Rockdale Hospital Authority Selects Signature Hospital Corporation to Purchase Hospital

Signature Hospital Corporation was selected yesterday to purchase and lead Rockdale Medical Center by the Board of Trustees of the Hospital Authority of Rockdale County and the Board of Directors of Rockdale Medical Center Inc., officials announced.

The decision follows a careful and deliberate evaluation by members of both hospital boards who spent more than a year exploring the options for strengthening the Hospital and ensuring access to quality hospital care for the residents of Rockdale County.

Yesterday’s decision is the first step of a public approval process that is expected to take several months. The purchase of the Hospital by Signature for approximately $90 million requires the review and approval of the Attorney General of the State of Georgia.

“We have found in Signature an experienced hospital operator that will commit to the Hospital the resources and tools it needs to successfully serve this community,” says Ethel Boyle, Chair of the Board of Directors of Rockdale Medical Center Inc.

“Our decision to sell the hospital will allow Rockdale to successfully emerge from the financial and operational issues that we, along with our employees and physicians, have worked so hard to overcome. While we have made significant progress, a sale to Signature brings access to capital, management and support systems that will ensure our long-term vitality in ways that we cannot on our own.”

Rockdale Medical Center is a Joint Commission accredited 138-bed hospital that serves Rockdale County, Georgia, and surrounding communities. Located approximately 25 miles east of Atlanta, the hospital provides acute care, diagnostic, emergency and outpatient services.

In 2002, Rockdale embarked on a Master Facility Plan, which significantly updated the hospital and elevated its status as a state-of-the-art provider in the metro Atlanta area. Since then, the hospital has had difficulty in meeting the bond covenants of the debt incurred to fund that expansion.

While the Hospital has made progress in the past year — it was successful in meeting its bond covenants for Fiscal Year 2006 after not meeting them in 2005 — the organization must have an infusion of capital to secure the long-term financial stability needed to deliver excellent patient care. With the purchase of the Hospital by Signature, the hospital’s debt will be erased and the Rockdale community will benefit from new tax revenue.

“A community partnership with Signature will allow us to capture the full potential of the investments we have already made, and will allow us to make new and needed investments in medical equipment and services so that the Hospital can serve our fast-growing community on a long-term basis,” says Bill Rogers, Chair of the Hospital Authority of Rockdale County.

As part of their evaluation process, members of the Authority and Board, as well as representatives of the medical staff and hospital administration, visited community hospitals operated by a number of potential purchasers, including Signature, and spoke privately with physicians, nurses, employees and community leaders there.

“We liked what we saw in Signature,” Rogers says. “We chose the company from among a group of interested parties because of their commitment to quality healthcare in communities similar to Conyers, where the hospital is not only a trusted, respected provider of care, but also a cornerstone of the community.”

Highlights from the purchase agreement approved by the boards include:

A purchase price of approximately $90 million. The final figure will be determined at the time the transaction is concluded, which will follow the approval of state officials. (With these proceeds, the Hospital Authority and the Medical Center will pay off all debt.)

The lease between the Hospital Authority and Rockdale Medical Center, Inc. will be terminated and all funds remaining after the sale – after payment of all debt and expenses – will be held by the Hospital Authority and used for charitable healthcare services throughout Rockdale County.

A commitment by Signature to additionally invest at least $32 million in the Hospital over the next five years in capital expenditures to include facility improvements and expansion of services, new medical equipment and for other hospital needs.

Establishment of a Rockdale Medical Center community healthcare fund that will receive at least $4 million from Signature over the next 10 years and will be used to fund and support community healthcare projects.

Offers of employment to all Hospital employees at the time of closing and full credit for the current years of service and rates of pay.

Local representation on the Signature Hospital Corporation Board of Directors and on the Rockdale Medical Center Board of Trustees.

A commitment by Signature to maintain the hospital’s core general acute care services, including emergency services and obstetrics.

A commitment by Signature to provide the same level of indigent care that the hospital provides today.

“Signature is honored to have been selected by the Authority and Medical Center Boards,” says Charles R. Miller, President and Chief Executive Officer of Signature.

“We see tremendous opportunity to further strengthen the Hospital’s role as a trusted provider of care in Rockdale County. Conyers is a great, fast-growing community and we are delighted to join the employees, physicians and patients that make the Hospital such a great place to receive care.”

This announcement marks the beginning of a public process, which is governed by Georgia law through the Attorney General’s office. Within approximately two weeks of yesterday’s announcement, the Hospital Authority of Rockdale County, Rockdale Medical Center and Signature will submit a filing with the Georgia Attorney General.

A public hearing will be held in Rockdale County approximately 60 days after that filing. The purpose of this hearing is to provide full disclosure of the purpose and terms of the proposed purchase, as well as an opportunity for local public input in order to ensure that the public’s interest is protected when the proposed disposition is completed.

About Rockdale Medical Center

Rockdale Medical Center is a 138-bed licensed hospital serving Conyers, Ga., and surrounding communities. Located about 25 miles east of Atlanta, Rockdale Medical Center is accredited by the Joint Commission as well as The American College of Surgeons Commission on Cancer. For more information, please visit www.rockdalemedicalcenter.com.

About Signature

Based in Houston, Texas, Signature Hospital Corp. is a privately held company dedicated to providing affordable, state-of-the-art medical services to communities in which it owns and operates hospitals.

Anchored by a strong commitment to patient safety, backed by proprietary technology for measuring and improving quality in its hospitals, Signature presently owns and operates four hospitals: 115-licensed bed Pampa Regional Medical Center in Pampa, Texas; 161-licensed bed Gulf Coast Medical Center in Wharton, Texas; 79-licensed bed Medical Park Hospital in Hope, Ark., and 325-licensed bed St. Joseph’s Hospital, in Parkersburg, W. Va.

Signature’s board and management team boast more than two centuries of combined experience in healthcare management and finance. Signature’s financial partner is Goldman Sachs, the nation’s premier investment banking firm. For more information on Signature, please visit www.signaturehospital.com.

Messner Recalls His Beloved Wife, Tammy Faye, and Pushes Onward

KANSAS CITY, Mo. _ Roe Messner mourned his beloved Tammy Faye but knew better than to draw it out too long.

His wife, the former Tammy Faye Bakker, wouldn’t have liked it. She rose from being a preacher’s wife to a symbol of televangelism excess, but even in the depths of scandal, she kept singing and laughing as her world fell apart.

She was famous for her tears, but Tammy Faye never cried the blues.

Soon after she died of cancer July 20 at the couple’s home at Loch Lloyd in Cass County, Mo., Roe Messner went back to the office.

“I cried a bucket of tears,” Messner said last week. “But I know she’d say, `Go do your work. Go do what you love to do.'”

His work is what got Messner past earlier hard times _ the collapse of his business, a bankruptcy scandal, prison, his own battle with cancer.

A quiet, reserved man, Messner also endured years of the limelight, media scrutiny and often public ridicule that followed Tammy Faye, whom he married in 1993 after her marriage to Jim Bakker ended and their PTL empire had crumbled in disgrace.

But now, Messner, perhaps America’s most prolific church builder, is determined to keep going.

From his lakeside home in Loch Lloyd, he oversees a company that is currently putting up 30 new churches across the country. He’s been at it more than 50 years and now, at age 72, his goal is to have built a church in all 50 states.

So far, he’s up to 47 states and a total of 1,738 churches he’s built or designed, including 37 in the Kansas City area. That’s one new church every 11 days for better than half a century. Every Sunday morning, an estimated 1 million people walk into a Roe Messner church.

But it wasn’t easy going back to blueprints and architect meetings after July 20.

He knows that to many, Tammy Faye was a national punch line _ a dumb blonde with tight pants, low tops, big hair and too much mascara.

“The press never did get her right,” Messner said, shaking his head. “She was smart. And Tammy was the most loving, kind and forgiving person I ever met. People loved her. When she died, she got a million Internet hits and 14 bags of regular mail.”

Messner smiled. “There are two persons who don’t need a last name _ Elvis and Tammy Faye. When she walked into the room, everybody turned and looked.”

Seventeen days after Tammy Faye’s death, Messner was leading a church construction seminar at the President Hotel in downtown Kansas City. A key in getting a plan approved, he advised the audience, was to keep the congregation’s building committee small.

“I’ve seen committees so big that I thought the Lord himself couldn’t get a plan approved by this bunch,” Messner told the group to laughter.

He has been at this a long time.

He was born an Oklahoma farm boy during the Great Depression. When he was 8, his family moved to Wichita, Kan., where his father took a job at Beech Aircraft. As a high school student, Messner began working on a construction crew.

“I knew right then what I would do with my life,” he said.

He started his own company and was building homes around Wichita when he landed a contract to do an office building for the Assemblies of God. The completed project led someone to ask if he could build a church.

Sure, he said.

“But I had never built a church,” Messner said Thursday.

He drew up the plans on a drawing board in his bedroom. He built that church and later designed and built the much larger Calvary Assembly of God Church in Wichita, a job that, according to Messner, “put me on the map.”

He was soon traveling to national church conferences and landing construction projects all over the country.

In 1961, his company, Commercial Builders of Kansas Inc., built Grace Church of the Nazarene, his entry into the Kansas City market.

He built small churches and mega-churches. In the late 1980s, his reputation brought him to the attention of television evangelist Jim Bakker, who invited Messner to appear on his PTL program. Bakker was unable to appear that day, so his wife, Tammy Faye, filled in.

“That was the first time I met her, and I remember being struck by how smart she was,” Messner said.

His company later landed the contract for PTL’s Heritage USA complex in Fort Mill, S.C. The project _ a hotel, condominiums and a 30,000-seat church _ dominated the firm’s architects and designers.

At that point, the largely private Roe Messner was about to become a very public figure.

Jim Bakker got caught in a sex scandal with church secretary Jessica Hahn, paid hush money to keep her quiet, and went to prison for defrauding thousands of his followers who bought time-shares at Heritage USA. Messner claimed that he remained unpaid for millions of dollars of work.

In 1992, Tammy Faye divorced Bakker while he was in prison. Within a year, she married Messner, who also had recently divorced and filed for bankruptcy. He won’t talk about it today, but in 1995 he was convicted of concealing $400,000 of assets during his bankruptcy case. He eventually served 27 months in federal prison.

After his release, he and Tammy Faye lived a quiet retirement until Messner decided to start building churches again. It didn’t take long for him and his new company, Commercial Builders and Architects, to reclaim his past glory.

“He’s built more churches than any man alive,” said Donnie Haulk, owner of Audio Ethics, a Charlotte, N.C., company that specializes in installing sound systems in big churches.

“And the reason for that … the thing that people like about Roe Messner … is that unlike some church builders, he will build the church the congregation wants, rather than the church the contractor wants to build.”

It’s hard to quantify for certain that Messner’s 1,738 churches make him America’s most prolific church builder. But as Toby Van Wormer, executive director of the National Association of Church Design Builders, put it recently: “A church builder is doing good business if he builds four or five a year _ do the math.”

On Thursday, Roe Messner wanted to show off “Tammy Faye’s Dream House.”

In June 2006, he and his wife, by then sick with cancer, decided they wanted to move from Charlotte to Kansas City to be closer to family. She told him to go buy her a house.

“I told her I would go buy her a lot and build any house she wanted,” Messner said.

They bought a stack of home-design books. She picked out a design and told him she wanted a white living room and a red bathroom.

“Then she handed me a pillow and said she wanted her bedroom to match this,” he said.

The pillow was rose-colored.

Messner built the house on the wooded lakeside at Loch Lloyd. It is peach-colored, with wide brick steps leading to the front door. Inside, among the dark cherry trim, are Tammy Faye’s 14-foot-by-21-foot walk-in closet and an organ that used to sit in Frank Sinatra’s home in Palm Springs, Calif.

“Tammy loved to sit there and play and sing, even when she was sick,” Messner said.

Melanie Hart, a longtime friend and personal assistant of Tammy Faye’s, said the couple was a match made in heaven.

“They were opposites, but that’s how God works _ he puts surprises in our path. Roe loved Tammy’s vibrancy, and she needed his peace. They were so comfortable with each other, and I know she loved that new house.”

When Tammy Faye died at home, the plan was to keep the death quiet until arrangements could be made. But the news leaked, and media satellite trucks were soon camped out at Loch Lloyd’s front gate.

“I knew it would be a circus, so I had a white van sneak in and pull into the garage and take her body,” Messner said.

He said her ashes were buried “next to my mom in a country cemetery in Anthony, Kan.”

His lip quivered.

The jokes about Tammy Faye always hurt him more than they did her. She would laugh them off.

But she’s gone now, and he is alone in her dream house.

“If people knew her, they wouldn’t have said those things. I hope they stop now.”

___

(c) 2007, The Kansas City Star.

Visit The Star Web edition on the World Wide Web at http://www.kansascity.com.

Distributed by McClatchy-Tribune Information Services.

_____

PHOTO (from MCT Photo Service, 202-383-6099): MESSNER

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The Impact of Psychological Profiling of Australian Correctional Officers

By Lough, Jonathan Wald, Elise; Byrne, Kenneth; Walker, Gordon

Correctional work is a highly stressful occupation that can impact the health of correctional officers (Casey, Dollard and Winefield, 2001). Health has a direct connection to the use of sick leave and stress claims, both of which are costly and can have a significant impact on the efficiency of an institution and the safety of officers and inmates. Hiring the right staff is crucial, as the cost of hiring the wrong person includes increased stress and sick leave. However, a poor hiring decision has other risks, too, such as low team morale; threats to safety of self, teammates and inmates; increased stress on managers; and risk of negative publicity. Coping with stress is an important quality in a correctional officer, but not everyone copes with stress in the same way. What can be very stressful for one person may be only a minor annoyance for another. Experience shows that some people are more psychologically suited to correctional work than others. Equally important is that some applicants are attracted to the role to satisfy pathological psychological needs.

Pre-employment psychological testing has become sophisticated during the past decade, and research has shown the tests to be reliable and valid predictors of many facets of job performance (e.g., Casey et al., 2001: Christensen, 2002; Lough and Ryan, 2005; Lough and Ryan, 2006). In addition, pre-employment psychological testing has become increasingly used in paramilitary fields such as law enforcement and corrections (Byrne, Culler and Culler, 2002). Few studies have exclusively examined correctional officers, and fewer have yielded results of any note. However, Holland. Heim and Holt (1976), while not finding any relationship between screening and job performance, did discover Minnesota Multiphasic Personality Inventory (MMPI) profile similarities between officers and inmates. In addition, Berkley’s (2001) 20-year review of Pennsylvania’s correctional officer personnel selection practices acknowledges both the potential of psychological screening and the lack of genuine research in the area.

This article examines a study of pre-employment psychological profiling performed with the Australian Institute of Forensic Psychology’s (AIFP) Public Safety Psychological Profiling System. The institute’s profiling system has good research support (e.g., Byrne et al., 2002; Lough and Ryan, 2005) and has been widely used for correctional officer applicant screening in Australia (Byrne, 2001; Choy, 1998).

Correctional Officer Roles And Job Demands

In recent years, custodial systems have moved toward a casework model (Casey et al., 2001), which combines the traditional security role of the correctional officer with a human relations role. This approach reduces the focus from incarceration and places greater emphasis on rehabilitation. The key goal of imprisonment becomes helping offenders to assume a law-abiding lifestyle that will result in them not returning to prison (King, 2000).

The adoption of this casework model has led to significant focus on the role and expectations of the correctional officer. The job has moved well beyond just containing and managing inmates. The successful officer in a casework model is required to have a host of additional skills, including, but not limited to, better interpersonal sensitivity, higher intelligence, self-insight and a more flexible approach to the enforcement of rules and procedures.

Job Stress and Burnout

Job stress refers to the specific relationship an employee has with the work environment (Schaufeli and Peelers, 2000). Job Stressors are the factors that drive this process. Typical job- related stress reactions include high blood pressure and other health problems, dissatisfaction, absenteeism, stress claims, and substance abuse.

The stresses a correctional officer faces are clearly greater than those faced in the vast majority of other vocations (Finn, 2000; Johnson and Johnson, 1997). Stressors such as the ongoing threat of violence, the negativity of inmates, shift work and society’s generally negative view of this role are all powerful contributors to the stress of the job. Extremely stressful events can sometimes lead to conditions such as post-traumatic stress disorder (Johnson and Johnson, 1997). Therefore, the appropriate mix of personality traits would appear to be important in selecting successful correctional officers. Individuals not psychologically suited to coping with the correctional environment are more likely to suffer more stress, which ultimately leads to more sick leave, stress leave and greater staff turnover.

Personality Screening

Determining who will be successful in a job – particularly over a period of four years – is an extremely challenging task. Pre- employment personality screening is usually better at detecting who will not succeed in a job than identifying who will. There are numerous reasons for this, as outlined by Byrne (1994; 2001).

First, it is exceedingly difficult to describe exactly what a “good performer” looks like. By nature, performance evaluations will always be subjective. People will tend to get higher ratings because of factors such as having a good sense of humor, sharing similar values as their boss and meeting the standards that a particular supervisor sets. A person who is regarded as below average by one supervisor can be seen as a good performer by another.

In addition, once individuals are hired, it is impossible to predict what challenges life will throw them. For example, there is no way of knowing that once a person is hired, he or she will get divorced in two years, leading to a period of depression and decreased work performance thereafter.

Despite all efforts, it is also very difficult for a person to know what a job really requires before he or she is actually in the job. Thus, people can genuinely say that they understand what is required and think they will enjoy it. However, no one ever knows until he or she is in the job.

Once hired, it is impossible to predict how any one applicant will get along with the supervisor to whom he or she is assigned. There will always be a variety of personalities among a group of supervisors. Similarly, there will be different levels of competency. How the “chemistry” between the applicant and supervisor works out is impossible to predict.

Finally, different facilities make different demands on the officer. Working in a maximum-security facility is likely to have different demands than a role in a minimumsecurity facility.

Despite these variables, it is usually necessary to hire correctional officers to a “one size fits all” standard. On the other hand, it is much easier to detect a constellation of personality traits that would strongly suggest that the person will not be suitable. For example, the applicant with a lower than average IQ, a high need to dominate others, a rigid and authoritarian attitude toward enforcing rules, poor interpersonal sensitivity and a high degree of racial bias is likely to be a problem performer in any correctional setting.

Australian Research With The AIFP System

The AIFP profiling system was designed to screen a variety of public safety applicants, including correctional officers. It has been widely used in the United States and is well supported by research (Guller, 1994; Culler, 2003). The system has been used in Australia since the early 1990s. The institute’s system comprises six separate psychological tests and a subsequent structured interview. All of the components have been fully adapted for Australian conditions, have good reliability and validity, and have solid Australian norms.

Choy (1998) compared New South Wales correctional officers screened for selection with the AIFP battery with an unscreened group. She reported significantly lower rates of attrition (dropout) and sick leave claims among the AIFP-screened cohort after two years of service. Similar findings were reported among South Australia correctional officers (Casey et al., 2001), with screened officers taking approximately half the number of sick days of their unscreened counterparts during their first two years of employment. Byrne (2001) examined AIFP-screened and unscreened Queensland correctional officers during their first two years of employment. The findings mirrored those of the New South Wales and South Australia officers. AIFP-screened recruits had a notably lower dropout rate and took a significantly lower number of sick leave days.

These performance improvements translate directly to cost saving – Choy (1998) reinforced the financial benefit of the screening process by noting that the New South Wales correctional department sick leave payouts had decreased by 39 percent, or about $1.36 million. Further analysis of Choy’s data revealed that, based on the reduced sick leave, the screening process yielded a return on investment of approximately 3,000 percent. Lough and Ryan (2005: 2006) also reported strong return on investment figures. Byrne, Culler and Culler’s (2002) summary of findings of AIFP profiling in the corrections context reinforced the utility of the process and its financial benefits.Research Question And Method The identification of applicants who are likely to be resilient to jobrelated stress (and thus have a lower level of absenteeism or attrition) is a crucial issue for correctional departments. Thus, this study examined the relationship between the AIFP battery and sick leave. More specifically, this research hypothesized that AIFP- screened correctional officers would have lower amounts of sick leave and attrition than those officers selected without profiling.

For this study, data from a total of 891 people were used. Archived sick leave data (supplied by the Queensland Department of Correctional Services) was provided for two groups of officers. The pregroup comprised 451 officers hired before the AIFP test battery was implemented. The post-group, or AIFP group, comprised 440 officers who took the AIFP test battery as part of their employment screening.

Sick leave data were only used for the first four years of each group’s employment, as many of those in the pregroup had been employed longer. Sick leave data were provided in total number of hours taken per year per person. All data were de-identified in order to maintain confidentiality. At no stage in the research process was it possible to identify an individual officer’s name.

AIFP Profiling System

As previously mentioned, the AIFP system includes six separate psychological tests and a subsequent structured interview. The six tests are described below.

The Candidate and Officer Personnel Survey (COPS) is a test designed by AIFP (through extensive research) specifically for the purpose of screening public safety officer applicants. It is a 240- item forced-choice (yes or no) bio-data questionnaire instrument. The COPS test contains 18 scales, which include such measures as social adjustment, self-discipline, motivation, aggression and attitudes toward work and superiors.

The psychometric properties of COPS are sound. Culler (1994) reports the internal consistency (KR-20) of COPS at 0.86. Test- retest reliability varies according to scale, but ranges from 0.74 to 0.94 (Culler, 2003).

The Edwards Personal Preference Schedule is a broad measure of personality that assesses characteristics directly related to correctional officer performance. These include levels of assertiveness and dominance, ability to fit into a team, willingness to follow orders, tolerance for routine tasks, desire to help others and ability to learn from experience. This is a published, widely available test.

The Social Opinion Inventory measures locus of control, which refers to the extent to which individuals feel in control of their own life or, in contrast, feel that they are the victims of fate, luck or other forces beyond their control. This is a well- established and thoroughly researched construct in psychology.

The How Supervise Scale is a measure of judgment in interpersonal situations. This is a published, widely available test.

The Shipley Institute of Living Scale is a standardized, well- researched test of general intelligence. It is also a published, widely available test.

The Opinion Survey is a measure that assesses attitudes toward enforcing rules and procedures, ranging from rigid and “hard line” to overly soft and naive. Byrne (1994) reports the reliability (Cronbach’s alpha) of the test at 0.82.

The six individual test findings are statistically integrated to provide an overall summary of the applicant’s psychological suitability for a correctional officer position. These findings are complemented by a highly structured follow-up interview. Unusual responses or issues flagged by the tests are investigated more thoroughly. Findings from both the testing and interview yield an overall profile of the person, which is compared with the job requirements. Once the process is complete, the profile is used to guide and assist the selection panel in deciding whether a candidate should be advanced to the next stage of the selection process.

It should be noted that the AIFP system attempts to exclude poor candidates rather than “select the best.” The system is not designed to predict top performers, but rather to limit the likelihood of an unsuitable individual being hired.

Results

Sick Leave. Each year of sick leave data was compared between groups. Table 1 shows how the pre-group and AIFP group differed during the four years. Data are presented as mean hours per person per year.

Independent samples t-tests revealed statistically significant differences (at the 0.001 level) between the groups at year 1 – the AIFP group’s mean (25.7) was noticeably lower than the pregroup’s mean (34.1). A similar result was evident for the second year – the AIFP group’s mean of 17.1 hours was significantly less than the pregroup’s mean of 49.1.

A difference in sick leave in the third year was observed (59.6 vs. 72.4, in favor of the AIFP group), but this difference was not statistically significant. Minimal differences were observed between the groups at year 4. The difference between groups over the full four years (AIFP: 169.1; pre-group: 220.0) was statistically significant.

On average, the AIFP group took significantly less sick leave than the pregroup during the first two years, and over the full four- year period (see Figure 1).

Dropout rate. At the end of four years, 133 employees from the pre-group had left work, and the AIFP group had 103 fewer employees. These figures represent an attrition rate of 29.5 percent (pregroup) and 22.8 percent (AIFP group), once the data were adjusted to account for the sizes of the original groups. Chi-square analyses revealed a significant association between dropout rate and group (chi sq = 18.42, p

Please note that, for each group, the number of employees providing sick leave data is not equal to the original group figure minus dropouts. This is because people who ceased employment in their fourth year still contributed to sick leave data.

Discussion

The goal of this study was to investigate the effect of psychological screening on objective performance measures among correctional officer applicants who had been hired. Sick leave and attrition were compared between two groups of employees. The pregroup was a sample of correctional officers hired without psychological profiling, while the AIFP group only contained applicants who were judged to be psychologically suitable for correctional work.

The current study’s findings support the notion that psychological screening is an effective selection tool for correctional organizations. During the first two years of service, the AIFP group took significantly less sick leave than the pregroup. There is still a difference in the third year, and while it may not be statistically significant, it still contributes to the overall finding; it is only in the fourth year that the groups converge. The three years’ worth of differences strongly contribute to, and are primarily responsible for, the overall four-year difference between the two groups.

The AIFP group was also significantly less likely to have its employees leave service within the first four years.

The simplest – and most logical – explanation for these results is that screening candidates ensures that only the personnel hired are the most psychologically suited for the job. These individuals are less likely to find the job overwhelmingly stressful and are probably also better equipped to handle the stress that they do feel. Consequently, they are less likely to require sick leave, and are also less likely to resign because they “can’t take it any more.”

The difference between the two groups narrowed noticeably at the fourth year of employment. This is an interesting finding. The likely explanation for this is “self-selection” in the pregroup. Pregroup members who find they are not suited to the role are likely to take more sick leave at an early stage and are also more likely to cease employment. In essence, those individuals unsuited for the position weeded themselves out of the pre-group during the first two years (this also explains the higher dropout rate of the pregroup). Consequently, those lasting to the third and fourth years are, by definition, better suited for the role. The question of whether they have been assimilated into an existing culture of higher sick leave and stress leave remains unclear. For example, it is conceivable that the (negative) modeling behavior of long-serving officers might influence and therefore modify the behavior of the newer officers after a period of time. Further research into this area would be illuminating. Comparing the psychological profiles of those individuals from the AIFP group who lasted more than two years, and those that left within the first two, would be an interesting avenue for future research.

A substantial strength of the current work was the relatively large number of participants and the similar size of each group. This allowed for enough instances of somewhat rare events (such as sick leave and dropouts) to be meaningfully compared across the two groups. It is possible that even larger group sizes would lead to more compelling statistical findings. However, given other Australian research with correctional officers (e.g., Casey et al., 2001; Choy, 1998), it seems unlikely that the directional trends noted would be altered.

The possibility of a historical artifact impacting the findings of the current study cannot be fully discounted. The study took place over a four-year period, during which time detainees came and went, work conditions may have changed, and the administrative environment evolved. While communication with the Queensland Department of Correc-tional Services during the study did not flag any such issues as possible influences, it must be acknowledged that the possibility of an undetected maturation covariate does exist. However, this is a challenge faced by almost all longitudinal studies of this kind. Important implications can be drawn from this study’s results. The ability to differentiate, using the AIFP profiling system, between more suitable and less suitable candidates at the hiring stage is clearly desirable. A healthier and more able work force provides obvious benefits.

Financial Implications

The financial benefits of lower dropout rates and reduced sick days are compelling. For example, over the four years the AIFP group took 2,101 fewer days of sick leave. If a conservative figure of $400 per sick day is used, that represents a financial savings of $840,400. That equates to nearly $250,000 per year. Keep in mind that the AIFP group was smaller than the pregroup.

Similar implications exist for the reduction in dropout or attrition rates. The AIFP had 29 fewer dropouts over the four-year period. If a figure of $50,000 is assumed for the entire recruitment process (Job ads, screening applications, profiling, interviewing and training), then the AIFP process yielded a savings of $1.45 million during the life of this study.

Future Research

The next phase in this research process is to examine the differences between the groups across new measures, such as disciplinary action and compensation claims. Investigating these areas will provide a more complete picture regarding the effectiveness of psychological screening. Furthermore, longitudinal data regarding work performance (e.g., supervisor ratings) could provide good information about whether a worker thrives in his or her work environment or whether he or she “just gets by.” Examining the deidentified (to continue to preserve anonymity) AIFP profiles of the dropouts might also reveal useful information, shedding light on why “more suitable” candidates still cease employment. However, complicating factors, such as changes in the correctional institutions or culture based on the different eras of employment, would need to be taken into account.

The new ground covered by this research represents an exciting step in the development of correctional officer selection procedures, both in Australia and elsewhere. Most important is that the findings of the current study have provided a clear foundation for further study. Psychological profiling as a method of selecting correctional officers appears to be a worthwhile and valid course of action – a course now backed by some targeted research.

Corrections Compendium (ISSN 0738-8144) is published bimonthly for $72 per six issues by the American Correctional Association, 206 N. Washington St., Suite 200, Alexandria, VA 22314. Periodicals postage paid at Alexandria, VA 22314. POSTMASTER: Send address changes to Corrections Compendium, American Correctional Association, Membership Department, 206 N. Washington St., Suite 200, Alexandria, VA 22314.

REFERENCES

Berkley, S. 2001. The selection of entry-level corrections officers: Pennsylvania research. Public Personnel Management, 30(3):377-418.

Byrne, K. 1994. Hiring – Strategies for success. Clifton Hill, Australia: Australian Institute of Forensic Psychology.

Byrne, K. 2001. Research into the effectiveness of the AIFP Critical Character Assessment System for screening new custodial correctional officer applicants. Clifton Hill, Australia: Australian Institute of Forensic Psychology.

Byrne, K., I. Guller and M. Guller. 2002. Slashing sick leave/ attrition rates through new recruit screening. Corrections Today, 64(5):92-95.

Casey, S., M.F. Dollard and T.H. Winefield. 2001. Selection of correctional services officers. Adelaide, Australia: University of South Australia.

Choy, J. 1998. Reducing sick leave in correctional officers: The role of psychological appraisal. Sydney, Australia: NSW Department of Correctional Services.

Christensen, G.E. 2002. Pre-employment psychological screening among correctional officers: An effective practice? American Jails, 16(4):9-16. (September/October).

Finn, P. 2000. The extent and sources of correctional officer stress. In Addressing correctional officer stress: Programs and strategies, ed. P. Finn, 11-17. New York: National Institute of Justice.

Guller, I. 1994. Evolution of a bio-data instrument for the screening of police and other public safety personnel. Oakland, N.J.: Institute for Forensic Psychology.

Guller, M. 2003. Predicting performance of law enforcement personnel using the Candidate and Officer Personnel Survey and other psychological measures. Unpublished doctoral dissertation, Seton Hall University.

Holland, T., R. Heim and N. Holt. 1976. Personality patterns among correctional officer applicants. Journal of Clinical Psychology, 32(4):786-791.

Johnson, R. E. and T.J. Johnson. 1997. Correctional staff victims – Job Trauma. 77ie Correctional Psychologist, 29(2):22-28.

King, S. 2000. Women and the changing work of prison officers. Paper presented at Women in Corrections: Staff and clients conference, 31 October to 1 November in Adelaide, Australia.

Lough, J. and M. Ryan. 2005. Psychological profiling of Australian police officers: An examination of post-selection performance. International Journal of Police Science and Management, 7(1):15-23.

Lough, J. and M. Ryan. 2006. Psychological profiling of police officers: A longitudinal examination of post-selection performance. International Journal of Police Science and Management, 8(2):143- 152.

Schaufeli, W.B. and CW. Peeters. 2000. Job stress and burnout among correctional officers: A literature review. International Journal of Stress Management, 7(1): 19-48.

Jonathan Lough is director of Lough Research Services in Melbourne, Victoria (Australia). Elise Wald is a member of Monash University’s Department of Psychology, Psychiatry and Psychological Medicine in Melbourne, Victoria. Kenneth Byrne is director of the Australian Institute of Forensic Psychology. Gordon Walker is a lecturer in Monash University’s Department of Psychology, Psychiatry and Psychological Medicine.

Copyright American Correctional Association, Incorporated Jul/Aug 2007

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

CAMC’s Orthopedic Trauma Group

By Eric Eyre

[email protected]

After the collision, the wail of the siren, the thump of helicopter blades slicing through the air, Dr. Frederic Pollock’s beeper goes off, and he rushes to Charleston Area Medical Center General Hospital where he helps the hospital’s trauma team save lives and limbs.

As chief of CAMC’s new Orthopedic Trauma Group, Pollock fixes shattered pelvises and fractured bones of people seriously injured in motorcycle, car and all-terrain vehicle wrecks all hours of the day and night.

“You’ve got to understand,” Pollock said. “At two in the morning, we’re ready to go. Twenty-four hours a day, trauma surgeons can be attending to life-threatening injuries and ask for orthopedic assistance.”

CAMC formed the bone trauma group in May.

Pollock left a successful orthopedic practice at Bone and Joint Surgeons Inc. in Charleston and joined the hospital full-time.

CAMC gave him office space in the Medical Pavilion beside General Hospital. He has hired a physician’s assistant and two medical staff members.

By next year, he plans to add at least three full-time bone trauma doctors to help cover emergencies, seven days a week, 24 hours a day at CAMC.

Meantime, Pollock has found temporary doctors – all with military backgrounds and extensive experience in orthopedic trauma – to fill in.

“It’s only a success if we can attract orthopedic surgeons who want to do trauma,” Pollock said. “We have our little niche here. Our own little world.”

Five years ago, CAMC General’s trauma center was struggling to stay afloat.

The state revoked the hospital’s Level I trauma status – the top grade for trauma certification – in August 2002.

Not enough bone surgeons were available to take emergency calls at the trauma center. Patients with serious injuries were sent to Huntington or Morgantown.

Within weeks, Pollock rallied a dozen bone surgeons to cover the emergency center. The doctors agreed to take more trauma calls after they were promised medical-malpractice insurance through the state’s Board of Risk and Insurance Management.

Pollock was determined to return Level I status to the trauma center.

“We said, ‘We can do this. We can make it work,'” he recalled. “We needed state support and tort reform.”

A month later, with help from then-Gov. Bob Wise, the hospital regained its Level I status, a designation that it has maintained ever since.

CAMC General is one of only two Level I trauma centers in the state. The other is the Jon Michael Moore Trauma Center at West Virginia University Hospitals in Morgantown.

To receive the designation, hospitals must have a trauma surgeon, emergency doctor, orthopedic surgeon, neurosurgeon and anesthesiologist available immediately day and night.

In the past, CAMC has had a difficult time persuading orthopedic surgeons to provide demanding on-call coverage.

Most bone doctors in the Charleston area already have thriving practices. They have a steady stream of patients who need shoulders fixed, and hips and knees replaced.

“They’re stretched to the limit,” Pollock said.

So the doctor has looked elsewhere for help.

Dr. Michael Charlton, a major in the U.S. Air Force, was between hospital jobs this summer when he spotted an advertisement for a temporary orthopedic trauma doctor at CAMC.

“It was an opportunity to get additional experience and help out at the trauma center,” he said.

Charlton stayed busy from the start.

He performed nearly 50 surgeries during the past month, working 70 to 100 hours a week. CAMC’s bone trauma service is the busiest in the state, with more than 850 surgically treated fractures a year.

The vast majority of patients served at the trauma unit come through CAMC’s three hospital emergency rooms. Other patients transfer from urgent-care centers, such as Health Plus. Some complicated cases are referred to the orthopedic trauma group from local bone doctors.

“It’s challenging,” Charlton said. “They’re complex injuries. Every day is a different day. You never know what’s going to come through the door.”

During his stint at CAMC, Charlton was most struck by the number and severity of ATV accidents.

“These are young people riding these,” he said. “A lot of them are permanently disabled with injuries they sustained on these things. It’s a real problem here.”

Pollock has signed up additional temporary doctors to work at CAMC General’s trauma unit through the fall.

Two of those doctors have served in Iraq, Pollock said. CAMC provides a three-bedroom house in South Charleston during their stay.

The trauma center also now has a small number of Charleston-area orthopedic surgeons in private practice who continue to answer emergency calls.

The orthopedic trauma group has its own suite of offices.

There are exam rooms and lightning-fast digital X-ray equipment that produces high-quality printouts that patients are given to take home. Doctors also can view three-dimensional images of bones in a conference room on a large-screen monitor. CAMC’s operating rooms are just a flight of stairs away.

The set-up will attract top-flight orthopedic trauma surgeons to CAMC, Pollock said. That will ensure that CAMC’s trauma unit maintains its Level I status, providing world-class care to accident victims throughout central and southern West Virginia.

“The most amazing thing is to see people after they recover from their severe injuries and are walking again,” Pollock said. “Mobility is life; life is mobility.”

To contact staff writer Eric Eyre, use e-mail or call 348-4869.

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

Testosterone Levels Declining in Men at Younger Ages: ZRT Laboratory Hormone Tests Reflect Global Trend

PORTLAND, Ore., Aug. 28 /PRNewswire/ — When researchers at ZRT, a leading hormone testing laboratory in Beaverton, Oregon, analyzed the hormone levels of over 8,000 men, they found that testosterone levels peaked in the men’s early 20’s and gradually declined after that. Testosterone that starts to wane in a man’s forties is to be expected, but in some men, testosterone drops more rapidly than normal. And in these men, ZRT finds they suffer more from low energy, erectile dysfunction, and loss of libido, prostate problems and weight gain.

The larger implications for male health and aging are discussed in the September issue of Men’s Health Magazine. Male staffers at the magazine tested their hormone levels using ZRT home test kits and reported their “scores”. All the men tested within the normal range for their age, but if recent research and testing trends are anything to go by, the Men’s Health team could become the exception.

Researchers in the US are finding testosterone levels to be substantially lower — by about 15 to 20% — than they were fifteen years ago. Scandinavian studies show similar declines, and in younger men too; a man born in 1970, for example, had about 20 percent less testosterone at 35 than a man of his father’s generation at the same age.

David Zava, PhD., President of ZRT Laboratory, and an acknowledged expert on hormonal health, makes the point that environmental toxins, lack of exercise, and prolonged stress often trigger hormonal imbalances that can block testosterone production or its access to tissues. “Hormones work together in symphony,” says Zava, “so you really need to look at testosterone in relation to other hormones like cortisol, estrogen, and thyroid that regulate its activity in the cells.”

Testosterone is a key player in muscle and bone strength, sex drive and mental sharpness in men. When levels drop below normal, the shortage not only impacts physical and mental performance, but can have serious long-term consequences for health and longevity.

Men who want to stay ahead of the curve can take a simple test in saliva and/or blood spot to check their hormone levels. Male Hormone Profile and comprehensive test kits are available at selected pharmacies, physician’s offices and online at http://www.zrtlab.com/.

   Contact: Candace Burch, Director of Education, ZRT Laboratory;            [email protected] (503) 597-1923 or Mary Smeby,            [email protected] (503) 597-1926  

Available Topic Expert(s): For information on the listed expert(s), click appropriate link. David T. Zava, Ph.D. http://profnet.prnewswire.com/Subscriber/ExpertProfile.aspx?ei=39329 Candace Burch http://profnet.prnewswire.com/Subscriber/ExpertProfile.aspx?ei=66670

ZRT Laboratory

CONTACT: Candace Burch, Director of Education, +1-503-597-1923,[email protected], or Mary Smeby, +1-503-597-1926, [email protected], both ofZRT Laboratory

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

Adult-Care.Org Launches First Online Consumer Access to State’s Adult Care Information

PORTLAND, Ore., Aug. 28 /PRNewswire/ — Adult-Care.Org launches today the first phase of a unique consumer-driven single source of information for all of Oregon’s licensed long-term adult care facilities. The initial program offers the only advanced search capabilities, complaint history and consumer rating system for all facilities licensed in the State of Oregon.

“Government agencies and consumers alike are aware of increased self-directed health care and the need for concise, streamlined information about long-term adult care options. After years of development, our decision to launch Adult-Care.Org in Portland was based on the incredible cooperation we’ve received from State and County agencies who realize how important it is to make this information available directly to the consumer,” said Ali Zamani, founder and CEO of Adult-Care.Org.

The Adult-Care.Org web site, the first of its kind in Oregon, provides consumers with time-saving, advanced search options such as geography and type of facility; background performance and complaint history for approximately 8,000 nursing homes, assisted living, residential care and adult foster care homes in Oregon; as well as a consumer rating system for each facility. The program enables an individual to quickly and conveniently narrow their search, compare facilities side-by-side and make more informed choices.

The process of selecting a long-term adult care facility is an important and emotional evaluation that requires time and thought. Adult-Care.Org gives consumers the information they need to make a life-changing decision for a loved one. In minutes, consumers can obtain information that before might have taken weeks or even months to find.

“Our passion is to improve the quality of long-term adult care and direct consumer access to information through a convenient, comprehensive and interactive system designed to help consumers make the right decision for their loved ones,” declared partner Jay Clemens. “It’s really that simple, but great ideas usually are. Phase one is now complete, and it’s the most comprehensive source available in Oregon. In our second phase, already well underway, member facilities can expand their listings to include photo tours, assessment forms, contracts, house rules, available services and limited response to complaints.”

   For more information, visit http://www.adult-care.org/.    Backgrounder  

Adult-Care.Org is a web-based Oregon company formed in 2006 by a husband and wife team who previously owned and operated one of Portland area’s most reputable adult foster care homes. They realized there was no easy way for consumers to gather information about all of the long-term adult care options and facilities, so they created one.

The process of selecting a long-term adult care facility is an important, emotional and life-changing decision that requires a lot of time and thought. Adult-Care.Org, in collaboration with Oregon’s Department of Human Services, is the first company in the state to combine a complete listing of all licensed adult foster care homes, residential care homes, nursing homes and assisted living facilities with advanced search capabilities, background performance and complaint history and a consumer-rating system. This is the only consumer-driven program not only in the state of Oregon, but also online.

Nine million adults ages 65+ required long-term care in 2006, and that number will increase by 50% in 2013. Today’s baby-boomer consumers will be responsible for making these life-changing decisions, and are taking more control of the kind of information they want, when they want it and how they get it. Adult-Care.Org is responsive to the changing nature of more self-directed health care and now offers a new generation of decision-makers access to information that was difficult to obtain until now, and the ability make better choices for their loved ones.

Today, Adult-Care.Org is Oregon’s only consumer-driven, single source of information for all licensed assisted living, nursing homes, residential care and adult foster care homes. Phase One is complete and includes unique tools not found anywhere else: the only consumer rating system of facilities’ performance, complaint history and advanced search capabilities. In Phase Two, already underway, member facilities can expand their listings to include photo tours, assessment forms, contracts, house rules, available services and limited response to complaints.

Mission Statement

Adult-Care.Org’s passion is to improve the quality of long-term adult care and consumer access to information through a convenient, comprehensive and interactive system designed to help consumers make the right decision for loved ones.

   Key Consumer Benefits   Phase 1:   * Complete Listing of all licensed Long-Term Adult Care Facilities in     Oregon   * Search by Type of Facility   * Search by Geography   * Search by Level of Care and Services Available   * Maps and Directions Provided   * See How Others Rate Facilities   * Post Your Own Review   * Read Facility Background Performance and Complaint History    Phase 2:   * Available Access Forms, House Rules, Policies and Government Reports   * On-Line Assessment of Care   * Compare Facilities Side-by-Side   * Read and Print Contracts Before Visiting   * See Interior and Exterior Photos   * Take a Virtual (Online) Tour    Member Facility Benefits   * Alternative to Costly Placement Services   * Opportunity to Respond to Complaints   * Affordable Web Presence for All   * Ability to Provide Management with Real Time Input   * Rewards Good Facilities and Helps Improve Others    Executive Partnership   Ali Zamani, Founder and CEO   Caroline Zamani, Membership Development   Jay Clemens, Public Affairs   Victoria Clemens, Advertising Development    The Partnership brings together a unique convergence of skills and   passion:   * Owners/Operators of Adult Care Facilities   * Exceptional Internet/Database Expertise   * Integrated Marketing/Public Relations   * Sales Management Experience  

Adult-Care.Org

CONTACT: Jay Clemens of Turtledove Clemens, +1-503-226-3581,[email protected], for Adult-Care.Org

Web site: http://www.adult-care.org/

Dallas to Destin: What a Drive!: A Guide to Making the Most of a Well-Traveled Route

By Lisa Thatcher Kresl, The Dallas Morning News

Aug. 27–OKALOOSA ISLAND, Fla. — My husband and I are former Floridians who can’t go six months without beach time. Galveston is fine, but it’s just not the same as the Florida beaches we grew up with. As a result, since we moved to Dallas 17 years ago, we’ve made many a trip to the Florida panhandle for the chance to walk the white sands and swim in the clear Gulf of Mexico.

We’ve seen almost as many Texas license plates in Destin traffic as we do on Central Expressway, so we know we’re not alone.

We’ve taken flights into Fort Walton Beach and Pensacola for long weekends, but inevitably we find ourselves hitting the highway for that familiar 700-mile drive from Dallas to the Fort Walton Beach-Destin area.

Some things have changed. The whining toddlers in the back of the minivan have grown into subdued, iPod-wearing kids. But some things haven’t: that long stretch through Louisiana and the familiar sights along the way.

Here are our favorite driving routes, the best Emerald Coast activities and a quiz to keep the family entertained on the drive.

OUR EMERALD COAST FAVORITES

We’ve driven by gorgeous developments such as Rosemary Beach and stayed in beautiful Seaside, but we find ourselves returning to our old Florida haunts. I married a Choctawhatchee High School grad, so home is Fort Walton Beach, an area just a few miles away from what most Texans know as Destin. We have our routine, and the children (ages 10 and 8) like us to keep it. (Warning: I’m more of a Boggy Bayou Mullet Festival gal than a resort queen.)

Beach day near the pier on Okaloosa Island. Lunch at Angler’s on the beach (1030 Miracle Strip Parkway, Fort Walton Beach; 850-796-0260; www.anglersbeachsidegrill.net). We eat fried grouper sandwiches (of course) while the kids play on the beach playground (photograph them in the plastic shark). Pay $1 to walk on the pier ( www.okaloosaislandpier.com), watch the fishing action and buy the kids a snow cone.

Afternoon at Gulfarium to see dolphin shows. It’s campier than the better-known SeaWorld at Orlando. Tickets are $18.50 (adults), $11 for children (ages 3 through 11). Contact: 1010 Miracle Strip Parkway SE, in Fort Walton Beach; 850-243-9046; www.gulfarium.com. Or see dolphins frolicking off the pier for less.

Seaweed or jellyfish rolling in on the Gulf? Head bayside to escape the flotsam. Gulf Islands National Seashore’s Okaloosa Area (in the center of Okaloosa Island, on the north side of U.S. 98; www.nps.gov/guis/planyourvisit/okaloosa-day-use-area.htm) has calm, shallow water so you can get some reading in while the kids entertain themselves with mask and snorkel.

Deep-sea fishing in Destin. There are many charter boats. We like the New Florida Girls’ American Spirit (three-tenths of a mile east of Destin bridge). A morning half-day trip is just the right amount of time. We caught white and red snapper, and the hard-working deckhands filleted our catch and gave us a grouper. (They earn their tips, so tip well.) A five-hour trip is $45; 10 hours, $70. Contact: 850-837-1293: www.newfloridagirl.com.

Evening: Goofy Golf! There are many miniature golf courses, but nothing compares to Goofy Golf, an old-Florida original. Hit the ball into the snake’s mouth on the last hole and win a free game. Buy the kids a slushy. Tickets are $1 for children to age 12 and $2.50 for older. Contact: 401 Eglin Parkway N.E., Fort Walton Beach; 850-862-4922.

On Navarre Beach, you can rent three-seater Yamaha Waverunners at Juana’s Pagodas. A half-hour is $65; hour, $85. Contact: 1451 Navarre Beach Causeway, Navarre Beach; 850-939-2130; www.juanaspagodas.com/beach%20rentals.htm.

Crab Island, just north of the Destin Bridge, is where people anchor their boats. It’s a big party scene.

Dinner at Magnolia Grill, a family-owned restaurant in a 1910 house filled with historical photos of the area. Contact: 157 Brooks St., Fort Walton Beach; 850-302-0266; www.magnoliagrillfwb.com.

Offbeat find from my sister-in-law: taco pizza from the Pizza Hut at 421 Racetrack Road N.W. in Fort Walton Beach. Yummy after a day at the beach. Contact: 850-863-4470.

Each family has its own routines and finds. E-mail me with your Destin-area favorites ( [email protected]).

STRATEGIES FOR THE DRIVE

You can get to Destin two ways: south through Louisiana or south through Mississippi. We’ve tried both and find the Louisiana route to be faster.

LOUISIANA ROUTE

— Take I-30 east out of Dallas, then U.S. 80 east via Exit 53B toward Terrell, Texas.

— State Highway 557 Spur east toward I-20 East/Shreveport, La.

— I-20 east to Shreveport, La.

— Merge onto State Highway 3132 East via Exit 11 toward Alexandria, La.

— I-49 south toward Alexandria, La.

— Merge onto I-10 toward Baton Rouge, La.

— Merge onto I-12 East via Exit 157 on left toward Hammond, La.

Merge onto I-10 East, Exit 85C, pass through Mississippi, Alabama and then cross into Florida.

— Take FL-85 South (Crestview exit).

— Go east on State Highway 20 to Choctawhatchee Mid-Bay Bridge in Niceville to Highway 98 in Destin.

We’ve driven straight through and split up the drive by leaving after work and staying overnight in Alexandria or Baton Rouge, La. We’ve stayed at the La Quinta Inn & Suites in Alexandria (6116 W. Calhoun Drive; 1-800-531-5900) because it’s easy on and off I-49. We’ve also tried the Marriott in Baton Rouge, La., (5500 Hilton Ave.; 225-924-5000) because it’s near the I-10/I-12 split.

MISSISSIPPI ROUTE

— Take I-30 east out of Dallas, then U.S. 80 east via Exit 53B toward Terrell, Texas.

— State Highway 557 Spur east toward I-20 East/Shreveport, La.

— Merge onto I-20 East via the exit on the left toward Shreveport/Tyler, passing through Louisiana then crossing into Mississippi.

— Take U.S. 49 South exit, Exit 47A, toward Richland/Hattiesburg, Miss.

— I-59 south toward New Orleans/Gulf Coast.

— Merge onto U.S. 98 East, Exit 59, toward Lucedale/Mobile (crossing into Alabama)

— Merge onto I-65 South.

Merge onto I-10 East crossing into Florida.

— Take the SR-85 exit, exit 56, toward the Crestview/Niceville.

— Merge onto FL-85 South toward Niceville/Eglin A.F.B./Fort Walton Beach

— Go east on Highway 20 to Chocktawhatchee Mid-Bay Bridge in Niceville to Highway 98 in Destin.

D TO D DRIVE-BY QUIZ

Driving the route through Louisiana? Keep the family entertained and the driver alert by checking off these roadside sights:

TEXAS

1. What is the statue near the flags and the “Welcome to Forney: Home to the Jack Rabbits” tower?

2. What kind of food is served at the McDonald’s Cafe (exit 509)?

3. What kind of ranch is Toon Town?

4. What is the big animal in front of Robertson’s Ham?

5. Which town claims to have the best view of East Texas?

6. What is the population of Canton, according to the town’s sign?

7. On what TV show has Tiger Creek been featured?

8. What celebrity claims Lindale as her hometown?

9. Spot this sign and fill in the blank: “Don’t ________ with your eternity.”

10. Find this sign and fill in the blank: “Bodacious ______.”

11. What’s special about the tables at the rest stop at mile marker 573?

12. Call 1-877-770-STOP, according to many billboards, to stop what?

13. Fill in the blank: “Lake O’ the ________.”

LOUISIANA

1. Fill in the blank: “Bienvenue en _________.”

2. What looks to be the first gambling opportunity in Louisiana?

3. What looks to be the first Cajun dining opportunity in Louisiana?

4. What could be the cousin of Hotel California?

5. What’s the cute name for the highway named after football player Terry Bradshaw?

6. What Indian culture is showcased at this National Center off of I-49?

7. Which of these lovely names is a real I-49 exit?

a. Grand Bayou

b. Coushatta

c. Lake End Ajax

d. All of the above

8. Fill in the blank: _____ River Plantation

9. The name of this exit is also a famous composer.

10. What’s so special about Leah’s lunchroom, according to the billboard?

11. Which of these names is a bogus Louisiana exit?

a. Meeker Turkey Creek

b. Bunkie

c. Ville Platte

d. None of the above

12. Tune in to FM 101.1 KBON around Opelousas to hear what kind of music?

13. Check out the red barn on the left and fill in the blanks: _____ Barn ______.

14. What do you see on the roof of the mobile homes on the left at Atchafalaya Homes RV?

15. What is “Slap Ya Mama?”

16. How many miles does it take to cross the bridge over the Atchafalaya Basin?

17. Fill in the blank: “Grosse ______”

18. Ponchatoula is “America’s ________ City.”

MISSISSIPPI

1. What is named after John C. Stennis?

2. Fill in the blanks: “Mississippi: It’s like _____ ______.”

3. Mississippi is home to the U.S. Navy’s headquarters for what?

4. A long stretch of Mississippi billboards features celebrities and entertainers coming to play where?

5. What is the name of the Jefferson Davis home?

ALABAMA

1. What do you say when angry Alabamans honk at you in traffic for staying in the far right lane until you merge into the lane going under the Mobile tunnel?

2. What is the name of the ship at Battleship Park?

3. “Shelton,” a big red building on the right, sells what?

FLORIDA

1. What’s the fastest way to Destin?

QUIZ ANSWERS

TEXAS

1. model of Statue of Liberty

2. barbecue

3. “Texotics”

4. pig

5. Longview

6. 5,147

7. Animal Planet

8. Miranda Lambert

9. gamble

10. Bar-B-Q

11. shelters are shaped like oil derricks

12. gambling

13. Pines

LOUISIANA

1. Louisiane

2. Love’s Truck Stop-Casino, Exit 3

3. Becca’s

4. Motel California

5. It’s called the Terry Bradshaw Passway. Get it? PASSway.

6. Adai

7. d

8. Cane

9. Chopin

10. “Pie capital of Louisiana”

11. d

12. Cajun. (Ever heard “My Woman Is Mad”?)

13. Bike (Barn) Saloon

14. two pickup trucks (one red, one yellow)

15. “Real Cajun seasoning”

16. 28.7 miles

17. Tete

18. Antique

MISSISSIPPI

1. Space Center

2. Coming Home

3. meteorology

4. Beau Rivage

5. Beauvoir

ALABAMA

1. “We didn’t know. We’re from Texas.”

2. USS Alabama

3. fireworks

FLORIDA

1. Mid-Bay Bridge

—–

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Copyright (c) 2007, The Dallas Morning News

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NYSE:MAR,

Incidence, Mechanisms, and Patterns of Fetal Cerebral Lesions in Twin-to-Twin Transfusion Syndrome

By Quarello, Edwin Molho, Marc; Ville, Yves

Abstract Objective. To determine the incidence of fetal cerebral lesions and their characteristics in twin-to-twin transfusion syndrome (TTTS).

Design and setting. This was a retrospective analysis at a single center for the period 1999 to 2004 in which 299 cases of severe TTTS at 15-28 weeks of gestation were reviewed.

Methods. Only cerebral injuries diagnosed during pregnancy or ischemic lesions diagnosed within the first week of life were considered in order to exclude those related to prematurity. We only included cases resulting in at least one survivor at one week after delivery, as well as fetuses that were terminated because of severe cerebral abnormalities. We excluded all fetuses delivered at

Results. Two hundred and ninety-nine pregnancies were evaluated. Three hundred and fifteen fetuses were reviewed. Cerebral abnormalities developed antenatally in 26/315 fetuses (8.25%). All lesions but one were diagnosed prenatally. Prenatal diagnosis of these lesions was achieved primarily by ultrasound (US) and magnetic resonance imaging (MRI), in 20/25 (80%) and in 5/25 (20%) fetuses, respectively. Cerebral abnormalities developed following primary laser coagulation in 12/222 (5.40%), following serial amnioreduction in 9/66 (13.63%), and following expectant management in 3/14 (21.4%) fetuses. Abnormalities developed after single intrauterine fetal death (IUFD) in 14 cases.

Conclusions. Cerebral morbidity in TTTS mainly occurs following vascular disruptive lesions. Both donors and recipients are at risk of developing either ischemic or hemorrhagic lesions. The risk of developing cerebral lesions in single survivors is significantly lower following laser treatment. Combined use of a targeted US and fetal MRI could detect most cerebral abnormalities antenatally. Timing of the triggering event is critical for planning serial US and MRI follow-up examinations.

Keywords: Twin-to-twin transfusion syndrome, fetal cerebral lesions, intrauterine death, hemorrhage, ischemia, ultrasound, MRI, amnioreduction, laser, ietoscopy

Introduction

The risk of developing white matter necrosis in complicated monochorionic pregnancies is 10-fold that in dichorionic twins (33% vs. 3.3%) [I]. The increased rate of prematurity and very low birdi weight in monochorionic twins cannot explain it all. Monochorionic placentation is characterized by the presence of vascular anastomoses that connect the twins’ umbilical circulations indirecdy dirough various patterns of artery-to-vein, artery-to-artery, and vein-to-vein connections on the chorionic plate. The number and distribution of chorionic plate anastomoses is likely to play a critical role in the development of twin-to-twin transfusion syndrome (TTTS) [2] in up to 15% of monochorionic pregnancy TTTS [3]. When the condition is untreated, up to 50% of single survivors are exposed to develop cerebral lesions [4] . Perinatal mortality and morbidity can originate from hemodynamic instability triggering some degree of exsanguination of one fetus into its co-twin, which culminates when one twin dies in utero.

Laser coagulation of inter-twin anastomoses is an effective surgical treatment for TTTS. The deadi of one twin occurs following serial amnioreduction in around 26% of cases and following laser coagulation in around 40% of cases [5] . Neurological morbidity in single survivors is not consistendy reported in the literature and ranges from 30% [6] to 35% [5] and from 7% [5] to 16% [7] following amnioreduction and laser coagulation, respectively.

The precise characterization of fetal cerebral lesions could improve the understanding of their padiophysiology as well as the accuracy of prenatal diagnosis. We therefore reviewed prenatal imaging of all cases of TTTS with congenital cerebral abnormalities in relation to clinical course and outcome.

Materials and methods

We reviewed all fetal cerebral lesions diagnosed in utero in TTTS cases in our unit over a five-year period Qanuary 1999 to December 2004). We only included cases resulting in at least one survivor at one week after delivery, as well as fetuses that were terminated because of severe cerebral abnormalities. We excluded all fetuses delivered at

Lesions were systematically assessed by ultrasound (US) and by magnetic resonance imaging (MRI) botii in utero and in the neonatal period. Fetal MRI examination immethately followed targeted US examination at around 32 weeks, and ultrasound findings were known by the radiologist reading the MRI images. MRI was performed earlier whenever US findings were suggestive of cerebral lesions. In the neonatal period, all scans were performed within 3 days following delivery as well as at between 4 and 7 days of life. High frequency probes were used for transabdominal (4-8 MHz), transvaginal (5-9 MHz), and transfontanellar (5-9 MHz) ultrasound examinations (GE Voluson 730 Medical Systems, Ultrasound & Primary Care Diagnostic, Gif sur Yvette, France). A 1-Tesla MRI (MRI Siemens Syngo, Erlangen, Germany) was used.

All cases were recorded and accounted for prevalence calculations. Groups were compared for cerebral abnormalities persisting over the first week of life using Fisher’s exact test. Means were compared using the Wilcoxon test. Statistical analysis was performed using Statview 4.55 software (SAS Institute Cary, NC, USA).

Screening for fetal anemia was based on sonographic features including ascites, frontal edema, hydrops, hyperechogenic bowel, and tricuspid regurgitation together with measurement of peak systolic velocity in the middle cerebral artery (MCA-PSV) [8,9] . Cerebral lesions in neonates were categorized as ischemic or hemorrhagic lesions using the classifications by Volpe and de Vries, respectively [10,11].

Results

During this five-year period, 298 pregnancies presenting with TTTS at 15-27 weeks (median 22 weeks) of gestation were managed primarily by laser coagulation (199), serial amnioreduction (79), selective feticide using cord coagulation (13), or expectant management (7). After exclusion of single and double fetal deadi and late miscarriage, 315 fetuses were reviewed, corresponding to 222, 66, 1 3, and 14 fetuses, respectively according to primary management. Two fetuses were excluded from analysis: case numbers 8 and 24 presented cerebral lesions before laser treatment.

Cerebral abnormalities were diagnosed in 26beta15 cases (8.25%). All lesions but one were diagnosed prenatally. The prevalence of fetal brain abnormalities according to primary management were of 5.40% (12/222), 13.63% (9/66), 0% (0/13), and 21.4% (3/14), respectively. MRI was not performed in 4/26 cases in which overt abnormal US features were diagnosed before 26 weeks (n = 3; numbers 10, 11, and 14) nor when delivery occurred unexpectedly at 27 weeks (n = 1; number 4) following normal US examination at 25 weeks. Antenatally, lesions were diagnosed primarily by targeted ultrasound in 20/25 fetuses (80%) and by MRI in 5/25 fetuses (20%) (Table I). MRI confirmed primary ultrasound features in 12 cases (11 abnormal and one normal). MRI features were discordant from primary abnormal US in 10 cases (five abnormal and five normal). Persistent cerebral lesions (=7 days of life) were diagnosed in 20 fetuses. Postnatal examinations were available in 16/26 fetuses (61%) either by transfontanellar US examinations in the survivors (9/16) or on postmortem examination (7/16). Postnatal examination could not be performed in cases with cerebral tissue maceration when selective feticide was performed for severe cerebral anomalies (w = 4; numbers 7, 15, 19, and 24).

The underlying persistent lesions were classified using either antenatal or postnatal imaging or by postmortem examination as being ischemic (15/20 (75%)), hemorrhagic (3/20 (15%)), or ischemichemorrhagic (2/20 (10%)). All types of lesions were evenly distributed among recipients (7) and donors (13).

Posmatal examination was at odds with prenatal ultrasound in 8/ 16 cases (50%; numbers 5, 8, 13, 18×2, 20, 22, and 23) and MRI findings in 2/16 cases (12.5%; numbers 12 and 22) (Table I).

In four pregnancies (five fetuses) ultrasound cerebral abnormalities were consistent with grade II intraventricular hemorrhage and mild ventriculomegaly (numbers 5, 8, 18 x 2, and 20) at 1 8 to 31 weeks, normalized on subsequent follow-up scans, and could not be seen on MRI 1-14 weeks later at 32 weeks of gestation nor at birth. In one fetus, pericerebral hemorrhage (number 12) diagnosed by MRI at 30 weeks was absent at birth. These five fetuses all underwent primary laser treatment.

Table I. Outcome of fetuses and neonates with cerebral lesions related to twin-to-twin transfusion syndrome.

Sixteen of the 20 persistent cerebral lesions followed serial amnioreduction (9/66) and laser coagulation (7/222). They were evenly distributed between donors (10) and recipients (6) (p = 0.003; Tables II and III). Persistent cerebral lesions were associated with the intrauterine fetal death (IUFD) of one twin in 11/21 fetuses (52.3%; five recipients and six donors) following expectant management (1/14 (7.1%)), serial amnioreduction (7/20 (35%)), and laser coagulation (3/55 (5.45%)) (? = 0.0027, Tables II and III). Cerebral injuries developed in 10 fetuses with a live co- twin. These cases included one affected twin pair (number 22) without treatment, and followed serial amnioreduction in 2/456 (4.34%), laser coagulation in 4/167 (2.39%) (p = 0.61, Tables II and III), a combined treatment in one case, and developed before a laser coagulation in one case. Bodi donors and recipients were at risk of developing either ischemic or hemorrhagic lesions (Table TV). Donors were significandy more involved following laser coagulation (p = 0.029, Table IV), especially when there were two surviving fetuses (p = 0.024, Table IV). Ten intrauterine transfusions were given to seven anemic fetuses. Transfusions were given following the death of one twin in five cases and in cases of feto-fetal hemorrhage in two cases. The mean interval between the death of one twin and the diagnosis of cerebral damage in the survivor was 5 + 3.6 weeks. This was 6.3 +- 4.2 weeks and 3.6 +- 2.5 weeks following laser and amnioreduction, respectively (p = 0.5).

Discussion

The interdependency of two fetal circulations is unique to monochorionicity. This is also the main anatomical and functional support for the development of vascular disruptive cerebral lesions. The risk culminates in single survivors but also when both twins are alive and subjected to hemodynamic instability, particularly in TTTS. Two theories have been proposed to explain the padiogenesis of these lesions over the period from the early sixties dirough to the nineties, by Benirschke [12], Bendon and Siddiqi [13], and Larroche et al. [14].

In 1961 Benirschke proposed that padiological findings in single survivors could be compatible with an embolization phenomenon, which could explain several visceral infarcts and lesions of necrosis. However, this remained only speculative and cannot account for the fact that similar brain lesions can also occur when bodi twins are born alive [I]. It is also unlikely that necrotic emboli can disseminate to the survivor against a positive pressure grathent. Bendon and Siddiqi [13] and Larroche et al. [14] highlighted the role of inter-twin hemodynamic imbalance as being the main phenomenon involved in the development of brain lesions in monochorionic twins. Aldiough a chronic and overall unidirectional transfusion from one twin, the donor, into its sibling, the recipient, merely causes significant discordance in hemoglobin levels in utero [15], hemodynamic imbalance can trigger massive feto- fetal exsanguination [4,16].

Table II. Comparison of groups with fetal cerebral lesions diagnosed within the first weeks of life according to their primary treatment and to the presence or absence of the death of one twin.

Table III. Distribution of persistent cerebral lesions according to the primary treatment and their primary characterization. Two fetuses (numbers 8 and 24) were excluded owing to the development of cerebral lesions before the primary treatment.

Table IV. Comparison of groups with fetal cerebral lesions diagnosed within the first weeks of life according to primary treatment, initial status (donor and recipient), and to the condition of the co-twin (dead or alive).

This hemodynamic theory was strengtiiened by the consistent association of severe anemia in single survivors irrespective of their initial status of donor or recipient with polycythemia in the first-dead twin bodi postnatally and in utero within hours following death [14,17-21]. Jou et al. [22] and Gembruch et al. [23] have even reported significant blood transfusion into the agonizing twin, prior to deadi, using color and pulsed Doppler examination.

The development of anemia in the surviving twin can be accurately monitored using maximum velocities in the middle cerebral artery considering a cutoff value of or greater than 1.5 multiples of the median (MoM). This can allow correction of anemia by intrauterine transfusion [6] in response to fetal exsanguination. Aldiough this may appear to be a life-saving procedure, its influence on the development of cerebral lesions in the survivor needs to be further investigated [20,21].

In TTTS, amnioreduction interacts significandy with feto-fetal hemodynamics with acute changes in fetal blood pressure in bodi donors and recipients [24]. In cases of incomplete laser surgery of the placenta, feto-fetal blood transfusion can also occur and cause severe anemia and polycythemia, respectively in the affected twin pairs [9]. Hemodynamic instability exposes the two fetuses to the risk of developing vascular disruptive lesions, particularly in the brain. The padiophysiology can be two-fold: lowflow and high-flow lesions. Bodi low-flow and highflow injuries can result from chronic or acute situations and they can equally affect the donor and the recipient twin (Figure 1).

Anatomical distribution and imaging of fetal cerebral lesions depend upon duration and type of injury as well as upon maturity of the brain at the time of the insult [25]. The fetal brain responds with increasing astrocytic reaction with maturation [25]. Porencephalic cysts without gliosis are therefore more likely to occur in immature brains aldiough septated cysts with irregular walls due to an intense astrocytic proliferation are more likely to develop when the injury occurred during the late second or early third trimester of pregnancy [25]. Low-flow insults occurring before 28 weeks of gestation may alter the neuronal population and interrupt neuronal migration [14,26,27]. This will lead to the development of periventricular leukomalacia, multicystic leukoencephalopathy, and hemorrhage in the subependymal germinal matrix, which can extend into the lateral ventricles and into the cerebral parenchyma. Hemorrhage of the germinal matrix may be associated with venous congestion in the adjacent white matter resulting into parenchymal venous hemorrhagic infarction. These different entities can be isolated or found in association. From 36 weeks onwards, subcortical leukomalacia [27] and ulegyria can also be observed. Closer to term, acute hemodynamic imbalance can also affect the basal ganglia or result in the development of lenticulostriate vasculopathy [28] (Figure 2).

Figure 1. Clinical situations associated with low-flow and high- flow cerebral lesions.

Figure 2. Anatomical location and patterns of cerebral lesions related to twin-to-twin transfusion syndrome in relation with timing of the insult.

Hypervolemia in the recipient can weaken the walls of immature vessels and cause hemorrhagic damage to the germinal matrix that can also affect the periventricular white matter. This can also occur in donor fetuses as a consequence of acute temporary high-flow particularly following amnioreduction. Hemorrhage can also occur within an ischemie lesion at the time of revascularization of immature vessels (Figures 2 and 3) as a mirror mechanism of that described above in the recipient. Thus, the same anatomical findings can be described in both donors and recipients. These patterns (Table II) are not specific and belong to a large spectrum of vascular disruptive cerebral lesions of which ITlS is one of many causes.

The risk of developing cerebral lesions in single survivors was significantly lower following laser treatment (5.45% vs. 35%, p = 0.0027, Table II). This can be explained by the protection of the survivor from exsanguination into its dead co-twin and placenta by the coagulation of the chorionic plate anastomoses. The presence of anemia or the development of cerebral lesions in the survivor may all be explained by incomplete coagulation of the inter-twin anastomoses. Incomplete coagulation can be suspected in at least 22% of the cases with IUFD of one twin and therefore in at least 8.3% of all procedures [29].

Figure 3. Sonographic aspects of the main types of cerebral lesions associated with twin-to-twin transfusion syndrome using transabdominal and transvaginal in utero ultrasound. (A, B) Ischemia of left thalamus and caudate nuclei on an anterior coronal and parasagittal planes at 21 weeks; (C) necrosis of the corpus callosum on a midsagittal plane at 27 weeks; (D) periventricular leukomalacia on a coronal posterior plane at 27 weeks; (E) subcortical leukomalacia on an anterior coronal plane at 27 weeks; (F) multicystic leukoencephalopathy with ex-vacuo ventriculomegaly on a parasagittal plane at 27 weeks; (G) bilateral periventricular leukomalacia (grade IA) on an anterior coronal plane at 27 weeks; (H) left temporo-parietal atrophy on an anterior coronal plane at 25 weeks; (I) microcephaly with diffuse enlarged subarachnoid spaces on a parasagittal plane at 25 weeks; (J) intraventricular hemorrhage (grade II) with heterogeneity of the right plexus choroid and of the ipsilatcral subependymal area on a posterior coronal plane at 30 weeks; (K) mild ventriculomegaly on a parasagittal plane at 18 weeks; (L) bilateral intraventricular hemorrhage with extension into the left periventricular parenchyma (grade III) on an anterior coronal plane at 27 weeks.

Ultrasound examination and MRI (Figure 4) are complementary techniques in depicting fetal brain lesions at an early stage. One case (number 23) had both normal antenatal cerebral US and MRI; however mild ventriculomegaly with cystic periventricular leukomalacia was diagnosed at 5 days of life. This condition can be explained in utero by a missed transient parenchymal hyperechogenicity that usually evolves towards mildly symptomatic periventricular leukomalacia.

Figure 4. MR images of the main cerebral lesions associated with twin-to-twin transfusion syndrome. (A, B): diffuse necrosis of the brain with multicystic leukoencephalopathy, microcephaly, and bilateral ventriculomegaly at 27 weeks on axial (A) and coronal (B) MR scans (T2-weighted HASTE sequences); (C, D): microcystic periventricular lesions corresponding to periventricular leukomalacia associated with microcephaly on parasagittal MR scans (T2-weighted HASTE sequences). Conclusions

In addition to therapy, screening for brain lesions is an important component of the management of ‘1″1″1’S. Ultrasound and MRI have both proven useful and complementary techniques. Fetal cerebral MRI proved reliable when performed from 28 weeks onwards. The interval between the insult and visualization of fetal cerebral damage by US or MRI is a critical factor in fetal surveillance. This was of 3-6 weeks following the death of one twin but could extend to more than 10 weeks. And it is more difficult to date the insult leading to brain damage when both twins are alive. The risk of developing cerebral lesions in single survivors is significantly lower following laser treatment. Transient ultrasound features in the absence of any MRI finding have a good prognosis as shown in up to 23% (6/26) of the cases reported here. Cohort studies should strive, in addition to long-term neurodevelopment follow-up, to correlate perinatal imaging with long-term development in survivors.

References

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2. Bajoria R, Wigglesworth J, Fisk NM. Angioarchitecture of monochorionic placentas in relation to the twin-twin transfusion syndrome. Am J Obstet Gynecol 1995;172:856-863.

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8. Senat MV, Loizeau S, Couderc S, Bernard JP, VuIe Y. The value of middle cerebral artery peak systolic velocity in the diagnosis of fetal anemia after intrauterine death of one monochorionic twin. Am J Obstet Gynecol 2003; 189: 1320- 1324.

9. Robyr R, Lewi L, Yamamoto M, Deprest J, Ville Y. Permanent feto-fetal transfusion from the recipient to the donor twin. A complication of laser surgery in twin-to-twin transfusion syndrome. AmJ Obstet Gynecol 2004;191:S163.

10. Volpe J.J. Intraventricular hemorrhage and brain injury in the premature infant. Neuropathology and pathogenesis. Clin Perinatol 1989;16:361-386.

11. Pierrat V, Duquennoy C, van Haastert IC, Ernst M, Guilley N, de Vries LS. Ultrasound diagnosis and neurodevelopmental outcome of localized and extensive cystic periventricular leucomalacia. Arch Dis Child Fetal Neonat 2001; 84:F151-156.

12. Benirschke K. Twin placenta in perinatal mortality. NY State J Med 1961;61:1499-1508.

13. Bendon RW, Siddiqi T. Acute twin-to-twin in utero transfusion. Ped Pathol 1989;9:591-598.

14. Larroche JC, Droulle P, Delezoide AL, Narcy F, Nessmann C. Brain damage in monozygous twins. Biol Neonat 1990; 57:261-278.

15. Denbow M, Fogliani R, KyIe P, Letsky E, Nicolini U, Fisk N. Hematological indices at fetal blood sampling in monochorionic pregnancies complicated by feto-fetal transfusion syndrome. Prenat Diagn 1998;18:941-946.

16. Wee LY, Taylor MJ, Vanderheyden T, Wimalasundera R, Gardiner HM1 Fisk NM. Reversal of twin-twin transfusion syndrome: Frequency, vascular anatomy, associated anomalies and outcome. Prenat Diagn 2004;24:104-110.

17. Fusi L, Gordon H. Twin pregnancy complicated by single intrauterine death. Problems and outcome with conservative management. BrJ Obstet Gynaecol 1990;97:51 1-516.

18. Okamura K1 Murotsuki J, Tanigawara S1 Uehara S, Yajima A. Funipuncture for evaluation of hematologie and coagulation indices in the surviving twin following co-twin’s death. Obstet Gynecol 1994;83:975-978.

19. Nicolini U, Pisoni MP, Cela E, Roberts A. Fetal blood sampling immethately before and within 24 hours death in monochorionic pregnancies complicated by single intrauterine death. Am J Obstet Gynecol 1998;179:800-803.

20. Tanawattanacharoen S, Taylor MJ, Letsky E, Cox PM, Cowan FM, Fisk NM. Intrauterine rescue transfusion in monochorionic multiple pregnancies with recent single intra-uterine death. Prenat Diagn 2001;21:274-278.

21. Senat MV, Bernard JP, Loizeau S, Ville Y. Management of single death in twin-to-twin transfusion syndrome: A role for fetal blood sampling. Ultrasound Obstet Gynecol 2002;20: 360-363.

22. Jou HJ, Ng KY, Teng RJ, Hsieh FJ. Doppler sonographic detection of reverse twin-twin transfusion after death of the donor. J Ultrasound Med 1993;5:307-309.

23. Gembruch U, Viski S, Baganery K, Berg C, Germer U. Twin reversal arterial perfusion sequence in twin-to-twin transfusion syndrome after the death of the donor co-twin in the second trimester. Ultrasound Obstet Gynecol 2001; 17: 153-156.

24. Smith JF, Pesterfield W, Day LD, Jones RO. Doppler evidence of improved fetoplacental hemodynamics following amnioreduction in the stuck twin phenomenon. Obstet Gynecol 1997;90:681-682.

25. Barkovich AJ. Brain and spine injuries in infancy and childhood. Congenital malformations of the brain and the skull in pethatrie neuroimaging. Chapters IV and V. In: Barkovich AJ, editor. Pethatrie neuroimaging. Third ed. Philadelphia: Lippincott, Williams & Wilkins; 2000. pp 157-249.

26. Larroche JC, Girard N, Narcy F, Fallet C. Abnormal cortical plate (polymicrogyria), heterotopias and brain damage in monozygous twins. Biol Neonate 1994;65:343-352.

27. Levene MJ, Chervenak FA, Whittle M, Benett MJ, Punt J, editors. Fetal and Neonatal Neurology and Neurosurgery. 3rd ed. Edinburgh, Scotland: Churchill Livingstone; 2 l:pp 323-404.

28. de Vries LS, Beek FJ, Stoutenbeek P. Lenticulostriate vasculopathy in twin-to-twin transfusion syndrome: Sonographic and CT findings. Pediatr Radiol 1995;25:S41-42.

29. Cavicchioni O, Yamamoto M, Robyr R, Takahashi Y, Ville Y. Intrauterine fetal demise following laser treatment in twin-to-twin transfusion syndrome. BJOG 2006; 11 3: 590-594.

EDWIN QUARELLO1, MARC MOLHO2, & YVES VILLE1

1 Department of Obstetrics and Gynecology, CHI Poissy St Germain- en-Laye, Universite Paris-Ouest, Poissy, France and

2 Department of Radiology, CHI Poissy St Germain-en-Laye, Universite Paris-Ouest, Poissy, France

(Received 26 June 2006; revised 1 February 2007; accepted 1 1 April 2007)

Correspondence: Pr Y. Ville, Service de Gynecologie Obstetrique, Hopital de Poissy, 10 Rue du Champ Gaillard, 78303 Poissy, France.

E-mail: [email protected]

Copyright Taylor & Francis Ltd. Aug 2007

(c) 2007 Journal of Maternal – Fetal & Neonatal Medicine. Provided by ProQuest Information and Learning. All rights Reserved.

‘Lucy’ Exhibit Worries Some Scientists

HOUSTON — In the Ethiopian language, she is called Dinknesh – a name that means the wonderful, the fabulous, the precious.

But to most of the world, she is known as Lucy, a 3.2 million-year-old fossil whose discovery 33 years ago yielded then-unparalleled insights to the origins of humankind.

Next week, the iconic set of bones will be the star of a much-hyped exhibit that is pitting the Houston Museum of Natural Science and the Ethiopian government against the world’s scientific community.

Houston museum officials say Lucy must be displayed to offer a glimpse into the history of mankind and a much-needed spotlight on Ethiopia as the cradle of humanity.

But a host of critics, including the world’s most influential paleoanthropologists, say it is irresponsible to exhibit a specimen so fragile and valuable. They fear the fossil will be damaged during the exhibit and a projected six-year tour.

Famed fossil hunter Richard Leakey reproached the Houston museum for using Lucy as a “prostitute” to spur ticket sales, extraordinarily high at $20. Noted museums such as The Smithsonian Institution in Washington, D.C., and the American Museum of Natural History in New York refused offers to exhibit Lucy.

Ethiopian immigrants in Houston are urging a boycott of the exhibit, which will run from Aug. 31 to April 20, 2008.

“There is a lot of damage you can’t see with the naked eyes, caused just by touching her and handling her,” said Yohannes Haile-Selassie, anthropology curator at the Cleveland Museum of Natural History, where Lucy was studied for six years after her discovery in 1974, but which has refused to exhibit her.

“I’m just sitting and praying that she comes back safe.”

Bringing Lucy to the United States for a museum exhibit also disregards a 1998 UNESCO resolution, signed by scientists from 20 countries, that says such fossils should not be moved outside of the country of origin except for compelling scientific reasons.

“There are two views going around. One is that every conceivable effort to protect Lucy for six years will be done. The other view is that there is no way this fossil is not going to be damaged irreparably,” said Rick Potts, director of the Smithsonian’s Human Origins program, and one of the scientists who objected to touring Lucy.

“If the fossil is going to be packed, unpacked, shipped again for a number of years, it is pretty likely damage will occur.”

Houston museum officials had named the Denver Museum of Nature and Science as a possible stop, but spokeswoman Laura Holtman said the museum has not yet decided whether to participate. The Field Museum in Chicago said it was working out the final details for exhibition possibly as late as 2010, said spokeswoman Nancy O’Shea.

For the past 27 years, Lucy has been carefully cached in a climate-controlled safe at the National Museum of Ethiopia, taken out only for scientific research or for public exhibit on two rare occasions.

The Houston exhibit will be the first public viewing outside her homeland. The exhibit, which is being heavily advertised on television and billboards, had already sold 2,150 advance tickets by Thursday.

“The concern that people express about safeguarding Lucy is one we share. We are on the same page,” said Dirk Van Tuerenhout, curator of anthropology at the Houston museum. “We will make sure she is kept safe, the same way we have kept safe other artifacts that have come here.”

Van Tuerenhout, who would not discuss the costs involved in mounting the Lucy show, said his museum had no problem handling the Dead Sea Scrolls for a 2004-2005 exhibit, noting they were far more fragile than what he called a “robust” Lucy.

Unlike the scrolls, however, Lucy seems to evoke an emotional reaction that goes beyond her scientific import.

“Lucy is not just the property of the Ethiopian people. She belongs to everyone,” said Cleveland’s Haile-Selassie. “She is the beginning of humanity.”

Lucy, a hominid fossil named after the Beatles’ song “Lucy in the Sky With Diamonds,” was discovered in the remote Afar province in northeastern Ethiopia. Although not the oldest human ancestor ever found, her skeleton is among the most complete, with about 40 percent of her bones intact.

Recognizable as something human, but not quite human, she likely weighed about 60 pounds and stood about 3 1/2 feet tall.

Thanks to Lucy, who is classified as Australopithecus afarensis, scientists were first able to establish that human ancestors walked upright before evolving a big brain.

“People care about her. They tend to forget that she is 3 million years old. They forget she is a fossil,” said Mamitu Yilma, director of the Ethiopian National Museum. “Lucy is very precious. We don’t have any replacement for her. Whenever any fossil is found, they are compared to Lucy.”

Even Lucy’s departure from Ethiopia – which took place without fanfare and at night – stirred a sense of loss and mourning among scientists and many Ethiopians, who say she deserved a better send-off.

However, Lucy did not leave Ethiopia alone.

Yilma and the man who has been Lucy’s personal caretaker for the past 20 years both traveled to Houston with the fossil. They flew aboard Ethiopian Airlines, with Lucy’s skeleton ensconced in two climate-controlled, foam-filled suitcases that took more than a year to design.

Before Lucy was packed, her caretaker and museum conservators inspected the fossil to check for signs of damage. After her arrival in Houston, she was examined again to ensure that no harm had come on the voyage.

Until she goes on display in Houston, Lucy will be kept in a climate-controlled vault similar to the one at the Ethiopian museum. Once the exhibit opens, the world’s most famous fossil will be visible inside a specially designed case.

“It was like when someone you love is getting married, both happy and sad,” said Yilma, describing her conflicting emotions when Lucy left Ethiopia. “The one thing that gives me comfort is that I’m here with her.”

Copart, Inc. Announces DSC Financing for Copart Buyers

Copart is now accepting payments from vehicle buyers through a financing solution supplied by Dealer Services Corporation (DSC), North America’s largest provider of diversified inventory financing for independent dealers. Copart will be accepting financing from buyers utilizing DSC at all 123 Copart salvage auction locations in the U.S., beginning immediately.

Copart will be working directly with DSC as a financing provider for Copart buyers during the sales process. Copart generates gross auction proceeds in excess of $2 billion annually.

“We are pleased to be working with DSC as a financing source for our customers,” said Willis J. Johnson, founder and CEO of Copart. “Like Copart, DSC is a customer-focused company, which has brought a higher level of service to the industry.”

“Copart is a leader in the remarketing of salvage vehicles,” stated John Fuller, DSC Chief Executive Officer, “and we are very pleased to be working with the company to provide its customers a level of service previously unavailable. By partnering with DSC as a financing source, Copart continues to demonstrate its focus on providing its customers top-notch service and efficiency.”

Founded in 1982, Copart provides vehicle suppliers (primary insurance companies), with a full range of services to process and sell salvage vehicles principally to licensed dismantlers, rebuilders, and used vehicle dealers. The company offers vehicle suppliers a full range of services which expedites each stage of the salvage vehicle sale process and minimizes administrative and processing costs. Copart currently operates 134 facilities worldwide. The company is listed on the NASDAQ under the symbol CPRT.

Headquartered in Carmel, Indiana, DSC is America’s largest independent inventory finance provider for new and used automobiles and other diversified products. DSC serves its 9,200 dealer customers through 68 branch locations across the U.S. DSC is committed to a mission of providing quality products, financing, and services to independent dealers of North America, with the highest level of service and integrity. Additional information on DSC is available at www.discoverDSC.com.

Pure Weight Loss Announces the Winners of First Ever Bikini Contest

HORSHAM, Pa., Aug. 24 /PRNewswire/ — After receiving an overwhelming response from Pure Weight Loss clients — including remarkable before and after pictures — Pure Weight Loss has selected the seven winners of its first ever bikini contest.

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Effect of Elbow Position on Grip Strength in the Evaluation of Lateral Epicondylitis

By Dorf, Erik R Chhabra, A Bobby; Golish, S Raymond; McGinty, Jasmin L; Pannunzio, Michael E

Purpose: This study evaluated the maximum grip strength in a position of elbow extension versus flexion as a diagnostic tool in the assessment of a patient with suspected lateral epicondylitis (LE). Methods: From our database we identified 81 patients with grip strength measurements and the diagnosis of LE. From these patient records we collected grip strength measurements with the elbow in full extension and with the elbow in 90[degrees] of flexion for the affected and the healthy extremity. We then compared 2 values: the pretreatment grip strength in flexion and extension for the affected extremity and the pretreatment grip strengths of the nonaffected extremity compared with the affected extremity. Grip strengths were compared with paired and unpaired 2-tailed t tests.

Results: Grip strength was no different in flexion and extension for the healthy extremity and 29% stronger in flexion than in extension for the affected extremity. The affected arm averaged 50% of the strength of the healthy arm in extension and 69% of the strength of the healthy arm in flexion. These differences were statistically significant. An 8% difference in grip strength between flexion and extension was found to be 83% accurate in distinguishing the affected from the unaffected extremities.

Conclusions: The measurement of extension grip strength is a useful objective tool to aid in the diagnosis of LE. In patients with LE, the grip strength decreases as one moves from a position of flexion to a position of extension. (J Hand Surg 2007;32A:882-886. Copyright (c) 2007 by the American Society for Surgery of the Hand.)

Type of study/level of evidence: Diagnostic III.

Key words: Tennis elbow, lateral humeral epicondylitis, hand strength, grip.

In patients with lateral epicondylitis (LE), pain at the lateral epicondyle during power grip occurs because the extensor carpi radialis longus and the extensor carpi radialis brevis (ECRB) must work to counteract the flexion moment generated at the wrist by the digital and wrist flexors. Snijders et al1 measured the electrical activity of the wrist extensors at the elbow in 8 healthy patients while gripping and found that as grip strength increased, so did extensor muscle activity. This increase in extensor muscle activity maintains the wrist in a position of slight extension, allowing the digital flexors to function near their ideal length-tension relationship and thus generate maximal grip strength.

Because the motor units for the wrist cross the elbow, their length and muscle tension are affected by elbow position. Several studies have been performed to evaluate the difference in grip strength between positions of elbow flexion and extension in healthy adults. Although results vary, these studies generally show higher values for grip strength measurements with the elbow in full extension (Gs-E) than for grip strength measurements recorded with the elbow in 90[degrees] of flexion (Gs-F).2-5

Numerous studies have used grip strength as an outcome measure for the evaluation and treatment of LE without controlling for elbow position.6-8 DeSmet and Fabry9 and DeSmet et al10 acknowledged the importance of elbow position on grip strength in patients with LE. We currently use a hydraulic hand dynamometer (Jamar, Preston Rolyan, Bolingbrook, IL) as part of the initial assessment of all patients presenting to our clinic with elbow pain. This study evaluated the maximum grip strength in a position of elbow extension versus flexion as a diagnostic tool in the assessment of a patient with suspected LE. This objective tool can be used by surgeons or primary care physicians to support the suspected diagnosis, or in the case of a negative test result, indicate the need for further work-up.

Materials and Methods

We reviewed the charts of all patients who presented to our hand clinic and were given the diagnosis of LE based on the physical examination findings by 1 of 2 fellowship-trained, attending hand surgeons from January 2001 to October 2004. Within this group of 107 patients, measurements of Gs-F and Gs-E were available for 81 patients. In 47 the dominant hand was affected, in 23 the nondominant hand was affected, in 3 no dominance was expressed, and 7 had both sides affected. Forty patients had grip strength measurements of both extremities. Forty-one patients had only grip strength measurements for the affected extremity. For each patient, we recorded handedness, Gs-F, and Gs-E. Patients then were assigned an anonymous identification code and their names and medical record numbers were omitted from the database. This study was approved by our hospital’s institutional review board.

To receive a diagnosis of LE, patients were required to have tenderness over the ECRB or the common extensor origin and at least 2 of the 3 following criteria: (1) pain with resisted wrist extension, (2) pain with resisted middle finger extension, and (3) pain with the elbow extended and the wrist flexed and pronated (Mills test).11,14 Exclusion criteria for this study included patients with other pathology contributing to lateral elbow pain such as known cervical radiculopathy, radiocapitellar joint instability, or degeneration. Patients who had received surgical treatment for LE previously also were excluded from the study. Grip strengths were measured in the seated position with a hydraulic hand dynamometer (Jamar) by the attending surgeon or a resident orthopedic surgeon. Measurements were taken both with the elbow in 90[degrees] of flexion, and with the elbow fully extended in front of the patient. Care was taken to ensure accurate limb positioning. Measurements were taken for the affected extremity only (41 patients) or for both the affected and healthy extremities (40 patients). Loss of grip strength from flexion to extension was recorded as a relative value as follows:

The Gs-F was compared with the Gs-E within the affected extremity for all patients. For patients who had grip strength data for an unaffected extremity, we compared the maximum Gs-F and Gs-E between the extremities. A t test was used with a 1- or 2-tailed distribution, either paired or unpaired. Patients who were affected bilaterally were eliminated from the comparison analysis.

To estimate a cut-off value to determine how much grip strength loss is significant, we computed a 2 x 2 contingency table that compared the loss of strength for affected extremities with pain- free extremities for all 40 patients with unilateral disease. The table was computed for multiple cut-off values. The sensitivity and specificity were computed from the table for each cut-off value. Chi- squared analysis was used for the contingency table results, and a ? value of less than .05 was considered significant. Power analysis was performed using post hoc analysis with the noncentral distribution theory. Data analysis was performed with statistical software (SPSS; SPSS Inc., Chicago, IL). Power analysis also was performed with statistical software (GPOWER; Heinrich Heine University, Dusseldorf, Germany).

Results

When comparing grip strength within the healthy arm, we found that Gs-F was no different than Gs-E; however, when comparing measurements within the affected arm we found that on average the Gs- F exceeded the Gs-E by 29% (p

When comparing a patient’s healthy extremity with their own affected extremity, we found that the Gs-E for the affected side was on average only 50% of the Gs-E for the healthy side, and we found that the Gs-F for the affected side was on average 69% of the Gs-F for the healthy side (p

Table 1. Differences in Flexion and Extension Grip Strengths

The loss of grip strength between flexion and extension in a single extremity was considered as a test to distinguish an extremity with LE from a painfree extremity. With a 5% decrease in the Gs-E the sensitivity was 83% and the specificity was 80%. With an 8% decrease in the Gs-E the sensitivity was 80% and the specificity was 85%. With a 10% decrease in the Gs-E the sensitivity was 78% and the specificity was 90%. Figure 1 shows the tradeoff between the sensitivity and specificity for multiple cut-off values. The results of the contingency table analysis were significant using the chi-squared test (p 0.5).

Discussion

DeSmet and Fabry9 are the only investigators who have provided clinical insight into the effect of elbow position on grip strength in patients with LE. They evaluated the Gs-E and the Gs-F in 55 consecutive patients with chronic LE. All of their patients had symptoms for more than 6 months and had been treated nonsurgically with various treatment modalities. They found a statistically significant mean grip strength loss of 43% from flexion to extension for the pathologic side, with a less than 2% difference for the control side. They performed a further prospective study in 17 patients with a minimum of 1 year of follow-up evaluation after surgery for LE. In their second study they found that the Gs-E and the Gs-F both improved significantly after surgery, and that an increased Gs-E correlated with a good clinical outcome.10

Table 2. Comparison of Affected Versus Unaffected Extremities Although DeSmet’ s observations4 were similar to ours, they offered no insight into why the ECRB is affected differently in different elbow positions, or why the ECRB is affected more than other wrist extensors. In an effort to explain this. Lieber et al15 performed a study that evaluated the length of the ECRB sarcomere through various degrees of elbow flexion. In their evaluation of 13 patients they found a biphasic change in sarcomere length as the elbow was moved from a fully extended position to a position of 90[degrees] of flexion. Sarcomere length was maximal with the elbow at 90[degrees] of flexion, and minimal between 30[degrees] of flexion and 60[degrees] of flexion. The sarcomere length again lengthened at full extension. In another study, Lieber et al16 examined the unique architecture of the wrist flexors and extensors and found that each flexor and extensor could be differentiated uniquely based on the fiber length to muscle length ratio, pennate angle, and muscle length with 100% accuracy. Lieber et al16 postulated that because of the unique architecture of the ECRB and because the ECRB sits close to the center of rotation of the elbow, it is exposed to eccentric muscle contracture through a range of elbow position and thus may be more prone to injury than the extensor carpi radialis longus. A position of full extension places the ECRB in a particularly vulnerable position with regard to muscle tension, thus exacerbating the symptoms of LE more than a position of elbow flexion.

Figure 1. Difference in grip strength considered as a test to distinguish an extremity with LE from a pain-free extremity. The sensitivity and specificity of the test were calculated for various values of grip strength (boxes, [black square]). The x-axis is the false-positive rate (FP) or 1 -specificity. The y-axis is the true- positive rate (TP) or the sensitivity. As one moves from left to right on the x-axis, the sensitivity increases and the specificity decreases. TP, true-positive rate; FP, false-positive rate.

Our work corroborates the work of DeSmet and Fabry9,10 and adds further clinical relevance to the work of Lieber.15,16 Although we offer no scientific evidence linking the works of DeSmet, Fabry, and Lieber, we have shown that patients who have LE by classic physical examination findings are likely to have significant differences between the Gs-F and the Gs-E. This finding may be secondary to the unique architecture of the ECRB and its relative position proximal to the elbow joint as elucidated by Lieber.15,16

In our study, loss of grip strength between flexion and extension in a single extremity was considered as a test to distinguish an extremity with LE from a pain-free extremity. We found that an 8% decrease from the Gs-F to the Gs-E was 80% sensitive and 85% specific. Implementing a 15% cut-off value (per DeSmet and Fabry9) showed a 70% sensitivity and a 98% specificity. In any diagnostic study, the choice of cut-off value is a judgment in which sensitivity is traded for specificity. Here, grip strength is used to distinguish LE from a pain-free extremity. When grip strength is used to diagnose LE in all painful extremities, we would expect grip strength to be equally sensitive but perhaps somewhat less specific.

The relative decrease in grip strength in a position of elbow extension is a diagnostic tool that should be used in the context of an extremity with suspected LE. The addition of this tool to the classic signs and symptoms of tennis elbow gives the doctor additional objective evidence implicating LE as the cause of a patient’s pain. In addition, the finding of decreased grip strength in a position of elbow extension provides further evidence supporting the diagnosis of LE in patients for whom the diagnosis is not entirely clear. Conversely, the objective findings of our study also may be useful in ruling out the diagnosis of LE in patients with other potential sources of elbow pain.

Our study had several limitations. First, there was a selection bias from our patient population. Because we are a tertiary referral center, many of our patients have failed one or multiple therapeutic modalities. In addition, our extremities were chosen retrospectively based on the diagnosis of LE. Although the diagnosis was made primarily by using the patient’s history and physical examination findings, the attending surgeons were likely to use the information from the grip strength measurements to aid in the diagnosis, and thus inadvertently may have selected for our group patients with a marked difference between the Gs-F and the Gs-E. In addition, we lacked control data. Although we had 81 patients with measurements for the affected limb, we only had bilateral data for 40 patients and thus we were forced to compare 2 different groups in several instances.

We did not evaluate the effect of elbow position on grip strength in patients who ultimately were found to have other conditions that also might present with lateral elbow pain, such as radial tunnel syndrome, radiocapitellar arthritis, radial head/neck fracture, or rheumatoid arthritis. Although we did not find any evidence in the literature to suggest that similar differences in the Gs-F versus the Gs-E would be seen in those conditions, further investigation is warranted to determine what other pathology about the elbow might produce the positional differences in grip strength we found in patients with LE.

Despite these limitations, there is a statistically relevant correlation between a relative decrease in the Gs-E and the diagnosis of LE. This retrospective review provides preliminary data to support a prospective study to evaluate the predictive value of differential grip strength measurements in the evaluation and treatment of LE. Our prospective arm seeks to evaluate grip strengths in flexion and extension for all patients who present with elbow pain to better support the specificity of this test for the diagnosis of LE.

The authors would like to acknowledge Dr. David P. Green for his training in the use and evaluation of grip strength assessments in patients with suspected LE.

References

1. Snijders CJ, Volkers AC, Mechelse K, Vleeming A. Provocation of epicondylalgia lateralis (tennis elbow) by power grip or pinching. Med Sci Sports Exerc 1987;19: 518-523.

2. Desrosiers J, Bravo G, Hebert R, Mercier L. Impact of elbow position on grip strength of elderly men. J Hand Ther 1995; 8:27- 30.

3. Kuzala EA, Vargo MC. The relationship between elbow position and grip strength. Am J Occup Ther 1992;46: 509-512.

4. Oxford KL. Elbow positioning for maximum grip performance. J Hand Ther 2000; 13:33-36.

5. Su CY, Lin JH, Chien TH, Cheng KF, Sung YT. Grip strength in different positions of the elbow and shoulder. Arch Phys Med Rehabil 1994;75:812-815.

6. Wuori JL, Overend TJ, Kramer JF, MacDermid J. Strength and pain measures associated with lateral epicondylitis bracing. Arch Phys Med Rehabil 1998;79:832-837.

7. Thurtle OA, Tyler AK, Cawley MI. Grip strength as a measure of response to treatment for lateral epicondylitis. Br J Rheumatol 1984;23:154-155.

8. Verhaar JA, Walenkamp GH, van Manieren H, Kester AD, van der Linden AJ. Local corticosteroid injection versus Cyriax-type physiotherapy for tennis elbow. J Bone Joint Surg 1996;78B:128-132.

9. DeSmet L, Fabry G. Grip strength in patients with tennis elbow. Influence of elbow position. Acta Orthop Belg 1996;62: 26- 29.

10. DeSmet L, Van Ransbeeck H, Fabry G. Grip strength in tennis elbow: long-term results of operative treatment. Acta Orthop Belg 1998;64:167-169.

11. Coonrad RW, Hooper WR. Tennis elbow: its course, natural history, conservative and surgical management. J Bone Joint Surg 1973;55A:1 177-1 182.

12. Nirschl RP, Ashman ES. Elbow tendinopathy: tennis elbow. Clin Sports Med 2003:22:813-836.

13. Dutton M. Orthopaedic examination, evaluation and interven- tion. The McGraw Hill Companies, Inc., New York, NY, 2004:543-544.

14. Lister GD, Belsole RB, Kleiner! HE. The radial tunnel syndrome. J Hand Surg 1979;4:52-59.

15. Lieber RL, Ljung BO, Friden J. Sarcomere length in wrist extensor muscles. Changes may provide insights into the etiology of chronic lateral epicondylitis. Acta Orthop Scand 1997;68:249-254.

16. Lieber RL, Fazeli BM, Botte MJ. Architecture of selected wrist flexor and extensor muscles. J Hand Surg 1990;15A;244-250.

Erik R. Dorf, MD, A. Bobby Chhabra, MD, S. Raymond Golish, MD, PhD, Jasmin L. McGinty, MD, Michael E. Pannunzio, MD

From the University of Virginia Hand Center, Charlottesville, VA, and the Reconstructive Hand Surgeons of Indiana, Carmel, IN.

Received for publication March 16, 2007; accepted March 17, 2007.

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

Support was received from the Orthopaedic Research Education Foundation and the NIH/N1AMS (AR49407).

Corresponding author: Michael E. Pannunzio, MD, Reconstructive Hand Surgeons of Indiana, 1 342 1 Old Meridian St, Suite 200, Carmel, IN 46032.

Copyright (c) 2007 by the American Society for Surgery of the Hand

0363-5023/07/32A06-0019S32.00/0

doi:10.l016/j.jhsa.2007.04.010

Copyright Churchill Livingstone Inc., Medical Publishers Jul/Aug 2007

(c) 2007 Journal of Hand Surgery, The. Provided by ProQuest Information and Learning. All rights Reserved.

Muscle Atrophy at Diagnosis of Carpal and Cubital Tunnel Syndrome

By Mallette, Paige Zhao, Meijuan; Zurakowski, David; Ring, David

Purpose: This study was designed to test the hypothesis that patients with an initial diagnosis of cubital tunnel syndrome are more likely to present with muscle atrophy than patients with an initial diagnosis of carpal tunnel syndrome. Methods: A list of patients presenting to the office of a single hand surgeon from January 2000 to June 2005 with an initial diagnosis of isolated, idiopathic carpal tunnel syndrome or cubital tunnel syndrome was generated from billing records. The medical records of 58 patients with cubital tunnel syndrome and 370 patients with carpal tunnel syndrome were reviewed for age, gender, diabetes, and presence of atrophy.

Results: Twenty-three of 58 patients with an initial diagnosis of cubital tunnel syndrome had atrophy compared with only 62 out 370 patients with an initial diagnosis of carpal tunnel syndrome. Multiple logistic regression revealed that age (odds ratio, 1.06; 95% Cl, 1.041.08) and diagnosis (cubital tunnel patients were more likely than carpal tunnel patients to present with atrophy; odds ratio, 4.5; 95% Cl, 2.7-8.6) were factors significantly associated with atrophy at presentation.

Conclusions: Patients with carpal tunnel syndrome present earlier in the course of their disease than patients with cubital tunnel syndrome. Patients with cubital tunnel syndrome are more likely to present with muscle atrophy, reflecting advanced nerve damage that may not respond to surgery. (J Hand Surg 2007;32A:855-858. Copyright (c) 2007 by the American Society for Surgery of the Hand.)

Type of study/level of evidence: Prognostic IV.

Key words: Atrophy, carpal tunnel syndrome, cubital tunnel syndrome.

Cubital tunnel syndrome-idiopathic compression of the ulnar nerve at the elbow-is second only to carpal tunnel syndrome among common compressive neuropathies of the upper extremity in adults.1,2 Patients with either disease present with complaints of numbness. Night-time numbness or numbness upon waking are characteristic. Signs of advanced nerve damage include persistent numbness, muscle atrophy, and weakness.

Whereas surgical intervention is effective at reducing or eliminating intermittent symptoms, advanced nerve damage is less likely to improve after operative treatment.3-8 We hypothesize that patients with cubital tunnel syndrome are more likely than patients with carpal tunnel syndrome to have muscle atrophy at the time of initial diagnosis.9,10 This hypothesis was tested by reviewing the medical records of patients that presented to a single hand surgeon with an initial diagnosis of an isolated and idiopathic carpal or cubital tunnel syndrome.

Materials and Methods

A list of patients presenting to the office of a single hand surgeon from January 2000 through June 2005 was generated from billing records. Inclusion criteria included (1) patients with an initial diagnosis of carpal tunnel or cubital tunnel syndrome; (2) the compressive neuropathy was idiopathic; (3) this was the only diagnosis made-it was an isolated problem (eg, no cervical radiculopathy, elbow arthrosis, etc.).

Fifty-eight patients with cubital tunnel syndrome and 370 patients with carpal tunnel syndrome satis- fied the inclusion criteria (Table 1). The average age of patients with cubital tunnel syndrome was 54 years (range, 22-90 years), and the average age of carpal tunnel patients was 56 years (range, 26-84 years). Patients with carpal tunnel syndrome were significantly more likely to be female: 255 (69%) of the carpal tunnel patients and 24 (41%) of the cubital tunnel patients were female (p

Table 1. Univariate Analysis of Carpal and Cubital Tunnel Syndrome Groups

The diagnosis of cubital or carpal tunnel syndrome was based on complaints of numbness. Painful numbness was included, but patients with complaints of pain only were not given these diagnoses. A specific diagnosis was applied only when the complaints and examination findings were consistent and characteristic of one of these diagnoses. In general, there had to be a complaint of intermittent or persistent numbness in the distribution of the involved nerve that could either be reproduced with the appropriate provocative test (Durkan’s or Phalen’s for carpal tunnel syndrome and an elbow flexion test for cubital tunnel syndrome) or was associated with objective signs of advanced nerve damage (weakness or atrophy). The following data points were recorded anonymously from individual medical records and placed into a database: age, gender, diabetes, and finding of atrophy (visible loss of muscle mass) on physical examination.

Data from electrophysiologic data were available in 30 of 58 (52%) patients with cubital tunnel syndrome and 231 of 370 (62%) patients with carpal tunnel syndrome. Electrophysiologic testing was ordered for all patients requesting surgery and in a few patients in whom the diagnosis was in some doubt. Several patients had testing prior to referral. Patients that did not have electrophysiologic testing had a presumptive diagnosis of carpal tunnel syndrome or cubital tunnel syndrome based on clinical and physiologic examination and were either not offered or declined operative intervention. The electrophysiologic testing confirmed the suspected diagnosis in all 261 patients in whom it was obtained. One neurophysiologist interpreted all the electrophysiologic studies and assigned categorical ratings: mild, moderate, or severe. Intrinsic hand muscle atrophy was diagnosed on physical examination: atrophy of the first dorsal interosseous for cubital tunnel and atrophy of the thenar eminence in carpal tunnel syndrome.

A chi-square analysis was used to evaluate the association between diagnosis and atrophy. Logistic regression modeling was also applied to determine (1) the relative odds of atrophy between patients with carpal versus cubital tunnel syndrome after adjustment for covariates including age, gender, and diabetes; (2) the factors associated with atrophy in carpal tunnel syndrome and cubital tunnel syndrome adding neurophysiologic testing parameters (distal motor and sensory latencies and the neurologist’s overall rating [mild, moderate, severe] for carpal tunnel syndrome, and the neurologist’s overall rating for cubital tunnel syndrome) to the other covariates. A backward selection procedure was used to identify significant variables, and 95% confidence intervals were constructed. Model fit was assessed using R-square, and maximum likelihood estimation was used to derive the probability of muscle atrophy based on diagnosis and other variables.12 All 2-tailed values of p

Results

In univariate analysis, age, diabetes, and diagnosis (carpal tunnel vs cubital tunnel syndrome) were significantly associated with atrophy and gender showed a non-significant trend for association with atrophy (Table 2). Twenty-three of 58 (40%) patients with cubital tunnel syndrome and 62 of 370 (17%) patients with carpal tunnel syndrome presented with muscle atrophy (p

Table 2. Univariate Analysis of Candidate Predictors or Risk Factors of Atrophy

Multivariate logistic regression revealed that older age (odds ratio, 1.06; 95% CI, 1.04-1.08) and diagnosis (cubital tunnel patients were more likely than carpal tunnel patients to present with muscle atrophy; odds ratio, 4.5; 95% CI, 2.3-8.6) were independently associated with atrophy at presentation (Table 3; Fig. 1) Determinants of atrophy among patients with carpal tunnel syndrome and electrophysiologic (EMG) data were age (odds ratio, 1.06; 95% CI, 1.03-1.10) and neurologist’s rating (odds ratio, 3.8; 95% CI, 1.8-7.8), but not distal motor or sensory latency. Neurologist’s rating was associated with atrophy among patients with cubital tunnel syndrome and EMG data, although this association only reached a trend (p = .09).

Table I. Multivariate Results for Significant Independent Predictors of Atrophy

Figure 1. Curves depict the age-based probability of atrophy for patients with carpal tunnel syndrome and cubital tunnel syndrome independent of gender and diabetes. Age and diagnosis were both associated with atrophy in multivariate analysis (p

Discussion

This study is limited by the fact that it represents a single surgeon’s practice and practice style, and electrophysiologic testing was not used routinely to confirm the diagnosis. Use of the neurophysiologist’s overall rating, although practical in a retrospective study, is also somewhat subjective. It is possible that the patients presenting to this surgeon and the diagnostic criteria used by this surgeon and neurophysiologist cannot be generalized to the average practice. An additional limitation of the study is that intrinsic muscle atrophy was determined by the judgment of the examiner, without objective testing. On the other hand, the diagnostic criteria are fairly well established, and routine objective neurophysiologic testing is not justified. Furthermore, muscle atrophy was only diagnosed when it was obvious and therefore might be considered as severe muscle atrophy. It could be argued that a case-control design would be better for determining risk factors for atrophy. We used a retrospective cohort design (1 ) because of the relatively low number of patients with ulnar neuropathy and (2) because our intention was to describe descriptive statistics of the overall consecutive cohort of patients presenting with carpal or cubital tunnel syndrome. In this manner, our study is able to report the prevalence of atrophy in one surgeon’s practice as well as factors associated with atrophy. In the final analysis, this study simply recognizes that patients with cubital tunnel present at a more advanced stage, and either study design demonstrates this.

Very few scientific investigations have addressed the initial clinical diagnosis of cubital tunnel syndrome, and we are not aware of any prior work addressing the prevalence of atrophy in patients with an initial diagnosis. Buschbacher studied weakness in patients referred for electrodiagnostic evaluation of numbness and made observations similar to those in our study.10 He identified weakness in 61 of 74 (82%) patients with electrophysiologic evidence of cubital tunnel syndrome compared with only 11 of 69 (16%) patients with electrophysiologic evidence of carpal tunnel syndrome.

If our data regarding atrophy can be reproduced by others, then it suggests some differences between these otherwise relatively similar diseases. One can only speculate as to why patients with carpal tunnel syndrome present with less advanced disease, prior to the development of intrinsic muscle atrophy or weakness. Perhaps it is easier to provoke the symptoms in a way that disturbs sleep. Perhaps the involvement of the median nerve aspect of the hand is more notable, more bothersome, or more worrisome to patients than involvement of the ulnar nerve aspect.

In any case, the findings are both interesting and useful for counseling patients. The observation of a higher prevalence of muscle atrophy at presentation in cubital tunnel than in carpal tunnel patients remains even after adjusting for age, gender, and diabetes. The greater prevalence of atrophy upon presentation would seem to reflect that cubital tunnel syndrome presents at a more advanced stage than carpal tunnel syndrome. Given that the damage associated with compressive peripheral neuropathies is incompletely reversible,3-8 patients and surgeons may be less satisfied with the results of surgery for ulnar nerve compression than they are for carpal tunnel syndrome if they are expecting complete recovery. Operations for carpal tunnel syndrome – where symptoms are annoying and even disabling and advanced nerve dysfunction relatively uncommon – may be perceived as curative and of having a major impact on quality of life. Based on evaluation of symptoms and signs, carpal tunnel release can often be assessed as having cured the problem although neurophysiologic testing usually remains somewhat abnormal except in very mild cases. In contrast, patients with cubital tunnel syndrome may be less likely to notice an effect from surgery and more likely to be left with residual symptomatic nerve dysfunction.

References

1. Latinovic R, Gulliford MC, Hughes RA. Incidence of common compressive neuropathies in primary care. J Neurol Neurosurg Psychiatry 2006;77:263-265.

2. Mondelli M, Giannini F, Ballerini M, Ginanneschi F, Martorelli E. Incidence of ulnar neuropathy at the elbow in the province of Siena (Italy). J Neurol Sei 2005;234:5-10.

3. Gelberman RH, Pfeffer GB, Galbraith RT, Szabo RM, Rydevik B, Dimick M. Results of treatment of severe carpal-tunnel syndrome without internal neurolysis of the median nerve. J Bone Joint Surg 1987;69A:896-903.

4. Lett ME, Weiser RW, Tomaino MM. Patient-reported outcome after carpal tunnel release for advanced disease: a prospective and longitudinal assessment in patients older than age 70. J Hand Surg 2004;29A:379-383.

5. Matsuzaki H, Yoshizu T, Maki Y, Tsubokawa N, Yamamoto Y, Toishi S. Long-term clinical and neurologic recovery in the hand after surgery for severe cubital tunnel syndrome. J Hand Surg 2004;29A:373-378.

6. Mondelli M, Reale F, Padua R, Aprile I, Padua L. Clinical and neurophysiological outcome of surgery in extreme carpal tunnel syndrome. Clin Neurophysiol 2001;1 12:1237-1242.

7. Mowlavi A, Andrews K, Lille S, Verhulst S, Zook EG, Milner S. The management of cubital tunnel syndrome: a meta-analysis of clinical studies. Plast Reconstr Surg 2000; 106:327-334.

8. Rhoades CE, Mowery CA, Gelberman RH. Results of internal neurolysis of the median nerve for severe carpal-tunnel syndrome. J Bone Joint Surg 1985;67A:253-256.

9. Clark CB. Cubital tunnel syndrome. JAMA 1979;241:801802.

10. Buschbacher R. Side-to-side confrontational strength-testing for weakness of the intrinsic muscles of the hand. J Bone Joint Surg 1997;79A:401-405.

11. Browner W, Newman T, Cummings S, Hulley S. Estimating sample size and power: the nitty-gritty. In: Hulley S, Cummings S, Browner W, Grady D, Hearst N, Newman T, eds. Designing clinical research. 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2001:65-91.

12. Hosmer DW, Lemeshow S. Applied logistic regression. 2nd ed. New York: John Wiley; 2000:92-128.

Paige Mallette, BA, Meijuan Zhao, MD, David Zurakowski, PhD, David Ring, MD

From the Hand and Upper Extremity Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA; Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA; Children’s Hospital Boston, Boston, MA.

The authors would like to acknowledge the expert and generous assistance of David Zurakowski, PhD. with the statistical analysis.

Received for publication September 2, 2006; accepted in revised form March 16, 2007.

Supported by unrestricted research grants from AO Foundation, Wright Medical, Joint Active Systems, Smith and Nephew Richards, and Small Bone Innovations.

Corresponding author: David Ring, MD, Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Yawkey Center Suite 2100, 55 Fruit Street, Boston, MA 02114; e-mail: dring(R) partners.org

Copyright (c) 2007 by the American Society for Surgery of the Hand

0363-5023/07/32A06-0014$32.00/0

doi:10.1016/j.jhsa.2007.03.009

Copyright Churchill Livingstone Inc., Medical Publishers Jul/Aug 2007

(c) 2007 Journal of Hand Surgery, The. Provided by ProQuest Information and Learning. All rights Reserved.

Capital Health Plan of Tallahassee Selects Health Dialog for Care Management Services

Health Dialog Services Corporation today announced it has been selected by Capital Health Plan (CHP) of Tallahassee, Florida to provide individuals access to whole person care management services. Capital Health Plan is highly rated for both quality and member satisfaction in the State of Florida.

Under the agreement, CHP will roll out Health Dialog’s Collaborative CareSM program, including Health Coaching and related support, to its 113,000 commercial and Medicare members and dependents.

Health Dialog Health Coaches, who are nurses, dieticians, and respiratory therapists, work with individuals and their family members telephonically and online to help them manage chronic conditions, significant medical decisions, and general health and wellness concerns. Using a Shared Decision-Making® approach, Health Coaches are available 24/7 to help individuals understand the total picture of their health, as well as risks, benefits, and outcomes of various treatment options, so they can gain the skills and self-reliance necessary to work more effectively with their physicians.

“We are very excited to provide our members with care management services that enhance the doctor-patient relationship,” said Dr. Nancy Van Vessem, Chief Medical Officer at CHP. “The depth and scope of Health Dialog’s offerings are exactly what we are looking for to help improve healthcare quality.”

“We are pleased to have been selected to make an impact on the health of individuals at Capital Health Plan,” said George Bennett, Chairman and CEO, Health Dialog. “Capital’s tightly integrated care systems and member-focused culture provide us with an excellent starting point for enhancing quality of care.”

As part of the Health Dialog program, individuals will have access to award-winning educational resources in print, audio, video, and online. The Dialog CenterSM, Health Dialog’s member-facing website, provides individuals with a variety of tools, including detailed health information through the Healthwise® Knowledgebase, decision aids to support assessment of treatment options, and a suite of online health & wellness modules that address issues such as back pain, smoking cessation, nutrition improvement, weight management, fitness and exercise, and stress management.

As part of the agreement, CHP physicians will also have access to Health Dialog’s industry-leading SMART® Registry tool. This reporting component provides primary care physicians with actionable clinical information. Reports generated for physicians through the SMART® Registry include patient reports, practice reports, and peer-comparison reports.

About Health Dialog

Health Dialog is a leading provider of care management services, including disease management, and is one of the fastest growing privately held firms in the U.S. The firm helps physician groups, health plans, and self-insured employers improve healthcare quality while reducing overall costs. The firm’s services include analytic services and telephonic, online, and other care management support for individuals, payors, and physicians. Health Dialog helps individuals become more actively engaged in the management of their health and healthcare and have more effective relationships with their physicians. For more information about Health Dialog, please visit their website www.healthdialog.com.

About Capital Health Plan

Capital Health Plan provides health care benefits to more than 113,000 residents of Leon, Gadsden, Wakulla and Jefferson counties in Florida. CHP is an affiliate of Blue Cross Blue Shield of Florida and an Independent Licensee of the Blue Cross Blue Shield Association. For more information, please visit www.capitalhealth.com.

New Protocol of Clomiphene Citrate Treatment in Women With Hypothalamic Amenorrhea

By Borges, Lavinia Estrela Morgante, Giuseppe; Musacchio, Maria Concetta; Petraglia, Felice; De Leo, Vincenzo

Abstract Objective. To determine if a new protocol of administration of clomiphene citrate (CC) is effective in menstrual cycle recovery in women with hypothalamic secondary amenorrhea.

Design. This was an open-label study.

Patients. Patients comprised a group of eight women with secondary amenorrhea.

Interventions. An oral preparation containing CC (50 mg/day) was administered for 5 days followed by a double dose (100 mg/day) for another 5 days, initiated on day 3 after estrogen/progestogen- induced withdrawal bleeding. If ovulation and vaginal bleeding occurred, treatment continued in the two next months with 100 mg/ day from day 3 to day 7 day of the cycle.

Main outcome measures. Cycle control was evaluated at each visit, when patients recorded bleeding patterns and tablet intake. Data on the intensity and duration of bleeding were collected.

Results. Six patients responded to the first cycle of CC administration, resuming normal menstrual cycles. The other two patients failed to menstruate after the first 10 days of treatment with CC and repeated the same protocol. After the second administration, these two women also had normal menstrual bleeding.

Conclusions. The present data show that this new protocol of CC treatment may be useful to restore normal menstrual cycles in young women with hypothalamic amenorrhea.

Keywords: Clomiphene citrate, hypothalamic amenorrhea, cycle control

Introduction

Reproductive function is controlled by a very sophisticated system composed by the perfect synchronization of neuronal and endocrinological functions. Stress situations, due to physical, psychological or metabolic stressors, can negatively modulate the hypothalamus-pituitary-ovarian (HPO) axis, blocking ovarian activity [I]. A disruption at any point in one of the complex feedback interactions between the ovaries, pituitary and hypothalamus may lead to irregularities in the menstrual cycle [2]. In the face of extremely reduced nutrient intake, non-vital processes such as growth, pubertal development and reproduction are minimized until the nutritional situation improves [3].

Hormone replacement strategies have limited benefit because they do not promote recovery from these allostatic endocrine adjustments in the HPO axis. Although the menstrual pattern can be restored with exogenous administration of estrogen/progestogens, the long-term deleterious consequences of stress-induced anovulation may lead to increased risk of cardiovascular disease, osteoporosis, depression, and other psychiatric conditions [4]. Because some physicians use the return of menses to demonstrate regained health in these patients, they may not want to mask this outcome with the use of oral contraceptives. Therefore, evidence to date does not support the routine use of oral contraceptives in the management of patients with stress-induced amenorrhea and newer modalities may be a perspective [5]. Indeed, the rationale for the use of sex steroid replacement is based on the erroneous assumption that functional forms of hypothalamic hypogonadism represent only an alteration in the HPO axis, whereas behavioral and psychological interventions are also necessary to permit resumption of ovarian function along with recovery of the HPO axis [4] .

Clomiphene citrate (CC) has been applied as the first-line treatment in anovulatory women since the 1960s, due to its low cost and minor side-effects or complications [6] . It is recognized that CC has partial antagonist/partial agonist properties, and its dominant effect on the HPO axis is related to its antiestrogenic properties [7] . Thus treating patients with secondary amenorrhea with CC should correct their hormonal abnormalities. Frequently the classic protocol (100 mg/day for 5 days) does not improve the menstrual pattern and women continue to be amenorrheic, which can be explained by low endogenous levels of estradiol (E2). After two or three negative efforts this sort of treatment is abandoned and replaced with an estrogen/progestin oral contraceptive [8,9].

The present study was therefore designed to assess the cycle control of CC and its effects on ovarian activity in women with secondary amenorrhea due to hypothalamic dysfunction.

Materials and methods

This open-label study evaluated the effect of CC on cycle control in women with secondary amenorrhea (bleeding interval >6 months). The study was approved by the Institutional Review Board of our center. Informed consent forms were signed by all subjects prior to enrollment.

From March 2004 and November 2004, a total of eight patients (age range 17-22 years) were enrolled (Table I), including five women who practiced intensive exercise and three who had lost weight after a restrictive diet. Serum E^sub 2^ levels varied between 18 and 25 pg/ ml. An additional inclusion criterion was low serum follicle- stimulating hormone (FSH) levels. Exclusion criteria consisted of the presence of any endocrine abnormality. A complete medical, gynecological and obstetric history was obtained from each patient before initiation of CC therapy. Physical and gynecological examinations were performed and body mass index (BMI) was calculated for all subjects. Endocrine screening included serum assays of FSH, luteinizing hormone (LH), prolactin (PRL), thyroid-stimulating hormone (TSH), (E2) and progesterone (P), performed before CC treatment and on the third month during the treatment (day 3). Transvaginal sonographic screening included assessment of the ovarian stroma echogenicity, ovarian volume, and total number of follicles. Concomitant use of medication and adverse events were registered.

Table I. Characteristics of subjects (n = 8).

CC medication was initiated on day 3 after estrogen/progestogen- induced withdrawal bleeding. All subjects received an oral preparation containing CC 50 mg/day for 5 days followed by 100 mg/ day for another 5 days. If ovulation and vaginal bleeding occurred, treatment continued in the two next months with 1 00 mg/day from day 3 to day 7 of the cycle; if not the same treatment was repeated. Cycle control was evaluated on each visit when patients recorded bleeding patterns and tablet intake. Data on the intensity and duration of bleeding were collected. The duration of follow-up for all patients included in this study was 6 months. Ovulation was assessed by mid-luteal serum P measurement (level > 25 nmol/1) combined with transvaginal sonographic endometrial thickness assessment.

Serum LH and FSH concentrations were determined using a double- antibody radioimmunoassay (Sorin, Saluggia, Italy) and immunofluorimetric assay, as described previously [10,11]. Serum TSH, PRL, E^sub 2^ and P concentrations were determined using a commercially available radioimmunoassay (Radim RIA; Pomezia, Rome, Italy). The samples were assayed in duplicate at two dilutions. All samples from each participant were assayed together. Intra-assay and inter-assay variations were 6.2% and 6.5% for FSH, 7.8% and 8.2% for LH, 4.2% and 4.9% for E^sub 2^, and 8.5% and 10.8% for P, respectively.

Results are expressed as mean +- standard deviation. Comparison between data was performed by the signed rank test because of the small size of the sample. Statistical significance was set at p

Results

Among the eight patients with secondary amenorrhea due to hypothalamic dysfunction, six patients responded to the first cycle of CC administration and resumed normal menstrual cycles. The other two patients failed to menstruate after the first treatment with CC; however, a normal menstrual pattern was recovered after a second cycle with the same protocol. Serum LH and P levels increased significantly (p

Serum PRL and TSH did not show any significant change during CC administration (Table II). At 6 months’ follow-up, all patients had resumed menses. The patients did not change their diet during therapy and their weight changed during treatment by 12 kg. No significant differences were seen in body weight, BMI or percent body fat at follow-up.

Discussion

The present data show that this treatment protocol with CC may be useful to restore normal cycles in young women with hypothalamic amenorrhea. In some selective cases this protocol may be an alternative to administration of estrogen/progestogens to correct menstrual abnormalities and restore ovulation.

Figure 1 . Serum levels of luteinizing hormone (LH) and progesterone (P) before and during treatment with clomiphene citrate (CC). Values are means, with standard deviation shown by vertical bars. Mean values were significantly different: *p

Reduced availability of metabolic fuel below a critical level due to food restriction or increased energy expenditure is accompanied by the activation of multiple neuroendocrine/metabolic changes resulting in anovulation and amenorrhea [12]. Selective estrogen receptor modulators are compounds which may function as agonists or antagonists depending upon the target tissue and the protocol of administration [13]. CC seems to display both selective agonist and antagonist activity at the gonadotrope level and on gonadotropin- releasing hormone self-priming of LH secretion. Despite the widespread acceptance of CC as a therapeutic agent for ovulation induction, its effects on other estrogen-dependent pathways, particularly on neural circuits regulating brain function and peripheral hormone secretion, are poorly understood. Figure 2. Serum levels of follicle-stimulating hormone (FSH) and estradiol (E2) before and during treatment with clomiphene citrate (CC). Values are means, with standard deviation shown by vertical bars. Mean values were significantly different: *p

Table II. Hormonal parameters of the patients (n = 8).

This is the first study to provide additional information on gonadotropin response after a 10-day, step-up, CC administration protocol in patients with functional amenorrhea. After the first cycle of CC administration six patients resumed spontaneous menstrual cycles and all subjects had a significant rise in LH secretion after the second cycle of treatment, suggesting the resumption of ovulation. All subjects continued to have spontaneous menstrual cycles 6 months after beginning the treatment. A normal response to CC in amenorrheic patients with functional amenorrhea offers reassurance that the HPO axis is intact and that the problem lies in the hypothalamus. It is reasonable to believe that nutritional disturbances, food intake and persisting psychological factors still affect reproductive function in patients with amenorrhea [14].

Psychological factors in addition to nutritional status contribute to the prolonged amenorrhea in anorexia nervosa, and CC appears to have only a limited role in the treatment and management of patients with the disorder [9]. Administration of exogenous estrogen/progestin combinations to women with functional hypothalamic amenorrhea does not appear to result in increased bone density in this severely undernourished state [15,16], showing the importance of endogenous gonadal function in the preservation of bone mass in these subjects.

The administration of CC was shown to be more efficacious than placebo for ovulation induction in patients with functional hypothalamic amenorrhea and patients with amenorrhea of less than 1 year responded better to CC than patients with prolonged amenorrhea, with noted high serum FSH and LH levels [17,18]. CC acts as an estrogen antagonist on the neural circuits controlling the neuroendocrine regulation of the HPO axis [19]. The gonadotropic response cannot be explained only by the classic antagonist effect, but we can predict that the step-up protocol of CC administration could have sensitized the HPO axis, permitting the resumption of menses. Even though the sample size in this study is limited and the population heterogeneous, the present results offer new insights for future investigation in a larger group of women affected by hypothalamic amenorrhea, a condition which is becoming very common but has poor therapeutic efficacy.

References

1. Genazzani AD. Neuroendocrine aspects of amenorrhea related to stress. Pediatr Endocrinol Rev 2005;2:661-668.

2. Warren MP, Hagey AR. The genetics, diagnosis and treatment of amenorrhea. Minerva Ginecol 2004;56:437-455.

3. Munoz MT, Argente J. Anorexia nervosa in female adolescents: endocrine and bone mineral density disturbances. Eur J Endocrinol 2002;147:275-276.

4. Berga SL, Loucks TL. The diagnosis and treatment of stress- induced anovulation. Minerva Ginecol 2005;57:45-54.

5. Seidenfeld MEK, Rickert VI. Impact of anorexia, bulimia and obesity on the gynecologic health of adolescents. Am Fam Physician 2001;64:445-450.

6. Van Santbrink EJ, Eijkemans MJ, Laven JS, Fauser BC. Patient- tailored conventional ovulation induction algorithms in anovulatory infertility. Trends Endocrinol Metab 2005; 16: 381-389.

7. Fiad TM, Smith TP, Cunningham SK, McKenna TJ. Decline in insulin-like growth factor I levels after clomiphene citrate does not correct hyperandrogenemia in polycystic ovary syndrome. J Clin Endocrinol Metabol 1998;83:2394-2398.

8. Rowe TC, Pride SM. The action of clomiphene in stress-induced amenorrhea. AmJ Obstet Gynecol 1984;148:613-616.

9. Wakeling A, Marshall JC, Beardwood CJ, Souza VF, Russell GF. The effects of clomiphene citrate on the hypothalamic-pituitary- gonadal axis in anorexia nervosa. Fertil Steril 1995;63:1200-1203.

10. Genazzani AD, Petraglia F, Fabbri G, Monzani A, Montanini V, Genazzani AR. Evidence of luteinizing hormone secretion in hypothalamic amenorrhea associated with weight loss. Fertil Steril 1990;54:222-226.

1 1. Genazzani AD, Petraglia F, Benatti R, Montanini V, Algeri I, Volpe A, Genazzani AR. Luteinizing hormone (LH) secretory burst duration is independent from LH, prolactin, or gonadal steroid plasma levels in amenorrheic women. J Clin Endocrinol Metabol 1991;72:1220-1225.

12. Practice Committee of the American Society for Reproductive Medicine. Current evaluation of amenorrhea. Fertil Steril 2004;82(Suppl 1):S33-S39.

13. Sanchez-Criado JE, Guelmes P, Bellido C, Gonzalez M, Hernandez G, Aguilar R, Garrido-Gracia JC, Bello AR, Alonso R. Tamoxifen but not other selective estrogen receptor modulators antagonizes estrogen actions on luteinizing hormone secretion while inducing gonadotropin-releasing hormone self-priming in the rat. Neuroendocrinology 2002;76: 203-213.

14. Djurovic M, Pekic S, Petakov M, Damjanovic S, Doknic M, Dieguez C, Casanueva FF, Popovic V. Gonadotropin response to clomiphene and plasma leptin levels in weight recovered but amenorrhoeic patients with anorexia nervosa. J Endocrinol Invest 2004;27:523-527.

15. Klibanski A, Biller BM, Schoenfeld DA, Herzog DB, Saxe VC. The effects of estrogen administration on trabecular bone loss in young women with anorexia nervosa. J Clin Endocrinol Metab 1995;80:898-904.

16. Grinspoon S, Thomas L, Miller K, Herzog D, Klibanski A. Effects of recombinant human IGF-I and oral contraceptive administration on bone density in anorexia nervosa. J Clin Endocrinol Metab 2002;87:2883-2891.

17. Armeanu MC, Moss RJ, Schoemaker J. Ovulation induction with a single-blind treatment regimen comparing naltrexone, placebo and clomiphene citrate in women with secondary amenorrhea. Acta Endocrinol (Copenh) 1992;126:410-415.

18. Yaginuma T. Progress and therapy of stress amenorrhea. Reprod Biomed 2002;4:303-310.

19. Wilson ME, Mook D, Graves F, Feiger J, Bielsky IF, Wallen K. Tamoxifen is an estrogen antagonist on gonadotropin secretion and responsiveness of the hypothalamic-piruitary-adrenal axis in female monkeys. Endocrine 2003;22:305-315.

LAVINIA ESTRELA BORGES, GIUSEPPE MORGANTE, MARIA CONCETTA MUSACCHIO, FELICE PETRAGUA, & VINCENZO DE LEO

Section of Obstetrics and Gynecology, Department of Pediatrics, Obstetrics and Reproductive Medicine, University of Siena,

Siena, Italy

(Received 28 December 2006; revised 28 February 2007; accepted 5 March 2007)

Correspondence: V. De Leo, Chair of Obstetrics and Gynecology, University of Siena, Policlinico ‘Santa Maria alle Scotte’, Viale Bracci, 1-53100 Siena, Italy. Tel: 39 0577 233 465. Fax: 39 0577 233 464. E-mail: deleotaunisi.it

Copyright Taylor & Francis Ltd. Jun 2007

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

CMA Head Says Canada’s Health-Care System in Crisis, Needs Change

By CAMILLE BAINS

VANCOUVER (CP) – The incoming president of the Canadian Medical Association says the country’s public health-care system is headed for crisis, but a greater role for private health care could be the right prescription.

Dr. Brian Day said in his inaugural speech to Canada’s medical establishment Wednesday that contracting out health services isn’t new and has helped slash wait lists.

“Let’s be clear: Canadians should have the right to private medical insurance when timely access is not available in the public system,” he said to applause from about 270 delegates at the annual convention.

Day, a Vancouver orthopedic surgeon, said the Supreme Court of Canada has already made a decision favouring such a move.

The Chaouilli case, named after the Quebec doctor who initiated it, struck down Quebec’s ban on private insurance in 1995, saying it contradicted the provincial charter of rights.

Day said injured workers in some provinces are treated in private facilities, saving workers’ compensation boards millions of dollars in wages and keeping people off long wait lists.

Day, who opened Canada’s first private surgery clinic in 1995, has often been criticized for his pro-privatization views that some say could pave the way for a for-profit system much like in the United States.

“No one I know wants to adopt a so-called American-style health system,” he told delegates at the association that represents 65,000 doctors across Canada.

He said the private-versus-public debate is largely irrelevant and counterproductive but that new ideas and concepts are bound to face opposition and skepticism.

The status quo must change, Day said, because the declining health of the country’s aging population will have a profound social and economic impact on Canada’s future.

“Canadians face difficult choices, but we must act. We and our patients remain frustrated by waiting periods that exceed all ethical standards.”

But while he advocated more choice in the private sector, Day said the ability to pay should never be a factor for any patient needing health care in Canada.

He called for the modernization of the Canada Health Act, saying it’s based on principles developed over 40 years ago and no longer meets the needs of today’s population.

“My support for universal health care is unequivocal, but I believe the act must be revised.”

Day also said provinces must change the way hospitals are funded because they suck the largest amount of money out of the health-care budget.

The current system of block, or global, funding doesn’t reward efficiencies or penalize failure to deliver service to patients, Day said.

“Hospitals must have incentives to reopen operating rooms, increase the number of beds available, hire more staff and treat more patients.”

Day is an advocate of the British system of funding hospitals, which compete with each other for public money based on the number of procedures they perform as an incentive to cut that country’s wait lists.

He said the market-oriented scheme has some problems but that Canada could adapt what’s working in Britain and other countries that have universal health care as part of their health-care system.

“There are those that dismiss these concepts of success and excellence as elitist or undesirable. They support the status quo and dismiss the plight and suffering of patients.”

Guy Caron, spokesman for the Council of Canadians, said that while Canada has a problem with wait lists, it’s too simplistic to say models from other countries can be applied here.

Caron said Britain and France, which each have a mixed public-private health-care system, have hired more doctors to cut wait lists.

“In the UK and in New Zealand they tried to bring market components to health care and it failed so they are actually reforming the system right now to bring more public (services) into the system.”

Day said Canada’s shortage of doctors and other health-care professionals is at a crisis point and that medical graduates leave the country every year because they don’t have the operating-room time and other resources they need to stay here.

Day also called for the use of technology, such as electronic medical records, in the health-care field to deliver safe, efficient care.

“We are in the information age and medicine needs to catch up,” he said. “Sadly, our access to new and valuable technologies is at a point where we rank near the bottom of developed countries. This must change.”

Before Day’s speech, delegates voted overwhelmingly in favour of several motions, with 99 per cent of them calling on provincial and territorial governments to implement strategies that would reduce emergency-room wait times and overcrowding.

Dr. Shelley Ross, a Burnaby, B.C., family doctor, said patients are waiting too long to be assessed and that the use of the acronym DIC, which stands for Died In Chair, indicates people are waiting too long to be assessed.

Many of the motions passed Wednesday urged the federal government to support environmental policies to protect the public’s health by implementing various measures.

They include improving the quality of the air people breathe – both inside and outside – ensuring access to adequate and safe drinking water, minimizing the effects of global climate change and banning smoking in vehicles that carry children.

Dr. Brad Fritz of Vancouver said half a million people living on about 600 reserves don’t have the same assurances as other Canadians that their drinking water is safe to drink.

Ninety-six per cent of the doctors also voted to pass a motion saying their association will develop a policy to safeguard physicians from fear of reprisal and retaliation when they speak out as advocates for their patients and communities.

And 93 per cent of them favoured a move by their association to let the federal government know that federal wait-list strategies have failed to provide Canadians with timely access to quality medical care.

One doctor called the government’s national wait-times strategy a charade and “a slap in the face of intelligent Canadians” because it targets areas that are already showing improvement.

Delegates also voted 98 per cent in favour of urging the federal government to promptly address the high cost of generic and off-patent drugs in Canada.

The Fertility and Reproductive Health Institute IVF Laboratory at Fertility Physicians of Northern California Receives Reproductive Accreditation

SAN JOSE, Calif., Aug. 22 /PRNewswire/ — The Fertility & Reproductive Health Institute In Vitro Fertilization (IVF) Laboratory at Fertility Physicians of Northern California in San Jose, CA (FPNC) has been awarded an accreditation by the Commission on Laboratory Accreditation of the College of American Pathologists (CAP), based on the results of a recent on-site inspection. For the third time in a row, the rigorous CAP inspection resulted in zero deficiencies indicating that the laboratory is one of an exclusive group of reproductive laboratories around the country that meet the accreditation standards with excellence.

(Logo: http://www.newscom.com/cgi-bin/prnh/20070822/AQW046LOGO)

“An outstanding lab is critical to a successful IVF program and programs such as ours in the fertility arena demand that every procedure is performed with the highest standards,” said Dr. Marina Gvakharia, director of Laboratory Services at the Fertility and Reproductive Health Institute IVF Laboratory. “This accreditation is also a testament to our cutting-edge lab enabling us to bring assisted reproductive technologies to our patients using the latest technology.” Dr. David Adamson, Director of FPNC, added “We are proud to earn this distinction, which is consistent with our efforts to provide our patients the highest quality personal service with the most sophisticated technology.”

During the CAP accreditation process, inspectors examine the laboratory’s records and quality control procedures and assess adherence to the highest standards set for the industry by the American Society of Reproductive Medicine (ASRM) and CAP for the preceding two years. CAP inspectors also examine the entire staff’s qualifications, the laboratory’s equipment, facilities, safety program and record, as well as the overall management of the laboratory. This stringent inspection program is designed to specifically ensure the highest standard of care for the laboratory’s patients.

The CAP is a medical society serving nearly 16,000 physician members and the laboratory community throughout the world. It is the world’s largest association composed exclusively of pathologists and is widely considered the leader in laboratory quality assurance. The CAP is an advocate for high-quality and cost-effective medical care.

About The Fertility and Reproductive Health Institute of Northern California

The Fertility and Reproductive Health Institute of Northern California (FRHI) is a state of the art facility that offers patients a full range of reproductive laboratory services, including in vitro fertilization, intracytoplasmic sperm injection, laser assisted hatching, preimplantation genetic diagnosis, and cryopreservation of embryos, sperm and eggs.

For more information, please visit: http://www.fpnc.com/team/embryologist.html

About Fertility Physicians of Northern California

Founded in 1984, Fertility Physicians of Northern California (FPNC) offers the full range of medical solutions patients need to start a family, from simple drug therapy to advanced procedures such as in vitro fertilization and pre-implantation genetic diagnosis.

From private offices in San Jose and Palo Alto (CA) they have helped thousands of people become parents. FPNC services include the highest levels of patient care, emotional support and educational programs to assist patients throughout their treatment.

FPNC physicians are board certified specialists in reproductive endocrinology, infertility and reproductive surgery, providing the most advanced training and education in the treatment of infertility, endometriosis, miscarriage and other reproductive disorders. The clinical, nursing and laboratory staff is also composed of highly trained experts.

For more information, please visit: http://www.fpnc.com/

Photo: http://www.newscom.com/cgi-bin/prnh/20070822/AQW046LOGOPRN Photo Desk, [email protected]

Fertility Physicians of Northern California

CONTACT: Shannon Hare of Fertility Physicians of Northern California,+1-408-907-0937, [email protected]

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

American Diabetes Association Names Laurence Hausner CEO

ALEXANDRIA, Va., Aug. 22 /PRNewswire-USNewswire/ — The American Diabetes Association, the nation’s premier voluntary health organization dedicated to conquering diabetes and supporting those who live with it, today named Laurence Hausner Chief Executive Officer, effective October 8, 2007.

Hausner comes to the ADA from The Leukemia & Lymphoma Society, where he served in various capacities as General Manager, Organizational Development; Chief Strategic Development Officer and Chief Operating Officer. Hausner succeeds Michael D. Farley, CFRE, ADA’s Chief Community & Corporate Relations Officer, who has led the organization as Interim CEO since January 2007. Farley will return to his role as Chief Community & Corporate Relations Officer.

Hausner joined The Leukemia & Lymphoma Society in 2003. The Leukemia & Lymphoma Society is the world’s largest voluntary health organization dedicated to funding blood cancer research, education and patient services. As Chief Operating Officer, Hausner had oversight and management of all of the Society’s operations, including revenue generation, finance, information technology, patient services, public policy, marketing, human resources and field management. His responsibility included management of 66 chapters in the US and Canada, with 1,250 employees and more than 50,000 volunteers.

At Leukemia & Lymphoma, and in his previous roles, Hausner has consistently led significant growth and has implemented successful national branding programs. Revenues for The Leukemia & Lymphoma Society grew under his leadership from $165 million to more than $270 million. Hausner recently partnered with the Board of Directors to develop The Leukemia & Lymphoma Society’s 2008-2011 strategic direction. The plans include a strong recognition of the role of volunteers in the achievement of the overall strategic goals of the organization.

“I am honored and excited to be joining ADA at this critical juncture in its history. Throughout my career at The National Multiple Sclerosis and The Leukemia & Lymphoma Societies, I have worked to bring focus to the needs of people affected by heartbreaking diseases and have worked with volunteers, staff and strategic allies to move a mission forward by increasing awareness, passion and financial growth,” Hausner said. “The American Diabetes Association is already the gold standard in serving the needs of people affected by diabetes, and I believe we have a tremendous opportunity to catapult the success of this organization to even greater heights. The need to educate the public and raise the awareness of diabetes and its seriousness are paramount at this time, and I look forward to engaging in that worthy effort with this great organization.”

Darlene L. Cain, American Diabetes Association Chair of the Board, said, “Larry Hausner joins the American Diabetes Association at a time when the prevalence of this devastating disease is growing and affecting the health and economy of the nation at an alarming rate. Larry brings to ADA an impressive track record of success in leading major voluntary health agencies that also address devastating diseases. We are thrilled he is joining us at a time when ADA is more committed than ever to outpacing and ultimately conquering diabetes.”

Hausner brings experience from the for-profit and nonprofit sectors to his new role. He began his career in financial services and product marketing for several large U.S. corporations. In 1986, he moved to the nonprofit sector when he joined the National Multiple Sclerosis Society, and has been serving the needs of others since that time. At the National Multiple Sclerosis Society, he moved quickly through the organization to become Vice President, Marketing, and was soon tapped to manage the operations of the organization, ultimately becoming Chief of Staff.

Hausner and his family will be relocating to the Washington, D.C. metro area from New York. He earned a B.S. in Marketing and an MBA in Marketing Management, both from the University of Rhode Island.

The American Diabetes Association is the nation’s premier voluntary health organization supporting diabetes research, information and advocacy. The Association’s mission is to prevent and cure diabetes and to improve the lives of all people affected by diabetes. Founded in 1940, the Association provides services to hundreds of communities across the country. For more information about the Association, please visit http://www.diabetes.org/ or call 1-800-DIABETES (1-800-342-2383). Information from both these sources is available in English and in Spanish.

American Diabetes Association

CONTACT: Helen L. Mitternight of the American Diabetes Association,+1-703-549-1500 ext. 2006, [email protected]

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

Want a Free Healthy Vending Machine?

SAN JOSE, Calif., Aug. 22 /PRNewswire/ — Healthy snacks and beverages now have a surprising new place to call home — the vending machine. YoNaturals Inc., with national headquarters in Solana Beach, California, is pleased to announce the arrival of its “YoZone” healthy vending machine which offers only all-natural and organic snacks and beverages. The innovative YoZone vending machines offer a healthier alternative to the junk food vending machines.

YoNaturals is rapidly expanding their nationwide network of healthy vending machines and it has now arrived in the San Jose/East Bay area. YoNaturals is actively seeking area locations such as schools, shopping centers, corporate offices, hospitals, and fitness centers that are interested in offering healthier options in their vending machines. Each YoZone vending machine is set-up and monitored by a local area distributor at no expense to the location.

“With our success in other markets across the country, the timing couldn’t be better for San Jose/East Bay area,” says Mark Trotter, CEO of YoNaturals. “These machines create and encourage a healthy environment that everyone can thrive on.”

The YoZone vending machines feature custom-design food menus that will cater to the specific needs of a location. Students will be able to have items such as organic milk and granola bars readily available in schools, whereas health clubs can be stocked with protein bars and organic energy drinks. In fact, YoNaturals offers over 150 healthy products such as Vitamin Water, Clif Bars, Function Drinks, Fiji Water, Pirates Booty, Stacy’s Pita Chips, Tazo Iced Tea and much more. Each YoZone machine displays customized graphics to match various location types, giving them a colorful and fresh feeling, much different from the dark and bleak look of traditional vending machines.

YoNaturals high-tech and innovative machines have made vending your favorite healthy snack a breeze with its unique credit and debit card payment option. State-of-the-art remote monitoring technology (wireless) ensures that YoZone machines are always stocked with an array of tasty and nutritious items. YoNaturals operators can oversee machine activity through a 24/7 on-line reporting system that notifies if a YoZone needs to be refilled or requires maintenance.

“People need a healthy alternative because they are too susceptible to the allure of fast food and junk food marketing. Too many calories and too much of the ‘wrong foods’ are the cause of many obesity-related diseases such as diabetes and heart disease,” says Trotter.

According to a 2006 report by the California Department of Health Sciences (CDHS), California residents have gained 360 million pounds in excess weight in the past ten years, a rate that is among the fastest in the country. The study also reports that a third of children, one in four teens, and over half of all adults in California are already overweight or obese. The California Obesity Prevention Plan produced by CDHS and backed by Governor Arnold Schwarzenegger, states that a principal factor in the obesity epidemic is that many individuals make food choices based on convenience and price. Unfortunately, Californians are exposed to an overabundance of cheap, low-nutrient, high calorie food, and have limited access to affordable, healthy foods.

YoNaturals believes the vending machine industry, which is not regulated by the USDA, is partially to blame for the rising obesity rates. YoNaturals healthy vending machines ensure that healthy snacks and beverages are always an arms length away. YoNaturals is a pioneer in the national effort to clean up vending machines and wants other to join them on their crusade to be at the forefront of the health revolution.

“There is no cost for a location to have a healthy vending machine installed. All one has to do to sign up to receive a machine is to visit http://www.yonaturals.com/, fill out our ‘Become a Location’ form, and they will be contacted immediately by YoNaturals,” says Trotter.

YoNaturals adds a healthy element to the popularity and convenience of vending machines with its nutritious snacks and beverages. The arrival of the YoZone vending machines promotes the message that healthy lifestyles are more achievable than ever. YoNaturals is convinced that finally vending machines can be associated with a leading movement in consumer health and wellness.

MORE ABOUT YONATURALS

YoNaturals offers a “one stop” solution to healthier vending including machine distribution, installation, training and complete food distribution of leading natural and organic brands. YoNaturals is also actively seeking San Jose/East Bay area locations for their healthy vending machines in schools, colleges, universities, corporate offices, health clubs, hospitals, malls and large retailers.

To have a healthy vending machine in your location call YoNaturals (http://www.yonaturals.com/) at (858) 794-9955 or email [email protected].

YoNaturals Inc.

CONTACT: Annalisa Harmon, Media Relations Officer, +1-858-794-9955

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

WXYZ-TV/Channel 7 Is ‘On Your Side’ With Healthy Living for Kids; Free Immunizations for Children on Sunday, August 26 at Charles H. Wright Museum of African American History

SOUTHFIELD, Mich., Aug. 21 /PRNewswire/ — WXYZ- TV/Channel 7, Detroit Department of Health and Wellness Promotion, Henry Ford Health System: Department of Pediatrics and Gardener White Furniture will give thousands of Detroit metro area children a “boost” at the 30th annual “HEALTHY LIVING FOR KIDS” program. This year the program will be held Sunday, August 26, 2007 from 10 a.m. to 5 p.m. at the Charles H. Wright Museum of African American History. Since its inception in 1977, “Healthy Living for Kids” has provided free immunizations to over 50,000 young people.

Eligible children three months and older will be given free immunizations against polio, rubella, measles, mumps, tetanus, varicella (chicken pox), diphtheria, pertussis (whooping cough), HPV (Human Papillomavirus), Hepatitis B and Hib (Haemophilus influenza type B). New this is year is the HPV (Human Papillomavirus) vaccine to prevent cervical cancer. Registered nurses from the Detroit Department of Health and Wellness Promotion will administer the shots with the assistance of over 150 volunteers from the Health Department and WXYZ-TV/Channel 7.

This year inside the popular “Children’s Village,” a variety of health services, community outreach organizations and entertainment will be offered. The first 200 children present will receive a bicycle helmet on behalf of the Wayne County Sheriff’s Department. Also on site will be State Farm Insurance, where kids will be able to practice 911 phone calls to be well prepared in case of an emergency. In addition, parents will be able to obtain Child ID kits from AAA of Michigan as well as receive pertinent information from Children’s Hospital.

Additional services provided include free lead poison testing, signups for the WIC (Women, Infant and Children’s) feeding program and enrollment for a wide variety of youth mentoring programs.

WXYZ-TV/Channel 7 Action News on-air personalities will be present to sign autographs and greet the children and their families. Helium balloons and “KidZone” magazines will be provided to all “Healthy Living” participants courtesy of WXYZ-TV/ Channel 7 along with a host of other giveaways including, back-to-school shopping coupons, books, sun visors, coloring books, cookies, book bags, toothbrushes and much more! WJLB-FM will provide entertainment with live radio remotes, a personality appearance, and giveaways. Chicken wings and free pizza will be provided by Pizza Hut and Little Caesars. The Kroger Co. will provide bottled water and Pars Ice Cream Company will distribute ice cream.

“Healthy Living For Kids” is a signature community service event for WXYZ- TV/Channel 7 and is a key initiative of the station’s ‘7 On Your Side’ brand. Grace Gilchrist, WXYZ-TV Vice President and General Manager, said, ” ‘Healthy Living For Kids’ is a shining example of how community service projects can make a real difference in the lives of metro Detroit families.”

The Charles H. Wright Museum of African American History is located in the heart of Detroit’s Cultural Center, at 315 East Warren Avenue. Free parking is available courtesy of Detroit Institute of Arts. Information regarding the immunization fair and specifics on immunizations is available through the Healthy Living For Kids Hotline, 1-888-630-1694 or online at http://www.wxyz.com/.

The E.W. Scripps Company is a diverse and growing media enterprise with interests in national cable networks, newspaper publishing, broadcast television stations, electronic commerce, interactive media, and licensing and syndication.

The company’s portfolio of media properties includes: Scripps Networks, with such brands as HGTV, Food Network, DIY Network, Fine Living, Great American Country and HGTVPro; daily and community newspapers in 17 markets and the Washington-based Scripps Media Center, home to the Scripps Howard News Service; 10 broadcast TV stations, including six ABC-affiliated stations, three NBC affiliates and one independent; Scripps Interactive Media, including a leading online search and comparison shopping services, Shopzilla and uSwitch; and United Media, a leading worldwide licensing and syndication company that is the home of PEANUTS, DILBERT and approximately 150 other features and comics.

WXYZ-TV

CONTACT: Christina Hardy of WXYZ-TV, +1-248-827-9302

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

World Renowned Eating Disorder Treatment Center, Remuda Programs for Eating Disorders, Opens New Facility in Virginia

PHOENIX, Aug. 21 /PRNewswire/ — Remuda Programs for Eating Disorders (http://www.remudaranch.com/), the nation’s leading and largest inpatient treatment center for women and girls suffering from eating disorders, today announced its opening of a new treatment center near Bowling Green, Va. The 48-bed facility, located on 500 secluded acres, offers intensive, inpatient programs for women, adolescents and children with eating disorders. The new center employs 120 professional and support staff.

“We’re very excited to bring our state-of-the-art eating disorder treatment program and experts to the east coast,” said Ward Keller, president and founder of Remuda Programs for Eating Disorders. “Since we first opened our doors in Arizona in 1990, we’ve treated more than 7,500 patients with eating disorders. We look forward to continuing to help those in need.”

Remuda’s scientifically valid outcome studies show that 95 percent of former patients no longer having a diagnosable eating disorder one year after completing its program. These recovery rates are the highest in the nation. The center’s program and settings are different from the traditional, institutional format offered at hospitals and clinics. Remuda’s Christian-based programs offer a balanced, multi-disciplinary team approach that is designed to treat the whole person and meet her unique medical, nutritional, psychological, and spiritual needs.

“Because our program includes equine, art and challenge course therapy, Caroline County is a perfect environment for our program,” adds Keller. “It’s very healing, secluded and peaceful.”

A formal ribbon-cutting ceremony will be held at 4 p.m. on Tuesday, August 28 at the new site. Remuda will also host a special “open house” for media, health professionals, and members of the community that day from 11 a.m. to 7 p.m.

To schedule an interview with one of Remuda’s experts on eating disorders and related issues, or to attend the open house, please contact Mary Anne Morrow at 602-332-9026.

About Remuda Programs for Eating Disorders

Remuda Programs for Eating Disorders offers Christian inpatient and residential treatment for women and girls of all faiths suffering from an eating disorder. Each patient is treated by a multi-disciplinary team including a Psychiatric and a Primary Care Provider, Registered Dietitian, Masters Level therapist, Psychologist and Registered Nurse. The professional staff equips each patient with the right tools to live a healthy, productive life. For more information, call 1-800-445-1900 or visit http://www.remudaranch.com/.

Remuda Programs for Eating Disorders

CONTACT: Mary Anne Morrow, +1-602-332-9026, [email protected],for Remuda Programs for Eating Disorders

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

Parents Abuse Infant: Putnam Couple Get Jail After Baby Suffers Fractured Bones

By Brian Evans, The Lima News, Ohio

Aug. 21–OTTAWA — Sometimes, little infant “Jane Doe” cried for 24 to 48 hours and when her parents tried to move her or pick her up, she screamed violently for hours.

Physicians later discovered the 3-month-old girl suffered 10 fractures to bones throughout her body.

The Putnam County Prosecutor’s Office last week concluded what many consider one of the worst infant-abuse cases in the county in recent years.

Heather Hitchcock, 20, of Continental, was sentenced in Putnam County Common Pleas Court on Friday to three years in prison for her involvement in the abuse of her daughter.

Assistant Prosecutor Todd Schroeder said the girl’s father, Brian Earles Jr., 22, of Continental, was previously sentenced to four years in prison. Prosecutors said Earles was largely responsible for inflicting the injuries.

Schroeder said the couple were convicted for child endangering, a felony of the third degree. Court records refer to the girl as “Jane Doe” and officials refused to release her name. She is in foster care in the area, where she has not suffered any additional fractures.

Schroeder said the couple lived together at their parents’ houses in Continental. The girl was born April 26, 2006, and abuse was first discovered Aug. 9, 2006.

Hitchcock told prosecutors she found the girl crying loudly at about 7 a.m. that day and her arm was swelling. By noon, the girl was still crying, at times screaming, her arm was worse and Hitchcock’s mother advised them to take the girl to the hospital.

Schroeder said the mother took the girl to a local ambulatory care center at 6 p.m., and from there she was sent to St. Rita’s Medical Center in Lima.

Physicians at St. Rita’s found the girl had a bone fracture in her upper arm. The X-ray also revealed two additional fractures in her right forearm, both in healing stages.

From there, the girl was flown by helicopter to St. Vincent Mercy Medical Center in Toledo where she underwent emergency surgery to save her arm. Her parents, Schroeder said, stayed behind.

The surgery went well, Schroeder said, however physicians at St. Vincent’s suspected child abuse and ordered a full body scan.

The scan revealed seven additional fractures — in her ribs, legs, arms and collarbone — in different stages of healing.

Physicians said the girl was healthy and had no medical conditions that would make her susceptible to such injuries.

The girl was immediately removed from the parents’ custody and they were charged. Prosecutors said both parents were unemployed and addicted to a narcotic pain medication.

“Both parents denied responsibility and knowledge,” Schroeder said. “Ultimately, the mother admitted the father shook the child violently over a long period of time because she was crying. When he shook her, it went from crying to screaming violently. … My hope is, if anyone experiences or witnesses a similar situation, with another family, they’ll take immediate steps to report it, to prevent something like this from happening again.”

You can comment on this story at www.limaohio.com.

—–

To see more of The Lima News or to subscribe to the newspaper, go to http://www.limanews.com.

Copyright (c) 2007, The Lima News, Ohio

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.

Rock River Valley Blood Center Contracts for Talisman’s Quality Donor System

VIENNA, Va., Aug. 21 /PRNewswire/ — Talisman Ltd., the biomedical research group and developer of the Quality Donor System (TM) (QDS) is pleased to announce that Rock River Valley Blood Center in Rockford, IL has implemented QDS, and will be implementing over the next year Internet QDS (iQDS) and the Talisman Phlebotomy System (TM) (TPS).

Rock River Valley Blood Center (RRVBC) was founded in 1952 by the Winnebago County Medical Society. It is a not-for-profit organization headquartered in Rockford IL that employs over 100 staff and collects more than 40,000 donations per year. RRVBC supplies blood and blood components to 8 area hospitals in Northern Illinois, and Southern Wisconsin and is accredited by the AABB and a member of America’s Blood Centers.

QDS automates the gap between donor registration and the processing and testing of blood. It utilizes state-of-the-art audiovisual touch screen computer assisted donor self interviewing with the AABB Uniform Donor History Questionnaire and provides staff review with AABB and custom materials. QDS includes standardized but modifiable staff comments, vital signs data and donor and staff signature capture. iQDS allows blood donors to respond to the health history questions online in the privacy and convenience of their home or office. TPS is operated by phlebotomists using wireless hand-held computers to capture vital blood draw information such as start and stop times.

QDS is available in English and Spanish. The system runs in network and standalone modes, can export data, requires only a US Food & Drug Administration CBE-30 notification and no donor training, necessitates only two to three hours of staff training, and can be updated by Talisman with new FDA required questions in less than one week.

Six community blood centers and two medical centers with blood programs currently use QDS. To date, these centers have successfully completed more than 1,250,000 donor self-interviews using QDS. Earlier versions of the Talisman system have been scientifically proven to reduce FDA reportable errors by over 60%, improve reporting of risky donor behavior by a factor of 9, reduce staff time by 5 minutes per donor and vastly increase donor and staff satisfaction. The version of QDS currently being installed is expected to reduce FDA reportable errors by over 90%. The most recently FDA 510(k) cleared version of QDS is expected to reduce errors still further and improve donor and sponsor satisfaction through use of the Internet interview.

Talisman Limited specializes in development of software systems that automate interviewing and thereby reduces or eliminates human errors in healthcare operations. Over the last 10 years the company has pioneered the use of automated donor health history screening for blood centers, with much of its recent product development and scientific research funded by National Heart Lung Blood Institute (NHLBI) Small Business Innovation Research (SBIR) grants titled “Paperless Quality Donor System(TM) with Decision Making” (HL072635). Additional information is available at http://www.talismanlimited.com/ .

Talisman Ltd.

CONTACT: Paul D. Cumming, Ph.D., of Talisman Ltd., +1-703-938-0300,[email protected]

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

Luby’s Opens New Dining Facility at Baylor College of Medicine

HOUSTON, Aug. 20 /PRNewswire-FirstCall/ — Luby’s, Inc. today announced that it has entered into a multi-year agreement with Baylor College of Medicine to provide culinary services for its Texas Medical Center campus in Houston. Luby’s worked closely with Baylor on the development and design of their new kitchen and dining facility that opened August 13, 2007.

“We are excited about this partnership and look forward to providing quality food and service to Baylor. Our culinary services initiative continues to gain traction as we work to provide food services for healthcare facilities,” said Chris Pappas, President and CEO. “In addition to the Baylor College of Medicine contract, we operate six dining facilities in long-term acute facilities and soon we will be announcing additional partnerships with acute care hospitals.

“Providing culinary services at hospital facilities is a natural extension of our business and utilizes our unique restaurant skill set for cafeteria style dining as well as short order food service for customer care room delivery. This growth business presents several opportunities which include contracting our services for a negotiated time period and a management fee. We are committed to this long term initiative and look forward to working with the Baylor College of Medicine facility,” said Mr. Pappas.

Baylor College of Medicine

Located in Houston, Texas at the Texas Medical Center, a 1,000-acre complex housing 46 member institutions, Baylor College of Medicine (BCM) has affiliations with eight teaching hospitals, each with a national and international reputation for medical excellence. In 2007, U.S. News & World Report ranked the college 10th overall among the nation’s top medical schools for research and 11th for primary care.

About Luby’s

Luby’s operates 128 restaurants in Austin, Dallas, Houston, San Antonio, the Rio Grande Valley and other locations throughout Texas and other states. Luby’s provides its customers with quality home-style food, value pricing, and outstanding customer service.

The company wishes to caution readers that various factors could cause its actual financial and operational results to differ materially from those indicated by forward-looking statements made from time to time in news releases, reports, proxy statements, registration statements, and other written communications, as well as oral statements made from time to time by representatives of the company. Except for historical information, matters discussed in such oral and written communications are forward-looking statements that involve risks and uncertainties, including but not limited to general business conditions, the impact of competition, the success of operating initiatives, changes in the cost and supply of food and labor, the seasonality of the company’s business, taxes, inflation, governmental regulations, and the availability of credit, as well as other risks and uncertainties disclosed in periodic reports on Form 10-K and Form 10-Q.

Contact: Rick Black, 713-329-6808

Luby’s, Inc.

CONTACT: Rick Black, +1-713-329-6808, for Luby’s, Inc.

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

How Well is the Bus System Working?

By Steve Harrison, The Charlotte Observer, N.C.

Aug. 19–How well is the bus system working?

–Opponents of light rail have rallied enough support to force a Nov. 6 vote on repealing the transit tax. Trains are a popular target, but the tax mostly pays for a beefed-up network of buses.

Steve Harrison

Voters deciding whether to repeal Mecklenburg’s half-cent transit tax often focus on light rail. But 65 percent of the money raised from the tax goes to fund the city’s bus system, which has grown significantly since voters approved the tax in 1998.

Charlotte Mayor Pat McCrory, a transit tax supporter, touts the success of buses and says the system faces deep cuts if the tax is repealed.

So what kind of bus system has the Charlotte Area Transit System built?

By one measure, the CATS expansion has been a success. Ridership is up 66 percent, or nearly 8 million new passenger trips, since 1998. Few transit systems nationwide can boast of such gains.

But growth has been costly. The bus system has become less efficient, and its operating budget, adjusted for inflation, has increased 170 percent since the tax was approved. One transit expert warns that if cost increases don’t slow, CATS risks operating a service that isn’t financially viable.

“You can’t have a cost structure that’s outgrowing your revenue structure,” said Steven Polzine of the Center for Urban Transportation Research at the University of South Florida.

CATS chief executive Ron Tober, who last week announced plans to retire Dec. 21, agrees the bus system has grown less efficient but called it an expected outcome of rapid growth.

“We put a lot of service out there. We put a lot of product on the street,” Tober said. “We are growing at a slower rate now, and we expect to see our performance improve.”

The Nov. 6 referendum will determine what kind of bus system Charlotte will have.

The system now is designed to serve riders without cars, but also to court the so-called “choice riders” — those who might be persuaded to leave their cars at home, often in the suburbs.

Brian Carreira, a recent bus convert, is typical of the “choice rider” CATS is pursuing.

His trip uptown on Route 62X from south Charlotte takes longer than driving, but he saves on gas and avoids parking costs at the BB&T building, where he works in commercial lending.

“I’ll talk to people on the bus who save between $1,800 and $2,400 a year,” said Carreira of Ballantyne, who uses a $70 monthly bus pass for express trips. That’s about $1.60 for a one-way trip.

Tober said he’s now getting more requests from commuters seeking later express buses home. He said that’s a sign of a “maturing bus system,” and that riders are starting to want, and expect, more service.

Transit-tax opponents have not put forward a unified position on the city’s bus service. Some say the system should return to a much smaller model, with fewer express routes into the suburbs. Others say the system could slash its operating budget from $85.3 million to $60 million and still be effective.

Cutting bus funding would be a mistake, McCrory says. He believes the system will become more efficient as the region — and bus ridership — grow.

The Charlotte metro area has grown from 1.33 million people in 2000 to an estimated 1.58 million in 2006. At that pace, the six-county region would top 2 million by 2014. Much of that growth would be outlying counties such as Lincoln and Iredell.

“The bus system has far exceeded my expectations. Just look at the Huntersville park-and-ride lot,” said McCrory, who faces GOP challenger and transit critic Ken Gjertsen in the Sept. 11 primary. “Those cars would be on the highway.”

Here are six key questions about Charlotte’s bus system.

What was the 1998 vision?

Mecklenburg voters were asked that year to approve a half-cent sales tax to fund mass transit. The plan called for multiple rapid transit corridors and a massive increase in bus service. The centerpiece was to be a light-rail line from uptown to near Pineville.

The plan was unveiled amid worsening traffic congestion — especially along Interstate 485 — and a regional air quality that was out of compliance with federal ozone regulations 11 times the previous year.

The Charlotte Department of Transportation, and its successor CATS, wanted to improve service for its core market — people without cars — by making bus service more frequent and to more places. It also wanted to lure “choice riders” out of their cars with express routes for commuters. And when rapid transit corridors were built, such as the light-rail line, buses would be used to bring passengers to stations.

Light rail also was to channel high-density development into corridors along the rail line. The bus expansion, however, was almost exclusively about moving people.

Critics said the plan was too vague and would do little to ease road congestion or improve air quality.

Voters approved the tax 58 percent to 42 percent. More than 25,000 voters skipped the tax question altogether — more than the margin of victory.

CATS chief executive Ron Tober arrived the following year.

Has the vision been fulfilled?

By some measures, yes.

Ridership has increased 66 percent since voters approved the transit tax.

Before the tax, about 10 percent of CATS riders were considered “choice riders.” Today, Tober says, an estimated 40 percent are opting to leave their cars behind.

To lure those riders, CATS expanded the number of express routes that target commuters. It now operates more than 20 such routes, some reaching deep into neighboring counties.

CATS also has seen ridership bloom on “community circulators” that go short distances along corridors such as Beatties Ford Road. These high-frequency buses often target people who have no cars.

Steven Polzine, of the Center for Urban Transportation Research at the University of South Florida, said CATS’s ability to increase ridership has been impressive. Spending money doesn’t guarantee new riders, he said.

The transit system in Austin, Texas, for instance, increased its operating budget for buses by 50 percent in inflation-adjusted dollars from 1998 to 2005, yet ridership rose only 11 percent.

When voters approved the transit tax, Charlotte transit officials had a goal to double bus ridership by 2010. They will likely fall short of handling 24 million passenger trips but could handle roughly 22 million if ridership trends continue.

Has the expansion been cost effective?

Before the tax, the city’s smaller bus system was one of the nation’s most efficient. That was due in part to its low labor costs, but also because the system was less ambitious: It mostly served people without cars who took short trips.

When CATS expanded its bus service into the suburbs, where populations are less dense and travel distances are greater, operating costs rose dramatically.

Though CATS has added suburban riders, critics question whether expansion has been worth the cost. The bus system’s operating budget has grown from $25.1 million in 1998 to $85.3 million in 2007.

In 1998 the bus system paid, on average, $2.12 for each passenger trip. That doubled to $4.31 in 2007 and is projected to reach $4.60 next year.

That cost-per-trip is more than other major N.C. cities and has risen faster than the national average.

Polzine said a bus system is no longer cost effective when its cost reaches $5 per passenger trip.

Another indicator to watch, Polzine said, is the average number of riders a CATS bus carries one mile.

Before the tax, CATS had roughly 10 passengers per mile, just under the national average of 11. The nationwide average has since declined to 10.3. In Charlotte, that average is estimated now to be between 7 and 7.5, according to an analysis of federal transit data.

Dropping below 7 is a problem, Polzine said, a sign that some buses may be burning more fuel and creating more traffic congestion than passengers would if they drove.

How big is the CATS system, compared with cities of

similar size?

CATS’s bus service is large when compared with similar cities, especially those with low population densities such as Charlotte.

It handles more than twice as many passenger trips as Nashville, Tenn., and nearly twice as many as Jacksonville, Fla. And it dwarfs Raleigh, which has roughly one-fifth the number of passenger trips.

But other cities similar to Charlotte also have poured money into buses.

Austin is a similar-size city but is more dense. It also operates a large bus system. Its 2005 budget (the most recent in a federal database) was $121 million, and it had 33 million passenger trips. CATS had 19.8 million passenger trips in fiscal ’07.

What happens if the tax is repealed?

Pam Syfert, Charlotte’s former city manager, said last spring that city residents likely would see a property tax increase to replace some of the lost sales tax revenue.

If the property tax were increased $58 on a home valued at $159,900, Syfert’s staff said, the light- rail line could operate with reduced service and CATS would return to a late-1990s bus system, mostly for riders without cars. It would cost $171 in additional property taxes on the same house to keep the bus system intact and to run the light-rail line as planned.

Former county commissioner Jim Puckett, who favors repeal, says CATS could return to what he calls an “urban system” that serves people without cars, rather than reaching to attract “choice riders.” Others believe the city can retain a robust system even with a smaller budget.

They question whether the half-cent sales tax is the best way to fund transit because it’s a guaranteed revenue stream, regardless of CATS’s need.

“The point of this whole exercise (repealing the tax) is right-sizing our transit system,” said Jeff Taylor, a CATS critic who said he believes CATS could operate its buses effectively for $60 million annually, down from 2007’s operating budget of $85 million. “If you were a private company, would you continue growing a system that is becoming less efficient?”

Will the bus system continue

to grow if the tax is kept?

Tober said CATS will continue to expand its buses, though at a slower rate. He offered no timetable for bus expansion but said the region’s projected growth will justify the higher budgets that the sales tax would likely generate.

Because the N.C. legislature approved the half-cent tax for transit only, it cannot be spent on roads or schools.

When evaluating CATS’ s performance, Tober and his staff don’t focus solely on cost-per-trip. They also consider factors such as how many people its buses move in an hour, and whether rider subsidies are going up or down.

A CATS bus in 1998 moved just under 30 people an hour. That fell significantly after the tax but recently has started to increase. It averaged 23 in 2005, according to government statistics, and rose to 24.2 in 2007, according to CATS.

Tober said he also watches the percentage of bus operations that are supported by riders, either through bus fares or service reimbursements from private businesses or governments.

Before the tax, riders paid 27 percent of CATS’s operating costs. That fell significantly early in the decade but has stood at about 17 percent for several years. The median is 22 percent for the 100 largest transit systems, according to data from the American Public Transportation Association.

Critics say CATS should raise fares to roughly 25 percent of operating costs.

CATS said that in fiscal year 2009 — the first full year of operating light rail — 68 percent of the sales tax will be spent on buses. Critics questioned whether that ratio would fall if more trains are built.

CATS says the sales tax can support buses and trains, but it is under no mandate to spend a set percentage on either.

CATS had 217 buses and vans in 1998. Today it has 497. CATS also improved numerous bus stops, adding better signage, 217 new shelters and 77 new benches. Other capital improvements include three new transit centers outside of uptown and new park-and-ride lots for commuters.

—–

To see more of The Charlotte Observer, or to subscribe to the newspaper, go to http://www.charlotte.com.

Copyright (c) 2007, The Charlotte Observer, N.C.

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.

NYSE:BBT,

It Really Happens: Heat Causes Mulch to Ignite

By Linda A Moore lmoore@commercialappealcom

Last week wood chips spread on an Arlington, Texas playground got hot enough to spontaneously combust.

In March 1995 Romano’s Macaroni Grill in Germantown was damaged in a fire officials believed started when mulch ignited all by itself.

It may sound bizarre, but experts say the right recipe of heat, decomposition and a little bit of wind can combine to start a fire, even in two inches of mulch around a flower bed.

“It’s possible and I’ve seen it happen,” said Michael McPeak, owner of Digger O’Dell’s Nursery in Arlington .

So has Chief Jerry Ray of the Fayette County Fire Department.

“Anything that is decomposing generates heat. Mulch is more susceptible, especially the black because black absorbs heat,” Ray said.

Black mulch may be more susceptible but the mulch fires at Digger O’Dell’s have been from brown mulch.

“First we noticed it smoldering. By the time we noticed that and approached the area there were flames,” McPeak said.

He’s seen it ablaze while in transport.

“There have been instances where a vehicle hauling mulch going down the interstate and that air starts circulating,” McPeak said. “I’ve seen it ignite on people’s trailers.”

Spontaneous combustion occurs when a substance generates enough heat to ignite without an outside source, Ray said.

“The fire triangle is heat, fuel and oxygen. You get those three together in the right combination and it will burn,” Ray said.

Compost piles, like mulch, can also spontaneously combust, they said.

Mulch and compost don’t have to be in a huge pile to catch fire, although it’s doubtful the mulch will ignite in a flower bed that is watered regularly, Ray said. It also doesn’t have to be hot outside.

“I’ve seen it happen in the winter,” he said.

Most of the mulch fires Gary McDonald, manager at mulch producer Nature’s Earth Products in Arlington has seen have been in the fall and winter.

“We very seldom have any problems in summer,” McDonald said.

He also hasn’t heard of mulch fires in flower beds that weren’t helped along by something else.

“Personally, I don’t believe it’s a problem unless it’s a huge pile or somebody throws a cigarette on it or something,” McDonald said.

Nevertheless, as a precaution, homeowners should turn their mulch and compost piles and sprinkle them with water a few times a week, cooling the bed enough to discourage a fire that could get out of control, McPeak said.

“As dry as the grass is if a compost pile does ignite it could spread to the grass easily,” McPeak said.

– Linda A. Moore: 529-2702

Originally published by Linda A. Moore [email protected] .

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

Ayer Mother Treated for Flesh-Eating Disease

By Lisa Redmond, The Sun, Lowell, Mass.

Aug. 17–A 35-year-old Ayer woman who gave birth to a healthy baby last week at Emerson Hospital in Concord has been transferred to Massachusetts General Hospital in Boston after being diagnosed with a rare flesh-eating disease.

The woman, whose name is not being released, was diagnosed with necrotizing fasciitis, a potentially fatal bacterial infection, according to Emerson Hospital spokesman Bonnie Goldsmith. She was listed in critical condition last night.

Goldsmith said the woman underwent a routine Caesarean section at Emerson on Aug. 9. Her pregnancy was normal and her baby is completely healthy.

The baby has since been released from the hospital to the care of the baby’s father, the woman’s fiance. The woman also has an 8-year-old child from a previous relationship.

“After delivery, the mother’s health declined and she was subsequently diagnosed,” Goldsmith said

On Sunday, the woman was transferred to Mass. General. Officials there were unavailable for comment last night.

Goldsmith said the disease

is “extremely rare” and this has been the only incident at Emerson.

“Emerson Hospital is reviewing the details of this extremely rare case and has taken every precaution to ensure the safety of staff and patients,” according to a statement released by Emerson. “Our analysis to date shows the patient received timely care, appropriate to her condition.”

Although hospital officials are doing an analysis of this incident, Goldsmith assured the public “it is not like there is an outbreak at the hospital. This is an extremely rare condition.”

About 30 percent of those who develop necrotizing fasciitis die from it.

Necrotizing fasciitis can destroy skin and the soft tissues beneath it, including fat and the tissue covering the muscles, according to the medical Web site webMD. Because these tissues often die rapidly, a person with necrotizing fasciitis is sometimes said to be infected with “flesh-eating” bacteria.

Many people who get necrotizing fasciitis are in good health prior to the infection. Those at increased risk of developing the infection are people who have a weakened immune system or cuts or surgical wounds.

Necrotizing fasciitis is caused by several kinds of bacteria. The most common cause is infection by a “Group A” streptococcal bacterium, most often streptococcus pyogenes, which also causes other common infections such as strep throat.

The infections caused by these bacteria are usually mild. In rare cases, however, the bacteria produce poisons that can damage the soft tissue below the skin and cause a more dangerous infection that spreads through the blood to the lungs and other organs.

A break in the skin allows bacteria to infect the soft tissue. In some cases, infection can also occur at the site of a muscle strain or bruise, even if there is no break in the skin. It may not be obvious where the infection started, because the bacteria may travel through the bloodstream to other parts of the body.

A person may have pain from an injury that lessens over 24 to 36 hours and then suddenly becomes much worse. Other symptoms may include fever, chills, vomiting and diarrhea.

Immediate medical care in a hospital is always necessary. Most people will need surgery to stop the infection from spreading. Extensive use of antibiotics is needed to kill the bacteria.

Rare, serious

n Necrotizing fasciitis is caused by several kinds of bacteria. The most common cause is infection by a “Group A” streptococcal bacterium, most often streptococcus pyogenes, which also causes other common infections such as strep throat.

n The infections caused by these bacteria are usually mild. In rare cases, however, the bacteria produce poisons that can damage the soft tissue below the skin and cause a more dangerous infection that spreads through the blood to the lungs and other organs.

n The bacteria that produce the toxins that cause necrotizing fasciitis can be passed from person to person. However, a person who acquires the bacteria is unlikely to develop a severe infection unless he or she has an open wound, chickenpox or an impaired immune system.

n In very rare cases, the bacteria can be spread from one person to another through close contact such as kissing. People who live or sleep in the same household as an infected person or who have direct contact with the mouth, nose, or pus from a wound of someone with necrotizing fasciitis have a greater risk of becoming infected.

Source: WebMD

—–

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“No Ideas but in Things”: Fiction, Criticism, and the New Darwinism

By Mellard, James M

In the past decade or so, a small but rapidly growing band of literary scholars, theorists, and critics has been working to integrate literary study with Darwinian social science. -Joseph Carroll, Literary Darwinism

Ian McEwan is among the most honored of today’s novelists. Three of his novels have been shortlisted for the Booker Prize, a fourth, Amsterdam, won that award, and some of his other works have won yet other prestigious ones-the Whitbread Award by The Child in Time and the Somerset Maugham Award by his story collection First Love, Last Rites. His most recent novel, Saturday (2005), made almost every list of best books of the year and has been a bestseller on both sides of the Atlantic. Of his generation of novelists, he has emerged as among the most consistently productive and critically appreciated. While McEwan’s works exhibit rather traditional realist techniques, they bring something new to contemporary fiction in the author’s attaching himself to a new Darwinism, that emerging mode of philosophy and interpretation claiming roots in cognitive science associated with brain science, evolutionary psychology, and evolutionary social science. Quite overtly, McEwan has allied himself with others who work the same field either as literary scholars and critics or as scientists in disciplines associated with evolutionary biology. For instance, in a Salon interview with Dwight Garner associated with the publication of his seventh novel, Enduring Love (1998), McEwan has said that his own “particular intellectual hero” is the sociobiologist Edward O. Wilson. Moreover, in McEwan’s acknowledgments appended to that novel and intended, apparently, to contextualize it, Wilson’s name shows up, along with titles of three of his books-Biophilia, On Human Nature, and The Diversity of Life. It is not surprising, then, given McEwan’s critical prestige and his avowed thematic intentions, that he has become the face of the new Darwinism in fiction. If there were any doubt remaining regarding his ideological placement, it will be allayed by McEwan’s appearance in a new book called The Literary Animal, in an essay entitled “Literature, Science, and Human Nature.” There, McEwan addresses some of the issues the new Darwinism foregrounds in the interface of fields-literature and science-conventionally regarded as offering so radical a dualism.

Despite-or because of-McEwan’s avowed interests, that novel Enduring Love has become something of a lightning rod for interest, pro and con, in neo- or “Ultra”-Darwinism. For instance, sociologists Paul Higgs and Ian Rees Jones have noted that the “fact that a novel such as Enduring Love can deal with, and to a considerable degree, sympathize with evolutionary psychology demonstrates the impact of what Steven Jay Gould has called ‘Ultra- Darwinism.'” From the side of medical sociology, these researchers worry that “evolutionary psychology ultimately reduces the social to the biological in ways that generally preclude further analysis of the complexity of social relations” (27). From the side of literary criticism, however, there are other issues (less important, of course, in the great scheme of things) that may trouble one’s sleep about the new Darwinists if not neo-Darwinism itself. One is whether it is a simple matter to incorporate science in literary criticism. Some critics apparently believe that merely claiming to use a scientific method is sufficient to make it so. As Jean Jacques Weber wonders, in a review of cognitive poetics, if “cognitive poeticians rely upon a new terminology rooted in cognitive science, does this confer a scientific character upon their analyses?” (519). The answer is, not necessarily.

A writer as prestigious as the novelist A. S. Byatt (perhaps most famous for Possession) may well illustrate the slippage between “applying” science and simply “doing” literary criticism “invoking” science. In a recent critical essay, Byatt links a discussion of Donne to brain science as outlined in a work by Jean-Pierre Changeux entitled L ‘Homme neuronal. Byatt’ s premise is that the “pleasure Donne offers our bodies is the pleasure of extreme activity of the brain” (13). But after a lengthy explanation of Changeux’s view of how the brain works in processing perceptions, imagery, concepts, and associations among these mental objects, Byatt essentially dismisses the neuroscientist. Although, she writes, “I was convinced on reading Changeux that the neurones Donne excites are largely those of the reinforced linkages of memory, concepts, and learned formal structures like geometry, algebra and language,” she has since concluded “that we are [not] yet within reach of a neuroscientific approach to poetic intricacy.” So what does Byatt do? For the remainder of her discussion of Donne, she relies on a literary critic. Giving up on neuroscience, she writes, “I was very excited by Elaine Scarry’s dizzily ambitious Dreaming by the Book” (14), and it is to Scarry that Byatt turns for discussion of specific effects in Donne’s poetry.

But even if in some sense a critical method is “scientific,” it raises a second issue as to whether the newer critical method offers much that in itself is new or that cannot be provided by methodologies eschewed for being unscientific. Are its results overrated? This issue, exemplified in Byatt’ s reading of Donne but raised also by Weber, is articulated well in a critique of Chomsky’s cognitive linguistics by Christiane Bongartz and Tony Jackson. Commenting about how cognitive linguists write of metaphor and cognitive rhetoricians treat narrative, they argue that in neither case do scholars really need a grounding in cognitive theory. “All [their] practical examples of interpretation,” they concede, “are interesting enough, but they can be achieved simply through a very close reading and explication of the words of the text” (43). That is, an old-fashioned, nonscientific method of reading can yield results just as valid intellectually.

A third issue involves how science-oriented criticism often dismisses out of hand-favored terms are “obsolete” and “historical curiosities”-knowledge from nonscientific modes of analysis of mind, consciousness, or human nature. In Literary Darwinism, Joseph Carroll articulates this position rather bluntly. To go from social science rooted in Darwinian theory to today’s ordinary humanities, he suggests, is to enter a time warp. It “can be likened to the technological shift that takes place when traveling from the United States or Europe to a country in the Third World.” It is, he says, to travel in space but “backward in time”: “In the humanities, scholars happily confident of their own avant-garde creativity continue to repeat the formulas of Freud, Marx, Saussure, and Levi- Strauss-formulas that have now been obsolete, in their own fields, for decades. It is as if one were to visit a country in which the hosts happily believed themselves on the cutting edge of technological innovation and, in support of this belief, proudly displayed a rotary-dial phone, a manual typewriter, and a mimeograph machine” (x). Witty enough, and perhaps even true enough in some particulars, comments such as this must make those who use all that outmoded critical technology think, “Thank, God. Finally, there’s someone to bring us to our senses.” But are things really as simple as Carroll suggests? Do creative artists or hard scientists look at things quite this way?

1

Biologists and evolutionary psychologists were reshaping the social sciences. The postwar consensus, the standard social- science model, was falling apart, and human nature was up for reexamination. We do not arrive in the world as blank sheets, or as all-purpose learning devices. Nor are we the “products” of our environment. . . . We evolved, like every other creature on earth.

– Ian McEwan, Enduring Love

Mainly a novelist, McEwan writes in other genres (drama, tv drama) and as a literary critic or at least as a public intellectual regarding literature. In The Literary Animal, a collection of about a dozen essays, McEwan joins such luminaries as E. O. Wilson and Frederick Crews in advocacy of new Darwinist criticism and the ideology it represents. Literature, McEwan admits, is more generally accessible than is science. “Greatness in literature,” he admits, “is more intelligible and amenable to most of us than greatness in science” (“Literature, Science, and Human Nature” 5). But it is in science, he suggests, that we discover why literature works for us. “We have,” he says, “in terms of cognitive psychology, a theory of mind, a more-or-less automatic understanding of what it means to be someone else. Without this understanding, as psychopathology shows, we would find it virtually impossible to form and sustain relationships, read expressions or intentions, or perceive how we ourselves are understood. To the particular instances that are presented to us in a novel we bring this deep and broad understanding” (5). With this understanding, based on an “unspoken agreement between writers and readers,” literature becomes intelligible to us between the poles of the specific and the general. “At its best, literature is universal, illuminating human nature at precisely the point at which it is most parochial and specific” (6). All of this McEwan connects to Darwinian theory- indeed, although somewhat beside the theoretical point, perhaps the most engaging portion of this essay is that in which he “reads” Darwin’s “life as a novel” (7). But on that theoretical point McEwan writes, “I think that the exercise of imagination and ingenuity as expressed in literature supports Darwin’s view” (1 1). This view, in the novelist’s words, is that Darwin proved why human expressions of emotion are universal, and, further, how those “expressions and the physiology [they require] are products of evolution” (10). Moreover, McEwan says, behind these expressions lies a human nature that is universal as well. Here, he contends, is the link between literature and evolutionary theory: “It would not be possible to read and enjoy literature from a time remote from our own, or from a culture that was profoundly different from our own, unless we shared some common emotional ground, some deep reservoir of assumptions, with the writer.” Indeed, McEwan further contends, literature, in dealing with the universal and the specific, encodes the genetic and the cultural. “Each of these two elements, genes and culture, have had a reciprocal shaping effect, for as primates we are intensely social creatures, and our social environment has exerted over time a powerful adaptive pressure.” Here, McEwan can shift from one favorite, Darwin, to another. “This gene-culture coevolution, elaborated by E. O. Wilson among others,” he says, “dissolves the oppositions of nature versus nurture.” We are the literary animal. But, doubt not, we are of the animal kingdom, and even our literature may be seen to derive from our evolutionary heritage. “If,” he says, “one reads accounts of the systematic nonintrusive observations of troops of bonobos-bonobos and common chimps rather than baboons are our closest relatives-one sees rehearsed all the major themes of the English nineteenthcentury novel: alliances made and broken, individuals rising while others fall, plots hatched, revenge, gratitude, injured pride, successful and unsuccessful courtship, bereavement and mourning” (11).

In the advocacy of the new Darwinism, there is also much of the nineteenthcentury novel’s social machinery. It is evident in the critical revolution in which McEwan participates. He understands no doubt that revolutionaries take sides, make alliances (know thy friends), wage war (know thy enemies). To establish a new research or critical paradigm, proponents must know what or whom to attack. Marshaling a growing army of enthusiasts for a new Darwinian naturalism, The Literary Animal quite unapologetically aims to recruit warriors in a battle against unscientific literary criticism. In it Edward Wilson writes that “[n]aturalism is a conviction, based upon the spectacular successes of science continuing to the present time, that scientific inquiry can be taken to any level of detail, including the productions of mind and culture” (x). To this philosophy, The Literary Animal recruits allies with the newest-of-the-new naturalism in the cognitivism associated with the brain sciences. Bunkered in the new Darwinism, an avant garde of these research fronts wields a naturalistic hard determinism supporting assaults in such disciplines as neuroscience, sociobiology, cognitive psychology, and evolutionary biology. As this book reveals, however, for literary criticism the enemy-as in the war on “terrorism”-is virtually everywhere. It may be ideological or political or institutional. Since all the new fronts mount essentially materialistic-mechanistic and deterministic- attacks upon knowledge in their subject domains, they each locate ideological, philosophical, and theoretical enemies in any idealism or even, as William Uttal argues in Dualism: The Original Sin of Cognitivism, in every waffling dualism. As applied in literary criticism, that means they also find their foes in formalism, contextualism, and any coalition of these that produces a specific literary-critical approach.

But while for the new Darwinist warriors there are many specific ideological enemies-feminism, cultural studies, structuralism, poststructuralism, psychoanalysis (of whatever ilk but especially Freudian and Lacanian)-the general antagonist is what they call social constructivism or the Standard Social Science Model. The SSSM, according to McEwan, “holds that there is no human nature at all beyond that which develops at a particular time and in a particular culture. By this view the mind is an all-purpose, infinitely adaptable computing machine operating a handful of wired- in rules. We are born tabula rasa, and it is our times that shape us” (14). Against this SSSM view, no less a cognitivist warrior than Wilson, the father of sociobiology, takes up arms. In his “Foreword from the Scientific Side,” Wilson-whose Sociobiology: The New Synthesis essentially founded that discipline-lays out the ideological antagonism driving the agenda of The Literary Animal and many of its specific essays. In literary study, that enmity lies in a “cleavage between naturalism and social constructivism.” In the war between these, Wilson suggests, this book’s ideological stakes are high, for its essays must do nothing less than expand “the foundation of knowledge itself.” But to do that, they must connect “the great branches of learning” found in the “natural sciences, social sciences, and humanities.” Relying on “a web of verifiable causal explanation,” Wilson suggests, the connection is fundamental. Without that causal connection, we are left with nothing more than C. P. Snow’s two cultures, and never the twain-the naturalists and the constructivists-shall meet. “Either,” Wilson insists, “existence can be mapped as a continuum with the aid of science, as the naturalistic theorists suggest, or science is ‘only one way of knowing,’ as the constructivist theorists believe, with many other disjunct truths arising from cultural and personal happenstance” (vii).

But if that goal of connection is to be achieved, there are also political and institutional enemies to be vanquished. Others in The Literary Animal besides Wilson and McEwan recognize that those antagonistic ideologies associated with constructivism hold the fort. In his “Foreword from the Literary Side,” Frederick Crews (one of the great acerb critics and satirists of the whole endeavor of literary criticism), while not so sweeping in his declaration of war as Wilson, does address the political side of the conflict. As he concedes that the enemy is not really “constructivism tout court but its most brittle branch, a sociopolitical determinism so thoroughgoing as to rule out any allowance for biological commonalities” (xiv), Crews nonetheless argues there are sociopolitical battles to be fought. “Our common aim,” he says hopefully, “is not to render literary criticism drier and more technical but to reclaim governance of the field-its appointments and promotions, its curricula, its standards of publication, its manner of debate-from the fast-talking superstars who have prostituted it to crank theory, political conformism, and cliquishness” (xv). Even so, in a bit of irony Crews misses, it seems the objective of the new naturalism in literary criticism is to replace “their”slick superstars with “ours”-it’s just that ours are bona fide heroes. Just how heroic? To make his point, Wilson offers-I’m not making this up-an analogy to such New World explorers as Columbus. To Wilson’s mind, “naturalistic literary theorists are would be Columbians. Embattled, even scorned, by tenured constructivists, they have launched their frail caravels on an uncertain sea.” Make no mistake: what these brave-new-world discoverers seek, Wilson suggests, is something real. It is nothing so insignificant or insubstantial as mere mental confabulations. Indeed, anyone with half a brain must choose to voyage with them. Rhetorically, Wilson asks, “Who will gamble against them? If there is any chance of success, who with any courage and ambition would not want to join them-or at least lend support?” (vii). Who indeed? And given confidence such as Wilson’s, one supposes that there may be grounds for arrogance among the new Darwinian critics.

2

It seems likely that within two decades the sheer force of progressive empirical knowledge will almost inevitably bring about a fundamental transformation in the social sciences. In all likelihood, the humanities will eventually follow in the train of this movement, but they will probably be slow and late in catching up.

– Joseph Carroll, Literary Darwinism

Clearly, there is much that is messianic in the aims of the new evolutionary critical theorists. In their messianism, they are not much different from apostles of any previous new methodology (just recall new criticism, myth criticism, structuralism, poststructuralism, deconstruction, and the like). But what one does not recall as a feature of those other apostles is such an arrogant intolerance of divergent intellectual perspectives. One does, however, frequently find it among the new evolutionist critics. While it seems not particularly obnoxious in isolated journal articles, it can acidify in a book collection. There, a book replete with selfavowed cognoscenti seems less Wilson’s frail caravel than a warship armed with crusaders bent upon conquering and converting nonbelieving infidels. In The Literary Animal, in the overt message of several essays and in the tone of many, there is the fervor of the converted, the righteousness of the believer, the self- satisfaction of the possessor of universal truths. In other words, beware. There are fundamentalists here. Perfervid testimony may irrupt at any moment, tales of how once I was lost and now am saved. Even in the title of the jointly authored “Introduction: Literature- a Last Frontier in Human Evolutionary Studies,” we find editors Jonathan Gottschall and David Sloan Wilson suggesting a bit of Edward Wilson’s metaphor of adventurous conquest upon which authors in the book have embarked. The “known” world from which these adventurers set out is science, especially those sciences depending upon evolutionary theory. The dark unknown, the last frontier, into which they sally forth is the world of literature and literary criticism. To the natives there, they hope to bring enlightenment, an understanding of “the nature of literature from an evolutionary perspective” (xvii). While in the enlightened world of proper science “the evolutionary perspective” not only is commonplace and provides “specific insights that turn out to be correct,” it also offers “a single conceptual framework for unifying disparate bodies of knowledge.” If vertical integration from the bottom up in the life and human sciences is the aim, then Darwinian theory is the only answer. It can “reverse the trend of extreme specialization of knowledge that has taken place in the absence of a unifying conceptual framework.” While, historically, literary study typically has embraced many critical perspectives, one that for nigh on to a century it has not embraced has been evolutionary theory. Indeed, “serving as a microcosm of why the human sciences as a whole initially lagged behind biology in embracing Darwin’s theory,” suggest Gottschall and David Wilson, it has as a consequence fallen behind biology. “The best way that we can explain this” failure, they believe, “is by relating our own stories” (xvii). What sort of stories? As the new Darwinism has become the new fundamentalism, with all the features of a new religion, the stories told are ones of conversion. Carroll’s story is typical. He has published two books devoted to the new field-Evolution and Literary Theory (1995) and Literary Darwinism (2004). In a statement in the latter, his conversion is clear, albeit implicit. In the early 1990s, he says, “I was profoundly dissatisfied with the irrationalism and textualism of the prevailing literary doctrines, and in adaptationist research found a solid basis for developing alternative views about such matters as personal identity, sexuality, gender, the family, social motives, and the relation between the mind and the world” (Literary Darwinism xvi). In The Literary Animal, there are two stories-by Gottschall and Dylan Evans-that offer examples of conversion narrative more explicit than Carroll’s. While the bulk of Evans’s “From Lacan to Darwin” deals with those features of Lacanian theory that prompt Evans to reject it, he does offer at the outset a rather sharp precis of his story. He calls it a tale “of an intellectual journey. It starts with [his] enthusiastic embrace of the ideas of the French psychoanalyst Jacques Lacan and ends with [his] eventual rejection of those ideas some five years later.” Among Lacanians (full disclaimer: I am a published member of that strange cult), Evans is actually rather admired for his extremely useful Introductory Dictionary of Lacanian Psychoanalysis (1996), but according to his story Evans gave up Lacanian theory “as the result of an honest and sincere search for truth” – though no doubt had it been dishonest and insincere it would have been just as interesting. While those who contacted him after he had begun publishing new items with such titles as Introducing Evolutionary Psychology regarded him, he says, as “a former disciple” who had “betrayed the faith,” he says that his conversion to evolutionary psychology from Lacanian psychoanalysis was neither “betrayal” nor “apostasy” nor “a fall from grace” (38).

So what was it? It was a salvation of sorts. After having become a Lacanian analyst, he felt that in his practice those ideas did not work. In his view, “Whether used in the clinic or the seminar room, Lacan’s ideas are hopelessly inadequate because they are predicated on a false theory of human nature. I came to realize this when I started to treat patients-the clinical reality did not fit with Lacan’s theory” (38). While Evans does not particularize any clinical failings, he does recount a variety of dissatisfactions with Lacanian theory. These include its not being based on Chomsky’s linguistics and Lacan’s failure to pursue two scientific interests- one in ethology, the other in cognitive science-evident in his early work but eventually abandoned. Regarding those sciences, which had potentially promising empirical approaches, Lacan, in Evans’s view, made an egregious mistake when he turned from them to something else that Evans regards as merely a misguided Romanticism. The upshot of Evan’s tale, in any case, is a conversion to evolutionary psychology and abandonment of the clinic entirely. These days, he takes his evolutionary psychology not into psychotherapeutic practice but into research in artificial intelligence. Still, like any convert, he retains a messianic zeal: “It is my hope that, by sharing my intellectual journey with those literary scholars who still use Lacanian theory, they may also come to realize the inadequacy of Lacan’s conceptual edifice” (39). Indeed, as he says in his conclusion, “Although … I have rather lost touch with the world of literary criticism, I know there remain lots of literary scholars who still rely on Lacanian theory in their work. This strikes me as very sad,” especially since Lacan “really was . . . sadly mistaken and perhaps even tragically deluded” (54). Happens to the best of them.

Gottschall’s story offers several features similar to Evans’s. For one, each writer emphasizes political elements (that is, academic politics). In 1996, as a naive youth, enrolled in a doctoral program in darkest academe, Gottschall happened upon a bestseller by Desmond Morris about the evolutionary background of human behavior. Writes Gottschall, “While the specifics of The Naked Ape [1967] were outdated by this time, its general attitude toward exploring human behavior was not: humans have complicated culture and stunning capacity to learn, yes, but this does not change the fact that we are also animals, vertebrates, mammals, primates, hominids, and great apes.” While he concedes that human “culture, intelligence, and symbolic behavior make us different from the other apes,” he agrees with Morris that “they do not emancipate us from our evolved biology or lift us above other animals onto an exalted link of the chain of being.” Thus, Gottschall concludes, “zoologists can apply basically the same theoretical and methodological concepts to the study of human behavior that they apply to the behavior of other animals” (x viii). He decides he wants to do the same in a literary study.

At this time, Gottschall was taking a required course in which he was reading Homer’s Iliad. Immediately, he found the central ideas of Morris’s book influencing his reading of it. He says he “experienced the Iliad as a drama of naked apes-strutting, preening, fighting, tattooing their chests, and bellowing their power in fierce competition for social dominance, desirable mates, and material resources” (xvii). Fully aware that two and a half millennia of readings of the epic had yielded just about every conceivable interpretation, he came to believe that Morris’s view of human life could offer a fresh approach, one, moreover, that “could do the same for literary analysis generally by providing it with its first truly scientific theory of human psychology and behavior.” For the aspirant graduate student, this approach was not based on some merely speculative notion but built upon “the bedrock of evolutionary theory and scientific method.” Inspired by possibilities of this approach, and in his innocence unaware of academia’ s dark side, Gottschall went to his professor with a plan to write a paper from the evolutionary perspective. Alas, the professor-“on the grounds of absurdity and irrelevance” (xix)- turned him down. Instead, the professor recommended a Freudian or- gasp- a Lacanian approach. Already converted to the truth of evolutionary theory-“I believed that the hard social constructivism that dominated the humanities had been definitively exposed by numerous and redundant studies as a failed theory. And I felt that fears about the baleful political and ideological ramifications of an evolutionary perspective were misplaced and misguided” (xx)- Gottschall goes outside the English department to write hisdissertation on Homer. In effect, he says, he chose “de facto exile” in the service of his new calling.

3

Vulgar materialism and idealism join forces against [the radical] plasticity [of the human brain]: idealism, to prove that the brain is just matter, a relay machine which has to be animated from the outside … ; materialism, to sustain its mechanical determinisi vision of reality.

– Slavoj Zizek, The Parallax View

And behind this calling what is sought by the new Darwinists? Depending on whether one is a brain scientist, a cognitive psychologist, or a cognitive social scientist, there are really three things-mind, consciousness, and human nature. It is with the mind that Edward O. Wilson starts. For the new evolutionary literary critics, the “ultimate key” lies in how the new sciences understand the mind. “Nowadays,” writes Wilson, “neuroscientists, cognitive psychologists, and evolutionary biologists appear to have gained an entree in the assault.” Their strategy is found in a “painstaking, bottom-up approach-process by process, circuit by circuit-[that] is at last disclosing the multiple workings of the brain.” Moreover, he predicts that within a few years they probably will find “at least a rough answer to the question universally regarded as premier in the natural sciences: What is the mind?” (viii). Understanding the mind (and what for many-in a bloody battlefield of contestation-is its corollary, consciousness) leads to the citadel: human nature. “As the properties of mind are clarified empirically,” Wilson suggests, “it will also be possible to define human nature with greater precision.” But since it is ‘human nature’ that links these hard sciences of mind to literature and literary criticism, they find themselves, paradoxically, forced to fraternize with the enemy. Wilson points out that, on the one hand, human nature “is not the genes,” but, on the other, neither “is it just the universal traits of culture, such as the creation myths, incest taboos, and rites of passage, possessed by all societies.” So what is it? It is something in the middle, somewhere between genes and culture, lying in “the inherited regularities of sensory and mental development that animate and channel the acquisition of culture” (viii). Thus it is incumbent upon both the hard sciences and the social sciences to study culture to find interfaces of one with the other. While hard scientific knowledge provides a base, a softer knowledge from social science provides a superstructure built upon it. For mind and consciousness, evolutionary biologists favor a metaphor of computer hardware and software. While it is easy to think the relationship of hardware to software sounds more than vaguely Marxian (see Zizek, Parallax View 209), evolutionists must start with genetic hardware and work toward cultural software. In human evolution, Wilson tells us, “The long-term interaction of genes and culture appears to form a cycle, or more precisely a forward traveling evolutionary spiral.” This spiral, he says, follows a sequence that we must almost inevitably associate with that of DNA. In a first step (Wilson’ s italics removed), we find that it is genes that “prescribe [the] epigenetic rules” determining “the regularities of sensory perception and mental development that animate and channel the growth of culture.” But Wilson says that in a second step it is culture that “helps to determine which of the prescribing genes survive and multiply from one generation to the next.” Thus, the human brain, in a third step, “develops its activity and thence mind and culture by epigenetic rules of thumb that channel learning” (ix). These three steps are “evolutionary” because they change human nature. “Successful new genes or gene combinations alter the epigenetic rules of the populations. The altered epigenetic rules change the direction and effectiveness of the channels of cultural acquisition.” But however evolutionary the spiral, it is not one that can be understood from the perspectives of hard science or of the Darwinians alone. If repeatability and predictability are necessary features of hard science, then understanding the relation between genes and culture cannot emanate from just one discipline. While, as Wilson says, “Scientists and other scholars have begun to map a few of the connections between genes and culture,” it is also the case that “details of the coevolutionary spiral cannot be predicted from knowledge of the genes or even the circuitry of the brain alone. It [the coevolutionary spiral] can only be adduced by joining the relevant data of cognitive psychology, the social sciences, and the humanities with those of biology” (x).

It is another of the scientists, the other Wilson-David Sloan Wilson-who articulates the linkage Edward O. proposes. In the very title of his essay, “Evolutionary Social Constructivism,” David Wilson suggests how the two domains may be integrated. He admits that those enemy “isms” associated with postmodernism’s SSSM are both different from and the most distinct opponents of sociobiology and evolutionary psychology. But, he points out, “in contrast to the inflexibility and determinism attributed to evolutionary approaches to human behavior,” those domains are nonetheless “united in their commitment to the idea that individuals and societies have enormous flexibility in what they can become.” It is this “middle ground,” where “the heart of social constructivism can be given an evolutionary formulation,” that in his essay David Wilson means to map. If it is the case that the lesser of the two, social constructivism, will gain the more from the conjunction, it is also the case, Wilson believes, that “sociobiologists need to incorporate large elements of social constructivism into their own framework” (20). Indeed, Wilson suggests, those two fields especially need to incorporate knowledge about “adaptive behavioral flexibility,” for otherwise it may appear to moot the laws of genetic determinism. “Numerous self-described sociobiologists and evolutionary psychologists,” writes Wilson, “have made the same points and justly feel misunderstood by their social constructivist critics who continue to associate evolution with inflexibility. Here, then, is an important meeting ground in which social constructivism can be placed on an evolutionary foundation” (25).

It is on the grounds of survival and reproduction that the armies of evolutionary theory and those from the social sciences might call a truce. Just as they are in any other species, these are the goals of human cognitive and social behavior. Thus, Wilson says, “the study of humans should be centered upon survival and reproduction- and indeed survival only to the extent that it leads to reproduction.” In one formulation, he says that humans “might be playing the reproduction game differently than other species [play it] in some respects, but we are playing the same game” (28). More than in other species, in humans genes change rapidly because of the future-changing, goal-directed activities of their brains. Here, adaptation, perpetuated by natural selection in behaviors directed toward survival and reproduction, provides the key to evolutionary social constructivism. If on the biological evolutionary side, the mechanism of change is the gene, on the social evolutionary it appears the change mechanism is narrative, the story. (Are we back in the land of the archetype? Was Jung more right than we have imagined?) “Genes,” Wilson says of the biological side, “contain the information about adaptations that have been hard-won by the process of natural selection” (29), and it is their purpose to communicate that information faithfully from one generation to the next. On the social side, if there is to be a nongenetic evolutionary process, it must have a means to transmit new data as faithfully as do genes. It is, says Wilson, our stories that possess this genelike nature. Better yet, as Edward Wilson tells us, “The mind is a narrative machine, guided unconsciously by the epigenetic rules in creating scenarios and creating options. The narratives and artifacts that prove most innately satisfying spread and become culture” (ix). Given that evolved mind, human beings are nothing if not well equipped for creating in the cultural domain those genelike structures that help them evolve.

It seems here, perhaps, in human evolutionary development, that materialism meets idealism in the dualism dreaded by the hard-core cognitivists. For whereas genes convey information materially, through chemical encoding, in symbolism stories offer encoding constructed upon a nonmaterial basis. “What made humans unique,” David Wilson writes, “was a natural environmental context that made symbolic thought adaptive in its initial stages, allowing us, and us alone, to cross over to the new adaptive peak.” If it is nothing else, Wilson insists, “Symbolic thought is … a system for the generation and selection of mental representations” that permit “a form of virtual evolution to take place inside the head” (31). In interaction of brain “hardware” and mind “software,” we find why many cognitivists, as McEwan has noted, make the computer a favored metaphor of the brain. Typically of the hard-determinist variety, they deny free will and make consciousness, regarded as being as precisely determined as one’s taxes done on a tax-preparation software program, strictly a material function dependent entirely on its programming. But the brain is not a computer, for, both dynamic and plastic, it does not function through digital logic. Thus, for his part, Wilson, sounding more humanistic than some of the new Darwinist literary critics, does not embrace the computer metaphor. In his view, “people are more than tax-preparation software writ large, responding to specific environmental stimuli with preevolved behavioral responses.” Rather, acting both individually and collectively, humans-in a process begun when the earliest hominids descended from the trees and adapted to the veldt-find “new solutions” to problems their lives throw before them. Calling this process “evolutionary voyages,” Wilson says that humans “rely fundamentally upon stories in the creation of new and untested guides to action, the retention of proven guides to action, and the all-important transmission of guides to action from one person to another. In short, stories play the role of genes in nongenetic evolutionary processes” (35). By accepting on the scientific side that stories act like genes in evolutionary processes, Wilson insists that there is no compelling reason any longer to deny to literary study and the social sciences a place in the halls of evolutionary knowledge.

In contemporary thought, to meet any demand for syncretism, however, all intellectual domains seek help going in one direction or another. On a continuum between materialism and idealism, they look for integration by moving either upward or downward. Situated in an empirical middle ground, both literature and social science fit somewhere between hard (empirical, materialist) science and soft (speculative, realist, or idealist) philosophy. As brain science pulls social science downward toward hard empirical knowledge, social science pulls brain science upward toward integration with philosophy. Whereas to literature and social science brain science offers bottom-up integration of evolutionary knowledge of human nature, brain science needs help toward integration upward from a branch of philosophy of science that attempts from the philosophic top down to integrate the new evolutionary knowledge with traditional philosophy, whether materialist (as in Daniel C. Dennett’s Freedom Evolves) or idealist (as, perhaps, in Zizek).1 Based mainly on an explosion of hard new empirical findings in cognitive brain science but also on recent ones in archeology and anthropology, writings of this sort feed an apparently insatiable appetite for the new knowledge. Indeed, represented recently and variously by such as Sean Carroll’s Endless Forms Most Beautiful, Nicholas Wade’s Before the Dawn: Recovering the Lost History of Our Ancestors, Michael S. Gazzaniga’s The Ethical Brain: The Science of Our Moral Dilemmas, Michael Wheeler’s Reconstructing the Cognitive World, Nicholas Humphrey’s Seeing Red: A Study in Consciousness, Gregg Rosenberg’s A Place for Consciousness, and Dennett’s Sweet Dreams, they suggest a growth industry in scholarly and popular publishing-in McEwan’s words, “a golden age.” As McEwan notes in that Salon interview, regarding such a moment, and referring to other such writers and researchers as Antonio Damasio, Thomas Metzinger, Francisco Varela, and Steven Pinker, it is “a kind of science writing that seems to bridge the gap between informing laymen but also informing other sciences” (Garner). But any gap these writings close is one of information. Between brain and consciousness, it is philosophers and philosophically minded biologists who recognize the breadth of the gap and try to find ways across it. But that gap remains. In a parallel almost too pat to be believed, in competing explanations of nature’s phenomena operating on two vastly different scales, physics-in general relativity and quantum mechanics-recognizes a similar gap. On the quantum side, the so-called standard model describes nature at the level of molecules, atoms, electrons, and downward; on its side, general relativity describes how nature operates on a scale ranging upward from ordinary objects to planets, galaxies, and the whole shebang. Between the two theories, for twenty years or so, in physics it has been string theory that has been expected to close the gap between them and to give us a unified theory of everything. But, so far, string theory has not done so, and physicists themselves are becoming skeptical that it will (see, for example, books by Lee Smolin and Peter Woit). Thus, even into physics a sort of humanism has been introduced. Given that physics is typically regarded as a science as ‘hard’ as anything in cognitive brain science, more peculiar than that gap between quantum and relativity models is a notion called the “anthropic principle” that puts “man” back into the center of things. Not universally accepted by physicists, of course, the anthropic principle puts, as it were, a homunculus into the universe in precisely the same way that, say, Descartes, in a standard philosophic view of consciousness, seemingly puts one into the human brain. That view is one Damasio’s Descartes’ Error is famous for critiquing. But between brain and mind, mind and consciousness, wave and particle, idealism and materialism, as the huge volume of studies in philosophy and philosophy of science suggest, neither science nor social science has eliminated what Zizek calls a parallax gap-“the confrontation of two closely linked perspectives between which no neutral common ground is possible” (4).

4

[C]onfronted with an antinomic stance in the precise Kantian sense of the term, we should renounce all attempts to reduce one aspect to the other . . . ; on the contrary, we should assert antinomy as irreducible, and conceive the point of radical critique not as a certain determinate position as opposed to another position, but as the irreducible gap between the positions.

– Slavoj Zizek, The Parallax View

In closing that gap, how can mere storytellers do any better than the scientists and philosophers? Novelists such as McEwan and David Lodge, whose recent novel Thinks works this territory, are pretty much in the same intellectual situation, for like their cohorts they tell stories that go downward toward concrete human existence but at the same time go upward toward those abstractions associated with ethics, moral values, and aesthetic concepts such as form and beauty. Different from Lodge, who is ultimately a Christian storyteller, McEwan locates himself and his recent fiction on the scientist’s ground. While in acknowledgments in Enduring Love he professes that admiration we have noted of the pioneering work of Edward O. Wilson, there he also identifies the work of several others who write in this middle world between brain science, on the one hand, and social science, philosophy, or philosophy of science, on the other. There where McEwan mentions Wilson’s name and three of his books, he also offers names and titles-Steven Weinberg’s Dreams of a Final Theory, Pinker’ s Language of Instinct, Damasio’s Descartes’ Error, Robert Wright’s Moral Animal, and Walter Bodmer and Robin McKie’s Book of Man-that strongly suggest he intends to explore themes foregrounding evolutionary science and eschewing philosophical interest in human nature. But no more than A. S. Byatt in her discussion of Donne does McEwan stick to brain science and ignore traditional humanistic studies. As Byatt invokes brain science but ends up relying on nonscientific literary criticism, so McEwan invokes new Darwinian science but in psychiatry and psychoanalysis crucially relies also upon nonscientific research. Ultimately, it appears that McEwan must fail to close that parallax gap but in the failure succeeds in doing what novelists do: exploiting the potential of human consciousness in its ideal and material expressions.

Though not a modernist novel of stream of consciousness, Enduring Love does show how one’s consciousness interacts with an unconscious and a preconscious. McEwan’s novel, we may say, is a tale in which the mind of a narrator very consciously works toward a knowledge lying in his unconscious not in order to resolve a neurosis but to solve two mysteries. A novel of detection, then, in much the same way as Freud’s case histories may so be regarded, Enduring Love frames one mystery within another. Its initiating event is a horrible accident outside Oxford, in the Chilterns, in which a hot- air balloon comes unmoored with a grandfather on the ground and his young grandson its only occupant. Diverse onlookers-passers by, picnickers, workers-note the boy’s danger, and several men attempt to anchor the balloon by grabbing hold of its trailing tethers. But when a hard gust of wind takes it rapidly upward, all but one of the men elect to let go in time to save themselves. Overcoming his initial panic, the boy uses enough ballooning technique eventually to help save himself, but that comes too late to prevent the one would-be rescuer’s falling to his death. One of the men who let go the balloon’s tethers is Joe Rose, McEwan’s first-person narrator and protagonist. Feeling humane concern for the man’s widow and two children but also guilt for having saved himself, Rose becomes involved with the man’s family. He hopes not only to explain himself to himself but also to attest to the family (a widow, daughter, and son) the dead man’s courage. In this plot element, it is with the widow that a mystery develops rather unexpectedly and calls upon Rose’s mnemonic skills. No, Joe and the woman do not fall in love. Rather, Rose rescues her love for her dead husband. The widow, on seemingly irrefutable evidence, comes to believe her husband was cheating on her and was in the Chilterns only because he was picnicking with a young lover. But Rose, searching deep into his memories of the incident of the balloon and interviewing others who were present at the time, eventually discredits the evidence for her conclusion and solves that mystery. By restoring to the grieving widow a good memory of the dead husband, he brings this story to a resolution characteristic of mystery and romance.

Dramatic as is the opening episode of the runaway balloon and the aftermath it brings, it exists largely to frame a narrative more significant. This narrative begins at the time of the balloon accident but strictly speaking has no logical connection to it.2 As with what one might call the widow’s plot, in this plot, the “love” plot alluded to in the book’s title, Joe Rose again solves a central mystery by probing his unconscious memory bank. During the moments of the balloon accident, one of the other men who grabbed the tethers but let go in time to save himself inexplicably seizes upon Joe Rose as a love object. The man eventually tells Rose that when their eyes had locked momentarily, before the two joined in the effort to save that boy in the balloon, he “knew” that Rose loved him and must be loved back. In research and probes into memories in his unconscious that surface as if through psychoanalytic free association, Rose eventually identifies the man’s sudden onset of psychosis as a form of psychotic passion. Motivated by his passion, this man-Jed-Parry-stalks Rose, threatens his sanity, endangers the woman he loves, turns him into an obsessive figure driven to understand what drives the man who stalks him, almost irretrievably sunders his domestic relationship, and makes him something of a persona non grata to the police to whom he repeatedly reports his stalker’s behavior. Given little help by the police or his domestic companion, however, Rose is left to help himself as best he can.

At some unconscious level, Rose knows that he knows about this man’s condition. But memory of it merely tantalizes him until a chance remark, by the widow’s son, concatenating the words palace, king, and signal, flashes it all before him. “It all came at once, and it seemed impossible that I could have forgotten,” we are told. “The palace was Buckingham Palace, the king was King George the Fifth, the woman outside the palace was French, and the time was shortly after the Great War.” Further, we are told, “She has traveled to England on a number of occasions and wanted nothing more than to stand outside the palace gates in the hope of catching sight of the king, with whom she was in love. She had never met him and never would, but her every waking thought was of him” (133). Moreover, before this narrative moment passes, Rose identifies the woman’s condition as “de Clerambault’s syndrome.” Indeed, before the novel ends, we learn that there is a massive literature on the syndrome and its various medical and legal consequences. Also called erotomania, the syndrome has several identifying nosological features and may take several specific forms. Its one constant is that, initially, the subject seizes upon another person as the one who loves. That is, the erotomanie begins with the notion that the other person loves him or her, not the reverse. That French woman had begun with the notion that the king loved her. In McEwan’s novel, Parry suffers the delusion that Rose, for no rational reason- indeed, before that moment at the balloon accident they had never laid eyes on each other-loves him. As regards the love-object, gender is not a deciding factor, for erotomania may manifest as heterosexual passion or-as with Parry-homosexual. Further, as the French woman fastened upon a king, the delusional subject often fastens upon a person of a higher class or caste. Regarding Rose, this feature seems not immediately to have been present, but Jed Parry makes it clear that after their first encounter he had done research on Rose, found he was a highly respected science writer, got copies of his writings, and spent hours obsessively pouring over them so he would “know” Rose. After the apparent initiating moment of the passion, then, it appears that, retroactively, Parry reified the syndrome through determining Rose’s status as a social and intellectual superior.

In working out this plot, McEwan makes central Rose’s solving the mystery of Jed Parry ‘ s psychosis. But, ironically, if not oddly, McEwan does not really turn to brain or evolutionary science for Rose’s solution. Despite his affirmation of new Darwinian cognitivism, McEwan does not demonstrate that even the most ancient knowledge of the human psyche is either a historical oddity or, worse, quite obsolete. In the novel’s most interesting formal feature, in “documentation” regarding the syndrome named for Gaetan Gatian de Clerambault, McEwan lends credence to the novel by pointing to its background in clinical descriptions and psychoanalysis as well. In a kind of scaffolding, the documentation appears in two appendices-an article and a letter-McEwan attaches to the main narrative text. The shorter of the two, the second item (26 1 -62) seems of a piece with the novel’ s fictional discourse: it is a letter written to McEwan’s narrator-Joe-Rose-from a mental institution by the very man-Jed-Parry-who in the narrative Rose recounts has made Rose’s life miserable but who in the letter expresses his enduring love for him. The longer of the two, the first item, however, seems well outside McEwan’s fictional discourse: it is an article entitled “A homoerotic obsession, with religious overtones: a clinical variant of de Clerambault’s syndrome” (249-60). It appears to be a genuine reprinting of a scholarly article, and, indeed, several early reviewers took it as such. Its authors are identified as “Robert Wenn” and “Antonio Camia,” and the source of its original publication as “The British Review of Psychiatry.”

While in McEwan’s novel the phenomenon addressed is real enough and clinically validated, in the two appendices all these-letter, article, its authors, and the journal-are faux. Though by their placement as appendices they appear as real documents outside the fictive discourse, they are in fact fictive fabrications of the sort familiar in the history of the novel. As Laura Miller reported in Salon, many readers and early reviewers (including psychiatrists) in major venues failed to recognize the fictive status of these items. Especially confusing was the purported article because McEwan does so well the “voice” of such research publications and because most of the items listed among its works cited, including de Clerambault’s essay, are quite real. There is, in fact, a British Journal of Psychiatry, and likewise real is the journal-Acta Psychiatrica Scandinavica-in which “Wenn” and “Camia” publish another article (“Homosexual erotomania”) listed in the references appended to the bogus article. Regarding the faux article, it has been revealed that McEwan went so far as to submit it to a psychiatric journal. But while it was apparently considered seriously enough, the journal’s editor rejected it, so it never achieved the level of the so-called Sokal’s hoax.3 All that aside, once we understand that McEwan-like a good Joe Rose-did the research, wrote the case study, and made it part of the novel’s fictional discourse, we are not surprised by how closely the novel’s main conflict adheres to the details of the case history outlined there. Nor, indeed, should we be surprised that, as part of the fiction’s discourse, it even reveals elements of plot resolution (we learn in the article, for instance, that Rose and Clarissa-his significant other-patch up differences precipitated by Parry’s behavior and even adopt a child in place of ones Clarrisa is unable to conceive) otherwise not resolved within the previous narrative text.

For those interested in reading Enduring Love as itself a document demonstrating McEwan’s new Darwinian cognitivism, odder or more ironic still than the “article” is that the novel’s central “fact”-de Clerambault’s syndrome-comes from the history of psychoanalysis, not brain studies as such. More ironic still, it even touches Jacques Lacan. Focusing on that French woman, de Clerambault’s original case study was published in 1932. From the research McEwan does, he surely knows that in that same year, as professor of psychiatry at Sainte-Anne’ s hospital in Paris, de Clerambault was master to a young Lacan. Under the influence of de Clerambault but also revealing his differences from him, in his psychiatric thesis, defended in 1932, Lacan also wrote on a case of erotomania, that of the woman named Marguerite Pantaine (called “Aimee” in the thesis) who with a kitchen knife tried to kill a then- famous French stage and film actress. At this time, de Clerambault was a commanding (albeit not beloved) figure in French psychoanalytic circles, and his concept of ‘automatism’ in psychosis influenced many psychiatrists and psychoanalysts, including Lacan, who with de Clerambault, as Elizabeth Roudinesco recounts, “had a conflictual love-hate relationship” (23). Burdened by various psychological problems of his own, de Clerambault committed suicide in 1934, and in time became a figure known, as Roudinesco also recounts, for two things (or three if we count his influence on Lacan)-his obsessive interest in costumes worn by Algerian men and women and the syndrome named for him. His collected works appeared in 1942, and it is to this edition that citations (including that in McEwan’s faux article) most frequently refer.

It is indeed this work, “Les psychoses passionelles,” that Joe Rose remembers he once had read. In that moment of revelatory recall, Rose realizes how that French woman-expressing another common feature of the syndrome exhibited by Parry-believes the king sends her secret messages she finds encoded in such phenomena as cloud formations and arrangements of palace drapery. Accounting for his worries about his own and Clarissa’s safety, Rose learns from de Clerambault (and other researchers listed in that faux article) that violence is a frequent, albeit not defining, feature of erotomania. Rose learns too that the erotomanie subject’s passion typically emanates in the social and legal phenomenon familiar today as stalking, and may (as in Mark David Chapman’s murder of John Lennon) devolve to lethal violence. In his experience with the police, and to his chagrin, Rose learns as well that victims of stalkers are not always protected or even believed. Because erotomania only sometimes leads to violence upon the objects of its obsessional passion, the stalking behavior (looking, hanging around, collecting memorabilia) may to others appear relatively benign. Thus, as Rose learns, victims of erotomania may have difficulty persuading others, including authorities and even loved ones, of the danger to which they may be subjected.

In Enduring Love, as noted, Jed Parry does indeed stalk Rose. He begins by phoning him late at night and later repeatedly leaves phone messages once Rose refuses to answer calls. Then he shows up at Rose’s residence, offers protestations of their “mutual” love, and otherwise makes Rose’s life miserable. But because Parry is very canny in his behavior and Rose makes some stupid mistakes (ones- such as erasing dozens of answering-machine messages before anyone else hears them-that prompt a reader to scream, “Don’t do it, Joe”), Rose can persuade neither Clarissa that Parry in fact is a stalker nor a police caseworker that Parry, even if a stalker, might actually be dangerous. For her part, Clarissa, deciding after several arguments that Rose is more obsessed with Parry than is Parry with him, packs up and leaves Rose. Even when Parry’s threats escalate into violence, it is so well cloaked-Jed hires a couple of goons to attempt a hit on Rose that goes awry (the goons shoot another man) and seems not even directed at Rose-that the writer is left still unable to persuade the police that he is in danger. Taking it as a duty to protect himself and Clarissa, who also comes under threat, Rose illegally buys a handgun that he ultimately must use to save Clarissa from Parry and, it turns out, the suicidal Parry from himself. It all sounds pretty melodramatic (and it is), but, as a novelist of the realist persuasion, McEwan so skillfully envelops every element-plot, scene, characterization-in metonymic detail that only at the end (in what amounts to a shootout between victim and stalker-cum-kidnapper) does the melodrama seem a bit over the top. All this said, of Enduring Love-which I find a fine, serious, and entertaining novel-the question one ultimately must ask is what, apart from the machinery of the book, would make it exemplary for new Darwinist evolutionary critics? In what sense is the world of Enduring Love “evolutionary”? Joe Rose talks the Darwinian talk often enough. Perhaps most intrusively, he does so in his account of the failure of those several men, himself included, to cooperate well enough to anchor that runaway balloon and thereby to save the life of the man who fell. “Cooperation,” he says, is

the basis of our earliest hunting successes, the force behind our evolving capacity for language, the glue of our social cohesion. Our misery in the aftermath was proof that we knew we had failed ourselves. But letting go was in our nature too. Selfishness is also written on our hearts. This is our mammalian conflict: what to give to the others and what to keep for yourself. (15)

But, in the larger plot of this novel, it seems that McEwan gives about as much credence to Clarissa’s views as to Joe’s. And Clarissa, in their arguments about Darwinian reductionism, calls “the whole project” of genetics, neo-Darwinism, and evolutionary psychology “rationalism gone berserk.” It is, she says, “the new fundamentalism.” Indeed, she adds, “Twenty years ago you and your friends were all socialists and you blamed the environment for everyone’s hard luck. Now you’ve got us trapped in our genes, and there’s a reason for everything!” (74-75). In her view, “Everything was being stripped down, . . . and in the process some larger meaning was lost” (75).

If in a Darwinian sense, the “larger meaning” Joe, if not Clarissa, would attribute to everything devolves to survival and reproduction, in what way does this novel suggest that? Are Joe Rose’s and Jed Parry’s actions so driven? As for Rose, nothing apart from ordinary human failings affects his ability to act ethically in the face of situations where survival and reproduction might have justified more extreme behaviors. As for Parry, he emerges as antagonist for Rose because of a type of impairment that eliminates as motives both survival and reproduction. As the nature of the antagonist in McEwan’s more recent Saturday emanates from a genetic physiological disease that progressively impairs cognition and emotional control,4 so also does Parry suffer from a psychological condition. But Parry’s psychose passioneile seems to have neither a genetic nor a physiological origin (although research more recent than McEwan’s novel, by Anderson et al., suggests that a physiological origin is possible). While evolutionary psychology devalues psychoanalysis, Parry’s syndrome seems clearly to model psychoanalytic issues. It can be corrected neither by drugs, surgery, nor gene therapy. Would psychotherapy do it? Probably not, since psychosis as such rarely ever is cured by anything, and the novel-in the faux article-indicates that Parry remains delusional and no cure for him seems imminent. Given that the subject afflicted with erotomania suffers from a psychological impairment rather than a genetically physiological one, is he more or less culpable for his criminal deeds than is Saturday’s Huntington’s sufferer? Because in Enduring Love McEwan focuses on how the erotomanie subject’s behavior affects the protagonist and his sense of moral responsibility, however, he does not really address this question. What McEwan does question, ultimately, as David Malcolm says, is knowledge: “The novel presents different kinds of knowledge,” and while the two main forms-Joe’s neo-Darwinian materialism and Jed’s Christian eschatology-“give their possessors considerable certainty,””what the novel also shows is that knowledge is (like love) a rather fragile thing, difficult to get and, indeed, rather unstable.” In sum, Malcolm rightly says, “an atmosphere of epistemological uncertainty bedevils the world of Enduring Love” (177).

Thus, where might analysis of Enduring Love and McEwan’s reading list leave us? To be sure, all those names and books are associated with the new evolutionary theory and its affiliated materialist philosophy. And, yes, new Darwinist critics (such as Carroll, Literary Darwinism ix) readily identify McEwan as one of them because much of his fiction exhibits considerable knowledge of current evolutionary science. Moreover, yes, his fiction often revolves around psychological issues (incest in The Cement Garden, for instance; mourning in The Child in Time), and he clearly orients himself intellectually toward the hard sciences, psychiatry, and the brain sciences in consciousness studies rather than toward a traditional psychoanalysis that is anathema now to cognitive and evolutionary psychology (talk about anxiety of influence). But, no, Enduring Love, while also exhibiting those attractions, does not ultimately offer a persuasive endorsement, if that is what one seeks in it, of any hard evolutionary theory. Thus, while it is clear that McEwan’s novel reaches out to evolutionary theorists and critics, it works-as perhaps all good fiction does-within that middle intellectual ground, somewhere between hard, empirical and soft, speculative knowledge, there where lurks the spectre of that dualism Uttal claims is the bane of cognitivism. In evolutionary terms, Enduring Love addresses not brain or mind but consciousness.5 It is a consciousness, however, that does give credence to a limited dualism, one of the sort found in the credo-“No ideas but in things”- expressed in William Carlos Williams’s Paterson. Though we have not closed Zizek’s parallax gap, ideas-and idealism-do come, albeit “in things,” and cannot simply be disregarded by ultramaterialists. Thus (and here we are, back in the material world), as p

Births is It a Boy or Girl? Births is It a Boy or Girl?

JULY 30, 2007

Victoriana Adams, Greensboro, a boy

Mary Allred, Stokesdale, a girl

Katherine Hill-Oppel and Wayne Oppel, Winston-Salem, a boy

Shannon Keith, Greensboro, a girl

Gloria and Omar Solis-Benitez, Greensboro, a boy

Amy and Chris Prato, Greensboro, a boy

Adriana Galeana-Vasquez, Greensboro, a boy

Felishia and Dramane Coulibaly, Greensboro, a boy

Ashley Perrin, Greensboro, a boy

Clarissa and Mark Yost, Greensboro, a girl

Margaret and Martin Halpin, Greensboro, a girl

Maria Garciduenas, Greensboro, a boy

Melissa and Albert Lord, Greensboro, a girl

Uon Mlo, Greensboro, a boy

JULY 31, 2007

Lisa and Trecy Tickle, Gibsonville, a girl

Heather and Jaime Southern, Mayodan, a boy

Vanessa Moser, Ramseur, a boy

Jennifer and Timothy Smith, Pleasant Garden, a boy

Nshimirimana and Abdirahman Fatou, Greensboro, a boy

Jessica Hood, Greensboro, a girl

Amma and John Allen, Greensboro, a boy

Carla and Stephen Porter, Greensboro, a boy

Aisha Graham, Greensboro, a girl

Christine and Michael Nay, Kernersville, a girl

Patricia and Andrew Dell, High Point, a boy

Kenisha White, Greensboro, a boy

Entsar and Mahmoud Osman, Greensboro, a boy

AUG. 1, 2007

Paula and Stewart Copenhaven, Summerfield, a girl

Sandra Whitener, Greensboro, a girl

Kimberly and Clifton Smith, Greensboro, a girl

AUG. 2, 2007

Kelly and Joel Ferguson, Greensboro, a girl

Marlina Collins, Greensboro, a girl

Brandi and Michael Potter, Greensboro, a boy

Hope and Brian Thacker, Greensboro, a boy

Michelle and Jake Vinal, Greensboro, a girl

Meagan Rohme, Jamestown, a boy

Shantel Saunders, Greensboro, a boy

Miriam Benavides-Bravo, Greensboro, a boy

Shiho and John Bancroft, Greensboro, a boy

Alicia and Jonathan Blackwell, Greensboro, a girl

Cassondra Sumner, Greensboro, a girl

Stephanie and Anthony Clewis, Liberty, a boy

Tasha Richardson, Greensboro, a girl

Shandi and Douglas Poindexter, Greensboro, a girl

Trisha and Bradley Hoover, Greensboro, a boy

Misty and Jeffrey Howell, Gibsonville, a boy

Brittany Black, Greensboro, a girl

Jennifer Young, Greensboro, a girl

AUG. 3, 2007

Yeny Maldonado, Greensboro, a boy

Autumn Stroud, Greensboro, a boy

Elicia and Brent Knight, Madison, a girl

Amanda and Christopher Hover, Greensboro, girl

Ashley and Jeff Neubauer, Greensboro, a girl

Dominique Jenkins-Owens, Greensboro, a girl

Lemlem Merga, Greensboro, a boy

Jennifer and Josh Sammons, Kernersville, a boy

Britany Watkins, Greensboro, a boy

AUG. 4, 2007

Kia Matthews, High Point, a boy

Margaret and Jason Nichols, McLeansville, a boy

Jessica and John Sauerbrei, Reidsville, a boy

Adriana Valenzuela, Greensboro, a boy

Katy Gomez, Greensboro, a girl

Amanda and Eron Adkins, High Point, a boy

Caroline Rollins, Browns Summit, a boy

AUG. 5, 2007

Amanda Greene, Greensboro, a girl

Celenia Sosa, Browns Summit, a girl

Atonya and Patrick Tate, High Point, a girl

Caitlyn Russell, Greensboro, a girl

Belinda and Tim Ratcliffe, Stokesdale, a girl

Samantha and Justin Michaux, Greensboro, a boy JULY 30, 2007

Victoriana Adams, Greensboro, a boy

Mary Allred, Stokesdale, a girl

Katherine Hill-Oppel and Wayne Oppel, Winston-Salem, a boy

Shannon Keith, Greensboro, a girl

Gloria and Omar Solis-Benitez, Greensboro, a boy

Amy and Chris Prato, Greensboro, a boy

Adriana Galeana-Vasquez, Greensboro, a boy

Felishia and Dramane Coulibaly, Greensboro, a boy

Ashley Perrin, Greensboro, a boy

Clarissa and Mark Yost, Greensboro, a girl

Margaret and Martin Halpin, Greensboro, a girl

Maria Garciduenas, Greensboro, a boy

Melissa and Albert Lord, Greensboro, a girl

Uon Mlo, Greensboro, a boy

JULY 31, 2007

Lisa and Trecy Tickle, Gibsonville, a girl

Heather and Jaime Southern, Mayodan, a boy

Jennifer and Timothy Smith, Pleasant Garden, a boy

Nshimirimana and Abdirahman Fatou, Greensboro, a boy

Jessica Hood, Greensboro, a girl

Amma and John Allen, Greensboro, a boy

Carla and Stephen Porter, Greensboro, a boy

Aisha Graham, Greensboro, a girl

Christine and Michael Nay, Kernersville, a girl

Patricia and Andrew Dell, High Point, a boy

Kenisha White, Greensboro, a boy

Entsar and Mahmoud Osman, Greensboro, a boy

AUG. 1, 2007

Paula and Stewart Copenhaven, Summerfield, a girl

Sandra Whitener, Greensboro, a girl

Kimberly and Clifton Smith, Greensboro, a girl

AUG. 2, 2007

Kelly and Joel Ferguson, Greensboro, a girl

Marlina Collins, Greensboro, a girl

Brandi and Michael Potter, Greensboro, a boy

Hope and Brian Thacker, Greensboro, a boy

Michelle and Jake Vinal, Greensboro, a girl

Meagan Rohme, Jamestown, a boy

Shantel Saunders, Greensboro, a boy

Miriam Benavides-Bravo, Greensboro, a boy

Shiho and John Bancroft, Greensboro, a boy

Alicia and Jonathan Blackwell, Greensboro, a girl

Cassondra Sumner, Greensboro, a girl

Stephanie and Anthony Clewis, Liberty, a boy

Tasha Richardson, Greensboro, a girl

Shandi and Douglas Poindexter, Greensboro, a girl

Trisha and Bradley Hoover, Greensboro, a boy

Brittany Black, Greensboro, a girl

Jennifer Young, Greensboro, a girl

AUG. 3, 2007

Yeny Maldonado, Greensboro, a boy

Autumn Stroud, Greensboro, a boy

Elicia and Brent Knight, Madison, a girl

Amanda and Christopher Hover, Greensboro, girl

Ashley and Jeff Neubauer, Greensboro, a girl

Dominique Jenkins-Owens, Greensboro, a girl

Lemlem Merga, Greensboro, a boy

Jennifer and Josh Sammons, Kernersville, a boy

Britany Watkins, Greensboro, a boy

AUG. 4, 2007

Kia Matthews, High Point, a boy

Margaret and Jason Nichols, McLeansville, a boy

Jessica and John Sauerbrei, Reidsville, a boy

Adriana Valenzuela, Greensboro, a boy

Katy Gomez, Greensboro, a girl

Amanda and Eron Adkins, High Point, a boy

Caroline Rollins, Browns Summit, a boy

AUG. 5, 2007

Amanda Greene, Greensboro, a girl

Celenia Sosa, Browns Summit, a girl

Atonya and Patrick Tate, High Point, a girl

Caitlyn Russell, Greensboro, a girl

Belinda and Tim Ratcliffe, Stokesdale, a girl

Samantha and Justin Michaux, Greensboro, a boy

(c) 2007 Greensboro News Record. Provided by ProQuest Information and Learning. All rights Reserved.

Walgreens Receives Value Chain Leadership Award

Recognizing the innovative use of technology to secure the pharmaceutical supply chain and deliver business value, SupplyScape Corporation today announced that Walgreens (NYSE: WAG) is the first retail pharmacy recipient of the Value Chain Leadership Award. The Value Chain Leadership Award honors forward-thinking companies that are solving pharmaceutical supply chain challenges in breakthrough ways.

Walgreens was recognized for its industry-leading contributions towards increasing patient safety at the retail level. Walgreens is the first national drugstore chain to rollout an electronic pedigree (ePedigree) system and has been receiving ePedigrees from its suppliers, including major drug wholesalers, for over a year.

The Value Chain Leadership Award was announced at SupplyScape’s customer dinner held Monday, August 13, in Boston, Mass. The event coincided with the National Association of Chain Drug Stores (NACDS) Pharmacy and Technology Conference, and was attended by healthcare executives from leading chain, specialty and ecommerce pharmacy companies, mass merchants, supermarkets, bio/pharmaceutical manufacturers and wholesalers.

“SupplyScape is proud to recognize Walgreens for its leadership in deploying electronic pedigrees at the retail level,” said Shabbir Dahod, SupplyScape’s president and CEO. “Innovative companies, such as Walgreens, are leveraging SupplyScape’s Product Security solution, the foundation of our On-Demand Value Networks, to increase patient safety, enhance collaboration within the supply chain and improve business performance.”

Electronic pedigrees enhance patient safety by providing a secure chain of custody record that traces a drug from manufacturer through wholesale distributor to pharmacy and preventing counterfeit product from getting into the legitimate pharmaceutical supply chain.

About Walgreens

Walgreen Co. is the nation’s largest drugstore chain with fiscal 2006 sales of $47.4 billion. The company operates 5,850 stores in 48 states and Puerto Rico, including 77 Happy Harry’s stores in Delaware and surrounding states. Walgreens is expanding its patient-first health care services beyond traditional pharmacy through Walgreens Health Services, its managed care division, and Take Care Health Systems, a wholly-owned subsidiary that manages convenient care clinics inside drugstores. Walgreens Health Services assists pharmacy patients and prescription drug and medical plans through Walgreens Health Initiatives, Inc. (a pharmacy benefits manager), Walgreens Mail Service Inc., Walgreens Home Care Inc., and Walgreens Specialty Pharmacy.

About SupplyScape

SupplyScape Corporation is a leading provider of enterprise software and services that maximize revenue, profitability and patient safety across the pharmaceutical supply chain through On-Demand Value Networks. On-Demand Value Networks deliver the real-time network platform, foundational set of product security solutions, and value-enhancing supply chain applications that integrate trading partners into the pharma value chain. Pharmaceutical and biotechnology companies, wholesalers, distributors, and pharmacies rely on SupplyScape On-Demand Value Networks to achieve rapid regulatory compliance, significant operational improvements, and superior business performance from their supply chains. For more information, visit http://www.supplyscape.com.

Mother, Daughter, Massage Hey, Maybe Your Four-Year-Old Would Want a Spa Party?

GRACE ZOBY parked her too-big, white cotton scuffs on the floor and took off her matching robe. In her wrap, she clambered up onto the bed, slipped under the sheet, pulled up the comforter. The coffee-colored room was dim; music drifted from a hidden speaker. “Is this your first facial, Gracie?” the aesthetician asked, wrapping a towel around her client’s wavy blond hair. “Mmm-hmm.””You have pretty skin,” the clinician added. “Thank you,” said Gracie, and her brown eyes fluttered shut.

When you are 8, it’s all pretty skin.

Gracie had come to Spa Phoenix in Virginia Beach with her mother for a little relaxation. As far as Gracie was concerned, this visit was not about smoothing out wrinkles, depuffing the eye area or plumping up collagen-poor lip lines.

This was a treat.

Spas are seeing younger clients these days, following in the footsteps of teens who discovered the indulgence a few years ago. A 2006 survey of teenage spa-goers conducted by the International SPA Association based in Lexington, Ky., showed that nearly 4 million teens ages 13 to 19 had patronized spas in the United States. The organization has not studied the use of spas by younger children.

But an unscientific survey of several local spas revealed that little girls in Hampton Roads have developed spa tastes. Some spas are designing services especially for them.

Gracie is having a busy summer, said her mom, Jessica Zoby. There’s camp for field hockey and lacrosse, tennis team and swim team. The kitchen of the family’s home in the Little Neck section of Virginia Beach is being renovated and, just as school was out, they were in a car accident.

“And she had a tough time this week,” Zoby said about her daughter. “She had her first time trials for swim.”

Cynthia Galumbeck is president, CEO and co-owns Spa Phoenix with her husband, Matthew A. Galumbeck, a plastic surgeon and the spa’s medical director. Before entering the skin care industry, Cindy Galumbeck was a child-and-adolescent psychiatrist.

She is not surprised that she’s seen more children in her spa in the past 12 to 24 months .

“I think it has a lot to do with the general trend in society. Adults are much more stressed, and kids are, too. There are scheduled practices for swimming and soccer, and they need this kind of relaxation just as adults do. Parents are becoming more aware of the benefits of spa treatment.”

Teens, she said, come in for lessons on good skin care routines to help them with acne. Young children tend to arrive with their mothers for joint treatments, especially pedicures where they can sit together and chat. That was the plan for Gracie and her mother – facials, then partner pedicures.

Around Hampton Roads, spa menus now list things like the “Little Miss Sunshine.” For that package, at Anthony’s Salon and Spa in Suffolk, children 8 to 12 years old receive a $60 minipedicure and oatmeal facial.

The salon opened in February and, in deciding what services to include, studied brochures from other spas and salons. The “Little Miss Sunshine” caught on quickly. “It’s very popular for, like, birthdays,” said Amanda Dryden, a cosmetologist apprentice at Anthony’s.

In Norfolk’s Ghent neighborhood, Serenity Spa manager Sandy Nguyen said she recently revised the spa’s menu to include offerings for children.

“Their skin is not a lot of work.” Nguyen said.

During the last few weeks of the school year, Serenity saw a bump in elementary school-age business.

“We had about six parties, and moms brought a whole bunch of kids here, sometimes four, five or six per party, sometimes seven or eight,” Nguyen said. “They had a lot of fun.”

In Portsmouth, Totally Pampered on the corner of Washington and High streets is also seeing younger and younger clients.

They’ve performed ear candling for children for a while. A hollow candle of paraffin wax is put into the ear canal and lit. The resulting vacuum removes ear wax and impurities. The spa has had regulars for that $40 service. The kids especially like the part where the candle is cut open and they can see what came out of their ears.

“Another really popular thing,” said Rhonnie Smith, the spa’s owner, “is your ‘Spa Buddies.’ A lot of moms and daughters come in and get couples massage, a full hour massage with heated stones and oil on tables that are side by side. Each has her own therapist. That’s $115 together.”

Valerie Jackson recently booked that massage for herself and her 12-year-old daughter. Destinee Jackson had begged her mother for a spa treatment for a couple of years. She was even willing to pay for it herself with money she received for making straight A’s in school.

Finally, Jackson decided to allow Destinee the experience as a birthday gift. The occasion also conveyed a message from mother to daughter.

“I’m 42,” said Jackson, a medical assistant and phlebotomist who lives in Suffolk, “and that was my first massage. A lot of her friends don’t get to do a lot of things. I want Destinee to know that there’s more out there, that things cost money, and that you have to go out there and work hard for what you want.”

Afterward, Destinee – who loved the feeling of the stones on her back – said it had been the best part of her summer vacation so far. It was just like she had always seen in the movies.

Gracie enjoyed her mother/daughter spa day, too. She lay limp under steamed towels, toner, sea mineral mask and a facial massage.

Georgia Petridis gave Gracie the lecture prearranged by Gracie’s mom about the need for daily face-washing and regular sunscreen use. Petridis also took a look at Gracie’s pores. A magnifying lens shows any congestion.

“This is where usually I would do an extraction,” Petridis said, patting Gracie’s smooth, pink cheek and pushing the magnifier out of the way, “but she’s a teeny bit young.”

Instead, she gave Gracie another face massage, a vitamin nourishing mask, an arm, hand and finger massage, another warm towel, a moisturizer full of vitamin C serum, another facial massage and, finally, a scalp massage.

It lasted 45 minutes. Petridis said she limits the amount of time she spends on young clients to keep them from getting antsy.

Gracie heaved a deep sigh, opened her eyes and climbed off the table. Her waffle-weave spa robe dragged on the floor on her way to the waiting room, where anti-aging minerals anchored a cosmetic display. Sitting cross-legged on a gray sofa, Gracie sipped a glass of ice water and thumbed through Interior Design magazine while she waited for her mother.

Fifteen minutes later, Zoby emerged from her own facial, took a look at Gracie and said, “Oooh, you’re all glowy.”

Krys Stefansky, (757) 446-2732, [email protected] If you are 6 years old and itching for a mud mask and manicure for yourself and a dozen of your best friends, Michelle Berard can help.

Berard has carved a business niche out of customers’ craving for spa treatments for children still too young to pay for them. Her original enterprise, a mobile hair salon called Hair, There and Everywhere, has been around for 20 years.

Four years ago, she added “Beautiful Birthdays” and painted the windows of her bubble gum-pink van to advertise the idea. “Glamour parties for Young Ladies,” the windows shout, and “Give her a party fit for a princess!”

She has watched, in traffic, as moms nearly run off the roads trying to scribble down her phone number or Web site – www.beautifulbirthdays.com. They call, seldom bat an eye at the requisite fee, then look on in delight as she throws themed parties for children ages 4 and up.

“It was a fast start from the get-go,” said the resident of Virginia Beach’s Kempsville area. “And it’s definitely increased. We get a lot of repeat business now. We have some girls that we’ve had for four years in a row.”

They love her tea party, her fairy princess party, her Cinderella party. The 4- and 5-year-old party guests think it’s funny when she dresses them up in drab clothing, a la Cinderella before her prince has come. Then Berard hands out brooms and feather dusters and tells them it’s time for their chores.

“They are horrified: We have to clean?” she said, laughing.

Lately, what Berard’s little clients really, really want is spa treatments.

Her mini-spa includes a mud mask, make up application and manicure and costs parents $150 for up to 10 kids. More, and she charges $12 per child with a maximum of 20. The cosmetologist’s regular spa party is $150 for up to five girls and $25 per girl after that for a maximum of 12 girls. It’s a bit more lavish with both manicure and pedicure.

Berard makes the whole thing happen with just one helper. To get things started, she twists the kids’ hair up in towels, ties aprons on everyone, then serves fruit smoothies all around. After the mask, girls make a spa kit with bath salts, body glitter, peppermint powder and more. It becomes the gift bag they take home. In between, there are spa games to win prizes – fun diversions like picking up jewels with bare toes and memorizing beauty items attached to a bath robe.

In May, Diane Wickum called Berard for a birthday celebration for her daughter, Marley.

“It was my idea,” Wickum said. “We have three kids and have done all kinds of birthday parties all around town. I was looking for something different, and Marley’s kind of a girly-girl and so are her girlfriends. It was a riot.”

Once the fun was over, it was back to reality. The rising fourth- grader will not be booking herself an appointment in a real spa anytime soon.

“I don’t want her to do it all now,” Wickum said. “She doesn’t have her ears pierced and I’m not going to color her hair when she’s in middle school. I think that those things should wait for a while.”

The sight of a flock of kids having facials still sometimes sets Berard back on her heels.

“Last weekend we were in the Princess Anne Country Club in the Founder’s Room doing mud masks for a 9-year-old’s birthday party,” she said, laughing. “I thought it was insane.”

Insane fun. Kimberly Cordle Smith was the country club mom. She had hired Berard before to make a dream or two come true. The sales rep is on the road a lot missing her girls, so she tends to pull out the stops for her two daughters’ birthdays. She doesn’t routinely take them to spas.

“You have to think about that a young child doesn’t need to be getting this all the time,” Smith said.

But because the day was special, her daughter Lauren’s bash for 16 guests included spa treatments, dancing, lunch and took up two rooms at the club.

Organic ingredients, lipstick and eye shadow, party bags full of goodies and enough video to record it all: “I don’t think this group of girls had ever experienced anything like it,” Smith said. “It was the most unique little spa party.”

(c) 2007 Virginian – Pilot. Provided by ProQuest Information and Learning. All rights Reserved.

Apria Healthcare Names Chief Accounting Officer and Controller

LAKE FOREST, Calif., Aug. 13, 2007 (PRIME NEWSWIRE) — Apria Healthcare Group, Inc. (NYSE:AHG) today announced the appointment of Peter A. Reynolds, CPA, as Chief Accounting Officer and Controller, effective August 13, 2007. Mr. Reynolds will serve as the company’s principal accounting officer, replacing Alicia Price, who recently resigned.

Mr. Reynolds joins Apria Healthcare from Skilled Healthcare Group, Inc., a Foothill Ranch, California-based public company, where he most recently served as Senior Vice President and Chief Accounting Officer.

“We are very pleased to welcome Pete to Apria,” said Chris A. Karkenny, Executive Vice President and Chief Financial Officer of Apria Healthcare. “He brings more than 22 years of healthcare industry experience and demonstrated expertise in all areas of financial reporting. He is a great addition to our team.”

Prior to his role at Skilled Healthcare, Mr. Reynolds was Senior Vice President, Corporate Controller of PacifiCare Health Systems, Inc. and earlier served there as a corporate controller for the insurer’s California operations. Additional experience includes serving as Director of Financial Reporting at Foundation Health Corporation; more than 11 years of public accounting experience at Deloitte & Touche and Ernst & Young, and service as a senior auditor for Blue Cross of California.

A 1981 graduate of Oregon State University with a Bachelor of Science in Business Administration, Mr. Reynolds is also a Certified Public Accountant. He will be based in Apria Healthcare’s corporate headquarters in Lake Forest, California.

Apria provides home respiratory therapy, home infusion therapy and home medical equipment through approximately 500 locations serving patients in all 50 states. With over $1.5 billion in annual revenues, it is one of the nation’s leading home healthcare companies.

This release may contain statements regarding anticipated future developments that are forward-looking statements within the meaning of the Private Securities Litigation Reform Act of 1995. Results may differ materially as a result of the risk factors included in the Company’s filings with the Securities and Exchange Commission and other factors over which the Company has no control.

This news release was distributed by PrimeNewswire, www.primenewswire.com

 CONTACT:  Apria Healthcare Group, Inc.           Lawrence M. Higby, Chief Executive Officer             949.639.4960           Chris A. Karkenny, Chief Financial Officer             949.639.4990 

Streetwalkers Leaving Streets Behind

By Stephen T. Watson

As visitors to her Web site can see, Cindeee is eager to please the right kind of gentleman. The Buffalo-area escort has a sophisticated Internet home, offering photos of her in skimpy lingerie and a rich description of what she offers customers.

The site even boasts a list of her prices, an interactive schedule of her future availability and links to reviews from clients.

“I will provide for you a unique, unforgettable experience – whether it may be a simple dinner date, a night on the town or just some discreet private time together,” Cindeee writes.

As Cindeee’s fans already know, prostitution today has moved from the street corner to the World Wide Web.

Now, prostitutes are setting up their own Web sites, advertising through national sites such as Escorts.com or through classified ads on craigslist. “Back in the day, prostitutes used to have to walk up and down the street. I don’t do that,” said a 26-year-old Town of Tonawanda woman who advertises her services online.

She was one of a dozen current and former escorts, an operator of an escort service, detectives, lawyers and others familiar with the industry interviewed by The Buffalo News. Several spoke about their work only on condition they not be named.

Some escort Web sites spell out in detail what a customer can expect to receive. But many walk a legal tightrope, promising pleasure without explicitly offering sex for money.

The Internet has been a boon for the women, taking the sex trade underground and out of plain sight. It’s also easier for their customers, who can find a wide selection of women whenever they wish from the comfort and safety of their home.

“It’s more discreet. They don’t have to drive through the seedy part of town looking for a woman standing on a street corner,” said Larry Dombrowski, chief detective with the Erie County (Pa.) district attorney’s office, which recently led a Web-based sex-for- pay sting.

Perhaps it was inevitable that the world’s oldest profession and the Internet would converge.

“Certainly that tie between sex and technology has always been there,” said Alex Halavais, an assistant professor of communication at Quinnipiac University who once taught a “Cyberporn and Society” class at the University at Buffalo.

>VHS versus Betamax

In ancient Pompeii, he noted, frescoes played that role: Many of the erotic drawings from that time were ads for prostitutes.

More recently, the VHS format for videocassette recorders beat out Betamax in part because the porn industry backed VHS, Halavais noted, and cybersex has flourished as a result of video file- sharing, Webcams and other advances.

Not everything has changed in prostitution. Street walkers still ply their trade on Niagara Street on Buffalo’s West Side, on Broadway and Walden Avenue on the East Side, and in Niagara Falls, observers said.

Escorts, however, typically are contacted by phone, through an ad in a free newspaper or the phone book. They also can be choosier about their clients.

They charge more than street walkers and usually meet their clients at a hotel room rented by the customer or the escort.

“Sometimes it makes me sick how much money I missed out on because I’m not in the business anymore,” said a Buffalo woman, now 28, who operated a small escort service for several years through 2005.

Police, lawyers and industry observers say a lot of prostitution activity – particularly that of the escorts – seems to have moved onto the Web.

“Online’s just taken over everything,” said David Sugg, a newly retired Buffalo police detective who spent 25 years in the department’s vice squad. “I’d have to say 75 percent of it has to be online now. That’s a guess.”

Escorts are becoming Internet entrepreneurs, setting up their own Web sites, advertising through established adult-entertainment companies or placing ads on classified-ad sites.

Large Web sites such as Escorts. com and TheEroticReview. com let prospective customers search through thousands of escorts by location, by the type of woman desired or by how highly her services were rated by former clients.

A search through Escorts. com in the Buffalo area brought up 85 local escorts, while TheEroticReview.com carries information on 24 “independent providers” who work in the region.

>Courtesan, not escort

One area escort, who calls herself Ciara, has an extensive Web site that features a blog, a list of rules, and quotations from Andy Rooney and Adlai Stevenson.

“Everything you will see here is from the fruits of my own labor. There is no way a stranger or Web design company could do my site. For heaven[‘ s] sakes! How would you get to know the REAL me?” Ciara asks playfully.

The Web sites the women set up vary in sophistication but most offer a brief biography, basic guidelines, alluring photographs, a fee schedule and a calendar of her availability.

One 28-year-old woman who has a Web site advertising her charms prefers to call herself a courtesan, not an escort, and said what she does is part of a lifestyle and not a job.

The Eastern European native, who lives in a Buffalo suburb, provides companionship and intelligent conversation to men of a certain socioeconomic status here and in Las Vegas.

She set up her site to reach a wider geographic range of men.

It describes her physical appearance, standards and fees. She does not like discussing money, but suggested “donations” range from $500 for an hour to $30,000 for a week.

The men pay for her time, she said, not the sex.

“Some men love their wives, but the excitement is not there, and they would like to have some spark,” she said. “And I don’t see anything wrong with that.”

>Help from husband

A 45-year-old man whose 36-year-old wife works as an escort first set up a Web site for her in 2001, when few local escorts had sites and competition was not as strong.

“The Internet has been the main key” to their business, the Niagara Falls man said.

He handles the books, answers e-mails from the men, drives his wife to her appointments and waits outside while she meets the men.

They earn good money – $250 to $300 per hour, plus tips – from clients in Erie and Niagara counties, Rochester and Syracuse.

He said his wife has received several cars as gifts from regular clients, including a BMW 3 Series convertible.

The couple hasn’t gotten into legal trouble but has a prominent local lawyer on retainer just in case. The husband said they report and pay taxes on their earnings.

Their three children – ages 12, 13 and 14 – know what their parents do, he said.

He admits he was uncomfortable at first with his wife sleeping with strange men, but now he views the sex as a business transaction.

“The money’s so good, it makes you look the other way,” he said.

How much can an escort make in a year?

The Niagara Falls man said his wife made $4,000 to $5,000 per week – or $200,000 to $260,000 per year – when she started working as an escort and there wasn’t much local competition. Now she earns less but still makes a good living, he said.

The Town of Tonawanda online escort said she sees an average of 12 to 15 clients per week and charges $200 per session – for an annual income of $125,000 to $150,000 per year.

She said she tries to save $100 per day and, after working as an escort for about 18 months, she has $30,000 in the bank.

The escorts say they couldn’t make as much as they do without the ability to reach customers through the Web.

Some of the sites are helpful for beginners, with answers to frequently asked questions and guidance on what the guy needs to do, plus a glossary that explains the shorthand used by most women.

One standard term – “GFE” – refers to the full girlfriend experience they promise to provide.

The client reviews, not unlike those found on eBay, help ensure customer satisfaction.

At TheEroticReview, for example, a local escort who goes by the names Rosary Gardyn and Sarah has received 10 reviews since June 2004.

Her ratings for her appearance range from “OK if you are drunk” to “Really Hot” and those assessing her performance range from “average” to “went the extra mile.”

Most escort Web sites include some form of legal fig leaf that the escorts are charging a fee for their companionship.

>Non-escort escorts

“They advertise an escort service, but they never go anywhere,” said Dombrowski of the Erie County (Pa.) district attorney’s office. “It kind of takes the escort out of the business.”

But as Mindy and Ricky McAllister, discovered, the system is not foolproof.

The Albion, Pa., couple ran “Take a Trip to Heaven with an Angel,” a Web site that advertised escort services to men in Western New York; Erie, Pa.; and Cleveland, Dombrowski said.

The McAllisters pleaded guilty to misdemeanor prostitution- related charges in Erie, Pa. Their Buffalo-area clients were not prosecuted.

Locally, one of the escorts arrested in an Internet-based sting conducted this spring by Buffalo police called her friends in the escort industry later that night to warn them, the Niagara Falls escort-service operator said.

The threat of arrest hasn’t stopped many escorts from using the Web to advertise. The Town of Tonawanda resident, a single mother of 5- and 6-yearold boys, said she entered the business after visiting friends who worked as escorts in New York City. They told her how to use craigslist and other Web sites to find clients.

>Safety precautions

“Where else can I earn $200 an hour?” asked the escort, who said she has earned an associate degree.

One of her ads on craigslist ran under the title “PLEASURES TREASURES” and featured four photos of her posing in lingerie.

“If they like what they see, they call me,” she said.

She requires the clients to use a condom, and said she undergoes regular testing, which never has come up positive for HIV or a sexually transmitted disease.

She said she doesn’t want to do this forever because having sex with strangers – often married, cheap and unable to carry on an adult conversation – takes an emotional toll.

“What this does is it puts a cold block of ice over your heart. Even if you sleep with someone who you might love. It’s hard to do that,” she said.

MONDAY: Prosecution is difficult

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

Widow of NFL Star to Speak: Connie Payton Will Recall Husband Walter’s Battle With Cancer.

By Jennifer L. Boen, The News-Sentinel, Fort Wayne, Ind.

Aug. 13–Walter Payton’s professional life as a running back for the Chicago Bears centered on being part of a team. He rushed for 16,726 yards, caught 492 passes for 4,538 yards and scored 15 touchdowns during his career.

In February 1999, 12 years into retirement, he announced he had a rare liver disease that would later turn to cancer. In doing so, he became part of a new kind of team with a new goal.

“We formed our own team, with family and friends,” said Connie Payton, his widow. “I would be lying if I said there weren’t days when I got upset or angry. When given a diagnosis of cancer, it affects everyone involved. I learned a lot about patience, about the real understanding of unconditional love.”

On Oct. 4, Connie Payton will be in Fort Wayne to speak at a fundraiser for Cancer Services of Northeast Indiana. She will share her story of hope, faith and lessons of unconditional love while being a part of Walter Payton’s cheer team throughout his life and his death.

Connie Norwood and Walter Payton met when she was a high school senior and he a member of the Jackson State University football team in Jackson, Miss.

“To be honest, it wasn’t love at first sight.” On their first date, “he talked about another girl,” Payton said during a phone interview from Montreal, where she was watching their son, Jarrett, play for the Montreal Alouettes of the Canadian Football League.

But a few weeks later, he called Connie again, and they married in 1976, a year after he graduated and was drafted by the Bears.

“Walter was pretty much the same everywhere. He was funny, always full of surprises,” Payton said. “He always had the right attitude. He was so positive. Even when the Bears were really bad, he was so positive. He’d say he felt like he was doing fine,” she said.

That attitude and perseverance played out in his life off the field too, particularly after he was diagnosed with primary sclerosing cholangitis, a disease that in some cases leads to cancerous tumors on the liver.

“His disease could not be contained, even with a transplant,” Payton said, recalling his public plea on television for people to consider organ donation. Although his cancer was too widespread for a liver transplant, he helped draw attention to the need for organ donors.

“It made a big difference in the state of Illinois, which rose to No. 1 in people signing up to be tissue and organ donors,” Payton said.

Her husband approached death the same way he approached football, Payton said, with a goal in mind.

“We really believed in the power of prayer, meditating on the Word,” she said. “I believe in traditional medicines. They work well, but there is only so much they can do.”

After Walter’s death at age 45 on Nov. 1, 1999, the Payton family established the Walter Payton Cancer Fund, which allows donors to pick areas of research they want to support, including how religion and faith intersect with cancer outcomes, nutrition issues and the effects of exercise.

“Everybody has a passion,” Payton said.

When she researched the work of Cancer Services of Northeast Indiana, she found its mission to provide direct support to patients through medical supplies and equipment, education and transportation aligned with her desire to help families living with cancer get resources they need to fight and cope with the disease.

“It is my hope and my dream that there will someday be a cure for cancer, but meanwhile, I want to help people live with dignity,” she said.

—–

To see more of The News-Sentinel, or to subscribe to the newspaper, go to http://www.FortWayne.com.

Copyright (c) 2007, The News-Sentinel, Fort Wayne, Ind.

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.

Einstein Bariatrics Designated a Center of Excellence By American Society of Bariatric Surgery

PHILADELPHIA, Aug. 13 /PRNewswire/ — Albert Einstein Healthcare Network announced today that its weight loss surgery program, Einstein Bariatrics, has been named an American Society for Bariatric Surgery (ASBS) Bariatric Surgery Center of Excellence. This national distinction recognizes Einstein Bariatrics’ commitment to safety and long-term patient success by providing experienced and comprehensive weight loss surgery services. The rigorous criteria necessary to achieve the Center of Excellence distinction has been met by only one other hospital in the Greater Philadelphia region.

Einstein Bariatrics is located at the Elkins Park campus, a full-service hospital in Montgomery County. Einstein Bariatrics is staffed by experienced surgeons that not only perform surgery, but also are personally committed to the long-term success and follow-up of all their patients.

“At Einstein Bariatrics, we have been extremely proud of our safety record. We have published in the medical literature some of the lowest complication rates. Most of our patients are able to go home after only an overnight stay. We are very happy that the ASBS Centers of Excellence program has recognized our track-record of good work,” said Ramsey Dallal, MD Director of Einstein Bariatrics and a nationally recognized leader in the field.

Dr. Dallal has performed more than one thousand weight loss procedures including the laparoscopic gastric bypass and the adjustable gastric band. “More than 99 percent of my patients have had a laparoscopic procedure, regardless of previous operations or extremely high weight.”

Laparoscopic surgery allows for a much quicker recovery and lower complication rate than the traditional large incisions that have been used in the past. Advanced technologies, when utilized by trained surgeons, have revolutionized the field of weight loss surgery.

Obesity is an extremely difficult medical disease to treat. “Combining multiple treatment approaches has been shown to improve weight loss results. We utilize many strategies, not just medical and surgical services. Experienced psychologists, dieticians and exercise trainers help our patients regain control of their lives,” added Alfred Trang, MD, a fellowship-trained laparoscopic bariatric surgeon who recently joined Einstein Bariatrics.

Weight loss surgery has been well documented to improve, and even reverse many medical illnesses such as diabetes, hypertension and sleep apnea. However, the most important change that occurs with massive weight loss is the dramatic improvement in quality of life. “I can’t promise every patient everything, but I can promise them new possibilities,” said Dr. Dallal.

For a personal consultation with our surgeons or to register for a free information session call 1-800-EINSTEIN or go online at http://www.einsteinbariatrics.com/.

About Albert Einstein Healthcare Network

Albert Einstein Healthcare Network, is a 1,200 bed integrated delivery network serving the communities of North Philadelphia and Montgomery County, PA. A founding member of the Jefferson Health System, Einstein combines the best of academic medicine and community service, employing nearly 7,000 people, and offering training programs for physician residents and fellows, nurses and other health professionals. The Network provides healthcare services through the Albert Einstein Medical Center and Einstein at Elkins Park hospitals, its MossRehab and Belmont Behavioral Health divisions, Germantown Community Health Services, Willow Terrace (a nursing home), Willowcrest (a center for subacute care), outpatient facilities such as Center One and Einstein Neighborhood Healthcare, network of primary care and specialist practices throughout the community. For more information, visit http://www.einstein.edu/ or call 1-800-EINSTEIN.

Albert Einstein Healthcare Network

CONTACT: Alexis Moore, Director of Communications of Albert EinsteinHealthcare Network, +1-215-456-6734, [email protected]

Web site: http://www.einstein.edu/http://www.einsteinbariatrics.com/

Tonsil Removal May Cure ADHD Behavior in Kids

TUCSON, Ariz. — Little T.J. was a monster. There’s no other way to say it.

Extremely hyperactive, the toddler ran around in circles, destroying everything in his path. He choked the cat and dragged it by its tail. He bit the teacher and hit other kids. He got kicked out of day care and banned from friends’ homes.

His own grandmother called the 2-year-old a “monster.” Friends told his family that T.J. _ short for Terence Johnson _ was destined to be “the next serial killer.”

“He was so out of control, I was at my wits’ end,” said his mother, Heather Norton. “It is hurtful to realize nobody likes your child. Even my family didn’t want him to come to events or reunions. Everyone kept telling me he’s got to get help.”

That was then.

Today, as T.J. gets ready to turn 3, he is a changed boy. Lively, to be sure, but affectionate instead of mean and aggressive.

“It’s a total turnaround _ this is a different child,” his mother said. “He’s a normal, active toddler now. He responds to punishment for the first time. He gives us hugs. He says, ‘I love you.’ He’s learning to share. Everybody notices the difference.”

A frontal lobotomy? Electroshock therapy? Powerful drugs? No.

T.J. had his tonsils out.

As medical studies are beginning to confirm, the removal of a child’s tonsils can, in some cases, significantly improve, even cure, severe hyperactivity often diagnosed as attention deficit hyperactivity disorder, or ADHD.

Now affecting more than 2 million U.S. children, ADHD most often is treated with controversial psychoactive drugs, sometimes taken for a lifetime.

But in a significant number of these children _ as many as half of those with an ADHD diagnosis, in one study _ simply removing the tonsils also has removed the diagnosis, by restoring normal behavior.

“Sometimes you get really great results, sometimes you see partial results in these children,” said Dr. Damian Parkinson, a psychiatrist who has been working with T.J. at Pantano Behavioral Services. Parkinson was the first to suggest T.J.’s terrible behavior might be related to his tonsils.

The key to making that connection is how the child sleeps. Snoring, restlessness, apnea, and gasping for breath during the night are clearly linked to hyperactive daytime behavior in very young children. And enlarged or infected tonsils and adenoids _ immune-related tissue masses in the back and upper throat _ most often are the cause of what’s known as “sleep-disordered breathing.”

“What I look for is the child who comes in with typical ADHD symptoms _ he’s hyper, not listening, acting impulsively, hitting other kids _ but who also has trouble sleeping,” Parkinson said. “If the parents notice, and the child is congested and breathing through the mouth, that makes me wonder if the tonsils are the source of the whole problem.”

That’s pretty much the story of T.J.’s young life.

“He never slept through the night, since he was a baby,” his mother said.

Always, T.J. snored _ so loudly his older brother had to move out of his room _ and had a chronically runny nose. But never in her wildest dreams did his mother think any of this was linked to T.J.’s behavior.

Unlike older children and adults, this lack of restful sleep _ and resulting oxygen deprivation _ does not produce daytime sleepiness and fatigue in very young kids. It tends to make them hyper.

“Chronic loss of sleep can drive kids crazy, and the less sleep they get, the more crazy they get,” said Dr. Brice Kopas, T.J.’s pediatrician. “T.J. was impossible. He just could not sit still, for even a second or two.”

But what has been less clear, until recently, is the direct effect of tonsil and adenoid removal on easing, even eliminating, full-fledged ADHD, in children who have sleep problems.

In one recent study, at the University of Michigan, 22 children with ADHD and sleep-disordered breathing had adenotonsillectomies. After one year, 11 no longer battled ADHD.

“These improvements are remarkable because hyperactivity and inattention generally are expected to be chronic features in affected school-age children,” the researchers wrote in a report published last year in the journal Pediatrics.

As a result of this and other recent studies, “doctors conducting healthy-child checkups should always ask about snoring, poor sleep, behavioral and learning problems, and look for physical signs such as enlarged tonsils and adenoids,” reads a summary of the issue published in the Journal of the American Medical Association in June.

And if all those signs converge, surgery is really the only option, said Dr. Sanford Newmark, a Tucson pediatrician who practices integrative medicine, using both mainstream and alternative therapies.

“There really is no other way to deal with it. The tonsils and adenoids are what obstruct the upper airway when a child lies down to sleep, so you have to get them out if that is happening.”

Missing this in young children can mean profound, even life-threatening effects _ including heart and lung damage, and permanent cognitive deficits _ if disrupted sleep persists for five years or longer.

“That’s what clinched it for us. As soon as we heard that, we knew we wanted the surgery for T.J.,” Norton said.

And so, the “little tyrant,” as he was sometimes known, had his tonsils and adenoids out in April at University Medical Center. His surgeon, Dr. David Parry _ Tucson’s only pediatric ear, nose and throat specialist _ had found them “grossly enlarged.”

Tonsils and adenoids swell when they mount an immune response to fight germs.

“Once that is done, they should go back to normal size, but in some kids they don’t,” Parry said. “That may be the result of a chronic low-grade infection that goes undetected.”

The positive effects showed up almost immediately, his mother said.

“Right away, he started sleeping through the night, for the first time in his life. No snoring, no gurgling, no sleeping all over the bed,” she said.

“When his behavior changed, we just didn’t believe it at first. We thought it had to be the pain medicine. But it’s four months later now.

“He’s a normal child.”

Study of Gay Brothers May Find Clues About Sexuality

By Robert Mitchum, Chicago Tribune

In Gregg Mierow’s family, there were six boys, brothers who grew into two groups as they reached maturity: Three are gay, and three are straight.

“It seems innate to me,” Mierow, who works in advertising and as a yoga teacher in Chicago, said of his homosexuality. “It doesn’t seem like there’s any choice involved, and it seemed very clear even when we were very young.”

Mierow stumbled upon a chance to help prove that hunch at the Northalsted Market Days festival four years ago. Spotting a banner reading, “Wanted! Gay Men with a Gay Brother,” he stopped by the booth and volunteered for what he thought would be little more than a survey.

Instead, Mierow found himself part of the Molecular Genetic Study of Sexual Orientation — the most extensive study yet to search for a genetic basis for homosexuality — embarked upon by a team of Chicago researchers from local universities.

The scientists hope that by gathering DNA samples from 1,000 sets of gay brothers like the Mierows they will be able to find genetic linkages smaller studies failed to detect. They’ll be recruiting brothers again at the Halsted Street festival this weekend.

The results may ignite controversy, the researchers acknowledge, both by providing ammunition in the raging cultural war over homosexuality and by raising fears about ethically questionable applications like genetic profiling and prenatal testing.

But, they argue, the research is essential to our biological understanding of sexual behavior.

“If there are genetic contributions to sexual orientation, they will not remain hidden forever — the march of genetic science can’t be stopped,” said Timothy F. Murphy, bioethicist adviser to the study. “It’s not a question of whether we should or should not do this research, it’s that we make sure we’re prepared to protect people from insidious uses of this science.”

Although the question of whether homosexuality is a choice remains a hot topic for pundits, scientists are largely in agreement that sexual orientation is at least partially determined by biology.

Studies that compare identical and fraternal twins for the frequency of a particular behavioral trait have consistently suggested there are both genetic and environmental causes of homosexuality. Identical twins, who share 100 percent of their genes, show a higher chance of both being gay compared with fraternal twins, who typically share the same family environment but only half their genetic code.

Researchers also have found physical traits that correlate with homosexuality, from the relative size of certain brain areas associated with sexual behavior to seemingly irrelevant characteristics like hair whorl direction and finger-length ratios.

Inspired by the accumulating circumstantial evidence of genetic factors, researchers in the early ’90s began trying to narrow down the wide expanse of DNA to a few promising regions. By comparing the genetic codes of gay brothers, who also share 50 percent of their genes, a “linkage study” tries to detect areas that show up in both men at a frequency higher than chance, suggesting one or more genes in that region might be linked to sexual orientation.

In 1993, geneticist Dean Hamer announced his group had found such a region on the X chromosome, which males inherit from their mothers. But the number of brother pairs used in the study was small and subsequent studies failed to replicate Hamer’s findings, throwing the result into question.

“In complex gene scenarios, people figured out that you need a larger sample size in order to get reasonable statistical power,” said Dr. Alan Sanders, a psychiatrist at Evanston Northwestern Healthcare and the leader of the current study.

To increase the chances of finding genetic areas associated with homosexuality, Sanders proposed assembling almost 10 times the sibling pairs of previous studies. The project received funding in 2001 and began recruiting subjects at gay pride festivals, through gay-oriented publications and on the Internet.

So far the Chicago researchers have obtained blood or saliva DNA samples and survey data from more than 600 brother sets, with several hundred other volunteers in the process of submitting one or the other. Sanders hopes to publish his findings from the first wave of DNA samples in a scientific journal sometime next year.

Sanders cautioned a linkage study can single out only regions of the genetic code, not individual genes.

“One of the advantages of linkage studies is that we don’t have to know those things ahead of time,” Sanders said. “It’s a big advantage here because we don’t know about the biology of sexual orientation yet, so we can find the genes first and then study the biology.”

At this point, the researchers do not know what types of genes they may find; they could be related to hormones, sexual development or a completely unexpected system.

“The genes would probably be doing their work by affecting sexual differentiation of the brain during prenatal life,” said J. Michael Bailey, a Northwestern University psychology professor involved with the project. “But what scientists are increasingly appreciating is that genes can affect a trait in ways you could never have guessed.”

The hunt for specific genes that affect sexual orientation may take several years, but the implications of this eventual finding are being fiercely debated already.

“I think this kind of research receives a lot more criticism and attention because people often think it has profound implications for social and moral decisions,” Bailey said. “This is a controversial area. Even though it fascinates people, it scares people from the research end.”

Researchers involved with the project believe finding a genetic linkage will help settle arguments over whether homosexuality is a choice or an innate trait.

“A lot of times people we talk to see this research as providing evidence for something they may [have] already had a notion for, that sexual orientation is influenced by pretty early events out of their control,” said Sanders.

Sanders also suggested that as proof of biological predisposition grows, so too does acceptance and tolerance of homosexuals. A Gallup poll conducted in May indicated 42 percent of the surveyed population believe homosexuality is biologically determined — the highest percentage witnessed in 30 years of polling.

Study volunteer Jason Palmer of Chicago said he hopes evidence of a biological source for homosexuality would change people’s opinions on sexual orientation.

“Our strongest opponents are the religious right, many of whom feel that God does not make mistakes,” Palmer said. “So if it’s a genetic factor and proven, perhaps many of them will find an acceptance for homosexuals.”

But some outside observers worry about how proof of a genetic component to homosexuality might be used politically and even medically.

“If you do research on any human behaviors that would allow us either to treat the behavior or to prevent it altogether by prenatal testing, you have got to ask yourself serious questions about societal context in which this type of research takes place,” said Udo Schuklenk, a professor of philosophy at Queen’s University in Kingston, Ontario.

Critics fear identifying a biological component will lead to prenatal testing and perhaps even treatments for homosexuality. While both Sanders and Bailey expressed doubt about the scientific feasibility or public demand for such applications, Schuklenk suggested they were not considering the worldwide implications.

“I understand why U.S. gays want to know why gay people are gay and understand where they are coming from — there are legal reasons, and the agenda is progressive within the context of the U.S.,” said Schuklenk. “What worries me is that they show a complete disregard of repercussions of research on the international scale, for gay people in societies where civil rights are not as well-protected.”

Mierow said he considered the potential negative ramifications when he volunteered for the study but trusted that changing social views on homosexuality will intervene.

“I hope that by the time science gets to the point [of prenatal testing], society would have progressed enough to not have those feelings,” Mierow said. “I feel like I have more trust in science. It seems like a lot of the bigotry is coming out of religion.”

“People who say that, ‘We shouldn’t know X because knowing X is dangerous,’ to me those are the dangerous people,” Bailey added. “They have provided no good evidence that knowing things is risky; ignorance is what messes us up.”

For now, these discussions will remain largely theoretical until the results of Sanders’ study, as well as others in progress around the country, begin to be released.

As Bailey noted, the results won’t just add to knowledge about the roots of homosexuality, they may also answer more general questions about gender and sexuality.

“Knowing what causes sexual orientation is important scientifically,” he said. “It’s an important aspect of who we are and will provide knowledge about the development of gender, how men and women differ from each other.”

****—

[email protected]

The Forefront of a Medical Revolution: Bioinformatics

By Eric Berger, Houston Chronicle

As candidates for medical pioneers go, Stephen Wong may seem an odd choice.

His two decades of research experience include helping develop the first inkjet printer, working with supercomputer databases and retooling the world’s largest e-commerce Web site. An engineer, he never attended medical school.

But he’s among those at the forefront of a new wave in medicine dubbed “bioinformatics,” which seeks to capitalize on the increasing power of computers as well as the torrent of new information about patients, such as their genes.

Someday, researchers say, doctors using sophisticated diagnostic and data analysis tools will be able to precisely identify a disease and tailor treatment to a person’s biological particulars.

For decades, Houston has been known for its leading-edge heart research. Yet, it is a clear sign of the times that Wong, a star recruited by The Methodist Hospital from Harvard University earlier this summer, will claim a large chunk of the hospital’s two floors of lab space formerly used by legendary heart surgeon Dr. Michael DeBakey.

Computers and molecular research labs will, by and large, replace the facility’s scalpels and heart pumps.

In addition to a lucrative offer from Methodist, which made a multimillion-dollar commitment to his bioinformatics lab, Wong came to Houston for the same reason others have: opportunity.

Here he will be able to test the limits of bioinformatics — whose fingers stretch into mathematics, physics, engineering and biology — without restrictions.

“Texas is a whole change in mind-set,” said Wong, 49, during a recent tour of his new labs. “We want to do something new. The whole idea is, we don’t want to do something small. And this is the place to come and do that.”

Unlike Harvard, with its centuries of history, Methodist offers the opportunity to build something from the ground up.

“I also love to start things from scratch,” Wong said.

Methodist had to start from scratch, too, when it formally split in 2004 from its longtime partner, Baylor College of Medicine. For half a century, Baylor had provided students and cutting-edge research, and many of its faculty members had practiced at Methodist.

After the split, Methodist decided to create its own research institute. In less than three years, the hospital has pumped $100 million into the operation and eventually plans to invest as much as a half-billion dollars.

Wong is among the institute’s highest profile catches, coming from Harvard with nearly two dozen members of his group.

He has never remained in one place for too long. Born in Hong Kong, Wong worked in Australia, Japan, Silicon Valley and several points on the U.S. East coast during his career.

Most recently, at Harvard, he served as founding director of the medical school’s Center of Bioinformatics. There, he helped develop next-generation imaging technologies to see the tiny molecular processes at work inside the body.

Futurist Dr. Steven Seltzer, chairman of radiology at Brigham and Women’s Hospital, which is affiliated with Harvard, characterized Wong’s tenure at the university from 2002 until earlier this year as exceptional.

“His best talent may be his ability to be involved in a wide variety of activities that reflect his broad understanding of the future of biomedical research,” Seltzer said.

Wong may have gotten even higher praise from Boston Globe columnist Steve Bailey, who wrote in June about the importance of intellectual capital in a globalized world.

“When I turn out the light after midnight, I find myself worrying about the Yankees. I worry even more, though, about Stephen Wong,” Bailey wrote.

Methodist expects Wong to bring his sense of innovation to Houston.

A recent meeting of his team here highlighted the scope of his lab and the potential of bioinformatics.

One of his team members, Dr. Hong Zhao, who is researching tumor development, spoke of using a special type of imaging to watch genes as they turn on and off inside cells. Zhao and others believe each type of cancer is marked by tiny molecular signatures that change as tumors spread.

“If we can find a specific biomarker for a specific type of cancer at a specific time, we can tell precisely what that cancer is in the clinic and how far advanced it is, with a simple test,” Zhao said.

Because there is no silver bullet for cancer, therapy relies on a combination of drugs.

Wong’s lab is developing cost-effective ways of screening cancer drug combinations. The goal is to find the best combination for each stage of a specific type of tumor, then ensure that patients, via a simple test during a doctor’s visit, get the right treatment.

Success in that endeavor would represent a major step toward the goal of personalized medicine.

Pulling it all together requires familiarity with a host of medical and biological specialties, from genetics to molecular biology. It also requires the ability to employ powerful computing skills to synthesize the information — finding the biomarkers for each cancer, linking them to effective drug therapy and putting it all in the palm of a physician — from an avalanche of data.

Wong “and his team bring a capability that is really not readily available in any research institute,” said Dr. King Li, chairman of the Department of Radiology at Methodist.

“The next phase of evolution in biomedicine is how to make sense of more and more complex data sets, how to help physicians make sense of this information,” said Li, a friend of Wong’s who helped recruit him to Houston.

Methodist is not alone in recognizing the growing importance of using computers and sophisticated databases to manage medical information.

Information overload The Human Genome Project, a map of human DNA completed a few years ago, is emblematic of the information overload in modern medicine.

Since then, dozens of organisms, from the chimpanzee to the sea urchin have had their DNA decoded. Similarly, scientists have recorded information about the function of as many as 2 million proteins in the human body. Sophisticated imaging and other diagnostic tools have added reams of information about disease and how the human body works.

“What we need to do is make sense of all that data,” said Bradley Broom, an associate professor and acting chairman of the Department of Bioinformatics and Computational Biology at The University of Texas M.D. Anderson Cancer Center.

Broom noted that M.D. Anderson recently acquired a cluster of 1,024 computer processors to do everything from studying how varying types of radiation affect the body to searching for genetic markers of disease.

“This is potentially a very strong area of innovation,” he said.

Wong’s value to Methodist ultimately will be measured in dollars as much as medical innovations. A simple yet critical measurement of a medical institution’s status is the amount of federal research dollars it draws from the National Institutes of Health.

For its first full year of operation, fiscal 2005, Methodist ranked 165th among research institutes, not unexpected for an institution that had just begun hiring. Methodist wants to be in the top 10 within a few years. Wong has his sights set on top five or even the top of the heap for radiology funding.

Seltzer said Wong has talent for obtaining outside grants. Yet it will be difficult for a newly created institution to rapidly ascend the NIH’s funding lists.

Houston’s new recruit has one other goal, one befitting Space City as well as being consistent with his aim of delivering care that combines diagnosis and treatment in a single, tidy bundle.

“My real dream,” Wong admitted, “is a Star Trek-like tricorder.”

[email protected]

New AltaMed East Los Angeles Adult Day Health Care Center Opening Provides Critical Resource for Latino Community

LOS ANGELES, Aug. 10 /PRNewswire/ — AltaMed Health Services and community leaders, today celebrated the Grand Opening of its Adult Day Health Care (ADHC) center located in East Los Angeles, further establishing the success and benefits ADHC’s provide to the community.

The ADHC is designed to offer support to adults 18 years and older through health programs and services that will maintain or enhance their medical, functional or mental status. The programs and services offered by ADHC include transportation to and from the ADHC, nursing care, individual counseling, physical, occupational and speech therapy, recreational activities, emotional support for caregivers, health education classes and community resources. With the Latino elderly population expected to increase 328% by 2030, the demand for this type of facility will continue to grow.

“Our approach to health care is patient centered, which means we put the patient and their families in the center of our care team of motivated and dedicated professionals,” said Castulo de la Rocha, President and CEO of AltaMed Health Services. “We have designed the East Los Angeles ADHC to meet the specific needs of Latino patients and their families who prefer to keep loved ones in the home rather than placing them in long-term care facilities.”

The new ADHC is focused on promoting independence for its participants, an important aspect to the well being of the adult and family caregivers. The most recent research on Latino family caregivers (Family Caregivers of Impoverished Mexican American Elderly Women: The Perceived Impact of Adult Day Health Care Centers — Albert A. Valadez, Christine Lumadue, Bibiana Gutierrez, Sabina de Vries-Kell) confirms what AltaMed’s ADHC centers have long known and experienced in their community — an inclusive Adult Day Health Care center provides benefits not only for those who use them but for family caregivers as well.

“AltaMed is one of the Nation’s leaders in providing culturally appropriate health care services to underserved populations,” said Assemblyman Charles M. Calderon. “This new ADHC answers a critical need within this community and provides families and caregivers with a wonderful resource to provide quality care for parents and other family members in order to maintain balance in their own lives. I am pleased the State of California continues to demonstrate its commitment to funding Adult Day Health Care Centers.”

Research suggests the responsibility of taking care of a family member can cause family caregivers to experience mild depression, stress, loss of morale, feelings of guilt, frustration, irritation and in rare cases resentment toward the adult in care. In turn, the adult in care can feel depressed and begin to isolate himself/herself from their environment. Community-based long term care services, such as AltaMed’s ADHC centers, enable adults to reach their maximum potential of independence and provide family caregivers with the support they need to continue providing their family with a healthy lifestyle and non-institutional environment.

“I look forward to seeing the AltaMed bus at my door in the morning, the center is a place where I can sit and talk with friends, exercise and even play games,” said Pedro Valle, a patient at the East Los Angeles ADHC. He continued, “my children don’t have to worry about me while they are at work because the staff at the center takes good care of us.”

The new AltaMed East Los Angeles Adult Day Health Care Center is located at 6210 Whittier Boulevard, Los Angeles, CA 90022 and is open from 7:30 a.m. to 4:00 p.m., Monday thru Friday.

The services offered by ADHC’s are available free of cost to individuals enrolled in Medi-Cal or Private Pay for non-Medi-Cal beneficiaries. For more information on AltaMed Services please call (877) 462-2582.

ABOUT ALTAMED HEALTH SERVICES CORPORATION

AltaMed Health Services, a private nonprofit organization, is a major provider of health and human services in the Greater Los Angeles area and one of the largest Federally Qualified Health Centers (FQHC) in the State of California. The mission of AltaMed is to provide high quality, coordinated, comprehensive health and human services to the underserved in Southern California, with particular attention to Latino and multi-ethnic populations. AltaMed began as the East Los Angeles Barrio Free Clinic in 1969, a volunteer-staff storefront providing basic medical services. Today AltaMed’s service area extends beyond East Los Angeles, to the immediately surrounding and contiguous Greater East Los Angeles area, Los Angeles communities and the San Gabriel Valley.

AltaMed Health Services Corporation

CONTACT: Janeth Hernandez of Arevalo Sanchez, Inc., +1-909-964-1414, forAltaMed

Playground Love: Landscape and Longing in Sofia Coppola’s The Virgin Suicides

By Hoskin, Bree

“Longing, we say, because desire is full of endless distances.” – Robert Hass

Sofia Coppola’s 2000 film The Virgin Suicides, based on the 1993 novel by Jeffrey Eugenides, is a meditation on longing and suburbia, filtered through the collective consciousness of a group of males looking back from adulthood at the experience of their adolescence when they were infatuated with five girls in their neighborhood – the Lisbon sisters. The film begins with the attempted suicide of the youngest girl, thirteen-year-old Cecilia, and ends with the suicides of all of them. However, The Virgin Suicides concerns itself not with the reasons behind the five deaths, but rather, the film concerns itself with the subjective phenomenon of longing – adolescent sexual longing, nostalgic longing for the experiences of youth, and the dilemma of both physical and temporal distance evoked by the word “longing.” The suburban landscape, presented at first as a type of residential playground where children play basketball, jump through sprinklers, and eat popsicles, is particularly significant. Its mundane familiarity and uniformity act as a universal space of nostalgia for the experience of childhood at the same time as it provides an innocuous veneer for the horror and mystery that reside behind the leafy foliage and the walls of the pleasant houses, thereby enabling The Virgin Suicides to be seen as a “suburban Gothic.” That is, the thematic concern of The Virgin Suicides – the destruction of childhood – is as much about anxiety as it is about longing, thus sharing similarities with a Gothic literary and filmic tradition in which fear and desire are often inextricably linked. Moreover, like contemporary Gothic literary and filmic culture that regularly uses suburbia to turn everyday, relatable events into terror, the use of setting in Coppola’s film is an integral component in that it gives a haunting immediacy to its concern with both remembering childhood and mourning its loss.

Coppola’s film is set in suburban Michigan during the 1 970s, an era characterized by an awareness of and anxiety over environmental degradation. According to VaI Stevens, the seventies saw the growth of the Ecology movement throughout the United States, Australia, New Zealand, and Europe:

With the setting up of the Conservation Society, Friends of the Earth (FOE), Greenpeace, then the Ecology Party, and, later, the Socialist Environment and Resources Association […] it seemed that there were more ways than one of destroying life on earth. Population growth [. . .] mounting pollution of air, land and sea, all loomed as insidious, but certain means of destroying our life support systems. (9)

Such apprehension over the gradual environmental changes induced by modern industrial society had found an ominous precursor in Rachel Carson’s 1962 text Silent Spring, which introduces a discussion of DDT and chemical pesticides with a description of “a town in the heart of America” that awakes to a spring without birds or flowers : “A grim spectre has crept upon us almost unnoticed, and this imagined tragedy may easily become a stark reality we all shall know” (qtd. in Buell 642). As such, Coppola’s film presents a suburban landscape dotted with trees marked for removal on account of Dutch elm disease and an atmosphere that at the end is overcome by a swamp smell arising from a spill at a Plant that has increased phosphates in the lake. Cecilia mourns the fact that another animal has been added to the endangered species list and the four eldest Lisbon sisters protest the removal of a tree from their front yard. This sense of environmental decay acts metaphorically for the narrative’s account of the short lives and suicides of the five adolescent Lisbon sisters-Cecilia (Hanna Hall), Lux (Kirsten Dunst), Bonnie (Chelse Swain), Mary (A. J. Cook) and Therese (Leslie Hayrnan). As the film narrates: “Everyone dates the demise of our neighborhood from the suicides of the Lisbon girls. People saw their clairvoyance in the wiped out elms, the harsh sunlight, and the continuing decline of our auto industry.” In turn, the death of both nature and the girls acts as a symbol for the idea that the growth from childhood to maturity involves the destruction of a part of the younger self. It is not for nothing that the theme to Alice O’Connor’s rite-of-passage debutante party is “Asphyxiation,” inspired by the chemical spill, where guests wear glittered gas masks and eat lurid green ice cream. The Lisbon sisters die while everyone else grows up. Girls their age throw debutante parties; Lux’s ex-lover Trip Fontaine (Josh Hartnett) recalls the affair from a detoxification ranch in his middle age; and the neighborhood boys live to tell the twenty-five-year-old story of the Lisbon girls. Coppola, in an interview given for the documentary The Making of the Virgin Suicides, articulates the symbolic space of loss and longing occupied by the sisters:

The story’s really a reflection of these boys when they’re older looking back on this time when they all had this infatuation, this obsession, with these ideal girls and these girls are kind of these magical, beautiful creatures and there’s always those kind of moments in life that are magical and perfect but they never last, and then you go on and they have always left something with you.

In an interview given for the same documentary, Eugenides expresses how the girls act as figures for the lost experiences of youth and for the type of infatuation that only comes with adolescence, stating, “it’s a lot about voyeurism and memory and the sort of obsessional (sic) love that you have when you’re thirteen or fourteen.”

In this analytical context, then, Susan Stewart’s writings on suburbia seem particularly resonant:

Let me begin with the invisibility and blindness of the suburbs [. . .] the absence of the landscape of voyage. The suburbs present us with a negation of the present; a landscape consumed by its past and its future. Hence the two foci of the suburbs: the nostalgic and the technological. A butterchurn fashioned into an electric light, a refrigerator covered by children’s drawings, the industrial “park,” the insurance company’s “campus” [. . .] Here is a landscape of apprehension: close to nature, and not consumed by her; close to culture, close enough to consume her [. . .] to walk in the suburbs is to announce a crippling, a renunciation of speed. In the suburbs only outsiders walk, while the houses are illuminated as stages, scenes of an uncertain action. In these overapparent arrangements of interior space, confusion and distance mark the light. (1)

It seems appropriate that the suburbs should be the setting for The Virgin Suicides – the space of nostalgia for childhood and a space within which a slippage occurs between nature and technology, thereby illuminating the tropes of dying nature and dying childhood, emblematized by the Lisbon sisters. Moreover, just as Stewart sees the suburbs as an insular landscape where “only outsiders walk,” Coppola similarly strove to film parts of the action from the view point of an outsider. Describing the deliberately theatrical arrangement of Cecilia’s death scene, Coppola explains:

I wanted it to look like the final scene of a tragic opera, so I pulled back wide [. . .] you see it from the neighbour’s perspective, from the outside. The boys are shocked, they don’t understand what has happened, and the audience can’t tell at first either. Cecilia looks as if she’s levitating – like a magic act. You’re seeing it through the haze of memory, so things are left out and things are added to it. It’s not as it really happened [. . .] Jeffrey [Eugenides] calls the Lisbons the fever dream of the boys. I wanted to make the movie a fever dream, (qtd. in Winter 144)

The rest of the film similarly drifts between dream and memory. A. O. Scott notices how the film takes advantage of the cinematic medium in order to evoke this dreamscape of recollection: “Edward Lachman, the director of photography, shoots the bright colours of the 1970s as if through a layer of gauze. His dimmed, fuzzy tones suggest the darkening shades of memory” (New York Times E. 1:16). The neighborhood boys conjure up images of the girls in a field with a unicorn and traipsing off to exotic locations widi them, where even Cecilia is not dead, but living as an Indian princess in Calcutta. The pin-pose of these images is to expose the fantastical element integral to understanding the discrepancy between the “real” past and the “remembered” past. That is, these images remind die audience that die film’s representation of the sisters, and the past in general, reside in the collective memory of the boys, a memory that both informs and is informed by their subjective longings in the present, manifested in dieir dreams. Their memory of the past may be susceptible to the erosive power of time, however, the fantastical images reveal how their memories, when tiiey are rediscovered and recalled, are able to take on an independent life colored by fantasy. Indeed, Celeste Olalquiaga recognizes this strong compatibility between memory and fantasy when describing die phenomenon of recollection:

Memories and idle fantasies slowly conform to the irregular panorama of the psyche [. . .] memories [. . .] often lie peacefully sequestered in the recondite folds of our mind, patiently awaiting the moment when they will be aroused from this entrapment to fly again on the wings of fantasy. (6-7) After this surrealist journey to exotic locations, the film narrates, “the only way we could feel close to the girls was through these impossible excursions which have scarred us forever, making us happier with dreams than wives.” These visions thus suggest that it is through dreams that both spatial and temporal distances are erased. However, these dreams, in which physical and temporal proximity are possible, also make clear the fact that a real proximity to the past is impossible to achieve. It is this dilemma of an irrecoverable past that forms the basis upon which nostalgia relies. Stewart’s writings on what she calls “the social disease of nostalgia” suggest that nostalgia, recalling her thoughts on suburbia as presenting a “negation of the present,” is inherently inauthentic “because it does not take part in lived experience,” in the “real” world of the present. That is, while still an aumentic, or “real” feeling, nostalgia denies the reality of the present and attempts to give the past an authenticity that is impossible to give, and thus the past it desires is “always absent, that past continually threatens to reproduce itself as a felt lack.” According to Stewart, what is remarkable about the nostalgic narrative is that its very existence self-consciously hinges upon this “felt lack”:

This point of desire which the nostalgic seeks is in fact the absence that is the very generating mechanism of desire. The realisation of re-union imagined by the nostalgic is a narrative utopia that works only by virtue of its partiality, its lack of fixity and closure. Nostalgia is the desire to desire. (23)

Moreover, the fact that nostalgia will always fail to reach its false goal of finding an authentic past as a lived, unmediated experience ensures nostalgia’s compulsive repetition: “Nostalgia is the repetition that mourns the

As experience is increasingly mediated and abstracted, the lived relation of the body to the phenomenological world is replaced by the nostalgic myth of contact and presence. “Authentic” experience becomes both elusive and allusive as it is placed beyond the horizon of present lived experience, the beyond in which the antique, the pastoral, the exotic and other fictive domains are articulated. In this process of distancing, the memory of the body is replaced by the memory of the object, a memory standing outside the self and thus presenting both a surplus and lack of significance. (133)

Beginning with the procurement of Cecilia’s diary, the boys “collect everything we could of theirs,” and the film visually catalogues various and sundry items such as year book photographs, invitations, eyelash curlers, lipstick, records, hair brushes, and nail polish. This process of locating authenticity in material objects is, then, a legitimate means of attempting to satisfy nostalgic desire, acting, like dreams, as a medium through which the temporal disjunctions that constitute nostalgia are resolved through their dissolution. For an instant, desire is fulfilled. Moreover, echoing Stewart’s writings on suburbia as a landscape of stagnation, the death of the Lisbon girls constitutes their entrapment in the stagnated world of nostalgia, their memory forever trapped in objects, repetitive dreams, and rows of pleasant houses on suburban streets. The boys will always be outsiders looking in and back at the Lisbon house, and the girls will always be inside, illuminating a lack of not only temporal, but also physical, proximity: “They hadn’t heard us calling, still did not hear us, calling them out of those rooms where they went to be alone for all time.”

Of course, The Virgin Suicides is not only about remembering adolescence, it is also about mourning its loss and, as such, Coppola’s film disturbs its fanciful nostalgic narrative by evoking a sense of unease characteristic of a Gothic literary and filmic tradition. Indeed, Marie MulveyRoberts, quoting Angela Carter, argues that for a text to be defined as “Gothic” it needs only to retain “a singular moral function – that of provoking unease” (xvii). Since Gothic as a literary form was initiated by Horace Walpole’s 1764 novel The Castle ofOtranto, which features a haunted castle, supernatural elements, a mad prince, and frightened heroines, Gothic tropes such as setting, atmosphere, and style have been employed in literature and film to provoke this fundamental sense of anxiety. During the evolution of the Gothic cultural tradition, these tropes have increasingly been applied to mundane or familiar settings, such as suburbia or high school corridors, in order to enhance their disruptive effects. The literary work of Stephen King, films such as Wes Craven’s A Nightmare on Elm Street (1984) and Sam Mendes’s 1999 American Beauty, and the television series Desperate Housewives have explored the dark side of small town or suburban life through the use of Gothic tropes such as the supernatural, violence, death, and entrapment.1 In the case of The Virgin Suicides, all these tropes are employed in order to represent the dark side of its suburban haze of adolescent life. The Lisbon house, which Stanley Kauffrnan calls “the prettified locus of the death” (31), becomes the haunted castle through which its darkened rooms and basement the neighborhood boys creep only to stumble upon the lifeless bodies of the Lisbon girls. After the girls are grounded for Lux’s failure to make curfew following their group date to a school dance, Lux’s complaint that she “can’t breathe in here” is reminiscent of Madeleine’s entombment, or live burial, in the sleeping compartment of Roderick’s house in Edgar Allen Poe’s 1839 tale “The Fall of the House of Usher,” while the various sightings of Cecilia’s ghost by Mr. Lisbon (James Woods) and the neighborhood boys Chase Buell (Anthony Desimone) and Tim Weiner (Jonathan Tucker) echo the preoccupation of many Gothic texts with the supernatural and the inexplicable. David Punter’s suggestion that, in Gothic texts, the ghost “comes to menace the bodily with its limitations” (2) is poignant considering that The Virgin Suicides can be seen as concerned with the idea that the body’s aging process involves the degradation and destruction of a part of the younger self.

Moreover, Coppola’s film shares similarities with fhe Gothic due to its excessive qualities – its concern with obsessive longing. Clive Bloom asserts that “Gothic signifies a writing of excess” as much as it signifies social disturbance, and goes on to identify this theory of excess with “theories of me excessive body” such as blood, sweat, and tears (4). In turn, Coppola’s film makes use of bodily functions to enhance its concern wim the excessive sexual longing of adolescence. Peter Sisten (Chris Hale), invited over to the Lisbon house for dinner, rummages tiirough their bathroom, sniffing a tube of lipstick and looking in awe at a closet full of boxes of Tampax tampons, and Dominic Palazzolo (Joe Dinicol), an Italian exchange student, declares his love for the young tennis player Diana Porter as he watches her wipe sweat from her brow. He even jumps from the roof of his relatives’ house “to prove the validity of his love” after Diana leaves on vacation with her parents. However, while die film can be read as a meditation on the subjective longing of males, the film also provides episodes that focus on excessive female longing for a male object of desire – Trip Fontaine. As the film narrates, “all the girls at our school were in love with Trip.” The film offers a fantastical montage in which he struts through die high school corridor to Heart’s “Magic Man” as dozens of girls turn their heads in his direction. As the soundtrack implies, Trip, like the Lisbon girls, is able to take on magical properties, and the camera meditates on his face and body as he smokes a joint in his car and floats topless in his above-ground pool. Even Lux is shown, in a moment of superimposed imagery, to have Trip’s name written in Magic Marker on her underpants. Cecilia’s diary earlier reveals that Lux had written the name of Kevin the garbage man on her underwear and “cried on her bed all day” when her motiier had bleached out all the “Kevins.” Coppola’s film, men, can be seen as concerned wim gender-neutral excessive longing. Of course, according to Eugenides, this kind of excess only comes “when you’re thirteen or fourteen” and, for Punter, this time of excess is ideal for fhe Gothic writer. Indeed, adolescence is “integral to Gothic.” On a physical level, adolescence lends itself to “theories of me excessive body”: Adolescence might be seen as a time when there is a fantasized inversion of boundaries. To put it very simply: we exist on a terrain where what is inside finds itself outside (acne, menstrual blood, rage) and what we think should be visibly outside (heroic dreams, attractiveness, sexual organs) remain resolutely inside and hidden. (Punter 6)

On an emotional level, adolescence certainly signifies an excess of desire:

Gothic heroes are “incommensurate.” Their relation to the world is posited on a pure trajectory of desire, with no appreciation of limits; the limits are for later, for an unimaginable maturity which will be marked by the ever-impending rule of law, when our bodies will bow down to the rule of “that which is” [. . .] Thus Gothic will always appear to have to do with a kind of madness, an inexplicability: as Stephen King puts it in Christine (1983), the assemblages are “teenage car songs,””teenage love songs,””teenage death songs,” all with lyrics never quite intelligible to the concerned adult. But there is therefore also a further shadow; as Gothic eludes the sliding under the sign of social normalcy, so also it carries with it tremulous memories of a past childhood (another “point of origin”) in which freedom did not have to be defended so vigorously, in which self-consciousness had not reared its head. (Punter 13)

In this analytical context, then, it is understandable that many of the adults in the film are shown to be ignorant or misguided. After Cecilia’s first suicide attempt, Mrs. Buell (Sherry Miller) suggests, “that girl didn’t want to die. She wanted out ofthat house,” to which Mrs. Scheer (Dawn Greenhalgh) adds, “she wanted out ofthat decorating scheme.” An adult guest at Alice’s debutante party jokingly bids farewell to the “cruel world” and falls into the swimming pool. He climbs out of the water and sarcastically cries, “I’m a teenager – I’ve got problems!” After the suicides, newsreaders confuse details and mix up the names of the girls, while Mrs. Lisbon (Kathleen Turner), who forces Lux to burn her rock records and tyrannically punishes her daughters by taking them out of school and incarcerating them in the house, says in hindsight, “none of my daughters lacked for any love. There was plenty of love in our house. I never understood why.” Her ineffectual husband talks to plants and sits staring up at the model solar system in his classroom. He hints at the adolescence he has lost when, during a conversation with Trip about football, he proudly remarks, “I was a safety in my day.” Thus, attempts to blame the suicides on the parents – Chris Chang, while accepting that the suicides are essentially inexplicable, nonedieless suggests that “Turner, with a severe maternal air [. . .] is not exactly above suspicion” (73) – are for the most part futile when it is considered, at least on a thematic level, mat the parents are more victims of the limits of maturity and thus doomed never to understand the excessive teenage passion and angst of their children, rather than aggressors of the suicides. Indeed, Coppola’s film can be seen as a dark artistic expression of the experience of anyone who has looked back on the obsessive crushes or rebellious actions of their teenage years and thought to themselves, “What was I thinking?” Moreover, the neighborhood boys, from the vantage point of twenty-five-years later and thus in their middle age, are also destined never to uncover the mystery of the Lisbon sisters. As they narrate, “in the end we had pieces of the puzzle, but no matter how we put them together, gaps remained, oddly shaped emptiness mapped by what surrounded them, like countries we couldn’t name.” As Punter observes, Gothic “carries with it tremulous memories of a past childhood,” and as such the neighborhood boys are destined only to speculate and dream about the past. The suicides must remain a mystery never to be solved, like nostalgia itself that never finds an end point but instead runs disconsolately round and round in the mind, dependent on the fantasy of memory and the evocative inanimate objects that the past leaves behind. Toward the end of the film the camera hovers over the empty, dimly lit Lisbon house while the neighborhood boys narrate, “[…] what lingered after them was not life, but the most trivial list of mundane facts.” It is no wonder, then, that the film’s website is cluttered with these banalities: photographs, album covers, and the cover art for the aptly titled board game “Mystery Date.”

Like the seemingly banal material vestiges of the past, the suburbs are loaded with significance in Coppola’s The Virgin Suicides, acting as a universal space of childhood experience, a space onto which is projected both the hope and hopelessness of nostalgic longing – the hope for a return to an authentic past and the hopelessness of the fact that this past is lost forever. In fact, Coppola herself lives in the suburbs and drew upon her own residential status as inspiration:

There’s something weird about it. It’s appealing to me because I live in suburbia. I’ve seen photos of suburbs in Iceland and Japan and here in America, and mere’s always something similar about them. They have a really similar feeling. All over the world, the suburban experience is the same, (qtd. in Denver Post 92)

As the camera sweeps over the leafy suburban street, the film ends, poignantly, with this sense of universal longing, narrating, “it didn’t matter in the end how old they had been, or that they were girls, but that we had loved them.” Over the rolling credits comes the music of Air and the vocals of Gordon Tracks, and the audience is left with an eloquent summary of the film’s ultimate preoccupation with excessive teenage longing in a traditional childhood space:

I’m a high school lover

And you ‘re my favourite flavour

Love takes hold

Of my soul

You ‘re my playground love.

Note

1 Particularly noteworthy here is Stephen King’s interest in the end of childhood. Rob Reiner’s film Stand by Me (1986), adapted from King’s short story “The Body,” tells of four twelve-year-old boys from the small American town Castle Rock who become privy to the whereabouts of Ray Brower, another twelve-year-old boy who had been hit by a train while on an excursion to pick blueberries. Before telling the police, the boys set out on a journey to see the body for themselves. The tale is a meditation on the end of innocence, symbolized by the dead body, as much as it is a nostalgic celebration of the adventure of adolescence.

Works Cited

Bloom, Clive. Gothic Horror: A Reader’s Guide from Poe to King and Beyond. Basingstoke: Macmillan, 1998.

Buell, Lawrence. “Toxic Discourse.” Critical Inquiry 24.3 (1998): 639-66.

Chang, Chris. “The Virgin Suicides.” Film Comment 36.2 (2000): 73- 74.

Denver Post 15 May 2000: 92

Eugenides, Jeffrey. The Virgin Suicides. London: Abacus, 1993.

Hass, Robert. “Meditations at Lagunitas.” Modern American Poetry 1 Sept. 2005 < hass online>.

Kaufiman, Stanley. “Youth and other puzzles.” The New Republic 222.20 (2000): 30-32.

The Making of The Virgin Suicides. Dir. Sofia Coppola. Paramount, 2000.

Mulvey-Roberts, Marie. The Handbook to Gothic Literature. Houndmills: Macmillan, 1998.

New York Times 21 Apr. 2000: E.l:16.

Olalquiaga, Celeste. 77ie Artificial Kingdom: A Treasury of the Kitsch Experience with Remarkable Objects of Art and Nature. New York: Pantheon, 1998.

Poe, Edgar Allen. “The Fall of the House of Usher.” The Complete Tales and Poems of Edgar Allen Poe. London: Penguin, 1982.

Punter, David. Gothic Pathologies: The Text, theBody, andtheLaw. Basingstoke: Macmillan, 1998.

Stand by Me. Dir. Rob Reiner. Columbia Pictures, 1986.

Stevens, VaI. “The Importance of the environmental movement.” The CND Story: The first twenty-five years of CND in the words of the people involved. Eds. John Minnion and Philip Bolsover. London: Allison and Busby, 1983.

Stewart, Susan. On Longing: Narratives of the Miniature, the Gigantic, the Souvenir, the Collection. Baltimore: Johns Hopkins UP, 1984.

The Virgin Suicides. Dir. Sofia Coppola. Paramount, 2000.

Walpole, Horace. The Castle ofOtranto. Ed. Michael Gamer. London and New York: Penguin, 2001.

Winter, Jessica. “Sofia Coppola’s mystery girls.” The Village Voice 45.15 (2000): 144.

Bree Hoskin

The University of Western Australia

Copyright Salisbury University 2007

(c) 2007 Literature/Film Quarterly. Provided by ProQuest Information and Learning. All rights Reserved.

Review Examines the Use of Sirtex’s SIR-Spheres(R) Microspheres in Patients With Hepatic Colorectal Cancer Metastases

A review article, published in the July issue of Archives of Surgery, an international peer-reviewed journal, examines the use of Sirtex’s SIR-Spheres® microspheres in patients with hepatic colorectal cancer metastases. According to the review, the use of SIR-Spheres microspheres is effective in improving response rates and extending survival times in patients with colorectal cancer liver metastases. Sirtex’s SIR-Spheres microspheres are currently FDA approved to treat colorectal cancer that has spread to the liver.1

Seza A. Gulec, M.D., F.A.C.S., director of the Goshen Cancer Institute Hepatic Oncology Program at Goshen Health System, and Yuman Fong, M.D., chief of gastric and mixed tumor service at Memorial Sloan Kettering Cancer Center, partnered to discuss the basic concepts involved in development of Yttrium 90 (Y-90) microsphere Selective Internal Radiation Therapy (SIRT) and review clinical data pertaining to its application.

Using retrospective data from several studies, including a Phase III randomized study of patients with metastatic colorectal cancer liver metastases, the oxaliplatin dose-escalation study, retrospective data from New Zealand, and U.S. experience, Gulec and Fong concluded that SIRT is a promising therapy in the treatment of patients with hepatic colorectal cancer metastases as part of a multimodality approach.

“This review is important because it not only reinforces the efficacy of SIRT, but also provides insight into how we can best treat metastatic liver tumors,” says Gulec. “By combining chemotherapy with SIRT, this approach has the potential to improve therapeutic outcomes by maximizing the effectiveness of both modalities.”

The authors concluded that clinical studies in neoadjuvant and salvage settings are needed for more concrete outcome data and design of optimal multimodality treatment strategies. For reprints of the article, visit http://archsurg.ama-assn.org.

1Sirtex Medical Inc.’s SIR-Spheres® microspheres are indicated for the treatment of non-resectable metastatic colorectal cancer in combination with intra-arterial FUDR chemotherapy. Information regarding other disease states or agents in combination with this device that is presented in peer-reviewed literature is different from the approved USA labeling for SIR-Spheres.

About Selective Internal Radiation Therapy (SIRT) using SIR-Spheres microspheres

Selective Internal Radiation Therapy (SIRT) is a novel treatment for inoperable liver cancer that delivers high doses of radiation directly to the site of tumors. In a minimally invasive treatment, millions of radioactive SIR-Spheres microspheres are infused via a catheter into the liver where they selectively target liver tumors with a dose of internal radiation up to 40 times higher than conventional radiotherapy, while sparing healthy tissue.

Clinical trials have confirmed that liver cancer patients treated with SIR-Spheres microspheres have response rates higher than with other forms of treatment, resulting in increased life expectancy, greater periods without tumor activity and improved quality of life. SIRT has been found to shrink liver tumors more than chemotherapy alone.

SIRT using SIR-Spheres microspheres is approved for use in Australia, New Zealand, the United States of America (FDA approval), European Union (CE Mark), Hong Kong, Malaysia, Singapore, Thailand, Israel and India. SIRT is available in 140 treatment centers around the world, and more than 6,500 patients have been treated to date.

Approximately 90 physicians in the United States use Sirtex’s SIR-Spheres microspheres in more than 86 medical centers. For more information, visit www.sirtex.com.

® SIR-Spheres is a Registered Trademark of Sirtex SIR-Spheres Pty Ltd

Sorin Group: ELA Medical, Inc. Enrolls First Patient in the NATURE Observational Study in the U.S.

Study Will Look Into the Evolution Of AV Conduction Disorders in Pacemaker Patients.

ELA Medical, Inc., a Sorin Group company (MIL:SRN) that specializes in the design and manufacture of implantable pacemakers and defibrillators, announced the first U.S. implant in NATURE, an observational study that will enroll 1,440 patients in North America and Europe.

The objective of the NATURE study is to observe the evolution of atrio-ventricular conduction disorders in pacemaker patients over a 2-year time period. Patients implanted with either ELA Medical / Sorin Group’s SYMPHONYTM model 2550 or REPLYTM DR (1) dual chamber pacemakers will be included in the study. Data will be collected using AIDA+TM, ELA’s exclusive feature that is capable of identifying different types of atrio-ventricular blocks.

SYMPHONYTM pacemakers are equipped with AAIsafeRTM, a unique algorithm designed to deliver right ventricular pacing only when needed. REPLYTM pacemakers incorporate the same algorithm.

Excessive ventricular pacing has been shown to have harmful effects on the heart, increasing the patient’s risk of developing heart failure and atrial fibrillation.

The advantages of an algorithm that reduces unnecessary ventricular pacing, coupled with functions providing a detailed history of the course of heart block should offer a wealth of useful knowledge to physicians implanting pacemakers.

The primary objective of the study will be to measure the incidence (frequency) of high degree heart block in patients with sinus node dysfunction or brady tachy syndrome. Sinus node disease is a disease of the heart’s natural pacemaker which causes low intrinsic heart rates. Brady tachy syndrome is defined as an arrhythmia originating in the atrium, the heart’s upper chamber, formed by the alternation of various atrial fast rhythms with sinus bradycardia or sino-atrial block.

The first US implant was performed by Dr. Linda Shuck, a cardiologist at Hugh Chatham Memorial Hospital in Elkin, North Carolina. The 70-year-old patient had sinus node dysfunction.

“We hope that the NATURE study will help better identify indications for implant and provide more appropriate pacing modes to pacemaker patients. This study may provide information which will help both physicians and industry towards eliminating deleterious right ventricular pacing in conventional pacemakers,” said Dr. Shuck.

“Sorin Group is pleased to start the NATURE study in the U.S. This study reflects the importance that the company puts in the continuous improvement of treatment for pacemaker patients. Because the study of the evolution of AV conduction disorders can best be conducted on large numbers of patients and requires routine data collection, the NATURE observational study is expected to yield valuable findings on AV conduction disorders that may eventually lead to significant changes in the way pacemaker patients are treated”, said Dick Ames Senior Vice President, U.S. Cardiac Rhythm Management (CRM), ELA Medical, Inc.

(1) The REPLY pacemaker was released in the European market in May 2007. The device is not available for distribution in the United States. Regulatory clearance of REPLYTM pacemakers in the U.S. is planned in early 2008.

ELA Medical, Inc.

ELA Medical, Inc., part of Sorin Group, is headquartered in Denver, Colorado. The company designs and manufactures implantable pacemakers and ICDs, leads, and Holter equipment and markets them in the U.S.

About the Sorin Group:

The Sorin Group (Bloomberg: SRN.IM; Reuters: SORN.MI), a world leader in the development of medical technologies for cardiac surgery, offers innovative therapies for cardiac rhythm dysfunctions, interventional cardiology and the treatment of chronic kidney diseases. The Sorin Group includes: Dideco, CarboMedics, Inc., COBE Cardiovascular, Inc., Stöckert, Mitroflow, ELA Medical, Inc., Sorin Biomedica, Bellco and Soludia. It has more than 4,500 employees working at facilities in more than 80 countries throughout the world to serve over 5,000 public and private treatment centers.

For more information, please visit our web site: www.sorin-crm.com or www.sorin.com.

South Texas Accelerated Research Therapeutics Gains Highly Respected Cancer Drug Researcher Michael Wick, Ph.D.

Michael J. Wick, Ph.D., a recognized leader in the research of new anti-cancer drugs, has been named director of preclinical research at South Texas Accelerated Research Therapeutics (START). He will join the START team on Sept. 3.

Dr. Wick comes to START from the Cancer Therapy & Research Center’s (CTRC) Institute for Drug Development, where he was director of preclinical research. He is a recognized expert in the testing of novel therapies in animal models of human cancer.

START, a clinical research organization focused on developing new anti-cancer drugs, is headed by world-renowned phase 1 trials investigator Dr. Anthony Tolcher, who was director of clinical research at CTRC before joining START in April as director of clinical research.

“Michael Wick brings an impressive track record of achievement to our cancer drug research team,” Dr. Tolcher said. “His stature among the most respected oncology researchers in drug development further establishes this organization as one of the world’s premier sites for development of innovative oncology drugs. We’re delighted to have Dr. Wick on board.”

In addition to Tolcher and Wick, START recently announced that Chris H.M. Takimoto, M.D., Ph.D., has joined START as director of pharmacology. Takimoto had previously served as director of pharmacology and as Zachry Chair of Translational Research at the CTRC’s Institute for Drug Development.

Dr. Wick also is an instructor in the department of pharmacology at the University of Texas Health Science Center at San Antonio (UTHSCSA).

He completed his undergraduate work in chemistry and biochemistry at the University of Texas at Austin, and a doctorate in molecular pharmacology at UTHSCSA. His post-graduate work was completed at the University of North Carolina, Chapel Hill. In addition to preclinical cancer research, Dr. Wick’s other research interests include molecular oncology, diabetes and aging, to name just a few.

Dr. Wick’s research has been featured in a number of leading scientific journals, including the Proceedings of the National Academy of Sciences, one of the world’s most-cited multidisciplinary scientific serials; the Journal of Biological Chemistry; and the Journal of Biochemical and Biophysical Research Communications, among others.

He has had presentations at the American Association for Cancer Research annual conference, the American Diabetes Association annual conference, and several UTHSCSA Department of Pharmacology symposia. In addition, Dr. Wick has lectured at the National Institutes of Health.

START is affiliated with South Texas Oncology & Hematology, which has offices in several locations in the San Antonio area, and is building a 120,000-square-foot, comprehensive cancer center in San Antonio’s South Texas Medical Center.

STOH will occupy 90,000 square feet of the new building, scheduled to open in July 2008 at the intersection of Medical and Ewing Halsell Drives. START will occupy 20,000 square feet. A radiology center will have about 10,000 square feet of space. The center also will feature a 660-space parking garage.

STOH and START physicians are known worldwide for their extensive experience in Phase I clinical trials, including trials of many of the leading cancer drugs on the market. Their numerous ongoing research affiliations include their work with the Pancreatic Cancer Research Team, which also involves world-class institutions such as the Mayo Clinic, Johns Hopkins University, Translational Oncology Research International (TORI, associated with Dennis Slamon and others at the University of California at Los Angeles), the Sarah Cannon Cancer Center in Nashville, Tenn., and Translational Genomics (TGEN) in Phoenix, Ariz.

More information about South Texas Accelerated Research Therapeutics is available at www.startthecure.com. More information about South Texas Oncology & Hematology is available at www.stoh.com/.

Prospect Medical Holdings Acquires Alta Healthcare System, Inc.

Prospect Medical Holdings, Inc. (AMEX: PZZ) (“Prospect”), which manages the medical care of approximately 250,000 HMO enrollees in Southern California, today announced that it has completed the previously announced acquisition of Alta Healthcare System, Inc. (“Alta”) for a combination of cash and stock totaling approximately $103.0 million.

Alta is a private, for-profit hospital management company that owns and operates four community-based hospitals that provide a comprehensive range of medical, surgical, and psychiatric services. The acquisition has transformed Prospect into a vertically-integrated healthcare provider. Prospect’s 250,000 HMO enrollees, nearly 24,000 of whom are Seniors, are now combined with Alta’s hospital operation, which generated audited revenues and operating income of $107.0 million and $16.9 million, respectively, for its fiscal year ended December 31, 2006.

Bank of America, N.A. arranged $155.0 million of financing for the acquisition, comprised of $145.0 million in term debt and a $10.0 million revolver, $3.0 million of which was drawn at close. Use of funds include refinancing approximately $41.0 million of existing Alta debt, refinancing approximately $47.0 million of existing Prospect debt, and payment of the cash portion of the Alta purchase price. The term debt is comprised of a $95 million seven year first-lien term loan at LIBOR plus 400 bps and a $50.0 million seven and one-half year second-lien term loan at LIBOR plus 825 bps. At closing, the blended interest rate on the borrowings is approximately 11%.

Prospect has entered into multi-year employment agreements with Alta’s former owners, Sam Lee and David Topper, who are now significant shareholders of Prospect. In addition, Mr. Lee will join Prospect’s Board of Directors, together with an independent director nominated by Alta, increasing Board membership to nine.

CONFERENCE CALL

Prospect will host a conference call on Monday, August 13, 2007 at 4:30 pm ET to discuss this news release. Interested parties may participate in the call by dialing (866) 820-1713 (Domestic) or (706) 643-3137 (International) approximately 10 minutes before the call is scheduled to begin and ask to be connected to the Prospect Medical conference call. In addition, the conference call will be broadcast live over the Internet at http://audioevent.mshow.com/334724/. To listen to the live call on the Internet, go to the web site at least 15 minutes early to register, download and install any necessary audio software. If you are unable to participate in the live call, the conference call will be archived and can be accessed for approximately 90 days.

ABOUT THE COMPANY

Prospect Medical Holdings manages the medical care of individuals enrolled in HMO plans in Southern California. The Company’s vertically-integrated medical services platform is comprised of Independent Physician Associations (“IPAs”), which contract with HMOs and health care professionals to provide a full range of services to HMO enrollees, and community-based hospitals.

This press release contains forward-looking statements. Additional written or oral forward-looking statements may be made by the Company from time to time, in filings with the Securities and Exchange Commission, or otherwise. Statements contained herein that are not historical facts are forward-looking statements. Investors are cautioned that forward-looking statements, including the statements regarding anticipated or expected results, and the future introduction of new products, involve risks and uncertainties which may affect the Company’s business and prospects, including those outlined in the Company’s Form 10-K filed on December 28, 2006 and Form 10-Q filed on May 15, 2007. Any forward-looking statements contained in this press release represent our estimates only as of the date hereof, or as of such earlier dates as are indicated, and should not be relied upon as representing our estimates as of any subsequent date. While we may elect to update forward-looking statements at some point in the future, we specifically disclaim any obligation to do so, even if our estimates change.

Superdrug: Differentiation Strategy Showing Signs of Success

Specialist health & beauty retailer Superdrug has reported a 2.7% increase in sales and a 34.8% increase in profits for the year to December 2006. Its strategy of differentiation from competitors appears to be paying off, but, with a young customer base and low margins, it still faces challenges.

Superdrug is the second largest UK health & beauty specialist, behind Alliance Boots. However, both retailers have been hit over recent years by the supermarkets, who have built up their share of the market to account for nearly half of all health & beauty expenditure. Both retailers have followed strategies to differentiate themselves from the supermarkets; Boots with greater focus on its health credentials and Superdrug by building itself into the “TopShop of the health & beauty sector”.

For Superdrug this has meant investing in new store formats to emphasize its fashion beauty credentials. Before current managing director Euan Sutherland joined in 2004, the retailer was on the verge of becoming a cut-price general merchandise store, with a wide mix of product and cluttered stores. Since then, the stores have reverted back to their health & beauty focus, but with additional products such as fashion accessories. Stores have been reconfigured and refurbished, making them much more attractive to shop in and the company has commenced an intensive training program for its staff to improve customer focus.

That said, the business still faces some major challenges. Though its sales for the year to December 2006 exceeded GBP1 billion (at GDP1,027,417), the 2.7% year-on-year uplift has been aided by new store openings – we estimate an additional 3.2% of sales space. While not of all this will have been in operation throughout the year, the company is still underperforming the market and therefore losing share. Furthermore, at 2.7% it has one of the lowest operating margins in the sector, less than half of Boots’ 6.8%.

The problem with Superdrug’s strategy is that is appeals mainly to younger women who, while inveterate shoppers, do not have high disposable incomes for health & beauty products, unlike Boots’ more mature female shoppers who are prepared to pay much more for benefit-led skincare and premium brands. Therefore, Superdrug needs to generate high volumes, which means driving high footfall and improving its conversion rates, which is its aim through its combination of more attractive stores, more high profile marketing, and better customer service.

Source: Verdict Research

Bilateral Renal Artery Embolization in a Case With Severe Proteinuria Secondary to Amyloidosis in a Hemodialysis Patient

By Turgut, Faruk Kanbay, Mehmet; Kaya, Arif; Uz, Burak; Akcay, Ali

Keywords: Amyloidosis, embolization, proteinuria Abbreviations: FMF = familial Mediterranean fever; NS = nephrotic syndrome

Abstract

Amyloid-associated protein (secondary, reactive) amyloidosis occurs most frequently as a complication of chronic inflammatory disease. Renal involvement with amyloidosis is common and proteinuria is often the first symptom. We submit a case with severe proteinuria and hypoalbuminemia, and end-stage renal disease secondary to bronchiectasis-related amyloidosis. Bilateral embolization of the renal arteries was performed to prevent loss of albumin.

Introduction

Bronchiectasis is a consequence of inflammation and destruction of the structural components of the bronchial wall. It may sometimes be associated to secondary amyloidosis. Secondary amyloidosis results from the extracellular deposition of fibrillar amyloid protein in various organs secondary to chronic inflammation. Proteinuria is often the first symptom associated with systemic amyloidosis. Involvement of kidneys can lead to severe proteinuria and in time can lead to end-stage kidney disease. We report a case with chronic renal failure secondary to bronchiectasis-related amyloidosis, with severe proteinuria and hypoalbuminemia. Bilateral embolization of the renal arteries was performed to prevent loss of albumin.

Case report

A 35-year-old man was admitted to the hospital with dyspnea and generalized pitting edema. He had a history of chronic kidney failure secondary to bronchiectasis-related AA type amyloidosis. He was under a regular hemodialysis program three times per week. On physical examination, he had clubbing, widespread ralles in the lungs, ascites and anasarca. The laboratory parameters of the patient are shown in Table I; 24-h protein excretion was 15 g/day. Although albumin infusions were given, the albumin levels decreased gradually. On his seventh day of hospital admission, his albumin level decreased to 0.8 mg/dl. He did not improve with general measures. Bilateral renal artery embolization was planned to prevent loss of albumin. High-density alcohol was injected via the right femoral artery catheter to the bilateral renal arteries. No complication was observed during the procedure. The levels of albumin started to increase without replacement. Generalized edema and dyspnea improved. Two months after the embolization, albumin level was 4.2 g/dl and he was under a regular hemodialysis program.

Discussion

Amyloid deposition may be either a primary process or secondary to various diseases and may be localized to one specific site or generalized throughout the body. Familial Mediterranean fever (FMF) is the leading cause of AA amyloidosis in our country and tuberculosis, bronchiectasis and chronic arthritis are other important underlying conditions [1]. In our case, secondary amyloidosis developed after frequent pulmonary infections in childhood and, eventually, end-stage renal disease occurred. The association of amyloidosis and bronchiectasis has been reported previously in the literature [2]. Renal involvement results in nephrotic syndrome (NS) which is characterized by heavy proteinuria, hypoalbuminemia and edema. Complications of NS that may require treatment include edema, thromboembolism and malnutrition. In our case albumin level decreased to 0.8 g/dl, although albumin was given intravenously. The patient had peripheral and pulmonary edema and there was no possibility for specific th crapy. The main goal of NS therapy is to prevent glomerular protein leakage and to decrease edema. In this state, it is usually not possible to prevent the decrease in serum albumin levels. This can be partly achieved by administering angiotensinconverting enzyme inhibitors, lowering the protein content of the diet, and cautiously using nonsteroidal anti- inflammatory agents [3]. Bilateral nephrectomy was the only available therapy before the development of interventional radiological techniques for the unsuccessful cases. The literature reports good results when renal embolization is applied to the nephrotic syndrome [4,5]. Bilateral renal artery embolization was planned to keep albumin levels within the normal range, although this technique has undesirable adverse side-effects, including the post-infarction syndrome (flank pain, fever, vomiting), hypertension, and embolization [6,7] . After the procedure, none of these complications occurred in our patient, the albumin levels increased and the symptoms of hypoalbuminemia improved. In addition, it is well known that mortality and morbidity are high in patients with hypoalbuminemia. Hence, we speculate that embolization should be seriously considered as soon as possible in hemodialysis patients with NS. We, therefore, report this case to emphasize that causes of chronic kidney failure with severe proteinuria can be evaluated relatively early for renal embolization.

Table I. Laboratory parameters of die patient.

References

1. Tuglular S, Yalcinkaya F, Paydas S, Oner A, Utas C, Bozfakioglu S, Ataman R, Akpolat T, Ok E, Sen S, Dusunsel R, Evrenkaya R, Akoglu E. A retrospective analysis for aetiology and clinical findings of 287 secondary amyloidosis cases in Turkey. Nephrol Dial Transplant 2002;17:2003-2005.

2. Akcay S, Akman B, Ozdemir H, Eyuboglu FO, Karacan O, Ozdemir N. Bronchiectasis-related amyloidosis as a cause of chronic renal failure. Ren Fail 2002;24:815-823.

3. Palmer BF. Nephrotic edema – pathogenesis and treatment. Am J Med Sci 1993;306:53-67.

4. Olivero JJ, Frommer JP, Gonzalez JM. Medical nephrectomy: die last resort for intractable complications of die nephrotic syndrome. Am J Kidney Dis 1993;21:260-263.

5. Kuhn C, Sonntag F, Runge M, Vogel H. Nephrotic syndrome as indication for one-stage bilateral renal embolization. Dtsch Med Wochenschr 1982; 107:461 ->>64.

6. Gang DL, Dole KB, Adelman LS. Spinal cord infarction following dierapeutic renal artery embolization. JAMA 1977; 237:2841-2842.

7. Lumerman JH, Smidi AD. Complete and partial renal infarction. Lesson 16. AUA Update Series; 1997. p. 186.

FARUK TURGUT1, MEHMET KANBAY1, ARIF KAYA2, BURAK UZ2, & AXI AKCAY1

1 Department of Nephrology, Fatih University School of Medicine, Ankara, Turkey and 2 Department of Internal Medicine, Fatih University School of Medicine, Ankara, Turkey

Correspondence: Dr. Mehmet Kanbay, 35. sokak 81/5 Emek 06490, Ankara, Turkey. Tel: +90 312 440 06 06. E-mail: drkanbaytoyahoo.com

Copyright Taylor & Francis Ltd. Jun 2007

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

The Healthy Start Program – Improving the Lives of America’s At-Risk Pregnant Women and Their Babies

What if we told you there’s a Federal government program that reaches thousands of America’s most disadvantaged people, dramatically improves access to essential pre-natal health care, and, quite probably, saves taxpayers at least as much as it spends every year? You’d probably say “Tell me more!”. The program is called Healthy Start and it’s funded and administered by the Health Resources and Services Administration (HRSA) of the Department of Health and Human Services (DHHS).

Healthy Start focuses on reaching at-risk pregnant women and providing access to pre-natal care, counseling, education, coaching, and encouragement. Research has repeatedly shown that these at-risk pregnancies often result in premature births, low birth weight infants, and numerous complications for both the mother and newborn. Healthy Start teaches “moms-to-be” about the importance of good nutrition, the need to eliminate cigarette and alcohol consumption, and other key lifestyle changes that dramatically improve the odds of a healthy infant at birth. The costs of health care alone for a significantly premature infant can exceed $1 million in the first few months of life. Low birth weight babies have substantially greater health problems as well as a greater risk of delayed learning. Reducing these and other consequences by changing the behaviors of the mother during their pregnancies can result in substantial cost savings, making Healthy Start a program that may, in fact, pay for itself.

Once a child is born, Healthy Start promotes breastfeeding as research has shown that it can significantly benefit both infant and mother. Breastfeeding provides nutritional advantages as well as bonding time for mother and child. Here again, the improved outcomes are physical as well and emotional for both mother and her infant.

The total annual budget for the Healthy Start program is just over $100 million, an amount about equal to what the federal government spends every 20 minutes of every hour of every day. The return on this investment in Healthy Start is nothing short of extraordinary. For example, the state of Maryland estimates it saves at least $7 million annually thanks to the results of Healthy Start.

There are nearly 100 Healthy Start program operating across the U.S., most serving lower income and/or minority populations including six that specifically address the needs of Native American and Native Hawaiian communities. These communities face some of the greatest challenges due to high levels of unemployment and poverty as well as geographic dispersion. Infant mortality rates among Native American and Native Hawaiian communities are two to three times higher than for White Americans.

Rick Haverkate, Director of Public Health for the Michigan Inter-Tribal Council, a consortium of Native American tribes in Michigan, said, “Healthy Start’s community-based maternal and child health care model is succeeding where other programs have failed with Native populations. Healthy Start is uniquely positioned to address racial and ethnic disparities experienced by Native people, to support the development of innovative, holistic and culturally appropriate strategies to address risky behaviors, and to put Native people at the helm of educating the public — all of this from the grass-roots, community level. In addition, Healthy Start programs seek to combat racism, discrimination, and unequal treatment, and as such, are agents of social justice within health care arenas.”

Mary Beth Badura, Director of the HRSA Maternal and Child Health Bureau, notes ‘Healthy Start is a truly effective program that brings resources directly to the people who need them. The program reaches over 80,000 pregnant women each year in 37 states, the District of Columbia and Puerto Rico. Many of the women we serve are young, alone, and scared. Their Healthy Start contact is a lifeline during a time of need. The ability of the program to reach so many at-risk pregnant women significantly improves the chances that these women can have healthy babies that get a great start on growing up healthy, physically, mentally, and emotionally. That good start gives these youngest Americans a much better chance to be lead successful and productive lives.”

Traci Karaja is a participant in Healthy Start who lives in the Hannahville Indian Community in Michigan’s Upper Peninsula. “Becoming pregnant introduced me to a supportive program called Healthy Start and, most importantly, to an amazing friend, Lori, the Healthy Start nurse. With this program, I became a mother with knowledge to help my babies grow healthy and strong.”

For more information on how Healthy Start is changing lives for the better in your community, a list of Healthy Start programs is provided below. Please contact the individuals listed or Peggy Sanchez Mills, the Chief Executive Officer of the National Healthy Start Association at (202) 296-2195.

Alabama

Birmingham — Birmingham Healthy Start — Rickey Green (205) 324-4133

Mobile — Mobile Teen Center — Kelly Warren (251) 694-5039

Arkansas

Mississippi County — Mississippi County Healthy Start Initiative – Maria Towery (870) 776-1054

Arizona

Phoenix — South Phoenix Healthy Start — Lisa Derrick (602) 304-1166

California

San Leandro – Alameda County Healthy Start — Dani Taylor — (510) 618-2080

Fresno — Babies First — Sandra Arakelian — (559) 445-2746

Compton — Shields for Families Healthy Start — Charlene Smith — (310) 668-9091 x106

Colorado

Aurora — The Healthy Start Project — Debbie Kunkel — (303) 695-1670 x111

Connecticut

New Haven – New Haven Healthy Start — (203) 777-2387 x219

District of Columbia

DC Healthy Start Wards 5&6 — Diane Davis — (202) 698-0772

Healthy Families healthy Start — Laura Charles-Horne — (202) 420-7104

Florida

Jacksonville — The Magnolia Project — Rhonda Brown — (904) 924-1570 x12

St. Petersburg — Pinellas Healthy Start — (727) 824-6900 x11249

Boynton Beach — Boynton Beach Healthy Start — Kim Bradley (561) 70-7000 x2216

Tallahassee — Gadsden Healthy Start — Maurine Jones — (850) 577-1421

Tampa — Central Hillsborough Healthy Start — Estrellita “Lo” Berry — (813) 974-0312

Georgia

Augusta – Augusta Partnership for Children , Inc. – Robettea McKenzie (706) 721-1040

Augusta — Enterprise Community Healthy Start Sandra Pittman (706) 721-8311

Atlanta — Atlanta Healthy Start — Jemea Smith (404) 688-9202 x19

Dublin — Heart of Georgia Healthy Start — Margaret Turner (478) 274-7616

Hawaii

Honolulu — Big Island Disparities Project — Althea Momi Kamau (808) 733-4044

Illinois

Chicago — Chicago Healthy Start — Jerry Wynn — (312) 793-4662

Chicago — Greater Englewood Healthy Start — April Watkins (312) 745-1309

Chicago — Healthy Start Southeast Chicago — George Smith — (708) 841-9515 x2234

Chicago — Westside Healthy Start — Marsha Herring — (773) 257-2425

Chicago Heights — Aunt Martha’s Healthy Start — Alice Sartore — (708) 754-1044

East St Louis — East Saint Louis Healthy Start — Paula Brodie (618) 271-2503

Indiana

Indianapolis — Indianapolis Healthy Start — Yvonne Beasley — (317) 221-2312

Hammond — Northwest Indiana Healthy Start — Rise Ross Ratney — (219) 989-3939

Iowa

Des Moines — Des Moines Healthy Start Project — Darby Taylor — (515) 557-9012

Kansas

Wichita — Northeast Wichita Healthy Start Initiative — Susan Wilson — (316) 660-7386

Kentucky

Louisville — Louisville Metro Healthy Start — Ryan Irvine — (502) 574-5275

Williamsburg — Voices of Appalachia Healthy Start — Peggy Henderson — (606) 549-9296

Louisiana

Baton Rouge — Family Road Healthy Start — Charletta Montgomery — (225) 201-8888

Lafayette — Family Tree Healthy Start – Glynis DeRoche — (337) 295-7021

Monroe — Healthy Start ABCs — Gatha Green — (318) 330-7700

New Orleans — New Orleans Healthy Start — Pharissa Dixon — (504) 658-2809

Maryland

Baltimore — Baltimore City Healthy Start — Natasha Ramberg — (410) 396-7318

Massachusetts

Boston – Boston Healthy Start — Xandra Negron — (617) 534-7828

Worcester — Worcester Healthy Start — George Mike Portuphy — (508) 854-2124

Michigan

Detroit — Detroit Healthy Start — Carolynn Rowland — (313) 876-4902

Flint — Genesee County Healthy Start John McKellar — (810) 424-4352

Grand Rapids — Strong Beginnings — Peggy Vander Meulen — (616) 331-5838

Kalamazoo — Healthy Babies — Healthy Start in Kalamazoo — Carmen Sweezy (269) 373-5165

Saginaw — Great Beginnings Healthy Start — Dawn Shanafelt — (989) 758-3853

Sault Ste Marie — Maajtaag Mnobmaadzid — A Start of a Healthy Life — Rick Haverkate — (906) 632-6896 x134

Minnesota

Minneapolis — Twin Cities Healthy Start — Doriscile Everett O’Neal — (612) 673-2622

Mississippi

Greenville — Delat Health Partners Healthy Start — John Bierma — (662) 335-4300

Missouri

Kansas City — Kansas City Healthy Start — Jean Craig — (816) 283-6242 x225

Portageville — Missouri Bootheel Healthy Start — Cynthia Dean — (573) 379-2020 x327

St. Louis — Maternal, Child and Family Health Coalition — Sandii Handrick — (314) 289-5680

Nebraska

Omaha — Omaha Healthy Start — Judith Hill — (402) 455-2229

New Jersey

Camden — HMHB Healthy Start — Wanda Roby-Dutton — (856) 963-1013

East Orange — Isaiah House Healthy Start — Sandra Schwartz — (609) 292-5616

Trenton — Childrens’ Futures — June Gray — (609) 989-3307

New Mexico

Deming — Luna County Healthy Start — Linda Macias-Miller — (505) 546-9254

Las Cruces — Dona Ana Healthy Start — Jonah Garcia — (505) 524-0767

New York

Brooklyn — Healthy Start/Brooklyn — Tamara Benjamin Green — (646) 253-5618

Manhattan — Central Harlem Healthy Start — Segrid Renne — (212) 665-2600 x324

Rochester — Healthy Start Rochester — Patricia Brantingham — (585) 546-4930 x211

Syracuse — Syracuse Healthy Start — Kathleen Coughlin — (315) 435-2920

North Carolina

Pembroke — Healthy Start Corps — Linda Greaver — (910) 521-6181

Raleigh — NC Eastern Baby Love Plus Healthy Start — Belinda Pettiford — (919) 707-5699

Raleigh — NC Northeastern Baby Love Plus Healthy Start — Belinda Pettiford — (919) 707-5699

Raleigh — NC Triad Baby Love Plus Healthy Start — Belinda Pettiford — (919) 707-5699

Ohio

Cleveland — Cleveland Moms First — Lisa Matthews — (216) 664-4281

Columbus — Columbus Healthy Start/Caring for 2 – Grace Kolliesuah — (614) 645-1697

Oklahoma

Oklahoma City — Central Oklahoma Healthy Start — Don Anderson — (405) 769-3301 x1263

Tulsa — Tulsa Healthy Start — Corrina Jackson — (918) 595-4404

Oregon

Medford — Family Foundations — Lillian Koppelman — (541) 774-8095

Portland — Healthy Birth Initiative — Sharon Smith — (503) 988-3387

Pennsylvania

Chester — Crozer-Keystone Healthy Start — Joanne Craig — (610) 497-7460

Philadelphia — North Philadelphia Healthy Start Project — Deborah Roebuck — (215) 685-5255

Philadelphia — Southwest & West Phila. Healthy Start Project — Deborah Roebuck — (215) 685-5255

Pittsburgh — Pittsburgh/Allegheny County Healthy Start — Cheryl Squire Flint — (412) 247-4009

Uniontown — Fayette County Healthy Start – Cheryl Squire Flint — (412) 247-4009 x 344

West Chester — Healthy Start for Chester County — Renee Fairconeture — (610) 344-5370 x107

Puerto Rico

San Juan — Puerto Rico Healthy Start — Teresa Taboas — (787) 274-5677

South Carolina

Columbia — Palmetto Healthy Start — Kimberly Alston — (803) 296-2786

Denmark — Low Country Healthy Start — Virginia Berry White — (803) 793-6000

Florence – Pee Dee Healthy Start — Madie Robinson — (843) 662-1482

South Dakota

Rapid City — Northern Plains Healthy Start — Lisa Dobyns — (605) 721-1922

Tennessee

Memphis — Memphis & Shelby County Healthy Start — Calondra Tibbs — (901) 545-7099

Texas

Dallas — Dallas Healthy Start — Gerilyn Laurence — (214) 590-2586

Ft Worth — Forth Worth Healthy Start — Barbara Beaty — (817) 534-0814 x3923

Harlingen — Valley Primary Care Network Healthy Start — Gloria Casas — (956) 425-6205

Houston — Sunny Futures — Healthy Start — Walter Jones — (713) 669-5250

Laredo — BCFS Healthy Start Laredo — Cindi Garcia — (956) 712-4700

San Antonio — San Antonio Healthy Start — Paola Tovar-Kurth — (210) 299-5035

Virginia

Richmond — Richmond Healthy Start — Rose Stith Singleton — (804) 646-3340

Richmond — Virginia Healthy Start Initiative/Loving Steps — Linda Foster — (804) 864-7764

West Virginia

Morgantown — West Virginia Healthy Start H.A.P.I. – Penny Womeldorff — (304) 293-1560

Wisconsin

Lac du Flambeau — Honoring Our Children With a Healthy Start — Barbara Stoddard — (715) 588-3324 x122

Milwaukee — Milwaukee Healthy Beginnings — Pat McManus — (414) 933-0064

Novant Health Selects Allscripts Practice Management System for 800 Physicians

CHICAGO and WINSTON-SALEM, N.C., Aug. 7 /PRNewswire-FirstCall/ — Allscripts , the leading provider of clinical software, connectivity and information solutions that physicians use to improve healthcare, today announced that Novant Health has selected the company’s practice management solution to automate billing, scheduling and other back- office functions for their 794-member physician medical group across 232 locations in North Carolina and South Carolina. The agreement follows Novant’s implementation of the Allscripts Electronic Health Record, providing one fully integrated information solution for the organization’s physicians.

(Logo: http://www.newscom.com/cgi-bin/prnh/20061005/ALLSCRIPTSLOGO-b )

Novant Health serves 3.4 million residents in 34 counties and is comprised of the Novant Medical Group and eight hospitals: Presbyterian Hospital, Presbyterian Orthopaedic Hospital, Presbyterian Hospital Matthews and Presbyterian Hospital Huntersville in the Charlotte region; Forsyth Medical Center and Medical Park Hospital in Winston-Salem; Thomasville Medical Center in Thomasville; and Brunswick Community Hospital in Supply, NC.

“Novant Health is committed to providing quality patient care in the most effective and efficient manner possible, and the Allscripts practice management solution makes it easier for us to deliver on that promise,” said Rich McKnight, Senior Vice President and Chief Information Officer of Novant Health. “This agreement completes our vision of an integrated electronic health record and practice management system, and is a direct result of our successful partnership with Allscripts.”

The Allscripts practice management solution combines sophisticated scheduling and revenue cycle management tools to help physician practices become more productive while improving service to patients. Important features include advanced billing and reconciliation, referral and eligibility indicators, and automated patient appointment reminders.

A.J. Patefield, MD, Executive Vice President of Novant Medical Group and physician sponsor of the Electronic Health Record, said the Allscripts practice management solution not only improves integration between clinical and financial operations but solves problems that the previous practice management system could not. For example, the Allscripts practice management enables Novant to automate “split billing” for services provided to the same patient in both the clinic and hospital.

“It’s in our best interest to have a single, integrated workflow between the clinical and administrative sides of our medical group and clinics, and we chose Allscripts based on the strength of our relationship and our confidence in the practice management product,” said Dr. Patefield.

“Novant Health’s decision to add Allscripts practice management reflects well on the product’s functionality but is also the result of the strong relationship we’ve built in our deployment of the Electronic Health Record,” said Glen Tullman, Chief Executive Officer of Allscripts.

About Novant Health

Novant Health is a not-for-profit integrated group of hospitals and physician clinics, ranked as one of our nation’s 10 best healthcare systems — caring for patients and communities in North and South Carolina. In addition to eight hospitals and a 794-physician medical group, Novant includes two nursing home and senior residential facilities, outpatient surgery and diagnostic centers, rehabilitation programs and community health outreach programs.

About Allscripts

Allscripts is the leading provider of clinical software, connectivity and information solutions that physicians use to improve healthcare. The Company’s business units provide unique solutions that inform, connect and transform healthcare. Allscripts award-winning software applications include Electronic Health Records, practice management, e-prescribing, document imaging, emergency department, and care management solutions, all offered through the Company’s Clinical Solutions units. Additionally, Allscripts provides clinical product education and connectivity solutions for physicians and patients through its Physicians Interactive(TM) unit, and medication fulfillment services through its Medication Services unit. To learn more, visit Allscripts on the Web at http://www.allscripts.com/.

This announcement may contain forward-looking statements about Allscripts Healthcare Solutions that involve risks and uncertainties. These statements are developed by combining currently available information with Allscripts beliefs and assumptions. Forward-looking statements do not guarantee future performance. Because Allscripts cannot predict all of the risks and uncertainties that may affect it, or control the ones it does predict, Allscripts’ actual results may be materially different from the results expressed in its forward-looking statements. For a more complete discussion of the risks, uncertainties and assumptions that may affect Allscripts, see the Company’s 2006 Annual Report on Form 10-K, available through the Web site maintained by the Securities and Exchange Commission at http://www.sec.gov/.

Photo: http://www.newscom.com/cgi-bin/prnh/20061005/ALLSCRIPTSLOGO-bAP Archive: http://photoarchive.ap.org/PRN Photo Desk, [email protected]

Allscripts

CONTACT: Dan Michelson, Chief Marketing Officer, +1-312-506-1217,[email protected], or Todd Stein, Senior Manager/Public Relations,+1-312-506-1216, [email protected], both of Allscripts; MarciaMeredith, Media Relations Manager of Novant Health, +1-704-617-2631,[email protected]

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

Dispensing Solutions, Inc. (DSI) to Offer eDispense(TM) Vaccine Manager

Dispensing Solutions, Inc., (“DSI”) through its POC Management Group Physician Network, will offer eDispense™ Vaccine Manager, a web-based solution for the submission and adjudication of claims for physician administered vaccines now covered by Medicare Part D.

“Pursuant to the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), certain vaccines administered in a physician’s office that were formerly covered under Medicare Part B are now covered by Medicare Part D,” states Richard A. Wolpow, Vice Chairman and Co-founder of DSI. “This new benefit created some interesting challenges for patients, Part D plans and physicians. Most physicians do not have the ability to process pharmacy claims, nor do most health and prescription drug plans contract directly with physicians. As a consequence, all parties were faced with having to deal with processing cumbersome and costly paper claims. eDispense™ Vaccine Manager changes all of that.”

Using eDispense™ at the point of care, DSI’s participating physicians can verify real time plan eligibility, be advised of the patient’s financial responsibility and determine the reimbursement amount the physician practice receives for vaccines administered in office. The entire coverage inquiry and claims submission process takes less than a minute to complete.

“The POC Management Group Physician Network is currently contracted with plans that cover approximately 50% of Medicare Part D beneficiaries and is rapidly growing. We expect to have over 80% coverage by October,” states Andrea Serrate, V.P. of Specialty Services and Contracting. “Our goal is to prove that, with the eDispense™ connectivity between providers and payors, we will be able to help create new benefits and access for payors, patients and physicians related to administered vaccines and other medications dispensed at the point of care.”

To enroll your physician practice in the POC Management Group Physician Network and the eDispense™ Vaccine Manager, go to https://enroll.edispense.com or call 866-522-EDVM (3386).

About Dispensing Solutions, Inc.

Dispensing Solutions, Inc., is a pharmaceutical supply chain company that develops integrated technology and dispensing solutions designed to enable optimal patient care. Operating a state-of-the-art pharmaceutical packaging facility, DSI is FDA registered and DEA licensed, providing prepackaged medications and web-based technology to the point of care.

Dispensing Solutions, Inc. 3000 West Warner Avenue Santa Ana, CA 92704 Phone: 714-437-0330 Fax: 714-437-0336 email: [email protected] / www.dispensingsolutionsinc.com

Former President of Sodexho Marriott’s Health Care Division Tony Alibrio Joins Beryl’s Executive Advisory Council

DALLAS, Aug. 6 /PRNewswire/ — Anthony Alibrio, a 37-year veteran of the service industry, has joined The Beryl Companies’ Executive Advisory Council. At the time of his retirement in 2001, Alibrio was president of the health care division of Sodexho Marriott, Inc., (formerly a division of Marriott International) where he managed sales in excess of $3.2 billion.

The highly regarded Executive Advisory Council is comprised of leaders from many of the nation’s best-known and widely respected hospitals and other healthcare organizations. For Beryl, the nation’s leading healthcare-exclusive customer interaction center, the Executive Advisory Council provides strategic guidance about and insight into the ever-changing healthcare industry.

“Tony is an accomplished leader who is exceptionally knowledgeable about the healthcare service industry, which is why we are delighted to have him join Beryl’s Executive Advisory Council,” said Alan Weinstein, Executive Advisory Council chairman and former president of Premier. “His in-depth understanding of hospital-outsourcing relationships is an asset to Beryl as it continues to expand its services.”

Alibrio helped grow the Sodexho Marriott Inc. Health Care Division into an industry leader that provided on-site department management and support services to the food and nutrition, environmental services and engineering departments of more than 1,000 hospitals and long-term care institutions. The division employed 6,000 managers and dieticians and managed more than 75,000 total employees. Alibrio served as a corporate officer for both Sodexho Marriott and Marriott International. He currently sits of the board of directors for American Health Products Corp. in Itasca, IL, and Precyse Solutions, Inc., in King of Prussia, PA, and has served as chairman and board member of the National Committee of Quality Care. He is also a member of the Health Insights Foundation and a fellow with the American Academy of Medical Administrators.

Other Executive Advisory Council members include Fred Brown, JCAHO chairman; Lynne Cunningham, senior executive with Studer Group; Doug French, former CEO of Ascension Health and St. Vincent’s Hospitals and Health Systems; Michael Guthrie, M.D., former CEO of Good Samaritan Health System; Sheldon King, former CEO of Cedars Sinai Medical Center and Stanford University Hospital; Charles Lauer, renowned author and speaker and former publisher of Modern Healthcare; Dave Loveland, former senior vice president of Evanston Northwestern Healthcare; Mark McKenna, retired Novation president; Bob Pallari, former CEO of Legacy Health System in Portland; Barry Schochet, former vice chairman of Tenet Healthcare; Marlowe Senske, former executive vice president of VHA; and Alan Weinstein, former president of Premier Inc.

Recently recognized as one of the nation’s top places to work, Beryl helps organizations grow revenue and build lasting customer relationships by connecting people to healthcare. As a leading provider of outsourced telephone and Web-based communications, Beryl delivers 24/7 exemplary customer service to more than three million consumers each year. Since 1985, hundreds of healthcare organizations have relied on Beryl for best-practices insight and data they can use to make more informed decisions about customer acquisition and retention. For more information about Beryl and its educational arm, The Beryl Institute, visit http://www.beryl.net/.

Beryl

CONTACT: Ross Goldberg for Beryl, +1-818-597-8453, ext. 1

Web site: http://www.beryl.net/