By Signorello, Lisa B Schlundt, David G; Cohen, Sarah S; Steinwandel, Mark D; Buchowski, Maciej S; McLaughlin, Joseph K; Hargreaves, Margaret K; Blot, William J

Objectives. We investigated whether racial disparities in the prevalence of type 2 diabetes exist beyond what may be attributable to differences in socioeconomic status (SES) and other modifiable risk factors. Methods. We analyzed data from 34 331 African American and 9491 White adults aged 40 to 79 years recruited into the ongoing Southern Community Cohort Study. Participants were enrolled at community health centers and had similar socioeconomic circumstances and risk factor profiles. We used logistic regression to estimate the association between race and prevalence of self-reported diabetes after taking into account age, SES, health insurance coverage, body mass index, physical activity, and hypertension.

Results. Multivariate analyses accounting for several diabetes risk factors did not provide strong support for higher diabetes prevalence rates among African Americans than among Whites (men: odds ratio [OR] = 1.07; 95% confidence interval [CI] = 0.95, 1.20); women: OR = 1.13, 95% CI = 1.04, 1.22).

Conclusions. Our findings suggest that major differences in diabetes prevalence between African Americans and Whites may simply reflect differences in established risk factors for the disease, such as SES, that typically vary according to race. (Am J Public Health. 2007;97:2260-2267. doi:10.2105/AJPH.2006.094482)

Members of racial and ethnic minority groups in the United States, including African Americans, suffer disproportionately from many chronic diseases, including type 2 diabetes (hereafter “diabetes”).1-3 Prevailing statistics suggest that African American adults are 50% to 100% more likely to have diabetes than are Whites,3-8 with evidence that diabetes precursors may even be more common in African American than in White children.9,10 Reasons for racial disparities in diabetes prevalence are not clear, but behavioral, environmental, socioeconomic, physiological, and genetic contributors have all been postulated.3,8,11

Because of the high prevalence of diabetes in the African American community, it has been suggested that African Americans may be more susceptible to the disease compared with Whites through direct genetic propensity or unfavorable gene-environment interactions. 11 The fact that diabetes prevalence rates among Whites exceeded those among African Americans through at least the first half of the 20th century12 has led to the hypothesis that modern lifestyle factors (especially those that promote obesity) may have a greater effect on African Americans than on Whites.11,13

However, treating race as an etiological factor has been the subject of debate,14-16 and it has been argued that despite some genotypic delineations, race largely represents a complex mixture of behavioral, environmental, and social exposures.17,18 In comparison with Whites, African Americans often are poorer, have less education, are more likely to live in distressed households and communities, are less able to access quality health care, and have a less favorable risk factor profile for many diseases.18-20 Because socioeconomic (and associated environmental) differences between racial groups are so pervasive, attempts to isolate an effect of race will typically involve substantial confounding,16 resulting in difficulty estimating the relative contributions of genetic and environmental factors.

There have been several attempts to evaluate whether the disparity between African Americans and Whites with regard to diabetes can be attributed to factors other than racial background.7,13,21-27 Studies involving nationally representative sampling frames7,21,23-25,27 provided the platform for many of these analyses, which poses a challenge in that the average African American is of substantially lower socioeconomic status (SES) than the average White American. Because racial disparities persisted in these studies after adjustment for known diabetes risk factors, including some measures of SES, a possible genetic explanation has been invoked for the residual association, although the precise biological mechanisms remain speculative. Many of the studies conducted to evaluate the underlying reasons for racial disparities in diabetes prevalence have included fewer than 1000 each of African American men and women.7,13,21,23,25

Using the study population from the ongoing Southern Community Cohort Study (SCCS), which includes large numbers of African Americans and members of other racial/ethnic groups from generally similar socioeconomic circumstances, we had a unique opportunity to evaluate racial disparities in diabetes in a context in which confounding by extraneous factors related to race and SES would be limited by design. If racial disparities are driven by SES, one would expect little racial difference in diabetes prevalence rates within this population. We addressed the question of whether differences in diabetes prevalence between African Americans and Whites can be fully explained by SES or by adjustment for other correlates of diabetes risk.

METHODS

Study Population

The SCCS is a prospective epidemiological cohort study with ongoing participant enrollment across the southeastern United States.28 For the present analysis, we included cohort members enrolled from the beginning of the study (March 2002) until January 2006. These participants were enrolled in person at 48 community health centers located in both urban and rural areas across the states of Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia, and West Virginia. Community health centers are government-funded health care facilities that provide basic health services primarily to low-income individuals.29 Nationally, approximately 70% of community health center patients live at or below the federal poverty level. African American and White participants were enrolled at the same community health centers.

The strategy used to enroll participants was to randomly approach people entering the community health centers (e.g., patients, individuals accompanying patients, community residents seeking other services offered by the community health centers) who appeared to be between the ages of 40 and 79 years and determine their eligibility for and interest in study participation. In addition to the age criterion, participants were required to speak English and to not have undergone treatment for cancer within the preceding year. The primary focus of the SCCS is determining reasons for racial disparities in cancer risk.

Data Collection

Participants completed a comprehensive, in-person, baseline interview covering various aspects of health and behavior, including personal and family medical history, diet, exercise, tobacco use, medication use, social support, psychological well-being, and access to health services. During this interview, participants were asked, “Has a doctor ever told you that you have had diabetes or high blood sugar?” Participants responding yes were asked follow-up questions regarding their age at first diagnosis and use (and names) of prescription medications taken to manage their diabetes. Women were specifically asked not to include gestational diabetes in their reporting.

Socioeconomic Status and Other Potential Confounders

The variables used to estimate SES were total household income in the previous year (less than $15000, $15000-$24999, $25000-$49999, $50000-$99999, $100000 or more), highest level of education completed, and type of job held for the longest period of time during the participant’s adult life (reported in 20 broad categories, including “never worked” and “housewife”). We used Nam- Powers-Boyd (NPB) occupational status scores30 (on a scale from 1 [lowest] to 100 [highest], representing the socioeconomic standing of an occupation) for the occupational categories by assigning each category the average of the scores for its individual job examples. In the case of a small number of participants (n=371; 0.8%) for whom we were unable to code longest-held job with our categories, or for whom this information was missing, we substituted the score for their current occupation.

Participants self-reported their current weight, their weight at age 21 years, the most they had ever weighed (not including weight during pregnancy), and their height. Because current weight may reflect weight adjustments (in either direction) after a diagnosis of diabetes,31 we chose to focus on participants’ reports of the most they had ever weighed and their weight at age 21 years (to account for long-term overweight or obesity). We calculated body mass index (BMI; weight in kilograms divided by height in meters squared) for each of these 2 weight measures; we defined overweight as a BMI of 25 kg/m2 or higher, obesity as a BMI of 30 kg/m2 or higher, and extreme obesity as a BMI of 40 kg/m2 or higher32 (categories are not mutually exclusive).

Participants also reported on leisure time physical activities they had engaged in during their 30s (amount of time per week). These activities included both moderate-level sports (e.g., bowling, dancing, golfing, and softball) and vigorous sports (e.g., jogging, aerobics, bicycling, tennis, swimming, weightlifting, and basketball). Statistical Analysis

We included in our cross-sectional analyses participants who identified themselves as either only African American or only White (n=43899; 97% of the cohort). We excluded an additional 77 participants (0.2%) who were missing self-reported information on diabetes status, leaving 43 822 (34331 African American, 9491 White) participants to serve as our study population.

We used multivariate logistic regression analyses to estimate measures of association (odds ratios [ORs] and 95% confidence intervals [CIs]). The following factors were selected a priori as covariates and modeled via the categories shown in Table 1: age at interview, educational level, total household income, NPB score, health insurance coverage, current BMI, highest BMI, BMI at age 21 years, and hypertension. Physical activity (in minutes), also selected a priori, was modeled with continuous variables. The (approximate) quartiles used for NPB scores were gender specific, with cutoffs for men of 22, 30, and 42.5 and cutoffs for women of 22, 30, and 56.

We evaluated additional variables as potential confounders, but they were found not to alter the main results by more than 5% and were not included in the final model. These variables were marital status, smoking status, and 2 measures of social support (participants’ reports of how many close friends or relatives would help with their emotional problems if needed and how many people they could ask for help in an emergency or with lending them money). Income adjusted for household size (determined by dividing the midpoint of the reported income category by the total number of people reported to be living in a given household) was also computed and substituted in the final model for the income variable, but it was not found to alter the results.

RESULTS

Participants’ mean age at enrollment was 51.2 years (SD=8.7). The majority (61%) reported a household income below $15000 per year, and one third reported less than 12 years of schooling (Table 1). At the time of the baseline interview, 73% of participants were overweight, 44% were obese, and 11% were extremely obese. The prevalence of obesity was significantly (P

Overall, 9223 (21%) of the participants reported having been diagnosed with diabetes, and of these individuals, 86% reported taking diabetes medication, including insulin (Table 1). Differences in the reported prevalence of diabetes between African Americans and Whites were modest. Among women, African Americans were more likely to report diabetes than were Whites (24% vs 21%), whereas the converse was true for men (20% for Whites vs 17% for African Americans).

Diabetes prevalence rates in relation to factors previously shown to have significant associations with the disease (age, educational level, income, BMI) are reported in Table 2. As expected, the prevalence of diabetes increased with increasing age and BMI, and with decreasing education and income. Diabetes prevalence rose 8- fold from a low of 5% among participants whose highest BMI was less than 25 kg/m2 to 40% among those whose highest BMI was 40 kg/m2 or greater. Among participants who had ever been obese, the prevalence of diabetes varied little according to race or gender (30% among African American women, 29% among White women, 28% among African American men, and 30% among White men).

The prevalence of diabetes was inversely related to educational level, particularly among women, and overall it was 1.6 times higher among participants with less than 9 years of education than among those who had graduated from college (Table 2). Similarly, among participants in the lowest income category (less than $15000 per year), the prevalence of diabetes was 1.4 times higher than among participants with a household income of $50 000 per year or more; however, there were variations in the relationship between income and diabetes in each gender-race stratum, and the general trend of prevalence rising with decreasing income did not hold for African American men.

After adjustment for age, we observed no association between race and diabetes among men (for African Americans relative to Whites, OR=0.92; 95% CI=0.83, 1.01) and a modest excess among African American women in comparison with White women (OR=1.39; 95% CI=1.29, 1.49; Table 3). After further adjustment for educational level, income, NPB score, health insurance coverage, highest BMI, BMI at age 21, hypertension, and physical activity, there was still no significant difference between African American and White men, and the difference for women had been attenuated and remained only marginally significant (OR=1.13; 95% CI=1.04, 1.22). To avoid any potentially biasing effects of including individuals with type 1 diabetes, we repeated the analyses excluding participants who reported their age at first diagnosis as younger than 30 years. The results (Table 3) were nearly identical to those of our main analyses.

Table 4 shows the strong association between (highest) BMI and diabetes estimated from multivariate regression models run separately for each of the 4 gender and race groups. The strong trend of increasing risk across increasing categories of BMI was seen in all groups but tended to be more enhanced among Whites, although race x BMI interaction terms in gender-specific regression models were statistically significant only for women. We used regression models containing these interaction terms to estimate the effect of race on diabetes prevalence at various levels of BMI. Among women, the odds ratio for the effect of race was highest at the lowest BMI level (ORs=2.03, 1.41, 1.26, 1.19, and 0.85 for women whose highest BMI was less than 25 kg/m2, 25-29.99, 30-34.99, 35-39.99, and 40 kg/m2 or higher, respectively), but no significant interaction was observed among men (ORs=1.03, 1.42, 1.34, 0.97, and 0.60 for highest BMI of less than 25 kg/m2, 25- 29.99 kg/m2, 30-34.99 kg/m2, 35-39.99 kg/m2, and 40 kg/m2 or higher, respectively).

DISCUSSION

In this large study of adults with similar socioeconomic circumstances and risk factor profiles, we found little evidence of a higher prevalence of diabetes among African Americans than among Whites. Even before we had controlled for BMI and other known determinants of the disease, we observed only a modest excess of diabetes among African Americans and only among women.

A social gradient in diabetes risk has been well documented both in the United States5,33-36 and in other Westernized countries.37- 40 The factors underlying this gradient may include fetal or infant malnutrition,41-43 chronic stress,44,45 depression and other psychosocial factors,37,38,46 obesity,24,47 inactivity,24 and lack of access to preventive health care. Controlling for SES is problematic because SES stands as a proxy for a myriad of (often unmeasured) confounders, is difficult to quantify, and is prone to a high level of measurement error.16 Because confounding by SES can be intractable in the analysis phase of a study, strategies designed to limit it in the design phase may be more effective.

Despite our advantage of having a study design that produced a population closely “matched” across racial groups in terms of SES and our efforts to quantify SES, residual confounding by SES was still, in all likelihood, a factor in our findings, possibly accounting for the small residual racial effect we observed among women. Racial disparities in diabetes are often reported to be stronger among women than among men,3,6,22,23,25 and it may be that SES is a stronger confounder among women than among men. We found some evidence for the latter possibility, with education and income showing a stronger relation with diabetes among women, both crudely (Table 2) and in our final multivariate regression models (data not shown).

Our overall finding of nearly equal rates of diabetes among African Americans and Whites is contrary to the results of practically all published epidemiological studies on this subject.7,13,21-27 Although the findings from these previous studies are somewhat mixed, a common conclusion has been that racial differences in diabetes prevalence cannot be fully explained by established risk factors. We believe, however, that few investigations have overcome the confounding inherent in studies of race and disease. Indeed, these studies noted striking differences in several important confounders (e.g., measures of obesity or central adiposity, education, income, occupational status, or physical activity) between African Americans and Whites in their samples,7,13,21-26 and adjustment for SES often involved adjustment for education only.7,22-25

In a recent investigation that undertook a more comprehensive evaluation of the effects of confounding by SES and other variables, an initial African American excess in diabetes prevalence among women of 76% was eliminated (OR=1.04) after adjustment for poverty income ratio (i.e., income divided by the federal poverty line for a given family size), a number of examination-related variables (e.g., length of fast, time of day), body size variables, and measures of physical activity, diet, smoking, and alcohol consumption.21 In the same study, however, adjusting for the identical set of variables did not negate the effect of race among men.21 It has been suggested that, in terms of diabetes risk, obesity may have a more detrimental effect among African Americans than among Whites.7,23,25 Such a finding was reported in a pair of investigations involving data from the National Health and Nutrition Examination Survey (NHANES)7,25; in one of these studies, the strongest effect of obesity was observed among African American women.7 We did not find supportive evidence for an interaction in this direction, and in fact we observed the effect of obesity to be greater among White women than among African American women. Our finding is consistent with clinical evidence indicating that upper body obesity is more strongly associated with a diabetes-promoting metabolic profile among nondiabetic White women than among African American women.48- 50

Our results raise the possibility that any racial differences in diabetes among women may be greatest at low BMI levels, with the racial gap disappearing as BMI increases. This has been noted elsewhere,23 but others have reported the opposite7 (i.e., similar diabetes prevalence rates among African Americans and Whites at ideal body weights, with a racial disparity growing with increasing percentage of desirable weight). One interpretation of our finding would be that if there is a race-based disparity among women, it may be more pronounced in women of normal weight; the reason may be that obesity has a greater effect on Whites, as we observed, or that the disparity is overshadowed in general by the strong influence of obesity on diabetes. Given the large number of comparisons made in this analysis, it is also possible that our finding of an interaction between race and BMI among women arose by chance.

The prevalence of diabetes in the SCCS is higher than the prevalence in the general population of the southeastern states. According to the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System, 2004 age-specific diabetes prevalence rates in the 12 SCCS enrollment states were in the range of 7% to 12% in the 45- to 54-year age group, 13% to 19% in the 55- to 64-year age group, and 14% to 22% among individuals 65 years or older51; by contrast, we found rates of 19%, 31%, and 34%, respectively. We believe that the reason for the high prevalence of diabetes in the SCCS is that participant enrollment takes place in impoverished communities and within community health centers in which people seek care for their diabetes. Thus, our prevalence estimates do not lend themselves to generalization outside of our study population, but internal comparisons between subgroups of participants (in this case, by race) remain valid.

Limitations

Systematic inaccuracies in reporting of diabetes diagnoses may have obscured actual racial differences in our study, but our collection of data in a standardized fashion across racial groups should have minimized this possibility. Nondifferential misclassification can also dampen true differences in reported outcomes but would have to be substantial to generate a null finding. Some confounders included as covariates in our analyses (e.g., participants’ weight at age 21 years and physical activity in their 30s) involved recall over a long period of time, but we would not expect race-specific differences in associated reporting errors.

Although exclusion of undiagnosed disease was a limitation of our study, it is not a likely reason for our null findings, given that self-reports have been used in other studies documenting strong racial disparities. 4,5,26 An estimated 29% to 44% of diabetes cases in the United States are undiagnosed. 4,6 However, African Americans in our study should not have been less likely than Whites to be diagnosed because of differential access to health care, because recruitment within community health centers ensured that all cohort members had essentially equal access to primary health care, and there were few racial differences in income level or type of health insurance coverage. Moreover, a recent analysis of NHANES (1999- 2000) data revealed similar rates of undiagnosed diabetes among African Americans and non-Hispanic Whites according to fasting plasma glucose test results.4

Conclusions

On the basis of familial aggregation, twin studies, and recent advances in identifying molecular markers of risk, it is clear that diabetes is a genetically influenced disease.52 However, success in identifying genetic underpinnings of racial disparities in diabetes prevalence has been elusive. Although the existence of a “thrifty genotype” (a genetic adaptation to feast and famine cycles) has been posited since the 1960s,53 it has yet to be characterized. Furthermore, the notion that the thrifty genotype would affect African Americans more than other groups such as European Americans has been called into question.54 Genome-wide scans have uncovered some candidate markers of diabetes risk in affected African American families,55,56 and racial variations in the adiponectin57 and other genes58,59 involved in insulin sensitization or resistance have been noted; however, the contribution of these polymorphisms to racial disparities, or to diabetes risk in general, has not been firmly established.

Our results suggest that major differences in diabetes prevalence between African Americans and Whites are unlikely to be tied to race per se; rather, it is likely that they are linked to differences in established risk factors for diabetes that typically vary between African Americans and Whites. Our findings do not discount the possibility of race-specific differences in the pathogenesis or pathophysiological characteristics of diabetes60-62 or the possibility of racial differences in the molecular etiology of diabetes, but they do seem to refute the position that there is an intractable diabetes excess among African Americans unexplainable by nongenetic risk factors. Curtailing rising trends in obesity and improving the economic conditions of disadvantaged groups in the United States may be the key to controlling diabetes across all racial groups.

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Lisa B. Signorello, ScD, David G. Schlundt, PhD, Sarah S. Cohen, MS, Mark D. Steinwandel, BBA, Maciej S. Buchowski, PhD, Joseph K. McLaughlin, PhD, Margaret K. Hargreaves, PhD, and William J. Blot, PhD

About the Authors

Lisa B. Signorello, Joseph K. McLaughlin, and William J. Blot are with the International Epidemiology Institute, Rockville, Md, and the Department of Medicine, Vanderbilt University, Nashville, Tenn, and the Vanderbilt-Ingram Cancer Center, Nashville. David G. Schlundt is with the Department of Psychology, Vanderbilt University, Nashville. Sarah S. Cohen and Mark D. Steinwandel are with the International Epidemiology Institute, Rockville, Md. Maciej S. Buchowski is with the Department of Medicine, Vanderbilt University, Nashville, and the Department of Family and Community Medicine, Meharry Medical College, Nashville. Margaret K. Hargreaves is with the Department of Internal Medicine, Meharry Medical College, Nashville.

Requests for reprints should be sent to Lisa B. Signorello, ScD, International Epidemiology Institute, 1455 Research Blvd, Suite 550, Rockville, MD 20850 (e-mail: lisa. [email protected]).

This article was accepted December 12, 2006.

Contributors

L. B. Signorello assisted with study design; supervised the field work, data collection, and data analysis activities; and led the writing. D. G. Schlundt assisted with study design, study activities, and analyses and participated in the writing. S. S. Cohen assisted with study activities, including supervision of field work, and led the statistical analysis. M. D. Steinwandel developed the computer-assisted personal interview; assisted with study activities, including supervision of field work; and assisted with the statistical analysis. M. S. Buchowski, J. K. McLaughlin, and M. K. Hargreaves assisted with the study design and study activities. W. J. Blot originated the study and oversaw all aspects of its implementation.

Acknowledgments

The Southern Community Cohort Study was supported by the National Cancer Institute (NCI; grant R01 CA92447). D. G. Schlundt, M. S. Buchowski, and M. K. Hargreaves received partial funding from the NCI (grants P60-DK20593, HL67715, and 5P20-MD000516, respectively).

Human Participant Protection

The Southern Community Cohort Study was approved by the institutional review boards of Vanderbilt University and Meharry Medical College. All participants provided written informed consent.

Copyright American Public Health Association Dec 2007

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

Magen BioSciences, Inc., a specialty dermatology company, today announced the appointment of Alexa Boer Kimball, M.D. MPH, Associate Professor Harvard Medical School, to its scientific advisory board (SAB).

“The addition of Dr. Kimball to our scientific advisory board is an important step in the growth of our company,” said Brian Gallagher, Ph.D., Magen’s president and chief executive officer. “As a researcher specializing in the design and execution of clinical trials, her extensive experience will greatly help Magen advance the company’s mission to identify and develop therapeutic treatments for several dermatological diseases. We are proud to add her to the already impressive roster of scientists who are members of the Magen scientific advisory board.”

Dr. Kimball is currently director of CURTIS, the joint Clinical Unit for Research Trials in Skin at Massachusetts General Hospital and Brigham and Women’s Hospital at Harvard Medical School in Boston. Dr. Kimball runs an active unit including phase 1 through phase 4 studies in diverse areas using topical and systemic agents for skin diseases. She has also done extensive research in the areas of physician workforce and quality of life.

A respected leader in skin research, Dr. Kimball received her medical degree from the Yale University School of Medicine in New Haven, Connecticut, after obtaining bachelor’s degrees in molecular biology and public and international affairs from Princeton University. Her postgraduate work included an internship at Beth Israel Hospital/Harvard University in Boston, Massachusetts, and residency in dermatology at the Stanford University School of Medicine in Stanford, California, where she also served as Chief Resident. Following her residency, Dr. Kimball went on to complete a clinical research fellowship in dermatology at the National Institutes of Health in Bethesda, Maryland, and she concurrently obtained an MPH with a focus on clinical trials from the Johns Hopkins School of Public Health.

Dr. Kimball also holds a number of major national appointments, including Chair of the Society for Investigative Dermatology’s Committee on External Relations and Chair of the Membership Committee for the American Academy of Dermatology.

About Magen BioSciences

Magen BioSciences was founded in 2006 by an outstanding group of scientists and investors to build a science-based dermatology company. The company is a research and development stage enterprise that acquires and develops novel and proprietary technologies and is headquartered in Waltham, Massachusetts.

FAIRFIELD, Calif., Dec. 3 /PRNewswire/ — With Sutter Regional Medical Foundation’s newly completed third building on Sutter Fairfield Medical Campus, community residents now have access to a full-range of state-of-the-art health care services in one convenient location.

The three-story, 69,000-square-foot care center, located at 2720 Low Court, replaces the 1234 Empire Street location, providing an enhanced environment and room for growth. Designed with comfort and healing in mind, the new care center houses:

   -- Family practice offices and an expanded laboratory on the first floor   -- Pediatrics, internal medicine, oncology, rheumatology and cardiology on      the second floor   -- Administrative offices and additional space for clinical growth on the      third floor     Services Are Steps Away  

Sutter Fairfield Medical Campus allows patients to care for all their health care needs in one place. One existing building houses the advanced Diagnostic Imaging Center and Ambulatory Surgery Center, and the other houses the After-Hours Care Clinic; surgical specialty offices; and newly constructed offices for obstetrics/gynecology, ophthalmology/optometry and urology. A covered walkway connects the new building to the existing imaging center, surgery center and surgical specialty offices.

“We designed this building with the needs of our patients, clinicians and staff in mind,” says Carolyn Appenzeller, R.N., chief operating officer at Sutter Regional Medical Foundation. “Patients will enjoy the upscale feel and spaciousness, as well as the natural light in the waiting area. They’ll also benefit from the enhanced flow, which will facilitate a higher level of communication among our personnel.”

Meeting Patient Demand

The new building will also give Sutter team members more room to care for patients. For example, cardiology will now have an additional treadmill room and more equipment to better meet the high patient demand for these services.

“Solano Regional Medical Group clinicians and their staff are excited about being able to enhance the services they provide to patients in beautiful, new surroundings,” says Appenzeller. “Based on the response we’ve had to the public display of the design boards, we know patients are excited about the new facility as well.”

For more information about Sutter Regional Medical Foundation’s care centers and medical services, please visit http://www.srmf.org/.

About Sutter Regional Medical Foundation

Sutter Regional Medical Foundation is a locally governed and managed affiliate of Sutter Health, a not-for-profit network of physicians and hospitals in Northern California. SRMF is affiliated with SRMG, Solano County’s largest multi-specialty physician practice that has served the community for more than 50 years. SRMF offers professional, high-quality and compassionate care from care centers in Vacaville, Vallejo, Fairfield, and Rio Vista, Calif., and is fully accredited by the Institute for Medical Quality.

Sutter Health is one of the nation’s leading not-for-profit networks of community-based health care clinicians, delivering high quality care to more than 100 Northern California communities. Sutter Health has relationships with more than 3,600 physicians and is the regional leader in infant deliveries, neonatology, orthopedics, and pediatric services. Sutter maintains medical foundation clinics in 11 Northern California counties.

Sutter Regional Medical Foundation

CONTACT: Russell Neilson of Sutter Regional Medical Foundation,+1-707-554-5123, [email protected]

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

RehabCare Group, Inc. (NYSE: RHB) and The Reading Hospital and Medical Center (The Reading Hospital) announced today a joint venture to develop the first long-term acute care hospital (LTACH) in Berks County, Pennsylvania. The 60-bed LTACH will be housed within a new post-acute facility being constructed in Spring Township, about five miles from The Reading Hospital’s main campus.

A groundbreaking ceremony for the new facility was held on Friday, November 30. (Photo available upon request)

The LTACH venture is a continuation of a nearly 10-year partnership between RehabCare and The Reading Hospital. Since 1998, RehabCare has managed the 44-bed acute rehabilitation unit (ARU) and 50-bed transitional care center at The Reading Hospital. The existing ARU will relocate to the new post-acute hospital, as will the outpatient rehabilitation clinic and diagnostic services necessary to support patient needs. A spring 2009 opening is anticipated.

“For more than 140 years, The Reading Hospital and Medical Center has had a reputation of advancing patient care, and we’re proud to join them in leading the way in bringing this new service to the community,” commented John H. Short, Ph.D., RehabCare President and CEO. “This project not only elevates our relationship with a valued partner, but is a complement to our other post-acute services in the area.”

RehabCare currently manages three nearby skilled nursing facility programs and an inpatient rehabilitation unit in addition to the two programs at The Reading Hospital.

Scott R. Wolfe, President and Chief Executive Officer at The Reading Hospital, said, “The development of an LTACH is further evidence of our commitment to extending our continuum of care for the Berks County community. Working with our trusted partner, RehabCare, we will offer the specialized services required by individuals whose complex health needs demand acute hospital care for greater than 25 days. The new post-acute facility also will enable us to expand the scope of services provided to individuals in need of acute rehabilitation.”

LTACHs provide specialized, around-the-clock care for extended stay patients with chronic or medically complex conditions, such as ventilator dependency, brain injury, cardiopulmonary disease, chronic pain and neuropathy. Patients are typically admitted to an LTACH following treatment in a traditional acute care hospital, and the average length of stay is 30 days.

Celebrating its 25th anniversary, RehabCare (www.rehabcare.com) is a leading national provider of physical rehabilitation services in conjunction with about 1,250 skilled nursing facilities and hospitals in 43 states and the District of Columbia. The Company also owns and/or operates 10 freestanding rehabilitation and long-term acute care hospitals.

The Reading Hospital and Medical Center is a not-for-profit healthcare center providing comprehensive acute care, post-acute rehabilitation, behavioral and occupational health services to Berks County and the surrounding area. Established as The Reading Dispensary in 1867, the hospital has since expanded to an 800-bed, 22-building complex, leading the region in tertiary care and perennially ranking among the top four Pennsylvania hospitals in patient admissions, surgical procedures, emergency care volume and outpatient services.

This press release contains forward-looking statements that are made pursuant to the safe harbor provisions of the Private Securities Litigation Reform Act of 1995. Forward-looking statements involve known and unknown risks and uncertainties that may cause our actual results in future periods to differ materially from forecasted results. These risks and uncertainties may include but are not limited to, our ability to consummate acquisitions and other partnering relationships at reasonable valuations; our ability to integrate acquisitions and partnering relationships within the expected timeframes and to achieve the revenue, cost savings and earnings levels from such acquisitions and relationships at or above the levels projected; our ability to comply with the terms of our borrowing agreements; changes in governmental reimbursement rates and other regulations or policies affecting reimbursement for the services provided by us to clients and/or patients; the operational, administrative and financial effect of our compliance with other governmental regulations and applicable licensing and certification requirements; our ability to attract new client relationships or to retain and grow existing client relationships through expansion of our service offerings and the development of alternative product offerings; the future financial results of any unconsolidated affiliates; our ability to attract and the additional costs of attracting and retaining administrative, operational and professional employees; shortages of qualified therapists and other healthcare personnel; significant increases in health, workers compensation and professional and general liability costs; litigation risks of our past and future business, including our ability to predict the ultimate costs and liabilities or the disruption of our operations; competitive and regulatory effects on pricing and margins; our ability to effectively respond to fluctuations in our census levels and number of patient visits; the adequacy and effectiveness of our information systems; natural disasters and other unexpected events which could severely damage or interrupt our systems and operations; changes in federal and state income tax laws and regulations, the effectiveness of our tax planning strategies and the sustainability of our tax positions; and general and economic conditions, including efforts by governmental reimbursement programs, insurers, healthcare providers and others to contain healthcare costs.

WAKE FOREST, N.C., Nov. 30 /PRNewswire/ — Digital Healthcare, a Wake Forest, NC company specializing in retinal risk assessment for diabetics, announced today that MacGregor Medical Center of San Antonio, Texas has selected the Retasure solution to provide retinal imaging risk assessment.

MacGregor Medical Center is a ten physician primary care practice offering a broad spectrum of primary care services, including preventative care, physicals and immunizations. The Center also provides special services for diabetic and hypertensive patients. The MacGregor physicians are committed to providing quality healthcare to improve patients’ quality of life. To advance their quality care efforts, the MacGregor physicians are implementing advanced technology tools, including electronic medical records and electronic prescription transmission.

“MacGregor physicians are known in their community to consider their patients’ welfare first,” said Scott Sanner, Senior Vice President, North American Operations of Digital Healthcare. “We are pleased that they understand the value of using the Retasure solution to provide patients greater access to eye assessments to fight against diabetic retinopathy and blindness.”

“Retinal scanning by the Retasure system will allow us to provide more comprehensive services to our many diabetic patients in one visit,” said Dennis Oliver, MD. “It will be especially valuable for those patients too busy in their everyday lives to get that needed eye exam or those who can little afford an extra co-pay for a specialist.”

The FDA-approved Retasure program provides a simple, affordable, and non-invasive solution that allows physicians to capture their patients’ retinal images during a three to five minute procedure. Images are transmitted over a secure, HIPPA compliant network to an accredited reading center. A state-licensed and board certified ophthalmologist reviews the images and results are returned to the original physician within 72 hours.

There are an estimated 21 million diabetic patients in the US, but only about half have any retinal assessments, despite a high risk of diabetic retinopathy. The National Eye Institute indicates diabetic retinopathy is the leading cause of blindness among working age American adults. More than a million patients around the world have received a retinal risk assessment using Digital Healthcare software.

About Digital Healthcare

Digital Healthcare is the global leader in retinal risk assessment. They are the world’s leading provider of care management programs for diabetic retinopathy. Their award-winning MS-HUG technology is used by leading hospitals and research centers including University Hospitals Case Medical Center at Case Western Reserve University, The Wilmer Eye Institute at The Johns Hopkins University and the United States Military. Digital Healthcare’s Retasure solution offers several advantages for primary care and endocrinologist physicians and their patients: It can be operated by non-clinicians; it is non-invasive and requires no dilation; it obtains exceptionally high-quality digital images of the retina using a simple-to-operate fundus camera; it returns results quickly to the ordering physicians; and it encourages patient compliance for retinal evaluation and comprehensive eye examinations.

Digital Healthcare

CONTACT: Bill Zaferos, +1-414-224-0210, for Digital Healthcare

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

By Kristin Rodine, The Idaho Statesman, Boise

Nov. 30–A photograph of a beaming little girl, playing on a swing, greets people who visit the Nampa Family Justice Center’s new forensic medical unit.

The girl, Ellen Marie Sinclair, was killed in August 2001, a few months before her third birthday. She represents the mission and the inspiration for the unit and those who work at the justice center, Executive Director Rebecca Lovelace said. On Friday, the medical unit will be dedicated in her memory.

“In her little life, she inspired so much,” Lovelace said.

Nampa Police Cpl. Angela Weekes, who investigated Sinclair’s murder, said the case inspired her to spearhead efforts to create the city-run justice center, which provides “wraparound services” to meet a wide range of domestic violence and abuse victims’ needs in one safe, welcoming environment.

Pete Sinclair, Ellen Marie’s father, plans to attend Friday’s dedication.

“I think it’s awesome,” he said Thursday evening. “It kind of gives my daughter a place in the community keeps her story alive.”

He noted the family justice center is “just about a block” from the house where his little girl was fatally injured.

The downtown Nampa building houses offices for most of the professionals that victims of abuse need — police officers, a prosecutor, legal aid, social workers, counselors and clergy. Now it will have nurses, a physician’s assistant and a medical facility to offer care and collect evidence in abuse and domestic violence cases.

“It’s a crucial piece for us — one more step we can cover without asking victims to go to another location, tell their story again,” Weekes said.

It’s especially appropriate to dedicate the medical unit to Sinclair, Weekes said, because “so much of her case was based on forensic medical findings.” Those findings helped convict Joshua Blue King, 27, of murdering the little girl while he was babysitting her in her Nampa home. King was sentenced in 2003 to 15 years to life in prison.

The forensic medical unit initially will have two major missions: examinations of adult sexual assault victims and physical exams of children entering foster care. Within a year, Lovelace said, it will have trained staff available to provide exams for children victimized by sexual abuse.

Since it opened two years ago, the Nampa Family Justice Center has served about 2,500 adults and children, Lovelace said. She said the center’s success has exceeded her expectations, largely because of strong support from city leaders and an all-for-one spirit among those who work there.

Many agencies partner to help people through the justice center, and Weekes said there is an amazing lack of conflict. Partners include the Idaho Department of Health and Welfare, Mercy Medical Center and Saltzer Medical Group.

“Everyone agrees: It’s all about the clients,” she said.

Kristin Rodine: 377-6447

—–

To see more of the Idaho Statesman, or to subscribe to the newspaper, go to http://www.idahostatesman.com

Copyright (c) 2007, The Idaho Statesman, Boise

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.

By Reid, Cecil

1. Aetiology The term macrocytosis is used to describe larger- than-normal red blood cells. Typically, a patient is said to have macrocytosis if their red blood cells have a mean corpuscular volume (MCV) greater than lOOfl (femtolitre, 1015 litres), as measured by an automated cell analyser. The reference range varies slightly between laboratories.

Macrocytosis can have a number of causes, some of which are benign. However, it may also indicate a serious underlying condition, such as myelodysplasia or leukaemia. It is important in primary care to identify which patients with macrocytosis require referral to a haematologist.

Benign macrocytosis

Macrocytosis without anaemia is often not of serious clinical significance. An elevated MCV is normal at birth and during the early newborn period. The size of the red blood cells then falls rapidly within the first few months of life and is replaced by the physiological microcytosis of childhood. Late pregnancy can also result in a transient mild elevation of MCV, usually under lOOfl.

Alcohol is a common cause of macrocytosis, even at comparatively low intake levels, and drug toxicity from treatments such as chemotherapy or antiretroviral therapy can also cause elevated MCV.

Macrocytic anaemia

Patients with macrocytic anaemia should always undergo further investigation to identify the underlying cause of the anaemia. It is sometimes caused by chronic illnesses including hypothyroidism and chronic liver disease. It can also occur in patients with haemolytic anaemia.

Deficiencies of folic acid or of vitamin B12 are the commonest causes of macrocytic anaemia, usually without neutropenia or thrombocytopenia. These deficiencies may simply be the result of poor diet, but they can also be the result of malabsorption. This may be specific, as in pernicious anaemia or more general as in coeliac disease.

Any malignant bone marrow infiltration can cause a macrocytic anaemia and multiple myeloma is not an uncommon cause. An intrinsic bone marrow disorder such as aplastic anaemia or leukaemia should be considered in any patient who has other cytopenias as well as macrocytic anaemia. The lab report should mention additional morphological changes.

A coloured light micrograph of a blood smear showing pernicious anaemia

2 Diagnosis

A full history and careful examination of patients with macrocytosis are needed to identify the underlying disorder.

A drug history must always be taken and alcohol intake assessed. Vitamin Bl2 and folate deficiency should be investigated.

Low folate may occur in diets deficient in fresh vegetables, and a low vitamin B,2 level can occur as the result of a vegan diet.

The presence of a smooth tongue (glossitis) suggests vitamin B12 deficiency. Diarrhoeal symptoms may indicate a malabsorption syndrome.

Laboratory tests

A number of laboratory tests should be carried out. Levels of folic acid can be measured either in serum or as red cell folate, the latter being a better measure of total body stores.

Other tests include vitamin B12 level, TSH to screen for hypothyroidism and liver function including liver enzymes.

Symptoms of numbness of the extremities,of paraesthesia or signs of subacute combined cord degeneration may indicate pernicious anaemia. An autoantibody screen can help in identifying pernicious anaemia. If the test is positive then an intrinsic factor antibody screen should be done to confirm the diagnosis.

However, although it is highly specific this test is only 60 per cent sensitive so a negative result does not rule out a diagnosis of pernicious anaemia. If no dietary cause for the anaemia is found, a Schilling test of vitamin B12 malabsorption should be requested, although this is not available in all laboratories.

Patients with low serum vitamin B12 level should not automatically be treated with a B12 replacement injection if dietary deficiency is the suspected cause.

Instead, they should receive oral cyanocobalamin 50\ig daily for two months followed by a repeat assay.

If the problem is a dietary deficiency, the level usually corrects to normal ruling out the need to test for malabsorption.

Referral

If the patient is anaemic but no folate or vitamin B12 deficiency is identified, immunoglobulin levels should be measured to test for myeloma.

Although myelodysplasia is very uncommon in younger patients, it is very important that these patients are identified since many will progress to acute leukaemia within a few months.

A urine specimen is needed to test for Bence Jones myeloma. Thrombocytopenia or neutropenia may indicate myelodysplasia, leukaemia or other bone marrow malignancy and these patients should be urgently referred to a haematologist.

3. Management

Very mild macrocytosis (MCV of 105fl or under) without anaemia or any other blood abnormality in an otherwise fit patient often does not require treatment.

In many patients a high alcohol intake is the cause of macrocytosis, while in a significant minority there is no apparent cause.

Vitamin supplements

Patients with folate and vitamin B12 deficiency due to poor diet can be treated with oral supplements and do not benefit from referral. Patients with pernicious anaemia confirmed by a positive intrinsic factor antibody screen can also be managed satisfactorily in the community.

Initial treatment is with 1 mg hydroxocobalamin by IM injection three times a week for two weeks followed by l,000mg injections at three month intervals for life.

Patients suspected of malabsorption should be screened for anti- endomysial antibodies and referred to a gastroenterologist for endoscopy and small bowel biopsy. Patients with vitamin B,2 deficiency and suspected malabsorption who do not test positive for pernicious anaemia in autoantibody screens should be referred to a haematologist and may require a Schilling test.

Blood transfusion

Blood transfusion remains the main treatment for myelodysplasia, although patients sometimes respond to erythropoietin treatment or to chemotherapy.

Contributed by Dr Cecil Reid, consultant haematologist at Northwick Park and St Mark’s Hospital NHS Trust, Harrow

Copyright Haymarket Business Publications Ltd. Nov 16, 2007

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

AUSTIN, Texas, Nov. 29 /PRNewswire/ — Girling Health Care and Harden Healthcare announced today that Harden Healthcare has acquired Girling Health Care, effective Thursday, November 29, 2007. Because the two companies are privately held and for competitive reasons, financial details have not been disclosed.

Girling Health Care was founded in Austin in 1967 by Bob and Bettie Girling and has home health operations in Florida, Illinois, New York, Oklahoma, Tennessee and Texas. The company also offers hospice services in Texas. Harden Healthcare, also headquartered in Austin, was founded in 2001 and consists of several companies that offer a post-acute continuum of care, primarily for seniors, including skilled nursing, assisted living, rehabilitation, hospice and home healthcare. With the baby boom generation aging, the market for home health services is expected to continue to be robust.

“Girling Health Care has enjoyed many years of success. As we look to the future, we are excited to join forces with Harden Healthcare, a company that has become a major force in providing excellent healthcare in Texas,” Dr. Bettie Girling, president and CEO of Girling Health Care, said. “Our two companies share very similar values and we are confident that our clients will continue to receive the same high level of care that they have come to expect from Girling.”

Dr. Girling continued, “Our family would like to thank the Austin medical community and the community at large for their support over these last forty years, and especially those who have let us come into their homes to provide care for them when they needed help. Leaving is hard, but we know our patients will continue to receive excellent care from Harden Healthcare.”

“Harden Healthcare is honored to partner with Girling Health Care. With 40 years of providing excellent service to their customers and referral sources, Girling represents the finest in the home health field,” Steve Hicks, chairman of Harden Healthcare and Capstar Partners, said. “We are excited about the future of the combined companies.”

Harden Healthcare acquired two home health companies, Auxi Health and American HomeCare, earlier this year. With the addition of Girling, all home health operations will operate under the Girling Health Care name. Lew Little, CEO of Harden Healthcare, will also serve as CEO of Girling Health Care. “This merger creates a win-win for our patients who will receive the same great patient care they have come to expect from Girling Health Care, with broader access to services through Harden Healthcare. Harden will focus its expansion in the central U.S. to provide a post-acute continuum of care for the elderly and infirmed,” Little said. “As a result, those patients will be able to utilize a range of services as their healthcare needs change.”

Auxi Health provides similar services to those offered by Girling, including continuous and intermittent nursing care, as well as physical therapy and home health aide services. Auxi Health is headquartered in Austin and includes operations in four states: Texas, Iowa, Missouri and West Virginia. American HomeCare is based in Missouri.

About Harden Healthcare

Headquartered in Austin, Texas, Harden Healthcare was founded in December, 2001, for the purpose of providing a complete continuum of care for seniors and others needing short- and long-term healthcare. The company, which offers a holistic approach to care, is comprised of several complementary subsidiaries including TRISUN Healthcare (skilled nursing and assisted living facilities), MBS Rehab, MBS Pharmacy (providing services to the long-term care industry), Lighthouse Hospice and Auxi Health. For more information, visit http://www.hardenhealthcare.com/.

About Girling Health Care

Girling Health Care provides a variety of home health, personal care and hospice services for clients in Florida, Illinois, New York, Oklahoma, Tennessee, and Texas. Services include skilled nursing, hospice, occupational therapy, medication management, and cardiac pulmonary care. Girling’s largest market is Texas, where it operates in more than 20 cities throughout the state. The family-owned company was founded in 1967 by Bob and Bettie Girling. For more information, visit http://www.girling.com/.

                                     Contact: Elizabeth Christian or Meg Meo,                            Elizabeth Christian & Associates Public Relations                                                                 512-472-9599  

Harden Healthcare

CONTACT: Elizabeth Christian or Meg Meo, both of Elizabeth Christian &Associates Public Relations, +1-512-472-9599, for Harden Healthcare

Web site: http://www.hardenhealthcare.com/http://www.girling.com/

By Chestovich, Paul J Schiller, Gary; Sasu, Sebastian; Hiatt, Jonathan R

We conducted a retrospective tumor registry review of a 36-year experience in a university center and identified 10 patients with duodenal lymphoma (five localized, five disseminated). Histologic types included diffuse large B-cell in four patients, mucosa- associated lymphoid tumor in three, and Hodgkin, follicular, and unclassified (one each). Treatments included chemotherapy in four patients, radiation therapy (RT) in two patients, Helicobacter pylori treatment in two, and observation in one. Five patients underwent operations (emergent in two, elective in three) for indications including massive bleeding in two patients, obstruction in two, or both in one. Survival for surgical group was 25 per cent at 1 year. One-year survival for nonsurgical group was 100 per cent, and all nonoperated patients lived at least 5 years, except for one who is alive 2 years after diagnosis. Surgical patients were younger and had more advanced lesions and less favorable cell types. When operation is required for bleeding or obstruction from secondary tumors in younger patients with disseminated disease, surgical challenges are formidable and survival is very limited. Tumors of less aggressive histology have far better prognosis. LYMPHOMAS ARE MALIGNANT transformations of normal lymphoid cells and are categorized histologically as Hodgkin and non-Hodgkin types. Epidemiological^, there are approximately 8000 cases of Hodgkin lymphoma and 60,000 cases of non-Hodgkin lymphoma diagnosed each year. Although the more common presentation is of a solid tumor of lymphoid tissues, lymphomas may arise in solid organs in as many as 25 per cent to 50 per cent of cases with incidence varying widely by geographic region.1 Extranodal lymphomas have a wide variety of clinical presentations, morphologies, and molecular compositions, making them challenging to diagnose and treat.2

The most common extranodal site is the gastrointestinal tract.1- 3-4 Gastrointestinal lymphomas make up approximately one-third to one-half of extranodal lymphomas, approximately 12 per cent to 13 per cent of all lymphomas, and approximately 1 per cent of all gastrointestinal neoplasms. The stomach is the most common site for lymphomas of the gastrointestinal tract, accounting for 50 per cent to 60 per cent of cases, small intestine 20 per cent to 30 per cent, and colon 10 per cent to 20 per cent.1,5 The duodenum is the least common site, making up only approximately 5 per cent of gastrointestinal lymphomas, and is rarely reported as a site of incidence separate from the small intestine.6 Two recent cases of duodenal lymphoma requiring operative therapy prompted us to review our institutional experience with this rare malignancy.

Methods

The University of California-Los Angeles Medical Center tumor registry was searched for all patients with a diagnosis of gastrointestinal lymphoma and then for the subset with lymphoma present in the duodenum. Charts of the latter group were reviewed to identify patient demographics, histopathology, method of diagnosis, treatment, complications, and outcomes. Pathologic slides of all specimens were reviewed to assign histologic diagnoses using current nomenclature.7 Details of operative therapy and outcome were analyzed in detail. The University of California-Los Angeles Institutional Review Board approved this research project.

Results

We identified 10 patients with gastrointestinal lymphoma in the duodenum (Table 1). Patients were seen between 1970 and 2006; average age was 51 years (range, 19-81 years), and five were male. Cell types included diffuse large B-cell lymphoma (DLBCL) in four patients, mucosa-associated lymphoid tumor (MALT) in three, and follicular, Hodgkin, and unclassified lymphoma in one each. Lymphomas were localized to the duodenum in five patients and disseminated in five.

TABLE 1. Duodenal Lymphoma in 10 Patients

Diagnosis of lymphoma was made by endoscopic biopsy in six patients, operative biopsy in three patients, and mediastinal biopsy in one patient. Treatments included surgery in five patients, chemotherapy in four, radiation therapy in two, antibiotics in two, and observation in one. Overall Kaplan-Meier survival was 67 per cent at 1 and 5 years and 22 per cent at 12 years.

Of the five patients who were treated nonoperatively, three were female, and average age was 70 years (range, 61-81 years). Histologic diagnoses were made by endoscopic biopsy in all patients and included MALT in three, follicular in one, and DLBCL in one. One patient had evidence of disseminated disease at diagnosis. Two patients received radiation therapy, two received chemotherapy, and two received triple therapy against Helicobacter pylori (proton pump inhibitor and combination antibiotic therapy). There were no known complications of the treatments received. The five patients have lived an average of 6 years after diagnosis (range, 2-12 years), and all are currently alive except for one who died of an unknown cause at 5 years.

Of the five patients who underwent operation, three were male, and average age was 33 years (range, 1962 years). Histologic diagnoses were made by operative biopsy in three patients, endoscopic biopsy in one, and mediastinal biopsy of disseminated disease in one. Diagnoses included DLBCL in three patients, classical Hodgkin (mixed cellularity type) in one patient, and unclassified lymphoma in one. Of the three patients with DLBCL, one had an anaplastic variant and another had a high proliferative index. Radiation therapy was used preoperatively in one patient and postoperatively in one; two patients received chemotherapy.

The operations were elective in three patients and emergent in two and included resections in three patients, oversewing of a bleeding vessel in one, and exploration only in one (Table 2). Four patients had evidence of disseminated disease outside of the duodenum at the time of operation. Postoperative complications occurred in four patients and included severe bleeding in three patients, sepsis in two, and biliary obstruction, deep venous thrombosis, and gastric outlet obstruction in one patient each. Three patients required reoperation, two for bleeding and one for gastric outlet obstruction. Three patients died in the early postoperative period, one is alive at 5 months, and one lived for 7 years before dying of recurrence. Causes of death included gastrointestinal bleeding in two patients and sepsis in one.

TABLE 2. Operative Therapy in Five Patients

Emergent operations for two recent patients with severe upper gastrointestinal bleeding were particularly challenging. The first patient had erosion of the gastroduodenal artery by a large ulcerated duodenal lymphoma. The bleeding was treated successfully with duodenotomy and oversewing of the bleeding vessel, but he required a gastrojejunostomy for gastric outlet obstruction 4 weeks later. The second patient was transferred to the University of California-Los Angeles with an ulcerated duodenal lymphoma and a large tumor mass encasing the celiac axis as well as metastatic spread in the mediastinum. Nonoperative management with angiographic embolization and chemotherapy was unsuccessful, and she required multiple operative attempts to control hemorrhage that also were unsuccessful. Bleeding and operative management were complicated substantially by pancytopenia secondary to her chemotherapy.

Patients treated with operative or nonoperative therapy are compared in Table 3. Patients who required operative therapy were younger and had higher grade and disseminated tumors as well as markedly diminished survival.

Discussion

Duodenal lymphomas are the least common variety of gastrointestinal lymphomas, which also are rare. The English- language literature includes over 150 patients, limited mainly to case reports. In 1961, Dawson and colleagues established criteria for differentiating primary and disseminated tumors as well as factors influencing prognosis.8 In 1984, Najem reviewed 95 cases of duodenal lymphoma, 27 with sufficient treatment and survival data for analysis, and found 2-year survival of 47 per cent.5 We have reviewed literature from 1970 to the present and identified 55 cases with sufficient data for comparison with our series.5-6-9-41

Duodenal lymphomas in our series included four specific histologic diagnoses (DLBCL, classical Hodgkin, MALT, follicular) and one unclassified lymphoma. More aggressive tumors such as DLBCL afflicted younger patients, were more likely to present with disseminated disease, and were more likely to require operative therapies. MALT and follicular lymphomas were seen in older patients, usually were primary tumors at presentation, and were treated successfully with radiation, chemotherapy, antibiotics, and even observation. Our most common type was DLBCL, which is considered the most prevalent cell type in gastrointestinal lymphoma.4 We did not observe the preponderance of follicular types in the duodenum reported by one institution.6

TABLE 3. Comparison of Patients Receiving Operative or Nonoperative Treatments

In the 55 cases reported on in the literature since 1970, histologic types included MALT in 14 patients, follicular/low-grade B-cell in 11, T/NK-cell in six, DLBCL/high-grade B-cell in five, and Burkitt and Hodgkin types in one each. There were also seven unclassified non-Hodgkin lymphomas and seven unclassified lymphomas, primarily from older case reports before advancements in cellular staining and gene rearrangements led to the classification of these tumors.7 Presenting symptoms included abdominal pain in 52 per cent, gastrointestinal bleeding in 29 per cent, weight loss in 27 per cent, nausea or vomiting in 19 per cent, jaundice in 19 per cent, and 17 per cent of patients were asymptomatic. Manifestations of gastrointestinal bleeding included anemia, hematemesis, or melena, whereas severe, life-threatening hemorrhage was uncommon. Multiple case reports describe jaundice from tumors arising in the region of the ampulla of Vater.10-18 Overall survival for reported cases was 79 per cent at 1 year. Survival for the lower grade tumors (follicular, MALT) was 100 per cent at 1 year for all patients, which emphasizes the more indolent nature of these neoplasms.19-29 Higher grade tumors such as DLBCL had lower survival,12-14-18-30-31 whereas T/NK-cell tumors, not observed in our series, accounted for the worst overall survival of 40 per cent at 1 year 15.16.32-34 Operations in our patients were required for significant tumor complications of bleeding or intestinal obstruction. The operations were complicated by technical challenges, recurrent bleeding, and postoperative sepsis. Survival was 25 per cent at 1 year compared with 100 per cent for patients who did not require operation. Nonoperative methods of hemostasis, including angiographic embolization and endoscopic coagulation, provided only temporary control of bleeding followed by recurrent severe hemorrhage.

Reported cases describe operative therapy in 62 per cent of patients since 1970 and are compared with our patients in Table 4. Indications for operation included bleeding, obstruction, resectable tumor, and jaundice from biliary obstruction. Although it is estimated that 30 per cent to 50 per cent of gastrointestinal lymphomas present with abdominal emergencies,4 only two patients (6%) with duodenal lymphoma required emergency procedures, both for severe gastrointestinal hemorrhage, and both were alive at 1 year.5- 9 The remainder of patients underwent elective or semielective procedures for less severe bleeding and partial obstructions and had overall 1-year survival of 86 per cent. Our patients were younger than those reported in the literature and tended to have more aggressive, high-grade, and disseminated tumors in contrast to reported cases with more favorable cell types and the presumed finding of resectable disease treatable by pancreaticoduodenectomv 5,6, 9,13,15,18,19,22,23,27-30, 32-40

Table 4. Surgical cases of Duodenal Lymphoma 1970 to the Present

Patients with lower grade tumors such as MALT and follicular fared better. Previous reports have recommended conservative treatments for these tumors.20-41

Of three patients in our series with MALT, one was treated with observation alone and is alive after 12 years. Two patients received antibiotic and proton pump inhibitor treatment for H. pylori and did well. One was subsequently treated with chemotherapy and is currently alive 4 years later; the other received radiation and is alive after 5 years. Treatment of H. pylori is well described for gastric lesions but only recently has been used for duodenal MALT.20- 21 Because there is documentation of MALT persistence after the eradication of H. pylori,24′ 28 as well as transformation into DLBCL,30 careful follow up is imperative. Treatment of the 14 patients with duodenal MALT in the literature included medical measures for H. pylori in five patients, chemotherapy in six, operations in six, and radiation in two. Reported survival for this group was 100 per cent at 1 year.19-29

Follicular lymphoma is a less aggressive B-cell tumor that may resolve spontaneously in up to onefourth of cases.42 Localized lesions are effectively treated using radiation therapy in combination with surgical resection.4 Disseminated disease requires chemotherapy, but resistance may develop and further treatment may be necessary for disease persistence. Rituximab, antiCD20 antibody, has shown effectiveness in treating recurrent or refractory follicular lymphoma.43 One patient in our series had Grade 1 follicular lymphoma treated with radiation and was alive 2 years after diagnosis. Of 11 reported follicular/lowgrade B-cell lymphomas, three underwent pancreaticoduodenectomy,6- 9-‘3 and four had duodenal resection6- 40, with all patients alive after 1 year.

In summary, duodenal lymphoma is an uncommon malignancy that may present with elective or emergent operative indications. Cell type, grade, and presence of disseminated disease are the principal determinants of therapy and prognosis. Bleeding from high-grade lesions requires early and aggressive operative therapy. Lower grade malignancies such as follicular lymphoma are effectively treated with surgery and radiation when localized. MALT is treated principally with medical measures to eradicate H. pylori and radiation or chemotherapy for persistent lesions.

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3. LeBrun DP, Kamel OW, Cleary ML, et al. Follicular lymphoma of the gastrointestinal tract. Am J Pathol 1992; 140: 1327-35.

4. Koniaris LG, Drugas G, Katzman PJ, Salloum R. Management of gastrointestinal lymphoma. J Am Coll Surg 2003; 197: 127-41.

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7. Harris NL, Jaffe ES, Diebold J, et al. Lymphoma classification- From controversy to consensus: The R.E.A.L. and WHO classification of lymphoid neoplasms. Ann Oncol 2000; 11 (suppl 1):3-10.

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17. Ugur H, Tacyildiz N, Yavuz G, et al. Obstructive jaundice: An unusual initial manifestation of intra-abdominal non-Hodgkin lymphoma in a child. Pediatr Hematol Oncol 2006;23:87-90.

18. Nagaraj N, Frank C, Gagliardi M, Adler DG. Smallintestinal B- cell lymphoma manifesting as pneumobilia secondary to involvement of the major duodenal papilla. Gastrointest Endosc 2006;63:326-7.

19. Wang H, Lin J, Chiu C, et al. Endoscopic features of mucosa- associated lymphoid tissue lymphoma of the duodenum. Gastrointest Endosc 1995;41:258-61.

20. Nagashima R, Takeda H, Maeda K, et al. Regression of duodenal mucosa-associated lymphoid tissue lymphoma after eradication of Helicobacter pylori. Gasteroenterology 1996;111: 1674-8.

21. Ventrucci M, Gherlinzoni F, Sabattini E, et al. Primary MALT- lymphoma of the papilla of Vater. Dig Dis Sci 1998;43: 214-6.

22. Ohtsuka T, Kodama K, Nishikata F, et al. Mucosaassociated lymphoid tissue lymphoma of the duodenum forming multiple polypoid lesions: Report of a case. Surg Today 1999;29: 557-9.

23. Toshima M, Aikawa K, Soga K, et al. Primary duodenal MALT lymphoma. Int Med 1999;38:957-61.

24. Kim JS, Jung HC, Shin KH, et al. Eradication of Helicobacter pylori did not lead to cure of duodenal mucosa-associated lymphoid tissue lymphoma. Scand J Gastroenterol 1999;34:215-8.

25. Lepicard A, Lamarque D, Levy M, et al. Duodenal mucosaassociated lymphoid tissue lymphoma: Treatment with oral cyclophosphamide. Am J Gastroenterol 2000;95:536-9.

26. Isomoto H, Kamihira S, Matsuo E, et al. A case of mucosaassociated lymphoid tissue lymphoma of the ampulla of Vater: Successful treatment with radiation therapy. Eur J Gastroenterol Hepatol 2O03;15:1037^1.

27. Frizelle FA, Hemmings CT, Whitehead MR, Spigelman AD. Familial adenomatous polyposis and duodenal lymphoma. Dis Colon Rectum 2003;46:1698-701.

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29. Patel VG, Eltayeb OM, Henderson VJ, et al. Primary duodenal low-grade mucosa-associated lymphoid tissue lymphoma presenting with outlet obstruction. Am Surg 2004;70:613-6.

30. Leone N, Brunello F, Baronio M, et al. High grade B-cell lymphoma arising in mucosa-associated lymphoid tissue of the duodenum. Eur J Gastroenterol Hepatol 2002;14:893-6.

31. Chim CS, Yuen WK, Loong F, et al. Primary large B-cell lymphoma of the ampulla of Vater. Haemotologica 2006;91: 18-20.

32. Kim YH, Song TJ, Ryu HS, Hyun JH. A case of primary T-cell lymphoma of the duodenum. Korean J Int Med 1991 ;6: 44-50. 33. Muchmore JH, Haddad CG, Goldwag S. Primary nonHodgkin lymphoma of the duodenum. Am Surg 1994;60:924-8.

34. Mizobuchi S, Yamashiro T, Ohmori Y, et al. Primary T-cell lymphoma of the duodenum: Report of a case. Surg Today 1999; 29:354- 7.

35. Balthazar EJ. Duodenal Hodgkin disease. Am J Gastroenterol 1977;68:306-11. Payson BA, Weingarten LA, Pollack J. Lymphosarcoma of

36. the duodenum associated with carcinoma of the lung. Am J Gastroenterol 1979;71:295-300.

37. Lillemoe K, Imbembo AL. Malignant neoplasms of the duodenum. Surg Gynecol Obstet 1980;150:822-6.

38. Grischkan D, Brown L, Mazansky H, et al. Localized duodenal lymphoma masquerading as duodenal ulcer. Can J Surg 1982;25:213-5.

39. Mondal A, Sen PK, Das RL. Primary non-Hodgkin lymphoma of duodenum. J Indian Med Assoc 1984;84:249-50.

40. Tanaka S, Onoue G, Fujimoto T, et al. A case of primary follicular lymphoma in the duodenum confined to the mucosal layer. J Clin Gastroenterol 2002;35:285-6.

41. Zhu L, Slee GR, Domenico DR, et al. B-cell lymphoma of ampulla of Vater: Observation for six years. Pancreas 1995:10: 208- 10.

42. Horning SJ, Rosenberg SA. The natural history of initially untreated low-grade non-Hodgkin lymphomas. N Engl J Med 1984;311:1471-5.

43. Leahy MF, Seymour JF, Hicks RJ, Turner JH. Multicenter phase II clinical study of iodine-131-rituximab radioimmunotherapy in relapsed or refractory indolent non-Hodgkin lymphoma. J Clin Oncol 2006;24:4418-25.

PAUL J. CHESTOVICH, M.D.,* GARY SCHILLER, M.D.,[dagger] SEBASTIAN SASU, M.D-[double dagger] JONATHAN R. HIATT, M.D.*

From the *Division of General Surgery, Department of Surgery, the [dagger] Division of Hematology-Oncology,

Department of Medicine, and the & Dagger;Department of Pathology and Laboratory Medicine, David Geffen School

of Medicine at UCLA, Los Angeles, California

Presented at the 18th Annual Scientific Meeting of the Southern California Chapter of the American College of Surgeons, Santa Barbara, California, January 19-21, 2007.

Address correspondence and reprint requests to Jonathan R. Hiatt, M.D., Room 72-160 CHS, UCLA Medical Center, 650 C.E. Young Drive, South, Box 956904, 72-160 CHS, Los Angeles, CA 90095-6904. E-mail: [email protected].

Copyright Southeastern Surgical Congress Oct 2007

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

By Chris Bowman, The Sacramento Bee, Calif.

Nov. 29–Air test results released Wednesday confirm that residents living near the Union Pacific Railroad yard in Roseville face a sharply higher cancer risk from locomotive exhaust than those living along nearby Interstate 80, a stretch traveled by an average 10,000 big rigs a day.

The spew from idling locomotives contains 5.5 times more of the most toxic particles than emissions from diesel-powered trucks on freeways, the study said.

“The diesel train stuff is much richer in the nastiest material,” said Thomas A. Cahill, a retired UC Davis professor of atmospheric physics.

The study recommended several ways to lower residents’ health risks. Paving the railyard would cut down toxic dust. Planting rows of tall trees along the edges of the yard would filter out a good portion of the exhaust particles, as would the installation of electrostatic air filters in homes.

The highly hazardous exhaust particles are polycyclic aromatic hydrocarbons, or PAHs, which California has classified as cancer-causing compounds. An extensive health study published last month found a strong link between bronchitis and elevated levels of these air pollutants among preschool children.

Cahill said he was alarmed to find airborne particles of benzo-a-pyrene — considered the most hazardous PAH compound — consistently measuring much smaller than those found in truck exhaust. The particles are small enough to reach the deepest recesses of the lungs, where they can cause the greatest harm.

“The lung captures these particles with extreme efficiency and retains them,” said Cahill, co-leader of the project with his son, Thomas M. Cahill, an assistant professor of environmental toxicology of Arizona State University.

The scientists traced the source of these compounds to burned engine oil, which is spewed from the stack as part of the locomotive exhaust.

“Now that we know where it comes from, we can talk seriously about mitigation,” Cahill said. “It opens up research into making an oil compound or changing the way you handle oil in a train.”

The samplers also found unexpectedly high levels of toxic metals such as lead. They said the metals likely came from the dirt surfaces of the train yard, where locomotives have been serviced for 100 years.

“The dust blown off the railyard is full of all sorts of stuff, even bomb debris from who-knows-what,” Cahill said.

On April 28, 1973, several 250-pound bombs bound for Vietnam exploded aboard a freight train in the railyard. Live bombs were found buried in the area as late as 1997.

The Cahills did the peer-reviewed air sampling and analysis earlier this year on behalf of the Sacramento area chapter of Breathe California, a clean-air advocacy group. The U.S. Environmental Protection Agency funded the project.

One of the reviewers, Ralph Propper, an air pollution researcher at the state Air Resources Board, said he was surprised by the findings.

“It’s a red flag that the PAHs that we know are the most potent components of diesel exhaust are elevated more than fivefold,” Propper said. “It makes you concerned that the overall toxicity of diesel is higher than you suspected.”

Cahill said his air measurements are consistent with findings from a 2004 air board computer analysis of the train yard exhausts. The study found locomotive exhaust extended about 100 square miles — encompassing most of Roseville, all of Citrus Heights and all of Antelope — and raising the cancer risk for an estimated 165,000 residents.

For example, living within 300 feet of the yard’s locomotive service and repair center boosts the cancer risk an average 950 chances in a million, the state analysis showed. By comparison, living within 300 feet of I-80 in Roseville increases the cancer risk 50 to 100 chances in a million, according to the air board study.

About 100 locomotives occupy the 780-acre yard at any given time, Union Pacific officials said in 2005. About one-quarter of those are part of trains passing through en route to Portland, Reno or Sacramento. Others stop to switch tracks, reassemble cars or crews, refuel or undergo inspection, repair or testing.

—–

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Copyright (c) 2007, The Sacramento Bee, Calif.

Distributed by McClatchy-Tribune Information Services.

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NYSE:UNP,

While some sex differences are still up for debate, one that’s hard to argue away is men’s greater fondness for pornography.

Over the years I’ve heard men explain this in various ways. One of the most popular is that men are “more visual” than women, a convenient excuse for ogling at the beach.

Is there any science behind this? “More visual” is too vague to investigate, but some studies have offered insight about why men consume most of the world’s vast store of Internet porn.

Neurobiologist and anthropologist Michael Platt of Duke University is studying differences in how the sexes respond to pictures in general. On average, his research shows, men will pay to see images of women. But you have to pay women to look at images of men!

Platt started with similar studies in monkeys. While most animals are indifferent to photos even of individuals in their own species, monkeys and apes respond to pictures much as humans do.

Rhesus macaques that Platt studied, for example, easily recognized the faces of familiar monkeys. And they liked some faces more than others, though the face wasn’t always the favorite part.

Platt found that male macaques strongly preferred to look at pictures of females’ rear ends and dominant males’ faces. They liked them enough to pay, by sacrificing a chance to get a treat. But you had to bribe those same monkeys with treats to persuade them to look at female macaque faces or the faces of subordinate males.

Female monkeys’ rear ends develop pink swellings around the time they ovulate – critical information that it makes sense male monkeys would be wired to detect, said Platt.

Those same males may also gather potentially lifesaving information by studying dominant males who could kill them if crossed. Platt is still waiting to do a reverse study – to see what catches the eye of female macaques.

Meanwhile, he’s applied the same technique to humans, male and female.

He used images of clothed people from www.hotornot.com, setting up the experiment so subjects had to pay a small amount of money to look at these images. Male subjects generally were more than willing. Not the females.

“For the most part, you had to pay females to look at any male pictures – even those where the guys were rated super hot,” Platt said.

Subjects were asked to rate the hotornot pictures, too. Males enjoyed the task; many wanted to keep going after the hour was up, Platt said. Female subjects, on the other hand, were begging to stop after 10 minutes.

I could relate to those women, but not because I don’t like looking at pictures. I just don’t care for pictures of strangers.

Another study, out of Emory University, more directly addressed the question of pornography and sex differences. Scientists put men and women under a brain-scanning machine known as functional MRI and then handed them some naked photos.

This time, both men and women reported being aroused by the pictures, which featured nude men, nude women, and heterosexual couples having sex. Participants’ brains showed activity in the visual cortex and a few other regions. The researchers found only one difference between the sexes – in men, the pictures caused more activation of a primitive region known as the amygdala. It’s an area we share with rats.

“Historically the amygdala has been seen as the center for fear and learning,” said Emory University psychologist Kim Wallen, one of the study’s authors. “More recently it appears the amygdala is involved in emotion.”

He speculates that men may find the sex pictures more emotionally salient than women do. So men and women may be equally visual, but men on average have different visual interests.

The researchers say these studies may eventually help pinpoint why some people with autism and other disorders don’t show an interest in gazing at other humans, naked or clothed. It may also help explain why, for some men, porn can go from a guilty pleasure to a destructive addiction.

It’s a losing battle for those trying to fight such addictions by ridding society of pornography. A better understanding of ourselves may go much further.

PHILADELPHIA, Nov. 28 /PRNewswire-USNewswire/ — Data from Phase II studies published today in the New England Journal of Medicine (NEJM) report that GlaxoSmithKline’s (GSK) investigational compound PROMACTA (TM) (eltrombopag) significantly raised platelet levels in patients with thrombocytopenia (low number of platelets in the bloodstream). The studies were conducted in chronic hepatitis C (HCV) (See Note 1)(where thrombocytopenia complicates disease treatment) and chronic idiopathic thrombocytopenic purpura (ITP) (See Note 2) (where thrombocytopenia increases the risk of bleeding and bruising). Elevating platelet counts in these settings can provide important patient benefits (See Notes 3, 4, 5). PROMACTA is an investigational oral, non-peptide platelet growth factor that induces the proliferation and differentiation of cells to produce platelets (See Notes 6, 7).

PROMACTA has not received regulatory approval in any market for any indication at this time.

“Thrombocytopenia significantly impacts the clinical progression and ability to successfully treat certain diseases, including chronic hepatitis C and chronic ITP,” said Paolo Paoletti, MD, Senior Vice President, Oncology Medicine Development Centre, GSK. “These two studies in the New England Journal of Medicine demonstrated that PROMACTA has the potential to raise platelet counts in these patient populations, which is a critical need to improve treatment. We are committed to the ongoing development of this compound by continuing to study it across several disease categories and work towards providing thrombocytopenia patients with the convenience of an oral therapy.”

Trial design – Phase II chronic hepatitis C-associated thrombocytopenia

The study was an international, multicenter, double-blind, randomized, placebo-controlled, dose-ranging Phase II trial. Seventy-four HCV-infected patients with platelet counts between 20,000 and 70,000/micoliter were randomized to receive PROMACTA (30mg, 50mg, or 75mg daily) or placebo for four weeks (pre-antiviral phase). The primary endpoint was a platelet count increase to >=100,000/micoliter at week four. Patients could then initiate antiviral therapy and continue PROMACTA or placebo for 12 additional weeks (antiviral phase).

Results – Phase II chronic hepatitis C-associated thrombocytopenia

After four weeks of treatment in chronic HCV patients, once-daily doses of PROMACTA at 30mg, 50mg and 75mg resulted in elevated platelet counts >=100,000/microliter in 75% (9/12), 79% (15/19) and 95% (20/21) of patients respectively compared to no platelet elevations >=100,000/microliter in patients receiving placebo (p<0.001). Treatment with PROMACTA enabled 71% (30mg dose) to 91% (75mg dose) of patients to initiate antiviral therapy. Up to 12 weeks of antiviral therapy were completed by 36% (5/14), 53% (10/19) and 65% (15/23) of patients in the 30mg, 50mg and 75mg PROMACTA groups, respectively, versus 6% in the placebo group. (See Note 1)

During the four-week pre-antiviral treatment phase, the most common drug-related adverse events (AEs) (generally of mild severity) were dry mouth, headache and nausea. Headache was the most common AE, reported in 36%, 16% and 17% of patients who received PROMACTA 30mg, 50mg and 75mg respectively, compared with 17% on placebo. In the antiviral treatment phase — which includes the addition of pegylated interferon alfa plus ribavirin — the most commonly reported AEs were flu-like illness (29%, 26% and 35% in the 30mg, 50mg and 75mg PROMACTA groups respectively), fatigue (29%, 26% and 22% in the 30mg, 50mg and 75mg PROMACTA groups respectively), chills (0%, 32% and 9% in the 30mg, 50mg and 75mg PROMACTA groups respectively) and headache (21%, 16% and 13% in the 30mg, 50mg and 75mg PROMACTA groups respectively). (See Note 1) The adverse events most commonly reported during this phase were influenza-like illness, fatigue, chills, and headache, all of which are known side effects of interferon-based therapy. The results have supported the initiation of Phase III studies in patients with thrombocytopenia and chronic HCV infection.

“These results published in the NEJM article will be welcomed by clinicians who are familiar with the complications of chronic hepatitis C treatment,” said John McHutchison, MD, Professor of Medicine and Associate Director, Duke Clinical Research Institute, Durham, North Carolina, US and lead author on this study. “Thrombocytopenia can seriously inhibit the optimal treatment of chronic hepatitis C — not only can it delay or prevent the administration of effective doses of antiviral therapy, but in some cases treatment may be terminated prematurely because of low platelet counts. In this study, PROMACTA, compared to placebo, increased platelet counts and enabled more patients to complete the first 12 weeks of antiviral therapy, giving them an opportunity to achieve sustained viral response, which is a critical goal in the treatment of these patients. We look forward to the results of the larger, Phase III clinical trials to confirm these initial observations in a larger patient population.”

Trial design – Phase II chronic ITP

The study was a multicenter, randomized, double-blind, placebo-controlled trial examining once daily oral dosing of PROMACTA. One hundred and eighteen adults with chronic ITP and platelet counts <30,000/microliter who had relapsed or were refractory to at least one ITP treatment were randomized to PROMACTA (30mg, 50mg, or 75 mg), or placebo. The primary endpoint was the proportion of patients with a platelet count >=50,000 per cubic millimeter after up to six weeks of dosing.(See Note 2)

Results – Phase II in chronic ITP

After six weeks of treatment in chronic ITP patients, PROMACTA at daily doses of 30mg, 50mg and 75mg elevated platelet counts to >=50,000/microliter in 28% (8/29), 70% (19/27) and 81% (21/26) of patients respectively compared to 11% (3/27) of patients receiving placebo (p<0.001). After seven days of treatment 44% and 62% of patients receiving PROMACTA 50mg and 75mg, respectively, achieved a platelet count of >=50,000/microliter. After 15 days, 88% and 81% of patients receiving PROMACTA 50mg and 75mg respectively had responded, with the average platelet counts approaching the normal range (i.e., 150-400,000/microliter). Platelet counts rose to >200,000/microliter in 4% (1/27) of placebo-treated patients and in 14% (4/29), 37% (10/27) and 50% (13/26) of PROMACTA 30mg, 50mg and 75mg-treated patients respectively. The incidence of bleeding events assessed by the World Health Organization bleeding scale was 17%, 7% and 4% in the PROMACTA 30mg, 50mg and 75mg arms respectively versus 14% in the placebo arm.(See Note 2)

PROMACTA was generally well tolerated in this study. The most common AE, mild-to-moderate headache, was observed at similar rates in both the PROMACTA 30mg (13%), 50mg (10%), 75mg (21%) and placebo (21%) arms. At least one AE was reported in 47%, 47% and 61% of patients in the PROMACTA 30mg, 50mg and 75mg groups respectively, compared with 59% in the placebo arm.(See Note 2)

Based on the results from this global study the authors concluded that PROMACTA shows promise as an efficacious short-term therapy with over 80% of PROMACTA treated patients achieving the trial’s primary endpoint to increase platelet counts to >= 50,000/microliter within two weeks.(See Note 2)

“Traditional treatments for ITP, such as glucocorticosteroids and intravenous immunoglobulins, focus on reducing platelet destruction,” said James B. Bussel, MD, director of the Platelet Disorders Center, Children’s Blood Foundation Division at New York-Presbyterian Hospital/Weill Cornell Medical Center and lead author for this study. “These treatments are associated with a high rate of relapse and may have undesirable side effects. The Phase II results published by NEJM suggest that PROMACTA may not only significantly raise platelet counts in most patients with ITP, but be well tolerated.”

Data from an open label extension study (EXTEND) assessing the long-term safety and efficacy of PROMACTA will also be presented at the forthcoming American Society of Hematology 49th Annual Meeting, December 8-11th in Atlanta, GA.

Ongoing PROMACTA Clinical Trials

There are several PROMACTA trials investigating long-term and repeated treatment of chronic ITP (See Note 8). EXTEND (Eltrombopag eXTENded Dosing Study) is an open-label study for patients who had participated in previous PROMACTA trials and were eligible to receive PROMACTA for the long-term treatment of their chronic ITP. RAISE (RAndomized placebo controlled ITP Study with Eltrombopag) is a global, randomized, double-blind, placebo-controlled Phase III trial currently assessing the safety, efficacy and tolerability of PROMACTA in a long-term treatment setting (up to six months) involving 189 patients across 135 centers in 26 countries. REPEAT (Repeat ExPosure to Eltrombopag in Adults with Idiopathic Thrombocytopenic Purpura) involves 50 patients with chronic ITP and will assess the safety and efficacy of repeated administration of PROMACTA. Both RAISE and REPEAT are closed to patient enrollment.

Two parallel trials investigating PROMACTA in the treatment of HCV-associated thrombocytopenia are currently open and enrolling. ENABLE 1 and 2 (Eltrombopag to INitiate and Maintain Alpha interferon Antiviral Treatment to Benefit Subjects with Hepatitis C related Liver DiseasE) are Phase III, parallel, multi-center, two-part studies assessing the ability of PROMACTA to raise platelet counts sufficiently to permit the initiation of antiviral therapy and to allow sustained antiviral therapy in patients with chronic HCV and thrombocytopenia.

For further information on the trials please visit http://www.itpstudy.com/ or http://www.clinicaltrials.gov/.

   To access the full manuscript please visit: http://www.nejm.org/.    About PROMACTA  

PROMACTA is an oral, non-peptide thrombopoietin receptor agonist that has been shown in pre-clinical research and clinical trials to stimulate the proliferation and differentiation of megakaryocytes, the bone marrow cells that give rise to blood platelets, and thus can be considered a platelet growth factor (See Note 9). The efficacy and safety profile will be further examined in ongoing clinical trials. PROMACTA was discovered as a result of research collaboration between GlaxoSmithKline and Ligand Pharmaceuticals. It is being developed by GlaxoSmithKline.

PROMACTA is an investigational compound that has not received regulatory approval in any market for any indication at this time.

About Chronic Idiopathic Thrombocytopenic Purpura

CONTACT: Jeff McLaughlin, +1-919-483-2839, or Mary Anne Rhyne,+1-919-483-2839, both of GlaxSmithKline

Web Site: http://www.clinicaltrials.gov/http://www.gsk.com/http://www.itpstudy.com/http://www.nejm.org/

BioAlliance Pharma has extended its ongoing acyclovir lauriad Phase III trial in the treatment of oral herpes to US. Ten clinical centers have been opened in the country and will join the 40 or so in Australia and Europe already participating in the trial, with a target of 640 patients.

The technology used in the trial, the Lauriad buccal muco-adhesive tablet, has already proved itself in the company’s Loramyc product. The healing time of herpes lesions after taking a single acyclovir Lauriad tablet will be compared with placebo. The company is planning to submit market authorization applications in the first half of 2009 in Europe and in the US, subject to additional regulatory requirements.

Furthermore, after successful completion of patient enrolment in the pivotal Phase III clinical trial performed with a view to registering Loramyc in the US, the company is continuing to open additional European centers for its Phase III doxorubicin Transdrug trial in primary liver cancer.

Dominique Costantini, president of the management board at BioAlliance Pharma, said: “With acyclovir lauriad in the US, our objective is to be able to access 60% of the potential market that the product represents.”

Capella Healthcare has signed a definitive agreement to purchase nine general acute care hospitals from Community Health Systems Inc., officials announced today.

Both companies are working on the regulatory approval processes and expect to close the transaction by first quarter 2008. Funding for the $315 million deal will come from a combination of equity capital from Capella’s partner GTCR Golder Rauner and debt financing led by Citigroup Global Markets Inc., Banc of America Securities LLC and Merrill Lynch Capital. Merrill Lynch acted as M&A advisor to Capella on this transaction.

“This is a banner day for the Capella team, in that this transaction represents significant growth for our company and our hospitals,” said Daniel S. Slipkovich, Chief Executive Officer of Capella. “CHS is known for running clinically strong, operationally sound community hospitals. We are excited about the opportunity to share our expertise and our resources with these facilities to build on their strong track records.”

Founded in 2005, Capella presently owns and operates five thriving hospitals across the nation. During its time of ownership, Capella has invested millions of dollars in improving and expanding its family of hospitals.

Combined, the nine hospitals being acquired by Capella have 1,070 beds and employ nearly 4,000 people. They include:

Willamette Valley Medical Center in McMinnville, Ore., an 80-bed hospital accredited by The Joint Commission that is located 40 miles southwest of Portland;

Saint Mary’s Regional Medical Center in Russellville, Ark., a 170-bed facility accredited by The Joint Commission that has served the Arkansas River Valley since 1925;

National Park Medical Center in Hot Springs, Ark., a 166-bed facility accredited by The Joint Commission that serves five counties in Central Arkansas;

Mineral Area Regional Medical Center in Farmington, Mo., a 135-bed facility accredited by the American Osteopathic Association and located 80 miles south of St. Louis;

White County Community Hospital in Sparta, Tenn., a 60-bed facility accredited by The Joint Commission that is located 60 miles east of Nashville;

Parkway Medical Center in Decatur, Ala., a 120-bed hospital accredited by The Joint Commission that is located approximately 35 minutes west of Huntsville;

Woodland Medical Center in Cullman, Ala., a 100-bed hospital accredited by The Joint Commission that is located 45 minutes from both Huntsville and Birmingham;

Hartselle Medical Center in Hartselle, Ala., a 150-bed facility accredited by The Joint Commission that is located 45 minutes southwest of Huntsville; and

Jacksonville Medical Center in Jacksonville, Ala., an 89-bed facility accredited by The Joint Commission that is located 80 miles east of Birmingham.

Four of the nine hospitals — Jacksonville Medical, St. Mary’s, National Park and Willamette Valley — were previously owned by Triad Hospitals Inc. Community Health Systems completed its acquisition of Triad in July.

“Capella is focused on providing quality care by helping hospitals reach their full potential and meet the healthcare needs of their communities,” said Tom Anderson, President and co-founder of Capella. “We are looking forward to working with the employees, medical staffs and boards of these hospitals to best serve their patients.”

About Capella Healthcare

Based in Franklin, Tenn., Capella Healthcare partners with communities to build strong local healthcare systems that are known for quality patient care. Capella’s senior leadership team has more than 200 years of combined experience managing over 200 hospitals. With the financial backing of GTCR Golder Rauner, the company has access to significant resources for the expansion and improvement of its hospitals and the services they provide. Capella operates five thriving hospitals across the nation. For more information, please visit www.capellahealth.com.

NEW YORK, Nov.27 /PRNewswire-USNewswire/ — Steven M. Safyer, MD, has been appointed President and Chief Executive Officer of Montefiore Medical Center, the University Hospital for the Albert Einstein College of Medicine (AECOM). The appointment was announced today by David A. Tanner, chairman of Montefiore’s Board of Trustees. An accomplished physician leader and highly respected healthcare executive, Dr. Safyer, 58, succeeds retiring President Spencer Foreman, MD, to the top medical center post effective January 7, 2008.

(Photo: http://www.newscom.com/cgi-bin/prnh/20071127/DC08231)

Throughout his 25-year career at Montefiore, Dr. Safyer has held increasingly senior leadership positions. As senior vice president and chief medical officer since 1998, he has directed all clinical operations of Montefiore’s integrated delivery system and provided oversight of the faculty, academic programs and clinical information systems. Dr. Safyer is a professor of medicine and professor of epidemiology and population health at AECOM.

“After a rigorous, eight-month, national search, the Search Committee determined that Dr. Safyer is the best person to lead Montefiore into the future, particularly because he has played such a key role in making Montefiore the successful, innovative health system it is today,” said Tanner. “Steve Safyer is the right person at the right time for Montefiore. He has proven himself to be an extraordinary leader with the experience, vision and drive for excellence needed in these challenging times for healthcare providers.”

“I am honored by the opportunity to lead an institution known for its innovation in medicine and health services,” said Dr. Safyer. “I look forward to working with my colleagues at Montefiore, AECOM and with our local healthcare partners. Together, we will advance a coordinated, comprehensive agenda to transform the health of this region and create a national model for healthcare reform.

“A more integrated, strategic alignment with AECOM will exponentially strengthen our commitment to being the best in academics and both translational and clinical research,” said Dr. Safyer. “Montefiore will become a hospital of choice for patients seeking excellence and innovation in specialty care and will achieve national recognition as a top tier academic medical center.”

“I am delighted with Steve Safyer’s appointment to the presidency,” said Spencer Foreman, MD, a healthcare industry statesman who is retiring after nearly 22 years as Montefiore president. “Steve is thoroughly familiar with every important institutional issue, and he has the maturity, judgment and experience to lead Montefiore to new levels of achievement. I wish him the very best and pledge my assistance in any way I can be of help.”

“Steve Safyer is the ideal choice, given his deep knowledge of the institution and his passionate commitment to its social mission. I am confident we can work together to develop a more effective partnership between Montefiore and the Albert Einstein College of Medicine, to bring both institutions to new heights of excellence,” said Allen M. Spiegel, MD, The Marilyn and Stanley M. Katz Dean, Albert Einstein College of Medicine.

“Steve Safyer is an immensely talented leader whose passion and intelligence are matched only by his experience,” said Kenneth E. Raske, president, Greater New York Hospital Association. “Having known and worked with Dr. Safyer for more than 20 years, I can say with certainty that Montefiore is moving forward in extremely capable hands.”

“Dr. Safyer is an instrumental part of Montefiore’s success and we look forward to working with him for universal healthcare,” said Dennis Rivera, chairman, SEIU Healthcare. “We are fortunate to have worked side by side with our inspiring friend Dr. Foreman and his team and we know we will enjoy a continued partnership with Montefiore under Dr. Safyer’ s leadership.”

“The appointment of Dr. Safyer represents a commitment to a Labor Management Partnership that is a model for the nation,” said George Gresham, president of local 1199 SEIU United Healthcare Workers East. “Dr. Safyer has played a critical role in fostering an atmosphere of respect and collegiality that recognizes the significant contribution our members make to Montefiore’s excellence. We look forward to working with him.”

Dr. Safyer received his Bachelor of Science degree from Cornell University and his medical degree from the Albert Einstein College of Medicine. He is Einsteinboard-certified in internal medicine and is a fellow of the New York Academy of Medicine. the Albert Einstein College of MedicineIn 2006, Dr. Safyer was named founding chairman of the Bronx Regional Health Information Organization, an independent not-for-profit community-based organization formed to build a technology-based regional health information exchange.

Dr. Safyer has been an appointed member of numerous panels and committees for regional and national organizations including the Hospital Association of New York State, The Greater New York Hospital Association and the Association of American Medical Colleges. He has been a long-standing advocate for underserved populations, including those incarcerated and affected by substance use, HIV infection and tuberculosis.

Dr. Safyer is married to Paula Marcus, MD, and they have two daughters.

Montefiore Medical Center, the University Hospital for the Albert Einstein College of Medicine, encompasses 125 years of innovative medical “firsts,” pioneering clinical research, dedicated community service and ground-breaking social activism.

A full-service, integrated delivery system caring for patients in the New York metropolitan region and beyond, Montefiore is a 1,122-bed medical center that includes three hospitals: the Henry and Lucy Moses Division, the Jack D. Weiler Division and The Children’s Hospital at Montefiore; a large home healthcare agency; the largest school health program in the US; and a 21-site medical group practice integrated throughout the Bronx and Westchester. Montefiore also comprises two wholly-owned subsidiaries: CMO, The Care Management Company, a care management organization providing services to 179,000 health plan members, and Emerging Health Information Technology.

The medical center is ranked by the prestigious Leapfrog Group among the top one percent of all U.S. hospitals based on its strategic investments in sophisticated and integrated healthcare technology.

Montefiore’s distinguished centers of excellence include cardiology and cardiac surgery, cancer care, tissue and organ transplantation, children’s health, women’s health, surgery and the surgical subspecialties. Montefiore is a national leader in the treatment of diabetes, headaches, obesity, cough and sleep disorders, geriatrics and geriatric psychiatry, neurology and neurosurgery, adolescent and family medicine, HIV/AIDS and social and environmental medicine, among many other specialties. For more information, please visit http://www.montefiore.org/ and http://www.montekids.org/.

Photo: http://www.newscom.com/cgi-bin/prnh/20071127/DC08231http://photoarchive.ap.org/PRN Photo Desk, [email protected]

Montefiore Medical Center

CONTACT: Pamela Adkins, [email protected], or Steve Osborne,[email protected],+1-718-920-4011, both of Montefiore Public Relations

Web Site: http://www.montefiore.org/http://www.montekids.org/

CIGNA (NYSE:CI) announced today that it has signed a definitive agreement to acquire Great-West Healthcare, the Healthcare Division of Great-West Life & Annuity, Inc. Under the terms of the agreement, CIGNA will pay approximately $1.5 billion in cash to Great-West Life & Annuity and to fund approximately $400 million of additional capital to support the acquired business. The transaction, subject to required regulatory approvals and customary closing conditions, is expected to close during the first half of 2008.

Headquartered in metro Denver, Colorado, Great-West Healthcare has 3,750 employees and currently serves 2.2 million covered lives, including approximately 1.5 million medical members in its employer segments. Great-West Healthcare’s national health care network consists of some 4,275 hospitals and more than 575,000 physicians and ancillary providers.

“Great-West Healthcare will be a significant addition to CIGNA. Great-West Healthcare’s talented team of employees has built the company’s reputation for strong service and innovation, and we look forward to welcoming them to CIGNA,” said H. Edward Hanway, CIGNA chairman and chief executive officer. “Great-West Healthcare’s capabilities clearly complement our own. This transaction will broaden our distribution reach and provider network in key geographic areas of the country, particularly the Western regions of the United States, and expand the range of health benefits and products we offer employers and their employees.”

Hanway noted that Great-West Healthcare’s competitively differentiated offerings appeal to employer groups of all sizes, and have been particularly well received by small to mid-sized businesses seeking the financial flexibility afforded by a variety of funding options. “This acquisition aligns very well with our strategy by enhancing our competitiveness in the middle market segment and expanding our participation and offerings in the small business segment.”

The acquisition is inclusive of Great-West Healthcare’s full portfolio of health and group insurance offerings and the supporting information technology infrastructure. Great-West Healthcare’s products include traditional managed care PPO, POS, HMO and Open Access plans, as well as consumer-driven health care products such as HRAs and HSAs, and are offered in association with a range of flexible funding options. Great-West Healthcare’s offerings will be added to the CIGNA portfolio to complement its current range of health benefits and related specialty products and services, expanding the choices it offers, particularly to small to mid-sized employers.

“CIGNA’s acquisition of Great-West Healthcare combines complementary strengths in products and expertise, and will build on the strong provider relationships that are important to both organizations,” said Rick Rivers, executive vice president of Great-West Healthcare. “Our customers and members will gain access to additional CIGNA resources and value-added services and programs. CIGNA intends to build on Great-West Healthcare’s competitively differentiated offerings to expand its operations and create near-term and long-term growth opportunities.”

CIGNA anticipates the acquisition to be accretive to its full year 2008 earnings per share outlook of $4.00 to $4.20 per share. The transaction is expected to be accretive to earnings in 2009 and beyond by achieving synergies related to managing medical costs, capturing operating expense synergies and growing membership over time.

Management will hold a conference call for analysts and investors to discuss this acquisition and provide additional details regarding financial expectations on Tuesday, November 27, 2007 beginning at 8:30 a.m. EST. The call – in numbers for the conference call are as follows:

Live Call

(888) 599-4858 (Domestic)

(913) 312-0945 (International)

 

Replay

(888) 203-1112 (Domestic replay)

(719) 457-0820 (International replay)

 

Passcode: 6674830

A replay of the call will be available from 11:30 a.m. EST on Tuesday, November 27 until 11:59 p.m. EST on Tuesday, December 11. Additionally, the conference call can be accessed on a live Internet web cast by clicking https://cis.premconf.com/sc/scw.dll/usr?cid=vlllrznwdwzvmddcr

Banc of America Securities LLC is acting as exclusive financial advisor and Skadden, Arps, Slate, Meagher & Flom LLP is acting as legal counsel to CIGNA in the transaction.

About CIGNA

CIGNA Corporation and its subsidiaries constitute one of the largest investor owned health and related benefits organizations in the United States. CIGNA (NYSE:CI) provides employers with benefits, expertise and services that improve the health, well-being and productivity of their employees. With approximately 47 million covered lives in the United States and around the world, CIGNA’s operating subsidiaries offer a full portfolio of medical, dental, behavioral health, pharmacy and vision care benefits and group life, accident and disability insurance. Web site: http://www.cigna.com/.

About Great-West Healthcare

Great-West Healthcare, is the healthcare division of Great-West Life & Annuity Inc.,, a Denver, Colorado-based, indirect, wholly owned subsidiary of Great-West Lifeco Inc. and a member of the Power Financial Corporation group of companies.

CAUTIONARY STATEMENT FOR PURPOSES OF THE “SAFE HARBOR” PROVISIONS OF THE PRIVATE SECURITIES LITIGATION REFORM ACT OF 1995

CIGNA and its representatives may from time to time make written and oral forward-looking statements, including statements contained in press releases, in CIGNA’s filings with the Securities and Exchange Commission, in its reports to shareholders and in meetings with analysts and investors. Forward-looking statements may contain information about financial prospects, economic conditions, trends, and other uncertainties. These forward-looking statements are based on management’s beliefs and assumptions and on information available to management at the time the statements are or were made. Forward-looking statements include but are not limited to the information concerning possible or assumed future business strategies, financing plans, competitive position, potential growth opportunities, potential operating performance improvements, trends and, in particular, CIGNA’s productivity initiatives, litigation and other legal matters, operational improvement in the health care operations, and the outlook for CIGNA’s full year 2007 and 2008 results. Forward-looking statements include all statements that are not historical facts and can be identified by the use of forward-looking terminology such as the words “believe”, “expect”, “plan”, “intend”, “anticipate”, “estimate”, “predict”, “potential”, “may”, “should”, or similar expressions.

You should not place undue reliance on these forward-looking statements. CIGNA cautions that actual results could differ materially from those that management expects, depending on the outcome of certain factors. Some factors that could cause actual results to differ materially from the forward-looking statements include:

1. increased medical costs that are higher than anticipated in establishing premium rates in CIGNA’s health care operations, including increased use and costs of medical services;

2. increased medical, administrative, technology or other costs resulting from new legislative and regulatory requirements imposed on CIGNA’s employee benefits businesses;

3. challenges and risks associated with implementing operational improvement initiatives and strategic actions in the health care operations, including those related to: (i) offering products that meet emerging market needs, (ii) strengthening underwriting and pricing effectiveness, (iii) strengthening medical cost and medical membership results, (iv) delivering quality member and provider service using effective technology solutions, and (v) lowering administrative costs;

4. risks associated with pending and potential state and federal class action lawsuits, purported securities class action lawsuits, disputes regarding reinsurance arrangements, other litigation and regulatory actions challenging CIGNA’s businesses and the outcome of pending government proceedings and federal tax audits;

5. heightened competition, particularly price competition, which could reduce product margins and constrain growth in CIGNA’s businesses, primarily the health care business;

6. significant changes in interest rates;

7. downgrades in the financial strength ratings of CIGNA’s insurance subsidiaries, which could, among other things, adversely affect new sales and retention of current business;

8. limitations on the ability of CIGNA’s insurance subsidiaries to dividend capital to the parent company as a result of downgrades in the subsidiaries’ financial strength ratings, changes in statutory reserve or capital requirements or other financial constraints;

9. inability of the program adopted by CIGNA to substantially reduce equity market risks for reinsurance contracts that guarantee minimum death benefits under certain variable annuities (including possible market difficulties in entering into appropriate futures contracts and in matching such contracts to the underlying equity risk);

10. adjustments to the reserve assumptions (including lapse, partial surrender, mortality, interest rates and volatility) used in estimating CIGNA’s liabilities for reinsurance contracts covering guaranteed minimum death benefits under certain variable annuities;

11. adjustments to the assumptions (including annuity election rates and reinsurance recoverables) used in estimating CIGNA’s assets and liabilities for reinsurance contracts covering guaranteed minimum income benefits under certain variable annuities;

12. significant stock market declines, which could, among other things, result in increased pension expenses of CIGNA’s pension plans in future periods and the recognition of additional pension obligations;

13. unfavorable claims experience related to workers’ compensation and personal accident exposures of the run-off reinsurance business, including losses attributable to the inability to recover claims from retrocessionaires;

14. significant deterioration in economic conditions, which could have an adverse effect on CIGNA’s operations and investments;

15. changes in public policy and in the political environment, which could affect state and federal law, including legislative and regulatory proposals related to health care issues, which could increase cost and affect the market for CIGNA’s health care products and services; and amendments to income tax laws, which could affect the taxation of employer provided benefits, and pension legislation, which could increase pension cost;

16. potential public health epidemics and bio-terrorist activity, which could, among other things, cause CIGNA’s covered medical and disability expenses, pharmacy costs and mortality experience to rise significantly, and cause operational disruption, depending on the severity of the event and number of individuals affected;

17. risks associated with security or interruption of information systems, which could, among other things, cause operational disruption;

18. challenges and risks associated with the successful management of CIGNA’s outsourcing projects or key vendors, including the agreement with IBM for provision of technology infrastructure and related services;

19. the ability of the CIGNA and Great-West to satisfy conditions to the closing of the transaction described in this release, including obtaining required regulatory approvals;

20. the ability to successfully integrate and operate the businesses being acquired from Great-West by, among other things, renewing insurance and administrative services contracts on competitive terms, retaining and growing membership, realizing revenue, expense and other synergies, successfully leveraging the information technology platform of the acquired businesses, and retaining key personnel;

21. the ability of CIGNA to execute its growth plans by successfully leveraging its capabilities and those of the business being acquired from Great-West to further enhance the combined organization’s network access position, underwriting effectiveness, delivery of quality member and provider service and increased penetration of its membership base with differentiated product offerings; and

22. any adverse affect to the CIGNA’s business or the business being acquired from Great-West due to uncertainty relating to the transaction described in this release.

This list of important factors is not intended to be exhaustive. Other sections of our most recent Annual Report on Form 10-K, including the “Risk Factors” section, the Cautionary Statement in Management’s Discussion and Analysis of Financial Condition and Results of Operations, our Forms 10-Q for the quarters ended March 31, 2007, June 30, 2007, and September 30, 2007, and other documents filed with the Securities and Exchange Commission include both expanded discussion of these factors and additional risk factors and uncertainties that could preclude CIGNA from realizing the forward-looking statements. CIGNA does not assume any obligation to update any forward-looking statements, whether as a result of new information, future events or otherwise, except as required by law.

Planet Nutrition Holdings, Inc. (PINKSHEETS: PNHL) welcomes highly acclaimed professional bodybuilder, fitness guru, personal trainer, and nutrition expert Johnny Stewart to work with Planet Nutrition. Stewart is using Planet Nutrition products to supplement his “Spartan”-like training discipline. Johnny is helping Planet Nutrition upgrade its already cutting edge product line. Not only does Stewart use Planet Nutrition supplements, the athletes he trains also use the products.

Stewart’s personal achievements include being a successful bodybuilding competitor for the past 25 years, winning six national championships such as winning the Team Universe Championships twice, Lightweight Mr. USA, etc. His accomplishments in the Pro division including placing second in the 2003 Mr. Olympia Masters and recently placing second in the 2006 IFBB Masters Pro World.

Stewart has been coaching several professional and national level figures and bodybuilding competitors for over 15 years. His resume also includes certifications in both Personal Training and Nutrition. He also owns and operates several Stewart Fitness Personal Training Studios throughout Charlotte, North Carolina and the surrounding area. Professional male bodybuilder includes Guy Ducasse, professional female bodybuilders include Anotonia Norman and Kim Perez and female figure competitors include Simona Douglas, Tammy Leady and Sonya Bruce. National level competitors include Darren Glenn (#1 Middleweight Bodybuilding Competitor), Perry McCrae (current Mr. USA Welterweight Champion), Heidi Bagwell, Pam Shealy, Tracei Tucker and Eric Powell, just to name a few.

Stewart’s goal is to train and develop the next tier of pro athletes by using his 25 years of experience in bodybuilding and the “Nutritional World.” Johnny prides himself by staying knowledgeable of cutting edge nutritional supplementation. By doing so, he is able to safely guide and nurture the growth of each individual athlete. Stewart is able to help them achieve their goals in the sport by providing individualized exercise, nutritional programs and supplementation.

“As a trainer, I live by three things of importance and they are: Your health, your success, and my reputation and I don’t compromise any of these.” — Johnny Stewart

Dan Starczewski, President and CEO of Planet Nutrition, stated, “Johnny Stewart is not only a highly acclaimed professional bodybuilder, fitness guru, personal trainer and nutrition expert, he is a quality individual who will help make Planet Nutrition’s already cutting edge products even better. Like Johnny, we want to be the leaders of innovation in our industry.”

About Planet Nutrition Holdings, Inc.

Planet Nutrition Holdings, Inc. has been in business since 1999 and is a retailer of nutritional products and programs in the diet and nutrition industry. By offering a superior product line, employing innovative marketing techniques and developing strategic partnerships with manufacturers and distributors, the company will maintain an uncompromising commitment to quality while ensuring the best value to our customers.

SAFE HARBOR: Statements in this press release other than statements of historical fact, including statements regarding the company’s plans, beliefs and estimates as to projections are “forward-looking statements.” Such statements are subject to certain risks and uncertainties, including factors listed from time to time in the company’s SEC filings, and actual results could differ materially from expected results. These forward-looking statements represent the Company’s judgment as of the date of this release. The Company does not undertake to update, revise or correct any forward-looking statements.

 Contact: M & M Investor Relations Domenic Martinez 866-508-2092  

SOURCE: Planet Nutrition Holdings, Inc.

By Shelley Shelton, The Arizona Daily Star, Tucson

Nov. 25–They work the mall corridors like carnival barkers, beckoning shoppers with visions of relaxation — a few minutes away from the hustle and bustle of daily life.

Employees of Oriental Chi’s three Tucson-area mall locations seem to speak limited English, but they know enough to ask, “How long?” when a prospect approaches.

As in, how long do you want your body worked on?

The company is careful not to use the word “massage” anywhere in its literature, saying instead they practice only Asian forms of “energy work” that don’t constitute massage. As varieties of “bodywork” have proliferated, practices such as Oriental Chi say they are fitting into loopholes in a recent state law that requires licenses of massage therapists and governs their practices.

“We are not doing exactly massage,” said Steven Chen, owner of Oriental Chi.

Rather, his employees engage in shiatsu and qigong energy relaxation work, he said. And that doesn’t require a license.

It’s a loophole Chen has tried to operate in for the five years or so that he’s had businesses here. He also has locations in California and Colorado — two states that have no licensing requirements.

Some massage therapists and regulators say even businesses such as Oriental Chi are covered by the law, and that they should be licensed to protect customers as well as the profession.

“They should be shut down immediately,” said Tucson massage therapist Denise Caywood. “They’re just skirting the law, and they could be hurting people.”

State board formed 4 years ago

Four years ago, the five-member Arizona State Board of Massage Therapy formed to begin regulating the massage therapists in the state. The board’s main function is to issue and renew licenses and to monitor the activity of the state’s 8,700 licensees, said Robert Wilson, deputy director of the board.

Licensing ensures that practitioners have passed a background check and that they know to ask about physical limitations — such as pregnancy, a heart condition or recent cancer treatment — that might affect how a person should be touched, Wilson said.

Licensed therapists in Arizona are required to have 500 hours — in January it goes up to 700 hours — of training and 25 hours of continuing education every two years.

“The more training you have, the safer you are, and the more you can do for somebody,” he said.

The initial license costs $189, and renewals are $75 every two years. Continuing education is a separate cost.

No wonder, then, that some licensed massage therapists bristle at the appearance of unlicensed competition. When Caywood saw Oriental Chi employees herding people onto massage chairs and tables at Park Place mall, with no questions asked, she approached and asked to see the employees’ Arizona massage licenses.

Arizona state law requires massage therapists to display their licenses in a place that is accessible to public view at each location where that therapist practices massage.

“He said, ‘We don’t need a license,’ ” Caywood said. “I said, ‘Oh, yes you do. You’re putting your hands on people.’ “

Arizona massage licensing law makes an exception for working on fully clothed customers who are only receiving energy work. But while clients remain fully clothed throughout the experience at Oriental Chi, the employees undeniably compress and stretch the body, which falls under the state definition of massage.

Practices have multiplied

As body-work practices have diversified, they’ve also multiplied, raising the issue of how to enforce the state’s massage laws.

As of August, there were 14,615 spas in the United States, according to the International Spa Association. That’s up from 13,757 the previous August, at which time about 23 percent were in the Southwest — Arizona, California, Nevada, Utah, Colorado and New Mexico. There has been 48 percent growth in spa locations since 2003, most of them offering varieties of bodywork.

In addition to traditional massage therapies, an entire category of “energy” therapies has cropped up, blurring the distinctions about what constitutes a massage. Shiatsu and Reiki are probably the best known of these, and there’s also “healing touch” — which requires no touching at all.

Such growth has created potential loopholes for practitioners who could end up rubbing people the wrong way.

The Arizona State Board of Massage Therapy deals with 20 to 30 “major cases” each year — situations where the board has to make a decision about someone’s license status, board deputy director Wilson said.

Practicing massage without a license is a misdemeanor, but the board doesn’t have anyone who is certified to make arrests. And it can’t revoke the licenses of unlicensed people.

The board relies heavily on assistance from local jurisdictions, Wilson said. But they’ve found the definitions bewildering, too.

“There seems to be confusion on the part of the police as to what is massage and what is energy work,” he said.

Where to draw line is tough call

Even the local massage community disagrees on where to draw the line between massage and energy work, partly because most types of massage affect a person’s energy as well.

Kathy Rinn, owner of The Right Touch, has had her own massage clinic for 24 years and practices Asian forms of bodywork, employing licensed massage therapists. But after hearing a description of Oriental Chi’s practices, she had no problem with them.

“What he’s doing is legitimate, and there are no state requirements that says he has to have a license. As long as he doesn’t use the terms ‘massage therapy’ or ‘massage’ anywhere in his advertising, he’s not breaking the rules. He’s done his homework.”

But the massage therapy board says otherwise.

“If they’re rubbing you, they’re doing massage therapy. It may be energy work as well, but it is massage therapy and requires a license,” Wilson said.

Chen said that before he hires his employees, he requires them to have 500 hours of training at a school for Oriental bodywork. He also requires them to have continuing education.

“I have a certain educational background. I believe education is the key. They have to get good training all the time,” he said.

Because all his workers are Chinese, he said, there is a substantial language barrier to getting them certified here, which would ultimately lay to rest all doubts about their qualifications.

That doesn’t wash with Caywood, who has spent much of the past year exchanging e-mails with the massage board, the governor’s office, the Tucson mayor’s office and the Tucson Police Department.

“Why even make all these rules if they’re not going to make everybody follow them?” she said.

Find more consumer news and the latest local business news at www.AzStarBiz.com.

State statutes govern licensure

What state law says about massage-therapist licensure

Arizona Revised Statutes 32-4201, section five:

“Massage therapy” means the following that are undertaken to increase wellness, relaxation, stress reduction, pain relief and postural improvement or provide general or specific therapeutic benefits:

(a) The manual application of compression, stretch, vibration or mobilization of the organs and tissues beneath the dermis, including the components of the musculoskeletal system, peripheral vessels of the circulatory system and fascia, when applied primarily to parts of the body other than the hands, feet and head.

(b) The manual application of compression, stretch, vibration or mobilization using the forearms, elbows, knees or feet or handheld mechanical or electrical devices.

(c) Any combination of range of motion, directed, assisted or passive movements of the joints.

(d) Hydrotherapy, including the therapeutic applications of water, heat, cold, wraps, essential oils, skin brushing, salt glows and similar applications of products to the skin.

Arizona Revised Statutes 32-4221 lists several exemptions to whom needs a massage license, including sections five and six which both mention exemptions having to do with whether someone is fully clothed. These sections are vague enough that some are able to cite them as reasons not to get a massage license:

5. When the customer is fully clothed, the practice of movement educators, such as dance therapists or teachers, yoga teachers, personal trainers, martial arts instructors and movement repatterning practitioners.

6. When the customer is fully clothed, the practice of techniques that are specifically intended to affect the human energy field.

Arizona Revised Statutes 32-4255 says anyone practicing massage without a license is committing a Class 1 misdemeanor.

Oriental Chi’s Southern Arizona locations

Foothills Mall, 7401 N. La Cholla Blvd.

Park Place, 5870 E. Broadway

Tucson Mall, 4500 N. Oracle Road

The Mall at Sierra Vista, 2200 El Mercado Loop, Sierra Vista

many professions require state licensing

Dozens of professions require licensing in Arizona. Find a complete list online at www.revenue.state.az.us/609/licensingguide.htm. Here is a sampling:

–Acupuncturist

–Barber

–Chiropractor

–Cosmetologist

–Funeral director and embalmer

–Homeopathic medical examiner

–Massage therapist

–Naturopathic physician

–Hearing aid dispenser

–Private investigator

–Contact reporter Shelley Shelton at 434-4086 or [email protected].

—–

To see more of The Arizona Daily Star, or to subscribe to the newspaper, go to http://www.azstarnet.com.

Copyright (c) 2007, The Arizona Daily Star, Tucson

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.

By VALERIE HILL

YAWNING can kill you, as poor Ben Shire, 34, nearly discovered when he was making tea to try to keep himself awake. He strained his jaw so badly that he dislocated it, then collapsed unable to breathe or swallow and started choking on his own saliva. His terrified wife Sam dialled 999 and paramedics got him to hospital with his jaw locked, which took four hours to reset.

What a terrific achievement for this well-trained emergency crew to arrive so swiftly that they saved his life by stabilising his horrendous accident. It really makes you proud of our ambulance services.

(c) 2007 Daily Post; Liverpool. Provided by ProQuest Information and Learning. All rights Reserved.

By MARY JO LAYTON and BOB GROVES, STAFF WRITERS

Jessica Costeniuc, 14, sat stoically as six stitches were removed from her hand Wednesday. It was the nurses who cried. They wept and hugged over the closing of Pascack Valley Hospital.

The 48-year-old community hospital that tended to countless heart patients, expectant moms and banged-up kids shut down at 3 p.m.

As workers placed black plastic over the “Emergency” sign in the rear of the Westwood hospital, Sue and Mary Rice, longtime employees, shook their heads and filmed the final chapter on their cellphones.

“We’re losing everything,” said Sue Rice, a nursing assistant who hasn’t yet found a job. “This stinks.”

The emergency department, the last service available, resembled the set for the farewell episode of the TV series “M*A*S*H.” Nurses and physicians who once worked shoulder to shoulder over critical patients shared a last sandwich. Doctors popped a bottle of champagne at 2:52 p.m. and toasted decades of stellar work. A veteran nurse departed the hospital with a miniature Christmas tree full of ornaments. “These are my balls,” she said. “I’m taking them with me.”

Then the crowd of 30 or so did what they had to do: retreat to Burke’s Restaurant on Old Hook Road, the familiar haunt where a stiff drink had soothed the tensions of so many hellish shifts.

“People are melancholy here,” said Dr. Steven Schreiber, who has worked at the hospital since 1989. “It’s a family here.”

“It’s very sad,” said Rosemary Schmitt, a medical technologist who had worked at Pascack for 33 years. Her husband, an intensive care nurse, had been on staff for 37 years.

The 280-bed hospital filed for bankruptcy Sept. 24, overwhelmed by more than $100 million in debt. It had employed 1,000 and, this year, delivered 1,000 newborns, admitted nearly 6,000 patients and operated on an additional 5,600 in its same-day surgery center.

Several suitors are expected to bid on the 20-acre property, including Hackensack University Medical Center along with Touro College. A urologist who owns several surgical centers, and commercial and residential developers, are also interested.

Bids are expected in U.S. Bankruptcy Court by early January, but it is unclear if the property will remain a hospital.

The state Health Planning Board, which heard dozens of residents testify Tuesday night in favor of keeping the hospital open, is scheduled to meet in December. The board will make a recommendation to state Health Commissioner Fred Jacobs on whether a hospital should remain in the area.

The last patient to spent the night at Pascack Valley was discharged on Sunday, said John Corcoran, vice president and spokesman.

On Wednesday, the only patients in the emergency room included the 14-year-old Dumont girl, a 28-year-old man with a minor hand injury and 22-year-old Danielle Cartaxo, the daughter of emergency room physician Kenneth Cartaxo. Danielle Cartaxo, the last patient, was treated for a knee injury.

Throughout the day, longtime patients like Betty Brinkerhoff came into the hospital to collect medical records. Most talked about how the hospital had saved their lives.

“I just want to cry,” said the 74-year-old Old Tappan resident, leaning on a cane with her X-rays tucked under her arm. “It’s like a wake. I hope they’ll be able to open again. We need this hospital so badly.”

While medical equipment will remain intact pending the sale of the property, other items were collected just hours before the hospital was shuttered.

The Rev. Thomas J. Norton, a Catholic priest who worked as a chaplain for 21 years at the hospital, emerged with a box of chalices and other religious items.

He questioned the management decisions that led to the closure of the hospital, including the building of a four-story addition with luxury maternity suites when the hospital was already in debt a target of universal wrath on Wednesday.

“Someday somebody will have to answer,” he said. “They haven’t yet. They haven’t said ‘I’m sorry.’ “

At 3 p.m., Pascack Valley Hospital’s ambulance crews turned over their duties over to the Westwood Volunteer Ambulance squad. Hackensack University Medical Center took over operations of Pascack Valley Hospital’s Mobile Intensive Care Unit. Hackensack spent $3.6 million for the unit, which accompanies ambulances to the scene of life-threatening illnesses or injuries.

Hackensack and other local hospitals reported an increase in patient volume since the hospital began phasing out services in the last three weeks.

Englewood Hospital and Medical Center has opened a transition unit to allow less seriously injured patients to receive expedited treatment. That will free up the emergency department for critically injured patients, spokeswoman Maria Margiotta said.

Meanwhile, the union representing 400 nurses and technicians said 30 to 40 percent of its membership is still searching for jobs. Employees will be paid through Nov. 30, said Shirley Terwilliger, president of the local Health Professionals and Allied Employees.

About 100 Pascack Valley doctors have joined Englewood hospital’s staff, as well as an additional 60 employees, Margiotta said.

But many employees fear the jobs they’ll find won’t pay as well or will be part time or per diem positions. One employee is commuting to Asbury Park for work. A radiation oncology technician is commuting hours more each week to work in New Brunswick.

Terwilliger has taken a part-time job at The Valley Hospital in Ridgewood. It pays less but includes health insurance. Bearing scars on her neck from recent surgery on her carotid artery, she said many others are just as frantic to have health insurance. Terwilliger is also a sole breadwinner.

“It’s a hard time to be out there,” she said.

Despite several news reports of the scheduled closing, public notices and chatter in surrounding towns, not everyone was prepared for the 3 p.m. closing.

A half hour after the hospital officially shut its doors, Fran Verdigi of Northvale came to collect her medical records.

“I was cooking,” she said. “I completely forgot about it.”

***

E-mail: [email protected]

***

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

By Bridget Scrimenti, The Sun, Lowell, Mass.

Nov. 23–Dr. Ingrid Balcomb is an obstetrician and gynecologist at Emerson Hospital in Concord. She has delivered 8,000 to 10,000 babies during the past 30 years. She was trained in Nova Scotia and came to Emerson in 1994, and she has chaired the OB/GYN department for the past five years. Balcomb, 57, says she doesn’t plan on retiring anytime soon. She loves obstetrics, and she can’t imagine not delivering babies. “It’s wonderful — I always have new patients, and to them it’s such a marvel that they see the birthing process,” Balcomb said. “Even if (childbirth) ever became routine for us, their excitement and marvel is contagious.”

Q: What should every expecting mother know that they don’t?

A: For moms expecting their second baby, I refer to the second pregnancy as the “more” pregnancy. Everything is more exaggerated. Mothers are more crampy, have more Braxton-Hicks contractions, and have more pelvic pressure. I tell all my patients that.

Q: What’s the funniest thing that’s happened when delivering a baby?

A: Amazingly

enough, it was when I was delivering the twins (in the photo). I delivered the first baby, and both the nurse and I heard a snap which sounded like either the collar bone of the baby or the tailbone of the mother, which was alarming. I was checking out the mother, and when I went to turn around to get an instrument to break her water, I realized what had happened. My bra snapped open. I whispered to the nurse and we both started laughing. We had to confess to the parents. The poor mother and father were wondering what’s so funny about this delivery.

Q: Have you ever had a dad pass out?

A: Unfortunately numerous times. The worst was when a dad who had been studying for exams literally passed out cold. He had to be on a stretcher with an IV. This was in Canada where we had delivery in a separate room. He laid next to his wife while she was in labor. We used to believe the dad’s when they say they’re fine, but now we make sure they’ve had something to eat and drink.

Q: What’s the most unusual gift you’ve received?

A: You usually get flowers, cards, and candy, but one patient brought in two beautiful gift bags with puppy treats. I have two shar pei’s.

Q: What’s your advice for new parents?

A: Take advantage of whatever help is offered to you, and don’t try to do it all at once. Be patient, because the first 6 to 12 weeks are the hardest, but after that it gets easier. The baby sleeps better and you’re more climatized to the change in your life. It’s hard to go from being pregnant to being a mom, and all the demands that go with it — physically and emotionally.

Q: Have you ever delivered a baby outside the hospital?

A: It was in a car in the parking lot of the hospital in Canada. I had to jump in the back of the car and do the delivery. The mother came back two years later and delivered in the elevator.

Q: What are the most unique baby names you’ve seen?

A: The one name I’ll never forget is Blue Mountain. It was a young couple with the last name Mountain, and they named him Blue.

Q: Have you ever had a baby named after you?

A: I’m happy to say there are two little Ingrid’s running around the Concord area. One of the couple’s really like the name, and the other couple had a Scandinavian background. My mother blessed me with an unusual name, but it took 20 years of my career before someone named their baby after me.

Q: What should people know about OB/GYNs that they don’t?

A: I think most people aren’t aware that OB/GYNs are actually surgeons. We perform the baby’s circumcision, (a woman’s) hysterectomy, as well as, deliver the baby and c-sections. An OB/GYN developed laparoscopic surgery. It’s a minimally invasive surgery where you go through the belly button and perform tiny incisions. We’re also menopausal experts. We get women from newborn through their whole life, and get to look after female health needs.

Q: Was it hard to be a patient when pregnant?

A: I’m the mother of two girls, and it was difficult to be a patient. I delivered in a small community hospital that didn’t have epidurals, so I was afraid one of my own patients would hear me in labor. My daughter is pregnant and due in two weeks. I think its harder for me to go through her pregnancy as a mom.

—–

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

Copyright (c) 2007, The Sun, Lowell, Mass.

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.

By Damush, Teresa M Plue, Laurie; Bakas, Tamilyn; Schmid, Arlene; Williams, Linda S

Physical activity after stroke may prevent disability and stroke recurrence; yet, physical impairments may inhibit post-stroke exercise and subsequently limit recovery. The goal of this study was to elicit barriers to and facilitators of exercise after stroke. We conducted three focus groups and achieved content saturation from 13 stroke survivors-eight men and five women-85% of whom were African American and 15% White, with a mean age of 59 years. We coded and analyzed the transcripts from the focus groups for common themes. Participants across groups reported three barriers (physical impairments from stroke, lack of motivation, and environmental factors) and three facilitators (motivation, social support, and planned activities to fill empty schedule) to exercise after stroke. Exercise activity can provide a purpose and structure to a stroke survivor’s daily schedule, which may be interrupted after stroke. In addition, receiving social support from peers and providers, as well as offering stroke-specific exercise programming, may enhance physical activity of stroke survivors including those with disabilities. We intend to incorporate these findings into a post- stroke self-management exercise program. KEY WORDS

exercise

rehabilitation

self-care

social support

Stroke is a high-volume medical condition. Stroke affects 700,000 people each year in the United States, of which 200,000 are recurrent episodes (American Heart Association, 2005). Stroke is the third leading cause of death, produces the greatest number of hospitalizations for neurological disease (Wolf et al., 1999), and is the leading cause of adult neurological, long-term disability in the United States (American Heart Association, 2005; Wolf et al., 1999). Up to 50% of stroke survivors still have some functional disability within 6 months of an ischemic stroke event (Dombovy, Basford, Whisnant, & Bergstralh, 1987). Moreover, patients who have had a stroke or a transient ischemic attack (TLA) are at risk for recurrent stroke (Hartley, 2004; Wolf et al., 1999) and death (Lai, Alter, Friday, & Sobel, 1994). More than 12% of stroke survivors will experience another stroke within a year (Lai et al.; Wolf et al.).

Managing stroke risk is often a goal of post-stroke care. Modifiable stroke risk factors include the following: atrial fibrillation, carotid artery disease, diabetes mellitus, diet, excessive alcohol consumption, high blood cholesterol, hypertension, obesity, physical inactivity, and tobacco use (Wolf et al., 1999). Most are effectively managed through a combination of life-style modifications and medication (American Stroke Association, 2007; Kenner & Kelley, 2005).

Although modifiable and effective at reducing the risk of stroke and other vascular events, most patients with stroke or TIA lack adequate stroke risk management control (Hajjar & Kotchen, 2003; Qureshi, Suri, Guterman, & Hopkins, 2001; Toole et al., 2004). In a recent randomized trial of high-dose folate vitamin therapy in patients with recent stroke, stroke survivors in the trial continued lifestyle practices that elevated their stroke risk (i.e., cigarette smoking, obesity, high blood pressure) (Toole et al.). Despite the knowledge of risk reduction, providers have not aggressively counseled or promoted behavioral practices for stroke prevention in the general population (Hanley,2004).

Promoting exercise, a strategy used to lower risk for recurrent stroke (Fonarow, 2003), is often considered for stroke patients through rehabilitation and may improve functional ability (Macko et al., 2001; Weiss, Suzuki, Bean, & Fielding, 2000). However, stroke impairments may hinder exercise participation (Gordon et al., 2004). Moreover, after clinical rehabilitation is completed, exercise participation may wane. Little is known about exercise barriers and facilitators among stroke survivors.

Currently, we are aware of no systematic behavior modification program for stroke survivors to promote exercise as a self- management strategy to reduce stroke risk factors. Therefore, the purpose of this qualitative study was to elicit barriers and facilitators of exercise after stroke to inform the development of a post-stroke risk factor program.

We used the chronic care model (CCM) (Wagner, Austin, & Von Korff, 1996) as a framework to guide our inquiry of barriers and facilitators involving community resources used, the experience of the healthcare system for stroke care, patient self-management, and the delivery of care by providers. The CCM was developed in an effort to improve chronic illness management in primary care practice (Hedrick et al., 2003). This conceptual model has been widely used across diseases including depression (Damush et al., 2003), diabetes care and heart failure (Lin et al., 2000), and most recently in implementation research projects (e.g., Mental Health QUERI depression collaborative care models and influenza vaccination rates) (Evans, Legro, Weaver, & Goldstein, 2003; Glasgow et al., 2002).

The CCM posits that chronic care is provided over two entities: (1) community resources and (2) the healthcare system that provides the structure, goals, and values for the provider organization. Community resources are effective programs that fill in gaps of needed services (e.g., public awareness of stroke). The healthcare system encompasses the organization structure that supports improvement strategies and organizational change (e.g., the Veterans Health Administration [VHA]). Within these two entities are four components that support chronic care: (1) self-management support, (2) delivery system design, (3) decision support, and (4) clinical information systems. These components are interdependent and cultivate informed, activated patients practicing stroke risk factor management behaviors collaborating with prepared, proactive providers who initiate and counsel stroke risk factor management, resulting in improved patient functioning and health-related quality of life. Given that decision support and clinical information systems are provider tools, we did not query patients on these components. The focus group contents emphasized the self-management support component of the chronic care model.

Within the CCM model, exercise promotion is a salient part of patient self-management component. We reviewed barriers and facilitators of exercise participation within a social-cognitive theoretical framework for promoting self-management Randomized controlled trials designed to increase physical activity among older adults, the age group of most stroke survivors, have often shown positive results with the incorporation of social-cognitive-theory principles (Conn, Minor, Burks, Rantz, & Pomeroy, 2003; King, 2001). Social-cognitive theory principles include personal, social, and environmental factors (Bandura, 1986).

Personal correlates, demographic and health variables, have been related to physical activity. Being a woman, overweight, or a smoker; older age (Conn et al., 2003); and having less education were factors associated with physical inactivity (Clark, 1996; King, 2001; Sternfeld, Ainsworth, & Quesenberry, 1999). Perceived poor health was another factor related to physical inactivity in older adults (Clark, 1999; Damush, Stump, Saporito, & Clark, 2001).

Among social factors, social support has been shown to correlate with physical activity in general populations (Sallis, Grossman, Pinski, Patterson, & Nader, 1987) and older adults (Orsega-Smith, Payne, & Godbey, 2003). In a recent self-report survey study of African American and rural older women, family support for physical activity was correlated with greater physical activity participation (Wilcox, Bopp, Oberrecht, Kammermann, & McElmurray, 2003). Other positive sources of social support studied among older adults were physician recommendations for physical activity (Damush, Stewart, Mills, King, & Ritter, 1999) and home-exercise support programs (Tudor-Locke et al., 2000).

Environmental factors of physical activity have recently received attention (Sallis, Kraft, & Linton, 2002). Program-related factors have not been rigorously studied as a product or service. One program factor, however, home versus group-based physical activity, has been studied. Older adults, on average, tend to prefer home- based activity with some instruction (Brownson et al., 1999) and are more likely to adhere to exercise in a home-based exercise program (King, Haskell, Taylor, Kraemer, & DeBusk, 1991). It is unknown whether older adults with chronic disease prefer professional, supervised instruction or home-based physical activity.

In another study, more them two thirds reported health symptoms (e.g., pain, fear of chest pain, and shortness of breath) and environmental reasons (e.g., weather, fear of crime) as barriers to physical activity participation among a stratified random sample of older, low-income, primary-care patients with diabetes (Clark, 1999). Most recently, Tu, Stump, Damush, and Clark (2004) found that objective measures of weather and sociodemographics of the neighborhood were barriers to adherence to a structured group- exercise program in the community.

Given that health perceptions, environmental factors, and bodily pain are barriers to older adult physical activity, and social support is a facilitator of exercise, the purpose of this study was to explore personal, social, and environmental motivators and barriers within the components of the chronic care model for stroke survivors to engage in exercise after experiencing a stroke to inform the development of a post-stroke risk factor program. Methods

This study used focus groups (Morgan, 1993) to elicit perceived exercise barriers and facilitators of exercise among stroke survivors to inform a stroke survivor program, as the authors had previously done for patients with low back pain (Damush et al., 2002). The local Institutional Review Board at Indiana University, Indianapolis, approved the study, and we obtained written, informed consent prior to data collection. Adults who had experienced a diagnosed stroke or TIA and received care at a local community, county or Veterans Administration (VA) hospital during the past year were invited to participate in a focus group by mail. Interested persons returned our letter in a postage-paid envelope, indicating their willingness to participate. A research assistant scheduled the groups at one facility based on availability of the participants. Prior to the group commencements, but after signing informed consent, participants completed a brief demographic questionnaire. A formally trained program coordinator moderated the groups, and the co-investigators served as note takers. Each focus group lasted 2 hours in duration and was audiotaped and transcribed to ensure accuracy of the data.

Focus Group Guide

We developed a focus group to guide the leader on eliciting patient barriers and facilitators of exercise and physical activity, as well as other questions as part of a larger study on the aftermath of surviving a stroke. The focus group sessions included open-ended questions about types of physical activity engaged in and how often the participants exercised as warm-up questions to help participants think about their physical activity participation. The leader asked questions to specifically elicit barriers to exercise; strategies that helped them to exercise; support received from healthcare system, caregivers and family, peers, and community resources to promote and sustain exercise; support received specifically from providers to help them exercise; and stroke impediments that prohibited exercise. In addition, we asked questions that focused on exercise prescriptions received from rehabilitation specialists and home maintenance of such programs.

Analysis

We used the session notes to catalog the principal themes that emerged and issues of both consensus and difference that transpired. The field notes and audiotapes were transcribed into computerized text. We transcribed and analyzed audiotapes of each focus group. Two investigators (Damush and Plue) independently reviewed and coded transcripts by assigning labels and codes to data segments on the transcripts. We permitted themes to emerge from the data.

In the first step in the analysis, we created a set of agreed- upon codes and a codebook that served as a template for coding of the data. The investigators used an iterative consensus-building process to generate codes. Each investigator worked independently and highlighted sections of the field notes and transcripts that illustrated a theme. In the margin of the notes or transcripts, we wrote the name of the theme, compared notes, reviewed agreements, and attempted to resolve disagreements until consensus was reached. All the authors coded a set of transcripts and participated in reaching consensus. The goal was to detect patterns within each data set that characterized potentially meaningful differences or similarities between groups, including common and useful facilitators of patient exercise self-management strategies after stroke to reduce risk for recurrent stroke and barriers to such activity. We described findings using quotes to illustrate points.

Results

Participants

Forty stroke survivors from an existing research study were invited, and 32.5% (13) agreed to participate. Stroke survivors were originally recruited from local community, county, and veteran hospitals. We held three focus groups and achieved content saturation from 13 stroke survivors including 8 men and 5 women who were 85% (11) African American and 15% (2) White. The mean age was 59 years (SD = 12.3) and the mean level of education was 11.5 years (SD = 2.6). Time since stroke event was less than 12 months for all participants. The majority self-reported experiencing slight (n = 6) or moderate (n = 4) disability since their stroke.

Analysis of the transcribed audiotapes of the three focus groups revealed three barriers to and three facilitators of exercise among stroke survivors. We describe each barrier and facilitator, illustrated with quotations from stroke survivors.

Exercise Barriers

1. Perceived stroke impairments discourage activity engagement

Stroke survivors reported that physical impairments experienced after the stroke prevented engagement in physical activity. Some examples from three participants included vision and walking difficulties that interfered with performing physical activities:

“My big problem is my eyes. I’ve lost my peripheral vision and I can hardly see.”

“My right arm hurts. I use it too much.”

“I find myself a little unstable at times. I still don’t have the full mobility in my foot; sometimes, I have to drag it. I’ve even got a special brace they made for me and sometimes if it gets to where I can’t support myself fully. It’s kind of an awkward thing because it doesn’t always fit in every shoe I have, but it helps to stabilize me.”

The limitations after stroke were related to participants’ fear of the consequences of exercising, which prohibited participants from engaging in physical activity. This was a common theme expressed by participants. Some examples included the following remarks by participants:

“I’m afraid of running into stuff and hurting myself.” (This comment was made by three participants.)

“I think one thing [that interferes with exercising after stroke] is fear, initially. I don’t have it [fear] anymore.”

“After I had my stroke, I was a little bit leery about exercising and bringing another [stroke] on.”

“You stop doing a lot of things (out of fear) until you see your doctor.”

Thus, perceived limitations after a stroke appeared as a barrier to engaging in exercise among survivors.

2. Lack of motivation.

Similar to the general population, stroke survivors reported that a lack of motivation, desire, or energy prevented them from exercising. The majority, 12 out of the 13 participants, endorsed this barrier. Participants made the following statements:

“That’s the hard part, to make yourself do it (exercise).”

“I can say I can go tomorrow, but when tomorrow gets here, I just lay down or sit down.”

“I know what I’m supposed to do, but I do not do it.”

Stroke survivors reported that post-stroke mood interfered with their ability to exercise.

“I was a very outgoing person before the stroke…. What the stroke did was affect me more mentally and physically. I don’t have any desire. I make myself do the things I do because they told me I had to, but it’s like I’m just like an [emotional] shell. I’m involved in a whole lot of activities, but when I go now, I just sit there. I’ve been in a lot of support groups. I used to feel people’s pain. I could cry with them. Now I just sit there. I’m emotionless. I struggle with that.”

Another survivor reported, “Since my stroke, I can’t concentrate on things like I used to.”

Many of the stroke survivors reported a lack of energy after the stroke, and this interfered with their ability to exercise. Some examples include the following statements:

“Yes, I don’t have the energy.” (Three participants stated this.)

“When I take my medicine because I’m on that depression pill, and it’s also a sleeping pill and I feel so tired.”

“I live in an apartment building, and I have a sister that lives over there, too. The women there walk all the time, and I just don’t have the energy to walk with them.”

This former quote illustrates that even when a stroke survivor has the social support to exercise, a lack of energy or motivation serves as a barrier to exercise after stroke.

3. Environmental factors.

A lack of exercise options was reported as a barrier to exercise after a stroke. Some stroke survivors perceived that there were no places for them to go for exercise. Some examples of participants’ comments include the following quotes:

“We don’t have that many places really to go. The only place I would have to go would be this YMCA.”

“There just aren’t enough meetings for us to participate in.”

Many of the stroke survivors perceived exercise as an event that was conducted in a formal or planned manner. Thus, exercise was something planned that was conducted in a facility or organization. Physical activity incorporated into daily living was not necessarily perceived as exercise. One example of this perception included the following:

“I don’t have a recommended exercise. I get out and walk around the neighborhood, go fishing, and all that sort of thing, but as far as going out every day and exercising, I don’t do that. I try to keep moving around.”

Another respondent perceived exercise as planned activity that is not maintained with age. “There are a lot of forms of exercise, but when you get to a certain stage in life, you don’t do them. You don’t ride a bike. You don’t run down the street.” These perceptions of exercise may inhibit physical activity after stroke.

Another environmental barrier to exercise was transportation. For several reasons, stroke survivors reported a lack of transportation as a barrier to exercise.

“I would have to drive, and I would have to get somebody to take me. If you can’t do something on your own, it’s pretty hard to get somebody to take you.”

“I go [to exercise] when I can when somebody can take me.”

Given the survivor’s driving limitation, a lack of public transportation system to transport the stroke survivor to an exercise facility was a common barrier reported in addition to a lack of stroke exercise programs in the community. Exercise Facilitators

Despite the exercise barriers reported by stroke survivors, some participants reported factors that served as facilitators to exercise after stroke. The three main facilitators include finding motivation to exercise, receiving social support to exercise, and treating exercise as a specific task or work to do to facilitate performing exercise.

Motivation

Stroke survivors discussed the benefits of motivators on their physical activity levels and discussed both external and internal motivators. For example, one participant discussed how his wife brought home a puppy for him to manage, and taking care of the puppy facilitated his exercise.

“I have a dog now. He makes me get up and take him out. Otherwise, I would still be in bed. He keeps me moving around.”

Other participants discussed the need for a trainer or external motivator to be active.

“To have someone come in for about an hour and put a belt around your back and say, “Now, oh, you’re doing fine. Oh, that’s good. That’s great,” and then, he leaves. It doesn’t help you a bit. You just need someone to say, “Get off your duff and move your legs.”

Moreover, stroke survivors discussed the benefits of self- motivation to exercise. Participants reported several examples illustrating this theme:

“You can do it yourself if you want to do it! I’m not saying that I am perfect as far as my exercise. There are times when I slough it off, too, because

I just don’t want to do it that particular time. You don’t need someone to come in every day or every other day;”

“I just kept fighting, and I kept doing what the doctors told me.”

“I’m not going to feel like this. I’m going to beat this.”

“Either you’re going to do it [exercise] or you’re not, but don’t hold me.”

Another source of exercise motivation was seeing physical improvements after exercising. This improvement facilitated further exercise participation according to the stroke survivors. Several participants cited examples:

“One thing that motivates me more is to see improvement. When I think about where I was and what I do now is a lot different.”

“I don’t know how many of you have problems with your legs. Putting a pair of pants on, I can see the improvement there. When I first had my stroke, I had a hell of time putting on a pair of pants.”

Another participant discussed his improvement seen with the distance walked:

“I’m trying to make it [walk] four miles. If I can make it four miles, I can feel it___It hurts, but after I’m done, it feels good.”

Exercise Social Support

Participants reporting receiving social support to exercise from several sources including professional support from rehabilitation services and providers, and peer support from fellow stroke survivors.

Stroke survivors mentioned the formal exercise instruction that they received from rehabilitation specialists helped them to be physically active afterward. For example, one participant mentioned, “I went to rehab, and there are a lot of things you can do as far as exercising, get a bike [sic]. They teach you how to stand somewhere and move your legs here and there. Move your body up and down against the door there.”

Another participant reported still using the equipment received from rehabilitation. “They [rehabilitation] gave me rubber bands to use, and I still use them. I use those balls in my hands. I do that every day.”

Home rehabilitation was also positively noted as a facilitator of exercise. “I still have a [therapist] come to the house. She gave me an exercise routine with my hands, and bicycle-like exercise with my legs.”

Providers were another source of support reported. Participants stated that receiving a physician recommendation to exercise provided motivation as illustrated by a participant:

“The [the doctor] said, ‘Walk more,’ and that’s what I’ve been doing since he stressed walking.”

“My circulation is better, and that was his [cardiologist’s] whole purpose [for telling me to walk], pump up the heart and make sure that it’s working properly.”

In addition to professional support, stroke survivors repeatedly reported that they would be motivated to exercise with fellow stroke survivors. Some example statements from participants include the following:

“We understand each other. You get somebody out there who’s never had a stroke; he would be bored with us. You lose part of your memory. You wouldn’t have each other dogging each other because you have the same thing.”

“Somebody who has been through virtually the same thing as we have [would motivate me to exercise].”

“One thing, if I had somebody to exercise with, go to the gym or somewhere, I would exercise more.””Somebody who would walk with me… an exercise buddy [would motivate me to exercise].”

Thus, social support from multiple sources was frequently reported as an important motivator to exercise after stroke.

Planned Activity to Fill Schedule

Stroke survivors reported that participating in an exercise program helped them to fill their empty daily schedule, which once was filled with occupational responsibilities. Having a planned activity to do helped survivors cope with their life changes after stroke. Several participants agreed that having a purpose would motivate them to participate in exercise.

“Having someplace to go [would motivate me to exercise]… so you don’t lie in bed all day.”

“I like to work on things … when I get up in the morning; I’ve got my mind already on what I’m supposed to be working on that day.”

Thus, the stroke survivors used exercise to fill their schedules, which had often become empty after resigning from employment due to their illness, according to participants.

Discussion

Stroke survivors elicited both common barriers and facilitators of exercise similar to the general population, as well as variables specific to stroke survivors. Common barriers brought forth by participants included lack of motivation and energy to be active, as well as lack of exercise programs available in the community and lack of transportation. These barriers are commonly reported among adults (Booth, Bauman, Owen, & Gore, 1997; Cohen-Mansfield, Marx, & Guralnik, 2003). Lack of energy and lack of programs available for patients were common perceived barriers reported by patients with spinal cord injury (Scelza, Kalpakjian, Zemper, & Tate, 2005).

Common exercise facilitators identified in these focus groups of patients with stroke were also reported in the literature among older adults in general including having a purpose in life (Damush, Perkins, Mikesky, Roberts, & O’Dea, 2005), having a place to go to be physically active (Damush et al., 2005), seeing improvements and having peer support (Courneya, Plotnikoff, hotz, & Birkett, 2000; Sallis et al., 1987), feeling self-motivated (King, 2001; Pinto et al., 2002), and receiving physician recommendations (Damush et al., 2001).

Of note, peer support was enthusiastically discussed across the focus groups. That is, participants stressed their willingness to exercise among fellow stroke survivors. Thus, stroke survivors were aware of their impediments and took refuge among those with similar experiences. These results echo those reported in another qualitative study of stroke consequences (Pound, Gompertz, & Ebrahim, 1998). They found that the loss of activities and social roles and contacts had affected the quality of life of stroke survivors and needed to be replaced. Thus, survivors may become isolated after stroke; however, a specific exercise class targeting stroke survivors may promote exercise as survivors report being comfortable around each other.

Stroke survivors identified external motivators (e.g., a pet) and rehabilitation as facilitators of exercise. Rehabilitation may be an opportunity to begin an exercise program with a therapist who may serve as coach. The rehabilitation program may be transitioned to independent exercise activity as a similar program, “Starting Again,” was successfully developed for cancer patients (Berglund, Bolund, Gustafsson, & Sjoden, 1994). Additionally, providing stroke- specific exercise classes would fulfill the exercise facilitator of having a planned activity to attend.

Equally important for promoting exercise among stroke survivors is the caregiver. In a recent study of patients with Alzheimer’s disease, caregivers were taught home exercises for their patients and to act as instructors (Teri et al., 2003). After 3 months, patients randomized to caregiver instructors reported spending more weekly minutes in physical activity and less days of restricted physical functioning. Thus, training the caregiver to coach the stroke survivor to exercise may promote physical activity.

Exercise barriers specific for stroke survivors included change in work or life status, stroke impairments (e.g., disability), fears of injury or bringing on another stroke, and lack of transportation, as many survivors were unable or unwilling to drive after the stroke. Participants reported that after the stroke, they often had to retire from work where they were once physically active on the job. Now, they were sedentary at home. These specific stroke barriers are similar to perceived barriers reported by people with spinal cord injury (Scelza et al., 2005). Fear of injury during physical activity is common among people with chronic disease. Our previous research among patients with low back pain found that fear of injury was related to less patient self-management (e.g., physical activity) (Damush et al., 2003). These patients significantly reduced their fears after participating in a patient self-management program. In addition, transportation is often a perceived barrier among disabled persons (Rimmer, 2005). In that case, home-based activities may be the most practical. However, our data suggest that stroke survivors would desire the opportunity to stay connected to their fellow stroke survivors. Therefore, technological devices such as Internet chat rooms such as those developed for patients with chronic disease (Lorig et al., 2002) or telephone conference calling may be useful to create a virtual exercise community for homebound stroke survivors and facilitate peer support for exercise. Fatigue was mentioned as a barrier to exercise after stroke. Post-stroke fatigue is a commonly reported symptom during the following year of the acute event and is related to depression, functional limitations, and mortality (Schepers, Visser-Meily, Ketelaar, & Lindeman, 2006). Research suggests that exercise participation may decrease cancer-related fatigue (Daley et al., 2007). However, the efficacy of exercise on post-stroke fatigue is unknown. Exercise rehabilitation is not routinely offered to stroke survivors as cardiac rehabilitation is after coronary events. Treadmill training may relieve post-stroke fatigue by decreasing energy cost of gait (Colle, Bonan, Gellez Leman, Bradai, & Yelnik, 2006).

Limitations

There are several limitations of this research study that should be considered. First, the participants were recruited from another research stroke study and may differ from those who did not participate. However, the study involved patients from three local hospitals that served veterans, inner-city residents with low income, and insured persons in community care. Thus, our sample represented a diverse background. second, the participants suffered a stroke within the past year. Perceptions may differ at the time of stroke compared to years after a stroke. Third, despite the fact that we completed only three focus groups, we achieved content saturation. That is, no new themes emerged from the third and final group. Equally important to designing a program is understanding the perceptions of the participants. This study took a step in this direction.

The results of this study suggest that peer support may be an avenue for exercise promotion among stroke survivors. One existing program that incorporates stroke peer support is the American Stroke Association’s Peer Visitor Program (American Stroke Association, 2007). It is designed to train stroke survivors to become peer supporters for recent stroke patients. An exercise promotion module may be incorporated into this program. As part of our research agenda, we plan to study the implementation of such a stroke peer support program to promote exercise after stroke. In addition to the need for peer motivators, rehabilitation and external motivators were mentioned as potential facilitators of exercise after stroke. Extensions of current rehabilitation programs may include training the caregiver to serve as a coach at home for the patient, as well as including behavior change strategies during planned rehabilitation to facilitate exercise after clinical rehabilitation has ended. Viewing rehabilitation as a transition point in which to facilitate general exercise in addition to specific therapeutic activities may be an opportunity to impact stroke survivor’s general health and reduce stroke risk in addition to enhancing recovery.

Conclusions

Physical inactivity is a modifiable risk factor for primary and recurrent stroke; increased physical activity after stroke may not only enhance stroke recovery but also may positively affect the healthrelated quality of life of stroke survivors. This study has identified barriers and facilitators of exercise after stroke. To facilitate exercise after stroke, clinicians should initiate assessment of stroke survivors’ concerns and address any fears about exercise prior to discharge. Future research may incorporate these findings into planned interventions and test their effectiveness for exercise promotion and impact on quality of life. We intend to incorporate these findings into a post-stroke self-management exercise program and evaluate its efficacy on patient outcomes.

Acknowledgments

Funding for this project was provided in part by a VA VISN Collaborative Grant #0404-73 awarded to Dr. Linda Williams, and the VA Stroke QUERI Center #STR-03-168, Indianapolis, IN.

All the authors coded a set of transcripts and participated in reaching consensus.

The results of this study suggest that peer support may be an avenue for exercise promotion among stroke survivors.

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Teresa M. Damush, PhD * Laurie Plue, MA * Tamilyn Bakas, DNS RN * Arlene Schmid, PhD OT * Linda S. Williams, MD

About the Authors

Teresa M. Damush, PhD, is the implementation coordinator for the VA Stroke QUERI and assistant research professor HSRD CIEBP at Roudebush VAMC, Indiana University Center for Aging Research, and Regenstrief Institute, Inc. Address correspondence to her at [email protected].

Laurie Plue, MA, is the administrative coordinator for the VA Stroke QUERI Center at the Roudebush VAMC.

Tamilyn Bakas, DNS RN, is an associate professor in the Indiana University School of Nursing and affiliated scientist with IU Center for Aging Research in Indianapolis, IN.

Arlene Schmid, OT PHD, is an assistant professor at VAMC in Indianapolis, IN, Indiana University Center for Aging Research, and Indiana University School of Rehabilitation Science.

Linda S. Williams, MD, is the research coordiantorfor the VA Stroke QUERI Center and chief of neurology at Roudebush VAMC and affiliated scientist with the IU Center for Aging Research.

Copyright Association of Rehabilitation Nurses Nov/Dec 2007

(c) 2007 Rehabilitation Nursing. Provided by ProQuest Information and Learning. All rights Reserved.

By Sternadori, Miglena Mantcheva

The Sept. 11 terrorist attacks, the war on Iraq and the frequent ethnic conflicts around the world have spurred many news stories about Islam and religious fanaticism. Recently, a new sensation emerged: Muslim women who blow themselves up in suicide bombings were depicted as mysterious figures, sometimes veiled and sometimes in high heels. The Western world was disturbed. At least on the surface, Islamic terrorists had become more gender-liberated than the exclusively male Sicilian Mafia (Jamieson, 2000). Expectations of how women are supposed to behave are apparently so prevalent that they were even included in a U.S. Senate resolution about violence in the Middle East: “The involvement of women in carrying out suicide bombings is contrary to the important role women must play in conflict prevention and resolution” (Epstein, 2002, April 6). Most news about female bombers underscored the discrepancy between femininity and violence, or at least between their stereotypical versions. Details about the attractiveness and reproductive history of the women often spiced up the coverage. Unfortunately, the sexy details not only reinforce gendered images but also serve the public relations strategies of terrorists, who largely depend on publicity to achieve their goals (Brunner, 2005).

This study is a rhetorical analysis of dramatized and gendered images of female suicide bombers in English-language newspapers and magazines. I argue that coverage of women terrorists is an example of a social construction of reality shaped by newsroom routines and selection of sources. The analysis has an intentionally broad scope, both in geographic and topical terms, and is a beginning exploration of international patterns of perpetuation of gendered narratives and frames. It not only confirms already existing evidence of stereotyping of women terrorists, but also attempts to hone the categorization of the stereotypes. In addition, the study explores the perceptions of skills and intelligence of women terrorists, a rarely approached issue.

The following questions are posed: What are the most common stereotypical categories that media have used to portray female terrorists in the 21 century? How are those “modern” stereotypes different or similar to historical representations of violent women? What, if any, linguistic and rhetorical approaches are used to convey that women terrorists are dumb, irrational, or immature?

Historical context

News coverage of women terrorists increased after a series of recent high-impact events involving female suicide bombers. In August 2004 two Chechen women detonated two Russian planes, killing 88 people. About a third of the Chechen rebels who held hundreds of people hostage in a Moscow theater in 2002 were women (Bowers et al., 2004). At least two of the terrorists in the deadly Beslan school siege in Russia were also women, who wore explosives. These events came after a string of Palestinian suicide bombings by women. Al-Qaeda in Iraq also began using women in its jihad. The first female terrorist in Iraq, dressed as a man, blew herself up in September 2005 (Dickey et al., 2005, December 12). A couple of months later, Mureille Degauque of Belgium became the first European to commit a suicide bombing in Baghdad.

The recent coverage of female political violence has inaccurately constructed women terrorists as a new phenomenon. History shows otherwise. Charlotte Corday attempted to change the course of the French Revolution by murdering Jean-Paul Marat. Vera Zasulich “heralded the onset of terrorism in Russia” by attacking the St. Petersburg police chief in 1878 (Knight, 1979). A 17-year-old Lebanese female committed the first ever suicide bombing in 1985 (Bloom, 2005). A woman, a member of the Tamil Tigers, assassinated Indian Prime Minister Rajiv Gandhi in 1991 (Bloom, 2005). Over the past two decades, female bombings have spread to Sri Lanka, Israel, Morocco, Egypt and Iraq. An expert analysis suggests 30 percent of suicide attackers are women (Bloom, 2005).

Theoretical framework

From a constructionist viewpoint, news stories represent not an actual reality, but a reproduction “created” by human beings and shaped by personal and external factors. Social construction of reality, a concept developed by Berger and Luckmann (1966) explains how stereotypes emerge and set foot in the so-called “social fabric.” People as social actors create mental images of each other’s actions over time; then those images become habitualized, institutionalized and come to be seen as carriers of meaning.

Tuchman (1978) suggests that news reports not only publicize events but also “impart character” to them by presenting only selected details. Other scholars call the imposing of some sort of an artificial order on a chaotic reality “framing” (Reese, 2001; Entman, 1989). There are time and staff constraints that do not allow news organization to cover every event as a “thing in itself” (Tuchman, 1978). Most experienced journalists seek culturally recognized narratives and use them as foundation stones on top of which to craft their reports.

Literature review

Emphasizing either the femininity or the violence of women terrorists but not the two together is a typical, constructed dichotomy, according to Talbot (2001). Existing research on portrayals of female terrorists contains many examples of such a constructed dichotomy. Struckman (2006) found that the female rebels in a documentary about the Moscow theatre siege were often presented as brainwashed victims and gentle women forced into a distasteful farce; by contrast, the actions of the male terrorists were seen as “natural.” In a textual analysis of news reports about Palestinian suicide bombers, Berkowitz (2005) discovered frames reflecting the mythical archetype of the Woman Warrior, an image that audiences know from shows such as Xena and Charlie’s Angels. The first six bombers fit that archetype, but the seventh had two young children and had allegedly cheated on her husband. Suddenly, journalists had to replace the “Woman Warrior” with the “Terrible Mother” archetype (Berkowitz, 2005). Handley and Struckman (2005) also found that female terrorists were more likely to be described in terms of age, appearance, “familial or relational context” and stereotypical traits, i.e., propensity to deception and incompetence; furthermore, stories mentioning female terrorists were more likely to include facts and assumptions about their motivation, the psychology of the act, the emotional response and the immediate effects of the bombing.

An interesting aspect of the portrayal of women terrorists is the focus on their corporeal traits and sexuality. Brunner (2005) explores three corporeal traits of female suicide bombers: (1) virginity, used to underscore that they are “something very precious, a human capital” being sacrificed for an ideal; (2) pregnancy, especially in the context of a “demographic war” between Israel and Palestine, and the history of female bombers disguising their explosive belts as protruding bellies; and (3) motherhood, or the choice of martyrdom that has been extended by Arab media to a “generalized Palestinian motherhood.” Arab newspapers often portray female suicide attackers as “chaste wives and mothers of the revolution” (Bloom, 2005). Such a “poetic storytelling” approach, used by Arab media in descriptions of female bombers, often finds its way into rational and “individual-based” explanations for Western audiences (Brunner, 2005). The result seems to be a gendered representation tailored to fit Western standards, a completely out- ofculture and out-of-context picture of female suicide bombers. Underscoring the obsession with the bodies of female terrorists is the anecdotal evidence that many have been “raped or sexually abused … thereby contributing to a sense of humiliation and powerlessness, made only worse by stigmatization within their own societies” (Bloom, 2005).

When female attackers are not Muslim, their representations seem to be even more sexualized. Steel (1998) found that British fiction, film and news media often include sexual connotations in portrayals of Irish female terrorists. From a somewhat Freudian perspective, such representations of female terrorists exploit a “metaphorical equivalence” of death and orgasm, since dying at the hands of a gorgeous woman can be perceived as the ultimate good time (Steel, 1998). The concepts of fear and pleasure have long been intertwined in folk representations of womanhood: Blackledge (2004) accounts for many examples of vaginal display, in various cultures, as a tool to frighten evil demons and opposing warriors (p. 8).

In coverage of the West German second of June movement, the Symbionese Liberation Army (SLA) and the Weathermen, female terrorists have almost uniformly been portrayed as “more violent, ruthless and uncompromising than their male counterparts”; also, they are likely to be perceived as sexual objects for men and as part of “male-engineered” terrorist structures (Galvin, 1983). Themes of submission and dominance also emerge in representations of female terrorists’ motivational factors, including avenging a lost husband or male family member (Bloom, 2005; Bowers et al, 2004).

Method

This study employed textual analysis based on feminist rhetorical theories and literature on news portrayals of gender and violence. The concept of “rhetoric” was viewed broadly as the symbols used to construct reality and from which “audiences derive meanings” (Foss, Foss & Griffin, 1999, p. 6). The analyses looked for frames, defined here as inclusion or exclusion of certain details; narratives; juxtapositions; metaphors; metonymies; and visual imagery conveyed through literary techniques. The analyzed stories were published in Englishlanguage publications in the United States, Canada, the United Kingdom and Australia between 2000 and 2005. A Lexis-Nexis search, which was not limited to specific publications or story length, found more than 100 stories mentioning women terrorists in Nexosweek, U.S. Nezvs & World Report, The Neiv Yorker, The Christian Science Monitor, The New York Daily Neius, The Montreal Gazette, The London Daily Telegraph, The Glasgoxo Herald, The Observer, The Irish Times, the Australian Magazine, and many others. In analyzing the results and crafting categories of stereotypes, I took into account the five notions that Talbot (2001) suggests have been historically used in representations of female terrorists: (1) extreme feminists; (2) only bound into terrorism via a relationship with a man; (3) only acting in supporting roles within terrorist organizations; (4) mentally inept; and (5) unfeminine in some way.

Results

As was to be expected from the review of the literature, women terrorists were cast in traditional feminine roles in most of the analyzed articles. Overall, the framing and stereotyping were subtle but consistent; however, there were some exceptions from the rule that will be enumerated here before the actual findings:

* Not every news story contained linguistic elements that suggested stereotyping. Many news briefs and short articles were neutral and contained no value-laden descriptions at all.

* Positions taken in some news reports ran the gamut from feminism to sexism without resorting to any subtle stereotypes. For instance, one male-authored article in The Irish Times was very non- stereotypical. It cited studies showing that women excel “in motivation, weapons skills, performance under pressure and leadership roles” and that “mixed-sex units outperform single-sex units in all phases of combat” (Clonan, 2002, Oct. 26). At the other end of the spectrum was a letter to the editor in the London Sunday Telegraph, also authored by a man, which suggested that “women are not physically or hormonally equipped for war;””doctrinal purism is quite a common female characteristic;””a woman’s instinct is to give life not to take it;” and “even when the ambition to be a killer exists, it is not usually matched by ability” (Myers, 2002, Oct. 27).

* At least two articles suggested untypical explanations for the deeds of female terrorists, such as need for money (Ward, 2004, October 10) and a practice of sale of young women into “suicidal slavery” (Groskop, 2004, September 5). A Washington Post story about Palestinian suicide bombers emphasized the women’s desire to be seen as “not less men than men” over individual circumstances (Copeland, 2002, April 27).

These exceptions apart, five stereotypical depictions of female terrorists emerged in the analysis: (1) the technically unskilled suicide bomber, (2) the “attack bitch” seeking revenge, (3) the failed (potential) mother, (4) the victim, brainwashed by a male, and (5) the sexy babe with personal issues. Some portrayals contained stereotypes that fell into more than one category. Overall, although the depictions reflected representations of female suicide bombers from the first few years of the 21 century, they are surprisingly similar to Talbot’s five “notions” (2001) about how women terrorists were represented over a period of many decades.

More often than not, stories about female terrorists mentioned how they were dressed, as well as their body language or facial expressions. For instance, a relatively short article in the London Daily Telegraph made it a point to mention that a 19-year-old student who blew herself up in the Northern Israel town of Afula was said to “be well-dressed and wearing high heels” (Gozani & de Quetteville, 2003, May 20). This is consistent with the findings of feminist scholars about gender biases in the news coverage of female athletes (with focus on the attractiveness and dress style of a tennis player, for instance), especially when compared with the coverage of male athletes (Eastman & Billings, 2000; Kinnick, 1998).

The following analysis is structured in seven subsections. The first five analyze the depictions of five prominent female suicide bombers who received significant coverage in English-language publications. Although these women are not representative of all female suicide bombers in the Middle East, their news coverage reflects the most common stereotypes. The sixth sub-section is about Chechen female terrorists, the “Black Widows.” The last sub- section, which is also the longest, is about generalizations on femininity within the context of terrorism. Not every article analyzed for this study is among the examples because of the sheer volume of the material; however, common narratives and frames were summarized if they appeared over and over again.

1. Wafa Idris

Idris, the first female suicide bomber in the IsraeliPalestinian conflict, was described as a volunteer with the Palestine Red Crescent Society. Her depictions in different publications cast her into four of the typical stereotypes: the; technically inept, the “attack bitch,” the failed (potential) mother and the “sexy babe with personal issues.”

In some initial reports, doubts emerged about whether Idris had really meant to kill herself or unintentionally set off the bomb in her purse as she was “rushing out of a shoe store” in Jerusalem (Lavie, 2002, February 6). Later, she was said to have shattered a glass ceiling and proven herself as a feminist in her own cultural environment (Bennett, 2002, February 11). A Milwaukee Journal- Sentinel article described her as a “sweet-natured woman” who had “curly brown hair” and did not wear a headscarf, but perhaps had a “secret life” Qohnson, 2002, February 3). A Christian Science Monitor article depicted her as enraged at Israel because of her volunteer experience treating “people wounded by Israeli troops, including children” (Lynfield, 2002, February 1).

News reports also reverted to seeking personal details about Idris to explain her violent act. Although described as physically attractive, Idris was also “divorced because of her infertility,””damaged goods,” old at 26″ and a “burden on the family,” according to an article in Australian Magazine (Toolis, 2004, November 13). The same article relied on a quote from an Israeli expert to frame all women terrorists as having personal issues of some sort:

“With female suicide bombers the same pattern repeats itself … There are always some family problems – divorce, infertility, or the male authority figures around them are weakened by sickness or death. There is always something about female suicide bombers that is a rupture from the usual social pattern” (Toolis, 2004, November 13).

2. Reem al-Reyashi

Depicted in English-language publications as a 22year-old mother of two children and a likely adulteress, al-Reyashi was the first and only female suicide bomber used by the Palestinian organization, Hamas. A dramatic narrative used in most of the news reports about her suggested that she was “forced” to blow herself up in order to restore her family’s name and avoid the shame of being killed as an adulteress. According to a Queensland Sunday Mail article, the juicy information about al-Reyashi’s extramarital affair came from Israeli sources and was dismissed by Hamas as “Zionist propaganda” (Chalmers, 2004, February 1).

Despite the compelling “adulteress” narrative, alReyashi’s media representations fit only the stereotype of the failed mother. Many reports described the pictures she took posing with a rifle and her children before the suicide attack. The only personal detail available about her was that she came from a middleclass family (Myre, 2004, January 15). None of the stories mentioned if al- Reyashi was attractive and whether she had a history of personal problems, other than allegedly having slept with a Hamas operative.

Some news reports also speculated that she had gotten pregnant from her illicit lover. Although alReyashi was “under orders” and a victim of cultural norms, she did not fit the typical image of a brainwashed fanatic sacrificing herself for Islam and the motherland (Chalmers, 2004, February 1).

3. Sajida Mubarak al-Rishawi

A suicide bomber who failed to detonate her bomb, al-Rishawi fit four of the five stereotypes. A Newsweek article described her as a vengeful 35-yearold virgin who had lost three brothers in the Iraq war and had married “a fellow bomber” in a union that was never sexually consummated (Dickey et al., 2005, December 12).

According to Western cultural and gender norms, those details cast her as a failed potential mother, since she was still a virgin at 35; an “attack bitch,” because she ferociously sought revenge for her brothers; a brainwashed victim, since she had close relations with male terrorists; and a technically unskilled woman, since she apparently did not figure out how to detonate her explosives.

The New York Times recently reported that alRishawi was sentenced to death by hanging. The news brief included a sentence that underscored yet another aspect of her unfeminine behavior: she “showed little emotion in the packed courtroom as the verdict was read” (Maayeh, 2006, September 22).

4. Hanadi Jaradat

A trainee at a law firm, Hanadi Jaradat was depicted in news stories as having nothing to live for by her own cultural standards. Already in her late 20s, she was an old maid. According to a story published in the Milwaukee Journal Sentinel, Jaradat, who had a Jordanian passport, passed through a checkpoint and took a cab to Maxim, a popular restaurant in Haifa, the third largest city in Israel. Here is how the article describes the subsequent bombing: “She bought her driver lunch, for $20, delivered it to his car, and returned to the restaurant, where she paused near a group of baby carriages and blew herself up. She and 21 patrons died in the blast, including a family of five” (Hermann, 2004, January 25).

The Mercury (Australia) described Jaradat as a “breathtakingly pretty 27-year-old,” who “rose before dawn to pray.” After her fiance was shot by Israeli soldiers, “she had nightmares and became obsessed with what was happening to her family and her people.” And although Jaradat always wore the traditional headdress and long black robe, on the day of the suicide attack she “discarded Muslim clothes, put on jeans and make-up, tied her hair into a ponytail and began the final part of her terrible mission” (Pendlebury, 2003, October 18).

Several months after her suicide bombing, Jaradat was again at the center of a scandal, this time because an Israeli-born artist and his wife compared her to a submissive fairy-tale character and made her the focus of an art exhibition in Sweden (Brown-Humes & Devi, 2004, January 19). The work, called “Snow White and the Madness of Truth,” consisted of a picture of Jaradat carried by a small white boat in the midst of a rectangular basin filled with red fluid. In addition, “on the wall at the art exhibit there was posted a text that interposed passages from the Grimm brothers’ story of Snow White with excerpts of a posthumous profile of Jaradat that ran in the Israeli newspaper Haaretz” (Martin, 2004, February 15). The Israeli ambassador to Sweden, Zvi Mazel, physically attacked the artwork, claiming it glorified Jaradat and signified anti-Semitism.

Jaradat fit three of the stereotypes. She was clearly a “sexy babe with personal issues;” a failed potential mother, who not only had no children of her own but cold-bloodedly killed other people’s children; and an “attack bitch” who was taking revenge.

5. Mureille Degauque

The first ever European suicide bomber, Mureille Degauque of Belgium, became a sensation. She was a Catholic who converted to Islam. A Newsweek article depicted her as a problem child who often ran away from home. Later, she had relationships with several Muslims. Her last marriage was with a man of Moroccan descent. At the time of her death, she was 38, childless, and framed as the brainwashed wife of a fanatic: “They went to live for at least three years in Morocco, and when she returned home she was fully veiled: alienated, lonely, in the thrall of a husband who consumed her entire world.” (Dickey et al., 2005, December 12).

The details and quotes in a New York Times article focused on her dress style as well as past transgressions (Smith, 2005, December 6). For instance, “Her teachers remember her as a well-dressed, well- behaved young woman, even if she was a middling student.” From a prim Catholic girl, in her teens she turned into a motorcycle club member and started wearing a black leather jacket. Her brother died in an accident. Then, she started appearing with a headscarf, and finally in a long black robe and fully veiled, with only her eyes showing (Smith, 2005, December 6).

Degauque fit three of the stereotypes: the “sexy babe with personal issues;” a somewhat less intelligent woman, thus an easy target for brainwashing; and the “technically unskilled” category, since she killed only herself in the detonation.

6. The ‘Black Widows’

Representations of Chechen female terrorists lacked any element of ineptness but fit the other three stereotypes. For instance, an article from The Montreal Gazette (McDonald, 2003, October 24), used direct quotes to describe the so-called “Black Widows” as childless young women who had lost their husbands and were damned to wear mourning dress for the rest of their lives. For instance, the women “had no reason to live,” had been allegedly brainwashed by “special psychologists” and “stuffed full of drugs,” and were “scarier than men,” barking orders and brandishing pistols “alongside their male comrades.” The Gazette story also quoted a source saying one of the terrorists was pregnant. Clearly, these descriptions cast the Black Widows into the stereotypical categories of brainwashed women, “attack bitches” and failed potential mothers. But an Observer article (Groskop, 2004, September 5), offered different viewpoints from siege survivors describing the “Black Widows” as courteous, trying not to frighten the hostages, letting children out of the theatre, crying and talking about their hard lives. Those mostly positive descriptions fit the “brainwashed victim” category.

7. Femininity within Violence

The juxtaposition of femininity and violence as nearly opposite concepts has sometimes led to representations of women terrorists as little more than “sex bombs,” in a literal sense. Some of the analyzed news reports implied that female bombers are frail, submissive and lacking in terrorist qualities because of physiological and emotional differences from men. For instance, an article in The San Francisco Chronicle claimed that Hezbollah, which used female bombers in the early 1980s, later “reverted to using men, apparently because the attacks by women and children were less effective” (Epstein, 2002, April 6). In addition, the same article suggested that Wafa Idris and the next two female Palestinians who followed her example “weren’t successful, compared with some of the horrific bombings in Israel in recent months.” Each of these female bombers killed only a handful of people rather than dozens or hundreds. Using a similar vantage point, Whitaker (2005, December 12), in a Newsweek editorial, described women in the jihad movement as nothing more than tools used to “go where men can’t” and to “taunt potential male recruits.” Also, female terrorists were acting under the influence of men and defining themselves through relationships with men (Whitaker, 2005, December 12).

As if to prove the artificiality of such stereotypes, other news reports cast female terrorists in exactly the opposite light: as tougher, scarier and more dangerous than their male counterparts. For instance, some news reports suggested that women terrorists are often more ferocious than men (for instance, McDonald, 2003, October 24) and even cited an alleged counterterrorism rule to kill the female terrorists before the male ones.

Gendered metaphors and metonymies were also used to transfer sets of gendered associations into a single word or phrase. For instance, the very names of the two existing female terrorist organizations, Palestinian “Army of Roses” and Chechnya’s “Black Widows,” rely on images of flowers and insects, which is consistent with the practice of describing women in trivializing terms (Wood, 2006, p. 121). Also consistent with feminist literature is the use of the word “girls” for adult women, a term that implies immaturity (Wood, 2006). For instance, an article in The Observer opened up with the following lead: “When there is a bombing, Russians are no longer surprised to discover a girl is responsible” (Groskop, 2004, September 5). A letter to the editor from the London Sunday Telegraph described the Black Widows in the Moscow theatre siege as “those terrorist girls in their burqas.”

A common technique in many of the analyzed articles was the juxtaposition of “life giving” and “life taking” to imply motherhood and/or femininity failure, at least by Western standards. For instance, Newsweek’s description of the first female bomber in Iraq (Dickey et al., 2005, December 12), referred to explosive strapped around her womb. In reality, the explosives were likely strapped around her waist, higher than the area of the uterus. The choice of the word “womb,” associated with childbearing, underlined the discrepancy between femininity and violence. A similar juxtaposition was used in the Montreal Gazette (McDonald, 2003, October 24) article, which described the 19 Black Widows who held up hundreds of hostages in a Moscow theater as wearing “packs of explosives … just about the size of bread loaves or newborn babies.”

Berkowitz (2005) discovered similar life-death imagery in a Neiv York Times article that borrowed from an Egyptian daily’s depiction of a bomber: “She bore in her belly the fetus of rare heroism, and gave birth by blowing herself up!” Even a Melbourne Herald Sun article about a new Australian theater performance, titled Woman- Bomb, was built around the same idea. The play’s director was quoted to say: “Women have always been the bringers both of life and death … Even the phrase ‘a bombshell of a woman’ is hinting at that area of someone that is capable of causing destruction” (Barclay, 2005, July 1).

Discussion and conclusions

News stories about female bombers have the difficult task of constructing deviant acts of violence in ways understandable to the audience. The problem is that such deviant acts not only contradict social norms (as do suicide bombings committed by men), but they also starkly contradict traditional views of femininity. Such double deviance has a significant news value; hence, stories about women terrorists are guaranteed prominent placement and sensational headlines. They are also guaranteed to contain juicy personal details, often unprecedented in this era of political correctness and third-wave feminism. It is usual for the media, especially in the United States, to seek details from the personal lives of people who unwittingly throw themselves into the public spotlight, as for instance, happened with the gay man who saved the life of President Ford.

But in the coverage of female suicide bombers, the issue is not so much about digging for juicy narratives as it is the use of a double standard that rarely pays attention to the personal stories of male terrorists. Stories about women terrorists generally conformed to Western gender standards and ideology. They almost always included details about physical appearance, sex life or lack thereof, and motherhood status or inability to have children. Only some articles, and only in passing, mentioned the professional background of Palestinian female bombers. None of the articles about the Chechen “Black Widows” included details about their education and jobs, although many of the terrorists older than 35 likely had professional careers under the Soviet regime. The study found five common frames or stereotypes used in representations of female terrorists. Figuratively speaking, those were “the inept ditz,” the “attack bitch,” the “failed mother,” the “brainwashed victim” and the “sexy babe with issues.” The categories were broad enough to cover most gendered depictions of female suicide bombers. Numerous examples supported these common stereotypes, which often overlapped or were used in combination. I also found multiple examples of linguistic and rhetorical techniques that depicted female terrorists as emotional and immature, for instance, by using trivializing terms or calling them “girls.”

Although the study did not aim to compare gender stereotypes in English-language newspapers from different countries, their approaches were similar and perhaps borrowed from each other’s descriptions of women terrorists. These commonalities in stereotyping may have been related to the selection of sources, such as Israeli and Palestinian scholars and Middle-Eastern newspaper articles. One can hope that the high visibility of women terrorists has had not only a negative effect, in terms of reinforcing Western gender stereotypes, but has also offered a more layered understanding of womanhood.

In her 2002 presidential address to the Eastern Sociological Society, Judith Lorber said that, although imagery surrounding September 11 and the “war on terrorism” was conventionally gendered, female bombers challenged “terrorist machismo”:

“As much as we may have mixed feelings about women militants, I think we must continue to commemorate women heroes and warriors so that we don’t go back to the old stereotypes of men as the rescuers and protectors and women as dependent on men to be their line of defense against domestic and foreign dangers” (Lorber, 2002).

The findings pose many more questions for future research. For instance, a content analysis of stories about both female and male terrorists could provide a quantitative comparison of just how often such reports focus on appearance, sexuality and personal problems. Also, how does the gender of the writer affect the overall tendency to stereotype and trivialize women terrorists in news accounts? Do articles about female suicide bombers use more Christian or more Muslim sources? How do the representations differ based on the affiliations of the sources? How does the presence or absence of historical context in the news articles affect the descriptions of female terrorists? Those questions will only continue to multiply, because complex phenomena involving gender and violence require anthropological and cultural contextualizing that is unlikely to fit any newspaper or magazine page.

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Miglena Sternadori is a doctoral student at the University of Missouri School of Journalism, where she also earned her master’s degree. Originally from Bulgaria, she worked as a neiuspaper reporter in Sofia for five years before coming to the United States for the first time in 2000 as a visiting professional. She later worked as a research assistant at Investigative Reporters and Editors (IRE), a reporter for the Columbia Daily Tribune and associate editor at the Missouri State Teachers Association. Her research interests include text comprehension, nezusgathering routines, gender and media ethics. This paper was originally presented at the 2007 annual conference of the International Cmmunication Association in San Francisco.

Copyright Communication Research Associates, Inc. Fall 2007

(c) 2007 Media Report to Women. Provided by ProQuest Information and Learning. All rights Reserved.

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Mr. Vangeison holds both a B.S. and M.S. degree from Southern Illinois University. He is an active board member in various local charities and groups including the National Kidney Foundation, Boy Scouts, and Greater Portland United Way. He has also held various Board positions with organizations such as Blue Cross Blue Shield Association, Maine Partners Health Plan, HMO Maine and Patriot Life Insurance Company.

About Viant, Inc.

Viant provides healthcare payment solutions through primary and supplemental networks, integrated network and contract management, specialized cost containment strategies and post payment recovery services focusing on timely, accurate and equitable payment for providers, payers and patients.

Viant, Inc.

CONTACT: Cliff Greifer, [email protected], or Bryan Adel,[email protected], both of Viant, Inc., +1-630-649-5000

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

Air Industries Group, Inc. (OTCBB:AIRI) today announced that it will acquire all of the outstanding shares of Blair Industries, Inc., Blair Accumulators, Inc., H.S.M. Machine Works, Inc. of New York, and H.S.M. Machine Works, Inc. of North Carolina (collectively, “Blair-HSM”). With a forty year history, Blair-HSM designs and manufactures fully dressed landing gear and other structural and hydraulic components primarily for commercial and military aircraft, and is comprised of sister companies operating out of one facility in Medford, Long Island, NY, and another facility in Leland, NC. As part of the purchase agreement, Air Industries Group has agreed to pay approximately $16.4 million in a combination of cash, restricted stock, and debt. The closing of the acquisition is expected to be on or about January 2008, and is subject to the satisfaction of standard terms and conditions.

“The agreement to acquire Blair-HSM, a company with annualized revenues of approximately $16 million which will be immediately accretive to earnings, is an exceptional fit for integration with our Air Industries platform,” said Air Industries Group President and Chief Executive Officer Peter Rettaliata. “This combination provides us with impressive capabilities and a premier customer base for landing gear and other critical flight safety components and assemblies.

“Our continued infrastructure expansion is enabling our ascent of the aerospace supply chain. With Blair-HSM, we are further transitioning from basic contract manufacturing to becoming a provider of comprehensive integration services, particularly for fully dressed landing gear.”

Founded in 1951, HSM produces structural landing gear components, complex airframe machined parts, as well as hydraulic components. Established in 1979, Blair Industries produces hydraulic actuators, mechanical assemblies, a wide variety of kits, and complete landing gear assemblies. Blair and HSM were merged into one facility in 1999. Today, Blair-HSM offers a low cost facility with capabilities ranging from basic to complex landing gear assemblies. Its workforce consists of a strong procurement department, vast manufacturing experience and capabilities, a tried and proven sub-contractor base, a fully capable assembly department, and other infrastructure.

The North Carolina facility occupies over 40,000 square feet and houses some of Blair-HSM’s largest equipment. Roughly sixty to eighty percent of the material removal process is completed in the North Carolina division. This extremely “lean” division has numerous multi-spindle machining centers that are interfaced to a central computer system.

For over 10 years, Blair-HSM has been a certified supplier for all divisions of the world’s largest provider of landing gear to the industry’s prime contractors, and maintains similar standing with France-based Messier-Dowty, the world’s second largest provider of landing gear.

Concurrent with the closing of the acquisition, Air Industries Group will enter into employment agreements with key executives of Blair-HSM to enable seamless integration and long term synergistic benefits.

Legal representation for Air Industries Group in this transaction was provided by Eaton & Van Winkle LLP of New York, NY. Legal representation for Blair-HSM in this transaction was provided by Lewis Johs Avallone Aviles, LLP of Melville, NY.

ABOUT AIR INDUSTRIES GROUP, INC.

Air Industries Group, Inc. (OTCBB:AIRI) is an integrated manufacturer of precision components and provider of supply chain services for the aerospace and defense industry. The Company has over 35 years of experience in the industry and has developed leading positions in several important markets that have significant barriers to entry. With embedded relationships with many leading aerospace and defense prime contractors, the Company designs and manufactures structural parts and assemblies that focus on flight safety, including landing gear, arresting gear, engine mounts and flight controls. Air Industries Group also provides sheet metal fabrication, tube bending, and welding services, as well as distributing specialty metals that are a critical component in the aerospace supply chain. Information on the Company and its products may be found online at www.airindustriesgroup.com.

Certain matters discussed in this press release are ‘forward-looking statements’ intended to qualify for the safe harbors from liability established by the Private Securities Litigation Reform Act of 1995. In particular, the Company’s statements regarding trends in the marketplace, firm backlog, projected backlog, potential future results and acquisitions, are examples of such forward-looking statements. The forward-looking statements include risks and uncertainties, including, but not limited to, the timing of projects due to the variability in size, scope and duration of projects, estimates, projections and forecasts made by management with respect to the Company’s critical accounting policies, firm backlog, projected backlog, regulatory delays, government funding and budgets, matters pertaining to potential and pending acquisitions subject to and after closings, and other factors, including results of financial audits and general economic conditions, not within the Company’s control. Certain of the Company’s forward looking statements, with the projected backlog in particular, are formulated based on management’s extensive industry experience and understanding and assessment of industry trends, customer requirements, and related government spending. Projected backlog may be subject to variability and may increase or decrease at any time based on a variety of factors, including but not limited to modifications of previously released orders, acceleration of orders under general purchase agreements, etc. The factors discussed herein and expressed from time to time in the Company’s filings with the Securities and Exchange Commission could cause actual results and developments to be materially different from those expressed in or implied by such statements. The forward-looking statements are made only as of the date of this press release and the Company undertakes no obligation to publicly update such forward-looking statements to reflect subsequent events or circumstances.

Solis Women’s Health today announced that it has opened its eighth breast care center in Arlington, Texas.

The Arlington center, located at 300 West Arbrook, in the greater Dallas-Ft Worth market, will provide screening mammography and related diagnostic services.

The 6,800 sq. ft. facility will offer full field digital mammography. In addition to digital screening, digital diagnostic mammography and computer-aided detection, Solis will offer breast ultrasound, stereotactic and ultrasound-guided biopsy.

The new Solis facility will be led by Dr. David Johnston. Dr. Johnston earned his medical degree from the University of Utah. After completing an internship at Ball Memorial Hospital in Muncie, IN, Dr. Johnston completed his residency and fellowship programs at Mallinckrodt Institute of Radiology in St. Louis, Missouri. Prior to joining Solis, Dr. Johnston practiced at Rose Imaging Specialists in Houston, TX.

Brad Hummel, Chief Executive Officer, said “The Arlington center represents a strategic collaboration of a number of premier Arlington healthcare providers, including Medical Center of Arlington (MCA) and Omega OB/GYN Associates, all of whom share a common goal of creating a center of excellence unrivaled in the metroplex. Notably, Solis, in conjunction with MCA will for the first time within our metroplex operations, be offering patients breast MRI, an increasingly called upon tool for the diagnosis and treatment of breast cancer.”

About Solis Women’s Health

Solis Women’s Health is a specialized healthcare provider focused exclusively on the screening and diagnosis of breast cancer. Headquartered in Austin, TX, Solis operates seven north central Texas facilities; the Bertrand Breast Center in Greensboro, North Carolina and has several sites under development in markets across the United States. Solis provides a complete range of breast health services including screening mammography, diagnostic mammography, computer-aided detection, breast ultrasound, bone densitometry and stereotactic and ultrasound-guided biopsy, breast specific gamma imaging and breast MRI. More information is available at www.SolisHealth.com.

By Steve Sternberg and Anthony DeBarros

BALTIMORE — Soon after Holly Russell-Milstein took her thyroid cancer medicine at Johns Hopkins University here on Oct. 18, she went into self-imposed isolation in a row house a short walk from the hospital.

The medicine, iodine 131, is a proven cancer fighter. But it’s also radioactive, and in higher doses, can cause cancer. Russell-Milstein — like thousands of other thyroid cancer patients in the USA each year — worried that the radiation might pose a risk to her family.

For two weeks after her treatment, Russell-Milstein, 29, chose to isolate herself rather than go home. Her doctor told her that if she stayed away from her four children and followed precautions, it would be safe to return to her family in McLean, Va. But Russell-Milstein says she couldn’t accept the consequences if the doctor was wrong.

“How can you have any peace of mind when you know you’re potentially putting your family at risk?” asks Russell-Milstein, who returned home Oct. 30, in time for Halloween. “I’d rather live in a box under a bridge than come home to my small children.”

Many other patients echo her concerns, even as I-131 is being used to treat a broadening spectrum of cancers. The isotope works so well in treating thyroid cancer — the five-year survival rate is 97% — that researchers worldwide have begun using it in treatments of lymphoma and cancers of the liver, colon and prostate.

“It’s an exciting time” for radioactive iodine treatment, says Russell-Milstein’s doctor, Paul Ladenson, director of endocrinology at Johns Hopkins Medical Institutions.

Doctors and scientists, however, disagree over the risks of secondhand exposure to I-131. Two years ago, the National Academy of Sciences reported that no amount of ionizing radiation is safe. However, an analysis done for USA TODAY suggests the risk is relatively low and that a hug from a radioactive mom is unlikely to sow the seeds of thyroid cancer in her child.

“Chances are, if you get a cancer, it’s not going to be related to this exposure,” says Owen Hoffman, an independent risk analyst for the consulting firm SENES in Oak Ridge, Tenn.

Hoffman calculates that the additional lifetime cancer risk for an infant girl — infants are most vulnerable to radiation exposure — is 2 in 1,000. For a boy, it would be 1 chance in 1,000. For adults, he estimates, the risk falls to a few chances in 10,000.

Even so, Hoffman says he can’t totally discount the risk of illness from secondhand exposure to I-131.

“Every exposure poses a risk,” he says. “These levels of radioactivity pose a risk far greater than the Environmental Protection Agency would accept for public exposures at Superfund sites.”

A USA TODAY survey, the first to examine the scope of thyroid cancer survivors’ concerns nationwide, finds that more than half of patients who received I-131 were treated and released rather than kept in hospitals. The survey also finds that 85% of outpatients worried about exposing their family members to radiation.

Not only are patients radioactive for several days after treatment, the objects they touch may become radioactive. Although patients excrete the bulk of their radiation in three days, traces may linger in the body for as long as two weeks.

A decade ago, I-131 patients didn’t have to worry much about exposing family members to radiation. Most patients were kept in the hospital for several days until radiation detectors indicated it was safe to send them home. In 1997 the Nuclear Regulatory Commission relaxed its rules, allowing doctors to give I-131 to outpatients.

That decision marked a tipping point for thyroid cancer patients. Many hospitals eliminated their radiation isolation rooms. Some doctors began treating patients in their offices. Health plans tightened restrictions on I-131 treatment so much that insurance often won’t cover hospitalization.

Now, with thyroid cancer diagnoses increasing, more patients are raising concerns about the safety of outpatient I-131 treatment. The issue has sparked controversy among patients in support groups and in Internet chat rooms. Doctors’ conflicting opinions add to the confusion: Some say it’s almost always safe to release patients treated with I-131. Others disagree.

‘Only two things can go wrong’

Ladenson says he rarely admits I-131 patients to the hospital. Before the NRC changed its rules, he says, “I admitted two patients a week. Now I admit two patients a year,” those who are so sick that they need whopping doses of the isotope.

To demonstrate the safety of low-dose I-131, he scanned his own thyroid with a radiation counter moments before Russell-Milstein’s treatment to show that he had no ill effects from the six treatments he had performed that week.

Then, wearing only standard doctor’s attire — a white coat over a shirt and necktie — the white-haired specialist produced a lead-like canister with hands sheathed in purple hospital gloves.

“There are only two things that can go wrong with this treatment. You can give the wrong dose to the wrong person, or you can drop the container on your foot. It’s made of tungsten and extremely heavy.”

Inside the canister, nested like Russian dolls, was a plastic cylinder containing a large capsule of I-131. Russell-Milstein retrieved the vial, held it to her lips and tossed down the capsule. Ladenson handed her a Styrofoam cup. She washed the pill down with water.

Russell-Milstein’s first question after she took the pill concerned the safety of those around her.

“It’s safe to be around people for a brief period,” Ladenson answered. “You don’t want to sit on a couch with your daughter for two hours.”

Russell-Milstein wouldn’t see her daughters for 12 days. She was determined to protect Alanna, 9, Ava, 7, Amelia, 4, and especially Ariela, 2, who was too young to understand that hugging Mommy might be risky. “She’s all over me,” Russell-Milstein laments.

To guard against contaminating her rented row house, Russell-Milstein brought her own bedding and lined the floors with plastic runners. She covered doorknobs and other surfaces with contact paper. She even wrapped the TV remote control in a plastic bag.

“I guess it’s better if you stay away for two weeks and come home healthy, than if you stay here sick,” she recalls Alanna saying.

A common thread runs through online thyroid cancer support groups. Members complain about people who describe the disease as a “good” cancer, because of its very high survival rate. “Some people actually think that you are ‘milking it,'” wrote one irate member of a Yahoo thyroid cancer chat group.

Thyroid cancer has a mild reputation because I-131 treatment is so effective for most forms of the disease. The approach exploits the thyroid gland’s hunger for iodine, a key ingredient in the thyroid hormone that regulates the body’s energy use. Because thyroid tissue soaks up any iodine it finds, I-131 is drawn directly to the cancer, wherever it has spread.

“It’s like the ultimate magic bullet,” says Robert Udelsman, a thyroid cancer expert and surgeon at Yale University. “Radioactive iodine goes straight to thyroid cells and kills them. If only we had such a wonderful magic bullet for other cancers, we’d have a lot fewer cancer deaths in this country.”

Doctors likely will be using I-131 more often as time goes by. Although it is still relatively rare — just 1.5% of all cancers — thyroid cancer’s incidence has doubled during the past 30 years, possibly because of improved diagnosis, research indicates.

Doctors now diagnose about 34,000 new cases a year, twice as many of them in women as men. “About 90% get treated with radioactive iodine. You’re probably talking about 28,000 patients a year,” says Douglas Van Nostrand, director of nuclear medicine at Washington Hospital Center in Washington, D.C., and a co-editor of Thyroid Cancer: A Guide for Patients.

The median age of diagnosis for women is 46. That means many of those needing I-131 treatment are likely to be women with young children. Kids are particularly sensitive to radiation, according to studies of survivors from the atomic bombings in Hiroshima and Nagasaki during World War II, and the 1986 meltdown at the nuclear power plant at Chernobyl, where escaping I-131 gave 5,000 children thyroid cancer.

Risks and uncertainties

Chernobyl released vastly greater amounts of radiation than the maximum of 500 millirems a bystander might receive from an I-131 patient. No one knows precisely how much damage the much smaller dose could do, because it’s virtually impossible to conceive of an ethical, large-scale experiment that involves exposing people to radiation.

The studies done so far are small and don’t mirror reality, says Peter Crane, a thyroid cancer survivor and former NRC lawyer who is challenging the agency’s decision to relax its rules on outpatient treatment with I-131.

To reduce the risk of secondhand I-131 contamination, the congressionally chartered National Council for Radiation Protection and Measurement recently released more than 200 pages of guidelines for treating patients with radioactive therapies. They advise I-131 patients to:

*Avoid holding children for more than 10 minutes a day for 21 days after treatment.

*Sleep alone for a full week after treatment or 24 days if your bedmate is pregnant.

*Try to stay as far from other people as possible, “to the extent that’s reasonable.”

Jean St. Germain of Memorial Sloan-Kettering Cancer Center in New York, chairwoman of the committee that wrote the recommendations, says she and her co-authors tried to clear up the confusion.

“If you have a patient who isn’t able to follow instructions, who is mentally challenged or is a young mother with three children, maybe this is not the best person to send home” from the hospital, she says.

The USA TODAY survey, carried out with the help of the Thyroid Cancer Survivors’ Association, discloses how patients react to the risks and uncertainties of 1-131 therapy. The survey drew 914 responses from the group’s 5,000-plus members. Because respondents weren’t chosen randomly, the survey isn’t scientific, but it offers a window into the world of thyroid cancer care:

*Eighty-six percent of the outpatients said they went directly home after being treated. Two percent used public transportation, potentially exposing others to radiation. About 4%, rather than going home, checked into hotels or other accommodations, potentially posing a risk to guests or cleaning staff.

*Ninety-one percent were warned of radiation’s risks, which means nearly 1 in 10 were not. Many respondents also commented that they were given confusing or conflicting information.

*Nearly half of all patients surveyed experienced nausea after treatment and 8% threw up, a side effect of I-131. Many of those reported they believed the vomiting, or the cleanup that followed, posed a radiation risk to others.

Just as revealing were the stories of hundreds of patients left to grapple on their own with the complexities and uncertainties of outpatient radiation treatment.

Ellen Hodge, 53, of Glendale, Ariz., says she and her husband were so worried that I-131 would harm his thyroid that he drove her home from treatment wearing a lead-lined dentist’s X-ray apron — not knowing it doesn’t block I-131 gamma rays. Hodge sat as far away from him as she could in the family’s dual-cab pickup truck.

Millie Hughes, 36, of Blue Ridge, Ga., says her husband slept in an RV in the front yard. Her son, Taylor, 11, and daughter, Austin, 12, stayed with Hughes’ mother, who would regularly drop off food. One day, she waited in the car and sent Taylor to the front door with a meal for his mom. “He’s my son, he wants to see me, but he can’t,” Hughes says. “That was horrible. I just shut the door, called my mom and said, ‘Let’s not have that happen again.'”

Then there’s Aileen Schlissel, 45, of Las Vegas. The mother of two young children, Schlissel rented a time-share apartment for a week to avoid irradiating her family. She decided to treat the week as a vacation, renting movies and buying chocolate. What she didn’t count on was becoming violently ill from I-131. Her doctor told her to go to the emergency room.

“When I got there, I said, ‘I can’t stand here, I’m radioactive.’ One of the woman behind the counter was pregnant. She looked at me like I had three heads. And I threw up in the lobby.” That wasn’t the worst part of her experience.

“What floored me,” she says, “is that not only was I radioactive, I was all alone.” (c) Copyright 2005 USA TODAY, a division of Gannett Co. Inc. <>

tell us!

Groups Offering Help is a free service of The Beacon. Listings are limited to nonprofit organizations and/or to items or services that can be shared between two parties, neither of which can receive financial compensation. Send items to [email protected], fax to (757) 222-5171 or mail to 4565 Virginia Beach Blvd., Virginia Beach, VA 23462.

ADDICTIONS + RECOVERY

Addiction Education Support Program For anyone interested in the addiction and recovery process. Meets at Church of the Holy Family, 1279 N. Great Neck Road. Call 481-5702.

Al-Anon, Changing Attitudes Meets Thursdays at 8 p.m. at St. Francis Episcopal, 409 Rosemont Road. Call Joan, 460-0949.

Alateen A fellowship for children 18 and younger who are affected by someone else’s drinking. Call 499-1443 for a local meeting information; other areas call (888) 425-2666 weekdays between 8 a.m. and 6 p.m. Al-Anon Family Group meetings for adults may also be held at the same time and location.

Alcoholics Anonymous Call 490-3980 for a list of Hampton Roads meetings.

Caring & Sharing Alateen Call 463-7501.

Celebrate Recovery London Bridge Baptist Church, 2460 Potters Road, sponsors 12-step recovery programs with a Christian perspective, including substance abuse for men and women; men’s sexual addiction and women’s co-dependency. Groups meet from 6:30 to 8 Thursday evenings. Child care is available. Call 486-7900, Ext. 40. n

Kempsville Church of Christ, 5425 Parliament Drive, offers Celebrate Recovery weekly at 7 p.m. in Room 14. Visit www.kccfamily.org or call 490-3925. n

Coastal Community Church Glenwood Campus, 2800 S. Independence, offers Celebrate Recovery Friday nights from 6 to 9. Call or e-mail Don, 286-9642, [email protected]; or Michelle, 581-5611, [email protected]

Christian Sex Addiction Recovery Partners Group. Women only meet Friday nights at 7 p.m. at Kempsville Presbyterian Church, 805 Kempsville Road. Call Karen, 672-1072, or e-mail [email protected].

Co-Dependents Anonymous (CoDA) A 12-step fellowship for men and women. For local meetings, call the 24-hour hot line, 552-1793, or visit www.codependents.org.

Clutterers Anonymous A 12-step support group for people with too much stuff meets monthly at Kempsville Area Library, 832 Kempsville Road. Call Randa at 286-7378 for specific dates.

Coastal Community Church Glenwood Campus, 2800 S. Independence Blvd., sponsors a faith-based 12-step recovery program Friday nights from 6 to 9. Child care is available. Call or e-mail Don, 286-9642 or [email protected]; Michelle, 581-5611, or [email protected].

Compulsive Eaters Anonymous – Honesty, Open-mindedness, Willingness. A 12-step support group. Meets Tuesdays from 7 to 8 p.m. at Good Shepherd Lutheran Church, 1489 Laskin Road. Call 456- 1435.

Debtors Anonymous Virginia Beach Debtors Anonymous or Virginia Beach Business Debtors Anonymous. Call Bill, 675-8747.

Emotions Anonymous Help for depression, anger, anxiety, panic, guilt, despair and worry. Call Emily, 479-4328, or Dave, 962-1591. Visit www.emotions anonymous.org.

Food Addicts Anonymous A fellowship of men and women meets Tuesdays from 7 to 8 p.m. at Emmanuel Episcopal Church. 5181 Princess Anne Road. Call Karon , 499-6078, or e-mail [email protected]. The group meets Thursday evenings at 7 in the school library at St. Pius X Catholic Church, 7800 Halprin Drive, Norfolk. Call Linda, 588-8980m or e-mail [email protected].

Gamblers Anonymous Meets at 6:30 p.m. Sundays at Sentara Virginia Beach General in the Health Education Building. Call 531-5129, ask for Tony J. or Tom K.

LifeRing Secular Recovery Secular sobriety support. No steps. Meets Tuesdays from 7 to 8 p.m. Call Jane, 581-1828, or Tom, 839- 2077. Visit www.unhooked.com.

Nar-Anon Support for family members of addicts. Call 622-1126.

Narcotics Anonymous Call 459-8467.

Nicotine Anonymous Call 482-0108.

Obsessive Compulsive Disorder support group. Meets monthly at Virginia Beach Central Library, 4100 Virginia Beach Blvd. Call Margie, 463-4222.

Open Arms Alateen Call 463-7501.

Open Co-dependency with a Christian perspective. Call 486-7900.

Overeaters Anonymous, a 12-step program for people wishing to stop compulsive eating. Call the Tidewater OA hot line at 456-1530, or visit at www.oa.org.

Recovery for the City A 12-step group with a Biblical basis. Meets Saturdays at Freedom Fellowship Ministries, 836 Regency Drive. Call Rhonda Tatum at 428-3277.

Sexaholics Anonymous, a 12-step program. Call the hot line at 872- 6537 or e-mail [email protected]. Visit www.sa.org .

First Baptist Church of Norfolk, 312 Kempsville Road offers encouragement groups for substance abuse, depression, and conquering codependency at 6:30 p.m. on Tuesdays. Free to the public. Free child care available. Call 461-3226 for specific meeting room information.

ABUSE + SURVIVORS

Domestic violence The Samaritan House has many services, including a support group each Thursday evening with child care available. Call 631-0710, or call the crisis line any time , 430- 2120. Visit www.samaritanhouseva.org.

Domestic Violence support group, meets 6 to 8 p.m. Wednesdays. Sponsored by the YWCA of Hampton Roads. Call 625-4248.

Families United Human Potential of Tidewater. Adult, mixed-group support for individuals and families who are dealing with the effects of sexual abuse, molestation and incest. Call Linda, 853- 1313

Families of Abused Children For adult secondary victims of sexual abuse. Call 481-9521 or 482-6564.

Family Advocacy Network Services Judicial assistance and support for domestic violence victims. Call 427-4361.

Group For Abused Girls Community Psychological Resources offers a support group for sexually abused girls, ages 8 through 12. The group meets from 4 to 5:30 p.m. Mondays at 249 W. York St., Norfolk. Call 622-6794.

Help and Emergency Response Inc. A shelter for battered woman and children, H.E.R. offers substance abuse screening, evaluation and counseling to domestic violence victims seeking emergency shelter. For information call the 24-hour hot line at 485-3384.

Incest Survivor’s Anonymous A 12-step recovery program for the survivors of sexual abuse. Call 479- 3532.

Survivors of Incest Anonymous Meets Tuesdays at 7:30 p.m. at Healthy Living Solutions Inc., 3905 Granby St., Norfolk. Call 313- 2313, or visit http://healthy-living-solutions.com.

ANIMAL + WILDLIFE RESCUE

Evelyn’s Wildlife Refuge accepts wildlife native to Virginia for rehabilitation and release. Call 430-2886, or visit www.evelynswildliferefuge.org.

Hope for Life Rescue Inc . helps abandoned, abused and neglected animals. Pets for adoption. Call 491-4609, or visit www.hopeforliferescue.com.

K-9 Newlife Center , a nonprofit rescue center for dogs. Call 721- 227, or visit [email protected].

Mid-Atlantic Pug Rescue Inc., a nonprofit dedicated to providing for the needs of abandoned or surrendered pugs. E-mail [email protected], or visit www.midatlanticpugrescue.org .

Pet Guardian Pet Service Inc. a not-for-profit organization that helps special need, shelter and abandoned pets by providing food, homes and medical care. Call 428-0653, or visit www.petguardianpets.petfinder.org.

Virginia Beach SPCA, 3040 Holland Road. Call 427-0070, or visit www.vbspca.com .

Web of Life Animal Outreach Inc., a nonprofit that provides animal rescue, education and sheltering services for cats, dogs, ferrets, rabbits and other small mammals. Call 502-0340, or visit www.weboflifeanimaloutreach.com .

Wildlife Referral Line A 24-hour wildlife help line. Call 427- 0070, Ext. 7.

Wildlife Response Inc. Provides a wildlife hot line, information and outreach programs for groups and schools regarding wildlife. Call 543-7000, or visit www.wildliferesponse.org.

CHILDREN + YOUTH

Advocating 4 Kids Parents of special education students support group meets monthly at Virginia Wesleyan College, 1584 Wesleyan Drive. Contact Jody Fischer, [email protected], or call 431- 1251.

American Guild for Infant Survival Inc. For families who have lost infants to SIDS and other causes. Meetings are in Virginia Beach and are open to all. For information and directions, call 499- 0658 or 463-3845.

Exploring A career education program offered by the Tidewater Council for those ages 14 to 21 who have completed the eighth grade. Young adults may participate in community, civic and professional organizations that match their interests. Call 497-2688, Ext. 26.

Fairy Godmothers of Virginia provides a special high school prom experience for qualified high school girls whose financial situations might otherwise prevent their attendance. The group provides prom gowns, shoes and similar accessories which have been donated to the organization. Visit www.mypromdress.org , or e-mail [email protected] for more information.

His Embrace A foster care and adoptive ministry offered by Atlantic Shores Baptist Church. Meetings are held in the church fellowship hall, 1861 Kempsville Road. Free and open to everyone. Call 479-1133.

The Making A Difference Foundation accepts applications throughout the year from children of Hispanic families in need for its SAT/ACT college preparation, mentoring, tutoring and volunteer programs. Contact Stacia Bobulinski at [email protected] or 615- 6109.

National Alliance for Newborn Angels A nonprofit organization offering layettes to needy premature and newborn children of Tidewater. Call 497-2868.

Rainbows is a nonprofit that offers free support groups for children, adolescents and parents struggling with loss due to death, divorce and separation. Call Rene’e DeVenny May, 622-9852, or visit www.rainbows.org .

Seton Youth Shelters offers the following free programs. For more information, call Renee Dupuis , 306-1840: n

Anger Management for Youth. A six-week education program, meets in the evenings at St. Aiden’s Episcopal Church, 3201 Edinburgh Drive. n

Actively Parenting Teens, a six-week education program. Weekly evening sessions begin periodically. Meets at Princess Anne Recreation Center, 1400 Ferrell Pkwy. n

Support Group for Parents of Adolescents, a free support group for parents of teens in crisis, meets 6 to 7:30 p.m. Mondays at St. Aidan’s Episcopal Church . n

Drug Education for Youth, a free 10-week education program for adolescents with a history of using drugs, meets 7:30 to 8:30 p.m. Tuesdays at Crow’s Nest street outreach center in Virginia Beach.

The STOP Organization accepts applications year-round for its Head Start program. STOP serves economically disadvantaged children ages 3 to 5 and their families without regard to religion, race, sex or national origin. For information, call 858-1383.

Tidewater Youth Enrichment Coalition provides educational, health and empowerment strategies that help teens make sensible choices in regards to high-risk behaviors and help in developing career goals and plans. Agencies within the coalition are the Making a Difference foundation, the lead agency; the Hampton Roads Mexican-American Club; Lakas Ng Loob; the World Affair Council of Greater Hampton Roads and the LaTasha Colander-Richardson Foundation. Call 490-8010 or 495-5009.

Volunteer Tutor/Mentors Community Housing Partners, a nonprofit affordable housing and community development organization, needs volunteers in Portsmouth and Virginia Beach who are willing to commit a minimum of two hours per week to tutor children, as well as provide homework and summer camp assistance for at-risk youth. Call Denise Key, 673-7513; Debbie Markwood, (804) 278-9781, Ext. 17; e- mail [email protected]; or Jerome Levisy, (804) 278-9781, Ext. 27, [email protected]. Visit www.communityhousingpartners.org .

Youth Crisis Network Crisis intervention for youth and their caregivers as a means to maintain the unity of the family. A 24- hour crisis hot line and more than 370 safe sites in South Hampton Roads. Crisis hot line: 623-2627. Business office: 623-0437.

DIVORCE

Divorced/Separated/Alone support group. Call 420-5208.

Divorce Recovery Group meets Tuesdays at 6:30 p.m. in Room 308 at First Baptist Church of Norfolk, 312 Kempsville Road. A resolution- focused encouragement group for marriage separation meets on the same day and time Room 304. Free and open to the public. Free child care available. Call 461-3226.

Expose, an organization providing knowledge and legal advice concerning divorce or separation for people in the military or retired from the military. Call 499-5386.

Separation and Divorce A support group to help people cope with pain and loss during separation and divorce. Meets at 7 p.m. Thursdays at Grace Bible Church, 2961 Shore Drive. Call 496-5700.

Singles Moving On meets at 6:30 p.m. the second and fourth Sunday of each month at Emmanuel Episcopal Church, 5181 Princess Anne Road. Call 754-7067.

Starting Over as a Single For divorced, single and widowed people. Meets at 6 p.m. Sundays at Church of the Ascension, 4853 Princess Anne Road. Call 499-0843 or 495-1886, Ext. 10.

Women’s Divorce Seminars Three-hour seminars, $30. Call 456- 1574.

GRIEF

Bereavement/Grief support group. Meets at 6:30 p.m. on the last Thursday of the month at Odyssey HealthCare, 6363 Center Drive, No. 6 Lynnhaven Building, Suite 201, Norfolk. Call James Ravenell, 461- 0600.

Bereavement Support Sentara Hospice Program, along with St. Gregory the Great Catholic Church, hosts six-week sessions of a bereavement support group. Free and open to anyone 18 or older who has lost a spouse, baby or loved one through sudden death, terminal illness, suicide or accident.. Contact Roger Gauthier at 549-5652 or [email protected], or Sue Bucher at 497-8830 or [email protected]. Visit www.sentara.com/support .

Bereavement Support Group Medi Home Health & Hospice sponsors a bereavement support group the second and fourth Thursday of the month from 1 to 2:30 p.m. at Unity Renaissance Church, 1120 Eden Way N., Chesapeake. The meetings are free to the public. Call 420-7192.

Compassionate Friends, Tidewater Chapter. Support for bereaved parents, grandparents and siblings following the death of a child. Meets at 7 p.m. the third Tuesday of each month at Kempsville Presbyterian Church, 805 Kempsville Road. Call 484-8161 or 482- 5856.

Empty Arms support groups. For parents who have experienced a miscarriage, stillbirth, ectopic pregnancy or neonatal death. Call 545-2667.

Good Grief Meets Tuesdays at 6:30 p.m. in Room 313 at First Baptist Church of Norfolk, 312 Kempsville Road. Free and open to the public. Free child care available. Call 461-3226.

Griefshare, a weekly meeting for those grieving the loss of a loved one, meets from 6:30 to 8 p.m. each Thursday at Virginia Beach Community Chapel, 1261 Laskin Road. Call 428-1881.

Heartland Hospice offers a weekly bereavement support group Mondays at 10 a.m. at Old Donation Episcopal Church, 4449 N. Witchduck Road. Call 490-9323.

The Parents’ Group For parents or any person affected by the death of a child, regardless of age or cause. Call 426-1358 or 404- 3747.

Peace by Piece A program for grieving children and teens offered by Edmarc Hospice for Children in partnership with Jewish Family Service of Tidewater. Edmarc Hospice is at 516 London St., Portsmouth. Information: 967-9251, [email protected] or www.edmarc.org.

Precious Memories KCP group creates and donates boxes for parents of still-born infants. Nurses and counselors use the boxes to initiate a discussion of grieving. No artistic talent needed. Call 497-2130.

Sentara Bereavement Support Group meets the first and third Wednesday of each month at Woodlawn Memorial Gardens, 6309 E. Virginia Beach Blvd., Norfolk. Call Megan Zieger, 388-2631.

Tragedy Assistance Program for Survivors. Offers support to military spouses and families who have had a loved one die while in the U.S. military. Call (800) 959-8277, or e-mail [email protected]. Visit www.taps.org

The Virginia Sudden Infant Death Syndrome Alliance. Parents’ support group meets from 7:30 to 9 p.m. on the last Thursday of the month at St. Mark’s Catholic Church, 1505 Kempsville Road. Call Terri Newman, 548-7011, or 523-1062; or Carolyn Walker, 382-0584.

Widowed Persons Service Open to all ages who have lost a spouse. Group meets at 7 p.m. Tuesdays at First Baptist Church Norfolk, 312 Kempsville Road, Norfolk, and 1 p.m. Thursdays at Virginia Beach Christian Church, 2225 Rose Hall Drive (corner of Great Neck Road and Rose Hall Drive). Call 461-9457.

Young Widows or Widowers A bereavement organization that provides a safe environment to men and women who have lost their spouses early in life. Call 468-2144 or e-mail [email protected]. Visit www.ywow.org.

Victims Against Crime holds a homicide support group meeting from 6 to 7:30 p.m. the second and fourth Thursday of each month, except August, at the YWCA, 5215 Colley Ave., Norfolk. Call 625-4248.

HEALTH

Alert, Well and Keeping Energetic A sleeping disorder support group. Call 395-8507.

Alopecia Areata Support Group Call 631-1722 or 638-9706.

Alzheimer’s Association, Southeastern Virginia chapter. Call 459- 2405.

Alzheimer’s Support. Thalia Support Group meets at 7 p.m. third Mondays at Thalia United Methodist Church, 4321 Virginia Beach Blvd. Call Carol Guriolo, 497-5887. Kempsville group meets at Kempsville Area Library, 832 Kempsville Road, at 1 p.m. on the first Thursdays. Call Ann Hathaway at 473-8686.

Amyotrophic Lateral Sclerosis, also known as ALS or Lou Gehrig’s disease. An educational support group for patients, family and friends. Meets from 7 to 9 p.m. at Trinity Methodist Church, 903 Forest Ave., Richmond, on the second Tuesdays. Call (804) 789-1215.

American Diabetes Association offers free diabetes information. Visit www.diabetes.org or call (800) 342-2383.

American Parkinson’s Disease Association, Tidewater chapter. Meets the last Monday of the month at 1:30 p.m. in the Central Library, 4100 Virginia Beach Blvd., and the Coffee Break Group meets the first and third Wednesdays at 10 a.m. at St. Andrew’s United Methodist Church, 717 Tucson Road. Call Barb, 538-0655 or Bart, 671- 1029.

Amputee Support Association of Hampton Roads meets from 1 to 3 p.m. on the second Saturday of each month (except June and December) in a room in the back of Sentara Leigh Hospital cafeteria, 830 Kempsville Road, Norfolk. Call Richard Childers, 200-3876 or e-mail [email protected]. Hot line, 558-1052.

Angel Flight, a nonprofit group, provides free air transportation to patients needing distant, specialized medical treatment, diagnosis or evaluation. Call 318-7149.

Anorexia Nervosa and associated disorders. Call 404-3010.

Autism Society of America Tidewater chapter. Call 461-4474.

Aware Worldwide Inc. presents Positive Living, a support group for people living with HIV/AIDS. Call 310-8764 or visit awareworldwide.org.

Blood Pressure Clinic Enoch Baptist Church, 5641 Herbert Moore Road, offers a free blood pressure clinic on the fourth Tuesday of the month from 10 to 11 a.m. Call 552-0620.

Bon Secours DePaul Medical Center, 150 Kingsley Lane, Norfolk, offers ongoing community education classes, support groups and senior activities and events for all members of the community. Classes include Lamaze, childbirth preparation, breast feeding, newborn care, diabetes education, infant massage and CPR. Support groups include breast cancer, diabetes, dizziness, headache, leukemia and lymphoma, schleroderma, perinatal loss and stroke. Senior events and services include mall walking, AARP driving, exercise classes, day trips, outings, cruises and line dancing classes. Call 889-2273.

Breast Cancer Support group. Meets monthly in Portsmouth. Call 393-2829.

Brain Tumor Support Group of Hampton Roads. For patients and families of those suffering from a brain tumor. Meets at Sentara Leigh Hospital, Norfolk, classroom one, the first Tuesday of each month. Call 714-6240.

Cancer Support Group Call 395-8686.

Caregiver Support Group For caregivers of impaired or elderly adults. Meets monthly from 10 a.m. to noon at Central Library, 4100 Virginia Beach Blvd. Call 385-4135.

Celiac Sprue Association Tidewater Chapter No. 71. Norfolk support group. Call 410-5245.

Children’s Hospital of The King’s Daughters offers free and low- cost monthly classes, lectures and programs for parents and children including safe sitting for teens; parenting; Project Link; positive discipline; behavior disorders; child safety; and “Healthy You” weight control sessions for children and teens. Call 668-7035 for registration and fee information. Tuition assistance is available for qualified families.

Chiropractic Doctors On Call A free phone service for anyone with questions about chiropractic care. Call 495-0907.

Chronic Pain and Illness a Christian group that shares support and clinical knowledge. For day, location and time, call Ellen, 496- 9614.

Crohn’s and Colitis support group. Family, friends also welcome. Call 479-0029, or e-mail [email protected].

Crohn’s and Colitis Adult support group for the Hampton Roads area. Meets last Sunday of the month. E-mail [email protected] or call Mike at 870-7095.

Colon Cancer support group. For newly-diagnosed patients and those who have completed treatment. Meets the second Monday at 6:30 p.m. at Virginia Oncology Associates, 5900 Lake Wright Drive, Norfolk. Call 437-1617 or 498-9738

Diabetes support group. Call 395-8836.

Full Circle Prostate Cancer support group. Help for newly diagnosed patients as well as those who have completed their treatments. Spouses and friends welcome. Call Bob or Carol Schultz, 486-5511 or 860-8125.

Lyme disease support group Meets quarterly. Call Debbie Suddeth, 546-9864.

Mid-Atlantic Carcinoid-Neuroendocrine Tumor Association meets the third Sunday of each month at 3 p.m. on the third floor of the Norfolk Public Health Department, 830 Southampton Ave. Provides support and information for those with carcinoid cancer and other neuroendocrine diseases. Call Dina, 482-3298, Susan, 464-0642 or Sandi, 456-5331.

HIV Health Services Planning Council of Greater Hampton Roads. Offers medical and support services to people with HIV, and allocates Title I funds. The council meets on the first Thursday of the month at the Norfolk Health Department, 830 Southampton Ave., classroom A, third floor. Meetings are open to the public. Call 441- 1403.

Virginia Breast Cancer Foundation Hampton Roads chapter. Group strives to advocate, educate and eradicate breast cancer. Call Eunice McMillan at 393-2829.

M.O.W. A nonprofit advocacy group for people in Hampton Roads with disabilities. Meets on the second Tuesday of the month at Eggleston Services, 1161 Ingleside Road, Norfolk. For information, call 671-1971 or e-mail [email protected].

Pancreatic Cancer Action Network meets meetings the second Tuesday of each month at 7 p.m. in Sentara Virginia Beach General Hospital’s Community Resource Center conference room, 1080 First Colonial Road. E-mail [email protected].

Hearing Loss Association of America-Virginia Beach Chapter meets at 10:30 a.m. the first Saturday of the month except during holiday conflicts, then meets the second Saturday, at Virginia Career Institute, 100 Constitution Drive. Call Stana Piazza, 460-0074 or Ed Cooper, 496-1308.

Down Syndrome Association of Hampton Roads. Call 466-3696.

Epilepsy support network. Call 499-7155 or the Epilepsy Association of Virginia at 459-8376.

Friends with Diabetes For parents and their children in kindergarten to high school. Call 431-4026.

HIV/AIDS Social Support Group Call 622-2989.

Lee’s Friends Helping people live with cancer. Visit www.sites.communitylink.org/leesfriends or call 625-3115.

Making Better Bodies Nutrition education for HIV and AIDS diagnosed individuals. Call 343-5287.

Man-to-Man Cancer Support A one-to-one program for men with prostate cancer with help provided by trained cancer survivors. Call (888) 227-6333. Held in cooperation with Sentara Virginia Beach General Hospital. Call 395-8686.

Mended Hearts Virginia Beach Chapter 233. A network of patients, family members, friends and medical professionals dealing with heart disease. Meets monthly at Tidewater Cardiac Institute. Call 395- 8662.

Mercedes Connection Pre- and post-liver transplant support. Call 467-9102, e-mail [email protected] or visit http://members.cox.net/jacq/

Multiple Myeloma support group Call Jerry Walton, 495-8432.

Multiple Sclerosis Association of America offers free services to local people with MS. Call (800) 532-7667 or visit www.msaa.com

Myasthenia Gravis Support Group Call 431-0262.

Narcolepsy Support Group Confidential. Call 436-3047 or 479-3297 or e-mail [email protected].

National Multiple Sclerosis Society Call 490-9627; or Southside morning support group, 424-3393.

Orthopedic Care for children 18 and younger. The Khedive Shrine center will treat free of charge: scoliosis, brittle bone disease, cerebral palsy, spina bifida, club foot, rickets juvenile rheumatoid arthritis, as well as cleft lip and palate treatment. For a screening appointment, call 420-4510.

Pancreatic Cancer Action Network, Team Hope PanCAN of Tidewater. For support and meeting information, e-mail Ellen Zeltmann at [email protected], or visit www.pancan.org.

Parkinson’s Disease Young Onset Support Group meets at 3 p.m. the first Sunday of the month at First Baptist Church, 312 Kempsville Road, Norfolk. Call Ann Perkins, 486-5677.

The Phoenix Longevity Center sponsors free support groups for cancer patients and those awaiting an organ transplant. Virginia Beach groups meet weekly. Call Donna Kennon, 460-6500.

Peripheral Neuropathy Support Group Call 518-8086 or 484-4177.

Project Lifesaver Virginia Beach Police Project Lifesaver program provides a transmitter bracelet for family members with Alzheimer’s or other dementia. Call 385-2721, 580-5966 or e-mail [email protected].

Safe Return An Alzheimer’s Association program that returns loved ones who have wandered away from home. Financial assistance is available. Call 459-2405 to register.

Scleroderma support group meets at Bons Secour DePaul Medical Center, 150 Kingsley Lane, Norfolk. Call 855-5200, or e-mail [email protected].

Self Help for Hard of Hearing Meets on the first Saturdays of the month in room 104 of the Virginia School of Technology, 100 Constitution Ave. Call 460-4390 or 461-8007.

Sentara Virginia Beach General Hospital support groups. A free service for cancer patients and their families. Call 395-8686.

Sisters Network Inc. Raising breast cancer awareness in the African-American community. Call Sharon Scott at 545-5531.

Sjogren’s Syndrome Support Group Call 523-5221. Visit www.sjogrens.com for details on the Sjogren’s Syndrome Foundation Inc.

Southside Well Spouse Group For those caring for seriously ill spouses. Call 424-3393.

Stroke support group. Call 481-3321, Ext. 37.

Crohn’s and Ulcerative Colitis support group for teens and adolescents. Call 425-8521.

Tidewater Brain Injury Support Group Call Joann Mancuso at 493- 0300.

Tourette Syndrome Association, meets regularly at the Central Library, 4100 Virginia Beach Blvd. Call Jessica, 713-4881 or Stephen, 292-9329.

Trigeminal Neuralgia Association Information, assistance and regular meetings for those suffering from the cranial nerve disorder. Call Joyce Russell at 424-6117 or e-mail [email protected].

Turbans for Transformation, a faith-based, nonprofit organization provides turbans to those with hair loss. Call Pat Bessey at 426- 6393.

Vestibular/Vertigo Disorder Support Group. Call 889-5201 or 889- 4394.

Women’s Health Source Registered nurses offer information on health and Sentara services for women. Call 436-3622.

MENTAL HEALTH

Alliance for the Mentally Ill A nonprofit organization to help families of persons with mental illness. Family support group meets 7 p.m. first Wednesday of each month at Beach House, 3143 Magic Hollow Blvd. Call Gerald Lavandosky at 424-0856.

Hope House Foundation has a speakers bureau to provide information about adults with mental retardation to provide information to civic, church and community groups. Call Stephanie Knowles, 625-6161, Ext. 24.

Tidewater Child Development Services, an affiliate of the Virginia Department of Health, offers mental health assistance and evaluation and diagnosis of developmental, behavioral, emotional and learning disorders to children and young adults through age 21 of families in need throughout southeastern Virginia, regardless of ability to pay. Children are seen by a team of professionals. Counseling is available. Call 683-8770.

Attention Deficit Disorders The Tidewater Children and Adults with Attention Deficit Disorder meets the first Thursday of each month for parents of children with ADD/ADHD (adults only, no children) and the second Thursday of each month for adults who have ADD/ADHD. Both meet from 6:45 to 8:45 p.m. at the Barry Robinson Center, 443 Kempsville Road, Norfolk. Call 479-9993, or visit www.tidewaterchadd.org.

Concerned Citizens for Special People An advocacy group for family members of people of any age with developmental disabilities. Meets at Thalia Baptist Church, 4392 Virginia Beach Blvd. Call 490- 0499.

Suicide Crisis Line A 24-hour suicide and crisis intervention service. Call 622-1126.

Depressive/Manic Depressive Support Group. Meets Thursdays in the library at Eastern Shore Chapel, 2020 Laskin Road, from 7 to 8:45 p.m . Call 340-3820.

The Mental Health Substance Abuse Division of the Virginia Beach Department of Human Services offers the following services. Call LeAnne Brant, 437-5787. n

Chit Chat is an on-going support and education group for people whose lives are affected by the substance use of another, particularly those waiting to start the next session of Friends and Family or people who have completed Friends and Family Education. The group meets from 6:30 to 8:30 p.m. Thursdays at the Human Services Building, 3432 Virginia Beach Blvd. Free, with no residency requirement. n

Friends and Family Education classes for adult family members and friends of people whose substance use is affecting their lives. Free six-week sessions start periodically and meet from 6:30 to 8:30 p.m. on Tuesdays. n

MESA Family Workshops for parents, siblings, spouses or other relatives of adults with mental illness. Free twelve-week sessions meet from 6:30 to 8:30 p.m. Wednesdays. n

A speakers bureau is available to visit churches and other faith- based communities and speak on mental illness issues.

Norfolk Mental Health Services’ psycho-social day program offers a speaker for free presentations to groups and organizations interested in learning about mental illness and its impact on patients, families and friends. Call John Creekmore, educational specialist, at 441-1170.

Regent University Psychological Services Center, staffed by doctoral students in the clinical psychology program, accepts referrals for psychological testing and counseling. Call 226-4488.

MISCELLANEOUS

Adventist Community Services A nonprofit organization that offers food, clothing, disaster relief and employment services to the sick, elderly and home-bound. The group offers companionship, housework help, grocery shopping and transportation. Call 479-2147 or 479- 0699.

Birthright An emergency pregnancy service that provides counseling, a hot line and community resource referrals. Call 489- 0222.

Barrett Haven Inc., a nonprofit corporation, provides housing and employment opportunities to single and single pregnant homeless women. Call 624-6990.

Catholic Charities of Eastern Virginia Inc. offers support groups and classes that meet on an ongoing basis. These include: n

Anger management classes; court-approved classes for adults. Call 467-7707. n

Consumer credit counseling services and home ownership classes held throughout the area. Call 484-0703. n

Mediation services to help couples requiring assistance in resolving conflict. Call 467-7707. n

“Alcohol 101,” a court-approved class for ages 16 to 21. Counsels young people on the consequences of alcohol use. Call 467-7707. n

Caregiver Support Group; call 533-5217 n

Free baby layettes for mothers in need. Call 490-4931 . n

Free pregnancy screening and counseling. Call 467-7707 . n

Help for Elderly People project assists low-income seniors with transportation to medical appointments and to run errands, and provides friendly visiting. Call 490-4931 n

Respite Care provides short-term in-home care by appointment for a fee. Call 533-5217. n

Grandparents as parents or relatives as parents support groups. Call 467-7707 . n

Cooperative parenting classes for individuals who are parenting from two separate homes. Call 467-7707.

The Community Mediation Center may help to resolve civil court conflicts in a confidential setting, at no cost, through its certified mediation program. Assistance is available to anyone with a civil case scheduled in the Virginia Beach General District Court on Mondays, Wednesdays or Fridays. Mediation is an alternative dispute resolution process sanctioned by the Supreme Court of Virginia and the Virginia Beach courts. If an agreement is reached, the case may be dismissed. If no agreement is reached, the judge will hear the case on the same day. Talk to certified professional mediators in the hall outside Courtroom 3 or 4, or call 480-2777. Visit www.ConflictCrushers.org .

Funeral Consumers Alliance of Tidewater Local chapter of the national Funeral Consumers Alliance. A nonprofit membership organization not connected with the funeral or cemetery industries that promotes simplicity and economy in funeral arrangements. Call 428-5134 for meeting information, or visit www.funerals.org.

Grow-Line Call a Virginia Beach master gardener volunteer at 427- 8156.

Helping Hands/Partners in Clean A Virginia Beach Clean Community Commission program that links the efforts of residents with community resources to assist senior citizens or physically challenged people in maintaining their yards. Call 427-4104 for a site recommendation form.

International Seaman’s House, 1222 W. Olney Road, Norfolk. Services to crews of ships entering local ports. Transportation, clothes closet, computer, recreation room, food and beverages. Religious services and counseling. Call 623-4222, or e-mail [email protected].

Loving Incarcerated Persons LIPS holds monthly meetings in Portsmouth as an outreach ministry of Tidewater Baptist Women’s Missionary and Educational Convention to support people with loved ones in jail or prison. Call 393-9407.

Oasis Opportunity Center, 1420 Chestnut St., Portsmouth. A nonprofit that aims to end homelessness. Soup kitchen, food pantry and thrift store. Job-related services, literacy education and housing assistance. Call 398-1970.

Operation Blessing offers help to children and families who need food, medical care, disaster relief, education and life essentials. The group needs donations, too. Call (800) 730-2537, or visit www.ob.org.

Project Light Learning Center at Providence Presbyterian Church, which helps children and adults improve reading skills, learn English as a second language or prepare for the GED test, has several seats available, at no charge, for students. After-school and evening classes are held twice a week at the church, 5497 Providence Road. Call Sandra Rushton, 467-2095.

Sher-Ker’s HOPE Inc. A nonprofit organization offering help to families with dire needs. Food, clothing, infant supplies and house hold items are provided to local families. Visit http:// groups.yahoo.com/group/sherkershopeinc/ or call Keri, 467-0090.

Small Business Help Free counseling by retired executives on Thursdays at 222 Central Park Ave., Suite 1000. Call 385-6412.

Virginia Beach Jaycees offers help to groups and organizations with community projects. Call 499-8822 and leave a message.

Women’s Therapy Child and Family Services of Eastern Virginia offers a therapy group for women in assertiveness and overcoming fear of conflict and anger from 6 to 7:30 p.m. Thursdays at 222 W. 19th St. Sliding scale fee. Call Mary Brantley, group facilitator, 622-7017.

MILITARY + VETERANS

Hampton Roads Auxiliary assists active-duty and retired service members as well as their families and survivors. Call 425-5789.

Disabled American Veterans, Virginia Beach Chapter 20. Certified male and female service officers assist veterans, widows, spouses or survivors file claims for benefits. Free. Call 519-9931, Ext. 4.

Military Wives Support Group, meets at 6:30 p.m. Wednesdays at London Bridge Baptist Church, 2460 Potters Road. Child care is provided. Call 486-7900, Ext. 40.

Navy-Marine Corps Relief Society Call 423-8830.

Navy Retired Activities Office Help for retirees, their family members, surviving spouses and former spouses of retirees in finding their entitled services and benefits. Call 462-8101 or 462-7763.

PARENTING

Adoptive Parents Support Group Provides education and support. Call Melinda Spence at United Methodist Family Services, 490-9791, Ext. 18, or e-mail at [email protected].

Adoption and Foster Care United Methodist Family Services offers free training and child placement to people who are interested in becoming an adoptive or foster parent. Financial assistance available. Call 490-9791.

Cooperative Co-Parenting, classes for parents who do not live in the same house. Sessions meet 5 to 9 p.m. third Tuesdays, and 8:30 to 12:30 p.m. first or third Saturdays at the Community Mediation Center offices, 588 Virginian Drive, Norfolk. The class fulfills Juvenile and Domestic Relations Court mandatory requirements for parents in custody hearings to attend a parenting class and is taught by certified family mediators. Cost is $40; couples, $60 and financial aid is available. Registration is required. Call Daryl Parks at 480-2777, Ext. 251, or visit www.ConflictCrushers.org.

Divorced Dads with Daughters A support group for separated or divorced dads who have visitation on Wednesdays and Saturdays. Dads will participate in activities such as dining out, in-line skating, bike riding, boogie boarding and shopping trips. Call 377-0400.

Exceptional Family Member Support for families with children with medical, educational or emotional needs. Call 460-1236.

Families of Autistic Children in Tidewater E-mail [email protected] or call 481-0970.

Foster Care Training United Methodist Family Services provides free training and child placement to individuals interested in becoming an adoptive or foster parent. Call 490-9791.

Grandparents as Parents support group. Call 490-4931.

Hampton Roads Families With Children from China welcomes families who have adopted or are preparing to adopt children of Chinese origin. Contact [email protected]

Moms Offering Moms Support club. To find a nearby chapter, e- mail [email protected], or visit www.momsclub.org. The Virginia Beach Southeast chapter (Red Mill, Strawbridge, Princess Anne, Ocean Lakes, and Creeds school districts) meets the first Monday of the month at 10 a.m. at Nimmo United Methodist Church, 2200 Princess Anne Road. E-mail [email protected]. Virginia Beach North (23452 and 23455 zip codes) meets the first Monday of the month at 10 a.m. at Thalia Trinity Church, 420 Thalia Road. Call Maureen, 692-6307.

Mothers of Multiples in Tidewater A support group for mothers and mothers-to-be of twins, triplets and more. Meets at Bayside Presbyterian Church, 1400 Ewell Road. Call 721-2329 or 427-2263.

Mothers with Bipolar Children and Adolescents. A support group meets on the second Thursdays from 6 to 7 p.m. at The Psychotherapy Center, 327 W. 21st St., Suite 205, Norfolk. Call 622-9852.

Parent Connection A support group that offers classes for parents of younger children and teenagers. Call 622-9622, Ext. 19.

Parents Without Partners A nonprofit support group for separated divorced, widowed or never married parents. Chapter 216, call 498- 2666 or 471-5650; and Chapter 166 (offering dances as well as support), call 428-2566.

TOUGHlove Parent Support A program for parents troubled by unacceptable teenage behavior. Call 481-7674.

Virginia Fatherhood Initiative Call 545-3237. Statewide nonprofit focusing on issues affecting fathers and their children. Call 545- 3237.

SENIORS

AARP Driver Safety Program offers classroom refresher courses to persons 50 or older. Classes are $10 and are held regularly in the local area. Some drivers age 55 or older may receive auto insurance premium reduction after completing the course. Call (888) 227-7669 for class location and times. Class information is also available at www.aarp.org/drive .

AARP Foundation Senior Employment Service has job openings in Virginia Beach. Individuals 55 and older may call 625-7001.

The Citizen’s Committee to Protect the Elderly offers visits to the elderly in long-term care facilities. Call 518-8500, from 10 a.m. to 6 p.m. weekdays.

ElderCare Legal Services hosts monthly seminars for seniors and baby boomers on “Protecting Your Assets and Inheritances: Finding Funds for Long-Term Care Costs.” Call 486-6570 or visit www.eldercarelegal services.com.

Senior Services of Southeastern Virginia Long-term care services designed to identify, inform and assist older Virginians through providing access to services, resources and care coordination; special employment programs for seniors; a senior nutrition program and some transportation for doctor appointments between 8:30 a.m. and noon. Call 461-9481 or visit www.ssseva.org.

Tidewater Association For Continuity of Care. Call Linda Tilley, 672-8465.

Virginia Beach Clean Community Commission offers a program that helps senior citizens and disabled homeowners maintain their properties with the help from volunteers. Residents can nominate themselves or be nominated by family or neighbors. Call 385.4104 or visit www.vbgov.com/vbclean .

WEIGHT ISSUES

Taking Off Pounds Sensibly Meetings every day in Virginia Beach. Call (800) 932-8677 to find out more.

Weight Loss Surgery Support Group Weekly meetings for post- operative patients during their time of rapid change. Contact Dr. Beverly Shropshire Orr, 474-6004, Ext. 405.

(c) 2007 Virginian – Pilot. Provided by ProQuest Information and Learning. All rights Reserved.

By Guzelmeric, Kadir Alkan, Nevriye; Pirimoglu, Meltem; Unal, Orhan; Turan, Cem

Abstract Background. Women with polycystic ovary syndrome (PCOS) are insulin-resistant and have increased risk for type 2 diabetes mellitus (T2DM) and coronary heart disease (CHD). But it is controversial whether the increased risk of CHD and T2DM is associated with endocrine abnormalities occurring as a consequence of PCOS or whether it is related to obesity or metabolic changes frequently seen in women with PCOS.

Objective. Since both homocysteine (Hey) and C-reactive protein (CRP) are supposed to predict T2DM and CHD, we investigated their possible relationship with insulin resistance, obesity, hyperandrogenemia and metabolic alterations in 44 PCOS women and 26 healthy controls matched by age and body mass index (BMI).

Results. Hey and CRP levels were significantly elevated in PCOS women compared with controls (13.30 +- 4.81 vs. 9.02 +- 3.36 [mu]mol/ l, p 0.05). Multiple regression analysis revealed BMI as the major factor examined that influenced both Hey and CRP levels.

Conclusions. In PCOS women, plasma levels of Hey and CRP were significantly elevated compared with age- and BMI-matched controls. Although most of the PCOS-related endocrine and metabolic changes are related to elevated plasma Hey and CRP levels in PCOS women, BMI seems to be the major factor determining CHD and T2DM in women with PCOS.

Keywords: Homocysteine, C-reactive protein, insulin resistance, body mass index, polycystic ovary syndrome

Introduction

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder of women of reproductive age and is associated with long- term health risks, including type 2 diabetes mellitus (T2DM) and coronary artery disease [1,2]. In particular, the insulin resistance, hyperandrogenemia and dyslipidemia associated with PCOS are major risk factors for coronary heart disease (CHD) [1-3].

Hyperhomocysteinemia is another important risk factor for the development of coronary and thromboembolic diseases [4]. Homocysteine (Hey) is a sulfur-containing amino acid formed during the metabolism of methionine [5]. Classic hyperhomocysteinemia has been characterized as the accumulation of Hey due to defects in enzymatic pathways [4]. Elevated plasma Hey induces oxidation of low- density lipoprotein (LDL), proliferation of smooth muscle cells, increased platelet adhesiveness and endothelial cytotoxicity [4-6]. It has been reported that insulin levels are associated with increased plasma levels of Hcy in healthy, non-obese subjects [7]. In addition, an association between insulin resistance and plasma Hcy concentrations has been described [8].

Inflammation is thought to play a key role in the pathophysiological mechanism of atherosclerosis and CHD [9]. C- reactive protein (CRP) is known to be a significant predictor of CHD and future cardiovascular events [9,10]. Recently, low-grade chronic inflammation has been linked to obesity and the insulin resistance syndromes, such as PCOS [11].

In the present study we investigated the possible relationships of plasma Hey and CRP levels with insulin resistance, obesity and known biochemical markers in PCOS women.

Materials and methods

Subjects

Between December 2004 and July 2005, 44 women (mean age: 23.5 + 4.7 years) with PCOS were enrolled in this study. The diagnosis of PCOS was made using menstrual, laboratory and ultrasound criteria. Menstrual criteria included oligo- and amenorrhea (cycle length irregular, >45 days or 2) and elevated plasma testosterone levels at the upper limit of the range (0.10-1.30 ng/ml). Ultrasound criteria used for diagnosis were normal or enlarged ovaries with the presence of microcysts (2-8 mm in diameter) and a hyperechogenic stroma. Serum prolactin, thyroid hormone and 17-hydroxyprogesterone (17- OHP) determinations were done on all patients and were within normal limits. All patients included in the study had not taken ovulation induction agents, glucocorticosteroids, antiandrogens or antihypertensive medications in the previous 6 months.

Twenty-six non-hirsute, regular cycling women, matched to cases in terms of body mass index (BMI) and age (mean age: 25.85 +- 5.82 years), who had been subject to the same menstrual, laboratory and ultrasound tests and had no ultrasound or clinical signs of PCOS, served as controls. Smoking status, coffee consumption and lifestyle were similar between cases and controls.

Each patient was examined to evaluate hirsutism according to the modified Ferriman-Gallwey score. BMI was computed as weight divided by the square of height (kg/m^sup 2^).

Laboratory tests

Hormonal assays and ultrasonography were performed during the early follicular phase, between the 3rd and the 5th days of the patients’ spontaneous or progestin-induced menstrual cycle. Blood samples were taken early in the morning subsequent to an overnight fast. Plasma was removed and stored at -20[degrees]C until analyzed.

Blood glucose was measured by the glucose dehydrogenase method on the Gobas Mira laboratory system (Roche Diagnostics GmbH, Mannheim, Germany). Insulin was measured by a commercial radioimmunoassay kit (Pharmacia, Stockholm, Sweden) with a lower limit of sensitivity of

Total plasma Hcy was assayed by fluorescence polarization immunoassay by the IMX System (Abbott Diagnostics, Wiesbaden, Germany). The intra-assay CV was 2.8% and inter-assay CV was 3.8- 5.0%.

Insulin resistance was determined from fasting glucose and insulin as HOMA-IR (homeostasis model assessment-insulin resistance) index: HOMA-IR= [glucose (mmol/1) x insulin (mIU/l)]/22.5. Correlations between clinical or biochemical parameters and insulin resistance were calculated using this index.

CRP was measured with a turbidimetric test (Wako, Neus, Germany) with the Gobas Mira laboratory system. Again all samples were analyzed in one assay. The intra- and inter-assay CVs were 17% and 12%, respectively.

Total testosterone was assayed by automated electrochemiluminescence immunoassay (Roche), while radioimmunoassays were used for free testosterone, 17-OHP and dehydroepiandrosterone sulfate (DHEAS) (Diagnostic Products Corporation, Los Angles, CA, USA). The intra- or inter-assay CVs were 9.5% and 11.8% for 17-OHP; 4.9% and 7.5% for total testosterone; 6.2% and 9.7% for free testosterone; and 5.2% and 7.7% for DHEAS.

Statistical analyses

All results are expressed as mean +- standard deviation, unless otherwise stated. Differences between the two groups were evaluated with use of the Student t test and the non-parametric Mann-Whitney U test for variables with persisting skewed distribution. The Kolmogorov-Smirnov test was used to evaluate whether the variables were normally distributed or not. Pearson’s correlation test was employed to analyze the correlations between parameters. In addition, the significance of the correlation and the relative contribution of each variable were calculated by single or multiple regression analyses, respectively. Significance was set as p

Results

The characteristics of the PCOS patients are summarized in Table I. As anticipated, in the PCOS women, total testosterone, free testosterone, LH/ FSH ratio, 17-OHP and DHEAS were significantly increased (p

The groups were similar in age. Their risk factors related to cardiovascular disease were significantly different, although BMI was not significantly different in PCOS cases compared with controls (26.50 +- 4.7 vs. 24.13 +- 3.59 kg/m^sup 2^, p > 0.05). Ferriman- Gallwey scores were significantly higher in the PCOS patients than in the control group (13.95 +- 6.7 vs. 5.27 +- 1.5, p

Table I. Clinical, hormonal and metabolic features of women with polycystic ovary syndrome (PCOS) and healthy controls.

Pearson correlations were calculated in order to define parameters associated with plasma levels of Hcy and CRP. There was no correlation between Hcy and CRP (r=0.171, p=0.05) as two risk markers. While plasma Hcy levels were correlated with BMI, LH/FSH ratio, total testosterone, free testosterone, triglyceride, insulin levels and HOMA-IR, CRP was correlated with BMI, total cholesterol, triglyceride, LJDL cholesterol, insulin levels and HOMA-IR (Tables II and III). There was no correlation of CRP with parameters of PCOS such as total testosterone and LH/FSH ratio. Plasma Hcy levels were associated with obesity, metabolic alterations or endocrine changes in PCOS women. Linear regression models were calculated to further investigate whether obesity (BMI) and insulin resistance (HOMA-IR) are predictors of Hcy or CRP concentrations. HOMA-IR was not associated with Hcy and CRP levels, after inclusion of BMI into the model. Both Hcy and CRP concentrations were significantly affected by BMI with adjusted R^sup 2^ of 0.12 and 0.14, respectively (Figure 2). In the case of Hcy, the beta coefficient of the model was 0.349 (p = 0.003) for BMI and 0.182 (p = 0.13) for HOMA-IR. With CRP as the dependent variable, the beta coefficient for BMI was 0.383 (p = 0.001) and for HOMA-IR was 0.179 (p = 0.131). In addition, PCOS status was not a significant independent factor affecting Hcy and CRP levels. Obesity seems to be the dominant factor determining Hcy and CRP values in PCOS women. Finally, multiple linear regression analysis showed that hormone levels and metabolic alterations are not predictors of CRP or Hcy levels in both PCOS and control women.

Figure 1. Serum homocysteine (Hcy) and C-reactive protein (CRP) concentrations in 44 patients with polycystic ovary syndrome (PCOS) and 26 age-matched healthy controls. Results are expressed as means, with standard deviation shown by vertical bars. For discussion, see text.

Discussion

Moderately increased total Hcy level is associated with an increased risk of atherosclerosis [6,7]. High Hcy concentrations may be associated with demographic, genetic, nutritional or metabolic factors [12-15]. Hyperhomocysteinemia induces sustained injury to the arterial endothelial cell, which accelerates the development of thrombosis and atherosclerosis [4,6,16]. On the other hand, the results of recent studies suggested that CRP, rather than being only a marker of low-grade inflammation, may directly promote endothelial dysfunction and complement activation and therefore could play an active role in atherogenesis [17,18]. Insulin resistance syndromes such as T2DM and PCOS have been linked to elevated plasma Hey levels [11,19]. Moreover, it has been shown that women with PCOS, as in T2DM, have significantly increased CRP concentrations relative to healthy subjects [10,20].

Table II. Correlations between homocysteine (Hcy) and the investigated variables.

Table III. Correlation between C-reactive protein (CRP) and the investigated variables.

Figure 2. Plasma homocysteine (Hcy) and C-reactive protein (CRP) as a function of body mass index (BMI).

In the present study both plasma Hcy levels and CRP concentrations in PCOS women were significantly elevated, with values higher than the upper range limits, compared with healthy controls. In comparison to matched controls PCOS women had greater serum insulin concentrations and HOMA-IR, confirming previous data.

While plasma Hcy levels were correlated with BMI, LH/FSH ratio, total testosterone, free testosterone, triglyceride, insulin levels and HOMA-IR, CRP levels were correlated with BMI, total cholesterol, triglycerides, LDL cholesterol, insulin levels and HOMA-IR. There was no correlation of CRP with parameters of PCOS such as total testosterone and LH/FSH ratio. This indicates that obesity and metabolic alterations associated with PCOS have more impact than other markers on chronic inflammation in PCOS women. This observation is consistent with previous data demonstrating a lack of association between total testosterone and lipid and lipoprotein subfraction concentrations in women with PCOS [21]. In another recent study, urinary sex hormone metabolites were not related to an increased CHD risk in women [22]. Plasma Hcy levels were associated with obesity, metabolic alterations or endocrine changes in PCOS women. Hcy and CRP were not dependent on one another although both were elevated in PCOS patients in comparison with BMI-matched controls.

Multiple regression analysis demonstrated that hormone levels and impaired lipid profile were not predictors of elevated levels of Hcy or CRP in women with PCOS, suggesting that hyperhomocysteinemia or high CRP concentrations are not affected by hyperandrogenemia or hyperlipidemia. In our study, although both high Hcy and CRP levels correlated with BMI and insulin sensitivity, stepwise linear regression analysis showed that BMI was the only strong predictor of serum Hcy and CRP concentrations both in PCOS patients and controls. In contrast, most studies have demonstrated insulin resistance as the determinant of Hcy in PCOS women and not necessarily body weight [8,23]. But there are studies showing the significance of the relationship between insulin levels and hyperhomocysteinemia as debatable. Giltay and colleagues found a significant association between high insulin levels and elevated Hcy plasma levels in healthy, nonobese subjects [7]. On the other hand, Abbasi and associates showed that plasma Hcy levels did not vary as a function of insulin-mediated glucose disposal [24]. Kilic-Okman and co- workers showed that age, BMI and insulin resistance were not predictors of Hcy [25], while Schachter’s group found that insulin resistance and hyperinsulinemia in patients with PCOS was associated with elevated plasma Hcy, regardless of body weight [23].

A number of variables that were not examined in this study, such as renal function, vitamin B status and enzyme dysfunction states, influence Hcy levels. Plasma Hcy levels may be influenced by genetic and non-genetic factors (diet, age, pregnancy, menstrual cycle) [12- 14]. In our study, the patient group and the control group were in similar age and all blood samples were collected during menstruation. Because of the conflicting data on the relationship between insulin and hyperhomocysteinemia in PCOS, we also included CRP concentrations as another cardiovascular risk parameter.

It has recently been reported that visceral adiposity correlates with CRP concentrations independently of total adiposity in a cross- sectional study of men [27]. This shows that adipose tissue-derived cytokine expression (tumor necrosis factor-alpha and interleukin-6) may be an important contributor to low-grade chronic inflammation. That means that accumulation of visceral adipose tissue may be the underlying feature of the metabolic syndrome and of low-grade chronic inflammation. These observations would explain the correlation of insulin resistance to CRP, as declined by Festa and colleagues [26].

Although not measured in our study, women with PCOS are likely to have increased visceral fat mass relative to BMI-matched controls. Mohlig and collaborators also revealed that BMI rather than HOMA-IR index was the dominant parameter determining serum interluekin-6 and CRP concentrations in women with PCOS [28].

In conclusion, we have shown that CRP concentrations, a marker of low-grade inflammation and CHD risk, measured using a highly sensitive assay, are significantly increased in PCOS women with elevated Hcy levels relative to those in BMI-matched healthy women. The main factor predicting Hcy and CRP levels in PCOS was BMI. Thus CHD or T2DM risk level in PCOS appears to be enhanced mainly by obesity, regardless of endocrine abnormalities. Further prospective studies are needed in order to confirm whether raised Hcy and CRP levels in young PCOS patients serve as a real risk marker depending on BMI.

References

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3. Solomon CG. The epidemiology of polycystic ovary syndrome. Endocrinol Metab Clin North Am 1999;28:247-263.

4. Clarke R, Lewington S, Donald A, Johnston C. Underestimation of the importance of homocysteine as a risk factor for cardiovascular disease in epidemiological studies. J Cardiovasc Risk 2001;8:363-369.

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6. Refsum H, Ueland PM, Nygard O, Vollset SE. Homocysteine and cardiovascular disease. Annu Rev Med 1998;49:31-62.

7. Giltay EJ, Hoogeveen EK, Elbers JMH, Gooren LJG, Asscheman H, Stehouwer CDA. Insulin resistance is associated with elevated plasma total homocysteine levels in healthy, non-obese subjects. Atherosclerosis 1998; 139:197-198.

8. McCarty MF. Insulin secretion as a potential determinant of homocysteine levels. Med Hypotheses 2000;55:454-455.

9. Alexander RW. Inflammation and coronary heart disease. N Engl J Med 1998;331:468-469.

10. Ridker PM, Henekens CH, Buring JE, Rifai N. C-reactive protein and other markers of inflammation in the prediction of cardiovascular disease in women. N Engl J Med 2000;342: 836-843.

11. Kelly CCJ, Lyall J, Petrie JR, Gould WG, Connell JMC, Satter N. Low grade inflammation in women with polycystic ovarian syndrome. J Clin Endocrinol Metab 2001;86:2453-2455.

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14. Guttormsen AB, Schneede J, Fiskerstrand T, Ueland PM, Refsum HM. Plasma concentrations of homocysteine and other aminothiol compounds are related to food intake in healthy human subjects. J Nutr 1994;124:889-891.

15. Wijeyaratne CN, Nirantharakumar K, Balen AH, Earth JH, Sheriff R, Belchetz PE. Plasma homocysteine in polycystic ovary syndrome: does it correlate with insulin resistance and ethnicity? Clin Endocrinol (Oxf) 2004;60:560-567. 16. Fonesca V, Guba SC, Fink LM. Hyperhomocysteinemia and endocrine system: implications for atherosclerosis and thrombosis. Endocr Rev 1999;20:738-759.

17. Pasceri V, Willerson JT, Yeh ET. Direct proinflammatory effect of C-reactive protein on human endothelial cells. Circulation 2000; 102:2165-2168.

18. Blake GJ, Ridker PM. Inflammatory biomarkers and cardiovascular risk prediction. J Intern Med 2002;252:283-294.

19. Temelkova-Kurktschiev T, Henkel E, Koehler C, Kame K, Hanefeld M. Subclinical inflammation in newly detected type II diabetes and impaired glucose tolerance. Diabetologia 2002;45:151.

20. Danesh J, Collins R, Appleby P, Peto R. Association of fibrinogen, C-reactive protein, albumin or leukocyte count with coronary heart disease: meta-analyses of prospective studies. J Am Med Assoc 1998;279:1477-1482.

21. Pirwani I, Fleming R, Greer IA, Packard CJ, Sattar N. Lipids and lipoprotein subfractions in women with women with PCOS. Clin Endocrinol (Oxf) 2001;54:447-454.

22. Gorgels WJ, Graaf Y, Blankenstein MA, Collette HJ, Erkelens DW, Banga JD. Urinary sex hormone excretions in premenopausal women and coronary heart disease risk: a nested case-referent study in the DOM-cohort. J Clin Epidemiol 1997;50:275-281.

23. Schachter M, Raziel A, Friedler S, Strassburger D, Bern O, Ron-El R. Insulin resistance in patients with polycystic ovary syndrome is associated with elevated homocysteine. Hum Reprod 2003; 18:721-727.

24. Abbasi F, Facchini F, Humphreys MH, Reaven GM. Plasma homocysteine concentrations in healthy volunteers are not related to differences in insulin-mediated glucose disposal. Atherosclerosis 1999;146:175-178.

25. Kilic-Okman T, Guldiken S, Kucuk M. Relationship between homocysteine and insulin resistance in women with polycystic ovary syndrome. Endocr J 2004;5:505-508.

26. Festa A, D’Agostino RJ, Howard G, Mykkanen L, Tracy RP, Haffner SM. Chronic subclinical inflammation as part of the insulin resistance syndrome: The Insulin Resistance Atherosclerosis Study (IRAS). Circulation 2000; 102:42-47.

27. Lemieux I, Pascot A, Prud’homme D, Aimeras N, Bogaty P, Wadeau A, Bergeron J, Despres JP. Elevated C-reactive protein: another component of the atherothrombotic profile of abdominal obesity. Arteriscler Thromb Vase Biol 2001; 21(6):961-967.

28. Mohlig M, Spranger J, Osterhoff M, Ristow M, Pfeiffer AF, Schul T, Schlosser HW, Brabant G, Schon C. The polycystic ovary syndrome per se is not associated with increased chronic inflammation. Eur J Endocrinol 2004; 150:525-532.

This paper was first published online on iFirst on 6 August 2007

KADIR GUZELMERIC, NEVRIYE ALKAN5 MELTEM PIRIMOGLU, ORHAN UNAL, &

CEM TURAN

Department of Obstetrics and Gynecology, Dr Lutfi Kirdar Kanal Education and Research Hospital, Istanbul, Turkey

(Received 8 February 2007; revised 4 April 2007; accepted 4 July 2007)

Correspondence: K. Guzelmeric, 34 Ada Yesim Sitesi Blok 12 Daire 8 Atasehir, 34758 Kadikoy, Istanbul, Turkey. Tel: 90 216 4566146. Fax: 90 216 3064294. E-mail: [email protected]

Copyright Taylor & Francis Ltd. Sep 2007

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

Evidence of Vincent van Gogh’s troubled mind can be seen in the genius’s brush strokes.

The proof is in the dark colors of “The Potato Eaters,” the globs of paint on “Wheatfield with Reaper” and in his serene yet solemn image in “Self Portrait with Pipe and Bandaged Ear.”

It doesn’t take an artist to see it.

It takes a doctor.

And Dr. Peter Whybrow is among the latest to diagnose one of the greatest artistic luminaries of the past 150 years.

Whybrow, director of the Semel Institute for Neuroscience and Human Behavior at UCLA, presented van Gogh’s life as a case study to a packed auditorium of Kern Medical Center staff Wednesday.

His diagnosis: manic depression.

“Vincent was not a great artist because he had manic depressive disorder,” he said. “But that may have shifted how he looked at painting.”

Manic depression, also known as bipolar disorder, is characterized by periods of excitability alternating with depression, according to the National Institutes of Health. People with this disorder can experience hyperactivity, lack of self-control, delusions of grandeur, reckless behavior, sexual promiscuity, difficulty concentrating, little need for sleep and poor control of their temper.

Whybrow studied the volumes of letters from the painter to his family, along with his paintings, and believes van Gogh suffered 13 psychotic episodes that lasted from one week to two months.

“One thing that manic depression does is break down the boundaries” of the mind, Whybrow said.

The Dutch painter first started experiencing the extreme ups and downs when he moved to London in 1874 as a curator, Whybrow said.

Van Gogh wrote that the gallery’s paintings provoked “violent emotion to the point of rapture.”

His emotions then plummeted after being rejected by Ursula, his landlady’s daughter.

To lift his spirits, van Gogh left London and pursued religion, flagellating himself with a cudgel or whip, Whybrow said.

He worked as an evangelist in the Borinage mining country of Belgium, and a few years after his younger brother, Theo, promises to financially support his painting, his psychosis shows up on the canvas.

His paintings from 1883 to 1886, which include “The Potato Eaters” and “Farmhouses Near Hoogeveen” are painted in dark browns, almost sepia tone. “The Flying Fox,” which shows a bat, wings spread, particularly depicts his melancholy, Whybrow said.

That changed after van Gogh moved to Paris with Theo in 1886, where he met several Impressionist painters. His mood lifted, which can be seen in the brightness of the palette, like in “Boulevard de Clichy.” He gave a sense of life to his work, like the running water in “Banks of the Seine.”

He drank absinthe, a bitter, green liqueur that can cause hallucinations and impulsive violence, Whybrow said, and probably exacerbated his illness.

“It seems as if he were two persons; one marvelously gifted, tender and refined, the other egotistic and hard-hearted,” Theo wrote of his brother. “They present themselves in turns.”

Van Gogh’s brushstrokes became bolder and laden with paint.

Van Gogh moved to Arles, France, with artist Paul Gauguin.

“The local population was scared of them,” Whybrow said. “They didn’t bathe too often.”

It is here, in December 1888, that van Gogh cut off his ear lobe, wrapped it in drawing paper and presented it to a local prostitute, Rachel, who van Gogh and Gauguin were attracted to.

Self-mutilation was featured frequently in the artist’s depressive delusions, Whybrow said.

“Vincent felt that prostitutes were fallen angels,” Whybrow said. “He protected them.”

Van Gogh was carted off to an asylum. He began to accept his “role as madman,” considering his madness is an illness like any other.

“He is a man before his time,” Whybrow said. “We have trouble doing that even now.”

During the 70 days before his death, he was hyperactive, producing 77 paintings and 30 drawings.

In 1890, at the age of 37, he shot himself in the chest but was a terrible shot, Whybrow said.

“He crawls back to the room and bleeds,” Whybrow said. “He dies, with Theo in attendance, from blood loss days later.”

Van Gogh’s illness has long perplexed physicians, who have offered up 30 different diagnoses, including lead poisoning, many psychiatric disorders and Meniere’s disease, a disorder of the inner ear, according to a paper published April 2002 in the American Journal of Psychiatry.

It’s useful to know how bipolar disorder manifests over a lifetime if left untreated, said Dr. Tai Yoo, joint chairman of psychiatry for Kern Medical Center and Kern County Mental Health.

If van Gogh had been treated, would he have been as prolific?

“Maybe a little less productivity, but the talent was still there,” Yoo said.

The illness did not produce those paintings, Whybrow said. The man did.

“Great artists are not made by madness.”

Rogue Valley Manor (RVM), a 668-acre Continuing Care Retirement Community by Pacific Retirement Services, Inc., is pleased to announce its recent ‘A’ rating from Fitch Ratings. Fitch has assigned an underlying ‘A’ rating to the $65 million Hospital Facility Authority of the City of Medford, Oregon, Revenue Bonds (Rogue Valley Manor Project) Series 2007, and to RVM’s outstanding 2002 bonds. The 2007 bonds are expected to be issued as variable-rate demand bonds backed by an irrevocable direct-pay letter of credit from Bank of America, and are anticipated to be priced by Cain Brothers, through negotiation, during the week of December 3, 2007.

According to Fitch Ratings, “The ‘A’ rating is supported by Rogue Valley Manor’s excellent competitive position, strong management practices, long operating history and community presence. Additional ratings factors were its solid liquidity position relative to expenses as evidenced by days cash on hand of 659 as of June 30, 2007, and its solid operating history and high occupancy in independent living. RVM has been in continuous operation since 1961 and is the only full-service retirement community in the Medford, Oregon, market. Management of the facility is led by Pacific Retirement Services, which Fitch views as an industry leader.”

“The Bond proceeds will help fund needed RVM renovation and expansion projects,” says Pacific Retirement Services CFO Jerry Schoeggl, “including the Health Care Center expansion; remodeling of the main Front Entrance, Lobby and Dining Room; and the Fitness Center expansion. The Health Care Center expansion is adding more independent living and residential living apartments to the RVM campus, which helped to lower our debt burden for this rating, according to Fitch. Bond proceeds will also fund approximately $5 million in routine capital expenditures and the issuance costs of the 2007 bonds.”

Fitch also says, “The Rating outlook is stable. Despite the increase in additional debt, Fitch believes that RVM is well positioned to improve profitability with strong liquidity indicators that provide it with flexibility in the unlikely event of soft occupancy in its independent living units. The Stable Rating Outlook assumes continued sound operating performance and stable occupancy rates in independent living and residential living units and improved occupancy in skilled nursing. Fitch expects liquidity to remain solid over the near term.”

RVM currently consists of 581 Independent Living residences, 44 Residential Living residences, 72 Skilled Nursing beds and 21 Special Care beds for Alzheimer’s and other memory impairing conditions. In the fiscal year that ended September 30, 2006, revenues for Rogue Valley Manor, Inc., totaled approximately $33.75 million.

“Rogue Valley Manor has received national awards for its services to seniors–on and off the campus–and residency is very much in demand,” says RVM Executive Administrator Kevin McLoughlin. “This will only increase as more and more baby boomers retire. As a not-for-profit organization, these Bonds allow us to make important improvements that will prepare RVM to meet the needs of current and future residents as they age.”

Fitch’s rating definitions and the terms of use of such ratings are available on the agency’s website at www.fitchratings.com. For more information about RVM’s Fitch rating, please contact Sarah Prewitt at (541) 857-7028. To learn more about living at Rogue Valley Manor, call (800) 848-7868 or visit www.retirement.org/rvm.

About Pacific Retirement Services, Inc.

Rogue Valley Manor is an affiliate of Pacific Retirement Services, Inc. (PRS), a nationally recognized not-for-profit corporation that serves a family of 50 retirement communities and service organizations. Headquartered in Medford, Oregon, PRS has approximately 1,714 employees and provides housing and services to more than 4,000 seniors through its many affiliated organizations, including seven Continuing Care Retirement Communities (CCRCs), two managed retirement communities, and twenty-five affordable housing communities.

PRS continues to grow, recently announcing that it has opened another office in Memphis, Tennessee, to serve seniors in the East, South, and Midwest. Last year it announced its new Mirabella brand of urban CCRCs (visit www.mirabellaretirement.org). PRS partners with cities to build affordable senior housing for low-income seniors, and contracts its services to support the success of other retirement communities. For more information about PRS, call (888) 724-6424 or visit www.retirement.org.

ATLANTA, Nov. 16 /PRNewswire/ — The Atlanta Cardiology Group (ACG) has signed an agreement formalizing an affiliation with Piedmont Healthcare as part of the Piedmont Heart Institute, effective November 15. The 25-member cardiovascular physician practice will become a new group practice under the Piedmont Heart Institute and open a new main office on the Piedmont Hospital campus in December, while maintaining offices across Georgia. With the addition of ACG, more than 80 cardiovascular physicians will be available at Piedmont.

“This is an exciting time for Piedmont. Our affiliation with ACG will enable us to more effectively provide our quality services to patients in the many communities we serve,” said Michele M. Molden, CEO of the Piedmont Heart Institute. “ACG will complement the existing cardiovascular expertise at Piedmont, a tradition that started over 50 years ago. We are proud that they’ve chosen Piedmont for their home.”

The Piedmont Heart Institute (PHI) is the first of its kind affiliated with a community hospital system in greater Atlanta. It will bring prominent cardiovascular physician groups together with one of the premier cardiac centers in the region. The Institute’s express purpose is to provide a new and innovative model to facilitate and enhance the quality of cardiovascular care for the community.

William S. Knapp, M.D., managing partner of ACG, said, “This is an excellent affiliation for us. Since ACG’s beginning 40 years ago, we have added physicians and expanded to new communities to deliver the best quality care. The relationship with Piedmont continues this legacy.” ACG has 15 offices in greater Atlanta and surrounding communities, from north Atlanta to Greensboro to Hiawassee and Douglasville.

Knapp also said that ACG physicians are particularly eager about the opportunity to become part of the Piedmont Heart Institute, which was launched in October, creating a platform through which physicians can provide enhanced care and services for their patients.

Since the mid-1960’s, Piedmont Hospital has continued to earn recognition as a leader in the prevention and treatment of heart disease. Piedmont was one of Georgia’s first hospitals to establish a dedicated coronary care unit (CCU), the first to hire a full-time director of a community CCU, and one of the first in the country to use telemetry monitors throughout the hospital. Piedmont has successfully developed cardiac catheterization, interventional cardiology, comprehensive electrophysiology and arrhythmia services, advanced heart failure management, open-heart surgery, and peripheral vascular services. This expertise culminated in 1994 with the centralization of services at the Fuqua Heart Center of Atlanta at Piedmont Hospital.

About The Atlanta Cardiology Group

The Atlanta Cardiology Group (ACG) is a member of Piedmont Cardiovascular Physicians and the Piedmont Heart Institute. With 25 physicians practicing at over a dozen locations throughout Atlanta and the surrounding areas, ACG has set standards of excellence in cardiovascular care since its inception in 1967. Through its expert team of physicians, with specialized training in specific cardiovascular conditions, the goal of ACG is to provide patients will the full spectrum of cardiovascular care.

About Piedmont Healthcare

Piedmont Healthcare, a not-for-profit organization, is the parent company of Piedmont Hospital, a 458-bed acute tertiary care facility in the north Atlanta community of Buckhead, offering all major medical, surgical and diagnostic services, a recipient of the 2006 and 2007 Distinguished Hospital Award for Patient Safety(TM) according to HealthGrades (a leading healthcare ratings company) and one of the nation’s Most Wired for four consecutive years in the 100 Most Wired Survey and Benchmarking Study; Piedmont Fayette Hospital, a 143-bed acute care community hospital in Fayetteville, named one of the nation’s 100 Top Hospitals(R) for the fourth year in a row and one of the nation’s Most Wired hospitals; Piedmont Mountainside Hospital, a 42-bed community hospital in Jasper and named the 2006 Hospital of the Year by the Georgia Alliance of Community Hospitals; Piedmont Newnan Hospital, a 143-bed acute-care community hospital in Newnan; the Piedmont Heart Institute, established in 2007 to enhance the practice of cardiology across Georgia; the Piedmont Hospital Foundation; the Piedmont Physicians Group, with more than 75 primary care physicians in 23 offices throughout metro Atlanta; and the Piedmont Clinic, a 527-member physician network. For more information, visit http://www.piedmont.org/ .

About Piedmont Hospital’s Fuqua Heart Center of Atlanta

The 162-bed Fuqua Heart Center includes more than 100 physicians and 550 support staff. The Center offers a full spectrum of integrated cardiovascular care – from initial testing to post-surgery recovery, including nationally accredited programs in cardiac rehabilitation, echocardiology, peripheral vascular and congestive heart failure. Services include cardiothoracic surgery, interventional cardiology, and endovascular, arrhythmia management, advanced heart failure management, genetic and metabolic preventive therapy and cardiac MR/CT imaging. The Center’s mission is to provide the highest quality patient care while becoming a national leader in the use of innovative, cost-effective, preventive and curative surgical, interventional and medical management for patients with cardiovascular disease.

Piedmont Hospital

CONTACT: Nina Montanaro for Piedmont Hospital, +1-404-695-3372

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

By Bud Kennedy, Fort Worth Star-Telegram, Texas

Nov. 16–Thanksgiving abounds with turkey dinners. Consider these destinations; reservations are always a good idea:

New this year

Fearing’s at the Ritz-Carlton, $95 for a three-course meal with several options, including tangerine-glazed turkey with tortilla dressing and bone-in tenderloin with black truffle-Madeira sauce.11 a.m.-3 p.m. and 5-9 p.m., 2121 McKinney Ave., Dallas, 214-922-4848; www.fearingsrestaurant.com

Copeland’s of New Orleans, $17 for a platter that includes fried turkey breast, oyster dressing and mashed sweet potatoes. 11 a.m.-10 p.m., 1400 Plaza Place, Southlake, 817-305-2199; www.copelandsofneworleans.com.

Truluck’s Seafood Steak Crab House, $24.95; offers a traditional Thanksgiving meal. Noon-7:30 p.m., 1420 Plaza Place, Southlake, 817-912-0500; www.trulucks.com.

Wildcatter Ranch & Resort, $35 for a buffet that includes turkey and dressing, beef and pork tenderloin, smoked ham, smoked salmon, boiled shrimp, chipotle and cheese grits, and chicken and sausage jambalaya. 11:30 a.m.-3 p.m., 6062 Texas 16 South, Graham, 940-549-3555; www.wildcatterranch.com.

La Choza Mexican Grill, $14.95 for a turkey buffet that will also offer maple-pecan baked ham, yams, cornbread dressing and desserts. 11 a.m.-2:30 p.m., 11210 Farm Road 730 South, Parker County, 817-444-9293.

Highland Park Cafeteria, $6.89-$7.99. Old-time cafeteria favorite returns serving turkey and cornbread dressing plus a choice of Southern vegetables; cakes and pies extra.10:45 a.m.-3 p.m., 1200 N. Buckner Blvd. (Loop 12), Dallas. 214-324-5000.

Best city birds

Lucile’s Stateside Bistro, $18.95, 11 a.m.-4 p.m., 4700 Camp Bowie Blvd., Fort Worth, 817-738-4761.

Anthony’s Place, $14.95, 10:30 a.m.-2:30 p.m., 2400 Meacham Blvd., Fort Worth, 817-378-9005.

The Keg Steakhouse, $19.95, 11 a.m.-10 p.m., 5760 S.W. Loop 820, Fort Worth, 817-731-3534.

Vance Godbey’s Restaurant, $17.99 buffet, 10 a.m.-6 p.m., 8601 Texas 199 West, Lakeside, 817-237-2218.

Ol’ South Pancake House, $8.99, 11 a.m. until it’s gone, 1509 S. University Drive, Fort Worth, 817-336-0311.

Ranchman’s Cafe, $16.99, 11 a.m.-3 p.m., 110 W. Bailey St., Ponder, 940-479-2221.Ferre Fort Worth, $29.95, 11:30 a.m.-9 p.m., 215 E. Fourth St., Fort Worth, 817-332-0033.

Silver Fox Steakhouse, $39.95, Fort Worth and Grapevine.

The big buffets

Bistro Louise, $42.50, 10 a.m. or 2 p.m., 2900 S. Hulen St., Fort Worth, 817-922-9244.

Kalamatas at the Renaissance Worthington, $45, 10 a.m.-2:30 p.m., 200 Main St., Fort Worth, 817-870-1000.

Gaylord Texan, $65, 10 a.m.-2 p.m.,1501 Gaylord Trail, Grapevine, 817-778-2000.

Cafe on the Green, Four Seasons Resort, $65, 10:30 a.m.-2 p.m. and 5:30-8 p.m., 4150 N. MacArthur Blvd., Irving, 972-717-0700.

Online exclusive

Find Bud’s full menu of Thanksgiving options at www.star-telegram.com

[email protected] Bud Kennedy’s Eats Beat appears Fridays in Go! 817-390-7538

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By Reynolds, Diane

Lifetime exposure to ultraviolet radiation is a major risk factor for all types of skin cancer. The purpose of this manuscript is to examine theory-guided empirical studies examining adolescent tanning practices. Skin cancer is the most common of all cancers, accounting for nearly half of all cancers in the United States. The American Cancer Society (2006) estimated that melanoma, the most serious type of skin cancer, accounted for about 62,190 cases of skin cancer in 2006 and most (about 7,910) of the 10,710 deaths due to skin cancer. Lifetime exposure to ultraviolet radiation is a major risk factor for all types of skin cancer. Ultraviolet radiation (UV) comes from the sun, sunlamps, tanning beds, or tanning booths. People who have fair skin that freckles or burns easily are at greater risk, as are those individuals who have red or blond hair and light-colored eyes. Just one sunburn increases the risk for skin cancer (National Institutes of Health, 2005).

According to the Skin Cancer Foundation (2006), of the more than 1 million people who tan in tanning salons, 70% are Caucasian women aged 16 to 49. Demko (2003) surveyed 7,000 teenagers and found that indoor tanning among white teenagers is significant, with 30% to 40% of 16 to 18-year-old white females using tanning booths, many of them repeatedly. Continued use of a tanning bed or sunlamp is especially dangerous for teenagers because they are still experiencing tremendous growth at the cellular level and the skin cells are dividing more rapidly than they do during adulthood (Fox as cited in Rados, 2005). Sunbathing and inadequate sun protection further compound the risk for developing skin cancer.

A national survey conducted in 1997 by Koh and colleagues revealed that respondents in the youngest age group (16-25 year olds) sunbathed frequently and were least likely to use the recommended sunscreen. Additionally, they estimated that 2.3 million teens tan indoors in the United States annually. Hall, Jones, and Saraiya (2001) used data collected from the 1999 National Youth Risk Behavioral Study to determine the prevalence and correlates of sunscreen use among high school students in the United States. They found that students aged 14 years or younger were more likely than older students to use sunscreen, and females were more likely than males to do so. Geller and colleagues (2002) used data collected from adolescent 12 to 18 years old who participated in the Growing Up Today study to describe tanning practices among this group and compare them with sun-protection recommendations from federal agencies and cancer organizations. The results were disturbing. Although girls used sunscreen more routinely than boys, they also reported that it was worth getting burned to get a tan, and had incurred at least three sunburns the previous summer. These respondents had nearly double the use of tanning beds than those without this belief.

Search of the Literature

An initial CINAHL search of the literature using search topics of “student attitudes” revealed 5,118 results. Adding “skin neoplasms” to the search revealed 1,526 hits. When these two search terms were combined, only nine results were obtained. An additional search using the terms “health behavior” combined with skin neoplasms yielded 94 results, only three were found in nursing literature and were the same articles discovered in this author’s original search. Sinni-McKeenhan (1995) authored an article on the health effects and regulation of tanning salons which was extremely informational but lacked empirical testing.

An additional search was conducted using PubMed to elicit articles from other disciplines that add to the body of knowledge. The index of individual nursing journals was searched to hone in on studies specific to nursing, which netted an additional four articles written by nurses published in the nursing literature. Conducting a citation search was extremely helpful in identifying additional sources of information and for drawing on a broad scope of referenced journals. This time-intensive search identified a gap in the literature in regards to the discipline of nursing in addressing the issue of adolescent tanning practices.

The majority of the studies found in the literature illuminate the issue of adolescent tanning practices and gather information on skin cancer knowledge, rather than address ways in which to promote primary prevention or change existing behavior. Most of the articles found addressed suntanning practices under the umbrella of health behavior and were written by psychologists or those in public health. The theories are based largely on behavioral health and social science. The Health Belief Model by Becker and Rosenstock was the most popular choice among researchers when examining the issue of adolescent tanning practices.

Review of Articles

The risk of melanoma increases if a person has one or more firstdegree relatives (mother, father, brother, and sister) with the disease (Glantz, Saraiya, & Wechsler, 2002). Swedish researchers Bergenmar and Brandberg (2001) conducted a study to describe attitudes toward sunbathing among young adults previously identified as having had two or more family members diagnosed with melanoma. Despite the fact that they were informed about their increased risk, the majority estimated that their own risk for developing melanoma was equal or lower compared with the general population. Although they did not cite the use of a theoretical framework, measurements included “self-efficacy” and “readiness to change,” which resonate with components of Bandura’s cognitive theory and Prochaska and DiClemente’s Transtheoretical model respectively (Pender, Murdaugh, & Parsons, 2006, p. 271).

Despite adequate knowledge of the adverse effects of ultraviolet exposure, such as skin cancer and premature aging, students in a large midwestern public university, freely and frequently used tanning lamps, primarily because they enjoyed a tanned appearance (Knight, Kirincich, Framer, & Hood, 2002). The demographic group was driven by the perceived immediate cosmetic appearance gained through tanning lamp use rather than by the potential longterm deleterious effects of their behavior. Teens may ignore what they know about the skin damage caused by ultraviolet rays because they strive to look like the dark tanned models and actors they see (Gorgos, 2002).

This perceived benefit of a tanned appearance was echoed in a similar study conducted by a professor of nursing. Lamanna (2004) used a survey design to examine the relationships among college students’ attitudes about general cancer and their knowledge, perceptions, beliefs, and behaviors concerning sun tanning and skin cancer. One of the instruments used to gather data was the College Student Sun Tanning Inventory, developed by Young in 1995. This instrument was based on several components of the Health Belief Model which hypothesizes that in order for individuals to take action to avoid disease they have to believe they are susceptible to the disease, that acquiring the disease would impact some component of their life, and they would benefit from reducing susceptibility to the disease. The results from random sampling of 224 Caucasian male and female students in a state university in New York revealed that most of the subjects tanned to the point of blistering, although they indicated that they perceived the seriousness of skin cancer and generally had a positive attitude toward cancer prevention. Female subjects engaged in more high-risk behavior than males. The Health Belief Model assumes that individuals who place a high value on health would take action to protect themselves from illness. In this study the model did not account for gender nor did it account for the desire for personal attractiveness and relaxation derived from tanning.

Reynolds and colleagues (1996) found similar results when examining predictors of adolescent sun exposure. Participants who thought that having a tan made them look attractive were 2.1 times more likely not to use sunscreens.

The belief that a tan acquired using a sunbed before a holiday would prevent against sunburn has also been cited as a rationale for tanning lamp use (Cokkinides, Weinstock, O’Connell, & Thun, 2000; Knight et al., 2002).

A 2003 study by Greene and Brinn utilized the perceived susceptibility component of the Health Belief Model to examine its impact on intention to tan as well as its effect on changes in actual tanning behavior. One hundred and forty-one Caucasian college students in the southeast were read randomly assigned messages related to the hazards of tanning. These messages either contained statistical or narrative information on skin cancer. They were also asked to complete self-assessments of their personality. They were later contacted for a followup telephone survey. The statistical messages rated higher on information value, increased perceived susceptibility, and resulted in decreased intention to tan. The narrative message, in contrast, increased perceptions of realism and also worked to decrease intentions to tan. Personality factors explained small portions of variance. This was a well-written article which clearly delineated the pros and cons of using the specific variable of perceived susceptibility when examining health behavior adoption such as the subjective nature of susceptibility. Treharne-Davies (1999) used multiple components of the Health Belief Model to assess health care students’ attitudes to sunbathing. Data were collected via a questionnaire that was distributed to 176 health professional students in a university setting in the United Kingdom. The author found that females were more pro-tan than males. The results indicated that as attitudes become more pro-tan, risks taken for UV exposure increase. In general, students did not feel personally susceptible to the disease. These findings were consistent with other studies in the literature.

Predictors of sun-protective practices among other behaviors were addressed in a 2004 study by Von Ah, Ebert, Ngamvitroj, Park, and Kang. Components from the Health Belief Model – perceived threat, perceived benefits and perceived barriers – were used as theoretical framework. The study hypothesized that perceived benefits and barriers would be stronger predictors of health-promoting behavior when perceived threat was high. Selfreported questionnaires were completed by 161 college students. Selfefficacy emerged as the only significant predictor of health behavior. Sun-protective behavior was directly impacted by sun self-efficacy when perceived threat was low. The higher the perceived self-efficacy, the more likely students were to engage in sun-protective behaviors. Perceived threat, benefits, and barriers did not have any significant role in sun-protective behaviors.

The Health Belief Model and Bandura’s Social Learning Theory were paired in a 1999 study conducted by Stone, Parker, Quarterman, and Lee. Through self-reported questionnaires, they elicited responses from 43 females, age 20 to 40, regarding skin cancer knowledge and preventive health measures used by parents and their children. The participants reported using minimal sun-preventive behaviors for themselves, but demonstrated moderate skin cancer knowledge levels. The Health Belief Model fails to explain why unsafe tanning practices continue even though there is knowledge of risk. There appears to be a gap between knowledge and actual threat of developing skin cancer, which is consistent with findings from other studies. Social Learning Theory proposes that behavior that is taught in early childhood and reinforced may be carried into later life. Although 62.8% of the participants in this study had taught their children to use sunscreen, that does not necessarily translate into sustained positive practices. Social Learning Theory may be more appropriate in a retrospective study looking at protective tanning practices among adolescents whose parents have modeled positive behaviors. The researchers never state which specific components of either frameworks guided the study, but it seems reasonable that vicarious learning (Bandura) could have been a unitary focus.

Several researchers examined the tanning practices by youth and their parents or caregivers (Cokkinides et al., 2002; James, Tripp, Parcel, Sweeney, & Gritz, 2002; Reynolds et al., 1996; Stryker et al., 2004; Tripp et al., 2003). James and colleagues applied the Theory of Planned Behavior and Social Cognitive Theory when examining correlates of sun-protective practices of preschool staff toward their students. Tripp, who also co-authored the previously mentioned article by James, applied Social Cognitive Theory when assessing sun-protection practices used by parents. The parents, particularly the female head of household, exerted a strong influence on the prevalence of risky tanning practices in these studies. Parents who conveyed approval and permissiveness for tanning, including the use of tanning beds, were more likely to have children who engaged in unsafe practices. These studies suggest that sun-exposure behaviors may be motivated in part by parental role modeling, especially female caregivers, underscoring the need for additional teaching in this area.

Turrisi, Hillhouse, and Gebert (1998) examined cognitive variables relevant to sunbathing among a convenience sample of 263 psychology students using Jaccard’s Theory of Alternative Behavior. According to the framework, an individual’s behavior is based upon the attitude they have toward performing the behavior as well as other behavioral alternatives. The researchers sought to examine sunbathing behavioral tendencies, attitudes towards sunbathing, and attitudes and perceptions about sunbathing alternatives, using questionnaires to collect data. The authors hypothesized that a decrease in favorable sunbathing attitudes would translate to a decrease in sunbathing tendencies, which was supported by the findings. The results were not reported by gender, leaving the reader wondering if there were alternative behaviors that were more important to males versus females. The questions that were to elicit attitudes and perceptions about sunbathing alternatives addressed activities such as shopping, watching television, going to a movie, working out, and also included feelings about the appearance of a tan, which didn’t seem to fit with the other behavioral variables. These preselected alternatives may have excluded other individual preferences.

A similar study design, based on the Theory of Alternative Health Behavior, was used by Danoff-Burg and Mosher (2006). A convenience sample of 164 undergraduates completed questionnaires that assessed tanning salon use, attitudes towards tanning salon use, and attitudes towards alternative behaviors for enhancing appearance, relaxing, and socializing. Results were presented logically in separate regression tables. Attitudes toward alternatives for enhancing appearance such as through the use of diet, clothing, exercise, and sunless tanning products were not significantly related to tanning salon use. Attitudes towards behavioral alternatives for relaxing such as watching television, going to the movies, meditating, yoga, going out with friends, or engaging in a favorite hobby were inversely related to frequency of tanning salon use. Lastly, attitudes for socializing such as going to the gym, going to restaurants or bars, and going to parties accounted for 14% of the variance. Tanning salon use was negatively correlated with favorable attitudes toward going to the gym to socialize and positively correlated with favorable attitudes toward going to a tanning salon to socialize. The authors provided a single sentence which states the main intent of the theory but never described any of its components. This study, unlike the earlier one outlined by Turrisi et al. (1998), reported gender differences in attitudes towards behavioral alternatives to tanning salon use.

In an effort to reduce UV exposure from tanning booth use among college students, Mahler and colleagues (2005) conducted an interventional study to examine the efficacy of UV photographs and information about photoaging, defined as the premature appearance of wrinkles and age spots. Their objectives were twofold: to determine whether UV photographs and information on photoaging could increase sun-protection intentions and behaviors, and also whether the intervention could be enhanced by providing a non-UV alternative for achieving a tan (sunless tanning lotion). The later assumption was guided by the Theory of Alternative Behavior. The research had a control and two experimental groups. The control group completed an initial questionnaire regarding sunbathing behaviors and a second questionnaire designed to assess future intentions to use sunscreen. The intervention for each of the experimental groups consisted of an initial questionnaire followed by a 12 minute informational video on sun protection and a black and white photograph as well as a UV photograph taken of each participant. Prior to completing the second questionnaire, some of the participants in the experimental group were given a sample of sunless tanner cream. Analysis of the results found that the experimental groups scored higher on self-efficacy for sunscreen use, higher perceived susceptibility of photoaging, and higher perceived efficacy for sunscreen prevention of photoaging, than did the control group. Additionally, the participants who received the intervention plus the sunless tanner cream scored significantly higher on perceived susceptibility to photoaging than those in the intervention only group.

Gibbons, Gerrard, Lane, Mahler, and Kulik (2005) also employed UV photography to highlight the damage to facial skin caused by previous UV exposure (tanning booth use). The authors used the Prototype-Willingness Model as a theoretical framework for the study. The model suggests that willingness is an inclination to engage in risky behavior if given the chance and argues that adolescents’ perceptions of the type of person who engages in risky behavior influences their participation in that behavior. They hypothesized that altering the tanner image should reduce the tanning behavior. All participants filled out a primary questionnaire followed by random assignment to either a UV photo or no-UV photo group. The UV group had their picture taken which highlighted visible damage from UV exposure. Both groups received informational brochures describing photoaging, melanoma, and sunprotection methods. All students were called for a retest 4 weeks later. The researchers discovered that the use of the UV photos did change tanners’ attitudes about tanning as well as their images of the type of person who tans.

Myers and Horswill (2006) used Ajzen’s Theory of Planned Behavior which is an extension of an earlier Theory of Reasoned Action (Fishbein & Ajzen, 1975), to examine social cognitive predictors of sun-protection intention and behavior. Ajzen added the perceived behavioral control variable to the Theory of Reasoned Action which posits that attitudes and subjective norms are amenable to change. Eighty-five participants between the ages of 16 to 27 completed a questionnaire before the summer and a second questionnaire in October. One item on the initial questionnaire that was used to measure intention asked the participants if they planned to use a high-factor sunscreen, but they never quantify “high factor.” The authors reported that the model predicted both behavior and intention to use sun protection, with 45% of the variance of self- reported sunscreen use and 32% of the variance in intention explained by the Theory of Planned Behavior. Previous studies using the Theory of Planned Behavior reported similar results (Godin & Kok, 1996; Hillhouse, Turrisi, & Kastner, 2000). Based on The Theory of Planned Behavior, a study of 131 (predominately female) students from a southeastern university revealed that attitudes were strongly associated with high-risk intentions such as not utilizing sunscreen, and the use of tanning salons (Hillhouse, Adler, Drinnon & Turrisi, 1997). Subjective norms were less predictive of behavior. Perceived behavioral control moderated the relationship among attitudes, norms, and intentions to sunbathe and tan at a salon.

Grunfeld (2004) applied the Protection Motivation Theory to examine 239 adolescents’ intentions to perform safe sun-exposure behaviors. This theory predicts that people’s intentions to engage in certain health behaviors are influenced by their attitudes and beliefs about both adaptive and maladaptive responses. Threat appraisal and coping appraisal are its two main components. Specific components of threat appraisal include perceived severity, and perceived vulnerability, which are reminiscent of the Health Belief Model. Specific components of coping appraisal include self- efficacy, and attitudes towards performing adaptive behaviors, which are suggestive of Social Cognitive Theory. Students from two British universities completed questionnaires that the authors state represented the components of Protection Motivation Theory. This research project supported results from other studies that found greater awareness and knowledge of the risks of sun exposure were not predictive of safe sunexposure practices. Previous performance of similar behaviors emerged as the strongest predictor of intention to perform safe sun-exposure behaviors, which is consistent with Pender’s revised Health Promotion Model.

Conclusion

Based on the literature search, it appears that efforts that focus on increasing knowledge in order to effect change in tanning practices among adolescents seems to be missing the mark perhaps due to perceptions of invulnerability in this group. Among the adolescent population, it appears that immediate benefits outweigh trepidation about long-term implications associated with tanning practices. Despite available nursing theories, which may be applied to studying tanning practices of adolescent youth, theories from behavioral and social sciences seem to be the gold standard. It is surprising that the nursing literature is scant in regards to identifying the magnitude of the health behavior problem of adolescent tanning practices. When nursing’s contribution to this salient issue is represented, the studies are mainly atheoretical or based on theory outside of nursing. Many of the studies outlined that were theoretical in nature assumed that the reader was familiar with the components of the theory. While this author recognizes the value of interdisciplinary teamwork, I am left wondering why nursing doesn’t draw from strengths that lie within rather than go outside of nursing to seek answers?

References

American Cancer Society. (2006). Skin cancer facts. Retrieved August 7, 2007, from http://www.cancer.org/docroot/PED/content/ ped_7_1_What_You_Need_ To_Know_About_Skin_Cancer. asp?sitearea=&level=

Bergenmar, M., & Brandberg, Y. (2001). Sunbathing and sun- protection behaviors and attitudes of young Swedish adults with hereditary risk for malignant melanoma. Cancer Nursing, 24(5), 341- 350.

Cokkinides, V.E., Weinstock, M.A., O’Connell, M.C., & Thun, M.J. (2002). Use of indoor tanning sunlamps by U.S. youth, ages 11-18 years, and by their parent or guardian caregivers: Prevalence and correlates. Pediatrics, 109(6), 1124-1130.

Danoff-Burg, S., & Mosher, C.E. (2006). Predictors of tanning salon use: Behavioral alternatives for enhancing appearance, relaxing and socializing. Journal of Health Psychology, 11(3), 511- 520.

Demko, C. (2003). Use of indoor tanning facilities by white adolescents in the United States. Archives of Pediatric and Adolescent Medicine, 157(9), 854-860.

Fishbein, M., & Ajzen, I. (1975). Belief, attitude, intention, and behavior change: An introduction to theory and research. Reading, MA: Addison-Wesley.

Geller, A.C., Colditz, G., Oliveria, S., Emmons, K., Jorgensen, C., Aweh, G.N., et al. (2002). Use of sunscreen, sunburning rates, and tanning bed use among more than 10,000 children and adolescents. Pediatrics, 109(6), 1009-1014.

Gibbons, F.X., Gerrard, M., Lane, D.J., Mahler, H.I.M., & Kulik, J.A. (2005). Using UV photography to reduce use of tanning booths: A test of cognitive mediation. Health Psychology, 24(4), 358-363.

Glanz, K., Saraiya, M., & Wechsler, H. (2002). Guidelines for school programs to prevent skin cancer. Morbidity and Mortality Weekly Report, 51(4), 2-16.

Godin, G., & Kok, G. (1996). The Theory of Planned Behavior: A review of its applications to health-related behaviors. American Journal of Health Promotion, 11(2), 87-98.

Gorgos, D. (Ed.). (2002). Skin cancer news. Dermatology Nursing, 14(6), 408.

Greene, K., & Brinn, L.S. (2003). Messages influencing college women’s tanning bed use: Statistical versus narrative evidence format and a self-assessment to increase perceived susceptibility. Journal of Health Communications, 8(5), 443-461.

Grunfeld, E.A. (2004). What influences university students’ intentions to practice safe sun exposure behaviors? Journal of Adolescent Health, 35, 486-492.

Hall, H.I., Jones, S.E., & Saraiya, M. (2001). Prevalence and correlates of sunscreen use among U.S. high school students. Journal of School Health, 71(9), 453-457.

Hillhouse, J.J., Adler, C.M., Drinnon, J., & Turrisi, R. (1997). Application of Azjen’s Theory of Planned Behavior to predict sunbathing, tanning salon use, and sunscreen use intentions and behaviors. Journal of Behavioral Medicine, 20(4), 365-378.

Hillhouse, J.J., Turrisi, R., & Kastner, M. (2000). Modeling tanning salon behavioral tendencies using appearance motivation, self-monitoring and the Theory of Planned Behavior. Health Education Research, 15(4), 405-414.

James, A.S., Tripp, M.K., Parcel, G.S., Sweeney, A., & Gritz, E.R. (2002). Psychosocial correlates of sun-protective practices of preschool staff toward their students. Health Education Research, 17(3), 305-314.

Knight, J.M., Kirincich, A.N., Framer, E.R., & Hood, A.F. (2002). Awareness of the risks of tanning lamps does not influence behavior among college students. Archives of Dermatology, 138, 1311-1315.

Koh, H.K., Bak, S.M., Geller, A.C., Mangione, T.W., Hingson, R.W., Levenson, S.M., et al. (1997). Sunbathing habits and sunscreen use among white adults: Results of a national survey. American Journal of Public Health, 87(7), 1214-1217.

Lamanna, L.M. (2004). College students’ knowledge and attitudes about cancer and perceived risks of developing skin cancer. Dermatology Nursing, 16(2), 161-176.

Mahler, H.I.M., Kulik, J.A., Harrell, J., Correa, A., Gibbons, F.X., & Gerrard, M. (2005). Effects of UV photographs, photoaging information, and use of sunless tanning lotion on sun protection behaviors. Archives of Dermatology, 141(3), 373-380.

Myers, L.B., & Horswill, M.S. (2006). Social cognitive predictors of sun protection intention and behavior. Behavioral Medicine, 32(2), 57-63.

Pender, N.J., Murdaugh, C.L., & Parsons, M.A. (2006). Health promotion in nursing practice (5th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Rados, C. (2005). Teen tanning hazards. FDA Consumer, 39(2), 8-9.

Reynolds, K.D., Blaum, J.M., Jester, P.M., Weiss, H., Soong, S.J., & DiClemente, R.J. (1996). Predictors of sun exposure in adolescents in a Southeastern U.S. population. Journal of Adolescent Health, 19(6), 409-415.

Sinni-McKeehen, B. (1995). Health effects and regulation of tanning salons. Dermatology Nursing, 7(5), 307-312.

Skin Cancer Foundation. (2006). The case against indoor tanning. Retrieved August 7, 2007, from http://www.skincancer. org/ artificial/index.php Stone, V.B., Parker, V., Quarterman, M., & Lee, C. (1999). The relationship between skin cancer knowledge and preventive behaviors used by parents. Dermatology Nursing, 11(6), 411-424.

Stryker, J.E., Lazovich, D., Forster, J.L., Emmons, K.M., Sorensen, G., & Demierre, M.F. (2004). Maternal/female caregiver influences on adolescent indoor tanning. The Journal of Adolescent Health, 35(6), 528.e1-528.e9.

Treharne-Davies, J. (1999). Healthcare students’ attitudes to sunbathing. Nursing Standard, 13(17), 42-47.

Tripp, M.K., Carvajal, S.C., McCormick, L.K., Mueller, N.H., Hu, S.H., Parcel, G.S., et. al. (2003). Validity and reliability of the parental sun protection scales. Health Education Research, 18(1), 58- 73.

Turrisi, R., Hillhouse, J., & Gebert, C. (1998). Examination of cognitive variables relevant to sunbathing. Journal of Behavioral Medicine, 21(3), 299-313.

U.S. National Institutes of Health. (2005). What you need to know about skin cancer: Risk factors. Retrieved August 7, 2007, from http://www.cancer.gov/cancer topics/wyntk/skin/page4

Von Ah, D., Ebert, S. Ngamvitroj, A., Park, N., & Kang, D.H. (2004). Predictors of health behaviors in college students. Journal of Advanced Nursing, 48(5), 463-474.

Diane Reynolds, EdD(c), RN, OCN, CNE, is an Assistant Professor of Nursing, Long Island University, Brooklyn, NY.

Copyright Anthony J. Jannetti, Inc. Oct 2007

(c) 2007 Dermatology Nursing. Provided by ProQuest Information and Learning. All rights Reserved.

By Wurster, Joan

Executive Summary * Pressure sores have plagued the nursing profession for many years as a major health care problem in terms of a patient’s suffering and financial cost.

* Pressure sores are increasingly common in hospitalized patients in the United States with a 63% increase from 1993 to 2003.

* The nurse leader is accountable for the occurrence of pressure sores, a nurse-sensitive indicator, by a scorecard which is benchmarked against other facilities.

* The nurse leader must take a systematic approach in the prevention of pressure sores, with the strategy being consistent and motivating to the staff in order to improve patient outcome.

* The chief nursing officer, the unit manager, and the bedside nurse must all collaborate to prevent tissue injury in patients at risk for developing pressure sores and to promote wound healing in patients with existing breakdown.

PRESSURE SORES HAVE PLAGUED the nursing profession for many years as a major health care problem in terms of a patient’s suffering and financial cost. A hallmark of quality nursing care is excellent skin care. Hospitals evaluate themselves based on the prevalence of skin breakdown (Suddaby, 2006). In the United States, approximately one million people are affected by pressure sores, with a cost of $1.6 billion annually. Stage 1, 2, and 3 pressure sores cost an estimated $2,000 to $30,000 per hospital stay, while a stage 4 pressure sore is estimated as high as $70,000 (Moody, Gonzales, & Cureton, 2004).

With an increasing demand for proof of quality patient care from legislators, payers, business leaders, and the public, the American Nurses Association (ANA) responded, in 1995, with the Safety and Quality Initiative. This resulted in the development of a national nursing database measuring the impact of nursing care and patient outcomes, driven by data and evidence- based practice, a standard toward which, Medicare and the Joint Commission on Accreditation of Healthcare Organizations are gravitating. Medicare developed a program, pay-for-performance (P4P), designed to reward providers for improving quality of care and exceeding specific benchmarks in regards to pressure sores using a national quality database known as the National Database of Nursing Quality Indicators (NDNQI) (Haberfelde, Bedecarre, & Buffum, 2005). The NDNQI is a proprietary database of the ANA. Data are collected and evaluated on unit- specific nurse-sensitive indicators from hospitals throughout the United States. Quarterly reports contain charts and maps comparing hospital unit averages with national averages. These reports enable hospitals to benchmark one institution against another. Pressure sores are used as a nurse-sensitive indicator because it is believed that the greater quality and quantity of nursing care, the greater the patient outcome.

Common Risk Factors

Pressure sores are increasingly common in hospitalized patients in the United States with a 63% increase from 1993 to 2003; the mean length of stay specifically for pressures sores was 13 days, with a cost of approximately $38,000 (Russo & Elixhauser, 2006). Early intervention is the key to the prevention of pressure sore development. Nurses must be educated and aware of the signs of tissue breakdown and factors that place patients at risk. Although there are more than 100 risk factors identified in the literature (Lyder, 2003), six of the most common risk factors will be discussed.

1. Reduced mobility is the most important element in the breakdown of tissue and the development of pressure sores (Clay, 2000). Tissue necrosis develops when soft tissue is compressed, usually between an external surface and a bony prominence for a prolonged period of time. Immobility or decreased mobility can be caused by sedation, restraints, trauma, dementia, or a disease process.

2. The nutritional status of an individual plays a significant role in tissue perfusion and skin integrity. Thin people who have little padding over bony prominences are more susceptible to pressure sores. Malnourished individuals are at a higher risk for tissue breakdown, as proteins and vitamins aid in the prevention of pressure sores by increasing tissue and cell wall integrity. Supplements and micronutrients play a major role in maintaining tissue integrity; likewise, deficiencies and deficits are detriments to wound healing (Williams & Barbul, 2003).

3. According to the National Pressure Ulcer Advisory Panel (NPUAP, 2001), incontinence of urine and feces can cause skin irritation and tissue damage especially with frequent washing using soap and water. Frequent washing causes excessive drying, friction, and irritation which could cause further skin breakdown.

4. Medications, such as sedatives and analgesics, particularly in the critically ill patient, can cause a reduced sensation and immobility (Clay, 2000). Patients placed in drug-induced comas or chemically paralyzed receiving neuromuscular blockades are at an exceptionally high risk since they are unable to communicate or move on their own.

5. Conditions that decrease tissue oxygenation or reduce oxygenated blood to the tissue, such as peripheral vascular disease, cardiac disorders, hypotension, arteriosclerotic disease, cigarette smoking, etc., are strong predisposing factors. Pressure sores are more susceptible to developing with any condition that reduces the quality or quantity of blood supply to the tissues (Clay, 2000).

6. Age is another high risk factor for pressure sore development and tissue breakdown, because elasticity, collagen, subcutaneous fat, and muscle diminish with increasing age. According to the NPUAP (2001), most pressure sores are preventable and, therefore, the incidence of pressure sores has been used as an indicator for quality patient care.

Executive Nurse Responsibilities

So, what can nurses do to prevent tissue injury and promote wound healing in patients with existing breakdown and what are the responsibilities and the role of nurse leaders? The executive nurse leader is responsible and accountable for the overall management of nursing services, including, nursing education, nursing practice, and nursing research. According to the ANA (2004), the nurse leader is responsible for ensuring that professional standards and values are maintained through the development, implementation, and evaluation of programs and that polices are supported by evidence. The nurse leader is accountable for the occurrence of pressure sores, a nurse-sensitive indicator, by a scorecard and is benchmarked against other facilities.

Nursing research is invaluable and an integral part of nursing care, which aids in shaping and delivering quality care regarding prevention and treatment of pressure sores. Understanding predisposing factors and the principles of pressure sore prevention, in conjunction with being able to select appropriate devices and equipment to reduce the risk of pressure sore development, are key factors to a successful prevention and treatment plan. The nurse leader must take a systematic approach in the prevention of pressure sores, with the strategy being consistent and motivating to the staff in order to improve patient outcome (Clay, 2000).

Initially, a risk assessment of the skin must be done systematically by using a risk assessment tool. One of the published and commonly used pressure ulcer risk assessment instruments is the Braden Scale (Braden & Bergstrom, 1988). The Braden Scale is a clinically validated tool that facilitates nurses and health care providers, scoring a patient’s level of risk for developing pressure sores. Six specific risk factors are consistently identified: sensory perception, moisture, activity, mobility, nutrition, and friction. These specific risk factors are rated from 1 to 4; with 1 representing the most severe and 4 representing no impairment; therefore, the lower the score the higher the risk for developing pressures sores. This tool enables nurses and staff to constantly and uniformly identify patients who are at risk, and to calculate the severity of risk. The NPUAP (2001) recommends that patients be assessed on admission and throughout their hospital stay.

Proper skin care is essential and must be implemented by using a mild cleansing agent followed by thoroughly rinsing the skin with water. It is recommended that the skin be patted dry without rubbing to avoid friction, and a moisturizing lotion be used to minimize excessive drying, especially with patients who are urine or feces incontinent (Clay, 2000). The Pressure Ulcer Prevention Protocol states patients should be turned at least every 2 hours while in bed, and every 15 to 30 minutes while in a chair (Hiser et al., 2006). The NPUAP (2001) recommends frequent turning, following the “rule of 30”: the head of the bed should not be elevated greater than 30 degrees and the body should be placed in a 30-degree lateral incline position on either side. Special cushioning devices and pressurereducing mattresses should be used and are beneficial in minimizing pressure, friction, shearing, and moisture. Mechanical injury to the skin from shearing forces and friction during repositioning and transferring maneuvers should be prevented by having the appropriate equipment and staff available. Lift sheets, transfer boarders, over-bed trapezes, and personal support devices with proper body mechanics should be used to facilitate these maneuvers when indicated to prevent staff injuries. Along with proper skin care, adequate nutritional intake must be assessed and managed, either by enteral or parenteral administration. When a patient is unable to consume enough nutrients orally, adequate nutrition must be obtained through tube feedings or hyper- alimentation. These interventions become increasingly challenging for the health care providers in the elderly and in patients with complex disease processes; especially with limited staffing. Addressing a Complex Issue

With today’s critical nursing shortage, it is no surprise that there would be an increase in hospitalinduced pressure sores given the complexity of this issue. Although nurses may complain there is not enough time to get everything done due to an overwhelming workload, a minimum nurse-patient ratio alone is probably not adequate to ensure quality of care. Patient acuity, nurse competence, institutional policies and procedures, and available supplies and equipment are essential to consider when confronting this issue and ensuring quality care. Equally important to consider is that proper treatment be implemented routinely and consistently in accordance with the institution’s policy and procedure manual. The responsibility ranges from the chief nursing officer to the bedside nurse to make sure treatment plans are implemented and evaluated, not just developed. Ultimately, it is the role and the responsibility of the executive health care leader to improve this nurse-sensitive indicator while reducing the cost of health care.

As the position of the chief nursing officer and the staff RN widens, the leadership role of the unit manager becomes pivotal to the performance of the unit in addressing nurse-sensitive indicators. A skin care plan to prevent tissue injury in patients at risk for developing pressure sores and to promote wound healing in patients with existing breakdown must be developed. The staff must be involved in planning, implementing, and evaluating the skin care plan for it to be effective. Developing a shared vision with a sense of team spirit within the unit can promote common interests and goals, which, ultimately, can lead to inspiration, motivation, and accountability (McGuire & Kennerly, 2006). The nursing staff must rely on the management skills of the unit manager to provide guidance with clear expectations while maintaining a challenging and effective approach. The role of the nurse leader is critical in shaping the environment of care; nurse executives play a vital role in quality patient care and safety. The chief nursing officer, the unit manager, and the bedside nurse must all collaborate to address this nurse-sensitive indicator and improve performance by exceeding benchmarks of the National Database of Nursing Quality Indicators.

Ultimately, it is the role and the responsibility of the executive health care leader to improve this nurse-sensitive indicator while reducing the cost of health care.

REFERENCES

American Nurses Association (ANA). (2004). Scope and standards for nurse administrators (2nd ed.). Washington, DC: Author.

Braden, B., & Bergstrom, N. (1988). Braden scale for predicting pressure sore risk. Retrieved July 31, 2007, from http:// www.ulm.edu/nursing/BradenScale.doc

Clay, M. (2000). Pressure sore prevention in nursing homes. Nursing Standard, 14(44), 45-52.

Haberfelde, M., Bedecarre, D., & Buffum, M. (2005). Nurse- sensitive patient outcomes: An annotated bibliography. Journal of Nursing Administration, 35(6), 239-299.

Hiser, B., Rochette. J., Philbin, S., Lowerhouse, N., TerBurgh, C., & Pietsch, C. (2006). Implementing a pressure ulcer prevention program and enhancing the role of the CWOCN: Impact on outcomes. Ostomy Wound Management, 52(2), 48-59.

Lyder, C. (2003). Pressure ulcer prevention and management. The Journal of the American Medical Association, 289(2), 223-226.

McGuire, E., & Kennerly, S. (2006). Nurse managers as transformational and transactional leaders. Nursing Economic$, 24(4), 179-185.

Moody, P., Gonzales, I., & Cureton, V.Y. (2004). The effect of body position and mattress type on interface pressure in quadriplegic adults: A pilot study. Dermatology Nursing, 16(6), 507- 512.

National Pressure Ulcer Advisory Panel (NPUAP). (2001). Pressure ulcers in America: Prevalence, incidence, and implications for the future. Reston, VA: Author.

Russo, A., & Elixhauser, A. (2006). Hospitalizations related to pressure sores, 2003. Healthcare Cost and Utilization Project, Statistical Brief #3. Retrieved October 13, 2006, from http:// www.hcup-us. ahrq.gov/reports/statbriefs/sb3.pdf

Suddaby, E. (2006). Skin breakdown in acute care pediatrics. Dermatology Nursing, 18(2), 155-161.

Williams, J., & Barbul, A. (2003). Nutrition and wound healing [Abstract]. The Surgical Clinics of North America, 83, 571-596.

JOAN WURSTER, MSN, RN, is Trauma Clinic Manager, St. Mary’s Trauma Center, West Palm Beach, FL.

Copyright Anthony J. Jannetti, Inc. Sep/Oct 2007

(c) 2007 Nursing Economics. Provided by ProQuest Information and Learning. All rights Reserved.

PAINESVILLE, Ohio, Nov. 15 /PRNewswire/ — The Lake Hospital Foundation today announced that it has received a $1 million cash donation from the prominent Lake County businessman Richard M. Osborne family. The donation, which is the single largest gift ever received by the Foundation, will support construction of TriPoint Medical Center, a new state-of-the-art digital hospital in Concord Township set to open in 2009.

“My family and I are delighted to support TriPoint Medical Center and Lake Hospital System. We believe the new hospital will be a vital asset to Northeast Ohio and serve generations of families in Lake County and beyond,” said Richard M. Osborne.

The lobby of TriPoint Medical Center will be named in honor of Mr. Osborne’s mother, Georgeanne S. Osborne, his late son, Tommy Osborne, and possibly other members of the family.

“The building of TriPoint Medical Center provides a great opportunity for a lasting legacy,” Osborne said.

Sunny Masters, executive director of the Lake Hospital Foundation, expressed the Foundation’s gratitude for this important gift.

“The Osborne name is synonymous with this community’s spirit of leadership and goodwill,” said Masters. “We’re extremely grateful for the family’s generous gift, which will have a significant impact on our capital campaign for TriPoint Medical Center.”

In addition to the $1 million gift, the Osborne family is also making two other monetary gifts that will support operations once the new hospital opens.

“The Lake Hospital System Board of Trustees and I are very appreciative of the Osborne family’s generosity. It’s through the support of donors like the Osbornes that Lake Hospital System can continue to deliver the highest quality care to the communities we serve,” said Cynthia Moore-Hardy, president and CEO of Lake Hospital System.

Construction is progressing on schedule for the four-story, 300,000-square-foot hospital that will introduce a new approach to community health care that revolves entirely around the patient. The $150 million medical facility will feature the latest medical technology and private patient rooms overlooking a natural setting, all designed to help heal lives faster.

The Lake Hospital Foundation is continuing to raise funds through its “Building For The Future” capital campaign. To date, more than $6.1 million has been pledged toward a $10 million goal.

“The hard work of campaign volunteers and the generosity of contributors have made early success possible. The community has clearly been very receptive to conversations about gift support. As we continue to talk with area individuals and business owners, we look forward to reaching and surpassing our goal,” said Carol Nelson-Rollins and Don Brinberg, M.D., co-chairs of the Building for the Future capital campaign.

About Lake Hospital System

For six consecutive years NorthCoast 99 has named Lake Hospital System one of the 99 Best Places to work in Northeast Ohio. In 2006, HealthGrades also named Lake Hospital System among the top five percent of all hospitals in the nation. A leader in community-based health care in Northeast Ohio, Lake Hospital System provides high-quality, accessible health services for all stages of life. Lake Hospital System delivers progressive, compassionate health care through eight state-of-the-art facilities staffed by more than 500 physicians and 2,600 health care professionals.

   Contacts:   Kristin Wilson, Brokaw   (216) 685-4526   [email protected]    Julieann Strogin, Lake Hospital System   (440) 354-1940   [email protected]  

Lake Hospital Foundation

CONTACT: Kristin Wilson of Brokaw, +1-216-685-4526, [email protected],or Julieann Strogin of Lake Hospital System, +1-440-354-1940,[email protected]

Web site:

AltaMed Health Services Corporation (AltaMed) has announced a merger that will make Community Care Health Centers (CCHC) a regional unit of the AltaMed Primary Health Care Division. Anticipated finalization of the merger is December 1, 2007 when AltaMed expects to receive final approval by the Attorney General of the State of California. The merger will combine two of the leading Federally Qualified Health Centers (FQHCs) operating in Los Angeles and Orange Counties, and will result in CCHC clinics being re-licensed under AltaMed. The merger will provide a springboard for launching a new division of AltaMed in Orange County.

AltaMed is among five of the largest FQHCs in the United States, and it has been providing quality health care to the working poor and medically underserved in Southern California for more than 38 years. AltaMed regularly serves more than 66,000 families each year, providing community access to medical and dental clinics, youth programs, prevention and treatment for HIV/AIDS and substance abuse, and comprehensive senior services such as adult day health care centers, case management, and the Program of All Inclusive Care for the Elderly (PACE).

“We look forward to a merger that builds on the individual strengths of both organizations to better provide for the working poor and medically underserved populations of Orange County, which is consistent with the mission statements of both organizations,” said Cástulo de la Rocha, J.D., president and CEO of AltaMed. “Those missions emphasize access to quality, affordable, primary health care for the medically underserved, with particular interest in addressing health disparities afflicting this segment of the community.”

The CCHC organization brings more than 37 years of history, experience, and knowledge of serving the needs of the medically underserved in Orange County. As such, AltaMed intends to build on the long standing primary programs and services of CCHC, as well as introduce its own successful adult day health care, long term care, and PACE programs to the senior and frail elderly populations of Orange County. The merger brings five medical and dental care clinic sites in the communities of Santa Ana, Orange, and Huntington Beach that will continue to operate under the name of Community Care Health Centers, as a division of AltaMed. Over 90,000 medical and dental visits are expected in the first year from a core customer population of medically underserved.

“This merger effectively strengthens the health care safety net access in Orange County, by expanding our programs, services and quality health care,” said Jacqueline Cherewick, M.B.A., president and CEO of CCHC. “We’re bringing a much needed service to the working poor, to keep them healthy, keep them working, and help them be productive members of their communities.”

About CCHC

Prior to the merger with AltaMed, CCHC grew into one of the largest unaffiliated non-profit community clinic network in Orange County. CCHC’s chartered mission is to lead in providing high quality, affordable, accessible health care to people in need. CCHC serves the entire Orange County and targets the working poor and medically underserved. After over 37 years of providing health care access, CCHC has emerged a key stakeholder in the local health care safety net with 35 collaborative partnerships countywide and a patient capacity of 30,000 unduplicated patients and 90,000 patient visits by the end of 2007.

About AltaMed

AltaMed Health Services has been providing quality health care to the underserved and uninsured in Southern California for more than 38 years. It regularly serves more than 66,000 families each year, providing community access to medical and dental clinics, complete senior services, including adult day health care centers, case management, and the Program of All Inclusive Care for the Elderly (PACE), youth programs as well as HIV/AIDS and substance abuse prevention and treatment. AltaMed is among five of the largest Federally Qualified Health Centers (FQHCs) in the United States. Community Health Centers are not required to be accredited; but AltaMed has three JCAHO accreditations in ambulatory care, home health and behavioral health, which validate its standard of providing excellent quality of care.

KING OF PRUSSIA, Pa., Nov. 14 /PRNewswire/ — A new study finds that a higher than expected number of COPD and severe asthma patients had abnormal low levels of alpha-1 antitrypsin (AAT), suggesting the need for broader criteria for AAT deficiency testing. AAT deficiency, also known as Alpha-1, is a widely undiagnosed hereditary disorder that is usually fatal in its severe form.

Alpha-1 is estimated to affect up to 100,000 Americans, but up to 95 percent are undiagnosed or have been misdiagnosed as having another form of chronic obstructive pulmonary disorder (COPD). Details of the study were presented at CHEST, the annual meeting of the American College of Chest Physicians held in Chicago from October 20 to 25. Study results are being announced today on World COPD Day to focus attention on the need for wider testing for AAT deficiency.

“Findings from this study suggest that simply all patients with moderate or severe persistent asthma and/or COPD with chronic pulmonary symptoms should be tested for AAT deficiency,” said Gary Rachelefsky, MD, Professor of Allergy and Immunology and Director of the Executive Care Center for Asthma, Allergy and Respiratory Diseases at UCLA School of Medicine and study investigator. “It is imperative that clinicians become more vigilant about Alpha-1 testing as many patients are going undiagnosed or misdiagnosed due to screening criteria and practices.”

The study, conducted by the Respiratory & Allergic Disease Foundation, recruited 40 office-based pulmonologists across the United States who tested 454 adult patients using the following simple screening criteria: persistent asthma and/or COPD patients with loss of lung function defined by either a FEV1 (forced expiratory volume at 1 second) or a ratio of FEV1 to forced vital capacity (FEV1/FVC) of less than 70 percent. Blood tests were taken to assess levels of AAT, and additional lab results and patient histories were noted and tabulated.

Of the 454 patients studied, 3.3 percent showed deficient levels of AAT. Low blood levels of AAT are commonly associated with progressive severe emphysema that becomes clinically evident by the third to fourth decade of life; a recent registry showed that 54 percent of AAT deficient patients had emphysema. Less commonly, low levels of AAT are associated with liver disease and cirrhosis.

Interestingly, patients who tested with low AAT did not significantly differ from the COPD/persistent asthma patients with normal levels of AAT in several key pulmonary function criteria, including levels of FEV1, ratios of FEV1 to forced vital capacity (FEV1/FVC), or the number of bronchial infections within the past 12 months. This lack of differentiating characteristics in deficient subjects indicates that if pulmonologists rely on standard screening criteria for Alpha-1 testing, the result will be incorrect and missed diagnoses.

“Our surveillance study found that physicians cannot depend on typical patient profiles to assess whether AAT deficiency screening is necessary. There is no ‘face’ to AAT deficiency,” said D. Kyle Hogarth, MD, FCCP, Assistant Professor of Medicine, University Chicago Medical Center, Director of the Alpha-1 Antitrypsin Deficiency Clinical Resource Center at the University of Chicago and lead author of the study. “A number of patients who would not normally be screened based on suggested guidelines turned out in fact to be positive for AAT deficiency. In the real-world setting, this suggests that thousands of patients who have been diagnosed with COPD or severe asthma may actually have Alpha-1.”

The RAD study was supported by an unrestricted educational grant from CSL Behring, maker of the Alpha1 Proteinase Inhibitor (Human), Zemaira(R).

About Alpha-1 Antitrypsin Deficiency (Alpha-1)

Alpha-1 antitrypsin is an anti-inflammatory protein that protects the tissue of the body. One of its most important roles is to shield the delicate tissues of the lungs by binding to neutrophil elastase, an enzyme released by certain white blood cells that digests bacteria and other foreign substances in the lungs. When a person with deficient levels of AAT inhales irritants or contracts a lung infection, the neutrophil elastase released to protect the lungs is uncontrolled and can injure healthy lung tissue. Repeated injury to the normal structure of the lungs can eventually result in emphysema, a condition affecting 54 percent of diagnosed AAT deficient patients, according to a recent registry. Identifying patients with AAT deficiency can be problematic, however. Because AAT deficiency typically involves such common symptoms as shortness of breath on exertion, wheezing, and coughing, the condition is often misdiagnosed as another chronic lung condition. In fact, retrospective studies show that even after an Alpha-1 patient has developed symptoms, it can take an average of seven years and visits to five different healthcare professionals before the correct diagnosis is made. Researchers estimate that up to 100,000 adults and children in the U.S. have severe Alpha- 1, and 25 million people nationwide may be carriers. Only about 5,000 patients are currently diagnosed as AAT deficient, meaning that up to 95 percent of people with the deficiency remain undiagnosed.

CSL Behring to Launch National Campaign to Improve Detection of AAT Deficiency

To advance the early diagnosis and treatment of AAT deficiency, CSL Behring, a leader in alpha-1 research and treatment, is launching a national education and support program called Test Today. Change Tomorrow. The initiative will target patients, caregivers and healthcare professionals with activities and services, such as a national disease awareness campaign about Alpha-1 deficiency, a toll-free information center and website, educational materials, and a program to support Alpha-1 testing in healthcare settings, called Champions for Alpha-1 Testing. Test Today. Change Tomorrow. will begin the week of November 18 with the launch of a national television show as part of the series Today’s Health. For more information, call CSL Behring Consumer Affairs at 1-866-936-2472, or visit http://www.testtodaychangetomorrow.com/.

CSL Behring is the maker of Alpha1-Proteinase Inhibitor (Human), Zemaira(R), which is indicated for chronic augmentation and maintenance therapy for individuals with established AAT deficiency and clinical evidence of emphysema. Zemaira(R) is not indicated as therapy for lung disease patients in whom severe congenital A1-PI deficiency has not been established. Clinical data demonstrating the long-term effects of chronic augmentation therapy with Zemaira are not available.

As with other Alpha-1 therapies, Zemaira may not be appropriate for the following adult individuals as they may experience severe reactions, including anaphylaxis: individuals with a known hypersensitivity and/or history of anaphylaxis or severe systemic reaction to Alpha-1 Proteinase Inhibitor products or their components and individuals with selective IgA deficiencies who have known antibodies against IgA.

In clinical studies, the following treatment-related adverse reactions were reported in 1 percent of subjects: asthenia (fatigue), injection-site pain, dizziness, headache, paresthesia (tingling) and pruritus (itching). Zemaira is derived from human plasma. As with all plasma-derived products, the risk of transmission of infectious agents, including viruses and, theoretically, the Creutzfeldt-Jakob disease (CJD) agent, cannot be completely eliminated.

About CSL Behring

CSL Behring is a global leader in the plasma protein biotherapeutics industry. Passionate about improving the quality of patients’ lives, CSL Behring manufactures and markets a range of safe and effective plasma-derived and recombinant products and related services. The company’s therapies are used in the treatment of immune deficiency disorders, hemophilia, von Willebrand disease, other bleeding disorders and inherited emphysema. Other products are used for the prevention of hemolytic diseases in the newborn, in cardiac surgery, organ transplantation and in the treatment of burns. The company also operates one of the world’s largest plasma collection networks, ZLB Plasma. CSL Behring is a subsidiary of CSL Limited, a biopharmaceutical company with headquarters in Melbourne, Australia. For more information, visit http://www.cslbehring.com/.

About the Respiratory & Allergic Disease Foundation

The Respiratory & Allergic Disease Foundation (RAD) is a physician-led 501(c)(3) non-profit corporation that provides education for patients and clinicians on allergic and respiratory diseases that affect millions of people in the United States. As new approaches evolve for the treatment of respiratory and allergic diseases, RAD is committed to developing scientific and educational programs for healthcare professionals that incorporate the latest developments in understanding and treating these conditions. With the assistance of our world-class steering committee, network of faculty and participants across the United States, RAD provides healthcare professionals with the cutting-edge, practical education needed to move respiratory medicine forward. Learn more at http://www.rad-foundation.org/.

    Media Contact:    Sheila A. Burke    Director, Public Relations & Communications    Worldwide Commercial Operations    CSL Behring    610-878-4209    [email protected]  

CSL Behring

CONTACT: Sheila A. Burke, Director, Public Relations & Communications,Worldwide Commercial Operations of CSL Behring, +1-610-878-4209,[email protected]

Web site: http://www.cslbehring.com/http://www.rad-foundation.org/http://www.testtodaychangetomorrow.com/

Pipex Pharmaceuticals, Inc. (AMEX: PP) (“Pipex”), a specialty pharmaceutical company developing innovative late-stage drug candidates for the treatment of neurologic and fibrotic diseases, announced clinical results of Alzheimer’s disease test using FreeBound, Pipex’s proprietary pharmacodiagnostic device for measurement of serum free and total copper.

Dr. David A. Newsome was also highlighted on a medical news segment by New Orleans CBS news affiliate, WWLTV channel 4, entitled, “Copper, drinking water and vitamins.” This segment can be viewed through Pipex’s website, www.pipexinc.com.

With the assistance of Dr. Joseph A. Quinn, Associate Professor of Neurology at the Oregon Health & Sciences University (OHSU), 52 frozen samples taken from Alzheimer’s disease patients (n=40) and age-matched controls (n=12), with an average age of 70 years were analyzed on a blinded basis for levels of serum free copper using the FreeBound diagnostic device. A seventy percent (70%) increase in free serum copper was detected in Alzheimer’s disease patients versus age-matched controls (p < 0.02). Additionally, percent free copper detected was also statistically significantly higher in AD patients than age matched controls (p < 0.018). The percent of free serum copper is the amount of free serum copper expressed as a percent of total serum copper. These samples were provided by the Oregon Alzheimer’s disease center.

The following table presents the results of the study using FreeBound:

Percent of Free Free Copper in Serum Copper in Serum (mean values, ug/dL) (mean values, ug/dL) AD Patients 16.8 11.2 Age-Matched Controls 9.9 6.6 P-values P < 0.02 P < 0.018

David A. Newsome, M.D., Chief Scientific Officer of Pipex, commented, “These highly statistically significant findings confirm previously reported scientific results implicating the involvement of elevated levels of ‘free’ copper in the pathogenesis of Alzheimer’s disease. One possibility is that these patients present with increased ‘free’ copper is due to their dietary source of highly oxidative mineral. It is well known that many municipal tap water sources as well as dietary supplements, such as multi-vitamins which generally contain up to 2mg of free copper, can supply more copper than an elderly patient might need. FreeBound’s ability to detect unbound copper is seminal to creating therapeutic modalities for the treatment of this devastating CNS disease, as well as being able to detect other copper mediated disorders, such as Wilson’s disease, Parkinson’s disease, Amyotrophic lateral sclerosis (ALS), autism and schizophrenia.”

Steve H. Kanzer, Chairman and Chief Executive Officer of Pipex, commented, “The purpose of this study is to build upon and confirm free copper’s involvement in Alzheimer’s disease. These results, along with our recent results using COPREXA, our lead anti-copper molecule which reduced insoluble amyloid-beta, a key AD protein by 40% (p < 0.05) in animal models, provides additional basis for further testing of this approach in this important CNS-localized disease. Our FreeBound diagnostic device should allow clinicians to pre-select patients with elevated levels of CNS copper who might benefit from copper-reduction therapy.”

John Althaus, Vice President of Advanced Technology and co-inventor of FreeBound commented, “Traditional methods to detect levels of free copper in serum are indirect, inconvenient and slow and can easily lead to inaccurate free copper values. These traditional methods may have also led to misdiagnosis and incorrect pharmacologic treatment of these patients. As a scientist, I am extremely pleased with the performance and versatile nature of our FreeBound diagnostic device and look forward to utilizing it in further clinical tests, to monitor the longitudinal effects of COPREXA therapy.”

Clinical Correlation of Copper and Alzheimer’s Disease

Over the last several years, an increasing body of evidence points to dysfunctional copper homeostasis in the pathogenesis of dementia. Most recently, a published observational six year study in 3718 patients over the age of 65, concluded that subjects that consumed a typical amount of a copper supplement (1.6mg of copper a day) when taken together with a high saturated and trans fat diet results in an equivalent of 19 years of mental decline (p < 0.001) (2).

In a separate European clinical study conducted in 53 patients, correlated the levels of the highly reactive “free copper” (also known as copper not bound to protein) pool in serum to disease severity in AD patients versus aged-matched control patients. These results demonstrated that the “free copper” serum pool was highly increased in AD patients (4).

These clinical studies are complemented by preclinical studies that show that AD amyloid-betta plaques when treated with copper chelating agents in vitro loosen and reverse fibril formation as determined by spectroscopy.

Subject to initial and necessary registration clinical trials to support its use in treating AD, COPREXA’s specificity and unique mechanism of action for lowering toxic free copper levels in the CNS, combined with its history of success in completed pivotal clinical trials of neurologically-presenting Wilson’s disease, may make it highly useful in the treatment of both the acute cognitive dysfunction (copper-mediated synaptic excitotoxicity) as well as long-term neurodegenerative aspect (copper-induced oxidation and neuronal death) of AD. COPREXA’s ability to specifically bind only toxic free copper, as opposed to increasing free copper levels by virtue of liberating bound copper, for example, amongst other properties, we believe differentiates COPREXA from other non-specific metal chelating compounds previously investigated for neurodegenerative diseases.

About FreeBound Device

Copper, an essential metal, is made available to organs throughout the body via the systemic circulation via a tightly regulated system of copper chaperones and copper transport proteins. Normally, approximately 90% or more of serum copper is tightly bound to the serum copper chaperone called ceruloplasmin (Cp). The remaining 10% of serum copper represents the so-called “free” or “non-ceruloplasmin bound” copper pool and can be highly toxic to the brain the organ which is most sensitive to the effects of free copper. In Wilson’s disease patients, the free copper pool is expanded and causes psychiatric symptoms and neurodegeneration in affected patients.

Direct and accurate measurement of this important toxic pool of free copper in serum has until now remained elusive. The current standard methodology for measuring free copper relies instead on an inexact indirect estimate involving a two step process. First, total serum copper is typically measured using an expensive and time consuming technique called atomic absorption. Second, serum Cp concentrations are determined by immunoassay or enzymatic assay. Once Cp is determined, the estimated amount of copper atoms believed to be bound to Cp is calculated and subtracted from total copper to arrive at an estimate of free copper in serum. The result is an inexact, expensive and time consuming process that carries a large potential for error based on erroneous assumptions and experimental deviations from multiple measurements.

We believe that by using the FreeBound device, free copper levels can be determined using technology similar to and as simple to use as a glucometer that incorporates electrochemical detection. Serum is applied to test strips attached to a meter. The meter is programmed to separate and measure free copper versus Cp-bound copper on the test strip immediately displaying the results on the meter.

About COPREXA

COPREXA is an oral, small-molecule, anti-copper agent that is highly specific for the reduction of free copper in serum, the most toxic form of copper in the body, and is thus ideally suited for the treatment of central nervous system (CNS) diseases in which abnormal serum and CNS copper homeostasis are implicated. COPREXA has completed pivotal clinical trials for the treatment of neurologically presenting Wilson’s Disease, an orphan disease of the CNS, and Pipex plans to file an NDA with the FDA for this indication during this month, November 2007.

Pipex is also developing COPREXA for fibrotic disorders based upon the rationale that the fibrotic disease process is dependent upon the availability of free copper in the body. COPREXA has demonstrated the ability to inhibit fibrosis in a number of well established animal models through the sequestration of available copper and inhibition of key fibrotric cytokines, including secreted protein acid rich in cysteine (SPARC), NFkappaB, TGF-betta, FGF-2, IL-1, IL-6, IL-8, and connective tissue growth factor (CTGF).

COPREXA has also completed a one year phase I/II clinical trial for the treatment of refractory Idiopathic Pulmonary Fibrosis (IPF), a deadly lung disease. Pending regulatory feedback on such a study, Pipex is planning to launch a phase III registration clinical for the treatment of IPF with COPREXA.

References and Further Reading About Copper and Alzheimer’s Disease

For further reading on the subject of free copper and Alzheimer’s disease, the following cited references may be quickly and easily accessed at www.pubmed.gov by simply entering the corresponding PubMed ID:

(1) Sparks DL, Schreurs BG, Trace amounts of copper in water induce beta-amyloid plaques and learning deficits in a rabbit model of Alzheimer’s

disease. PNAS 100(19):11065-9 (2003) PubMed ID: 12920183

(2) Morris et al., Dietary copper and high saturated and trans fat intakes associated with cognitive decline., Arch. Neurol 63:1085-1088; (2006) PubMed ID: 16908733

(3) Miller LM et al., Synchrotron-based infrared and X-ray imaging shows focalized accumulation of Cu and Zn co-localized with beta-amyloid deposits in Alzheimer’s disease. J Struct Biol 155(1):30-7 (2006) PubMed ID: 16325427

(4) Squitti et al., Excess of serum copper not related to ceruloplasmin in Alzheimer disease. Neurology 67:76-82; (2006) PubMed ID: 15781823

(5) Syme D et al., Copper binding to the amyloid-beta (Abeta) peptide associated with Alzheimer’s disease: folding, coordination geometry, pH dependence, stoichiometry, and affinity of Abeta-(1-28): insights from a range of complementary spectroscopic techniques. J Biol Chem 279(18):18169-77 (2004) PubMed ID: 14978032

(6) Ma QF et al., Binding of copper (II) ion to an Alzheimer’s tau peptide as revealed by MALDI-TOF MS, CD, and NMR. Biopolymers 79(2):74-85 (2005) PubMed ID 15986501

(7) Barnham KJ et al., Structure of the Alzheimer’s disease amyloid precursor protein copper binding domain. A regulator of neuronal copper homeostasis. J Biol Chem 278(19):17401-7 (2003) PubMed ID: 12611883

(8) Angeletti B et al., BACE1 cytoplasmic domain interacts with the copper chaperone for superoxide dismutase-1 and binds copper. J Biol Chem 280(18):17930-7 (2005) PubMed ID: 15722349

(9) MiyataM, Smith JD, Apolipoprotein E allele-specific antioxidant activity and effects on cytotoxicity by oxidative insults and beta-amyloid peptides. Nat. Genet. 14(1):55-61 (1996) PubMed ID: 8782820

About Pipex Pharmaceuticals, Inc.

Pipex Pharmaceuticals, Inc. (“Pipex”) is a specialty pharmaceutical company that is developing proprietary, late-stage drug candidates for the treatment of neurologic and fibrotic diseases Pipex’s strategy is to exclusively in-license proprietary, clinical-stage drug candidates and complete the further clinical testing, manufacturing and regulatory requirements sufficient to seek marketing authorizations via the filing of New Drug Applications (NDAs) with the FDA in the U.S. and Marketing Application Authorizations (MAAs) with the European Medicines Evaluation Agency (EMEA).

For further information, please visit, www.pipexinc.com. This press release contains forward-looking statements, within the meaning of Section 21E of the Securities Exchange Act of 1934, that reflect Pipex Pharmaceuticals, Inc. and subsidiaries (“we” or “our”) current expectations about its future results, performance, prospects and opportunities, including statements regarding the potential use of FreeBound or its use as a diagnostic tool, COPREXA(TM) for the treatment of Alzheimer’s disease, inflammatory and fibrotic diseases, as well as the prospects for regulatory filings in the treatment of neurologic Wilson’s disease, including filing NDA with the FDA during November 2007 and that such NDA will be accepted for filing by the FDA and/or that the FDA will agree with our analysis of data supporting the safety, clinical efficacy, manufacturing, stability and other regulatory requirements necessary for COPREXA to be approved for use in neurologically presenting Wilson’s disease or that even if approved for initial indication, that we will be able to conduct and complete necessary initial and registration clinical trials required to support and receive FDA approval for a Supplemental New Drug Application to market COPREXA for the treatment of Alzheimer’s disease or other disease indications, such as, idiopathic pulmonary fibrosis, for example. Where possible, the Company has tried to identify these forward-looking statements by using words such as “anticipates,””believes,””intends,” or similar expressions. These statements are subject to a number of risks, uncertainties and other factors that could cause actual events or results in future periods to differ materially from what is expressed in, or implied by, these statements, including risks set forth in our filings with the Securities and Exchange Commission. We cannot assure you that we will be able to successfully develop or commercialize products based on our technologies, including COPREXA(TM), TRIMESTA(TM), SOLOVAX(TM), EFFIRMA(TM) or Anti-CD4 802-2, particularly in light of the significant uncertainty inherent in developing, manufacturing and conducting preclinical and clinical trials of new pharmaceuticals, and obtaining regulatory approvals, that our technologies will prove to be safe and effective, that our cash expenditures will not exceed projected levels, that we will be able to obtain future financing or funds when needed, that product development and commercialization efforts will not be reduced or discontinued due to difficulties or delays in clinical trials or due to lack of progress or positive results from research and development efforts, that we will be able to successfully obtain any further grants and awards, maintain our existing grants which are subject to performance, that we will be able to patent, register or protect our technology from challenge and products from competition or maintain or expand our license agreements with our current licensors, or that our business strategy will be successful. All forward-looking statements made in this press release are made as of the date hereof, and the Company assumes no obligation to update the forward-looking statements included in this news release whether as a result of new information, future events, or otherwise, other than as required by law.

For Further Information Contact: Steve H. Kanzer, CPA, Esq. Chairman and Chief Executive Officer (734) 332-7800 Thomas Redington, Ph.D. (investor relations) Redington, Inc. (203) 222-7399

SOURCE: Pipex Pharmaceuticals, Inc.

Xcorporeal, Inc. (OTCBB:XCPL) announced today that The Los Angeles Times has featured the company’s Wearable Artificial Kidney prototype device (WAK) in a story following a presentation delivered by Victor Gura M.D., the company’s Chief Scientific Officer, at The American Society of Nephrology’s (ASN) Renal Week. The presentation, titled, “Continuous Renal Replacement Therapy with a Wearable Device,” discussed the first human study conducted in London earlier this year with a prototype of the company’s WAK. The article may be viewed at: http://www.latimes.com/features/health/la-he-lab12nov12,1, 6584708.story?coll=la-headlines-health&ctrack=1&cset=true (Due to its length, this URL may need to be copied/pasted into your Internet browser’s address field. Remove the extra space if one exists.)

The ASN is organized and operated exclusively for scientific and educational purposes, including enhancing the field of nephrology by advancing the scientific knowledge and clinical practice of that discipline through stimulation of basic and clinical investigation, providing access to new knowledge through the publication of journals and the holding of scientific meetings, advocating for the development of national health policies to improve the quality of care for renal patients, cooperating with other national and international societies and organizations involved in the field of nephrology, and using other means as directed by the Council of the Society.

About Xcorporeal

Xcorporeal, Inc. is a medical device company developing an innovative extra-corporeal platform technology that may be used in devices to replace the function of various human organs. The platform leads to three initial products; a device for home hemodialysis, another device for hospital Renal Replacement Therapy (RRT) and the WAK, being presented today, for continuous ambulatory hemodialysis. These devices will seek to provide patients with improved, efficient and cost effective therapy. The RRT markets represent multibillion dollar opportunities.

For the RRT market, Xcorporeal is developing a portable, multifunctional renal replacement device that will offer cost effective therapy for those patients suffering from Acute Renal Failure (ARF) which causes a rapid decline in kidney function. In the U.S., the disease affects more than 200,000 patients annually, with a mortality rate of 50%. The Xcorporeal platform technology is a natural fit for the hospital market of renal replacement therapy since the technology is designed to provide cost-effective, continuous therapy without the need for expensive replacement fluids. The projected 2007 market opportunity for the U.S. is approximately $1.4 billion. The disposable market is expected to grow at 10% per year. The devices typically need to be replaced every five years. The Company intends to commercialize this device during the first half of 2009.

Xcorporeal also plans to commercialize a home hemodialysis machine and the WAK for the End Stage Renal Disease (ESRD) market, which includes patients with severe kidney disease in which the kidneys cease to function. Xcorporeal’s devices will combine the best attributes of currently marketed home hemodialysis machines to create hemodialysis devices which offer patients convenient, durable and truly portable devices for home use. The Company believes its machines will provide a cost-effective alternative to current home treatment modalities, due to their ability to offer hemodialysis without the need for dialysate fluids. The WAK is in addition a revolutionary device intended to enable patients with ESRD to achieve a quality of life closer to that of healthy individuals.

Additional Company information may be found on the Internet at: www.xcorporeal.com.

Forward-Looking Statements

Except for statements of historical fact, the matters discussed in this press release are forward looking and made pursuant to the Safe Harbor provisions of the Private Securities Litigation Reform Act of 1995. These forward-looking statements reflect numerous assumptions and involve a variety of risks and uncertainties, many of which are beyond the company’s control that may cause actual results to differ materially from stated expectations. These risk factors include, among others, limited operating history, difficulty in developing, exploiting and protecting proprietary technologies, intense competition and substantial regulation in the medical device industry; and additional risks factors as discussed in the reports filed by the company with the Securities and Exchange Commission, which are available on its website at http://www.sec.gov.

By Poff, D J Wong, R; Bulsara, M

Poff DJ, Wong R, Bulsara M. Acute decompression illness and serum s100beta levels: A prospective observational pilot study. Undersea Hyperb Med 2007; 34(5):359-367. Background: S100beta, a calcium binding protein associated with astroglial cells and other tissues has been shown to be raised in the serum of patients with a number of neurological pathologies. As there are no published data on serum S100beta determinations in recreational divers affected by decompression illness (DCI) this pilot study determines whether S100beta is a possible biochemical marker of DCI worthy of further investigation. Methods: Venous blood samples were drawn from patients diagnosed with, and treated for acute DCI at a hyperbaric facility and analysed for serum S100beta concentration and Creatine Kinase (CK) activity. Samples were taken at initial presentation, and again following final treatment. Results: Twenty one patients were included in the study. Neither S100beta, nor CK levels were significantly raised above population normal limits. Conclusion: S100beta is not a clinically useful serum marker of acute DCI. INTRODUCTION

Decompression Illness (DCI) refers to a disease state suffered as a consequence of bubble formation from dissolved inert gas within tissues or blood following a reduction in environmental pressure or by bubble introduction into the vasculature such as might be caused by pulmonary barotrauma. This term encompasses both Decompression Sickness (DCS) and Cerebral Arterial Gas Embolism (CAGE); the former referring specifically to a clinical or pathophysiological situation associated with bubble formation from dissolved inert gases, and the latter, to a situation of bubble gas introduction to the arterial blood (1).

The diagnosis of DCI is made purely on clinical grounds, involving the consideration of the history of events leading to the illness (including the dive profile(s), environmental conditions and post dive activity (such as airline flight), the symptoms complained of by the patient and the physical findings on examination of the patient. There are no laboratory tests that aid in the diagnosis or subsequent treatment of this condition, or indeed any that might serve to help a clinician to advise on issues including the period of time before a patient might safely return to diving or go to altitude (such as flying where cabin pressure is usually at 0.8ATA). Any such marker might be invaluable in both determining an appropriate treatment regime and assisting in prognostication.

Whilst the primary pathological event in DCI is known to be the formation or introduction of bubbles into blood or tissues, the fundamental pathological process which gives rise to the clinical manifestations as diverse as, and including general malaise, joint ache, itch, soft tissue swelling, confusion, altered memory, parasthesia or paralysis is not clearly understood. Tissue injury, including that to neurological tissues in the brain, spinal cord, and peripheral nerves, is thought to result in part from the mechanical disruption of blood supply to tissues and subsequently from the biochemical actions of a complex of inflammatory processes set in motion by this injury (2, 3).

Attempts to quantify the changes in physiological parameters in association with diving have led to the description of changes in hematological (4-7) and hormonal (8, 9) parameters. In addition, the relationship between elements of the coagulation and complement systems and diving, with or without the issue of DCI, has been investigated (10-12). Work on these aspects of diving physiology is ongoing and there is increasing interest in looking at aspects of proinflammatory mediators and markers of inflammation (13, 14). Much of this research has been focused on describing the underlying physiological change associated with diving in an effort to determine the basis of pathophysiological change resulting from DCI.

The S100 proteins are a subfamily of calcium binding proteins which have a diverse array of tissue associations and both intra- and extracellular functions(15). There has been a rapid evolution of the understanding of the numerous subtypes of these proteins, including S100beta, an astroglial protein that is present in the blood of healthy persons in low levels at a concentration that is both age and sex independent 16). It has been associated with promise as a marker of brain tissue injury in both stroke and traumatic brain injury(17-19). Changes in levels of S100beta have also been described in the settings of cardiac surgery both adult and paediatric as a potential indictor of neurological injury(20- 22). It has been described as a possible surrogate marker for successful clot lysis in hyperacute cerebral artery occlusion(23) and as a pointer to the influence of peripheral neuropathy in GullainBarre syndrome(24). It has also been suggested that it may have value as a marker of both treatment and prognostic value in relation to carbon monoxide poisoned patients(25-27).

S100beta is also regarded by some as a marker of physiological stress per se. Recent work indicates that this may be independent of the hypothalamic-pituitary-adrenal axis associated with glucocorticoid mediated stress responses(28). There is increasing understanding too, that S100beta is also expressed in adipose issue and skeletal muscle(29) and that it may not represent a marker with sufficient specificity to delineate neurological injury in for example acute head injury(30, 31). Further attempts to define S100beta role as potential marker of neurological injury versus physiological stress have been carried out in a range of physical pursuits including marathon runners(32), elite ice hockey and basketball players(33), distance swimmers(34) and boxers(35). Data presented at the Breath Holding Diving Symposium in Orlando Florida, June 2006 by Andersson demonstrated increased serum levels of S100beta in the 30 minutes following competitive breath-hold diving. The levels returned to baseline before 1 hour and again it is not clear if this brief increase in S100beta level represents a normal stress response or is indicative of a pathological process. It is suggested that S100beta has the role of a neurotrophic peptide in regular healthy exercise(36).

Efforts to differentiate the tissue source of S100beta in situations of physiological stress versus possible neurological injury have included the use of correlation studies between it and creatine kinase (CK)(32). Hasselblatt and colleagues demonstrated that CK determination may improve the specificity of S100beta as a marker of brain tissue injury in the setting of acute trauma.

There is no published data on the levels of S100beta in the diver, recreational or commercial, with symptoms of DCI. The aim of this study was to determine whether there is any significant rise in the serum levels of S100beta in the diver clinically diagnosed with DCI either before or following treatment. In order to identify any confounding influence by an identifiable extraneural source of S100beta, serum CK was measured concurrently.

MATERIAL AND METHODS

A total of 37 adult patients (> 18 years of age) presented to the Fremantle Hospital Diving and Hyperbaric Medicine Unit (FHDHMU) between 29 December 2004 and 13 February 2006. Of these, 11 patients were not enrolled because they either chose not to consent, or were not included due to failure on the part of the treating physician to consider the patient for enrolment. No patient was excluded on the basis of being too ill. The principal author was not involved in either the enrolment of subjects or the decision to treat.

The study group therefore consists of 26 consenting divers, all of whom were enrolled on the basis of the attending diving physician’s intention to treat with standard recompression therapy for the initial diagnosis of DCI. The diagnosis was made on the basis of clinical history and examination findings in the absence of alternative diagnosis in keeping with diving medicine practice. They were all recreational divers, 24 of whom were diving on SCUBA equipment and two were using surface supply “Hookah” equipment. Following enrolment into the study, five subjects were excluded from the analysis. One was excluded on the basis of an alternative diagnosis and was not treated for DCI. Four subjects who were enrolled were excluded from the final analysis having incomplete sets of blood results.

The study was given ethical consent by the South Metropolitan Health Services’ Human Research Ethics Committee and all subjects gave written consent for inclusion in the study and the storage of blood samples for the duration of the study.

Venous blood samples were taken prior to the subjects’ first recompression treatment, and again following their last. CK levels were assayed on a routine basis using a Cobas Integra 800 analyser (Roche Diagnostics, Castle Hill, NSW, Australia) with IFCC recommended reagents. As the S100beta assay was a nonstandard laboratory test, samples were stored at -20[degrees]C as recommended and batch analysed at intervals using an electrochemiluminescence immunoassay ‘ECLIA’ assay (Elecsys(R) 1010/2010/Modular Analytics E170, Roche Diagnostics GmbH, Mannheim, Germany). The measurement range for this assay is 0.00539 [mu]g/1.

Normal ranges for the two parameters were predefined by (i), the normal limits for serum CK activity used by the Fremantle Hospital Laboratory Services, and (ii), data provided by Roche Diagnostics as pertaining to the normal levels of serum S100beta in healthy adults. This data accompanied the immunoassay kit. Statistical analysis was done using both paired and single sample non-parametric tests; Wilcoxin signrank and Kolmogorov-Smirnov tests. Correlation between CK and S100beta was examined using the method of Pearson. Mean +- sd are reported. The level of statistical significance was set at p

No funding beyond the resources of the Fremantle Hospital Diving and Hyperbaric Medicine Unit was required for the completion of this study.

RESULTS

The average age of the 7 women and 14 men was 38 +- 8 years. The average time between the last dive undertaken and initial treatment was 3 +- 2 days and the average number of treatments was 3 +- 1. Patient demographics, symptoms and signs are detailed in Table 1, opposite page.

There was no rise in the serum concentration of S100beta above the 95th percentile of the normal range in any of the divers diagnosed as suffering DCI prior to their initial treatment. The mean of the measured levels was significantly lower than the normal range 95th percentile (p

Serum CK activity in the initial sample and the upper limit of the normal range were not significantly different (p=0.916, single sample Kolmogorov-Smirnov test). While there was a statistically significant difference between the initial mean CK activity and the final value (p=0.0007 Wilcoxin signrank test), both levels fell within the normal range of activity. (Figure 2)

There was no correlation between the CK activity levels and the measured serum S100beta concentrations, (beta-coefficient not significantly different to zero; p=0.663) (Figure 3)

DISCUSSION

In the absence of any other reasonable explanation, the clinician presented with a recreational diver who has what is often a constellation of vague complaints, is left to conclude a diagnosis of decompression illness. This not infrequently occurs when the patient has no discernable abnormal clinical signs (Table 1 ), and indeed the dive profile(s) may not be regarded as provocative, that is, falls within accepted limits for depth and time. Regardless of the lack of palpable evidence, the treatment of the injured diver with recompression therapy brings satisfaction to both the patient and the clinician in the vast majority of cases. In this series of 21 divers, 70% had full resolution of their symptoms with treatment. Only 2 divers had a poor response, with the remaining having a partial relief of their symptoms.

There are a number of possible explanations as to why a patient with presumed DCI might not respond to therapy including delay to presentation and severity of illness. Frequently however, when the symptoms are vague, the clinician is left to wonder if the diagnosis truly is DCI and may elect to treat expectantly with standard recompression tables, interpreting a good clinical response as supporting the diagnosis of DCI. A quantitative marker of this pathological process could be helpful.

The use of biochemical markers to help diagnose and prognosticate permeates the practice of medicine in a number of disciplines. The usefulness of such markers is dependent on the positive predictive value of the test at the presumed prevalence of disease in the group of interest (the prior probability of disease). Routine application in the absence of an accurate estimate of prior probability may not be helpful for diagnosis. Hence they can on occasion be useful aids when used in a considered manner together with the clinical information.

Given that the understanding of the fundamentals of DCI pathophysiology is far from complete, it might be considered somewhat hopeful to pluck a new biochemical marker out of the literature and expect it to provide the desired outcome. The usefulness of S100beta as a marker of neurological injury or physiological stress is debatable; however there is some rational with respect to diving injuries. The fact that other sports activities have been associated with an increase in its measurable activity both with and without the presumption of neurological injury raises the possibility of its applicability to the sport of diving. While recreational diving is not regarded as a typically strenuous activity when compared with marathon running, boxing or elite ice hockey it can be very physically stressful under certain environmental conditions such as adverse tide and wind. What is not known is how and why the apparent accumulated stress of tissue bubble accumulation gives rise to certain symptoms some of which have particular neurological features, such as parasthesia and disordered thinking or concentration.

This study recruited a typical cohort of patients that presented to a hyperbaric facility for assessment and treatment of apparently diving related illness. The decision to treat was undertaken by physicians experienced in diving medicine, and the treatment undertaken was routine. The outcomes of treatment as described by the treating physicians were equally typical with the majority of patients experiencing a full resolution of their symptoms. They were an ideal group to help determine whether or not S100beta was worthy of further research into its usefulness as a biochemical marker of DCI.

There are a number of limitations of this study:

Not all of the 37 patients who were diagnosed and treated for DCI during the study period were recruited thus raising the issue of selection bias. Whilst unlikely given the results, there remains a possibility that those recruited represent a subset of affected divers that were less likely to have a rise in serum S100beta as a consequence of milder disease. This makes an assumption that those excluded were more severely affected and this cannot be corroborated.

There is no control population against which the subjects are compared. Whilst initially considered as part of the study design, it was felt that to attempt to find an adequately matched population for age, sex, dive profile and dive conditions would be beyond the scope of this initial pilot study. By the same token, to use an inadequately matched cohort, e.g. noninjured divers under a given set of conditions may not have provided an adequate solution. It was felt that in the event of results worthy of further investigation then these issues would need to be addressed by further study. Given the results this would appear unnecessary.

The diagnosis of DCI was made by experienced diving medicine physicians in keeping with their normal practice. As such the diagnoses were not made on the basis of explicit pre-study criteria with an assumption of diagnostic accuracy. There is therefore the possibility of selection bias and lack of external validity.

There was also an assumed predive population normal value for each of the measured parameters. As there was no way to pre-dive test the affected patients, it is possible that their normal population values were different to those used. This does not seem likely as the normal values reported in a number of previous studies, with particular reference to those involving subjects undertaking other vigorous sporting activities, were similar to those used in this study. Raised levels of S100beta in those studies were significantly above the baseline normal levels(32-35).

It is possible that a delay to presentation, diagnosis and treatment of on average 3 days would have influenced the levels of S100beta since the half life of S100beta has been shown to be about 30 min in patients after cardiac surgery (37). Previous studies of the relationship between S100beta and a wide range of clinical situations as cited above have invariably been associated with the taking of samples in a period of less than 6 hours following the physiological insult under investigation. One could argue that despite ongoing symptoms in divers suffering DCI, the delay to investigation was time enough for any rise in S100beta to be eliminated. One study did show that a single S100beta sample taken at 48-96 hours post insult was indicative of successful clot lysis at

CONCLUSION

This pilot study supports the null hypothesis in that there is no significant change in serum levels of S100beta in recreational divers suffering decompression illness at the time of treatment initiation. It provides data that refutes any idea that the level of S100beta could be clinically useful as a biochemical marker of decompression illness. It would also suggest, that if any of the symptoms attributed to decompression illness have their origin in underlying neurological injury, this injury will not be reflected in a change of serum S100beta at the time of treatment. ACKNOWLEDGMENTS

The authors thank the medical, nursing, and clerical staff of the Fremantle Hospital’s Department of Hyperbaric and Diving Medicine, Western Australia, and the staff of the Laboratory Services of Fremantle Hospital for their cooperation in the undertaking of this study.

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Submitted 9/29/06; Accepted 3/28/07

D.J. POFF1. R. WONG2, M. BULSARA3

1 Advanced Trainee in Emergency Medicine, Australasian College for Emergency Medicine; Medical Officer, Royal Flying Doctor Service, Western Operations, Western Australia, 2 Medical Director, Department of Diving and Hyperbaric Medicine Fremantle Hospital, Western Australia,3 Research Fellow/Consultant Biostatistician, School of Population Health, University of Western Australia, Faculty of Medicine and Dentistry

Copyright Undersea & Hyperbaric Medical Society Sep/Oct 2007

(c) 2007 Undersea & Hyperbaric Medicine. Provided by ProQuest Information and Learning. All rights Reserved.

Through the Fremont Adult School, instructor Sifu May Chen offers ongoing tai chi classes for adults of all skill levels.

Great Outdoor Tai Chi classes are from 8 to 10:45 a.m. Mondays, Wednesdays and Fridays at the Senior Center, 40086 Paseo Padre Parkway, Fremont. 510-790-6602.

Other classes at 4700 Calaveras Ave., Fremont:

-Yang Style Tai Chi Chuan Routine No. 24, 1 to 3 p.m. Mondays and Wednesdays. No class Nov. 19, 21; Dec. 24, 26 and 31.

-Yang Style Tai Chi Chuan No. 42, 5:15 to 7:15 p.m. Mondays.

-Chen Style Tai Chi Chuan, 5:15 to 7:15 p.m. Wednesdays.

Call 510-793-6465.

Elephant Pharm

Homeopath Myra Nissen gives tips on how to care for winter colds and flu from 3:30 to 4:30 p.m. Thursday.

All classes are free. 1388 S. California St.,

Walnut Creek. Call 925-658-5300 or visit http:// www.elephantpharm.com.

American Red Cross

To make an appointment to donate blood, call 1-800-GIVE-LIFE (800- 448-3543).

Any healthy person age 17 or older, weighing at least 110 pounds, may be able to donate blood. You can visit http://www.BeADonor.com and search for the blood drive or center location nearest you. The Red Cross has blood centers in Newark, Oakland, Pleasant Hill, Pleasanton and San Jose.

Bariatric Surgery Program

Alta Bates Summit Medical Center’s weight-loss surgery support group “New beginnings” will be having meetings for people who have had or are considering weight-loss surgery. Pre-operative patients will meet from 6 to 7:30 p.m. on the fourth Tuesday of each month. Post-operative patients will meet from 10 to 11:30 a.m. on the second Saturday of each month. Family and friends are welcome. Admission is free. At 3100 Summit St., Suite 2600, Oakland. Call 510- 869-8972.

Hospice gay men’s grief group

Hospice By the Bay’s eight-week grief support group for gay men who have lost a life partner or close relationship. From 7 to 8:30 p.m. Thursdays through Dec. 6.

There is no charge for those who received Hospice by the Bay services within the past year. $160 fee for community members. To reserve a space, call 415-487-4313. Located at 1902 Van Ness Ave., 2nd floor, San Francisco.

Axis Community Health

The center has scheduled its free fall immunization clinics for children from 9 to 11:30 a.m. Dec. 1.

At 4361 Railroad Ave., Pleasanton. Call 925-462-1755 for an appointment.

Public flu shot clinics

Sutter VNA & Hospice will be vaccinating children 9 and older and adults in Alameda County. The clinics continue through December.

To find dates and nearby locations call 800-500-2400 or visit http://www.vnaa.org/vnaa/flu/findclinic.aspx.

Stroke support group

The Alta Bates Summit Medical Center Regional Stroke Center hosts a support group for those in stroke rehabilitation and their family and friends. Held from 4 to 5 p.m. the first Tuesday of every month (except December). Free.

At the Herrick Campus, 2001 Dwight Way, Berkeley. Call 510-204- 4503.

Alta Bates Summit Medical Center

From 11 a.m. to noon, Thursdays, the Berkeley campus hosts free drop-in yoga classes for cancer patients. At 2001 Dwight Way. Call 510-508-1653.

Free yoga

Relax the mind and find peace, balance and renewal with free Sahaja Yoga meditation classes every Monday from 7 to 8 p.m. The sessions are open to everyone.

At 2029 Durant Ave., Berkeley. Call 510-522-3436.

Food addicts in recovery

A free 12-step recovery program is held Saturdays in Tracy from 9 to 10:30 a.m. for people suffering from food obsessions such as overeating, undereating and bulimia.

At Tracy Community Church, 1790 Sequoia Blvd. Call 209-835-5577 or visit http://www.foodaddicts.org.

Quit-smoking support group

From 6:30 to 7:30 p.m. Mondays, Nicotine Anonymous meets at the First Presbyterian Church in Livermore. The ongoing support group is open to the public.

At 2020 Fifth St., Livermore. Call 925-339-5199.

Chemical dependency workshops

The Alta Bates Summit Medical Center’s Merritt Peralta Institute offers treatment for alcohol or drug abuse. The workshop is open to addicted people or their friends and families. Workshops include: Disease of Chemical Dependency, Family Illness, Intervention, Treatment and Recovery and Adolescent Chemical Dependency. From 10 a.m. to noon Saturdays. Free.

At the medical center’s Health Education Center, Room 201, 400 Hawthorne Ave., Oakland.

Send press releases at least three weeks in advance to Health Calendar, Bay Area Living, 4770 Willow Road, Pleasanton, CA 94588, or e-mail Dino-Ray Ramos at [email protected]. Faxes can be sent to 925-416-4850. Include the name of the event, time, date, place, description, cost and a telephone number. Event listings are free.

Alta Bates Summit Medical Center

The Latina Breast Health Program hosts a free breast cancer support group for Spanish speaking women from 2 to 4 p.m. the first and third Monday of each month. Registration required.

Located at the Summit Campus, Peralta Pavilion, Markstein Cancer Education and Prevention Center 430 30th St., Room 2810, Oakland. Call 510-219-3532.

Elephant Pharm Flu Shots

Stop by Elephant Pharmacy locations for a flu shot. Proceeds benefit Sutter Hospice Program. Preservative-free shots for pregnant women or nursing mothers are in limited supply for $30. All other shots are $25. Located in Berkeley: 1607 Shattuck Ave., 510-549- 9200. Walnut Creek: 1388 South California St., 925-658-5300. Check http://www.elephantpharm.com for details.

Hospice By the Bay

The nonprofit organization offers an ongoing weekly grief and art support group that combines work with various art media and group discussion. Participants focus on healing grief from the loss of a loved one. No art background required.

Meets 6:30 to 8:30 p.m. Mondays. Located at 1902 Van Ness Ave., 2nd floor, San Francisco. There is no charge for family members who have received services within the past year. Otherwise, the cost is $20 per group. Call 415-469-2521.

Maternity classes in Spanish

Eden Medical Center gives free tours of its birthing facilities and childbirth preparation classes in Spanish. Tours are at 7 p.m. on the second Tuesday of the month.

The medical center is at 20103 Lake Chabot Road, Castro Valley. Call 510-889-5078 to register or visit http:// www.edenmedcenter.org.

HIV testing

The Santa Clara County Department of Public Health has approved the DeFrank LGBT Community center as an alternative HIV test site. The center offers a pilot HIV program that uses rapid testing technology. Hours are 10 a.m. to 2 p.m. for appointments; 5 to 8:30 p.m. for walk-ins Monday through Thursday.

The center is at 938 The Alameda, San Jose. Call 408-293-3040 ext. 119, http://www.defrank.org/services/health/hiv–aids.html.

Laugh and stretch

The Dublin Senior Center invites you to Laughter Yoga classes from 7 to 8 p.m. Mondays. This form of exercise combines the power of laughter with yoga to fill the body with oxygen, lower stress levels and make you feel good. All ages welcome. $5 per class.

The center is at 7600 Amador Valley Blvd., Dublin. To register call 510- 390-4105.

Cancer support

The East Bay Cancer Support Group meets Thursdays at Faith Lutheran Church, 20080 Redwood Road, Castro Valley. The charitable organization serves cancer patients and caregivers for free. For scheduled meeting times call 510-889-8766 or visit http:// www.ebcancersupport.org.

Send press releases at least three weeks in advance to Health Calendar, Bay Area Living, 4770 Willow Road, Pleasanton, CA 94588, or e-mail Dino-Ray Ramos at [email protected]. Faxes can be sent to 925-416-4850. Include the name of the event, time, date, place, description, cost and a telephone number. Event listings are free.

(c) 2007 Oakland Tribune. Provided by ProQuest Information and Learning. All rights Reserved.