia for Overall Cardiac Services -- 5          Years in a Row (#2 in 2008; #5 in 2007 and 2006; #4 in 2005; #3 in          2004)        * Ranked Among the Top 5 in Georgia for Cardiac Surgery -- 5 Years in          a Row (#3 in 2008; #2 in 2007; 5 in 2006; #3 in 2005 & 2004)        * Ranked Among the Top 5 in Georgia for Cardiology Services -- 5          Years in a Row (#3 in 2008; #5 in 2007, 2006,& 2004; #4 in 2005)        * Ranked Among the Top 10 in Georgia for Coronary Interventional          Procedures -- 5 Years in a Row (#7 in 2008; #10 in 2007; #6 2006 &          2004; #4 in 2005)        * Five-Star Rated for Cardiac Surgery -- 2008        * Five-Star Rated for Coronary Bypass Surgery -- 2 Years in a Row          (2007 and 2008)        * Five-Star Rated for Treatment of Heart Attack -- 5 Years in a Row          (2004-2008)        * Received the Highest Possible Star Ratings for Coronary Bypass          Surgery -- 2008        * Received the Highest Possible Star Ratings for Treatment of Heart          Attack -- 2008, 2006, 2004    

Samantha Collier, HealthGrades’ chief medical officer and author of the study, said, “Our research shows that while the overall quality of hospital care in America is improving, the gap between the best-performing hospitals and the worst persists. This persistent gap makes it imperative that anyone planning to be admitted to a hospital do their homework and seek our highly rated facilities.”

Among the study’s key findings:

* Large gaps persist between the “best” and the “worst” hospitals across all procedures and conditions studied. Five-star rated hospitals, such as Piedmont Hospital, had significantly lower risk-adjusted mortality across all three years studied.

* Across all procedures and conditions studied, there were lower mortality rates in a five-star rated hospital compared to a one-star rated hospital, and compared to the U.S. hospital average.

The 2008 HealthGrades ratings for all hospitals nationwide are available, free of charge, on the organization’s Web site, located at http://www.healthgrades.com/. More than three million individuals and employees of some of the nation’s largest employers and health plans visit HealthGrades each month to access quality information about hospitals, nursing homes and physicians. HealthGrades also provides consumers and payers with detailed assessments of hospitals’ patient-safety outcomes, based on indicators developed by the U.S. Agency for Healthcare Research and Quality.

About Piedmont Hospital

Building on over a century of experience at Piedmont Hospital, the Piedmont Heart Institute combines world-class cardiovascular physicians with the proven excellence of the Fuqua Heart Center of Atlanta at Piedmont Hospital, one of the Southeast’s premier cardiac centers. Piedmont Hospital has been ranked Best in Atlanta for Overall Cardiac Care and Cardiac Surgery (2008) by HealthGrades(R), the leading healthcare ratings organization.

The Piedmont Heart Institute is the first integrated cardiovascular healthcare delivery program affiliated with a community health system in greater Atlanta. This novel approach offers patients a continuum of care from primary and secondary prevention, to outpatient and inpatient cardiovascular care. The Piedmont Heart Institute represents a unique, comprehensive and innovative approach to cardiac care that focuses on achieving the best patient outcomes.

Piedmont Hospital is a member of Piedmont Healthcare, a not-for-profit organization that also includes Piedmont Fayette Hospital in Fayetteville; Piedmont Mountainside Hospital in Jasper; Piedmont Newnan Hospital in Newnan; the Piedmont Heart Institute; the Piedmont Physicians Group; the Piedmont Clinic; and the Piedmont Hospital Foundation. For more information, visit http://www.piedmont.org/.

Piedmont Hospital

CONTACT: Diana Lewis of Piedmont Hospital, +1-404-605-3372

Web site: http://www.piedmont.org/http://www.healthgrades.com/

Visant Corporation Boosts Employee Healthcare Quality With Best Doctors

Best Doctors(R), Inc., the trusted medical resource for ensuring patients with serious illnesses have the right diagnosis and the right treatment, today announced that Visant Corporation has made the Best Doctors unique diagnosis evaluation service available to its U.S. employees. Through Best Doctors, eligible employees and family members have access to advanced medical expertise when faced with decisions about the diagnosis and treatment of serious health conditions.

Now Visant’s employees and their families who wish to seek further evaluation and input on a serious diagnosis, or who have questions about their treatment plan, can receive answers from world-renowned doctors by contacting Best Doctors. An expert doctor, selected from the Best Doctors’ database of 40,000 world-class physicians, evaluates the patient’s case and Best Doctors delivers an easy-to-understand report providing recommendations on the diagnosis and course of treatment, based on a comprehensive review of the member’s medical information. Best Doctors is available to eligible employees on a confidential and voluntary basis.

“Visant has made it a practice to offer innovative tools to our employees to assist them in the care of their health and managing their healthcare dollars, while continuing to advance high quality healthcare as an important priority,” said Shari Davidson, vice president of benefits at Visant Corporation. “We evaluated a number of different approaches in our continuing efforts to help our employees make informed and quality medical decisions and decided that Best Doctors, which allows our employees to draw on the expertise of world-class medical experts, offers an invaluable tool that can directly impact their critical healthcare decisions.”

“More than ever, patients need tools such as Best Doctors to help them navigate the complex healthcare landscape when faced with acute and serious illnesses,” said David Seligman, CEO of Best Doctors, Inc. “Visant is a forward-thinking and innovative organization that is providing their employees with the right tools to get the right care.”

About Visant Corporation

Visant Corporation is a leading marketing and publishing services enterprise servicing the school affinity, direct marketing, fragrance and cosmetics sampling, and educational publishing market segments. For more information on Visant, visit www.visant.net.

About Best Doctors

Best Doctors(R) is the trusted medical resource for ensuring patients have the right diagnosis and the right treatment. The Company serves employers, insurers and health plans by dramatically improving the quality of healthcare at the point of treatment for individuals with serious illnesses and injuries. Founded in 1989 by two Harvard Medical School professors, Best Doctors serves more than 260 insurers, employers and health plans, touching 10 million people in 30 countries. For more information, visit www.bestdoctors.com or call 1-800-223-5003.

 Contacts: Jon Siegal Christian Potts Schwartz Communications 781-684-0770 Email Contact

SOURCE: Best Doctors

Jamie Freedman, M.D., Ph.D. Joins Locus Pharmaceuticals As Chief Medical Officer and Vice President, Clinical Research & Regulatory Affairs

Locus Pharmaceuticals, Inc. announced today the appointment of Jamie Freedman, M.D., Ph.D. as Chief Medical Officer and Vice President, Clinical Research & Regulatory Affairs.

Prior to joining Locus, Dr. Freedman was at Merck Research Labs for nearly five years where he held various positions of increasing responsibility in Clinical Pharmacology, Clinical Oncology, and Experimental Medicine conducting and supervising drug development programs. During this period, he was responsible for the clinical development of several novel cancer compounds. Dr. Freedman received M.D. and Ph.D. degrees from Tufts University, and trained in Medicine and Hematology-Oncology at UCSF and Harvard, respectively. His research focused on the structure and function of proteins involved in blood coagulation and cancer. He also held a clinical staff position at the University of Pennsylvania.

“We are extremely pleased that Dr. Freedman, a very experienced and accomplished oncologist and scientist has chosen to join the Locus team,” stated H. Joseph Reiser, Ph.D., President & Chief Executive Officer of Locus Pharmaceuticals. “Jamie’s background represents a unique mix of scientific and clinical expertise that is highly relevant in leading Locus’ development programs into the critical clinical proof of concept stage,” added Dr. Reiser. Dr. Freedman’s appointment is particularly timely given the corporate transition of Locus Pharmaceuticals as a clinical stage company in the areas of oncology and inflammation. Therein, Locus expects to advance its lead oncology program for LP-261 into Phase II development and also anticipates filing a new IND application in 2008.

About Locus Pharmaceuticals

Locus Pharmaceuticals, Inc. is a world leader in computational drug design. Locus has effectively integrated its proprietary computational approaches with in-house expertise in chemistry, biology and crystallography to create a competitive preclinical drug development platform.

Locus is using its capabilities to develop its own compounds and has also entered into various drug design/development collaborations with numerous pharmaceutical partners. All of the Company’s internal development programs emanate from its computational technology and are focused on oral drug therapies, principally in cancer and inflammation. Locus’ lead oral oncology compound, LP-261 is in late Phase I studies and is expected to enter Phase II studies in early 2008. In its inflammation program, Locus created uniquely selective, first in class p38 inhibitors that bind to an allosteric binding site rather than the ATP site, which may offer an improved safety profile.

Locus has also identified an orally active multi-kinase inhibitor for cancer currently in preclinical development targeting a unique non-VEGF kinase profile. Locus is also working on earlier stage projects targeting Heat Shock Protein 90 which is being conducted in collaboration with the National Cancer Institute (NCI), an EPO antagonist program in collaboration with the National Institute of Health (NIH) and an oral gp41 program for AIDS/HIV.

Locus is a privately-held company. Visit www.locuspharma.com for more information.

Meteor or Mosquitoes – Who Killed the Dinosaurs?

We all know the story – dinosaurs were supposedly wiped out by an asteroid over 65million years ago. However, it is now being suggested that it could have been disease-spreading mosquitoes and other biting insects that lead to their demise.

Husband and wife team George and Roberta Poinar from Oregon State University suggest that disease spread by mosquitoes, mites and ticks was probably the major factor that finished off the reptiles.

By changing the nature of plant life, these insects could ultimately affect plant eating dinosaurs, thus leading to the demise of their natural predators.

This theory could help explain why dinosaurs took so long to die off.

The most widely known explanation is that the extinction of dinosaurs was caused after an asteroid or comet hit the Earth between the Cretaceous and Tertiary periods. A secondary theory suggests that they were driven to extinction by massive volcanic eruptions in India, which led to extreme climate change.

However, George Poinar, a courtesy professor of zoology at Oregon State University, points out that they did not disappear immediately. According to he and his partner, their extinction was drawn out over hundreds of thousands or even millions of years.

The popular asteroid theory would have certainly led to an abrupt extinction. And certainly climate change would most likely have wiped them out in a relatively short time, he said.

The Poinars’ theory suggests that emerging diseases spread by biting insects, combined with the spread of flowering plants, and competition with insects for plant resources, was “perfectly compatible” with a lengthy process of extinction.

The Poinars outline their theory in “What Bugged the Dinosaurs? Insects, Disease and Death in the Cretaceous,” published by Princeton University Press.

The professors reported that examination of insects preserved in amber found organisms which can cause malaria, dysentery “and other abdominal disturbances”.

The infections the insects carried would have caused repeated epidemics that slowly wore down dinosaur populations, which had little or no immunity.

Professor Poinar added: “Other geologic and catastrophic events certainly played a role.

“But by themselves, such events do not explain a process that in reality took a very, very long time, perhaps millions of years. Insects and diseases do provide that explanation.”

Gambro Healthcare Becomes Diaverum and Introduces a New CEO

Gambro Healthcare has been operating as an independent company since July 2007, 100% focused on renal services. As a consequence, Gambro Healthcare is now changing name to Diaverum. Dag Andersson, formerly Molnlycke Healthcare, has been appointed CEO and assumes responsibility January 7, 2008.

Gambro Healthcare has been one of the world’s leading providers of renal services for over 15 years and has a patient base of over 13,000 patients worldwide. In July 2007 Gambro Holding sold Gambro Healthcare to the private equity firm Bridgepoint. “As a stand alone company with 100 % focus on renal services and clinic operations, we at Diaverum can work even harder to provide our patients and other stakeholders with the absolute best renal services,” says Dag Andersson, new CEO. “I feel very excited to become part of a leading healthcare company focusing solely on service. I am looking forward to, together with my team around the world, growing this business over the next coming years”.

The new name

Diaverum is a name with two key facets. The first part, ‘dia’, represents Diaverum’s core activity, dialysis, and signals that Diaverum focuses exclusively on renal services. The second part ‘verum’ means truth in Latin. Hence this new name is symbolic of the honesty, transparency and reliability that the company will continue to be known for.

No changes for the patients

Though the name on the clinic doors and the name badges on the doctors and nurses will say Diaverum, for the patients everything else will stay the same. The treatment will proceed as usual, and the nurses, doctors and other clinic personnel will be the ones that the patients know and trust already.

Going even further

The number of patients with kidney failure is increasing globally. Diaverum will respond to the need for further dialysis capacity by expanding our operations around the globe.

“As renal service specialists we will continue to build on our global knowledge and our dedication to continuous improvement. Our goal is to provide the best renal services available – assuring superior medical outcomes, considerate personalized patient services and support, as well as streamlined and professional clinic operations,” says Dr. Jorgen Hegbrant, Senior Medical Director & VP Medical Operations.

The name change to Diaverum will be implemented throughout Diaverum clinics over the coming year.

Diaverum is one of the world’s leading providers of renal care services, and offers a full range of end-stage renal disease treatment and patient care. The business is the second largest corporate provider of dialysis care services in Europe with 170 clinics in 14 countries serving more than 13,000 patients and with ancillary businesses in South America and Australia.

For further information please visit our website: www.diaverum.com

This information was brought to you by Cision http://newsroom.cision.com

Difficult to Treat Erectile Dysfunction Patients

CHERRY HILL, N.J., Jan. 7 /PRNewswire/ — TriMix Laboratories LLC today announced the introduction of TriMix-gel(TM). TriMix-gel(TM) has been suggested as an alternative for patients who fail on Viagra(R) type pills and cannot or will not self inject with a needle. With twenty million American men currently suffering with ED, current treatments are sufficient in many cases, but there remain more and more men who can’t tolerate the side effects of Viagra(R) type pills and cannot bring themselves to self inject with a needle.

TriMix-gel(TM) is not an herbal remedy. It contains prescription medications listed in the US Pharmacopoeia. The active ingredients in this compounded medicine, prostaglandin, papaverine and phentolamine, have been tested and widely prescribed by physicians for many years.

Typically, TriMix for injection would have to be refrigerated and then self injected at time of use. But this new compound in gel form called TriMix-gel(TM), allows the patient to carry the medicine on his person at room temperature. More importantly, an ED patient will not have to use a needle to self inject himself before sexual intercourse.

TriMix-gel(TM) doesn’t require needles because it uses a novel methodology. At the time of use, before sexual intercourse, the patient uses an “all-in-one” application device which stores, mixes and applies the medicine. The patient does not need a needle for self injection. And the medicine does not require refrigeration.

To obtain the medicine, a patient needs to visit his physician for a thorough ED examination and if appropriate, the patient will be prescribed this medicine by his own doctor. The doctor can fax the prescription to the pharmacy (877-387-4649) and the pharmacy will ship the medicine directly to the patient. Applied Pharmacy Services, Inc., a licensed pharmacy in Mobile, AL has been chosen as the exclusive compounding pharmacy for TriMix-gel(TM) (877-887-4649).

T.J. Harkins, President of TriMix Laboratories says “Physicians have been looking for a new delivery method for these medications for a long time and TriMix-gel(TM) is exactly what ED patients have been asking for.”

The profession of pharmacy has always been based on the patient-physician-pharmacist relationship, known as the “Triad.” Through this “Triad” relationship, patient needs are determined by a physician, who chooses a treatment regimen that may include a compounded medication. Physicians often prescribe compounded medications for various reasons, such as when a patient cannot ingest a medication in its available form. A pharmacist can prepare the medication in cream, liquid, gel or other form that the patient can more easily take.

TriMix Laboratories LLC is a medical research and marketing firm specializing in the urological subspecialty of erectile dysfunction. Applied Pharmacy is a recognized leader in pharmaceutical compounding, helping Physicians and Veterinarians with medicine precisely customized for each individual patient. Applied Pharmacy maintains federal and state licenses and permits and is registered to dispense in almost all states. For more information, visit http://www.trimix-gel.com/.

This press release contains forward looking statements. These statements involve risks and uncertainties which may cause results to differ materially from those set forth in the statements. No forward-looking statement can be guaranteed and actual results may differ materially. Ingredients in TriMix-gel(TM) are FDA approved but TriMix-gel(TM) is a custom compound made in a pharmacy and therefore has not been approved by the FDA for treatment of ED. TriMix-gel(TM) requires a valid prescription from a physician. You should discuss the risks and side effects associated with this drug with your physician. Before taking any action, consult your physician.

   Contact   TJ Harkins   TriMix Laboratories   Cherry Hill, NJ   856-755-3600  

TriMix Laboratories LLC

CONTACT: TJ Harkins of TriMix Laboratories, +1-856-755-3600

Web site: http://www.trimix-gel.com/

Systemax Announces Definitive Agreement to Acquire Selected Assets and Retail Stores From CompUSA

Systemax Inc. (NYSE:SYX) today announced it has entered into a definitive agreement to acquire selected assets and retail stores of CompUSA Inc. Completion of the transaction is subject to customary closing conditions and is expected to close at several dates throughout the first quarter of 2008.

Under the agreement, Systemax will purchase the CompUSA brand, trademarks and e-commerce business, and as many as 16 CompUSA retail outlets.

“We believe the value of the CompUSA brand remains very high. The company has a long legacy of value pricing, service and customer loyalty among consumers nationwide,” said Richard Leeds, Chief Executive Officer of Systemax. “We view this acquisition as a strong complementary business to our TigerDirect operation.”

According to TigerDirect Chief Executive Officer Gilbert Fiorentino, CompUSA.com’s customer base enhances that of TigerDirect.com and the CompUSA retail stores will strengthen the company’s planned retail expansion. TigerDirect currently operates 11 retail stores in Florida, Illinois, North Carolina and Ontario, Canada. Pending required approvals, up to 16 CompUSA stores in Florida, Texas and Puerto Rico will be added during the first quarter of 2008.

“Millions of loyal customers will come to the Systemax and TigerDirect family of businesses through this acquisition,” Fiorentino said. “We anticipate hiring many experienced CompUSA employees, preserving hundreds of store management and sales positions and making us stronger and better in the process.”

As the select CompUSA retail stores are acquired, they will be integrated into TigerDirect’s existing retail operating environment.

“We have a terrific opportunity to continue the great CompUSA brand and establish a new heritage that will extend for generations to come,” Fiorentino added.

TigerDirect, a subsidiary of Systemax, is one of the industry’s top computer and computer-product retailers. The company’s web site (www.tigerdirect.com) was ranked as one of the Top 15 online retail sites for “Customer Focused Excellence” by the Forrester Group in November 2007 and is consistently in the Top 10 for web traffic among computer shopping sites as measured by HitWise.

Until the agreement is closed, CompUSA’s web site (www.compusa.com) and retail operations will continue to operate under CompUSA’s existing leadership. Once the acquisition is completed, the new, improved CompUSA.com web site will operate within Systemax’s family of ecommerce web sites. The new CompUSA.com will feature advanced searching and enhanced content including photo galleries and videos on thousands of the most popular PC, TV and consumer electronics items. The direct costs of the acquisition will depend on the specific retail store locations that are ultimately taken over and are expected to approximate $30 million. The indirect costs of the acquisition — primarily integration and recruiting costs, legal fees, inventory purchases, and other expenses — will be incremental to the direct costs.

About TigerDirect

TigerDirect serves the needs of personal and business computer users, selling consumer electronics, computers, digital media technology and peripherals via retail stores, catalog and Internet channels. TigerDirect is a subsidiary of Systemax Inc. (NYSE:SYX). Visit www.systemax.com for more information.

About Systemax Inc.

Systemax Inc. (www.systemax.com), a Fortune 1000 company, sells personal computers, computer supplies, consumer electronics and industrial products through a system of branded e-commerce web sites, direct mail catalogs, relationship marketers and retail stores in North America and Europe. It also manufacturers and sells personal computers under the Systemax and Ultra brands and develops and markets ProfitCenter Software, a web-based, on-demand application for multi-channel direct marketing companies.

Forward-Looking Statements

This press release contains forward-looking statements about the Company’s performance. These statements are based on management’s estimates, assumptions and projections and are not guarantees of future performance. The Company assumes no obligation to update these statements. Actual results may differ materially from results expressed or implied in these statements as the result of risks, uncertainties and other factors including, but not limited to: (a) unanticipated variations in sales volume, (b) economic conditions and exchange rates, (c) actions by competitors, (d) the continuation of key vendor relationships, (e) the ability to maintain satisfactory loan agreements with lenders, (f) risks associated with the delivery of merchandise to customers utilizing common carriers, (g) the operation of the Company’s management information systems, and (h) unanticipated legal and administrative proceedings. Please refer to “Risk Factors” and the Forward-Looking Statements sections contained in the Company’s Form 10-K for a more detailed explanation of the inherent limitations in such forward-looking statements.

Churches Tweak Tradition to Oblige Allergy Sufferers

COLUMBIA, Md. — The Rev. Bill Miller-Zurell was recently presiding over Communion, moving from congregant to congregant, offering the body, offering the blood, until he got to a little boy who, seeing the piece of bread, stopped the pastor short.

“He asked me if there were any nuts in it,” Miller-Zurell said. “His mom, who was standing behind him, made him. And he only took it after I assured him that there were no nuts.”

With more people realizing that things such as nuts and wheat and even certain pungent scents can make them sick, religious organizations are reconsidering time-honored traditions.

Wheat communion wafers are now available in rice and soy. Religious supply stores are offering hypoallergenic incense. Churches are banning cologne and cutting back on Easter lilies. Fresh pine boughs for the holidays are often out. A group of nuns invented a host with only a trace of wheat so the gluten-sensitive could digest it.

“I’ve just been amazed – there’s more and more and more,” said Miller-Zurell, who leads New Hope Lutheran Church in Columbia. “I suspect it’s an increase in allergies and certainly an awareness on my part.”

According to the Centers for Disease Control and Prevention, as many as 8 percent of children suffer from a food allergy. Every year, the organization reports, allergic reactions are responsible for 30,000 cases of anaphylaxis, 2,000 hospitalizations and 150 deaths.

The Rev. Sue Montgomery, a Pennsylvania pastor who works on a national level to help the Presbyterian church become more accessible for disabled parishioners, said that as more people are diagnosed with allergies, clergy must bend to meet their needs.

“The invitation to the Lord’s table is for everyone,” she said she likes to tell people, “even those with food allergies.”

Just a few years ago, national media attention turned to the Roman Catholic Church after two dioceses refused to offer first Communion to girls suffering from celiac disease – an inability to tolerate wheat. Under orders from the Vatican, the churches, one in Massachusetts and the other in New Jersey, would not consider using soy or rice wafers, insisting that only the traditional wheat host was legitimate.

Then Benedictine nuns in Missouri developed a wheat wafer with only trace levels of gluten – a wafer that’s passed muster with the U.S. Conference of Catholic Bishops and those with celiac disease.

When Bruce Watson told the leaders at Baltimore’s Cathedral of the Incarnation, which is Episcopalian, that his daughter, Rosemary, will swell up and wheeze if she eats wheat, they had no problem allowing her to take a rice wafer for Communion. The church has since discovered other parishioners with the same problem.

“We’re trying to figure out what would make sense for her, to make sure she’s fully included,” said the Rev. Jan Hamill, canon for Christian formation at the Watsons’ Episcopal church.

In some churches, the institutional memory is scented with candles, oils and the heady aromas of frankincense and myrrh. But they’re having to make changes; the heavy scents can cause people with perfume allergies to sneeze, itch or experience trouble breathing.

At Religious Supply Center in Davenport, Iowa, owner Mark Gould said he has noticed more requests from pastors for less-potent incense.

“We actually get calls where they ask for smokeless incense,” he said, “which is kind of a funny one, if you think about it, because it doesn’t exist. We do, however, have something where you can still visualize the smoke but it’s not – and I don’t know if ‘offensive’ is the word – it’s not as strong a smell.”

some alternatives

Some churches are offering Communion wafers made with rice or soy, or even using hypoallergenic incense, so parishioners with allergies can participate in services without the threat of allergic reaction.

Allscripts Acquires ECIN

Clinical software and information solutions company Allscripts has acquired hospital care management and discharge planning software company Extended Care Information Network for $90 million in cash to strengthen its healthcare delivery system.

Allscripts said that on the completion of the acquisition, it will have one of the largest installed bases of care management clients in the country with about 700 hospitals and one of the largest networks of post-acute care facilities.

Extended Care Information Network (ECIN) is privately-held company with a client base of about 400 hospitals and 5,000 post-acute care facilities. ECIN said that its web-based software-as-a-service solutions automate and streamline the care management process in hospitals.

Allscripts said that according to a recent survey by the American Care Management Association, less than 20% of hospitals have automated their discharge planning. The company added that the federal government has proposed the automation of Medicare patient information exchanged between hospitals and the providers to whom they refer discharged patients.

Under the terms of the agreement, the company has created a hospital solutions group under Jeff Surges, chief executive of ECIN. The company added that the new business unit will provide a suite of products and services by combining ECIN with its emergency department information systems and Canopy, its existing care management solution.

This is the company’s first acquisition since March 2006, when it acquired A4 Health Systems for $215 million to expand its product portfolio by including integrated practice management solution.

Source: ComputerWire daily updates

CHCcares of South Carolina Now Available in the South Carolina Healthy Connections Choices Program

WellPath of South Carolina, Inc. announced today that it received final approval from the South Carolina Department of Health and Human Services to begin enrolling Medicaid beneficiaries in its CHCcares of South Carolina Medicaid product, a new Healthy Connections Choices health plan. Healthy Connections Choices is a state program offering managed care services to Medicaid recipients. In comparison to the traditional Medicaid program, CHCcares of South Carolina offers Medicaid recipients comprehensive medical and pharmacy benefits with less out-of-pocket costs.

Medicaid recipients who reside in Richland, Fairfield, Orangeburg and Calhoun counties may immediately begin choosing CHCcares of South Carolina. Additional counties are expected to be added into CHCcares of South Carolina’s coverage area throughout 2008.

“We are very excited to provide Medicaid recipients with a new alternative in the Healthy Connections Choices program,” said Jan Hodges, senior vice president of parent company Coventry Health Care, Inc.’s State Government Programs. “We are offering recipients a great health plan that includes no restrictions on the number of adult doctor office visits, no restrictions on the number of prescriptions filled, and no co-pays for prescription services, office visits, or hospital stays.”

WellPath of South Carolina, Inc. is a managed care company based in Columbia, S.C., and a subsidiary of Coventry Health Care, Inc.

More information is available on the Internet at www.chcsouthcarolina.com and www.scchoices.com.

Amneal Pharmaceuticals Completes Acquisition of Liquid Form Generic Pharmaceuticals Manufacturing Plant

PATERSON, N.J., Jan. 3 /PRNewswire/ — Amneal Pharmaceuticals is pleased to announce the completion of its most recent acquisition, a 30,000 sq ft liquid form generic pharmaceuticals manufacturing plant in Branchburg, New Jersey and intellectual property for 18 generic prescription products. This state-of-the-art, cGMP compliant production and R&D facility complements Amneal’s existing 40,000 sq ft oral solid pharmaceuticals plant in Paterson, NJ and its new 74,000 sq ft R&D Centre in Gujarat, India to provide a robust offering to the marketplace and enable a strong and diverse pipeline to fuel Amneal’s aggressive growth plan.

This new plant, built in 2004 and equipped with the latest equipment and technology, has a production capacity of 7 million bottles per year of Rx liquids as well as over 1 billion tablets/capsules per year of oral solids. The ideally outfitted R&D lab provides the tools and technology necessary for Amneal’s superb scientific team to file 10-12 liquid and/or niche oral solid ANDAs to the US FDA annually. As of December 5, 2007 Amneal’s Regulatory, R&D, Quality Assurance and Manufacturing management teams have been implementing its methods and standards to bring the operation to Amneal’s high levels.

Of the 18 products acquired, one is approved, five have been submitted to the FDA with approvals anticipated in second quarter 2008 while 12 products are in the development pipeline to be filed in 2008-09. The first Amneal products from this plant will begin shipping in February and will be distributed through Amneal’s sales and distribution teams via wholesalers and distributors as well as directly to customers.

“This addition of an outstanding generic liquid pharmaceuticals manufacturing plant advances Amneal’s strategic plan and enables us to provide a broader offering to our customers. It nicely complements our oral solid capabilities as well as our ophthalmic category joint venture,” said Chirag Patel, Amneal’s president. The company has been on a steady and rapid expansion mode during 2007 and will continue the same aggressive pace over the next several years.

Amneal Pharmaceuticals LLC, headquartered in Paterson, NJ, is a USA-based firm that develops, manufacturers and distributes generic pharmaceutical products regulated and approved by the US FDA. Positioned as “Generic’s New Generation,” the company utilizes diverse R&D and manufacturing expertise to conceive breakthrough developments with lasting impact. Vigorous ANDA growth and broad product acquisitions are key features of Amneal’s strategic growth plan, as is the company’s commitment to building deep relationships with its customer base. Amneal delivers superior service levels, quality products, and dynamic value throughout the pharmaceutical industry.

Amneal Pharmaceuticals

CONTACT: Jim Luce, Executive Vice President-Sales & Marketing of AmnealPharmaceuticals, LLC, Direct: +1-949-610-8018, Mobile: +1-949-633-2293, Fax:+1-949-610-8218, [email protected]

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

Neighbors’ Teen Son Hangs Out at Home in the Nude

DEAR ABBY: I have lived next door to the “Smiths” for 18 years. They’re nice people. When problems have arisen, they have helped me out, and I have done the same for them. We’re good neighbors and friends.

I have known the Smiths’ children their whole lives. Their daughter is now 17. Their son was born a year later.

My question: Is it normal for a 16-year-old boy to walk around the house naked, in plain view of family members? No one seems to notice or care. There are no looks or comments.

In the morning he gets up around 6:45. He walks into the kitchen and fixes a bowl of cereal. Then he stands at the counter, watching the morning sports shows while eating his breakfast in the nude. There is absolutely no evidence of arousal of any kind. When the bathroom becomes available, he goes in for a shower.

I have never seen any of the other family members naked. This boy has no compunctions about being seen by his father, mother, sister or next-door neighbor. He’s been nude in my presence dozens of times. I know it’s common for little boys to run around without clothes on sometimes, but, Abby, he’s not a little boy anymore.

Clothes-Minded in Wisconsin

DEAR CLOTHES-MINDED: Standards regarding nudity vary from family to family, and obviously the Smiths are casual and open-minded on the subject. It’s possible that you have been their neighbor so long that the young man considers you part of the family.

Because he has matured sufficiently that his nudity now makes you uncomfortable, you should hang curtains on your windows that face the Smiths’ kitchen and before dropping over there, call to ask whether he’s presentable. If he’s not, then don’t go over.

DEAR ABBY: My mother has been a single parent for the past seven years. She doesn’t have any really close friends there are two women she goes out with occasionally, but all she does is complain about them. She seems to have forgotten what makes her happy and who she is.

I may be biased, but I think Mom is an amazing person. I’m in college now, but whenever I’m home I always try to spend lots of time with her and make her happy.

How can my mother make new friends or start a new relationship? How can she figure out what she likes and be a happier person?

Wants to Help Mom in Philly

DEAR WANTS TO HELP MOM: You are a loving and caring daughter, but you can’t “make her happy.” Only she can do that.

It is possible that losing your father (through death or divorce) has caused your mother to withdraw and go into a depression. Most depression is treatable if the person is willing to discuss the problem with a mental health professional. However, this is a step that you cannot make for her.

Your mother needs to look beyond herself, volunteer some of her free time to the community, and allow herself less time to wallow in her discontent. In that way she will meet new friends and perhaps find a new relationship. But none of this can happen until she decides to reach out.

CONFIDENTIAL TO MY READERS: If you are partying tonight to celebrate the arrival of the new year, please don’t drink and drive. Make sure you have a designated driver.

I wish you all a very happy, healthy and prosperous 2008!

***

Write Dear Abby at dearabby.com or PO Box 69440, Los Angeles, CA 90069.

(c) 2007 Record, The; Bergen County, N.J.. Provided by ProQuest Information and Learning. All rights Reserved.

HealthEdge Names Maria Malavenda Senior Vice President, Marketing

BURLINGTON, Mass., Jan. 2 /PRNewswire/ — HealthEdge, the leading provider of next-generation administration, business intelligence and portal software products for health plans and other healthcare payors has named Maria Malavenda Senior Vice President, Marketing. In this role, Ms. Malavenda will be responsible for the company’s marketing and communications, branding and market development.

Rob Gillette, CEO of HealthEdge, said, “We’re very pleased to have someone with Maria’s depth and industry expertise join the management team. Getting the message out about the shift to a consumer-oriented healthcare industry and how HealthEdge provides the only software products to truly enable this change is critical. With Maria’s industry, technology and marketing leadership, we expect to continue our strong growth and to expand in providing our clients the software platform they need to compete in the new healthcare economy.”

Ms. Malavenda has more than 20 years of successful marketing, strategy, operations and management consulting experience in healthcare, financial services and human capital environments. She has been a partner in the Healthcare Strategy and Operations practice at Accenture, Capgemini Ernst & Young and a director at Deloitte, and has occupied leadership roles in sales and marketing for Johnson and Johnson and Aetna.

Ms. Malavenda said, “I’m extremely enthusiastic about HealthEdge’s enterprise claim and benefits software products and their capability to assist health plans cope with the important challenges they face today and in the years ahead. The industry desperately needs the kind of scalable, flexible and agile technology solution that only HealthEdge is providing.”

About HealthEdge

HealthEdge is an agile and innovative software company that is transforming healthcare claims and benefits management. Health plans, employer groups, and insurance carriers of any size improve business performance and outperform their competitors with HealthEdge products. HealthEdge provides HealthRules(R), a next-generation solution for core administrative processes, business intelligence, modeling and web self-service. The company is headquartered in Burlington, Massachusetts.

   Contact: HealthEdge   Maria Malavenda   781-419-6134   [email protected]  

HealthEdge

CONTACT: Maria Malavenda of HealthEdge, +1-781-419-6134,[email protected]

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

Local Anaesthetic During Cataract Surgery: Factors Influencing Perception of Pain, Anxiety and Overall Satisfaction

By Modi, Neil Shaw, Steve; Allman, Keith; Simcock, Peter

KEYWORDS Anaesthesia / Anxiety / Cataract / Handholder / Pain / Satisfaction To assess factors influencing perception of pain, anxiety and overall satisfaction during local anaesthetic cataract surgery an audit was carried out at the West of England Eye Unit. Patients receiving sub-Tenons after previous peribulbar anaesthesia had significantly higher pain scores. Patient satisfaction was significantly higher when a handholder was present in theatre. Finally, no difference was found in the three variables whether anaesthesia was administered by an anaesthetic practitioner or an anaesthetist.

Introduction

Nursing feedback from the West of England Eye Unit expressed concern that some patients were not satisfied with their ‘cataract experience’. An audit was performed to investigate if this was a frequent occurrence or a rare event. Data regarding patients’ pain, anxiety and satisfaction with local anaesthetic cataract surgery was collected and compared to standards from the literature.

Local anaesthesia is currently the preferred method of anaesthesia for cataract surgery in the UK (Royal College of Anaesthetists & College of Ophthalmologists 2001). A pain free operation remains the gold standard for surgery. Absence of pain however, does not always equate to patient comfort. Anxiety or sensation of pressure may increase the requirement for sedation (Nielsen & Allerod 1998). Patients’ pain, anxiety and overall satisfaction following local anaesthetic cataract surgery has been extensively reviewed (Briggs, Beck & Esakowitz 1997, Katz et al 2000, Friedman et al 2001, Zafirakis et al 2001, Bellan, Gooi & Rehsia Mathew et al 2003, Sauder & Jonas Fung et al 2005, Muttu et al 2005).

These reviews have not, however, considered the effect of handholders in theatre on patients’ pain, anxiety and satisfaction. This was assessed here to address management efforts to cut back numbers of theatre staff. The use of anaesthetic practitioners in our unit is not universal in ophthalmic theatres, and the management of patients’ pain in particular, as well as their anxiety and satisfaction is important in validating this practice. Again this has not been assessed in the literature.

Patients and methods

For 10 weeks from April 2006 we consecutively collected patients having routine day case local anaesthetic cataract surgery at the Royal Devon and Exeter NHS Trust. The patients demographic details, anaesthetist and surgeon name and grade, local anaesthetic technique, handholder presence, duration of surgery and details of any previous cataract surgery were noted.

Anaesthesia was performed by anaesthetic nurse practitioners (sub- Tenons only), senior house officers, specialist registrars and consultants. In total, 26 anaesthetists were involved in this audit. sub-Tenons anaesthesia and peribulbar anaesthesia were used with topical proxymetacaine applied prior to both techniques.

Surgery was performed by clinical assistants, senior house officers, specialist registrars, fellows and consultants. In total, 15 surgeons were involved in the audit. Small-incision phacoemulsification cataract surgery was performed on all patients.

Following surgery ophthalmic-trained nurses asked patients to place a mark on a 90mm visual analogue scale (1-10) representing their experience of pain, anxiety and their satisfaction, giving a continuous variable.

Non-parametric Mann-Whitney and KruskalWallis tests were used for comparing the pain, anxiety and satisfaction scores of different groups. Spearman’s correlation was also used for looking at the relationship with duration. Note that pain, anxiety and satisfaction scores were all clearly not normally distributed (hence the use of non-parametric methods).

Results

Two hundred and sixty eight patients were audited (101 male, 167 female). Results were compared to the findings of the Misericordia Cataract Comfort study 3 as the ‘standard comparator’. This standard found mean pain, anxiety and satisfaction to be 13.5,14.9 and 87.9 respectively when converted to a comparable scale to facilitate comparison with our results. The other factors were reviewed descriptively and where possible assessed with multivariate statistical analysis.

Overall pain, anxiety and satisfaction

Overall pain, anxiety and satisfaction with local anaesthetic cataract surgery for all patients in our audit (Table 1) were compared to the ‘standard’. Mean values were used as they were the only numerical values presented in the ‘standard’: 28.3% felt more pain, 55.3% felt more anxiety, and 40.4% felt less satisfied overall than the standard.

Table 1 Summary statistics for outcome scores: pain, anxiety and satisfaction (based on n=268 patients)

Table 2 Percentages of non-sedated patients having either sub- Tenons or Peribulbar local anaesthetic who experienced more pain, anxiety and less satisfaction than standard

Table 3 The three outcomes for non-sedated patients having sub- Tenons local anaesthesia

Table 4 The three outcomes for non-sedated patients having Peribulbar local anaesthesia

Table 5 Percentages of patients who had more pain, anxiety and less satisfaction than the standard, for patients both with and without handholders in the anaesthetic room

Table 6 Percentages of patients who had more pain, anxiety and less satisfaction than the standard, for patients both with and without handholders in theatre

The mean values of the three outcomes were within one standard deviation of the standard. We concluded that overall pain, anxiety and satisfaction with local anaesthetic cataract surgery for all patients in this audit were comparable to the standard.

Local anaesthetic technique

One hundred and fifty three patients received sub-Tenons and 109 received peribulbar anaesthetic. Six patients received peribulbar and needed a top-up of sub-Tenons anaesthetic intraoperatively.

Only non-sedated patients (n=145) were analysed (as sedation often causes amnesia) (Table 2); 114 received subTenons and 31 received peribulbar anaesthetic. Tables 3 and 4 give the summary statistics for the three outcomes when using sub-Tenons and peribulbar local anaesthesia respectively.

The mean values for both types of anaesthetic were within one standard deviation of our chosen standard. We conclude that there was no significant difference between the three outcomes for our patients, and the standards. Of our patients, we found no evidence of any significant differences between those who had Peribulbar (n=31) and those who had sub-Tenons (n=114) anaesthesia for pain (p=0.76), anxiety (p=0.75) or satisfaction (p=0.42).

Previous cataract surgery

We found no evidence of difference in pain, anxiety or satisfaction in patients having their first (n=151) or second (n=104) cataract operation (p>0.1). In patients having their second cataract operation, we noted our patients experienced significantly more pain if they received sub-Tenons after previous peribulbar technique (n=20, p=0.007). In patients having peribulbar after previous sub-Tenons technique (n=15, p>0.1) no significant difference in pain, anxiety or satisfaction was seen.

Figure 1 Mean of the three outcomes with handholder present and not present

Table 7 The three outcomes for patients with a handholder present in theatre

Table 8 The three outcomes for patients with no handholder present in theatre

Handholder

Table 5 compares the data from this audit to the standard when a handholder was present (n=55) in the anaesthetic room with no handholder being present (n=189).

No significant difference in pain (p=0.39) or anxiety (p=0.076) was noted with or without a handholder in the anaesthetic room. Satisfaction scores were lower when a handholder was present (mean=79.9, median=79.9) compared to when there was no handholder (mean=84.8, median=89), but with a borderline p value of 0.046.

Table 6 compares whether a handholder was present (n=215) in theatre with no handholder being present (n=48) with respect to the standard.

The mean standard values for the three outcomes were within one standard deviation of our audit data. We concluded that there was no significant difference between the three outcomes with or without handholder present, and the standard.

It can be seen descriptively from Figure 1 and Tables 7 and 8 that patients felt less pain, anxiety and were more satisfied with a handholder present in theatre compared to no handholder. We found no significant evidence of a difference in pain or anxiety whether (Figure 7) or not (Figure 8) a handholder was present in theatre. Our data did show that satisfaction scores were significantly higher (p

Grade of individual anaesthetist and surgeon

This study involved four grades of anaesthetist (anaesthetic practitioner n=51, consultant n=136, senior house officer n=59 and specialist registrar n=21). We found no significant difference in any of the three outcomes between the different anaesthetist grades (p>0.1). The study encompassed five grades of surgeon (clinical assistant n=23, consultant n=109, senior house officer n=10, specialist registrar n=87 and fellow n=38). No evidence of any differences in anxiety or satisfaction (p>0.25) was noted but there was some evidence of differences in average pain scores between grades of surgeon. Average pain scores were lowest for consultants and highest for SHOs with the other three grades between. Magnified view of a cataract in a human eye, seen on examination with a slit lamp using diffuse illumination

No valid comparisons could be made between individual surgeons or anaesthetists as the small numbers for each individual would give invalid results.

Discussion

The purpose of audit is to assess the efficacy of current clinical practice and to contribute to improving that practice. Our aim was to consider our patients’ experience of cataract surgery in terms of pain, anxiety and their overall satisfaction, and determine whether the measures we have in place are effective. We drew our conclusions by comparison of our results with standards from chosen from the Misericordia Health Centre Cataract Comfort Study (Bellan, Gooi & Rehsia 2002). The Cataract Comfort Study was selected because it was similar to ours, and looked at the same three outcomes.

This audit was of a large size compared to many papers in the literature (Briggs, Beck & Esakowitz 1997, Neilsen & Allerod 1998, Zafirakis et al 2001, Bellan, Gooi & Rehsia 2002, Mathew et al 2003, Sauder & Jonas 2003, Srinivasan et al 2004, Cagini et al 2006). The Royal Devon and Exeter Hospital was representative of a broad range of settings as 15 surgeons and 26 anaesthetists were involved, performing over 2,000 cataract operations per year. We consecutively accepted all patients having routine local anaesthetic, day-case cataract surgery over a three month period. This study was an audit and not a controlled clinical trial. It therefore has limitations as a single centre study without patient randomisation with the possibility of selection bias. There were no specific inclusion or exclusion criteria, which leads to great variability between patients. Staff were not blinded to the surgery or which method of anaesthesia was used. No single member of staff was responsible for collecting the data and many anaesthetists and surgeons were involved. Finally, sedation causes amnesia which might lead to reduced reporting of pain (Nielsen & Allerod 1998). We have reduced this to some extent by removing patients who had sedation when comparing the two local anaesthetic techniques.

The audit data indicated that pain, anxiety and satisfaction with local anaesthetic day case cataract surgery at the Royal Devon and Exeter is comparable (within one standard deviation) to that found in the Misericordia Cataract Comfort Study (Bellan, Gooi & Rehsia 2002).

The large standard deviation of our results is unavoidable because of bias, subjectivity, lack of good methodology to test the small degrees of pain associated with cataract surgery, along with amnesia caused by intravenous sedation (Nielsen & Allerod 1998). Many studies did not report standard deviations, and those which did were of similar magnitude (Srinivasan et al 2004).

When comparing the two local anaesthetic techniques, excluding sedated patients because of amnesia, we found no significant difference. Nielsen and Allerod (1998) noted significantly more pain on administration of retro-bulbar anaesthesia, but less perioperative discomfort. They concluded that patients preferred subTenons anaesthesia. Briggs, Beck & Esakowitz (1997) also considered pain scores for the two techniques, finding significantly lower scores on administration of sub-Tenons anaesthetic compared to peribulbar. The main difference of these from our own studies was that they considered pain scores on administration of the anaesthetic and during the operation, whereas we considered our three outcomes at the end of the operation in recovery. There is good evidence that anxiety levels vary, being highest when the patient first arrives at the department to being lowest after the operation (Bellan, Gooi & Rehsia 2002, Habib, Mandour & Balmer 2004). Perception of pain from a procedure may vary also, perhaps diminishing with time as the patient’s anxiety reduces. This might reduce our pick-up rate for patients’ perception of pain, by rendering the difference between the two groups less and thus nonsignificant.

Pain, anxiety and satisfaction were not related to whether the patients were having their first or second cataract operation. Interestingly, we did find that patients who had sub-Tenons after previous peribulbar technique felt significantly more pain. There was no difference when we looked at the three outcomes for patients who had peribulbar after previous sub-Tenons anaesthesia. Although the numbers for both groups were small, the difference was highly significant and as a recommendation from this audit, we will advocate the use of a peribulbar technique if a patient has previously had this technique on the fellow eye.

Budget cuts to ophthalmic theatres have made it increasingly difficult to justify the expense of staff such as handholders. In ophthalmic theatres however, handholders are not just as a means of comfort for patients but also an important tool for communication between surgeon and patient. In the anaesthetic room handholding did not appear beneficial but patients with a handholder in theatre, however, felt less pain and anxiety and were significantly more satisfied than those without a handholder.

In the anaesthetic room 22.5% of patients had a handholder, whereas in theatre 82.7% of patients had a handholder. It is not usual however for handholders to be present in the anaesthetic room, unless a patient specifically requests this or if they are particularly anxious. This is an obvious selection bias and the patients in the two groups are not comparable. This may explain why patients with handholders in the anaesthetic room appeared more anxious and less satisfied (although did not reach statistical significance). There was no such selection bias for patients having handholders in theatre, as all patients received a handholder except when staff numbers would not permit this.

We found no difference in any of the three outcomes depending on the grade of anaesthetist. This includes the anaesthetic nurse practitioner trained in sub-Tenons anaesthesia. This finding offers the possibility of expanding their role in cataract surgery, as a more cost-effective alternative to employing an anaesthetist.

Consultants were found to have the lowest patient pain scores whereas SHOs had the highest. The other three grades were similar to each other. Mathew, Webb & Hill (2002) also found a greater level of discomfort of around 11%, when comparing a trainee with an experienced surgeon (although not statistically significant). This again is difficult to explain as the anaesthesia was the same for the various grades of surgeon.

Presentations

This paper was presented at the South West Ophthalmic Society meeting in Bristol 2006.

No significant difference in pain or anxiety was noted with or without a handholder in the anaesthetic room

We found no significant difference between two anaesthetic techniques with regard to pain, anxiety and satisfaction

Summary and implemented changes

* Pain, anxiety and satisfaction with local anaesthetic day-case cataract surgery at the Royal Devon and Exeter is comparable to a published standard.

* We found no significant difference between two anaesthetic techniques with regard to pain, anxiety and satisfaction.

* More pain is experienced if patients received sub-Tenons after previous peribulbar technique. In future, peribulbar anaesthetic will be recommended if the fellow eye had previous surgery with this technique, if resources allow.

* Patients reported less pain and anxiety and significantly higher satisfaction scores with hand holder present in theatre. This provided positive feedback, demonstrating a valuable role for handholders and further motivation for staff. This also proved useful information for nursing colleagues and administrators who are considering reducing theatre budgets by cutting funding for staff, including handholders.

* Satisfaction was higher and anxiety was the same in patients selected to have sedation compared to those who were not – suggesting that sedation reduces anxiety and increases satisfaction.

* The three outcomes were independent of the grade of anaesthetist, suggesting a possibility to increase the role of the anaesthetic nurse practitioner in daycase sub-Tenons technique cataractsurgery as a more cost-effective alternative to an anaesthetist.

We will advocate the use of a peribulbar technique if a patient has previously had this technique on the fellow eye

References

Bellan L, Gooi A Rehsia S 2002 The Misericordia Health Centre cataract comfort study Canadian Journal of Ophthalmology 37 (3) 155- 160

Briggs MC, Beck SA, Esakowitz L 1997 sub-Tenons versus Peribulbar anaesthesia for cataract surgery Eye 11 (5) 639-643

Cagini C, De Carolis A, Fiore T, laccheri B, Giordanelli A, Romanelli D 2006 Limbal anaesthesia versus topical anaesthesia for clear corneal phacoemulsification Acta Ophthalmotogica Scandinavica 84 (1) 105-109

Friedman DS, Bass EB, Lubomski LH et al 2001 Synthesis of the literature on the effectiveness of regional anesthesia for cataract surgery Ophthalmology 108 (3) 519-529

Fung D, Cohen M, Stewart S, Davies A 2005 What determines patient satisfaction with cataract care under topical local anaesthesia and monitored sedation in a community hospital setting Anesthesia & Analgesia 100 (6) 1644-1650

Habib NE, Mandour NM, Balmer HC 2004 Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anaesthesia Journal of Cataract and Refractive Surgery 30 (2) 437- 443

Katz J, Feldman MA Bass EB et al 2000 Injectable versus topical anesthesia for cataract surgery: patient perceptions of pain and side effects Ophthalmology 107 (11) 2054-2060

Mathew M, Webb L, Hill R 2002 Surgeon experience and patient comfort during clear corneal phacoemulsification under topical local anesthesia Journal of Cataract & Refractive Surgery 28 (11) 1977- 1981 Mathew M, Williams A Leonard W, Lennox A, Bennett S, Harry C 2003 Patient comfort during clear corneal phacoemulsification with sub-Tenons local anesthesia Journal of Cataract & Refractive Surgery 29 (6) 1132-1136

Muttu S, Liu E, Ang S, Chew P, Lee T, Ti L 2005 Comparison of dexmedetomidine and midazolam sedation for cataract surgery under topical anesthesia Journal of Cataract & Refractive Surgery 31 (9) 1845-1846

Nielsen PJ, Allerod CW 1998 Evaluation of local anesthesia techniques for small incision cataract surgery Journal of Cataract & Refractive Surgery 24 (8) 1136-1144

Royal College of Anaesthetists and College of Ophthalmologists 2001 Report of the Joint Working Party on Local Anaesthesia for Intraocular Surgery Available from: www.rcoaac.uk/ docs/ RCARCOGuidelines.pdf [Accessed 20 November 2007]

Sauder G, Jonas J 2003 Topical versus Peribulbar anaesthesia for cataract surgery Acta Ophthalmologica Scandinavica 81 (6) 596-599

Srinivasan S, Fem AI, Servaraj S, Hasan S 2004 Randomized double- blind trial comparing topical and sub-Tenons anaesthesia in routine cataract surgery British Journal of Anaesthesia 93 (5) 683-686

Zafirakis P, Voudouri A Rowe S 2001 Topical versus sub-Tenons anesthesia without sedation in cataract surgery Journal of Cataract & Refractive Surgery 27 (6) 873-879

About the authors

Neil Modi

MBBS, SSc, DHMSA

ST1 in Ophthalmology, Royal Cornwall Hospital

Dr Steve Shaw

Statistician,

University of Plymouth

Dr Keith G Allman

MD FRCA

Consultant Anaesthetist, Royal Devon and Exeter

NHS Trust

Mr Peter R Simcock

MRCP FRCS FRCOphth DO

Consultant Ophthalmologist, Royal Devon and Exeter NHS Trust

Copyright Association for Perioperative Practice Jan 2008

(c) 2008 British Journal of Perioperative Nursing. Provided by ProQuest Information and Learning. All rights Reserved.

Cain Reign of Terror is Finally Broken ; Racketeering Charge Sticks Against Thugs

By Dan Herbeck

Chuck Bracey was never the same man after a gang of thieves and arsonists burned his logging and tree removal business to the ground in February 2002.

The fire destroyed his business in Newfane — he was not insured – – and within a month, the lumberman’s reddish-brown hair turned gray.

Less than four months after the blaze, Bracey died of a heart attack at age 68. Friends and family members are convinced that the stress caused by the fire killed him.

“He was the finest, strongest, hardest-working man I’ve ever known,” his wife, Carol, recalled in a recent interview. “But on the day of the fire, I knew I was looking at a broken man. He never got over it.”

But police say the fire that ruined Chuck Bracey also was the beginning of the downfall of the man who ordered the arson — David R. Cain Jr., 37 — and his rural gang of thugs who became known as the Backwoods Sopranos because of their thuggery.

Cain Jr. — who ran his own logging and tree removal business — and his brother and cousin were convicted earlier this month in federal court of racketeering, arson and other charges. They are awaiting sentencing and pursuing appeals.

Cops in both Niagara and Orleans counties are hoping the convictions will bring an end to a crime saga that goes back more than 30 years, involving members of the Cain family and their close relatives, the Rutherfords.

Crime victims, witnesses — and even some cops and judges — had feared members of the two families for decades, according to Niagara County Sheriff Thomas A. Beilein and other police officials. Members of Cain’s gang were heavily involved in drug dealing, burglary and other crimes, police say.

“When the Cains or the Rutherfords came up in a criminal investigation, people would become fearful and reluctant to cooperate,” said Patrick Weidel, a Niagara County sheriff’s investigator who worked on the case for years with his partner, Raymond Degan.

“We even had burglary victims who wouldn’t want to file a complaint if those two names came up.”

But after the fire at Bracey’s, police received information that Cain Jr. had talked about destroying Bracey’s and other businesses that competed with him for logging and tree removal contracts.

That prompted Beilein to ask for help from powerful federal agencies — the U.S. attorney’s office, the Bureau of Alcohol, Tobacco, Firearms & Explosives and the FBI. A task force was formed, combining federal agents with personnel from Beilein’s office, the Niagara County district attorney’s office and the Orleans County Sheriff’s Office.

Their investigation turned up a lot of intimidation linked to Cain Jr. and his family.

In the early 1970s, someone threw a firebomb into the home of Beryl T. Coleman, a Somerset town justice who had several cases involving the Rutherfords. A trash bag filled with animal carcasses was left on the judge’s front porch. No one was ever charged in the two incidents. But Coleman started carrying a gun in court.

Five months after a Niagara sheriff’s deputy ticketed Cain’s pickup in 1994, Cain went to the deputy’s Newfane home and set his private car on fire. Cain and his brother, Christopher, were convicted of that crime at the federal trial.

In August 1995, a Barker police officer went to Cain’s home to serve a warrant on him. Cain knocked the officer out cold. Cain eventually pleaded guilty to misdemeanor assault.

In 2003, Cain Jr. discussed a plan to kill Coleman — who is now retired — and last year, he allegedly made threats to kill Weidel and Assistant U.S. Attorney Anthony M. Bruce, federal prosecutors have alleged.

In November 2004, Cain and his father, David Sr., were accused of assaulting federal marshals and a state trooper who went to their home with a warrant. The assault charges were dismissed in late 2006, after two mistrials.

>People start talking

After the fire at Bracey’s logging business, authorities decided to pursue a racketeering case — similar to the prosecutions that have been successful against the Mafia in New York City. Individual crimes, such as arsons and extortions, would be pieced together to show a pattern of racketeering activity.

“People who would never speak to us about the Cain family before began providing information after the feds became involved,” Degan said. “We were interviewing people in Dave’s inner circle, his associates. They were scared, but little by little, we got some information.”

When a federal judge put Cain Jr. in jail after his alleged assault on federal marshals, more people began to talk. One of them was Cain’s cousin, Paul Rutherford Jr., 32, who was charged with a violent home invasion robbery at the home of an Orleans County woman in October 2003.

Rutherford admitted that he had spent most of his life as a thief. He took a plea deal, received a 13-year federal prison sentence and agreed to testify against Cain Jr.

“Witnesses began implicating themselves and Dave Cain,” Weidel said. “With federal agents involved, they realized we were serious about this investigation and it really was going somewhere.”

One by one, more than a half-dozen other Cain associates took plea deals and began to cooperate. And in May 2006, a federal grand jury indicted Cain, his brother, Chris, and their cousin, James Soha, on racketeering and other charges.

U.S. Attorney Terrance P. Flynn says it was a perfect case to get involved in. “This is exactly the kind of case where the federal government should be helping the smaller local police agencies,” he said.

>Cain’s supporters

But not everyone agrees that pursuing a racketeering case was the right thing for the federal government to do.

“The government took a series of state crimes involving Dave Cain and some personal disputes he had, and turned it into a racketeering case,” said James P. Harrington, Soha’s attorney. “There are some very serious issues with the trial that we’ll be looking at on appeal.”

Cain is “the hardest-working man I’ve ever met,” said George V.C. Muscato, a Lockport attorney who represents Cain’s mother, Ann Rutherford Cain.

“He’s a very intelligent guy who worked 24 hours a day, seven days a week,” Muscato said. “He is a tough man in a rough-and- tumble business. He would blow off some steam, but I never saw him do anything violent.”

Prosecutors say Ann Cain, 53, tried to cover up her sons’ crimes. After a trial in September 2006, she was convicted of felony witness tampering. Jurors convicted her of telling one of David Cain Jr.’s henchmen, Sean Cooper, to lie to police. Her sentencing date has not yet been scheduled.

Carol Bracey is thankful that the feds took up the Cain case.

After her husband died, she got a big Great Dane named Lady for protection and companionship. She said the dog, her horse Charlie, and her friends at the Grace Bible Church in Newfane helped her deal with her losses.

Slowly, with the help of several loyal employees, she has been rebuilding the business her husband built. She tries not to dwell on David Cain Jr., but can’t help but wonder about him at times.

“My husband was loved by so many people . . . Five hundred people came to his wake,” Bracey said. “I think about David Cain and I wonder, how could he destroy a man and his life’s work like that? If he knew how much pain he was causing, would he do it anyway?”

e-mail: [email protected]

Originally published by NEWS STAFF REPORTER.

(c) 2007 Buffalo News. Provided by ProQuest Information and Learning. All rights Reserved.

Hmong Doctor Opens Pioneering Practice: Fenglaly Lee is Fresno’s First Female Hmong OB/GYN.

By Vanessa Colon, The Fresno Bee, Calif.

Dec. 30–Dr. Fenglaly Lee grew up as a refugee in Fresno living on welfare and harvesting Asian vegetables on the weekends.

Now, she is delivering babies as the first female Hmong OB/GYN doctor in the central San Joaquin Valley and possibly the state.

Her arrival provides the Valley’s large population of Hmong women with a physician who understands Hmong customs and can explain why it sometimes is necessary to set customs aside for the patient’s health.

Lee opened a private practice in downtown Fresno in August and delivers babies at Community Regional Medical Center. Lee, 33, felt compelled to pursue a college degree after watching how hard her parents worked harvesting green beans, sugar peas and cherry tomatoes. The death of her father after a stroke in 1998 propelled her to study medicine.

Lee said it’s a big leap from refugee to physician but it’s an important achievement.

The Valley has at least seven Hmong physicians including Dr. Mouatou Mouanoutoua, a cardiologist in Fresno through the University of California at San Francisco; Dr. Long Thao, a family practitioner in Merced; and Dr. Tou Vang, a pediatrician in Fresno.

“It is overwhelming sometimes, but overall it’s exciting to have such a big stride. It was not a shock. I know in general there is a lack of Hmong physicians in Hmong society,” Lee said.

About 33,000 residents of Hmong descent live in Fresno County. Merced County has more than 6,000 residents.

Lee arrived in Fresno from Laos when she was 6 or 7 years old.

She grew up with three sisters, five brothers, and parents who earned about $10,000 a year in the 1980s. Her family went off welfare in 1987 when her father opened a shipping and packaging business in the Valley.

Lee wanted more from life than farmwork and an early marriage. She persuaded the high school to let her skip the eighth grade and enter ninth grade so she could graduate quickly.

“I was afraid I was going to get married too soon, so I wanted to hurry up and go to college,” she said.

Lee graduated from McLane High School in 1992. At 19, she married Long Lao. Lee earned a bachelor’s degree in physiology from the University of California at Davis in 1997, then graduated from UC Davis’ medical school in 2003. Lee did her residency at UCSF in Fresno.

“She’s small but very assertive. She’s always been a tremendous leader,” said Dr. Jeffrey Thomas, associate program director at UCSF-Fresno’s OB/GYN residency and training program.

Thomas describes her as motivated and much in demand when she opened her private practice.

“She had people waiting for her to graduate. There was a need,” he said.

Thomas said she has been an asset to medical students and physicians in the Valley. He learned from her that Hmong women follow a diet of boiled chicken and rice after giving birth. Thomas said it was helpful to understand Hmong customs such as patients who consult their parents on a decision for surgery.

Ma Yang, who gave birth to a baby boy Nov. 12, said she was relieved to have a Hmong doctor who understood her. Lee speaks Hmong.

“It makes me feel more comfortable. … I know I can open up and tell her my problems,” Yang said.

She said her baby’s head faced upward instead of downward. Hmong custom is for Hmong midwives to reposition the baby so its head is facing down for delivery.

Yang said Lee told her she shouldn’t have allowed the midwives to do that, even if it’s a Hmong custom, because that kind of forced movement can injure the baby. Luckily, the baby was fine and Yang and her parents agreed that Yang should have a Caesarean section. Yang’s parents initially didn’t want her to have a Caesarean, but changed their minds after listening to Lee.

“She made a good decision. She said I needed an emergency C-section,” Yang said of Lee.

Lee said she respects Hmong customs such as getting advice from the clan or parents. But she advises her patients about the risk of death in delaying a Caesarean section.

“I don’t think they understand the level of fetal deaths. I don’t discourage the practices, [but] if it’s harmful I’d discourage it.”

Lee hopes to motivate more Hmong women, especially the older generation, to have pelvic exams and Pap smears.

“They’ve never been encouraged to get health screenings or medical screening until the conditions are terminal,” Lee said.

Lee has a busy life. She has an 8-year-old girl and two boys ages 2 and 5. Lee also mentors a female undergraduate at California State University, Fresno, in addition to holding a faculty position at UCSF-Fresno.

Thomas said he admires Lee because she came back to Fresno and is helping other medical students as well as her community.

“She could have gone north, but she stayed in downtown to give back to the community that supported her. … She’s the real deal,” Thomas said.

The reporter can be reached at [email protected] or(559) 441-6313.

—–

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Copyright (c) 2007, The Fresno Bee, Calif.

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Cyclical Dydrogesterone in Secondary Amenorrhea: Results of a Double- Blind, Placebo-Controlled, Randomized Study

By Panay, Nicholas Pritsch, Maria; Alt, Jeannette

Abstract Secondary amenorrhea in women with normal estrogen levels increases the risk of endometrial carcinoma. Cyclical dydrogesterone induces regular withdrawal bleeding and effectively protects the endometrium of postmenopausal women receiving estrogens. In order to assess the efficacy of dydrogesterone in inducing regular withdrawal bleeds in premenopausal women with secondary amenorrhea or oligomenorrhea and normal estrogen levels, a double-blind, randomized, placebo-controlled, multicenter study was conducted in 104 women using cyclical dydrogesterone as is used for estrogen replacement therapy. Treatment consisted of dydrogesterone (10 mg/day on days 1-14 followed by placebo on days 15-28 of each cycle) given for six cycles of 28 days. The control group received placebo throughout the six cycles. Bleeding was documented by the patient on diary cards. The number of women with withdrawal bleeding during the first cycle was twice as high in the dydrogesterone group as in the placebo group (65.4% vs. 30.8%; p = 0.0004). Superiority of dydrogesterone was also observed for regularity of bleeding over the six cycles (p

Keywords: Secondary amenorrhea, oligomenorrhea, withdrawal bleeding, bleeding pattern, dydrogesterone

Introduction

Secondary amenorrhea broadly refers to the cessation of menses once menstruation has been established. It has, however, been specifically defined in various ways, some of which overlap with oligomenorrhea (infrequent menstrual flow at intervals of 35 days to 6 months), thus reflecting the diffuse patient populations who suffer from this condition. The overall prevalence of secondary amenorrhea in women of menstruating age is around 3% [1,2], although it is considerably more common in certain subgroups such as competitive athletes, gymnasts and ballet dancers [3,4]. Amenorrhea is a symptom rather than a diagnosis and is indicative of anatomical, genetic or neuroendocrine abnormalities. The majority of cases, however, are related to ovarian dysfunction.

Patients with secondary amenorrhea may be more likely to develop endometrial hyperplasia or endometrial cancer, notably those with normal or high endogenous estrogen levels and luteal insufficiency [5-7]. This increased risk was demonstrated in a study of 2496 infertile women, followed-up for a mean period of 21 years, in which the observed number of endometrial cancers in those with normal estrogen production but progesterone deficiency was 9.4-fold higher than that expected in normal women [5]. Inadequate progesterone production due to lutealphase insufficiency in the presence of normal or elevated estrogen levels may have a number of causes, such as anovulatory cycles in menarche or menopause, or polycystic ovary syndrome (PCOS). PCOS is the most common endocrine disorder in women; approximately 20% of premenopausal women will show ovarian cysts on an ultrasound scan and up to 10% will have symptoms [8,9].

The endometrium can be protected from the proliferative effects of estrogen by progestogens. Dydrogesterone is a retroprogesterone that is used in a number of indications including dysfunctional uterine bleeding, endometriosis and threatened and habitual abortion, as well as in combined hormone replacement therapy (HRT). Sequential administration of dydrogesterone (10 mg/day) for 14 days per 28-day cycle has been shown to be highly effective in protecting the endometrium in postmenopausal women receiving estrogen replacement and to result in regular withdrawal bleeding [10-16].

Dydrogesterone is available as Duphaston(R) tablets containing 10 mg dydrogesterone and is currently indicated to treat secondary amenorrhea in combination with an estrogen once daily from day 1 to day 25 of the cycle, and a dosage of 10 mg dydrogesterone twice daily from day 11 to day 25 of the cycle. The aim of the present study was to compare the efficacy of sequential dydrogesterone with that of placebo in inducing regular withdrawal bleeding in premenopausal women with secondary amenorrhea or oligomenorrhea and normal estradiol levels. The chosen dose is known to effectively protect the endometrium of postmenopausal women on estrogen replacement. This is the first double-blind, placebo-controlled, randomized study to assess dydrogesterone-induced bleeding in this population.

Methods

Patients

This double-blind, randomized, placebo-controlled, parallel- group, multicenter (12 centers in Germany, Austria and Switzerland) study was carried out in 104 premenopausal women with secondary amenorrhea (cessation of bleeding for at least 50 days without pregnancy) or oligomenorrhea (infrequent menstrual flow at intervals of 35 days to 6 months, documented for at least four of the previous six cycles). The patients were aged between 20 and 50 years old, had premenopausal levels of endogenous estrogen (> 30 pg/ml) and follicle-stimulating hormone (FSH) (6 mm (bilayer). Exclusion criteria included clinically relevant disease that might limit participation in or completion of the study, any gynecological neoplasia or anatomical abnormality, icterus or pruritus during previous pregnancies, Herpes gestationis, a positive pregnancy test, breastfeeding, severe drug allergy or history of severe abnormal drug reactions towards a progestogen, intake of any investigational product in the previous 12 weeks or former participation in a study with dydrogesterone, use of a progestogen in the previous 3 months or other hormones or antidiabetics in the previous month.

All patients provided written informed consent. Patients were advised that the treatment was non-contraceptive. The protocol was approved by the Independent Ethics Committee or Institutional Review Board of each centre and the study was conducted in accordance with the Declaration of Helsinki and ICH guidelines for Good Clinical Practice.

Treatment and assessments

Following a screening period of maximum duration 2 weeks, the patients were randomized to receive sequential oral dydrogesterone 10 mg/day from day 1 to day 14 (followed by placebo from day 15 to day 28 of each cycle) or placebo for 24 weeks. The active medication, as well as the placebo, was presented as cyclical treatment with red encapsulation during the first 2 weeks of the cycle and white capsules during the second half of the cycle. In vitro release rates did not show a clinically relevant reduction of release rates due to the encapsulation. Randomization was performed in blocks of four at a ratio of 1:1. Patients who had spontaneous bleeding during the screening period started medication 15 days after the first day of bleeding, while those who did not experience bleeding started medication on the day of randomization (day 1). Concomitant treatment with antidiabetics, insulin, sex hormones, barbiturates or rifampicin was not permitted.

Physical and gynecological examinations, transvaginal ultrasound scan (TVUS), and measurement of vital signs and laboratory parameters (pregnancy test, urinalysis, blood chemistry, and blood levels of FSH, estradiol and progesterone) were performed at the start of the screening period. Demographic and baseline data, medical history and any concomitant medications were also recorded. On the day of randomization, the patients were given a diary containing three daily diary cards to complete during cycles 1 to 3 (day 1-84) and were instructed on the correct ways to document drug intake (yes/no), vaginal bleeding and body temperature measured with an ear thermometer. Vaginal bleeding was recorded as follows: 0 = no bleeding, 1 = spotting (not requiring sanitary protection), 2 = slight bleeding, 3 = normal bleeding and 4 = severe bleeding. TVUS, pregnancy test, measurement of vital signs and blood estradiol and progesterone levels, and recording of baseline complaints and concomitant medication were also repeated at the randomization visit.

Assessments were performed on day 28 (i.e. after one cycle of treatment), day 84 (after three cycles) and day 168 (after six cycles). TVUS, pregnancy test, measurement of vital signs and plasma progesterone, and recording of concomitant medication, compliance and any adverse events were performed at each visit. The first diary was collected on day 84 and a new diary for use during cycles 4 to 6 (day 84-168) was handed out. This second diary was collected on day 168. Blood chemistry and urinalysis were repeated on days 84 and 168, while physical and gynecological examinations and measurement of body weight and plasma estradiol were performed on day 168.

Statistical analyses

The primary efficacy variable was the occurrence (yes/no) of withdrawal bleeding during the first treatment cycle. Bleeding episodes were defined as one or more successive days with a severity of bleeding coded as >0. According to World Health Organization conventions [17], two bleeding episodes separated by a single day without bleeding, or by a day on which bleeding information was missing, were regarded as a single episode. A bleeding episode was defined as withdrawal bleeding if it occurred between days 12 and 28 of the cycle, lasted at least three consecutive days with a maximum gap of one day, and had a bleeding intensity of at least 1 (spotting). To test the null hypothesis of a lower or equal rate of withdrawal bleeding in the dydrogesterone group compared with placebo against the alternative hypothesis of a higher rate of withdrawal bleeding, the one-sided Fisher’s exact test was used. The significance level was fixed to a = 0.025.

Sample size was determined as follows. Based on published data, the expected percentage of patients with withdrawal bleeding was 70% with dydrogesterone. The expected percentage with placebo was in the range of 30-35%. When the level of significance was set to 0.05 and the power to 80%, the number of patients required to complete each treatment arm was 24 to 31. Taking into account an expected dropout rate of 25%, the total number of patients required to investigate the primary efficacy variable was 84. In addition, in order to gain an insight into the regularity of bleeding in the cycles following the first withdrawal bleeding, it was decided to recruit 100 patients.

The intention-to-treat (ITT) population used in the analysis of the primary endpoint comprised all randomized patients; those with missing data or missing diaries were considered as ‘failures’. The secondary efficacy variable was the regularity of bleeding pattern during the six cycles of the study. The ITT population for this analysis included all randomized patients who had documented data in the diary for at least five cycles (drug intake and bleeding data). The regularity of bleeding with an intensity of at least 2 (slight bleeding) was scored by an index for each cycle as follows: an index of 1 if the episode was within an interval of 28 days (+- 4 days) of a bleeding episode in the previous cycle, and an index of 0 if no episode occurred or if the start of the episode was not within an interval of 28 days (+- 4 days) after an episode in the previous cycle. The indices of all cycles were added together, resulting in a score ranging from 0 (absence of bleeding) to 6 (regular bleeding during all six cycles). These regularity scores were compared between groups using the Mann-Whitney U test.

Further exploratory analyses were performed to compare the effects of dydrogesterone and placebo on endometrial thickness, to determine the effects of stratification by secondary amenorrhea and oligomenorrhea, and to evaluate any correlation between endometrial thickness and bleeding pattern and between the starting day of bleeding episodes and their regularity. The basis of these evaluations was the ITT population. Comparisons between the groups were carried out by the Mann-Whitney U test or the Kruskal-Wallis test in cases of ordinal or continuous data, and by the Fisher’s exact test in the case of categorical data. The Spearman rank correlation was used to describe correlations between ordinal or continuous data. For within-group comparisons, the Wilcoxon matched pairs signed rank test was used for continuous data. All tests in the exploratory analyses were carried out two-sided and a result with a p value of

All randomized women who received at least one dose of study medication were included in the safety analysis. Safety parameters included adverse events, vital signs, physical examination findings, body weight, TVUS, concomitant medication, laboratory tests and body temperature.

Results

The distribution of patients during the study is shown in Figure 1. A total of 104 patients were randomized to treatment, 52 in each group. The baseline and demographic characteristics of these patients are shown in Table I; there were no relevant differences between the groups. The study was completed by 47 patients in the dydrogesterone group and 42 in the placebo group. The main reason for withdrawal was loss to follow-up (two patients in the dydrogesterone group and seven in the placebo group). Adverse events accounted for the withdrawal of two patients given dydrogesterone (one for heavy erratic bleeding and one for increase in body weight) and three given placebo (one pregnancy/miscarriage, one pregnancy/ hyperemesis and one increase in body weight). One patient in the dydrogesterone group withdrew due to lack of effect. All 104 patients were included in the ITT analysis of the primary efficacy variable and in the safety analyses (Figure 1). Analyses of the secondary efficacy variables did not account for six patients in the dydrogesterone group and 13 in the placebo group due to missing diaries.

Figure 1. Distribution of patients.

Bleeding parameters

The number of women with withdrawal bleeding during the first cycle of treatment was twice as high in the dydrogesterone group as in the placebo group (65.4% vs. 30.8%; p = 0.0004). The 95% confidence interval for the difference was 16.6-52.6%). Dydrogesterone was therefore superior to placebo with regard to the primary efficacy variable. In a sensitivity analysis where the definition of withdrawal bleeding was changed from bleeding for at least three consecutive days to at least two or four days, dydrogesterone remained superior to placebo. If the definition of withdrawal bleeding was changed from bleeding for at least three consecutive days with intensity of at least 1 to intensity of at least 2, the withdrawal bleeding rate was 32.7% in the dydrogesterone group and 25.0% in the placebo group (p = 0.52). If the definition was further changed to bleeding intensity of at least 3, the rates were 23.1%) vs. 3.9%, respectively (p = 0.008).

Table I. Demographic and baseline characteristics.

During the six cycles of treatment, the percentage of patients who experienced bleeding episodes of any type was consistently higher with dydrogesterone than with placebo (Figure 2). In both groups, however, the incidence of bleeding was highest in the first cycle of treatment. The mean duration of the bleeding episodes was longer in the dydrogesterone group than in the placebo group in each of the six cycles (Table II).

The regularity of bleeding (regularity score) was better in patients treated with dydrogesterone than in those given placebo (median regularity score: 4.0 vs. 1.0; p 0 compared with 21 patients (53.8%) in the placebo group (Figure 3). Regular bleeding in at least four cycles was achieved in more than half of the dydrogesterone-treated patients (n = 27; 58.7%) but in only a fifth of placebo-treated patients (n = 8; 20.5%). Nine patients (19.6%) in the dydrogesterone group and two (5.1%) in the placebo group experienced regular bleeding in all six cycles; the regularity score by number of patients is shown in Table III. There was less variability in the starting day of bleeding in patients treated with dydrogesterone compared with placebo.

Figure 2. Percentage of patients with bleeding episodes per cycle during treatment with dydrogesterone (n = 52) or placebo (n = 52) (intention-to-treat (ITT) population).

Table II. Duration (days) of bleeding episodes per cycle during treatment with dydrogesterone or placebo (intention-to-treat population).

Figure 3. Regularity score per patient of treatment with dydrogesterone (n = 46) or placebo (n = 39) (intention-to-treat population).

Table III. Regularity score by number of patients during treatment with dydrogesterone or placebo (intention-to-treat population; n = 85).

Subgroup analyses

Comparing the subgroups of patients with secondary amenorrhea (n = 79) and oligomenorrhea (n = 25) with respect to demographic and baseline parameters revealed significantly (p = 0.004) more patients with endocrinological disorders in the oligomenorrhea subgroup (8; 33.3%) than in the secondary amenorrhea subgroup (6; 10.2%). With the exception of one patient with oligomenorrhea, all patients with endocrinological disorders were suffering from thyroid disease (most commonly hypothyroidism). The uterine cavity was also longer (median: 34.0 vs. 29.0 mm; p = 0.036) and the endometrium thicker (median: 10.0 vs. 8.0 mm; p = 0.015) in women with oligomenorrhea. There were no other significant differences between the two subgroups with regard to demographic and other baseline characteristics.

Although estradiol levels were within the normal range in both subgroups, the incidence of bleeding during the first cycle in both treatment groups combined was significantly higher in patients with oligomenorrhea (17; 68.0%) than in those with secondary amenorrhea (33; 41.8%) (p

Endometrial thickness

Median endometrial thickness, measured at baseline and at the end of treatment cycles 1, 3 and 6, decreased from baseline to the final visit with dydrogesterone (8.2 to 6.0 mm; p

Endometrial thickness and bleeding

A correlation between endometrial thickness and the maximum bleeding intensity in the following cycle was observed for endometrial thickness measured at baseline and after one and three cycles of treatment. The effect was seen in both the dydrogesterone and placebo groups and was most pronounced in the baseline measurement with the following first treatment cycle (Table IV). The correlation between endometrial thickness and maximum bleeding intensity in the previous cycle was weaker. The findings were similar if the sum of the bleeding intensity over the 28 days of the cycle was analyzed in place of the maximum bleeding intensity.

Safety and tolerability

Dydrogesterone was well tolerated. There were no serious adverse events in the dydrogesterone group; the three pregnancies in the placebo group (one of which was associated with severe hyperemesis and another resulted in miscarriage) were classified as serious adverse events. Treatment-emergent adverse events were reported in 12 patients (23%) treated with dydrogesterone (19 events) and 13 patients (25%) given placebo (16 events). The most common events were infection (n = 3), back pain (n = 2) and depression (n = 2) in the dydrogesterone group and flu (n = 3), unintended pregnancy (n = 3) and abdominal pain (n = 2) in the placebo group. All other events were reported no more than once in each group. There were no clinically significant differences between the groups with regard to vital signs, laboratory values, body temperature, body weight, TVUS or physical examination findings. The body temperature did not change significantly during the study in either group.

Discussion

In women with secondary amenorrhea, normal or elevated estrogen levels in combination with inadequate progesterone can increase the risk of endometrial hyperplasia or cancer. In women with amenorrhea or oligomenorrhea, the induction of artificial withdrawal bleeding with a progestogen is therefore considered prudent management of these patients. The results from this study show that sequential dydrogesterone, 10 mg/day on days 1-14 of each cycle, has statistically significant advantages over placebo with regard to the induction of withdrawal bleeding and the regularity of the bleeding. The percentage of patients experiencing withdrawal bleeding during the first cycle was 65.4% in the dydrogesterone group and 30.8% in the placebo group. These values were close to the incidence assumed for the original sample size calculation. The percentage of patients with bleeding was highest during the first cycle and tended to fall thereafter in both groups. Although there were a significant number of ‘withdrawal’ bleeds in the placebo group, the regularity of bleeding throughout the study was markedly better in the dydrogesterone group. Regular bleeding during at least four cycles was achieved in more than half of the patients treated with dydrogesterone compared with only around a fifth of those given placebo. The fact that the body temperature did not change during the study indicates that there was no increase in endogenous progesterone levels in either group.

Table IV. Correlation between endometrial thickness and the maximum bleeding intensity in the following cycle: baseline endometrial thickness and following first cycle of treatment.

A number of previous studies have also demonstrated that dydrogesterone induces a withdrawal bleed in women with secondary amenorrhea providing the endometrium is sufficiently primed with estrogens. With the exception of one double-blind, randomized study showing that dydrogesterone was as effective as medroxyprogesterone acetate in inducing withdrawal bleeding [18], the majority of these studies were uncontrolled [19-23] and employed a different dosage regimen to that used in the current study. There is, nevertheless, considerable evidence from the use of combined HRT showing that dydrogesterone 10 mg/day given for 14 days per 28-day cycle effectively protects the endometrium from the proliferative effects of estradiol and results in regular and predictable withdrawal bleeding [10-16].

A placebo effect on bleeding, similar to the one noted in the current study, has been previously described. A response rate of 30% was reported in women with secondary amenorrhea and/or persistent oligomenorrhea and adequate estrogen production, providing the placebo was accompanied by positive suggestion [24,25]. In another study involving 56 women with secondary amenorrhea, oral or intramuscular placebo resulted in bleeding in 48% of the women [26]. The majority of the responders had at least two cyclical bleeding episodes and the beneficial effects stopped once the placebo had been withdrawn. A subgroup analysis in this study demonstrated, however, that the incidence of bleeding during placebo treatment is much higher in oligomenorrhoeic women than in those with secondary amenorrhea (63.6% vs. 22.0%). It appears that patients with oligomenorrhea may have a higher propensity to menstruate spontaneously. Differences were also seen with regard to the regularity of bleeding, with the clear significant advantages of dydrogesterone over placebo observed in patients with secondary amenorrhea not being observed in those with oligomenorrhea. This may be accounted for by the more frequent spontaneous bleeding in the oligomenorrhea group.

There was evidence of a correlation between endometrial thickness and bleeding intensity, but the correlation was not consistently reflected in monotonously increasing medians and the value of endometrial thickness as a predictor of subsequent bleeding was low. Although previous studies have indicated that progestogen-induced withdrawal bleeding can indeed be predicted from the endometrial thickness, there is a wide variation in the cut-off points identified in the different studies and the predictive value is not very good [18,27-29]. In addition, in contrast to previous studies, patients were included in the current study only if they had normal estradiol levels, thus excluding those with an insufficiently stimulated endometrium. The clinical value of using endometrial thickness as a predictor of bleeding in an individual patient must therefore be considered limited.

Endometrial thickness was reduced with both dydrogesterone and placebo, with no significant differences between the groups. However, a more marked reduction occurred with dydrogesterone than with placebo in the subgroup of patients with oligomenorrhea. It should be noted that the sample size was determined based on the expected percentage of patients with withdrawal bleeding, and the study was not designed to analyze endometrial thickness. The small number of patients in this subgroup therefore weakens the statistical result of this exploratory analysis.

Exploratory analyses revealed a number of other differences between patients with secondary amenorrhea and those with oligomenorrhea. For example, the endometrium was thicker in women with oligomenorrhea, which might reflect greater estrogenic stimulation, although the estradiol levels were within the normal range in both subgroups. The incidence of withdrawal bleeding during the first cycle was also higher in the oligomenorrhea subgroup, which again points towards greater stimulation of the endometrium. Comparison of the baseline characteristics of the two subgroups showed that there were significantly more patients with a history of thyroid disorders in the oligomenorrhea subgroup. Thyroid disorders are known to be associated with changes in estrogen and androgen metabolism, impaired fertility and menstrual disorders [30]. For example, auto-immune thyroiditis is about three times more common in patients with PCOS than in the general population [1]. Similarly, around a quarter of patients with hypothyroidism or hyperthyroidism suffer from some form of menstrual disorder, oligomenorrhea and hypomenorrhea being the most common.

In conclusion, the results of this study showed that dydrogesterone is significantly superior to placebo in inducing withdrawal bleeding in women with secondary amenorrhea and that the pattern of this bleeding is significantly more regular with dydrogesterone, while adverse events are no different from those seen with placebo.

Acknowledgements

We would like to thank the following investigators: Dr Eisinger (Berlin), Dr Frank (Munich), Dr Herold (Munich), Dr Ihm (Munich), Dr Jakubek (Berlin), Dr Kranzlin (Munich), Dr Peschke (Berlin), Dr Lindecke (Berlin) and Dr Michel (Diessen) in Germany; Dr Musfeld (Binningen) and Dr Scott (Trimbach) in Switzerland; and Dr. Potsch (Leibnitz) in Austria.

References

1. The Practice Committee of the American Society for Reproductive Medicine. Current evaluation of amenorrhea. Fertil Steril 2004;82(Suppl 1):S33-S39.

2. Speroff L, Fritz MA. Amenorrhea. In: Speroff L, Fritz MA, editors. Clinical gynecologic endocrinology and infertility. 7th ed. Philadelphia (PA): Lippincott Williams & Wilkins; 2005. pp 401-464.

3. De Souza MJ, Metzger DA. Reproductive dysfunction in amenorrhoeic athletes and anorexic patients: a review. Med Sci Sports Exerc 1991;23:995-1007. 4. Klentrou P, Plyley M. Onset of puberty, menstrual frequency, and body fat in elite rhythmic gymnasts compared with normal controls. Br J Sports Med 2003;37:490- 494.

5. Modan B, Ron E, Lerner-Geva L, Blumstein T, Menczer J, Rabinovici J, Oelsner G, Freedman L, Mashiach S, Lunenfeld B. Cancer incidence in a cohort of infertile women. Am J Epidemiol 1998;147:1038-1042.

6. Gibson M. Reproductive health and polycystic ovary syndrome. Am J Med 1995;98:67S-75S.

7. Balen A. Polycystic ovary syndrome and cancer. Hum Reprod Update 2001;7:522-535.

8. Birdsall MA, Farquhar CM. Polycystic ovaries in pre and post- menopausal women. Clin Endocrinol (Oxf) 1996;44: 269-276.

9. Farquhar CM, Birdsall M, Manning P, Mitchell JM, France JT. The prevalence of polycystic ovaries on ultrasound scanning in a population of randomly selected women. Aust N Z J Obstet Gynaecol 1994;34:67-72.

10. van der Mooren MJ, Hanselaar AGJM, Borm GF, Rolland R. Changes in the withdrawal bleeding pattern and endometrial histology during 17beta-estradiol-dydrogesterone therapy in postmenopausal women: a 2-year prospective study. Maturitas 1994;20:175-180.

11. Burch DJ, Spowart KJW, Jesinger DK, Randall S, Smith SK. A dose-ranging study of the use of cyclical dydrogesterone with continuous 17beta-oestradiol. Br J Obstet Gynaecol 1995;102:243- 248.

12. Ferenczy A, Gelfand MM. Endometrial histology and bleeding patterns in postmenopausal women taking sequential combined estradiol and dydrogesterone. Maturitas 1997;26: 219-226.

13. Bergeron C, Fox H. Low incidence of endometrial hyperplasia with acceptable bleeding patterns in women taking sequential hormone replacement therapy with dydrogesterone. Gynecol Endocrinol 2000;14:275-281.

14. van de Weijer PHM, Scholten P, van der Mooren MJ, Barentsen R, Kenemans P. Bleeding patterns and endometrial histology during administration of low dose estradiol sequentially combined with dydrogesterone. Climacteric 1999;2:1-9.

15. Ferenczy A, Gelfand MM, van de Weijer PHM, Rioux JE. Endometrial safety and bleeding patterns during a 2-year study of 1 or 2 mg 17beta-oestradiol combined with sequential 5-20 mg dydrogesterone. Climacteric 2002;5:26-35.

16. Gelfand MM, Fugere P, Bissonnette F, Wiita B, Yang H-M, Lorrain J, Ferenczy A. Conjugated estrogens combined with sequential dydrogesterone or medroxyprogesterone acetate in postmenopausal women: effects on lipoproteins, glucose tolerance, endometrial histology and bleeding. Menopause 1997;4:10-18.

17. Belsey EM, Machin D, D’Arcangues C. The analysis of vaginal bleeding patterns induced by fertility regulating methods. Contraception 1986;34:253-260.

18. Battino S, Ben-Ami M, Geslevich Y, Weiner E, Shalev E. Factors associated with withdrawal bleeding after administration of oral dydrogesterone or medroxyprogesterone acetate in women with secondary amenorrhoea. Gynecol Obstet Invest 1996;42:113-116.

19. Bernard I. New progesterone derivatives active by the oral route. Bull Fed Soc Gynecol Obstet Lang Fr 1962;14:683-684.

20. Rockenschaub A. On the problem of oral therapy in menstrual disorders. Wien Klin Wochenschr 1962;74:285-287.

21. Bompiani A, Moneta E. Progestational activity of isopregnolone in cases of secondary amenorrhoea. Ann Ostet Ginecol 1962;84:607-621.

22. Tillinger KG, Diczfalusy E. Progestational activity of stereoisomeric progesterone-analogues following oral administration in amenorrhoea. Acta Endocrinol (Copenh) 1960;35:197-203.

23. Serfaty D, Nahmanovici C, Thompson N, Le Gral M. Traitement symptomatique des ameorrhees secondaires par la dydrogesterone. A propos d’une etude propective et multicentrique. Gaz Med Fr 1986;93:81-84.

24. Presl J, Horsky J. Uterine bleeding as a placebo effect. Cesk Gynekol 1970;35:413-415.

25. Presl J, Bechinie K, Horsky J. The possibility of placebo effect in the progesterone test. Cesk Gynekol 1970;35:409-412.

26. Crosignani PG, Mattei AM, Maggioni P, Testa G, Negri E. Efficacy of placebo in the treatment of patients with amenorrhea. Gynecol Obstet Invest 1994;37:183-184.

27. Nakamura S, Douchi T, Oki T, Ijuin H, Yamamoto S, Nagata Y. Relationship between sonographic endometrial thickness and progesrin- induced withdrawal bleeding. Obstet Gynecol 1996;87:722-725.

28. Morcos RN, Leonard MD, Smith M, Bourguet CB, Makii M, Khawli O. Vaginosonographic measurement of endometrial thickness in the evaluation of amenorrhea. Fertil Steril 1991;55:543-546.

29. Shulman A, Shulman N, Weissenglass L, Bahary C. Ultrasonic assessment of the endometrium as a predictor of oestrogen status in amenorrhoeic patients. Hum Reprod 1989;4:616-619.

30. Krassas GE. Thyroid disease and female reproduction. Fertil Steril 2000;74:1063-1070.

31. Janssen OE, Mehlmauer N, Hahn S, Offher AH, Gartner R. The high prevalence of autoimmune thyroiditis in patients with polycystic ovary syndrome. Eur J Endocrinol 2004; 150: 363-369.

This paper was first published online on iFirst on 19 September 2007

NICHOLAS PANAY1, MARIA PRITSCH2, & JEANNETTE ALT3

1 The Menopause and PMS Centre, Queen Charlotte’s & Chelsea Hospital and Westminster Hospitals, London, UK,

2 Department of Medical Biometry, University of Heidelberg, Heidelberg, Germany, and 3 Solvay Pharmaceuticals,

Hannover, Germany

(Received 4 July 2007; revised 18 July 2007; accepted 18 July 2007)

Correspondence: N. Panay, The Menopause and PMS Centre, Queen Charlotte’s & Chelsea Hospital, Hammersmith Hospitals NHS Trust, Du Cane Road London, West London, UK. Tel: 44 20 8383 3513. Fax: 44 20 8383 3521. E-mail: [email protected]

Copyright Taylor & Francis Ltd. Nov 2007

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

Allied Health Professionals With 2020 Vision

By Miller, Thomas W Gallicchio, Vincent S

Allied health professionals in all disciplines must be visionary as they address education, training, and health care delivery in the next decade. Examined herein are forces of change in education, training, health care, the recognition of essential leadership styles, and the paradigm shifts facing the allied health profession in the health care arena. Some visionary directions are offered for allied health professionals to consider as health policy and clinical agendas emerge toward the year 2020. J Allied Health 2007; 36:236-240. ALLIED HEALTH PROFESSIONALS are experiencing shifts that education, technology, the economy, and society are driving as we enter the new millennium.1 Allied health professionals should have a vision for the health care marketplace over the next 20 years and see it with clarity. In doing so, allied health professionals must consider (1) the effects of technology and automation on research and health care delivery; (2) the important influences of political, economic, and social change; (3) the progress made to develop and understand more clearly professional needs of health care personnel; and (4) the changes in population demographics in the United States that will have a direct impact on the first three points.

The advent of telemetry, technology, and other new mediums of communication, which aid in both obtaining and analyzing information, provides new challenges to health care professionals.2 The impact of the Human Genome Project will continue to uncover discoveries toward improving our understanding of the molecular mechanisms in preventing, diagnosing, and treating human diseases.3 Emerging paradigms provide an organizational focus that will shift from single-site initiatives to networks of health care services bonded and partnered by Web-oriented technology and integrated delivery systems.4,5 These changes force health care professionals to explore and examine the way in which the providers deliver services in the emerging paradigms of a health promotion and disease prevention delivery network for the future.

What Are the 21st Century Driving Forces for Allied Health?

The new millennium brings the potential for an integrated clinical, research, and educational collaborative environment that must consider economic, demographic, environmental, social, epidemiological, political, and technological change.6,7 The focus of this collaborative environment must address the critical elements of globalization, empowerment, technology, and leadership in the health care arena today.

Globalization is a historical process, the result of human innovation and technological advances. It refers to the increasing integration of economies around the world, particularly through collaboration and partnering. The world is rapidly changing, and globalization is helping to establish common social, economic, and political agreements between countries, as evidenced by the 1993 Maastricht Agreement that established the European Union and the 1994 North American Free Trade Agreement by the United States, Canada, and Mexico.8 These agreements provide the content and rationale for government involvement in enhancing educational opportunities and removing barriers that heretofore have limited the flow of students, educators, professionals, and practices across borders. Globalization refers to the movement of people (labor) and knowledge (technology) across international borders. There are broader cultural, political, and environmental dimensions of globalization, but for the allied health professions it refers to a holistic perspective, the ability to bridge disciplinary, technological, and cultural gaps and to become global in our learning and problem solving in health care. To date, globalization in the health care professions has yet to be fully addressed because of the barriers in place that relate, in many instances, to issues such as the competitive nature of our health-related disciplines, a hierarchy reflected by a vertical rather than horizontal model, and credentialing and licensure variation by discipline, state, and/or nation. The global mobility of health care professionals is at present limited because international education and training standards are yet to be determined, as well as who has jurisdiction to purpose, implement, and/or monitor international standards; however, discussions and importantly dialogue have been initiated by a number of allied health professional bodies to address these issues. For example, the American Society of Clinical Pathology Board of Registry and the National Accrediting Agency for Clinical Laboratory Sciences have both recognized the shifting global demands placed on the laboratory profession by the widespread use of advanced laboratory-based technologies and the current workforce shortage of qualified laboratory personnel.21 The American Society of Clinical Pathology Board of Registry has created a Global Task Force Committee consisting of qualified laboratory-based practitioners and educators to articulate what are the emerging issues that need to be addressed to more effectively deal with these global concerns. Partnership with the International Federation of Biomedical Laboratory Science is also seen as a first step in this arena as a way to move forward to address the global issues pertaining to the international practice of the laboratory profession.21 No doubt other health care disciplines will soon articulate a similar agenda.

Importantly, some of the barriers that have limited international mobilization are now being addressed for the first time, and governments have recognized that these barriers need to be overcome if true globalization of the health care professions is to become a reality. Development of a shared vision with administrators, consumers, competitors, and providers will be the critical factor for the success of our allied health professions over the next decade.9 Disciplines, individual allied health professionals, and organizations will need to focus more on serving the public and the community good, with greater emphasis on health promotion and disease prevention strategies. Mastering change for health care professionals will be essential for success. “Systems thinking” will surpass linear thinking.10″12 This has the potential of leading to a more integrated understanding of the problems and their solutions in the allied health professions.

Accelerated change and increasing complexity require an “empowered allied health workforce.”13 Empowerment may be defined as self-direction, allowing health care professionals to take responsibility and authority for decisions that affect them. Empowerment permits speed in decision making, allows practitioners to collaborate and partner more freely, and promotes the cultivation of creativity, quality, safety, and a true liberation of the human spirit. Empowerment requires a new administrative leadership paradigm for 21st century health care.

Trofino9 and Miller10 suggest that two forms of leadership are needed for our health care system. (1) Transactional leadership is leadership in which relationships among allied health professionals are based on an exchange for some resource valued by them. To the allied health professional, interaction between administrators and clinicians is usually episodic, short lived, and limited to the exchange transaction. (2) Transformational leadership is more potent and complex and occurs when one or more allied health professionals engage with others in a collaborative environment in which clinicians and administrators raise one another to higher levels of commitment and dedication, motivation, and productivity. Through this transforming process, the motives of the leader and followers become identical. This relationship transforms both parties by raising the level of human conduct and ethical aspiration of both health administrators and clinicians to a new level.

Technology is another major element.14,15 Technology offers the advantages of access, speed, and flexibility and serves as a major mode of accelerating learning, building information capacity and global knowledge. The world is indeed getting flat. As technology has embraced the digital field, the true reflection and impact of this technology are now being realized. Any piece of health care information, whether it is an X-ray, computed tomographic scan, laboratory record, telehealth component, or patient’s history, if it can be digitalized, it can be transmitted across space and time. Implementation of such a system to aid in the diagnosis and prognosis of an individual patient’s health care is already in place in many parts of the world. User-friendly access pathways and clinical models of health care such as interdisciplinary collaboration will be of primary importance to ensure easy access to information systems for the global population.3

The multiskilled allied health professional is a person with 2020 vision! Highly technical competencies, along with content expertise, cultural competence, and having a global perspective, will permit multiskilled allied health professionals to address complex systems analysis in an indigenous user-friendly manner.

Education in the allied health professions must reassess and reformulate its curriculum for the needs and requirements of health care in the 21st century. Emerging clinical and administrative models of differentiated practice have begun to identify the cadre of expert specialists needed to provide educational services in the future. New alliances with many disciplines, including science, health care, business, industry, and global educational initiatives, will be forged. These empowered “knowledge specialists” will use current technology to provide clinical services through nontraditional models and use school districts as a primary model for providing health promotion, prevention, and universal health care in a disease prevention education-oriented marketplace. Finally, there is a shift from a traditional model of health care delivery that uses new technology involving telehealth and telemedicine to a broad spectrum of consumers in business, medicine, health care, schools, and the world community through distance learning technology.16,17

What Are the Paradigm Shifts for the Allied Health Professions?

There are numerous emerging shifts in education and training in allied health, models of health care delivery, technology and information systems, accountability, financial incentives, prevention and wellness, and use of human resources. These shifts will force us to explore and examine the way in which the practitioner delivers and provides services to the global network of health care consumers.9,10,16 Economic strategies will likely see shifts driven by capitation and contracts for providers and with financial incentives for consumers in maximizing cost-effectiveness of health care services (Table 1).

In shifting to a new paradigm, accountability will also see major shifts. Controls against duplication of effort and liability for incompetence must be developed through integrated networks of accountability at both the local and national levels. Accreditation will provide, as it currently does, monitors to assess improved markers for health care delivery. Likewise, networks of prevention- oriented programs, organizations and government programs that promote disease prevention, will impact delivery of services.

Allied health professionals have already witnessed a variety of changes in the information technology paradigms.14 The advent and use of advanced computers and information systems, work stations, and integrated communication systems involve worldwide networks of accessibility. Databases and data warehouses, along with hypertext formats with linked information structures, are clearly seen as a part of the emerging information technology models over the next two decades. These will replace the organized sets of documents, data files, local network accessibility, and separate applications health administrators utilize in traditional models of disseminating evidence-based health care decision making.17

Stephen Covey et al.18 have has provided the allied health professions with a series of important issues in preparing for the year 2020. The professional with 2020 vision needs to be a person with the following characteristics. The first is self-awareness, which is the capacity to stand apart from one’s losses and examine one’s thinking, motives, and history to understand oneself. Self- awareness makes it possible for allied health professionals to become aware of our development and recognition as health care providers to the world community. Michael Hammer and Steven Stanton, in their book The Reengineering Revolution, make the point that all change will bring some loss and will require grieving. Covey challenges us to understand the internal guidance system, that self- awareness and development of conscience that allows us to sense and understand ourselves within new models of health care delivery. The extent to which we engage this force is the extent to which we prepare ourselves for change and adaptation in both delivery of health administration and the educating of the whole person-the health promotion and disease prevention component.

The third endowment that Covey discusses is that of independent wealth, which focuses on one’s understanding of what competencies and skills each brings to the world table of health competencies and the ability as scientists to act in our best interest as well as in the best interest of others. While recognizing that multicultural, environmental, and genetic factors may affect the way in which individuals take action, we must recognize that these influences do not have to limit us in our quest for relevant application of science. Together with self-awareness and conscience, health care professionals must be able to obtain responsibility for new models of intervention and move toward a “vision” for change in the health and well-being of a global population.

The final of the human endowments discussed by Covey et al.18 involves creative imagination, which is the power to envision the direction for which we are responsible as both persons and professionals. As allied health professionals, it is this endowment that enables us to see ourselves as well as our colleagues differently and from a new perspective. As health administrators who examine the changing components of our profession, we recognize that both the insights and the vision of all those who have contributed to the profession are recognized and appreciated for the evolving dynamic model of scientific understanding and the contribution that health administrators have made to society and to the world for the new millennium.

Allied health professionals with 2020 vision must consider a number of important factors for the first two decades of the 21st century.

* Enhanced public education will emerge designed to educate the public about the value of prevention and health promotion. Programs will utilize multimedia and telehealth approaches in providing consumers with accurate and understandable information. Strategies for health administrators and practitioners in educating the public and marketing services will be an essential part of the public education program.

* Allied health professionals will require a cutting-edge understanding of the international marketplace academically, educationally, economically, socially, culturally, ethically, and politically.

* Allied health professionals must embrace a holistic perspective and bridge the multicultural similarities and differences we have come to realize among the various countries and cultures of the world.19

* Allied health researchers will engage with empowered groups of educators, practitioners, and consumers and will facilitate rather than direct changes and new directions in health care delivery.

* Quality control testing and evaluation will be replaced by a complex analysis system and networks that will analyze how learning styles, consumers, and genetic factors influence behavioral markers that result in decision making and compliance with health promotion and disease prevention.

* The use of clinical monitors will aid in assessing both physical and psychological markers for a spectrum of disorders served by the allied health professions. Much like the pacemaker and blood glucose monitors, these microbackpacks will assist in regulating physical and psychological stability for consumers in need of this technology. This level of intervention has already appeared in certain areas of the world.

* Allied health professionals will by necessity be multiskilled information specialists serving new alliances of clinicians, researchers, and educators for health care delivery.

* Scientists, clinicians, and administrators in allied health will realize new paradigms of service provision that will include algorithms and pathways of care mediated by genetic factors, technology, and new interventions for health care delivery.

* Dissemination of prevention research findings will occur through classic courses at all levels of education. Education will be offered in grade schools, high schools, and universities through new technology with specialized distance learning technologies. This will feature the world’s most competent educators, scientists, researchers, and professional practitioners in health care, all sharing in the educational process to improve the instructional paradigms of allied health education.

* Allied health prevention specialists will have aligned with scientists to develop new models of testing that integrate biochemical, genetic, and psychological markers into standard clinical profiles.

* World consciousness will grow to ask for an ethical and moral conscience with respect to worldwide provision of health promotion and disease prevention.

* Barriers and borders that currently limit the transnationalization of allied health education and professional practice will yield more international exchanges of education through distance education and coursework offered to create an international body of professionals who will be free to live, work, and practice their clinical skills internationally.

* The Human Genome Project,20 genetic mapping, testing, and genetic diagnostics will lead allied health professionals to improved identification of highly “at-risk” individuals for selective interventions that will be accomplished through genetic therapeutics.

* Prevention education programs for health and wellness will be successful in producing convenient and schoolbased “health super centers” that feature health food, exercise, medical screening and care, health counseling, vitamin counseling, and health promotion and disease prevention education that will improve quality of life and manage various medical conditions.

* Educational curricula will become more standardized across university training sites, thus allowing for the accrediting of educational training and practice over a wider area than is currently practiced. This will be done to encompass as large a geographic area as necessary that would be not necessarily be limited by countries. Larger geographic demarcations are likely, such as the European Union as an example. This will allow education and clinical standards to be implemented to reach the largest target population possible. This strategy is already taking shape in Europe. The Treaty of Bologna has allowed all of the educational institutions within the European Union the opportunity to establish a single set of guidelines to govern all instruction and curricula of the educational programs within the European Union member states by 2010. The impact of this unique initiative to further promote educational unity with the European Union will not only further promote globalization but will also place pressure on the United States to move in this direction. This may be an absolute if the United States is to maintain its technological edge in education and clinical practice of its educational programs in general and its health care programs specifically. * New alliances in prevention education, law, and science will emerge with health administrators, practitioners, and consumers as significant partners in health care and reform efforts. Lifelong education, the SMART Medical Home, and information awareness with a “health promotion” emphasis become the critical ingredients in improving quality-of-life issues for all age levels and the members of the world community.

These visionary concepts provide areas in which the allied health community can begin to address changes likely to occur during the first quarter of the 21st century. The issues confronting allied health professionals today are increasingly complex and varied in content. In the domains of academics, research, industry, and health care, health care professionals with 2020 vision represent an enormous wealth of talent and energy, competency and capability, cost-effective models of health care in practice, science, research, and service. The effects of technology and automation; the influence of global, social, economic, and political changes; and our role and responsibilities as health care professionals have been explored. Allied health professionals with 2020 vision must have clarity of vision for the future and the competency to adapt to forces of change for the benefit of science and practice for the world’s consumers of competency-based health care.

The authors thank Robert F. Kraus, MD, Scott Hasson, EdD, Mike Zito, FT, David Tiberio, PhD, Tom Holcomb, EdD, Jeanine Adams, EdD, OTL, Katherine Hegedus, RN, DSN, Lane J. Veltkamp, MSW, Joseph Smey, EdD, and colleagues in the Allied Health Professions, Alpha Eta, and the North American Consortium of Nursing and Allied Health for support and assistance, as well as graduate students Kathy Long, PA- C, Bruce Elliott, PT, Cheryl Marzenac, OT-L, Michelle Moder, MS, RD, Janet Saier, MS, Kate Bassouda, BS, Tag Heister, MLS, and Jill Livingston, MLS, for their assistance in the preparation of this manuscript.

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21. Global Task Force Report: Reshaping pathology and laboratory medicine for a flat world. Pathology Today 2006; 3(6): 1. Available at http://www.ascp.org/aboutus/newsroom/pdf/Nov_06_Web.pdf.

Thomas W. Miller, PhD, ABPP

Vincent S. Gallicchio, PhD, MT(ASCP), CLS(NCA)

Dr. Miller is Professor, College of Medicine, University of Kentucky, Lexington, KY; and Dr. Gallicchio is Associate Vice Ptesident for Research and Economic Development, Director of the Office of Sponsored Programs, and Professor of Biological Sciences and Public Health Sciences, Clemson University, Clemson, SC.

Received February 22, 2006; revision accepted August 29, 2006.

Address correspondence and reprint requests to: Thomas W. Millet, PhD, ABPP, College of Medicine, University of Kentucky, 3470 Blazer Parkway, Lexington, KY 40509-1810. Email [email protected].

Copyright Association of Schools of Allied Health Professions Winter 2007

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

Queen Alexandra’s Birdwing

Queen Alexandra’s Birdwing (Ornithoptera alexandrae), is the largest butterfly in the world. The species was named by Lord Walter Rothschild in 1907, in honor of Queen Alexandra, wife of King Edward VII of the United Kingdom. The first European to discover the species was Albert Stewart Meek in 1906, a collector employed by Lord Walter Rothschild to collect natural history specimens from Papua New Guinea. Although the first specimen was taken with the aid of a small shotgun, Meek soon discovered the early stages and bred out most of the first specimens.

Female Queen Alexandra’s Birdwings are larger than males with markedly rounder, broader wings. This sex can reach a wingspan of 14 inches, a body length of 3.2 inches and a body mass of up to 0.42 ounces, all enormous measurements for a butterfly. The female has brown wings with white markings and a cream-colored body with a small section of red fur on its thorax. Males are smaller than females with brown wings that have iridescent blue and green markings and a bright yellow abdomen.

The female Queen Alexandra’s Birdwing lays about 27 eggs during its entire lifespan. Newly emerged larvae eat their own eggshells before feeding on fresh foliage. The larva is black with red tubercles and has a cream-colored band or saddle in the middle of its body. Male pupae may be distinguished by a faint charcoal patch on the wing cases; this becomes a band of special scales in the adult butterfly called a sex brand. The time taken for this species to develop from egg to pupa is approximately six weeks, with the pupal stage taking a month or more. Adults emerge from the pupae early in the morning while humidity is still high, as the enormous wings may dry out before they have fully expanded if the humidity drops. The adults may live for three months or more and have few predators.

The adults are powerful fliers most active in the early morning and again at dusk when they actively feed on flowers. Males also patrol areas of the host plants for newly emerged females early in the morning. Females may be seen searching for host plants for most of the day. Courtship is brief but spectacular; males hover above a potential mate, dousing them with a pheromone to induce mating. Receptive females will allow the male to land and pair, while unreceptive females will fly off or otherwise discourage mating.

Males are strongly territorial and will see off potential rivals, sometimes chasing small birds as well as other birdwing species. Flight is usually high in the rainforest canopy, but both sexes descend to within a few meters of the ground while feeding or laying blue eggs.

Photo Credit: Robert Nash, Curator of entomology, Ulster Museum

Scooter Crash Victim Killed Teacher in ’81

By Patrick Malone, The Pueblo Chieftain, Colo.

Dec. 27–The scooter-riding victim of a fatal collision on Christmas Day has been identified as a killer who as a teenager performed necrophilia on the corpse of his victim in the 1980s.

Randy Riggs, 42, died from injuries suffered in the crash on Tuesday. He had spent the past 25 years at the Colorado Mental Health Institute, where he was committed after a finding that he was not guilty by reason of insanity in the 1981 killing of a teacher in Larimer County. One day after strangling the woman, Riggs returned and had sexual intercourse with her corpse. At the time of his death, Riggs was being monitored on an ankle bracelet and was still under the state hospital’s care.

According to Pueblo police Capt. Linda Grisham, Riggs was traveling east on Northern Avenue at 6 p.m., when his scooter collided with a Nissan Pathfinder driven by Travis Olguin, 23, as it made a left turn from westbound Northern Avenue onto southbound Prairie Avenue.

Riggs was pronounced dead at St. Mary-Corwin Medical Center soon after the crash. He was not wearing a helmet.

Grisham said police plan to forward their investigation to the district attorney’s office for possible filing of charges. Specifically, Olguin could face a charge of careless driving resulting in death.

Grisham cautioned drivers to be mindful of the growing number of scooters on the road. Like motorcycles, they are more difficult to see than cars, and other motorists tend to have trouble gauging the speed of these vehicles.

“They’re like a smaller version of a motorcycle,” she said. “We started seeing a lot more of them during the summer. People are aiming to keep their gas costs down and buying these things, but there are certainly safety concerns that come with them.”

Grisham said the scooters are street-legal and require a valid driver’s license to operate. They are classified as motorized bicycles by the state’s Department of Motor Vehicles.

Ironically, insurance is not mandatory for these increasingly common vehicles.

During the 1990s Riggs unsuccessfully sought to be released from the hospital numerous times. He had been diagnosed with a sexual disorder with antisocial and narcissistic features and borderline personality disorder.

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Copyright (c) 2007, The Pueblo Chieftain, Colo.

Distributed by McClatchy-Tribune Information Services.

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

‘Clinical and Economical Considerations For IV Push Drug Delivery’ By Industry Expert Richard Rosenfeld Is Now Accessible on Expert411.Com for Media and Professional Use

ENGLEWOOD, Colo., Dec. 27 /PRNewswire/ — The “Clinical and Economical Considerations For IV Push Drug Delivery” technical paper — authored by Industry Expert Richard Rosenfeld, RPh, MBA, for Baxa Corporation — is now accessible at http://expert411.com/_wsn/page16.html for media and professional reference. The paper is an overview of the historical background for IV push and a model for implementation of a successful program.

IV push of cephalosporin antibiotics and other drugs is an alternative method of administration that can be safe, efficacious and cost effective. This paper concentrates on IV push of cefazolin as a case study, since it is a high-use cephalosporin with physical and chemical properties similar to other drugs that can be administered by the IV push method.

Rosenfeld has personally implemented the use of IV push antibiotics within two hospital systems. During the first year that this IV push program was in place, more than 50,000 doses of cefazolin were administered by the IV push method with no occurrences of phlebitis or adverse drug events directly associated with the change in the administration method of this drug. The paper discusses the economical advantages of moving to IV push, as well as the resulting nurse satisfaction and patient benefits seen through the resulting research followup.

Executive Director of Pharmacy Management for the Scripps Health Hospital System in San Diego, CA, Rosenfeld has responsibility for all system pharmacy services through his position with Cardinal Technology and Services. Prior to joining the Scripps Health team, he served as a consultant at Sharp Healthcare, a five-hospital IDN in San Diego, California, where the IV push method of administration for cephalosporins was implemented.

Rosenfeld earned a BS in Pharmacy from Ferris State University and a BA in Chemistry from San Diego State University. He holds an MBA from California State University, San Marcos.

About Baxa Corporation

Baxa, a customer-focused medical device company, provides innovative, solution-based technologies for fluid handling and delivery. Its systems and devices promote the safe and efficient preparation, handling, packaging, and administration of fluid medications. Key products include the PadLock(R) Set Saver, Rapid-Fill(TM) Automated Syringe Fillers, Exacta-Med(R) Oral Dispensers, MicroFuse(R) Syringe Infusers, Repeater(TM) Pharmacy Pumps, and Exacta-Mix(TM) and MicroMacro(TM) Multi-Source Automated Compounders; used worldwide in hospitals and healthcare facilities. Privately held, Baxa Corporation has subsidiaries and sales offices in Canada and the United Kingdom; direct representation in Austria, Belgium, Finland, France, Germany, Luxembourg, The Netherlands and Switzerland; and distribution partners worldwide. Further information is available at http://www.baxa.com/.

   Contacts:    Marian Robinson, Vice President, Marketing   Baxa Corporation: 800.567.2292 ext. 2157 or 303.617.2157   Email: [email protected]   http://www.baxa.com/    Maggie Chamberlin Holben, APR, Absolutely Public Relations   303.984.9801, 303.669.3558   Email: [email protected]   http://www.absolutelypr.com/  

Baxa Corporation

CONTACT: Marian Robinson, Vice President, Marketing of Baxa Corporation,1-800-567-2292, ext. 2157, or +1-303-617-2157, [email protected]; orMaggie Chamberlin Holben, APR, of Absolutely Public Relations,+1-303-984-9801, or +1-303-669-3558, [email protected], for BaxaCorporation

Web site: http://www.baxa.com/http://expert411.com/_wsn/page16.html

Competitive and Cooperative Positioning in Supply Chain Logistics Relationships*

By Klein, Richard Rai, Arun; Straub, Detmar W

ABSTRACT Cooperative logistics relationships between logistics companies require the sharing of information, which must be enabled by the integration of disparate information systems across partners. In this article, we theorize business-to-business logistics relationships should be managed using cooperative and competitive postures. Based on data from 91 dyadic relationships using interorganizational information technology (IT), we find that performance gains accrue when parties share strategic information and customize IT; mutual trust enables IT customization and strategic-information flows and equitable relationship-specific investments positively impact IT customization, mutual trust, and performance. Among other scholarly and practical implications discussed, partners should compete on resources for IT customization and cooperate to share strategic information. Managers tend to think of relationships with firms as polar opposites and view them as entirely cooperative or entirely competitive. Our results support active balancing and understanding of both competitive and cooperative stances. Such an approach enables conditions for participation symmetry that yields greater performance gains.

Subject Areas: Collaborative Partnerships, Dyadic Data, Exchange Relationships, Field Studies, Information Sharing, Logistics Service Performance, Structural Equation Modeling, and System Integration.

INTRODUCTION: THE MANAGERIAL PROBLEM OF RELATING TO PARTNERS

Recently, collaborative customer relationships and integrated partnerships have been gaining in popularity in business-to- business (B2B) markets (Day, 2000). Traditional intermediaries for logistics and distribution are changing their roles and value propositions through digital networks (Brousseau, 2002). These service providers are drawing on vast informational resources to exploit market knowledge. While early Internet-based initiatives fostered sales and new transaction opportunities, recent innovations redefine relationships, share processes, and increase collaboration (Wladawsky-Berger, 2000; Patnayakuni, Rai, & Seth, 2006; Rai, Patnayakuni, & Patnayakuni, 2006). Accordingly, the ability to easily, efficiently, and economically access information outside firm boundaries (Hitt, 2000) can generate further efficiencies for participants in exchange relationships (Lee & Whang, 2000; Kotabe, Martin, & Domoto, 2003; Vickery, Jayaram, Droge, & Calantone, 2003).

These generalized informational advantages aside, how should managers sculpt their day-to-day relationships with vendors, particularly logistics providers? In which cases should they be concerned about opportunism and in which cases should they not? Every day, managers make decisions about the posture they need to assume regarding business partners. If the posture is competitive, they bargain for the best deal for their own organization. If the posture is cooperative, then they must take into account the consequences of decisions and actions on their business partner.

Earlier management thinking viewed the vertical supplier-firm and customer-firm relationships as quintessentially competitive. In Porter’s work on industry structure (Porter, 1985; Porter & Millar, 1985), managers cope with the five forces by improving bargaining power with respect to customers or suppliers. In fact, the force of internal rivalry between competitors is viewed in the same light. The environment in which a manager makes decisions about interacting with other firms is seen as being entirely adversarial.

Management thinking has evolved to perceive customers and suppliers as partners and to focus more attention on the relationship (Brandenburger & NaIebuff, 1996). This evolution has occurred across the administrative disciplines. In marketing, for example, the earlier view of customers was an arm’s-length, transactional view (Coviello, Brodie, Danaher, & Johnston, 2002). Later, this was supplemented by a view that not all customers should be held at arm’s length. The term relationship marketing captured this perspective, likely introduced by Berry (1983).

In the management literature, the concept of the relational view has emerged to describe situations in which B2B trading partners are, in effect, competing for resources with each other, but in which the advantages conferred by the relationship, in some cases, outweigh the need to be opportunistic (Dyer & Singh, 1998). What this change in paradigmatic focus suggests is that decision makers can no longer assume that their partners are adversarial and that they should be entirely wary in their dealings with them. The new view posits that such cooperative activities as the extensions of trust and information sharing work well in some situations.

Consider the traditional logistics intermediary relationship that is being transformed. Expanded electronic intermediary functions include sharing private information related to inventory movement or financial flows based on me characteristics of the customer’s supply chain or product. Such information sharing requires the customization of information technology (IT) systems used in an exchange relationship. By integrating the vendor’s logistics IT solutions with their own organizational systems, processes in the client and vendor firms can be aligned (Stein, 1998; Walker, Bovet, & Martha, 2000). In fact, clients can tap into information held by vendors to streamline processes, develop value-added products and services, and strengthen customer ties (Gulati & Kletter, 2005). On the other hand, logistics vendors can pool information about client requirements across time, channels, and services, to globally optimize plans and adapt process execution (Lewis, Rai, Forquer, & Quinter, 2007).

However, will these asset-specific investments lead to mutual benefits and stronger cooperation in relationships? Before exploring this topic, though, we must consider the underlying competitive dynamics for the IT investment required to support the partnership. If firms in logistics exchange relationships intend to cooperate by sharing private information, they must create such customized IT systems. While logistics vendors have developed technology solutions that offer clients value-added, information-based services, employing even the most generic solution requires some integration effort on the part of at least one party to the exchange. The issue that emerges is how partners should contribute to the IT customization, in that the client and vendor firms vary in their specializations in hardware platforms, telecommunications protocols, data formats, enterprise systems, process standards, and employee skill sets (Gnyawali & Madhavan, 2001). These variations generate competitive forces that shape the negotiation between partners with respect to who bears the burden for IT customization or whose resources and capabilities dominate.

Past research indicates that the vendor firm’s positioning, specifically centrality within the industry as a whole, affects the firm’s ability to negotiate and influence how assets, information, and status flow, giving rise to resource asymmetries (Gulati, Nohria, & Zaheer, 2000). Centrality provides the vendor with the power to establish standards for services and to achieve economies of scale. In this scenario, clients are likely to assume a disproportionate amount of the effort to integrate sourced services with their internal systems and processes.

Moreover, vendor firms can achieve growth through the replication of technology and solutions subject to lack of imitation (Kogut & Zander, 1992). Not surprisingly, logistics vendors who are dominant in the industry strive to develop repeatable solutions for supply chain services such as merge-in-transit, cross-docking, inventory management, and order fulfillment (Sonnenfeld & Lazo, 1992; Quelch & Conley, 1997; Rivkin, 1999; Lewis et al., 2007).

Alternatively, vendors not occupying a central position within an industry may serve a niche market segment or specific dominant clients. Accordingly, the vendor may bear the burden of customization. For instance, consider Fritz Company, a freight forwarder and now a part of UPS Supply Chain Solutions. This vendor assumed the IT customization onus to establish the necessary visibility for the just-in-time delivery solution that it rolled out for Apple Computers (Healy, Laschinger, & Shroff, 2002; Morton, 2002).

Finally, a client firm that holds a central position within its own industry and represents a significant potential revenue stream can motivate the vendor to bear a significant portion of the customization onus (Subramani & Venkatraman, 2003). In fact, the vendor can improve its own network position, enabling it to tap into additional resources and opportunities by establishing ties with just such a high-centrality client (Gulati, 1998). In addition, a dominant client firm may be so central within its industry that it holds far greater negotiating power than the vendor, as in the case of Wal-Mart (Rigby & Haas, 2004; Yoffie & Mack, 2005).

Common to all of the noted scenarios, one party within the exchange relationship bears a disproportionate burden for IT customization required for information flows. This situation gives rise to tension between parties as each takes a posture with respect to its investments for the customization effort, even when they are to cooperate for information sharing. It becomes important then to understand the conditions under which safeguards exist in a relationship to enable firms to make relationship-specific investments in IT customization, which should facilitate both firms sharing strategic information. In sum, best practice demands that managers make conscious decisions about safeguarding their own positions while also opening themselves to the possibility of gaining Ricardian rents through benefits generated via interorganizational relationships. Given the previous discussion, our study examines two related managerial questions: (i) How can managers safeguard disproportionate investments for IT customization and cooperation for the flows of strategic information in logistics exchange relationships? (ii) What are the performance implications for an exchange relationship that includes a conscious strategy for maintaining competitive and cooperative postures for IT customization and information sharing, respectively? In addressing these questions, we draw upon the relational exchange perspective in marketing.

To test our model, we gathered dyadic data in a field study of a Global 500 logistics vendor’s client-vendor exchange relationships employing interfirm technology solutions. These vendor offerings are specifically aimed at facilitating interfirm information flows between client and vendor. We demonstrate how logistics firms and their clients make relationship-specific investments to customize IT for a relationship and how they share information. Mutual trust and the symmetry in contributions to relationship-specific investments create an environment of cooperative governance, enabling cooperative information sharing while safeguarding disproportionate IT customization investments. Moreover, we find that this duality of competition for disproportionate investments in IT customization and cooperation for information sharing yields mutually beneficial performance gains.

This article proceeds by detailing the theoretical rationale of our research model that specifies the competitive and cooperative initiatives in exchange relationships for logistics services. Subsequently, we outline specific research hypotheses and then describe the research methodology, data analysis, and results. In the final sections, we interpret the findings and their implications for theory, practice, and future research.

THEORETICAL BACKGROUND

Marketing exchange theories tend to focus on relationship exchanges, specifically on (i) behaviors of buyers and (ii) sellers directed at consummating exchanges, (iii) institutional frameworks directed at facilitating exchanges, and (iv) societal consequences of buyers, sellers, and institutions (Hunt, 1983). These B2B exchange relationships range from transactional to collaborative (Day, 2000), with the transactional end of the spectrum characterized by anonymous transactions and automated purchasing and the collaborative end exhibiting high integration between supplier and customer/channel partners.

To engage in exchange relationships, firms must develop capabilities that are multifunctional and cover numerous organizational levels, including, but not limited to, information sharing and process integration (Day, 2000). Business strategies aimed at customer offerings that meet basic transactional requirements (i.e., physical delivery within the logistics function) are required for purely transactional exchanges. By contrast, collaborative exchanges with customers and channel partners require technology and process integration. The current evolution in technological capabilities and depth of information resources available to logistics providers has positioned these vendors to formulate offerings that increase their level of collaboration with partners (Brousseau, 2002).

Discussions about the content of exchange have also evolved in die B2Brelationship theoretical literature. Past research points to an increasing shift in these relationships from the exchange of tangible goods to the exchange of intangibles, namely specialized skills, knowledge, and processes (Vargo & Lusch, 2004). Consistent with the service-centric view, customers in a logistics exchange relationship are coproducers, with vendors engaging client firms in customizing offerings that maximize value for them while continuing to meet their immediate transactional needs. There are, however, unique challenges to managing servicecentered exchange relationships. Namely, “firms must learn to be simultaneously competitive and collaborative” (Vargo & Lusch, 2004, p. 13).

Strategic-information sharing is a key capability required under the servicecentric perspective for collaborative exchange relationships. However, achieving some degree of equity in strategic- information sharing requires a certain level of IT customization. Importantly, it is not just the magnitude of customization that is relevant here. Competitive positioning in achieving the requisite IT customization should result in partners efficiently using their technological resources and capabilities, ideally avoiding duplication of effort for customization. Thus, the degree of exchange partners’ collective IT customization determines whether competitive forces have been applied to the configuration of this asset for the exchange relationship.

Based on this line of reasoning, we suggest that earning Ricardian rents requires firms to adopt cooperative positions with their partners for some initiatives and to assume competitive positions for others. Performance benefits accrue to relationships that efficiently manage this delicate dynamic between cooperating and negotiating hard with partners. This is in contrast to past research that focuses on either competitive or cooperative relationships, and capabilities for each of these types of relationships, but not on managing these domains simultaneously (see, however, Brandenburger & Nalebuff, 1996). For example, Rai, Borah, and Ramaprasad (1996) suggest strategic alliances that cooperate to share information can result in a win-win game. Similarly, Joskow (1988) and Nooteboom (1996) show that competitive positioning shapes the unequal nature of contributions made by parties with respect to time, organizational resources, and effort for IT customization. Thus, there is a theoretical gap in evaluating how exchange relationships can be structured to simultaneously cooperate in certain domains and to compete in others.

To begin to fill the gap in how managers should structure logistics exchange relationships, we draw on relational models that suggest cooperative governance architectures safeguard asymmetric investments by one partner and promote cooperation in resource sharing. Specifically, mutual trust (Das & Teng, 1998) and relationship-specific investments are two key elements of a cooperative governance orientation. The stock of investments in relationships includes financial costs and/or investments in time and effort expended to develop the exchange relationship (Joskow, 1988; Dasgupta & Sengupta, 1993; Bensaou & Anderson, 1999).

In our focusing on the relational exchange perspective, we should note why transaction cost economic (TCE) theory is an inadequate theoretical basis from which to understand how logistics exchange relationships should be structured to be mutually beneficial. First, TCE posits that firms must safeguard against opportunism within interorganizational exchange relationships. Thus, TCE is not designed to explain value cocreation through collaboration in exchange relationships. Second, TCE identifies mechanisms, such as monitoring and contractual governance, that can be applied to safeguard against opportunism, especially under conditions of high- asset specificity (Williamson, 1985). Logistics exchange relationships involve collaboration patterns, which are hard to control through formal monitoring and contracting. In these relationships, the client and the vendor share private information, the vendor has visibility to physical and financial flows between its client and their customers, and the vendor can learn about the growth or decline in its client’s business with customers and across channels and products based on order and shipment patterns. Prior marketing research efforts found similar limitations in applying TCE to the manufacturer-principal agent channel relationship (Heide & John, 1988).

Accordingly, we draw on the relational-exchange perspective to posit that the degree and symmetry of trust and relationship- specific investments should promote cooperation between partners for information sharing while safeguarding IT customization partners undertake. In turn, high IT customization levels and mutual information sharing should promote mutual performance gains for the client and vendor.

ASSESSING DEGREE AND SYMMETRY IN RELATIONAL DYADS

Traditional monadic models conceptualize constructs on either one side of the business relationship or the other. That is, the researcher tests supplier/vendor-only or buyer/client-only models. Our research considers pairs, or dyads, of firms as the unit of analysis, which is the most natural approach for studying interfirm exchange relationships (demons & Row, 1993; Anderson, Hakansson, & Johanson, 1994; Dyer & Singh, 1998; Chen & Paulraj, 2004). Practical difficulties associated with dyadic research designs often lead researchers to collect, and subsequently examine, only one side of the relationship. Kotabe et al. (2003), for example, explored how relationship duration in customer and buyer dyads improved performance in U.S. and Japanese auto firms. Yet, likely because of the complications of acquiring customer data matched with supplier data, monadic supplier performance measures served as the basis for their data analysis. Examining both sides of exchange relationships at once allows for measures of the relational dyadic symmetry. However, measuring only symmetry in a relationship fails to capture the degree or extent of the construct values. The empirically modeled and tested technique (Straub, Rai, & Klein, 2004) employed here conceptualizes the degree symmetry of constructs by assessing both symmetry and value (i.e., degree or magnitude). Table 1 details the derivation of degree-symmetric constructs. In brief, (i) summing all measures for a given construct and standardizing to a value between O and 1 yields the magnitude for the client, C^sub C^, and vendor, C^sub V^. Next, (ii) the mean value of the client and vendor magnitudes, C^sub C^ and C^sub V^, yields the degree value, C^sub DV^. Conversely, (iii) dividing the lesser magnitude by the greater yields a standardized value between 0 and 1, reflecting the symmetric value of the construct, C^sub SV^. Ultimately, (iv) the mean value of C^sub DV^ and C^sub SV^ yields the degree-symmetric value for the construct, C^sub DS^.

We capture dyadic cooperative behaviors through measures that simultaneously assess both degree and symmetry within the logistics provider-client dyad through degree-symmetric (C^sub DS^) constructs. We apply the degree symmetry formulation to other constructs for which we hypothesize the existence of higher levels of a variable for both parties for the sake of parity across the exchange relationship. Within the current work, we examine performance outcomes, specifically focusing on the extent to which these outcomes achieve higher levels and equivalence for both vendor and client. Hence, we apply this previously validated approach (Straub et al., 2004) to assessing the total magnitude mathematically combined with symmetry as a surrogate for the dyadic relationship-specific performance-dependent variable. Moreover, in considering relative levels of trust that have developed in the other party and each party’s investment in developing the relationship, we similarly consider the effects for higher levels of the constructs that are also equivalent across the dyad.

Finally, the degree value (C^sub DV^) measures the level of IT customization in the exchange relationship, irrespective of each firm’s contributions. Consistent with the service-centric view, vendors treat each relationship independently of others potentially absorbing the customization for some relationships, while in other instances deferring to clients or some combination in between. This construct formulation represents the result of competitive positioning for IT customization within dyadic exchange relationships.

MODEL OF INTERFIRM LOGISTICS EXCHANGE RELATIONSHIPS

Figure 1 depicts our proposed model of competitive and cooperative positioning in logistics exchange relationships. The current research greatly extends prior work proposing degree- symmetric constructs (Straub et al., 2004) by exploring both competitive and cooperative positioning within logistics exchange relationships. Specifically, we investigate the relationships between IT customization resulting from competitive positioning and strategic-information flows (H^sub 1^) resulting from interfirm cooperation. In addition, we focus on performance outcomes and examine antecedents to equitable higher levels of performance, namely, strategicinformation flows (H^sub 2^) and relationship- specific investments (H^sub 7^). Our model further considers the relationship between mutual trust (H^sub 3^) and IT customization. In addition, we hypothesize that mutual trust (H^sub 4^) and relationship-specific investment (H^sub 6^) are associated with strategic-information flows. Finally, we posit a relationship between relationship-specific investments and mutual trust (H^sub 5^).

Table 1: Degree and degreee-symmetric construct derivations.

Figure 1: Model of competitive and cooperative positioning in logistics exchange relationships.

Competitive Positioning Enabling Cooperative Behaviors

Within the context of logistics exchange relationships, vendors focusing on developing service-centered, value-added initiatives with clients tend to tap into information-sharing opportunities in an effort to advance strategic partnerships. Traditionally, information sharing within exchange relationships ranges from open lines of communication to complete digital integration of partners, often accomplished through electronic data interchange (EDI) (Day, 2000). Internet-based electronic business applications represent a form of interorganizational systems that enable buyers to interact digitally with suppliers. EDI and electronic business systems share common features, although EDI is far more expensive and falls out of the reach of smaller enterprises (Zhu & Kraemer, 2005). The proliferation of Internetbased business applications overcomes many financial and technical constraints inherent with EDI.

Researchers identify operational, strategic, and strategic/ competitive classes of private information shared between partners in supply chain relationships (Seidmann & Sundararajan, 1997). Shared operational information leverages the capabilities of the other partner. Consider vendor-managed inventory systems, in which a buyer shares inventory position data. These data leverage the supplier’s capabilities witii respect to replenishment and inventory management. In turn, buyers develop and refine the functionality, service levels, and cost structures of their operations and offerings. Strategic information yields specific value to the owning firm and has the potential to accrue operational benefits to business partners through sharing. For example, point-of-sale history offers limited and specific value to a firm, but enhances the business partner’s ability to successfully forecast demand and subsequently improves service efficiency to client firms. Finally, strategic/competitive information enables the owning party to allow partners to derive additional benefits through sharing across strategic areas such as product/service development as well as sales and marketing.

This work additionally notes the existence of order information, which more closely resembles data than information (Seidmann & Sundararajan, 1997). Such information most often describes the transactions necessary for the execution of business exchanges. The operational, strategic, and strategic/competitive information classes by contrast go beyond order information, with such order- extrinsic information possessing the ability to create value-added gains for firms engaged in the relationship. For the sake of simplicity, we use the term strategic in referring to private, order- extrinsic information.

Information sharing among partners calls for some level of IT customization due to the varying specializations or differences in capabilities across firm boundaries (Carlile & Rebentisch, 2003). IT- related resource differences in hardware platforms, telecommunications protocols, data formats and process standards, enterprise systems, and employee skill sets arise from the differentials in the flow of resources and capabilities among partners (Gnyawali & Madhavan, 2001). In attempting to achieve the necessary levels of IT integration, partners invariably vie to have their unique resources, such as standards and legacy systems, drive these relationship-specific asset investments and/or otherwise mitigate their expended effort and investment.

The core theoretical argument that we make is that buyers and sellers within exchange relationships pursue investments in relationship-specific technology assets that enable increased collaboration between them and possess a joint profitmaximizing benefit (Ring & Ven, 1992; Gulati, 1995). Based on this logic, the customized IT infrastructure that results from the relationship- specific IT investments should facilitate the exchange of information between parties in the relationship. We make no claim with respect to which party assumes the greater burden for the IT customization. Circumstances might dictate that this role falls to either party, a stance that makes the hypothesis more generalizable. We posit that a greater collective level of IT customization effort within the logistics exchange relationship is associated with greater levels of strategic-information sharing coupled with equity in flows across the relational dyad, as stated in our first hypothesis:

H^sub 1^: The greater the IT customization dv, the greater the strategicinformation flows ^sub DS^.

Relationship-Specific Performance

The Information Systems Success Model (DeLone & McLean, 1992,2003) formulates the presence of both individual and organizational performance with potential intermediate levels at different points in between (e.g., the business unit). Using a similar logic, relationship-specific performance seeks to examine outcomes realized by two interacting but independent organizations that have recurring business interactions. The performance results derived through such an exchange relationship are, dierefore, a viable and relevant construct (Straub et al., 2004). Relying on this prior formulation of degree-symmetric constructs, we measure performance by aggregating the magnitude of specific tangible and intangible outcomes for each party to the relationship and the subsequent equity, or symmetry, in these outcomes.

We contend that rent generation requires firms to adopt cooperative positions with their partners for interfirm strategic- information flows. Such an argument is consistent with the notion that managers in strategic alliances promoting cooperative information sharing see performance benefits for both participants (Rai et al., 1996). Similarly, increased operational improvements are noted outcomes of supply chain coordination (Robinson, Sahin, & Gao, 2005). Moreover, information exchanges that support joint planning and forecasting at multiple levels can yield operational performance gains (Saeed, Malhotra, & Grover, 2005). Accordingly, the cooperative-strategies perspective lends further insight into the relationship between information exchanges and performance. Contemporary theoretical work in cooperative strategies evolved from older theories of games and economic behavior (Von Neumann & Morgenstern, 1953). This stream of research posits how businesses cooperate for mutual benefit or, conversely, the concept of noncooperative games (Nash, 1951). Cooperative strategies provide a basis for theorizing how both significant levels and symmetry in information sharing within strategic supply chain relationships can result in greater performance across the dyad. In addition, some work contends that effectively leveraging complimentary resource endowments (i.e., information) generate economic rents for both parties (Hamel, 1991; Hill & Hellriegel, 1994; Walker, Kogut, & Shan, 1997; Dyer & Singh, 1998). Hence, we posit that, when equitable and at sufficient levels, such strategic, order-extrinsic information flows between partners in a logistics relationship equate to similar mutual performance gains, as stated in the following hypothesis:

H^sub 2^: The greater the strategic-information flows ^sub DS^, the greater the relationship-specific performance ^sub DS^.

Mutual Trust

By investing in customized IT for business partners, firms commit to time, money, and effort with the expectation of enabling gainful future interactions (Ahmad & Schroeder, 2001). All tilings being equal, trust is a necessary but not sufficient condition for repeated market transactions (Ring & Ven, 1992). We contend that mutual trust, although essentially a cooperative mindset, also affects competitive decisions and actions. Research supports this viewpoint, with some work concluding that interorganizational trust serves to mitigate conflict between parties (Zaheer, McEvily, & Perrone, 1998). Work studying network dyads finds trust present in complex interorganizational integration efforts (Larson, 1992). In fact, firms are more likely to make disproportionate IT investments in a relationship if they have established prior trust in their partner’s capabilities and motivations, and vice versa. Such mutual trust potentially safeguards against opportunistic behavior and creates conditions for dedicated investments in a relationship. Hence, our third hypothesis states that both higher levels and parity in trust are correlated with higher levels of IT customization.

H^sub 3^: The greater the mutual trust ^sub DS^, the greater the IT customization dv

Researchers hypothesize that effective governance such as mutual trust between partners can generate economic rents within exchange relationships by lowering transaction costs and/or providing for incentives to engage in value-added initiatives (Dyer & Singh, 1998). Moreover, work emphasizing transaction value highlights the influence of trust in advancing partnering relationship initiatives (Zajac & Olsen, 1993). Other findings suggest that interorganizational trust reduces die negotiation costs for enhancing performance within interfirm relationships (Zaheer et al., 1998). Mutual trust is an effective governance mechanism for lowering transaction costs and reinforcing cooperative behavior between participating firms (Dyer & Singh, 1998). Prior studies also recognize how trust influences cooperation and teamwork within organizations (Jones & George, 1998). Other work also recognizes mutual trust as important in strategic supply chain cooperative relationships when partners work to establish an adequate level of confidence in each other (Das & Teng, 1998). Empirical research has determined that imbalances in dyadic manufacturer and distributor relationships, when one party browbeats the other, negatively influence perceived levels of mutual trust (Anderson & Weitz, 1989). Moreover, recent work suggests that cooperative activity is a natural effect of earned trust (Johnston, McCutcheon, Stuart, & Kerwood, 2004).

Hence, we view the existence of mutual trust as a key ingredient for cooperative behavior. With regard to interfirm exchange relationships, information sharing constitutes one form of cooperative behavior that is potentially promoted through mutual trust. Consistent with these arguments, we assert that higher levels of mutual trust in logistics relationships are associated with higher levels of cooperative behavior by both parties, namely, increased degree and symmetry of strategic-information flows between them.

H^sub 4^: The greater the mutual trust ^sub DS^, the greater the strategic-information flows ^sub DS^.

Relationship-Specific Investments

To sustain and grow relationships, firms make relationship- specific investments in time, money, and effort (Joskow, 1988). For example, to develop relationships, firms dedicate resources to respond to requests for proposals, to market solutions to clients, for customer support, and toward similar initiatives (Dwyer, Schurr, & Oh, 1987). When these costs cannot be readily transferred to otiier vendor relationships, such costs can only yield benefits through continuous interaction.

What pattern of relationship-specific investment should promote mutual trust? Ring and Van de Ven (1992) note that trust emerges as a consequence of recurring market transactions between buyers and sellers, as repeated prior contact enables them to learn about each other and develop norms (Shapiro, Sheppard, & Cheraskin, 1992). Moreover, through these repeated interactions, organizations see the prospect of future interactions, which discourages attempts to seek short-term opportunism and promotes mutual trust (Maitiand, Bryson, & van de Ven, 1985). Thus, firms making investments in a relationship should be far more inclined to trust their partner’s intentions when the partner also makes commensurate investments. Hence, we suggest that a greater degree and symmetry in relationship- specific investments are associated with higher mutual trust between parties.

H^sub 5^: The greater the relationship-specific investment ^sub DS^ the greater the mutual trust ^sub DS^.

Relationship-specific investments can yield productivity gains as specialization of assets constitutes “a necessary condition for rent” (Amit & Schoemaker, 1993, p. 39). Some researchers observe that firms often elect to develop their own specialized assets in conjunction with partners’ assets in an effort to gain market advantages (Klein, Crawford, & Alchian, 1978). Moreover, nonrecoverable investments within strategic interorganizational alliances (i.e., relationship-specific asset investments) have been shown to be positively related to firm performance (Parkhe, 1993). Empirical work also demonstrates that commitment of nonrecoverable resources and effort within strategic alliances is positively related to performance (Parkhe, 1993; Dyer, 1996). Thus, greater degree and symmetry in relationshipspecific investments in logistics exchange relationships should relate to higher relationship- specific performance for both parties, as stated in the following hypothesis.

H^sub 6^: The greater the relationship-specific investment ^sub DS^, the greater the relationship-specific performance ^sub DS^.

As noted earlier, relationship-specific investments in time, money, and effort can serve to sustain and grow cooperation in exchange relationships (Joskow, 1988). Such mutual investments enhance each firm’s capabilities to leverage the partner’s resources. As a result, we suggest that mutual relationship- specific investment should be associated with mutual information sharing (i.e., degree and symmetry in strategic-information flows) between partners in the relationship.

H^sub 7^: The greater the relationship-specific investment ^sub DS^, the greater the strategic-information flows ^sub DS^.

RESEARCH DESIGN

Our study involved both exploratory and subsequent confirmatory phases. During the exploratory phase, both clients and vendors provided qualitative data that led to a validated survey instrument for the primary data collection for theory confirmation (Stone, 1978; Kaplan & Duchon, 1988; Creswell, 1994). The initial phase employed a case technique (Yin, 1994), while the second, confirmatory, phase used a field study methodology (Creswell, 1994). The confirmatory field study examined customizations of integrated logistics supply chain functions between an outsourced service provider and its clients and the other constructs of interest to our study.

Measurement Development

Information obtained through the exploratory phase served as the basis for the development of a three-item scale for the IT customization construct as well as a three-item scale for relationship-specific investment not directed at a specific class of assets, such as IT. Table 2 details the items used for all constructs as well as the descriptive statistics from the confirmatory stage for their derived degreesymmetric values. For measures of trust, we adopted a validated 11-item scale of omnibus measures of trust from prior works (McKnight, Cummings, & Chervany, 1998; McKnight, Choudhury, & Kacmar, 2002). This multidimensional measure captures trusting beliefs of interest in the study, namely, ability, benevolence, and integrity, and is based on the integrated model of organizational trust (Mayer, Davis, & Schoorman, 1995).

For strategic-information flows, the qualitative data served as the basis for development of a five-item scale of order-extrinsic (strategic) information shared, specifically, cost structures, inventory/capacity planning, margin structures, marketing strategies, and production schedules. To assess each partner’s performance emerging from the relationship, we created an eight- formative-item scale capturing performance outcomes, namely, improved asset management, improved capacity planning, improved resource control, increased flexibility, increased productivity, lower operating costs, and reduced workflow. Confirmatory Phase

Prior research emphasizes the importance of dyadic research designs to investigate interfirm relationships (Clemons & Row, 1993; Anderson et al., 1994; Dyer, 1996; Chen & Paulraj, 2004). However, practical difficulties associated with such research designs have often led to monadic data collection. Consistent with Dyer (1996), we employed a dyadic research design for our field study. We focused on strategic relationships that employed the vendor’s Internet- based technology solutions for interfirm information flows. As we are interested in strategic interfirm relationships, we considered relationships that were managed through dedicated account managers, as opposed to those served through call center operations.

A secure Internet-based survey tool facilitated final data collection. As with Dyer’s (1996) approach for gathering dyadic data, we worked through a senior executive within the vendor’s e- commerce marketing organization. This executive contacted all account managers assigned to overseeing accounts employing Internet- based IT interfirm solutions. The executive encouraged each of them to complete the survey with regard to a single relationship. As a single account manager oversaw multiple customers, selection of the specific relationship was random with respect to client size, tenure, profitability, and/or nature of recent interactions. Subsequently, primary account representatives at 183 different buyer organizations received the matching survey instrument. In total, 132 of the 183 different vendorfirm account managers responded to the survey for a response rate of 72% for the vendor side of the survey. With respect to clients, 91 of the 183 client contacts responded for a response rate of 49% for the client side of the survey. Therefore, the final matching of client and vendor responses resulted in 182 completed client and vendor surveys or 91 usable matched-pair dyadic responses. Averaging the response rate for the vendor side with the client side yields a 61% overall rate.

Table 2: Summary of descriptive statistics of measures.

Matching responses from firms on both sides of an exchange relationship to form dyads is a difficult undertaking. Given that the average for other research employing this same strategy is approximately 58% (Dyer, 1996; Johnson, Cullen, Sakano, & Takenouchi, 1996; Fein & Anderson, 1997), our study achieved a reasonably high number of usable dyadic data. Consider that in Dyer’s 1996 study of suppliers within the automobile manufacturing industry, he captured 83 usable pairs, reporting a 61% response rate for the supplier side and 77% for manufacturer side. Employing this same survey strategy in studying international cooperative alliances, researchers report achieving a 44% overall response rate with 98 matched dyads (Johnson et al., 1996). Finally, in examining territory and brand choices witiiin manufacturer-distributor relationships, Fein and Anderson (1997) realized 362 usable pairs, with a reported overall response rate of 72%. Thus, our response rate is reasonable for a dyadic interfirm research design.

Sample demographics and descriptive statistics

The sample demographics reflect a diverse representation of both client and vendor respondents with respect to overall work, IT, and business relationship-management experience. Moreover, client firm respondents were primarily from mid to senior management levels, with firms representing a cross-section of major industry sectors. Table 3 provides a profile of the relationships examined within this study.

Nonresponse bias

Methodological literature frequently cites a 60% response rate as a reasonable assurance of an absence of systematic bias from respondents (Bailey, 1978). Again, averaging the vendor and client sides yields a 61% overall rate, meeting the prescribed threshold. Moreover, comparing construct means between the early wave of respondents and those who responded during the fourth and final week of data collection provided an additional insight into nonresponse bias. This wave technique treats late respondents as a proxy for nonrespondents (Bailey, 1978). Exactly 43 of the 182, or 23%, of the total respondents forming the 91 dyads completed the survey during the latter period. Analyses of variance for differences across waves on key characteristics (primary industry, primary location by region, number of employees, tenure, individual respondent’s gender, work experience, IT, and relationship-management experience) revealed no significant differences.

Table 3: Firm demographics.

Common method bias

In specifying measures, our analysis sought to safeguard against common metiiod bias by employing different types of measures for some key constructs and different scale types for certain measures. In addition, we evaluated common method variance by applying the Harmon one-factor test (Podsakoff & Organ, 1986). Five factors were extracted from the data on both sides of the dyad. No single factor accounted for the bulk of the covariance, suggesting that common method bias is not a significant issue for our data.

To complement the Harmon test, we conducted an additional analysis outlined by Podsakoff et al. (2003) and Williams, Edwards, and Vandenberg (2003). This procedure specifies, besides substantive factors, a common method factor whose indicators include all the principal construct items in the partial least squares (PLS) model. The result is the proportion of the variance explained by the common method. As reported within Appendix A, our results show that the average explained variance of substantive indicators is .68, while the average method-based variance is .02. The subsequent ratio of substantive variance to method variance is 34:1, with no significant method factor loadings detected for all but three items at p

Analysis and Results

Quantitative analysis included measurement validation and hypothesis testing. The proposed research model involved multiple interdependent relationships and some formative constructs. This combination of factors was conducive to PLS (Gefen, Straub, & Boudreau, 2000), which allows for the examination of both measurement and structural models (Barclay, Higgins, & Thomson, 1995; Chin, 1998b). The presence of both formative and reflective constructs calls for assessing the convergent and discriminant validity of measures through variants of the standard validation techniques. Formative measures included strategic-information flows and relationship-specific performance. Reflective measures included IT customization, mutual trust, and relationship-specific investments. The measurement model provides for the primary assessment of instrument validity within PLS, through the specification of the relationship between the observed variables, or indicator variables, and the latent variables (Igbaria, Guimaraes, & Davis, 1995).

Reliability

As noted, this study adopts previously validated measures of strategic-information flows and relationship-specific performance from Straub et al. (2004) and of mutual trust from McKnight et al. (2002). However, as suggested in methodological research, the current study fully retested instrumentation (Straub & Carlson, 1989). Cronbach’s alphas for reflective measures, namely, IT customization, mutual trust, and relationship-specific investment, all exceed the prescribed 0.7 threshold (Nunnally & Bernstein, 1994). For formative measures, specifically, strategicinformation flows and relationship-specific performance, Cronbach’s alphas are not an appropriate test (Chin, 1998a, b; Gefen et al., 2000). Table 4 reports all findings of the reliability and validity analysis.

Discriminant validity

Average variance extracted (AVE) measures the percentage of overall variance in indicators captured by a latent construct through the ratio of the sum of captured variance and measurement error (Hair, Anderson, Tathem, & Black, 1998). When using PLS as an analytical tool (Gefen et al., 2000), AVE serves as a means for assessing discriminant validity, or the extent to which indicators differentiate among constructs. When the square root of the AVE of a measure exceeds the correlations between the measure and all other measures, adequate discriminant validity exists (Gefen et al., 2000). In Table 4, the pattern of intercorrelations and square roots of AVEs reflect no discriminant validity issues among reflective constructs.

AVE analysis assumes reflective measures; therefore, in assessing formative constructs, we examined the pattern of correlation between items and constructs. We adopted a technique based on work proposing that formative items should correlate with a “global item that summarizes me essence of the construct” (Diamantopoulos & Winklhofer, 2001, p. 272). PLS provides item weights that reflect the influence of individual formative construct items (Bollen & Lennox, 1991). We normalized item weights and men computed and summed the products of item values and weights for each construct, a technique previously proposed (Bagozzi & Fornell, 1982). Next, we examined interitem and item-to-construct correlations. A second version of this technique takes the product of normalized item scores and their PLS weights to derive weighted item scores (Ravichandran & Rai, 2000). Employing either technique, items for each construct correlate higher with one another than with other item measures or constructs, finding no significant discriminant validity issues.

In further assessing discriminant validity, we examined the correlations among the three control variables, specifically client’s industry and organization size as well as relationship longevity. These should not correlate remarkably with study variable measures. Model variables show no substantial correlation with the controls. Of the 11 trust items, only 3 correlated at a low level with the number of employees (i.e., client organization size) at a significant level. The analysis finds no other significant correlations between constructs and control variables. Campbell and Fiske (1959) note that normal statistical distributions in a large matrix often result in a few meaningless exceptions. The overall patterns of results allow us to conclude that reasonable discriminant validity exists among constructs. Convergent validity

In assessing convergent validity, measures believed to be related to the same construct should correlate at a significant level with one another (Campbell & Fiske, 1959). As suggested by Fornell and Larcker (1981), each reflective construct should explain 50% or more of the variance of each of their measurement items with observed item loadings in excess of .7; our data pass all of these thresholds.

Table 4: Reliability, intercorrelations, and average variance extracted (AVEs).

Figure 2: Path coefficients and explained variance in the structural model.

Hypothesis testing

Figure 2 summarizes the results of the PLS analysis. Competitive positioning through IT customization ^sub DV^ has a significant positive direct effect on cooperative strategic-information flows ^sub DS^, supporting H^sub 1^ Moreover, with respect to H4, mutual trust ^sub DS^ also positively influences strategic-information flows ^sub DS^, with both antecedents explaining 54.9% of the construct’s variance. In addition, mutual trust ^sub DS^ has a positive direct effect on IT customization D^sub V^, with 31.2% of the variance explained, supporting H^sub 3^. Strategic-information flows ^sub DS^ and relationship-specific investment ^sub DS^ both have a positive direct effect on relationship-specific performance ^sub DS^. finding for H^sub 2^ and H^sub 7^ explaining 36.7% of the variance of performance. Finally, in testing H^sub 5^, relationship- specific investment ^sub DS^ positively affects mutual trust ^sub DS^. with an explained variance of 20.9%. Our analysis found no support for H^sub 6^, a relationship between relationship-specific investment ^sub DS^ and mutual strategicinformation flows ^sub DS^.

Mediation analysis

Our proposed research model includes potential mediation effects. Specifically, strategic-information flows may serve to mediate the impact of both (i) mutual trust ^sub DS^ and (ii) IT customization ^sub DV^ on relationship-specific performance Ds- We tested for mediation effects within our work through two complementary procedures (Subramani, 2004). The first, which assesses the exploratory power of competing models, compares the research model that proposes full mediation against a competing, partially mediated model and proposes both direct and mediated effects. The second procedure employs mediation analysis techniques (Hoyle & Kenny, 1999; Subramani, 2004) and provides information on the significance of mediation effects.

In comparing the research model with full mediation to partially mediated nested models, PLS can be employed to statistically compare results (Chin, Marcolin, & Newsted, 2003; Subramani, 2004). We compute two alternative, partially mediated models by adding one path for each to the fully mediated model. One path is added from (i) mutual trust ^sub DS^ to relationship-specific performance ^sub DS^ and, in the other, a path is added from (ii) IT customization ^sub DS^ to relationshipspecific performance ^sub DS^. Appendix B depicts the results for both models. The R^sup 2^ for relationship- specific performance ^sub DS^ for the full model is 36.7%. The R^sup 2^s for relationship-specific performance ^sub DS^ for the partially mediated models are 37.2% for mutual trust ^sub DS^ [arrow right] relationship-specific performance ^sub DS^ and 37.5% for IT customization ^sub DV^ [arrow right] relationship-specific performance ^sub DS^.

To understand the additional contribution of paths, we examine the incremental changes in R^sup 2^. A procedure for measuring the effect size and significance of the change in R^sup 2^ between models is an f^sup 2^ statistic calculated by dividing (R^sup 2^ ^sub partially mediated^ – R^sup 2^ ^sub full mediation^) by (1 – R^sup 2^ ^sub partially mediated^). Subsequently, a pseudo F test for the change in R^sup 2^ with 1 and (n – k) degrees of freedom was calculated by multiplying the f^sup 2^ statistic by (n – k – 1). In applying this formula, the f^sup 2^ statistic for mutual trust ds – > relationship-specific performance ^sub DS^ is 008, while IT customization ^sub DV^ [arrow right] relationship-specific performance ^sub DS^ is 012, with insignificant pseudo F(1,86) statistics of 0.68 and 1.02, respectively. These results are summarized in Table 5. Accordingly, the additional variance explained by the inclusion of either of the direct paths does not significantly add to the exploratory power of the overall model.

The second procedure for mediation analysis is based on the path coefficients and standard errors of the direct paths between (i) independent and mediating variables (i.e., iv [arrow right] m) and (ii) mediating and dependent variables (i.e., m [arrow right] dv). The magnitude of mediation is computed as the product of path coefficients between iv ^sub DS^ m and m ^sub DS^ dv. Hence, the magnitude of mediation for mutual trust ^sub DS^ ^sub DS^ relationship-specific performance ^sub DS^ is -201, and for IT customization ^sub DV^ ^sub DS^ relationship-specific performance ^sub DS^ is .123. An approximation of the standard error of the mediated path is computed based on standardized path coefficients and standard deviations for the direct paths, (i) iv ^sub DS^ m and (ii) m ^sub DS^ dv (as summarized in Table 6 and discussed in detail in Hoyle and Kenny (1999)). The resulting z statistics are 3.76 and 2.32 for mutual trust ^sub DS^ and IT customization ^sub DV^ to relationship-specific performance ^sub DS^, respectively; both are significant at p

Table 5: Test of mediation, nested model analysis.

Table 6: Test of mediation, mediated path analysis.

DISCUSSION

Managers sculpt their relationships with other firms by determining when to engage in hard bargaining and when to compromise for mutual benefit. In this article, we argue that strategizing for these positions can and should take place simultaneously. In some aspects of each relationship, cooperative disclosure is useful, which, in this case, is information sharing. In other aspects of the interorganizational connection, the parties must competitively negotiate a settlement as to who will make the most sizable IT investments for customizing their transactional exchanges. Positioning oneself properly calls for a recognition of, as Kenny Rogers sings, “When to hold ’em and when to fold ’em.”

Our study found tiiat, indeed, effective logistics exchange- relationship partners cooperate with respect to the sharing of strategic information while competing with respect to investments for IT customization. Offering one of the first empirical studies capturing both domains within a single nomology, our work suggests that these relationships result in symmetric Ricardian performance gains for both partners. Hypothesized elements of symmetry and/or degree played out cleanly in all of our findings. From a managerial perspective, evolving exchange relationships have seen the emergence of Internet-based technology solutions that enhance strategic- information flows between partners. We find that such information sharing results in subsequent positive performance results for both parties. In adopting tiiese solutions, parties face differences with respect to IT resources and capabilities, giving rise to tension in the relationship while determining who will bear the burden of integration.

Implications for Managerial Decision Making

From a practical perspective, this research provides a number of insights into how managers should make decisions about how they approach evolving servicecentered exchange relationships. Importantly, decision makers need to manage those less tangible aspects of their relationships from both competitive and cooperative postures. In particular, results indicate that firms must rethink the strategy of acting purely in their own self-interest and not cooperating with partners. In managing strategic information, natural inclinations lean toward carefully guarding external disclosures. Our results suggest achieving some level of magnitude and parity in these behaviors gives rise to outcomes that might not otherwise have been attainable, strengthening the basic tenet set forth in the prisoner’s dilemma (Poundstone, 1992).

Managers seem to feel their way toward achieving parity in what critical information each party is willing to share. When the parties trust one another, this process is smoother, but, in any case, the data suggest that, in the higherperforming relationships, the parties are relatively balanced in the extent to which they cooperate with information requests from their partners. Decision makers faced with choices about which alliances to pursue and how to structure these alliances should keep this finding in mind when they negotiate contracts. The loss of parity in the sharing of strategic information will lead to decremental mutual performance. It is in the interest of both parties to ensure that the other party believes it is receiving the information necessary for the relationship to work.

Besides pursuing a cooperative approach for sharing of strategic information, managers must realize that they compete with one another with respect to IT customization investments. While vendors often develop a variety of technology solutions aimed at furthering partner relationships, they find a vast majority of clients possess varying specializations or differences in capabilities (Carlile & Rebentisch, 2003). As noted, IT-related resource asymmetries emerge with respect to hardware platforms, telecommunications protocols, data formats and process standards, enterprise systems, and, most significantly, knowledge-based skill sets (Gnyawali & Madhavan, 2001). Despite their best efforts to deploy universally applicable innovations, the adoption process within the context of individual relationships necessitates some investment in developing customizations that make use of vendor solutions. From a practical perspective, managers should embrace tension in the course of interactions and recognize this as the natural course of business, actively negotiating to ensure efficient use of resources across the interfirm dyad, and agreeing to bear a disproportional share of the burden where justified and within their capabilities. The best managerial choice in this situation is to analyze the relative capability of the partner to provide the required IT customization. If the customization is much less burdensome for one party than the other, or if one party needs the relationship much more than the other, the choice can be clearer and mutual agreement less complicated. But if the investment will be difficult and costly for either, and if bargaining power between the parties is relatively equal, the resolution of the situation will call for a healthy competitiveness in bargaining. In the final analysis, our results suggest that performance metrics that represent the partnership will not suffer with an imbalance in who provides the IT infrastructure. But the requisite infrastructure must be supplied by one party and/ or the other in order to experience Ricardian rents.

Scholarly Contributions

From an academic perspective, our research examined recent propositions set forth in theories of exchange relationships to better understand the cooperative versus competitive phenomena and subsequent consequences within interorganizational supply chain relationships. The service-centric view highlights the limitations of examining discrete transactions (Vargo & Lusch, 2004). Hence, our work focuses on the overall characteristics of the exchange process and relationship within which these transactions occur. Moreover, our findings also demonstrate applicability of derived degree- symmetric constructs (Straub et al., 2004). Benefits from cooperation and competition in strategic partnerships inevitably lead to studying constructs core to such relationships, both in terms of their symmetry as well as degree or extent. Traditional monadic research models limit our ability to capture data for constructs to only one side of the business relationship or the other. The current study employs a dyadic approach to observing the constructs on both sides and focusing the unit of analysis on the relationship itself. Within business disciplines, marketing studies have been among the first to adopt dyadic approaches as their research questions have focused on interorganizational constructs (Anderson & Narus, 1990; Anderson et al., 1994; Fein & Anderson, 1997). The current study joins a limited number of interdisciplinary focused research efforts (demons & Row, 1993; Dyer, 1996; Kirsch, Sambamurthy, Ko, & Purvis, 2002) and employs a dyadic research design to investigate key interorganization phenomenon.

Besides these major theoretical and methodological contributions, our work offers numerous specific findings that should inform and influence future research. From the standpoint of understanding the role of IT in this context, the present research investigates IT integration as suggested by past work. Prior research hypothesizes that the investment climate in supply chain relationships shapes such integration (Klein et al., 1978; Maddigan, 1981; Dewan, Michael, & Min, 1998; Frohlich, 2002; Vickery et al., 2003). Our findings support the view that specializations of IT assets play an important role in the creation of economic rents (Amit & Schoemaker, 1993), in addition to supporting suggestions that asset-specific investments enable richer forms of interfirm collaboration (Joskow, 1988).

Limitations and Future Research

The focus on a logistics vendor in this work limits the potential generalizability to similarly structured business relationships in other supply chain processes. Indeed, the relationship between a logistics vendor and its clients might differ from the relationship that exists between an organization’s internal IT department and internal clients. Moreover, the findings might restrict generalizability beyond the logistics function, given that different externally sourced functional relationships might produce different results.

As noted, the current study specifically examines the combining of IT assets and resources. Other specific resources and/or capabilities within different relational settings might support a cooperative, as opposed to competitive, domain interpretation. Future efforts should further explore the IT customization construct in an effort to gain a greater understanding of partners’ contribution to interfirm integration. Prior work on network externalities, sponsorship of technology and standards by firms, and technology compatibility (Katz & Shapiro, 1986) might provide a useful basis to inform such investigations.

In addition, the current study uses a dyadic research design and surveys 91 logistics exchange relationships from the perspective of the vendor and its customers. While our response rate is comparable to past research employing a similar dyadic data collection strategy, the sample size constitutes a limitation of this work. Given the inherent difficulties in dyadic data collection, researchers should investigate research designs

Tender Mercies: Mary Catherine Bunting – Former Nun, Nurse and Philanthropist – Gives Her Time and Money From the Heart

By Abigail Tucker, The Baltimore Sun

Dec. 26–From the cover

Last in a series of occasional features highlighting people in the Baltimore area who exemplify the “Spirit of Sharing,” The Sun’s annual holiday campaign.

For Mary Catherine Bunting, giving is a diverse enterprise. The former nun sometimes drops by a local homeless shelter with fresh tomatoes and cucumbers, offerings from her own garden. She helps an elderly neighbor with her oxygen tanks. And she volunteers once a week with the Hospice of Baltimore, sitting at the bedsides of the dying.

This fall, Bunting also presented Mercy Medical Center with the largest philanthropic gift in its history, an undisclosed amount that will help build the hospital’s new 18-story facility, to be named after her. Previously, the largest gift was $10 million.

“Being Catholic, I thought, what are you supposed to do with your blessings?” the rosy-cheeked 70-year-old said. “Share them.”

Bunting shuns the word “heiress.” Yes, she is the granddaughter of Dr. George Avery Bunting, who founded the Noxzema Chemical Co.; his children and grandchildren inherited his whopping fortune and have given generously to area charities for decades. But Bunting, who spent many years as a Sister of Mercy and as a nurse to Baltimore’s poor, has long supplemented monetary gifts with her physical presence.

She still volunteers several times a month at the hospice and at My Sister’s Place Lodge, a transitional housing center for homeless women with mental illnesses. She takes residents for weekly outings to area museums or the movies.

“She’s your neighbor, the lady next door,” said Lina Day, who works at the lodge. “She doesn’t come in wearing a Cartier diamond ring as big as my stapler. She’s every woman.”

Becoming a nurse and a nun was not the obvious path for Bunting. But at 16, while a passenger in her boyfriend’s car, she was in a serious accident.

“My head hit the dashboard,” she remembered. She broke bones in her face and spent 10 days in the hospital, her jaw wired together.

During that time, “I saw what nurses did,” she said. The tenderness of the care she received inspired her to earn her nursing diploma in 1958 at the Mercy Hospital School of Nursing.

She went on to receive a bachelor’s degree in sociology from Mount St. Agnes College and advanced degrees in nursing from the University of Maryland. Over the years, she worked in Mercy’s labor and delivery department and taught at the nursing school. From 1972 to 1996, she practiced at Mercy Southern Health Center, an outreach center in South Baltimore, eventually becoming a nurse practitioner.

While pursuing her career, she also followed her faith. In 1959, after earning her first nursing degree, Bunting joined the Sisters of Mercy. She was raised in a very Catholic household, and “I really felt that was what God was calling me to do.”

While a member of the order, she no longer had access to her inheritance. But even before she took her vow of poverty, she says, money was not a major interest of hers. A shy child, she grew up only vaguely understanding where her parents’ wealth came from; she knew about her grandfather’s role but didn’t dwell on it.

For the most part, neither did people she associated with. In nursing school, she remembers only one unpleasant confrontation with a new roommate who thought Bunting’s outfit was too fancy.

“She called me a rich snob, and we had it out the first day,” Bunting remembered. After the initial fireworks, though, the women made up and became close friends.

Especially after she became a nurse practitioner in 1982, Bunting functioned much like a doctor, treating multiple generations of Baltimoreans at the old Mercy Southern Health Center, which was for a time based in a renovated funeral home — a far cry from the planned Mary Catherine Bunting Center at Mercy, with its two-story atrium lobby and rooftop meditation gardens. She kept a low profile back then. Occasionally, she came across patients who worked for her family in some capacity, but for the most part she knew much more about them than they did about her.

“You knew if someone had an alcoholic in the family. You knew where the AA meetings were, and who didn’t have food,” she said. “They trusted you, and you cared about them.”

Bunting was remembered long after she left the outreach center for her willingness to work far more than her scheduled hours, to make home visits and to reach out to people in distress. Based in what is now Federal Hill, Mercy Southern was part of what was then a much less opulent community, where many people lacked the resources to properly monitor their health. Bunting was well- known for taking time to teach her patients.

“I still meet families who say, ‘I haven’t had anyone to do my health care since Mary Catherine Bunting,” said Joanne Manzo, a pediatric nurse practitioner and former Sister of Mercy who worked with Bunting for many years in South Baltimore.

“It was her belief in the spiritual aspects of life, that faith-filled way about her,” said Catherine Kelly, another Mercy nurse practitioner who worked with Bunting and was one of her patients. “She was just utterly unimpressed with herself.”

After leaving the order in 1974 — she says she no longer felt called by God to remain — Bunting continued to nurse and volunteer, but regained access to her worldly possessions, which she proceeded to dispose of at a considerable rate.

Especially after traveling the world and seeing desperate poverty in places such as Nicaragua, she’s realized “you just can’t give enough. I can give so much, but I can’t change the system so everyone has health care. I’m not Mother Theresa.” The scope of global poverty can be dispiriting even to cheerful ex-nuns.

But Bunting’s doing what she can. “I don’t have any children, and I don’t need to pass a lot on.” While she will save “something” for her nieces and nephews and their children, she plans to give away much of her wealth.

She spreads her gifts over a variety of causes, educational (the College of Notre Dame and the Johns Hopkins University Bloomberg School of Public Health, for instance), environmental (the Chesapeake Bay Foundation and the Conservation Fund) and cultural (Center Stage and the Baltimore Symphony Orchestra).

Human welfare organizations remain a priority. She gives to Catholic Charities, Catholic Relief Services, Habitat for Humanity, Healthcare for the Homeless, Partners in Excellence and others.

And, naturally, to Mercy. Bunting had been among the hospital’s benefactors for years, but when the time came to raise funds for the new building, Sister Helen Amos, executive chairwoman of the board of trustees of Mercy Health Services, sat down with her for a talk. The two had first met as young nuns; back then, Amos said, she could hardly have imagined having such a conversation. Yet she wasn’t surprised when Bunting offered her historic gift.

“She was a person who could always be counted on to do her part and more, a person whose generosity comes from her heart,” Amos said. Amos said she knew it was difficult for Bunting, a very private woman, to become a figurehead for the capital campaign.

“But she would do it for a cause close to her heart,” she said.

For her part, Bunting, who lives in the area, still doesn’t fraternize with the super-rich very much. Mostly she hangs out with her friends from her parish, St. Vincent de Paul in Baltimore. She loves to garden.

“My next-door neighbor laughs and says, ‘You may have left, but you’re still a nun,'” Bunting recalled.

Bunting says the best presents she herself has been given are “my life, by my mother, and my faith.” The latter remains a guiding force as she continues to share with others.

The women she meets at My Sister’s Place Lodge “always say to me other people give us money, but you give us time,” Bunting said.

She doesn’t see how she could do otherwise.

The Bible “doesn’t say, ‘Blessed are the people who give to the poor,'” she said. “It says, ‘Blessed are the poor.'”

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HongKong:0988,

Mexican Marijuana is Still Plentiful — and Cheap

A car, a home, a gallon of milk — most everything costs more now than a generation ago. Except a baggie of Mexican marijuana.

Give or take a few dollars, authorities say, pot grown in Mexico and sold in Houston and other Texas cities still goes for about the same price as 25 years ago: $60 to $80 for an ounce.

In economic terms, marijuana is far cheaper since the decade when a three-bedroom home in upscale West University cost $150,000, a new ride was less than $6,000 and first lady Nancy Reagan urged kids to “Just Say No.”

“I guarantee you it is probably cheaper than it was back in the day,” said Lt. Gray Smith of the Houston police narcotics division. “Since I’ve been in the dope business, it has been pretty much the same,” he said of prices during 20 years of monitoring sales.

Others agree.

“I don’t care if you put 10 Marine divisions along the Mexican border, you are never going to be able to stop the movement of drugs, marijuana, across the border,” said Mike Vigil, the Drug Enforcement Administration’s former chief of international operations.

The problem is not only that the 2,000-mile-long border is huge, but also that the U.S. depends on people and commerce being able to freely flow in and out of the country.

“If you were to search everything, you’d have lines going back 100 miles,” Vigil said.

Although rarely bestowed with the infamy or educational focus of other illegal substances, the dried, greenish-brown plant remains the most-used illicit drug in the United States, according to the National Institute on Drug Abuse.

Seizures have climbed An estimated 97 million Americans age 12 or older have smoked marijuana, according to the 2006 National Survey on Drug Use and Health. Among schoolkids, it is considered the leading drug problem after alcohol.

“The efforts to stop the flow of marijuana — despite cost and manpower involved — have failed,” said Bruce Bagley, who studies illegal drugs for the University of Miami. “There is a surplus and an abundance of marijuana flowing into the United States.”

Despite the emergence of fancy designer marijuana, most of the pot in the U.S. comes from Mexico.

Discussion about the marijuana market and attitudes about the drug comes as the White House recently announced disputable findings that there is a shortage of cocaine in many U.S. cities.

Drug czar John Walters portrayed a spike in cocaine prices during the first six months of 2007 as progress because a key drug-war goal is to squeeze supply and drive up prices to discourage use. DEA spokesman Steve Robertson said low marijuana prices, however, don’t signal defeat.

“Every time we seize an amount of marijuana, no matter how small or large, that is a blow against these criminal organizations, and that deprives the organization of money. It is also one less opportunity for somebody to mess up their lives,” he said.

According to a drug market analysis released earlier this year, federal, state and local police assigned within the Houston-based High Intensity Drug Trafficking area saw marijuana seizures climb from 85,582 pounds in 2005 to last year’s haul of 191,000 pounds.

Based on the weight of a typical marijuana cigarette, enough marijuana to roll more than 171 million joints was taken out of commission in a 16-county area, including Houston and portions of the Texas Gulf Coast.

‘A lot of customers’ “It is phenomenal,” Robertson said of the amount of marijuana. “There is a lot of grass coming across the Southwest border, and we’re seizing a lot, but the reason there is a lot is because there are a lot of customers.”

Jorge Cervantes, who has a Web site on marijuana growing and is a columnist for High Times magazine, said governments worldwide know they can’t snuff out drugs.

“They know there is no way they can win,” said Cervantes, who spent part of last year visiting Mexican marijuana farms.

Marijuana can be bought for as little as $30 a pound in remote stretches of Mexico and can be sold for $500 in Houston, or for at least twice that amount when packaged in smaller user quantities, said David Gonzalez, a 26-year-old West Texan who ran a drug-trafficking organization started by his father and served prison time in Texas.

“Start breaking it up for high school kids or small-time consumers — a joint here, a joint there — you can make almost a thousand bucks off it,” he said. “But the risk is greater. You have to peddle it on the street.”

Mexican marijuana prices stay low because the major drug-trafficking cartels don’t charge smaller players a fee to do business or smuggle through their turf, Gonzalez said. “You never hear of people getting killed over a few pounds of marijuana, but you do over a few ounces of cocaine. Marijuana is pretty much an open market. Nobody controls it, nobody wants to control it.”

Some speculate that Mexican marijuana remains popular because many drug-using Americans are not willing to pay for more powerful and pricey plants grown in the United States. “Mexican marijuana is inferior. They have not innovated as much as the California hippies,” said Bagley.

Price not indicative Still, Mexican marijuana holds a steady place in the market because it is far cheaper than the U.S.-grown marijuana and is not as debilitating, especially for new users.

It might be like comparing bargain beer to Chivas Regal, an upscale Scotch whiskey.

Rosalie Pacula, a senior economist and co-director of the RAND Drug Policy Research Center, said that not much information is gathered on the price and potency of marijuana grown outside the United States because it’s hard to draw conclusions from the prices.

“The dollar price on a bag of marijuana is not indicative of the value of the bag, as you must also know the quantity and potency of the marijuana inside to know its real price,” she said. While figures could indicate law enforcement isn’t impacting prices, she said, the market also changes.

Jon Gettman, an analyst and former national head of the National Organization for the Reform of Marijuana Laws, said marijuana prices could stay low because Texas is so close to an unlimited supply of the drug.

“Presumably Gulf Coast shrimp is cheaper in Houston than it is in Minnesota, and this is true for many commodities throughout the country and the world,” he said.

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Petition to Alter NRC Training Regs Denied

By Anonymous

The U.S. Nuclear Regulatory Commission (NRC) announced in the Federal Register on October 24 that it had denied a petition for rulemaking (PRM35-19) originally submitted by William Stein, III, MD (Metairie, LA), on June 14, 2006. Stein had requested that the NRC amend Title 10 Code of Federal Regulations (CFR) 35 regulations governing training for parenteral administration of ^sup 153^Sm- lexidronam (Quadramet), ^sup 131^I-tositumomab (Bexxar), and ^sup 90^Y-ibritumomab tiuxetan (Zevalin). During the 2002 revision to 10 CFR part 35, the NRC increased the required amount of training and experience from 80 to 700 hours for most medical uses of unsealed byproduct material requiring a written directive. In 2005, the NRC noted that to properly cover the topics important for safety for these uses, the minimum amount of classroom and laboratory training was 200 hours for the alternate pathway to authorized status. To achieve authorization via the board certification pathway, the individual must successfully complete multiple-year residency training in a radiation therapy or nuclear medicine training program or a program in a related medical specialty, each of which also includes a total of 700 hours of training and experience. Stein asserted in his petition that these regulations were burdensome and requested that they be amended to stipulate that 80 hours of laboratory and classroom training, supervised work experience, and written attestation should be sufficient for physicians seeking authorized user status for therapeutic administrations of these unsealed byproduct materials. Stein provided 3 options for addressing this issue, but, after review and a period for public comment, the NRC rejected both the petition and the proposed remedies.

In summarizing the 25 comments received, the NRC noted that 18 supported the petition. In general, “these commenters stated that not granting the petition would intrude into the practice of medicine, discourage physicians from treating patients, and establish barriers to the use of potentially effective therapies, thus adversely affecting patient access to these therapies and increasing health care costs.” Commenters also noted that the activity administrations of Quadramet, Bexxar, and Zevalin are from a radiation safety perspective less hazardous than oral administration of 1311, for which the NRC requires only 80 hours of classroom and laboratory training.

Among the 7 letters opposing the petition were statements from the American Association of Physicists in Medicine, the American College of Radiation Oncology, the American College of Radiology, and the American Society for Therapeutic Radiology and Oncology. Many of these commenters raised concerns about radiation safety issues and exposure of patients to additional risk if medical oncology/ hematology training does not include the extensive background necessary for administering these radiopharmaceuticals.

In denying the petition, the NRC noted that current 10 CFR 35.390 and 35.396 regulations establish “the appropriate amount of training and experience for a physician to become an authorized user for the parenteral administration of unsealed byproduct material requiring a written directive, including Quadramet, Bexxar, and Zevalin.” In reviewing the various reasons for this decision, the complexity of product-specific variations in training was noted: “The current approach to training and experience for the medical use of unsealed byproduct material accommodates the introduction of new radiopharmaceuticals without requiring additional rulemaking, with its associated costs to the Agreement States. Attempting to tailor the training and experience requirements to specific uses of unsealed byproduct material and to the amount of flexibility that a user may wish to have would significantly increase the complexity of the regulatory oversight. The NRC does not believe that such added complexity would be of benefit to patients, the Agreement States, licensees, current and prospective authorized users, or the medical specialty boards.”

The full NRC ruling is available at http://a257.g.akamaitech.net/ 7/257/ 2422/01 jan20071800/edocket.access. gpo.gov/2007/E7- 20918.htm.

U.S. Nuclear Regulatory Commission

Copyright Society of Nuclear Medicine Dec 2007

(c) 2007 Journal of Nuclear Medicine, The. Provided by ProQuest Information and Learning. All rights Reserved.

Relief From Sinus Pain: In Sinuplasty, Balloon Opens Blocked Cavities

Like an estimated 37 million other Americans, Glen Templeton has sought medical treatment for sinus infections. The 20-year-old Carroll High School graduate, who now attends Ball State University, began experiencing severe problems a couple of years ago due to allergies.

He took antibiotic after antibiotic in an attempt for relief.

“He’d finish one round, and then a couple weeks later, he’d have another infection,” said his mother, Cheryl Templeton. In August, he developed an infection in the left frontal sinus cavity above his eye that would not clear up.

“Before the sinus infection I could bike 10 miles and not be hurting at all,” he said. “Now I go 2 miles in the time I did 10. I knew something had to be done about it.”

On Thursday, Templeton underwent a new type of sinus surgery that has been available in Fort Wayne for about a year. Sinuplasty, or balloon angioplasty of the sinus, parallels angioplasty of the heart, in which a balloon is used to open vessel walls.

In the nose, two frontal sinus cavities are among eight adjacent to or above the nose. Each has an opening into the nose that allows air to move in and out.

A continuous membrane lines the cavities. Mucus keeps the lining moist and is moved along the pathways via tiny hair-like cells called cilia. The sinuses do not drain by gravity, but by the action of the cilia.

A cold or allergies can irritate and inflame the lining, causing increased and thickened mucus. The inflammation can become severe enough to block the sinus, trapping mucus in the cavity and leading to infection. Sometimes air gets trapped, causing pain and pressure.

In an operating room at Lutheran Hospital, Dr. David Stein prepared a thin, flexible guide wire that he carefully snaked through Templeton’s nasal passage, past several structures along the way and up into his left frontal sinus.

With the end of the catheter millimeters away from Templeton’s brain, Stein could see on the monitor exactly where to stop. Then he slid a balloon catheter over the guide wire to the desired location. He slowly inflated the balloon, which pushed out the tissue and eggshell-like bones in the cavity to open the blocked passageway.

A smooth appearance on the sides of the balloon indicated he had inflated it to the level needed. In less than a minute, the balloon was deflated. Then Stein inserted an irrigation tool to wash out the pus and debris.

Templeton snoozed away under general anesthesia and was home less than two hours later. On Friday, he was back to helping shoppers find last-minute gifts at Macy’s, where he has a seasonal job during his college break.

“I feel great,” he said late Friday, noting he had almost no pain afterward and no swelling in his face.

“The procedure anatomically changes the sinus,” said Stein, an otolaryngologist with Ear, Nose and Throat Associates in Fort Wayne.

Balloon Sinuplasty is not approved for use in all sinus cavities, and the technology, developed by Acclarent Inc., a California medical-device company, “does not fix allergies,” Stein said. But for people like Templeton, it is a good alternative to traditional sinus surgery, which involves cutting away tissue and fracturing bone.

Although traditional surgery was discussed, Templeton said, “That didn’t sound pleasant at all.”

Sinuplasty involves less tissue damage and avoids scarring that can sometimes occur after traditional surgery and cause new blockages.

Recovery lasts several weeks, with swelling around the nose and eyes.

Stein said Templeton’s re-opened sinus should remain that way indefinitely, although studies at this point are limited to about two years post-surgery. In severe cases with difficult blockages, doctors sometimes try Sinuplasty before resorting to traditional surgery.

Stein has done 10 Sinuplasty procedures so far and all were without complications, he said. A careful screening of patients, however, is crucial.

Technology is changing so rapidly that despite Sinuplasty’s short history, the way it will be done will soon change. In the coming months, the large machine used to take the moving X-rays of the advancement of the guide wire and the balloon catheter will be replaced by a lighted guide wire that can be seen through the surface of the skin.