MOST, LLC Changes Name to iSALUS Healthcare

INDIANAPOLIS, Jan. 3 /PRNewswire/ — MOST, LLC is now iSALUS Healthcare. The name change supports the company’s commitment to help physicians provide the services that their patients need to achieve optimal health.

“Salus” was the Roman goddess of health, who was entrusted with the wellbeing of individuals and society. Including Salus in the new name represents the company’s commitment to helping physicians and healthcare organizations meet the needs of their patients. The “i” stands for the company’s ability to meet those needs via the Internet.

“We want people to easily recognize what we do: Provide the software and workflow support needed to support healthcare organizations and particularly clinicians in their mission and to cost effectively help their patients achieve optimal health,” says Mark Day, President and Chief Executive Officer. “Medicine is becoming more and more patient centric. Providers need to have the most up-to-date technology to help them provide consumers with what they want and need. These expectations will only increase as more patients/consumers have responsibility for more of their first dollar out of pocket. Physicians will face increased pressure from many sides, and we believe that our focus on the workflow of these relationships can bring real value to physicians.”

iSALUS Healthcare does just that by offering easy-to-use online tools that provide 360-degree support to healthcare providers, making it possible to provide quality healthcare, streamline office operations and increase profitability of the practice or clinic. Because the iSALUS Healthcare software solution was developed specifically for use in an Internet environment, it offers a truly integrated online computing experience for physicians, nurses, and back office support staff across the continuum of care. Because it is one product, there are none of the application integration risks or product development risks typically associated with patching legacy solutions together.

iSALUS Healthcare makes it easy for healthcare organizations to access OfficeEMR(TM), which provides the following:

   -- An innovative electronic medical records system that enables clinicians      and staff members to access charts at the point of care or from      anywhere else the physician may need access to this critical data.      Patient data can safely be shared for referrals or emergency care      support.   -- A comprehensive and highly intuitive practice management system that      handles patient registration, scheduling, encounter tracking and other      business related functions.   -- An electronic claims processing system that shortens the billing cycle,      increases collections and improves productivity.     

The name change is only part of the company’s renewed focus on meeting the technology needs of healthcare providers-and, subsequently, the healthcare needs of patients. In addition, iSALUS Healthcare is moving into its new corporate headquarters located in the Indiana BioCrossroads/Healthcare corridor of downtown Indianapolis. With new offices in the Stutz building (212 W. 10th Street, Suite B120, Indianapolis, IN 46202), iSALUS Healthcare is now located in close proximity to the Indiana University School of Medicine as well as several major hospitals. Named for Henry Stutz, entrepreneur and founder of the Stutz Motor Car Company, the building once housed the factory that built the Bearcat, a car that raced in the first Indianapolis 500.

“Being in the healthcare corridor places us in a location that is at the center of the industry’s innovation,” Day says. “The additional office space will support our predicted growth, as iSALUS Healthcare will more than double in size over the next year.”

About iSALUS Healthcare

Based in Indianapolis, iSALUS Healthcare develops and hosts an Internet-based healthcare and business solution, OfficeEMR(TM). The solution, which was specifically developed to be used via the Internet, is designed to help healthcare organizations focus on providing optimal patient care experiences while improving operations and financial performance. iSALUS Healthcare’s customers across the United States represent more than a dozen specialties and several different clinic settings. For more information, go to http://www.isalushealthcare.com/ .

iSALUS Healthcare

CONTACT: Media, John McCormack of By McCormack Public Relations,+1-708-447-4491, or [email protected] , or Sales, Simon Lee of iSalusHealthcare, +1-847-574-5016

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

Stress and Coping: a Study of Project Managers in a Large Ict Organization

By Richmond, Arin; Skitmore, Martin

ABSTRACT

Information technology (IT) project managers face a multitude of stressors in their workplaces. This has implications not only for the individual practitioners but also for their employers and society. Exactly what stressors are faced by IT project managers and how they cope with them has received little attention in the literature. In addressing this situation, this paper reports on an exploratory study aimed at identifying the sources of stress, coping strategies, and outcomes that are relevant to IT project managers in a large Queensland-based ICT organization. A critical incident analysis method was used involving interviews with a sample of 12 project managers, resulting in the identification of 50 stressor, coping, and outcome incident chains. These were then coded into categories for frequency analysis.

Keywords: stress; stressors; coping; outcomes; information technology

2006 by the Project Management Institute

Vol. 37, No. 5, 5-16, ISSN 8756-9728/03

Introduction

Rapid technological change combined with increasing market pressures has resulted in project management becoming an essential pan of the general management strategies of many businesses today (Kerzner, 2003). The information technology (IT) industry is no exception in this respect, with an increasing employment of project managers in recent years (Calisir & Gumussoy, 2005). Although general management is a high stress occupation (Haynes & Love, 2004), the level of stressors experienced by project managers is known to be even higher due to the conflicting demands of completing a project on time, within budget, to quality, and satisfying stakeholders (Haynes & Love).

This results in several costs. One is the cost to the organization, both in terms of employee turnover and job satisfaction (Thong & Yap, 2000). Another is the legal implication for employers following the successful litigation of employers both in the United States and the United Kingdom (Howard, 1995). Turnover is also of particular concern within the IT industry, which has higher than average levels, resulting in increasing recruitment and training budgets, as well as lowering the morale of remaining employees (Lim & Teo, 1999).

Stress has become a topic of academic interest since the 19th century when it was considered a basis for ill health (Lazarus & Folkman, 1984). Selye (1976) used the term stress to describe physiological changes induced by environmental demands. The study of occupational stress has been pursued within a number of occupations, including teaching (Guglielmi & Tatrow, 1998), policing (Storch & Panzarella, 1996), and managing (Broadbridge, 2002). Relatively few studies have been conducted with project managers (Gallstedt, 2003; Haynes & Love, 2004; Lysonski, Nilakant, & Wilemon, 1989), and of these only Gallstedt focused on IT project managers. The extent to which Gallstedt’s findings apply outside the sample studies is not known.

This paper reports on research aimed at validating and extending Gallstedt’s work by identifying the sources of stress, coping strategies, and outcomes that are relevant to IT project managers in Australia’s South East. In particular the following question was addressed “What are the stressors faced by IT project managers, how do they cope with them, and how effective is their coping?” Using critical incident analysis, exploratory interviews were conducted with 12 project managers resulting in the collection of 50 stressor, coping, and outcome incident chains. Although preliminary, the results suggest that the stressors faced by IT project managers are similar to those faced by other managers hut with resource control appearing to be more salient than in previous studies. The most effective coping strategies were found to be problem-solving, planning, and social support with university graduates being more likely to use problem-solving and planning strategies.

Stress and IT Project Management

Stress and coping is becoming increasingly relevant in the cut rent global marketplace. There are huge costs associated with occupational stress, both for the employee and for employer (Howard, 1995; Thong & Yap, 2000). It can be seen then, that the study of occupational stress is justified, not only from an academic perspective, but also for the implications it has for occupational practice.

However, defining stress is not as easy as one might believe. Researchers have proposed a number of models and theoretical frameworks of the stress process, including the person-environment fit (Edwards, 1996; Edwards & Rothbard, 1999), demand-control (Karasek, 1979), and cognitive appraisal (Lazarus & Folkman, 1984). Cognitive appraisal has advantages over other frameworks in its ability to explain stress and coping in many different contexts and acknowledging the importance of individual differences and other moderating variables.

Forty stressors for managers were identified by Cooper and Marshall (1978) and this research was extended by Broadbridge (2002). The stressors expected to be experienced by project managers include new technology, boundary spanning, role conflict, workload, and uncertainty. These are drawn mainly from research on project managers (Haynes & Eove, 2004; Eysonski et al., 1989) although some extrapolation of results from other industries is needed due to the lack of research in the occupational stress field in the project management discipline (1 laynes & Love; Lysonski et al.). The literature on coping suggests that there are two main categories of coping responses: problem-focused and emotion-focused (Lazarus & Folkman, 1984). Evaluating the effectiveness of these types of coping responses has provided mixed results, with some researchers arguing that problem-focused coping is more appropriate for project managers (I laynes & Love).

In the solitary study of IT project managers stress to date, Gallstedt (2003) applied an exploratory, qualitative approach, interviewing project managers and participants from the IT consulting and telecommunication industries. This enabled her to identify two broad categories of incidents impacting on perception of working conditions on projects-resource allocation problems and priority problems. The level of stressors was also found to vary over the project life cycle and between project managers and project team members, with project managers experiencing the greatest number of stressors in the beginning and end of projects, and team members finding the execution phase most stressful. An example of the high levels of stressors was the pressure felt by project team members in the design phase before the goals of the project were clearly defined. In addition, uncertainty was identified as a source of pressure leading to long working hours. For coping responses, risk management was a strategy used in many companies. Project managers would also respond to stressors by sharing their concerns with co- workers-a social form of emotion-focused coping that may be related to a construct studied in some stress research referred to as social support.

Methodology

Background

Occupational stress is typically studied through the use of questionnaires containing lists of stressors, determined a priori by the researcher. These questionnaires commonly also contain measures of affective states, psychological or physical health, or other outcome variables such as job satisfaction. However, there are several potential problems with this research design:

* It may suffer from the influence of common method variance (Tennant, 2001; Tuten & Neidermeyer, 2004).

* It does not allow subjects to report those stressors that may fall outside of the predetermined categories (e.g., Tuten & Neidermeyer, 2004; Jackson & Schuler, 1987; O’Driscoll & Cooper, 1994; Wetzels, de Ruyter, & Bloemer, 2000).

* The self-report measures may be confounded with personality (Greiner, Krause, Ragland, & Fisher, 2004; Spector, 1992).

Qualitative methods, on the other hand, such as interviews, allow a more sophisticated understanding to be developed (Briner, 1997). Coping strategies, for example, are situationally dependent, with different responses being elicited in different contexts (Lazarus & Folkman, 1984), and therefore, it is likely to be more fruitful to study this within the context of a particular encounter, rather than asking subjects to list their ways of coping with generic stressors. Qualitative interviews also allow the participant to relate particular stressors to situations rather than having to select stressors from a global list without any contextual information.

In view of the small amount of research on IT project management stress, the problems inherent with a priori stressor, coping and outcome categories, and the context dependency of the stress process, it was therefore decided to use a qualitative interview method. O’Driscoll and Cooper (1994) proposed a method for studying stress and coping utilizing a critical incident approach conducted by structured interviews. This method aims to improve the ecological validity of responses as well as provide links between stressors and coping responses (O’Driscoll & Cooper), and forms the basis for the method utilized in the current study.

Procedure

Twelve staff members of a large ICT organization based in Queensland, Australia, were interviewed from a potential pool of 22. This represents a 55% resp\onse rate to the invitations for interview. All subjects had current or very recent experience as project managers within the organization. The sample consisted of seven male and five female participants. There was a slight bias toward subjects being male; however, due to the small sample size the bias is exaggerated.

To minimize possible bias from fear of repercussions, participants were assured that all responses would be anonymous and any names of people or projects would be changed to protect their anonymity. The subjects were also informed that they may withdraw from the study at any time.

The interview.was conducted in three parts: the stressors, coping behaviors, and outcomes of the stressor-coping behavior interaction:

1. To generate responses about stressors the subject was asked to respond to the following: “Please recall an incident, in your work as a project manager that placed demands on you or caused you problems or difficulties. Please describe the incident.”

2. To ascertain the specific behavioral responses to the stressor, the subject was then asked to describe what they did in response to the situation or incident that they had described. The subjects were also asked about the behaviors of those around them, in order to elicit information about the coping resources available to them.

3. Outcomes of the stressor-coping behaviors were obtained by asking the subject to describe the consequences of their behavior. In line with O’Driscoll and Cooper’s (1994) suggestion, both a description and evaluation of the effectiveness of the coping behavior was obtained to allow the separation of behavioral consequences and evaluative assessment, avoiding confounding of the two related concepts.

This process was repeated with the goal of obtaining at least three complete stressor-coping-outcomes examples from each subject and resulted in 50 stressful incidents, their corresponding coping strategies, and outcomes. These were then coded into themes describing the stressors or coping mechanisms, respectively, while outcomes were coded into categories describing the effectiveness of the coping strategy in reducing strain as judged by participants. The outcome categories consisted of positive, neutral, and negative categories.

Data analysis was then conducted in two stages, each making use of a different epistemological research paradigm. The first stage involved utilizing content analysis to code the responses into categories developed from earlier studies to avoid coding bias. This approach falls within the interpretive paradigm as opposed to the more empiricoanalytical approach taken in the next stage, which utilizes the more positivist technique of frequency analysis (Byrne- Armstrong, Higgs, & Horsfall, 2001). This allowed the frequency of links between particular stressors and coping responses to be analyzed, as well as those between coping responses and outcomes (O’Driscoll & Cooper, 1994).

Results

Demographics

With seven males and five females, there was clearly a slight bias toward subjects being male; however, due to the small sample size the bias is exaggerated.

The subjects interviewed were evenly spread across the age ranges of 26 to 55, with three subjects in each age group of 26-35, 36-45, and 46-55. However, no subjects were younger than 26 nor were any 56 or older. In the case of the lack of younger participants this may indicate that project management requires some experience in the workforce. Although in the case of the lack of older participants, this may indicate an example of the younger workforces commonly found in IT organizations.

Eight subjects had attained an undergraduate degree or higher qualification, with four of these obtaining postgraduate qualifications. Of the remaining four subjects, two had completed a TAPE or trade certificate, and two had completed their studies at high-school level.

Individual Stressors and Coping Strategies

As a result of performing a content analysis of the interview notes and transcripts, 15 categories of stressors and 15 coping strategies were identified. These are discussed and explained in detail in Appendix A with examples given from the interviews.

Table 1 summarizes the frequency of stressors raised and the relationship with their corresponding coping strategies. This shows that different coping strategies are used when faced with different stressors. In other words, coping is situationally specific or context dependent. The most commonly cited stressor is the lack of control over project resources, followed by having to deal with a new or unknown technology and high workload, the conflicting needs of the project manager and third panics, and the weight of responsibility.

In terms of coping strategies, social support is used for a wide range of stressors. There is also an increased use of social support when faced with a new or unknown technology. Communication is most often used to cope with a lack of control over project resources, while engaging additional resources is also used to cope with this situation in addition to high workload, high level of responsibility, and unreasonable deadlines. Emotional avoidance, or trying not to think about the problem, was most common when project managers felt the weight of responsibility upon them, lacked control of resources, and when the workload was high. Problem-solving was used to cope with new and uncertain technology as well as difficulties with delegated work.

When broken down by gender, age groups, and education, the results are quite similar for most stressors, although work overload was mentioned by all five female project managers in contrast with only one of the seven male project managers. Uncertainty was also mentioned by two of the five female project managers but by none of the males, although this may be an age effect, as the two female project managers were both in the 46 to 55 year-old category. Delegation and interpersonal conflict, on the other hand, were mentioned by two of the seven male project managers and by none of the female project managers.

Table 1: Stressors faced and the frequency of use of different coping strategies per stressor

Table 2 shows the frequency of the coping strategies in association with the different outcomes, indicating social support to be the most frequent strategy employed. The outcomes for social support are also mostly positive. Other coping strategies associated with more positive than negative outcomes are adding resources, problem-solving, and planning. Those associated with mixed results are communication, avoidance, work increase, and exercise.

It was noted that only one of the five female subjects, in contrast with four of the seven male subjects, use problemsolving as a coping strategy. Also, the university-educated subjects employed problem-solving and planning strategies more often the than high- school or TAFE-educated subjects.

Other Results

An additional finding was the feeling of some project managers that stress was to be expected: “The longer I do projects the more I find that these issues will pop up, and you really stress about them and they seem to be all consuming, but if you don’t worry about them and still do the work towards getting them done they seem to blow over. It’s a bit like being on the ocean and having various storm cells coming over you. You do get to the eye of the storm and then you get to the other side and you’re in a calm spot.”

Two of the project managers interviewed also mentioned that the pressure they felt varied across the project life cycle, with the most demanding times being at the beginning and end of projects. This result also corresponds with Gallstedt’s (2003) previous study.

Discussion

Demographic Differences in Stressors

Many of the 15 stressor categories correspond with the findings from the general stress literature. One major difference, however, is that of control of resources-the most frequently reported stressor in the study and yet not featured at all in the literature.

Table 2: Coping strategies used and their frequency of outcomes per stressor

In addition, this aspect points to a characteristic peculiar to the project management occupation and is most likely attributable to what has been termed the boundaiy-spannins role of the project manager (Lysonski et al., 1989). All the interviewees have responsibility for staff across organizational boundaries but lacked the necessary authority within the different organizational domains to exercise effective control-giving rise to frustration due to an inability to issue instructions and see them carried out. Boundary spanning may also be the reason for conflicting needs being one of the more prominent stressor categories as it leaves them vulnerable to conflicts between demands placed on them from different sources- as evidenced by reported conflicts between requests for information and conflicts in the expectations of participants.

The results that are consistent with the literature include work overload and time pressures (Haynes & Love, 2004; Leung, Ng, Skitmore, & Cheung, 2005). This is not a surprise as project management is well known for such pressures. Of course, the two are interrelated, as time pressures are likely to be a major cause of work overload. Further research utilizing longitudinal designs should provide future insights into this aspect.

Although from only a very small sample, the gender differences are also consistent with Lim and Teo (1999) who found significant differences in stress scores for men and women on a number of dimensions, including work demands, attributing feelings of guilt about the neglect of families caused by work overload to the increased stress of the women. Likewise, the possibility that uncertainty is more stressful for women project managers may be explained by the Lim and Teo’s assertion that women are more likely than men to appraise uncertain events less confidently.This effect may be amplified by the male-dominated nature of the IT industry and Lim and Teo’s further finding that women were more likely than their male counterparts to fear falling behind technologically.

New or unknown technology was raised seven times as a stressor and corresponds with Sachdeva and Namburi’s (1993) views concerning project managers and Broadbridge’s (2002) findings with retail managers on its importance. However, both of these cases were concerned with the effect of technology on people, while the current study was concerned with the understanding of the technology. As one project manager stated “We had never sold that product before. We didn’t have the infrastructure in place. We didn’t know the technology.” This difference in findings may be due to the difference in occupations of those involved, with the involvement with technology being much greater for IT project managers.

Also some of the project managers in charge may not have had enough experience or skills in the project management field. In the S9 Delegation section, for example, it could be argued that the project managers should have supervised the work more closely if they already noticed that their staff was not doing the work. Similarly, the coping technique of “getting the work done themselves, and the other by micro-managing in order to have the work completed” suggests likewise, as do the results in S11, S12, and S13.

Coping Strategies

As the results indicate, the project managers use a wide variety of coping mechanisms. Clearly, what may be successful for some are not necessarily successful for others. That coping strategies are also situationally specific supports Lazarus and Folkman’s (1984) similar contention. A number of mechanisms have also been proposed to explain the effects of social support. These include the direct, moderating and mediational effects models (Viswesvaran, Sanchez, & Fisher, 1999). As social support is positive in the majority of instances it supports the direct effects model, which states that social support and stressors act independently on strains (Viswesvaran et al., 1999).

On the other hand, that a less effective coping strategy, avoidance, was found to have been effective only some of the time is surprising given that llaynes and Love (2004) found avoidance coping to be significantly related to anxiety and depression. I lowever, the present study did not measure outcome variables such as depression but rather relied on subjective evaluations of effectiveness and this may have led to some bias in the results due to the tendency of people to relate positive memories in dealing with negative events (Dewhurst & Marlborough, 2003).

Problem Versus Emotion-Focused Coping

It is believed that social support and avoidance do reduce stress (Tyson, Pongruengphant, & Aggarwal, 2002), and the use of social support as an effective coping mechanism is certainly supported by several studies (Babin & Boles, 1996; Gallstedt, 2003; Swickert, Rosentreter, llittner, & Mushrush, 2002), and it may be that it is more beneficial in highly stressful situations. Haynes and Love (2004), however, believed problem-focused coping to be a more effective approach. In this study, both forms seem to exist in practice. As might be expected from project managers, such problemfocused project management skills as problem-solving and planning are also employed as stress reducers. This will involve considering the treatment of stress as a project in its own right; solving the problem of its reduction and devising plans to implement the solution. Communication, on the other hand, met with mixed results and strategies such as work increase and training tended toward negative results.

The same mixed results are found in emotion-focused forms of coping, with social support receiving positive evaluations while avoidance, exercise, and alcohol consumption were reported as having mixed effectiveness. Therefore, it does not appear that either form of coping is superior. Moreover, the mixed results suggest that the most appropriate coping strategy is again highly dependent on the individual project manager and the situational context involved.

Summary and Conclusions

Although only of a preliminary nature, the study identifies three areas for further investigation:

1. The stressors faced by project managers are similar to those reported in the literature as being faced by other managers. However, there are some differences that are attributed to the differing requirements faced by project managers as opposed to general managers.

2. Project managers utilize more problem-focused coping strategies than emotion-focused strategies. However, in terms of total instances of each strategy the comparison is more even, with the prevalence of a single emotion-focused strategy, social support.

3. Social support is the most effective coping mechanism. This is despite previous research suggesting it to be associated with high stress (Haynes & Love, 2004). Planning and problem-solving were also effective, with university graduates more likely to employ these strategies, inviting the recommendation that project managers should undertake additional formal training or self-study in project management to allow them to better cope with stressors.

Should these results turn out to be true in general, there are a number of possible implications for the practice of IT project management:

* A number of coping strategies, including planning, risk management, time management, and communication, were widely regarded as effective. It is possible that these coping strategies may be learned and their application enhanced by formal training. Typically, this would involve such project management skills as planning, communication styles, risk management, resource management, and time management.

* Training project managers about the technologies they were implementing was found to be of mixed effectiveness after the project had commenced. However, this may be of benefit for project managers prior to being assigned to the task. It may help if project managers are kept up to date with the technical advances in their areas of expertise so as not to add the burden of learning about new technology while performing the already demanding role of the project manager.

* The support networks available to a project manager appear to be critical. Project managers may benefit from having access to a network of project managers with which they can consult about issues they encounter on their projects.

* In order to relieve uncertainty, it may be beneficial for project managers to have access to project records of past projects. This can allow project managers to build upon the effort of previous projects and give them guidance on what can be considered for their own project.

* That control of resources was the most prevalent stressor for the IT project managers interviewed suggests that project managers may benefit from having clear authority over project staff. This may involve allowing project managers to take project team members on as if they were their line managers. However, this might meet with resistance in some organizations and may not be feasible in some circumstances. The culture and structure of an organization would need to be considered when making changes to lines of authority.

The exploratory nature of this study limited its scope to interviews conducted with one organization. Of course, this inherently leads to the problem of small sample sizes and limits the generalizability of its conclusions. There also some doubts about the expertise of the project managers involved. Further studies that are broader in scope are therefore required in order to improve the validity and scope of application of the findings of the current study beyond a single organization. In addition, for future research in this topic:

* Several stressors were identified not previously included in quantitative stress and coping studies. These could be used to build upon those compiled from previous literature. Quantitative research could then be used to gain access to a larger sample and provide more generalizable results, providing greater predictive power when referring to the discipline of IT project management.

* The current study aimed to group results into broad categories for comparison. A deeper analysis might provide greater insight into the stressor, coping, outcomes relationship and provide direction on appropriate avenues for further research.

* Although the current study gained insight into the effectiveness of coping strategies by having project managers make subjective evaluations, it may prove useful to compare such evaluations with more objective measures of outcomes such as job satisfaction, mental health, physical health, turnover intention, and other commonly used outcome variables. This would provide insight into the accuracy of subjective measures of effectiveness.

* A longitudinal design that measures the effectiveness of the implications for practice might be conducted. Such a study might measure the prevalence of stressors and the well being of project managers at time A, then stress management interventions or business processes might be altered and stressors and wellbeing measured again at time K in order to determine the effectiveness of such changes.

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ARIN RICHMOND, Queensland University of Technology, Australia

MARTIN SKITMORE, Queensland University of Technology, Australia

ARIN RICHMOND completed a BA at the University of Queensland in 1999 and gained a Masters degree in project management from the Queensland University of Technology. He has worked for a range of ICT service providers and consulting companies in both Brisbane and London, including work for ThruPoint, Reuters, and The Royal Bank of Scotland. He is currently consulting on a network design for Queensland Health.

MARTIN SKITMORE is a professor of construction management and economics, School of Urban Development, Queensland University of Technology, where he is currently leader of several postgraduate courses in project management. He has published widely in project management related topics, with a particular interest in procurement.

Appendix A: Individual Stressor Categories and Coping Strategies

Stressor Categories

Sl. Control of Resources

Control of resources refers to the lack of authority or control over the human resources required to complete a project. This stressor was the most frequently cited source of pressure faced by the project managers interviewed.

Most commonly this stressor was raised by those interviewed in the context of the project being made up of team members from different parts of the organization in a matrix structure. This was effective in providing skilled resources to work on projects; however the authority of the project manager over team members was often not established, and was even met with resistance. As one project manager stated, “My project involves people from groups all over the organization. They had to perform the project work along with their regular service support activities. So you’ve got management not replacing staff, two major organizational change overheads, and people are very resistant to assisting you, both the project staff and their managers. I couldn’t get resources without a lot of resistance and a big fight in some instances.”

One project manager mentioned that he or she had been asked to give orders to a team member who was their junior on the project but within the organization was senior to them. As there was no formal announcement of his or her authority on the project, he or she felt as if they had no control over this staff member.

Another project manager was given a project that was strategically important to the company, however, lacked support from general managers and the staff assigned to the project. As the project manager interviewed stated, “The target was to deliver it in three months. It’s now 13 months, due to no commitment from management or staff… The quote from my manager was ‘yu/re the PM, they’re your staff,’ but projects around here don’t work that way. I had no day-to-day authority over staff on the project. The team leaders of the staff would have them work on other jobs and not my project.”

One project manager raised a resource pressure about those outside of the organization. In this case the project was stopped due to technical difficulties and it was put upon the vendor’s developers to come up with a solution. The project manager found his or her complete lack of control over the outcome very difficult to deal with as evidenced by the following quote. “We encountered a technical problem that stopped the project for six weeks. We didn’t have a solution. The way forward was dependent highly on the vendor. I was waiting at the whim of someone else, watching the clock ticking forward and you can’t do a damn thing about it.” This resulted in them drinking heavily to cope with the pressures, which led to increased absence at work.

Coping with a lack of control of resources was handled in other ways as well. Most commonly, communication was used by project managers. This was typically in the form of discussions held with line managers and staff members on the importance of the project. Some project managers used more formal communication with their direct superiors to flag the problem and have it dealt with by senior management.

S2. New or Unknown Technology

Working with new or unknown technology was the second most prevalent stressor raised by project managers. This involved the project manager being required to manage the implementation of new technology or technology with which they were not familiar with. As one project manager stated, “I don’t have a degree in IT, I’m not a geek or a tech head, I’m a process person. That can be worrying; I mean you don’t have an in-depth technical knowledge of what you’re doing.”

In many cases project managers had to deal with a technology that had not been used within the company before. They found that this often left them inappropriately resourced or that deadlines were not estimated correctly due to the lack of understanding of \the technology within the organization. In the words of one project manager: “We had never sold that product before. We didn’t have the infrastructure in place. We didn’t know the technology. All the information we had from initiation was wrong. There were bits missing, the timeframes we’d given the client weren’t accurate, we had to reassess the hours needed for implementation. This was basically all due to the lack of knowledge of the technology being implemented.”

A number of different coping strategies were used for dealing with the demands of implementing new or unknown technology. These included social support in the form of talking to colleagues, friends, and family, as well as obtaining extra resources, such as in one case having a vendor provide staff to assist in technically challenging components, or in other cases of having the project team spend more time on learning about the technologies or obtaining extra team members to work on the project. One project manager found this challenge exciting and devoted a lot of time to learning about the technology and became a knowledge expert on the subject. However, they pointed out that this level of commitment would not be sustainable across multiple projects.

S3. Work Overload

Work overload was the next most reported stressor. It was usually associated with having to do a large amount of work in a small time frame in order to meet a milestone or complete a task. l;or example, one project manager spoke of a project that had been neglected until the project manager’s arrival: “There was a PM assigned from February to December, 1 arrived to find that it was really just a talkfest and nothing had been done. Planning risk management hadn’t even been attempted. I had to start working around the clock to get it in place.”

In other cases, work overload was caused by an increased level of reporting demanded by the program manager or project office within the organization, typically because the project had gone off track or was in trouble. The project managers interviewed understood why the reporting was necessary but felt it placed an additional burden on them when their project was already in need of greater attention. “The reporting goes from fortnightly to weekly and you have to front to every project office meeting. On top of that you have to explain all your rpons personally. The time squeeze makes it hard. It’s like you’re trying to dig yourself out of a hole, and they’re just shoveling more dirt in on top of you. I understand why they need the reports, hut it’s just not easy to deal with.”

Another project manager said, “There were not enough resources to do the work that needed to be done. So I found myself doing the work of maybe three or four people. So I was working 12-hour days every day. I went to the program manager and said we don’t have enough resources and he said tough. This work had to be done or the company would grind to a halt. I felt totally responsible for it.”

The most common response to having an increased workload was to assign additional resources to the project. Two project managers also said that they tried to stop thinking about work while they were at home, trying to focus more on recreational and family activities.

S4. Conflicting Needs

Conflicting needs refers to the project manager being faced with a conflict in the needs of third parties. In two cases the project manager was asked to produce separate reports for different stakeholders. The project manager was buried in reporting-“Every time you’re reporting to a different person they have their own spin on what level of reporting you have to do… [this lead to] having to re-invent your reporting process two or three times.” In another case, a set of key performance indicators (KPI) was assigned to the project without consultation with the project manager. In order to meet these KPIs the project manager had to completely redo their project schedule and change significant parts of the project. In another case mentioned, the project manager felt that he or she was in conflict between the success of the project and the client’s needs. Another project manager found himself or herself in conflict with the project sponsor on what the scope of the project should include.

Social support and communication were the most commonly used coping mechanisms with four project managers seeking support from colleagues and three discussing their projects with project sponsors. Two project managers also used exercise to relieve tension, with eating more and engaging additional resources were mentioned once each.

S5. Too Much Responsibility

This category refers to the responsibility that the project managers interviewed felt that they had for project success. This stressor was often accompanied by another stressor. In one case responsibility was coupled with a lack of control over project resources, so the project manager felt he or she were to be held accountable for project success while having little control over the people working for him or her. “There is only a small portion that I have control over, but I’m charged with delivering it on time.” In another case it was coupled with having to implement new technology. In this case there was a problem with the new equipment and the project manager felt he or she was being blamed for the technical difficulties encountered. Lastly, one project manager felt that the complexity of the project was underestimated and consequently under- resourced, this was coupled with a project sponsor who was demanding success from the project manager.

The project managers coped with these situations by asking for additional resources, trying not to think about work, or emotionally distancing themselves from work, as one project manager said, “It’s only work, in the end it doesn’t matter, I can always get another job.”

S6. Time Pressures

Deadlines refer to the time frame given to complete a piece of work. One project manager had been given unreasonable deadlines when there were given only nine days to complete work that would ordinarily take two weeks. This theme was borne out by another example where a project manager was not given enough time or resources to complete tasks. Another had to roll out a project with a drop-dead date for completion and found this placed them under a huge amount of pressure. Finally, one project manager stated put it this way, “We couldn’t procure the equipment until we had sold the product to a client. By selling to the client we had to commit to a very tight delivery timeline, and then had to adjust timescales of the project based around this timeline. That created immediate pressure from the project. All the slippage in the project had pretty much disappeared.”

The most common coping strategies were communication and assigning additional resources each being used twice, while social support, avoidance, risk mitigation, and increasing workload were also used.

S7. Role Conflict

Three project managers raised conflict between their role as project managers and their operational roles as a source of pressure, an example of which is in the following quote: “Still being tied to an operational role at the same time as trying to run a project is frustrating. You’re always tempted to work on operational issues, but this puts you further behind on the project. On the client side, it’s the same, their project team is the same as their operational team, which means work with the client gets mixed between project and operational.” Two found it difficult to juggle their responsibilities between the two roles, while another was given conflicting directions by the manager that were not of benefit to the project they were running.

The coping strategies used in these cases were mixed, with one project manager attempting not to think about work when not on the job, while another engaged additional resources to reduce his or her operational workload in order to focus on the project, while the third project manager found time management and seeking social support useful.

S8. Uncertainly

The common theme with uncertainty which project managers reported was the feeling that they had missed something in their project planning. Three project managers reported that they worried that they had missed a key task or not thought of a potential risk that could spell disaster for their projects. One project manager said, “…at the back of your mind, the whole time, you really feel like ‘have I thought of everything? There was always the fear that you would miss something or forget something.”

Again, the coping strategies were mixed, with planning being one response, combined with relaxing after work with dinner and a glass of wine. Another project manager had their project team role-play all possible scenarios in order to generate ideas about what could have been missed. This was classified as a problem-solving strategy. Lastly, a project manager sought support from his or her partner and held discussions with contractors to determine if anything had been missed.

S3. Delegation

Two project managers had found it difficult to deal with staff that had been assigned to complete work but had failed to do so. “I had to do a fair bit of research on technical strategies. To do that 1 needed a lot of information so I engaged a technical person to do a component of the work. I estimated it would take him about three days…l gave him a target deadline of five days. When I went to see him he hadn’t even started… I gave him another three days and again he hadn’t started. I started to get a bit upset about it.”

The common response in this case was to problem solve, one by getting the work done themselves, and the other by micro-managing in order to have the work completed. Other responses included avoiding thinking about work, exercising more, and talking to co-workers in order to let out the frustration they were feeling.

S10. Interperson\al Conflict

Interpersonal conflict was mentioned twice by the project managers interviewed. Once it was in the context of a conflict between the designer of the solution being implemented and the project manager, and in the other case it was an argument between the project manager and a project team member over the work that was to be completed; “We had a meeting and 1 told her that my expectations weren’t being met and asked what she was going to do about it. She burst into tears and left the meeting.”

In the first case the project manager avoided thinking about work and the overly complicated design, as well as adding additional resources to the project in order to implement it, while in the second case the project manager talked with the staff member involved and tried to smooth things over.

S11. Project Scope

The scope of the project was another source of pressure. In the two cases mentioned, one found that the scope was changed when the software to be implemented was completely replaced from tender to implementation, while in the other case there was a lack of definition of scope and the project manager felt that the work was slipping behind but did not have a way to gauge the progress as the scope of the project was not understood: “The scope wasn’t originally defined, what was included or required by certain dates… You had a sense that you were getting behind, but you don’t know how far behind.”

In the first case the project manager spent time training on the new software, promoting it to the client, and seeking support from other project managers who had faced similar situations. In the second case much time was spent on planning in order to have the scope defined more clearly.

S12. Team Conflict

Team conflict occurred where there was conflict between team members within project teams. This was raised twice, and in one case the project manager used the problem-solving approach of re- organizing the teams in order to avoid clashes, while in the other case the project manager communicated to the team members involved the importance of the work that they were doing. “I had to deal with a lot of conflict with teams of people. Because I was new to the project I didn’t know that if you put Frank and Sarah together they hated each other’s guts. I just saw them as a resource. I had to change team members.”

S13. Poor Communication

In this case the program manager was not communicating the outcomes of other projects within the program and as a result the project manager did not know the requirements of the project and how it fit into the bigger picture: “Because we were only a part of it, we didn’t get invited to project meetings. We were very much left out of what was going on, and so we always had our ear to the ground to get information about what was happening. The program manager just didn’t want to communicate.” In order to cope with this, the project manager set up meetings with the program manager and attempted to improve communication flows.

S14. Project Risks

One project manager was managing a project where the core infrastructure had to be replaced, which if not done would pose a high risk to the organization. “Because we were delayed we had these devices in the network that were no longer supported by service agreements. That was the producer of anxiety for me, the fact that we’d increased the risk to us, of having these things that could fail at any time and had no support at all.” In order to cope with the pressure of being exposed to such high risk, the project manager developed a risk mitigation strategy and purchased spare equipment.

S15. Reputation

Another project manager found that in having to switch to an unfamiliar product, the project manager’s reputation was at stake. “I found out that we had chosen to use software that was completely different to the tender. I felt that the solutions architect was getting a kickback from the new vendor. I felt it was a bad decision for this client. I found out the new software was vaporware, it didn’t even exist. I thought that my reputation was at risk.” This occurred in combination with the change of scope in the solution being implemented. As previously mentioned in the scope section, training/self-study, promotion of the new product to the client and social support from other project managers was used as coping mechanisms. Of course, in this example, the issues of planning and management of resources are also involved in terms of failure to reevaluate earlier assumptions.

Coping Strategies

C1. Social Support

Social support was the most frequently used coping strategy. Examples of social support were talking to co-workers about what was happening, expressing feelings of frustration to family, and talking to a manager in order to share feelings about what was happening. “The only thing I did was to talk to other people about it and have a laugh. You would say to them what you would really like to say to the person involved. It helped to get it off my chest.”

Social support was used in response to nearly every stressor raised, and had an overwhelmingly positive evaluation of effectiveness by the project managers. The majority of project managers felt that talking about their problems helped them to reduce feelings of anxiety. Only in one case did a project manager rate social support as worsening the situation. In this case, the project manager felt that things were beyond his or her control and was confronted with managing a project with which was totally unfamiliar. As such, he or she felt that no coping strategies could have helped.

C2. Communication

Communication may initially be thought of as being similar to social support; however, there is a difference. Social support was focused on obtaining emotional support from others, whereas communication was defined as seeking or providing information in order to resolve an issue. For example, one project manager said that he or she “…went around and held one-on-one discussions with the steering committee members. I wanted to find out what the key issues were for them, what was driving them.” As such, it is more of a problem-focused style of coping as opposed to the more emotion- focused style found in social support.

The evaluations of effectiveness for communication were mixed with almost half of the participants saying it was very helpful, while the other half said that it did not help. This split holds true even when we look at the stressor, coping, outcome chain, with like stressors resulting in a communication coping strategy but having differing outcome ratings.

C3. Adding Resources

The project managers interviewed generally found adding resources to be a positive strategy in dealing with stressors, especially those of high workload or impending deadlines. This strategy involved adding resources to the project team or hiring contractors to perform work. As one project manager put it, “In order to deal with the workload we got our team to work on it 100% and had the vendor provide staff to work on the product for us.”

C4. Avoidance

The avoidance category describes behaviors such as avoiding thoughts of work or of thinking about work as unimportant in the scheme of things. One project manager said, “I just tried to stop thinking about it constantly,” while another said, “I would tell myself it’s not important, it’s just work.” It met with mixed results, again with about half and half positive and negative evaluations. Of the five positive ratings, three involved the stressor of responsibility. The negative ratings were for role conflict, high workload, and having a lack of control over resources.

C5. Problem-Solving

Problem-solving described behaviors that were aimed at tackling the problem that was being faced. These involved strategies such as working on improving processes and reorganizing project teams to reduce personal conflict. In one case the project manager said, “…got my team to role-play all the possible scenarios, trying to come up with anything 1 could have missed.” The project managers rate it as a positive strategy for coping in five of the eight cases, with two neutral and only one negative.

C6. Work Increase

Increasing the number of hours worked was a strategy adopted by six project managers. One project manager said, “increased [my| working hours to 12 hours per day until it was done.” Unsurprisingly, in three of these cases one of the stressors cited was a high workload. This coping strategy was met with mixed evaluations, with it being rated as positive twice, neutral once, and negative three times. Two project managers reported taking increased sick leave as a result of working long hours.

C7. Exercise

Five project managers said that they increased the amount they exercised in order to cope with the pressures they faced in their job. In three cases exercise was rated as having a positive impact and in two cases the project managers felt they had a negative outcome. One project manager described exercise as “… a good way to take my mind of my problems.”

C8. Planning

Planning involved analyzing the problem and planning what needed to be done. For example, one project manager produced a statement of work and scope document in order to combat feelings of anxiety about a lack of scope while another produced a detailed project plan when faced with uncertainty about what had to be done. Planning was rated as overwhelmingly positive, with four of the five incidents being rated as such. Only once was it rated neutrally, and in this situation multiple coping mechanisms had been employed.

C9. Alcohol

Increasing alcohol consumption was utilized twice, once by itself and once in combination with adding resources to the project. When used as the only coping strategy, the project manager said, “I started drinking more and taking sleeping tablets to help myself sleep at night. 1 just felt worse though. I suppose 1 took a lot more sick leave in thatperiod.” In the other case it was rated as positive and the project manager found it a useful way to relax at the end of the day.

C10. Relaxation

Relaxation with family in the evenings was raised by two project managers. One said that she “…made sure I found time to do fun things with my husband. It helped me to lead a balanced life.” Both found it to make a positive contribution to their coping with the pressure they were faced with.

C11. Risk Mitigation

Risk mitigation describes executing formal risk management strategies. In one example the project manager said, “…we were looking at mitigation strategies the whole time. We bought a stack of spares to mitigate the lack of support. It turned out there was no need, but everyone had a warm and fuzzy feeling about having spares.” This was carried out by two project managers and was evaluated by them as being a positive coping strategy by both.

C12. Time Management

Time management involved prioritizing tasks and using time saving methods. One project manager tried to save time by submitting documentation electronically but found it to be ineffective as a coping mechanism. Another project manager said, “I set up a system of priorities and dropped tasks that were of lower importance…. 1 found it was very effective in managing my work levels. I felt better about it.”

C13. Training/Self-Study

Two project managers spent time learning about the products they were implementing. As one project manager put it, “1 had to do a lot of self-training to be comfortable with the product. Sometimes people spin you rubbish, so I had to be fairly familiar with it.” In one case it was evaluated as having no affect on coping, while in the other case it was rated as producing a negative outcome.

C14. Eating

One project manager increased his or her food consumption to cope with the pressure. “… sat at my desk and ate, I would eat snacks all the time. I don’t think it helped me feel any better though.”

Copyright Project Management Institute Dec 2006

(c) 2006 Project Management Journal. Provided by ProQuest Information and Learning. All rights Reserved.

Ads of Ultra-Thin Send Wrong Message

Glamorizing thin teen girls wearing makeup and posing suggestively in ads promotes unhealthy bodies and unhealthy attitudes, says a U.S. expert.

The age of diagnosis for several types of eating disorders has gotten younger, as I’m now treating girls ages 7 to 9, versus 13 to 14 years old being the youngest diagnosis several years ago, says Dr. Stephanie Setliff, a University of Texas Southwestern Medical Center psychologist who specializes in eating disorders.

Messages being sent to girls and young teens by the media and popularized by ultra-thin movie stars and models contribute to the pressure these girls feel to be perfect.

However, genetic and biological components also factor into the situation, as well as these children’s personality characteristics and temperament, and how they and their families resolve conflicts in their lives, according to Setliff.

Setliff suggests that parents be alert to any indication that their child may be developing an eating disorder. Signs may include an obsession with food and/or exercise; wearing clothing that disguises the body; spending less time with friends; frequent trips to the bathroom — especially after meals; dieting; and changes in sleep patterns.

Old Rovers Learn New Tricks to Kick Off Year Four

NASA’s twin Mars rovers, nearing the third anniversary of their landings, are getting smarter as they get older.

The unexpected longevity of Spirit and Opportunity is giving the space agency a chance to field-test on Mars some new capabilities useful both to these missions and future rovers. Spirit will begin its fourth year on Mars on Jan. 3 (PST); Opportunity on Jan. 24. In addition to their continuing scientific observations, they are now testing four new skills included in revised flight software uploaded to their onboard computers.

One of the new capabilities enables spacecraft to examine images and recognize certain types of features. It is based on software developed for NASA’s Space Technology 6 “thinking spacecraft.”

Spirit has photographed dozens of dusty whirlwinds in action, and both rovers have photographed clouds. Until now, however, scientists on Earth have had to sift through many transmitted images from Mars to find those few. With the new intelligence boost, the rovers can recognize dust devils or clouds and select only the relevant parts of those images to send back to Earth. This increased efficiency will free up more communication time for additional scientific investigations.

To recognize dust devils, the new software looks for changes from one image to the next, taken a few seconds apart, of the same field of view. To find clouds, it looks for non-uniform features in the portion of an image it recognizes as the sky.

Another new feature, called “visual target tracking,” enables a rover to keep recognizing a designated landscape feature as the rover moves. Khaled Ali of NASA’s Jet Propulsion Laboratory, Pasadena, Calif., flight software team leader for Spirit and Opportunity, said, “The rover keeps updating its template of what the feature looks like. It may be a rock that looks bigger as the rover approaches it, or maybe the shape looks different from a different angle, but the rover still knows it’s the same rock.”

Visual target tracking can be combined with a third new feature — autonomy in calculating where it is safe to reach out with the contact tools on the rover’s robotic arm. The combination gives Spirit and Opportunity a capability called “go and touch,” which is yet to be tested on Mars. So far in the mission, whenever a rover has driven to a new location, the crew on Earth has had to evaluate images of the new location to decide where the rover could place its contact instruments on a subsequent day. After the new software has been tested and validated, the crew will have the option of letting a rover choose an arm target for itself the same day it drives to a new location.

The new software also improves the autonomy of each rover for navigating away from hazards by building better maps of their surroundings than they have done previously. This new capability was developed by Carnegie Mellon University, Pittsburgh, and JPL.

“Before this, the rovers could only think one step ahead about getting around an obstacle,” said JPL’s Dr. John Callas, project manager for the Mars Exploration Rovers. “If they encountered an obstacle or hazard, they’d back off one step and try a different direction, and if that direction didn’t work they’d try another, then another. And sometimes the rover could not find a solution. With this new capability, the rover will be smarter about navigating in complex terrain, thinking several steps ahead. It could back out of a dead-end cul-de-sac. It could even find its way through a maze.”

This is the most comprehensive of four revisions to the rovers’ flight software since launch. One new version was uplinked during the cruise to Mars, and the rovers have switched to upgraded versions twice since their January 2004 landings.

Callas said, “These rovers are a great resource for testing software that could be useful to future Mars missions without sacrificing our own continuing mission of exploration. This new software will be a baseline for development of flight software for Mars Science Laboratory, but it’s also helpful in operating Spirit and Opportunity.” NASA’s Mars Science Laboratory is a next-generation Mars rover in development for planned launch in 2009.

Spirit and Opportunity have worked on Mars for nearly 12 times as long as their originally planned prime missions of 90 Martian days. Spirit has driven about 6.9 kilometers (4.3 miles); Opportunity has driven about 9.8 kilometers (6.1 miles). Spirit has returned more than 88,500 images, Opportunity more than 80,700. All the raw images are available online at http://marsrovers.jpl.nasa.gov/gallery/all/ .

Currently, Spirit is investigating rocks and soils near a ridge where it kept its solar panels tilted toward the sun during the Martian winter. Opportunity is exploring “Victoria Crater,” where cliffs in the crater wall expose rock layers with clues about a larger span of Mars history than the rover has previously examined.

Opportunity’s key discovery since landing has been mineral and rock-texture evidence that water drenched and flowed over the surface in at least one region of Mars long ago. Spirit has found evidence that water in some form has altered mineral composition of some soils and rocks in older hills above the plain where the rover landed.

Among the rovers’ many other accomplishments:

— Opportunity has analyzed a series of exposed rock layers recording changing environmental conditions from the times when the layers were deposited and later modified. Wind-blown dunes came and went. The water table fluctuated.

— Spirit has recorded dust devils forming and moving, events which were made into movie clips. These provide new insight into the interaction of Mars’ atmosphere and surface.

— Both rovers have found metallic meteorites on Mars. Opportunity found one rock with a composition similar to a meteorite that reached Earth from Mars.

NASA’s Mars Technology Program and New Millennium Program sponsored development of the new capabilities included in the new flight software.

JPL, a division of the California Institute of Technology, Pasadena, manages the Mars Exploration Rover Project for the NASA Science Mission Directorate. For images and information about the rovers, visit http://www.nasa.gov/rovers . For descriptions of technologies being developed for future Mars missions, see http://marstech.jpl.nasa.gov . For information about the New Millennium Program’s Space Technology 6 mission, see http://nmp.nasa.gov/st6/ .

California Man Pleads Guilty to Pharmaceutical Drug Fraud

KANSAS CITY, Mo., Dec. 28 /PRNewswire-USNewswire/ — Bradley J. Schlozman, U.S. Attorney for the Western District of Missouri, announced that a California man pleaded guilty in federal court today to defrauding the government by arranging for the purchase of stolen pharmaceutical drugs.

Noah Salcedo-Smith, 35, of San Fernando, Calif., pleaded guilty before U.S. District Judge Ortrie D. Smith this morning to the charge contained in a Dec. 14, 2005, superseding indictment.

“This defendant turned a blind eye to the suspicious source of these drugs that had been stolen from a Miami warehouse,” Schlozman said. “His actions were part of a larger criminal scheme that put profits ahead of public safety. We will not tolerate unscrupulous businessmen greedily shortcutting the federal system that protects consumers from unsafe prescription drugs.”

By pleading guilty today, Salcedo-Smith admitted that he participated in a scheme to defraud the U.S. Food and Drug Administration (FDA) by obstructing the lawful functions of the FDA to regulate the interstate sale and distribution of drugs and to safeguard the health and safety of consumers who purchase drugs.

Salcedo-Smith was a salesman involved in the secondary wholesale market. Prescription drug manufacturers use a multi-tier system of wholesalers to distribute prescription drugs and pharmaceutical products in the United States, Schlozman explained. A few large companies with publicly traded stock occupy the top tier of the distribution system, purchasing drugs in large volumes directly from a drug manufacturer. In turn, these top-tier companies sell to several large regional wholesalers. Below the regional wholesalers are the secondary wholesalers, who buy and sell drugs to and from each other and also sell drugs to hospitals, clinics, doctors and pharmacies.

While acting on behalf of Albers Medical Distributors Inc. and OTS Sales Inc., Salcedo-Smith arranged for the purchase of prescription drugs from a seller who did not provide pedigree documents establishing the legitimacy, source and origin of the drugs being sold. Those drugs, which were manufactured by Glaxo-Smith, had been stolen from a warehouse in Miami, Fla., in December 2001. The stolen drugs were purchased by co-defendant Albert David Nassar, 51, of New York, N.Y., then sold and re-sold through a series of secondary wholesale distributors, including Salcedo-Smith. In a series of purchases in January 2002, co-defendant Douglas C. Albers , 55, of Leawood, Kan., owner of Albers Medical Distributors, paid approximately $3.3 million for some of the stolen Glaxo drugs. Albers then re-sold the drugs to other distributors for approximately $3.5 million.

Salcedo-Smith also admitted that he helped create false pedigrees for the drugs so that they could be resold in the secondary wholesale market by Albers Medical Distributors and appear to have a legitimate pedigree. Under federal statutes, Salcedo-Smith could be subject to a sentence of up to five years in federal prison without parole, plus a fine up to $250,000.

Salcedo-Smith is the fifth co-defendant to plead guilty to charges contained in the federal indictment. This case is being prosecuted by Senior Litigation Counsel Gene Porter. It was investigated by the FDA Office of Criminal Investigations.

U.S. Department of Justice

CONTACT: Don Ledford of the U.S. Department of Justice, +1-816-426-4220

Web site: http://www.usdoj.gov/usao/mow

Charges Against Doctor Rise to 18

By Jeremy Pawloski, The Olympian, Olympia, Wash.

Dec. 28–The number of criminal charges against Dr. Jitesh Chawla, formerly employed at Providence St. Peter Hospital, has jumped from three to 18, based on allegations of sexual touching and rape made by patients and co-workers of Chawla at his other former employer, Group Health Tacoma.

The 15 new criminal charges against Chawla include 10 counts of indecent liberties, three counts of fourth-degree assault with sexual motivation and two counts of second-degree rape.

Thurston County Deputy Prosecuting Attorney Jodilyn Erikson-Muldrew said the 15 new counts filed in Thurston County Superior Court on Dec. 19 are all based on accusations made by 13 accusers from Pierce County.

Tacoma attorney Thaddeus Martin said Chawla’s 13 new accusers are all clients of his in a civil suit he has filed against Group Health based on Chawla’s alleged behavior.

“I have 13 women who were victimized and should not have been,” Martin said. Chawla “should not have been a doctor based on his history of violating women and overstepping the physician-patient boundaries. He should never been around any patients, based on his history.”

Chawla’s attorney in his criminal case, John Sinclair, said Wednesday: “Those who know Dr. Chawla know him to be a sincere and dedicated medical professional. These are just allegations and have not been proven. That’s what trials are for.”

Martin’s lawsuit against Group Health alleges that Chawla sexually harassed and assaulted female patients and colleagues.

The suit alleges a pr oper background check could have confirmed Chawla had a history of inappropriate behavior, including that Chawla had been kicked out of a medical school on a Caribbean island for “similar sexually assaultive behavior he engaged in at Group Health.”

The state Department of Health suspended Chawla’s medical license Oct. 13, based on the allegations made against him when he was employed at Providence St. Peter — that he touched in a sexual manner two women and an underage teenage girl while he was employed at the hospital’s chemical dependency unit.

In court Oct. 6, Sinclair said Chawla was then employed at Valley View Health Center in Chehalis. However, Sinclair said Wednesday that Chawla is not currently employed.

“It’s difficult for him to work at the present time,” Sinclair said.

Chawla was fired from Providence St. Peter on Dec. 23, 2005, after three women complained to a hospital official on Dec. 19, 2005, court papers state.

Chawla was fired from Group Health in April 2006 after staff members complained about him, a Group Health spokesman has said.

Officials at Group Health Tacoma could not be reached Wednesday. However, in a prior statement, Group Health spokesman Michael Erikson said: “As employees brought forth complaints about Dr. Chawla, they were thoroughly investigated, and those complaints were part of what led to his termination. At the time that we employed him, there were no complaints against his license.”

Chawla never disclosed to Group Health that he was employed at Providence St. Peter, Erikson also has said.

Erikson said in October that Group Health conducts background checks on all of its physicians, including criminal background checks, references, previous employment, claims history and any prior complaints bef ore the state’s licensing board.

In court papers, one of the women enrolled in the chemical dependency unit alleged that after she complained about Chawla, he responded, “Who are they gonna believe, me or you?”

Jeremy Pawloski covers public safety for The Olympian. He can be reached at 360-754-5465 or [email protected].

—–

Copyright (c) 2006, The Olympian, Olympia, Wash.

Distributed by McClatchy-Tribune Business News.

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.

Teenager Gets Probation for Putting Bleach in Drink

By Domingo Ramirez Jr., Fort Worth Star-Telegram, Texas

Dec. 27–HURST — A former L.D. Bell High School theater student has been sentenced to two years’ probation for spiking a rival’s drink with bleach in February.

In a plea agreement reached Thursday, Katherine Smith, 19, of Hurst was sentenced on the charge of attempted assault/bodily injury for putting Clorox in a Mountain Dew and then handing it to a 16-year-old sophomore.

The sophomore had the lead role in Ha!, a school theater production. Smith, who was the understudy, wanted the role, according to the arrest warrant affidavit.

In addition to probation, Smith was fined $530.

Information was not available Tuesday on whether Smith pleaded guilty or no contest to the charge.

The plea agreement was reached in County Criminal Court No. 2 in Fort Worth.

Smith and her attorney, Sylvia Andrews of Fort Worth, could not be reached Tuesday for comment.

The arrest warrant affidavit gave this account of the incident:

On the morning of Feb. 9, the sophomore student said she received the Mountain Dew from Smith, who was in her theater class.

The production was scheduled to open that night.

The student told school officials that she didn’t drink the soda because it smelled funny when she opened it. She took it took to a school official, who reported that the liquid inside the bottle smelled like bleach.

In an interview with school officials, Smith said she bought the drink from a vending machine as a gift for her classmate. She admitted taking a drink from it, but she said she put the lid back on and didn’t put anything in it.

School officials alerted police.

On Feb. 10, investigators learned that Smith was the understudy to the sophomore in the production. If the sophomore became ill, Smith would have the lead role.

Smith told school officials that she had a lot of relatives coming from out of town to see her perform. Smith’s mother, Janet Smith, was under the impression that her daughter had the lead role.

Later that day, Smith admitted that she poured bleach into a small vial at home and brought it with her to school. After buying the Mountain Dew, she went to the girls bathroom, squirted an eyedropper full of bleach into the drink and gave it to her classmate.

She hid the vial under her desk and threw it into a storm drain after school.

Smith surrendered to authorities in June after test results confirmed that the drink contained components of bleach.

——

Domingo Ramirez Jr., 817-685-3822 [email protected]

—–

Copyright (c) 2006, Fort Worth Star-Telegram, Texas

Distributed by McClatchy-Tribune Business News.

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.

Video Games Fill Various Voids

Kids and adults will stay glued to video games this holiday season because the fun of playing actually is rooted in fulfilling their basic psychological needs.

Psychologists at the University of Rochester, in collaboration with Immersyve, Inc., a virtual environment think tank, asked 1,000 gamers what motivates them to keep playing. The results published in the journal Motivation and Emotion this month suggest that people enjoy video games because they find them intrinsically satisfying.

“We think there’s a deeper theory than the fun of playing,” says Richard M. Ryan, a motivational psychologist at the University and lead investigator in the four new studies about gaming. Players reported feeling best when the games produced positive experiences and challenges that connected to what they know in the real world.

The research found that games can provide opportunities for achievement, freedom, and even a connection to other players. Those benefits trumped a shallow sense of fun, which doesn’t keep players as interested.

“It’s our contention that the psychological ‘pull’ of games is largely due to their capacity to engender feelings of autonomy, competence, and relatedness,” says Ryan. The researchers believe that some video games not only motivate further play but “also can be experienced as enhancing psychological wellness, at least short-term,” he says.

Ryan and coauthors Andrew Przybylski, a graduate student at the University of Rochester, and Scott Rigby, the president of Immersyve who earned a doctorate in psychology at Rochester, aimed to evaluate players’ motivation in virtual environments. Study volunteers answered pre- and post-game questionnaires that were applied from a psychological measure based on Self-Determination Theory, a widely researched theory of motivation developed at the University of Rochester.

Rather than dissect the actual games, which other researchers have done, the Rochester team looked at the underlying motives and satisfactions that can spark players’ interests and sustain them during play.

Revenues from video games””even before the latest Wii, PlayStation 3, and Xbox systems emerged””surpass the money made from Hollywood films annually. A range of demographic groups plays video games, and key to understanding their enjoyment is the motivational pull of the games.

Four groups of people were asked to play different games, including one group tackling “massively multiplayer online” games””MMO for short, which are considered the fastest growing segment of the computer gaming industry. MMOs are capable of supporting hundreds of thousands of players simultaneously. For those playing MMOs, the need for relatedness emerged “as an important satisfaction that promotes a sense of presence, game enjoyment, and an intention for future play,” the researchers found.

Though different types of games and game environments were studied, Ryan points out that “not all video games are created equal” in their ability to satisfy basic psychological needs. “But those that do may be the best at keeping players coming back.”

On the Web:

http://www.rochester.edu

Popular Craigslist Web Site Now Charges $25 Fee for Help Wanted Listings

By Long, Jessica

While Craigslist claims its new policy of charging local employers to post job openings will discourage abuse of its popular Internet-based social networking and classified advertising service, one critic says the fees would certainly generate more revenues.

“It’s a bit disingenuous to say he’s doing it solely to knock out the scams, because the community already does a good job of notifying you when something isn’t right, and it’s not hard to get them off there once you know,” said Howard Rosen, operations director for the San Diego Reader, which distributes 175,000 copies weekly throughout the county. “But he’s certainly entitled to charge because it is an opportunity for him to make money.”

Craigslist Inc., the San Francisco e-company that offers online ads in various U.S. and foreign cities, began charging employers $25 per help wanted listing last week. San Diego is one of four markets where fees will be charged, the others are Seattle, Boston and Washington, D.C.

The four cities account for more than 20 percent of Craigslist’s traffic, the company says.

The new fee does not apply to non-job-related postings, nor does it charge to browse the ads. Nor does it apply to the site’s “Gigs” category, which lists postings for smaller projects, odd jobs, personal attendants and domestic help.

According to Craigslist spokeswoman Susan MacTavish Best, the fee improves the quality of postings by discouraging abuse of a free service.

“All changes to the Craigslist site come from user requests and that includes when and where we charge for ads,” she said. “As a CL site becomes more and more popular, it makes it time consuming for users to wade through repeat postings and spam-like ads.”

This is not the first time that Craigslist has imposed a fee on specific markets.

Other markets where employers pay a fee to post job ads are San Francisco, Los Angeles and New York City.

The fee in San Francisco is $75 and began eight years ago. A $25 fee in Los Angeles and New York City began two years ago.

Upon initiating those fee structures, Craigslist officials admit that the sheer number of job postings fell significantly in those markets, but insist the overall quality of postings increased.

Leveling The Playing Field

Craigslist was launched in the San Francisco Bay Area in early 1995, and then incorporated as a for-profit business in 1999 when founder Craig Newmark first began offering the service in multiple cities.

Since then, Craigslist has entered more than 300 cities globally, from Bangkok, Thailand, to Calgary, Alberta, Canada.

Despite its bare-bones design, the site, Craigslist.com and Cragislist.org, gets more than four billion page views per month with just 22 employees.

It’s rated as one of the 10 most popular English-speaking sites on the Internet.

In 2004, online auction giant eBay purchased a 25 percent stake in the company. The company, which employs about 20 people, does not disclose financial information.

Varinda Missett, director of advertising for the North County Times, a 90,000 circulation daily newspaper based in Escondido, said she welcomes competition from Craigslist.

However, she believes the service has been too lax in its screening process for years. Because of that, Missett believes the decision to charge San Diego job posters is a positive development.

“Craigslist has had a huge impact, as everybody knows,” Missett said. “But we’ve always hated the fact that they don’t have to follow any guidelines.”

Missett is not the only one to chastise Craigslist for allowing unregulated postings.

The service has come under fire for allowing people to post ads that openly discriminate and allegedly facilitate illegal activities, such as prostitution.

To Charge Or Not

In order to compete with Craigslist, the San Diego UnionTribune, a 300,000-plus circulation daily, decided last fall to offer free classified ads to individuals both online and in print.

The Virginia-based Newspaper Association of America reports that newspapers nationwide took in a total of $17.3 billion on classified ads last year. About $5.1 billion of that was from employment ads.

Although 2005 classified spending in newspapers increased slightly from 2004, it’s still down from its peak of $ 19.6 billion in 2000, the nonprofit association reported.

At the North County Times, classified ads have been revamped in recent years in response to the growing popularity of Craigslist among users.

Although the paper still charges fees to post, special promotions allow customers to place classifieds online at nctimes.com and in the NCT’s print editions.

Advertising director Missett said the paper also recently began offering customers the choice of posting a photo with their classified message in the print edition.

Taking The Offensive

Unlike the dailies, the Reader has taken an entirely different approach, opting to combat fire with fire. The Reader is one of 59 publications to contract with Phoenixbased Backpage.com, which was founded in 2004 by Village Voice Media, a group of alternative newspapers.

A link from the Reader’s Web site drives traffic to the Backpage.com site.

Like Craigslist, users pay nothing to view classified ads, but unlike Craigslist, users can also find coupons for everything from oil changes to restaurant meals. Businesses pay nothing to post coupons, unless they wish to include an image, in which case a small fee is charged.

“When we did Backpage, we realized we’d be competing with ourselves, too, but something had to be done to keep up,” Rosen said. “Everyone’s print ads are down no matter what they tell you, they’re down.”

Copyright San Diego Business Journal Oct 30, 2006

Chest Pain and ST Segment Elevation Attributable to Cholecystitis: A Case Report and Review of the Literature

By Nasir, Javed M; Durning, Steven J; Sweet, Jon M; Cation, Lannie J

Chest pain with electrocardiographic changes is usually a life- threatening presentation of cardiac ischemia. There are, however, a variety of noncardiac conditions that have been reported to mimic these clinical and electrocardiographic changes. An Asian woman presented with chest pain and ST segment elevations in the distribution of the left anterior descending artery. She had persisting chest pain and ST segment elevations that were refractory to medical therapy, leading to thrombolytic therapy and rescue angiography, which revealed no evidence of coronary artery disease by coronary catherization. Cholecystitis was subsequently diagnosed with hepatobiliary scintigraphy. The patient’s fever and ST segment elevations promptly resolved with antibiotic treatment. Four previous cases of ST segment elevation attributed to cholecystitis have been reported. Although the electrocardiographic changes attributed to cholecystitis have been shown to be correctable, the pathophysiological mechanism underlying these changes remains unclear. Prompt recognition of cholecystitis can ensure appropriate treatment and may prevent the performance of unnecessary diagnostic and therapeutic interventions.

Introduction

Chest pain with electrocardiographic (ECG) changes is often a life-threatening presentation of cardiac ischemia. However, a variety of noncardiac conditions have been reported to mimic the ECG changes seen with ischemic heart disease, including cholecystitis,1- 9 pancreatitis,10-13 and pneumonitis.14 With these conditions, the changes usually manifest as diffuse, nonspecific, T wave inversions or ST segment depressions.5-9 Although chest pain with ST segment elevation is considered to be nearly pathognomonic for cardiac injury, this presentation has also been described with gastric distention,15 cholecystitis,1-3 acute stroke, pericarditis, subarachnoid hemorrhage, neoplastic invasion of the myocardium, acute cor pulmonale, and hypothermia. Prompt recognition of these noncardiac causes may reduce morbidity and mortality rates, costs, and patient anxiety.

We report on a patient with chest pain with anterior ST segment elevation that resolved with treatment of the patient’s cholecystitis. We are aware of only four previous cases of ST segment elevation attributable to cholecystitis.1-4 We discuss our case, compare it with previously published reports, and review the potential association between gallbladder disease and heart disease, including the potential pathophysiological conditions underlying these ECG changes.

Case Report

A 63-year-old Asian woman with diabetes mellitus, hypercholesterolemla, asthma, and tobacco use presented with a 24- hour history of intermittent, “band-like,” substernal, chest pain, dyspnea, nausea with vomiting, and low-grade fever. The pain was not pleuritic and did not radiate. The patient denied cough, abdominal pain, chills, or changes in her bowel or bladder habits. Her medications were insulin, theophylline, and terbutaline.

The patient’s blood pressure was 130/60 mm Hg, pulse rate was 110 beats per minute, respiratory rate was 18 breaths per minute, and temperature was 38.2C. The patient appeared to be in mild distress. Her heart rate was regular, without murmurs, rubs, or gallops. The patient had scattered, diffuse, expiratory wheezes, with good air movement. Her bowel sounds were normal, and her abdomen was soft, nontender, and without palpable masses. The patient had no jugular vein distention or peripheral edema. Her musculoskeletal and dermatological examination results were normal.

Chemistry results were normal except for a glucose level of 200 mg/dL. The aspartate aminotransferase level was 46 U/L (normal range, 0-31 U/L), alanine aminotransferase level was 43 U/L (normal range, 0-31 U/L), bilirubin level was 0.6 mg/dL (normal range, 0- 1.0 mg/dL), alkaline phosphatase level was 134 U/L (normal range, 39- 117 U/L), and lactate dehydrogenase level was 361 U/L (normal range, 122-220 U/L). The serum amylase level was 61 U/L (normal range, 25- 115 U/L). The complete blood count revealed a white blood cell count of 13,500 cells per mm^sup 3^ (82% neutrophils and 4% bands), hemoglobin level of 15.2 g/dL, and platelet count of 297,000 cells per L (normal range, 250,000-450,000 cells per L). Urinalysis results were normal except for glycosuria. The creatine phosphokinase level was 69 U/L (normal range, 0-203 U/L), and creatine kinase-MB was undetectable.

The chest X-ray revealed hyperinflation without cardiomegaly, effusion, or infiltration. An acute abdominal series showed a nonspecific bowel gas pattern, without evidence of obstruction. The initial ECG assessment demonstrated sinus tachycardia (rate, 110 beats per minute), with new 3- to 4-mm ST segment elevation in Vl to V3. An ECG recording from an outpatient visit several months before presentation did not demonstrate ST or T wave changes suggesting ischemia. The patient’s chest pain and ECG abnormalities initially resolved after she received aspirin and nitroglycerin in the emergency department, and heparin was infused Intravenously. Echocardiography demonstrated normal left ventricular systolic function, without effusion, wall motion abnormalities, or valvular disease. The patient’s chest pain and anterior ST segment elevation returned 5 hours after admission, prompting the administration of tissue plasminogen activator. Rescue coronary angiography was subsequently performed because of lack of clinical or ECG improvement. There was no evidence of coronary artery disease or coronary artery spasm. Empiric calcium channel blocker administration because of vasospasm failed to resolve the ST segment elevation.

Four hours after cardiac catheterization, the patient’s temperature rose to 40.8C. No new findings were noted on cardiopulmonary examination. However, the patient’s bowel sounds had become hypoactive and her abdomen was distended. Laboratory tests at this time demonstrated a leftward shift in her complete blood count (white blood cell count of 9,400 cells per mm^sup 3^, with 71% neutrophils and 22% bands), with persisting, mildly elevated, liver enzyme levels. Intravenous ticarcillin/clavulonate acid therapy was started after additional blood cultures were obtained. Right upper- quadrant ultrasonography demonstrated gallbladder wall thickening without stones. Subsequent hepatobiliary scintigraphy confirmed cholecystitis.

Blood cultures grew KlebsfeUapneumonioe on the second day of hospitalization. The patient’s symptoms and ECG abnormalities completely resolved within 48 hours after initiation of antibiotic therapy. The patient had no enzymatic evidence of myocardial infarction, with a peak creatine phosphoklnase level of 133 U/L (normal range, 0-203 U/L). Troponin was not available when this patient presented to our medical center (she presented before the advent of troponin use). Cholecystectomy was performed, and acute cholecystitis was confirmed through histopathological evaluation.

Discussion

We report on a 63 year-old woman with chest pain and ST segment elevation in the distribution of the left anterior descending artery, prompting thrombolysis and angiography. She had no evidence of coronary artery disease or spasm, and her ST segment abnormalities promptly resolved with antibiotic treatment. Cholecystitis was subsequently diagnosed with hepatobiliary scintigraphy and was confirmed histologically. ECG abnormalities have been reported with a variety of noncardiac conditions, and ST segment elevations with chest pain have been reported with cholecystitis,1-3 gastric distention,15 acute stroke, pericarditis, subarachnoid hemorrhage, neoplastic invasion of the myocardium, acute cor pulmonale, and hypothermia. Prompt recognition of these noncardiac causes of ECG changes can ensure appropriate treatment and may prevent unnecessary diagnostic and therapeutic maneuvers, which can lead to significant patient anxiety, morbidity, cost, and potentially death. Chest pain and ST segment elevations have also been described for takotsubo cardiomyopathy, a rare disorder that is associated with emotional stress and is likely attributable to increased sympathetic activity.

A diseased gallbladder has been long associated with heart disease.16-18 Swartz and Herman19 credited Gueneau de Mussey with associating these diseases as early as 1878. This association has prompted several studies examining the ECG effects of biliary distortion.20,21 In those studies, the ECG changes usually manifested as diffuse, nonspecific, T wave inversions or ST segment depressions.

We conducted a Medline literature search and reviewed the citations of the articles identified in this manner. We found only four previous cases of ST segment elevation attributed to cholecystitis (Table I).1-4 Patient ages ranged from 46 to 64 years. Three of the patients presented with chest pain and one with abdominal pain. All four were men, and two had a history of coronary artery disease. The lack of coronary artery disease detected with angiography for our patient is notable, because this is only the second case of cholecystitis presenting with chest pain and ST segment elevation with no evidence of coronary artery disease with cardiac catheterization. Earlier studies with animals20 and humans21 suggested that the gal\lbladder could elicit ECG changes only if coronary artery disease was present.

Two of the four patients underwent cardiac catheterization, and one of the previously reported patients received thrombolytic therapy, without effect. All previous cases with ST segment changes diagnosed through 12-lead ECG evaluations (n = 3) showed ST segment elevations in the distribution of a single coronary artery, anterior (n = 2) or inferior (n = 1). Two patients had resolution of ECG changes after cholecystectomy, two had resolution of ECG changes without further treatment, and our patient had resolution of ECG changes after antibiotic therapy.

Although the ECG changes attributed to cholecystitis have been shown to be correctable in humans with surgery5,22,23 and atropine treatment,5 the pathophysiological mechanism underlying the ECG changes remains unclear. Gallbladder distention has been shown to increase heart rate, arterial blood pressure,24,25 and plasma renin levels,26 and studies in animals suggest that its effect on coronary blood flow may be a significant factor underlying these ECG changes.27-29 Decreased coronary blood flow was demonstrated in dogs during distention of the common bile duct.29 Additionally, distention of the common bile duct in pigs28 demonstrated that the decreased coronary blood flow persisted with control of heart rate and arterial blood pressure. In this swine model, a reflexive reduction in coronary blood flow always occurred with gallbladder distention and exhibited a graded response to the magnitude of the distention. This reflex was abolished with bilateral cervical vagotomy but was unaffected by severing of the splanchnic nerves, suggesting a vagal afferent pathway. The coronary vasoconstriction of this reflex was unaffected by atropine and propranolol but was abolished with phentolamine, indicating that this reflex has an α-adrenergic sympathetic efferent. These animal study findings may also play an important role in humans and may explain how gallbladder distention during gallbladder disease may limit coronary flow, providing a mechanism for the association of gallbladder disease and myocardial ischemia.

Summary

To our knowledge, this is the fifth report of ST segment elevation attributable to cholecystitis and the first case to resolve with antibiotics. Contrary to historic belief that ST segment elevation in the setting of cholecystitis is seen only in patients with underlying coronary artery disease, we report the second case of cholecystitis leading to ST segment elevation with no angiographie evidence of coronary artery disease.

Chest pain accompanied by St segment elevation is typically regarded as a condition for which prompt thrombolysis or percutaneous coronary intervention is recommended by the American College of Cardiology and the American Heart Association.30 This is the second reported case of thrombolytic therapy and the third reported case of cardiac catheterizatlon for a patient with ST segment elevation attributable to cholecystitis. Heparin, thrombolytic therapy, and/or coronary angiography can lead to significant morbidity as well as death, hi addition, there are significant costs and patient anxiety with such interventions. Furthermore, delays in diagnosing cholecystitis may lead to serious complications, including sepsis and death. When the initial diagnostic and/or therapeutic interventions for chest pain with ST segment elevation do not yield the expected results (i.e., normal cardiac enzyme levels and normal cardiac catheterization results), then alternative diagnoses should be considered, including a search for cholecystitis.

References

1. Ryan ET, Pak PH. DeSanctis RW: Myocardial Infarction mimicked by acute cholecystitis. Ann Intern Med 1992; 116: 218-20.

2. Clarice NE: Electrocardiographs changes in active duodenal and gall bladder disease. Am Heart J 1945; 29: 628-32.

3. Doorey AJ, Miller RE: Get a surgeon, hold the cardiologist: electrocardiogram falsely suggestive of myocardlal Infarction in acute cholecystitis. Del Med J 2001; 73: 103-4.

4. Cohen OJ: Electrocardlographlc ST-segment elevation in cholecystitis. Hosp Physician 1991; 27: 15-8.

5. Kaufman JM, Lubera R: Preoperative use of atropine and electrocardiographic changes. JAMA 1967; 200: 109-12.

6. Ravdin IS, Fitz-hugh T. Wolferth CC, Barbiert EA, Ravdin RG: Relation of gallstone disease to angina pectorts. Arch Surg 1955; 70: 333-42.

7. Krasna MJ, FlancbaumL: Electrocardlographic changes in cardiac patients with acute gallbladder disease. Am Surg 1986; 52: 541-3.

8. Breitwiesser ER: Electrocardlographlc observation in chronic cholecystitis before and after surgery. Am J Med Sci 1947; 213: 598- 602.

9. Welss MW, Hamilton JE: The effect of gall-bladder disease on the electrocardiogram. Surgery 1939; 1: 893.

10. Pezzilli R, Barakat B, Billi P, Bertacclnl B: Electrocardiographic abnormalities in acute pancreatitis. Eur J Emerg Med 1999; 6:27-9.

11. Fulton MC, Marriott HJL: Acute pancreatitis simulating myocardlal infarction in the electrocardiogram. Ann Intern Med 1963; 59: 730-2.

12. Patel J, Movahed A, Reeves WC: Electrocardiographic and segmental wall motion abnormalities in pancreatitis mimicking myocardlal infarction. Clin Cardiol 1994; 17: 505-9.

13. Variyam EP, Shah A: Pericardial effusion and left ventricular function in patients with acute alcoholic pancreatitis. Arch Intern Med 1987; 47: 923-5.

14. Seedat MA, Feldman C, Skoularigis J, Promnitz DA, Smith C, Zwi S: A study of acute community-acquired pneumonia, including details of cardiac changes. Q J Med 1993; 86: 669-75.

15. Frais MA, Rodgers K: Dramatic electrocardiographic T-wave changes associated with gastric dilatation. Chest 1990; 98: 489-90.

16. Breyfogle HS: The frequency of coexisting gallbladder and coronary artery disease. JAMA 1940; 114: 1434-7.

17. Walsh BJ, Bland EF, Taquini AC, White PD: The association of gall bladder disease and of peptic ulcer with coronary disease: a post-mortem study. Am Heart J 1941; 21: 689-97.

18. Babcock RH: Chronic cholecystitis as a cause of myocardial incompetence. JAMA 1909; 52: 1904-11.

19. Swartz M, Herman A: The association of cholecystitis with cardiac affections: a study based on 109 cases. Ann Intern Med 1930; 4: 783-94.

20. Hodge GB, Messer AL, Hill H: Effect of detention of the biliary tract on the electrocardiogram. Arch Surg 1947; 55: 710-22.

21. Hodge GB, Messer AL: The electrocardiogram in biliary tract disease and during experimental biliary distention. Surg Gynecol Obstet 1948; 86: 617-28.

22. Brettwlesser ER Electrocardlographic observation In chronic cholecystitis before and after surgery. Am J Med Sci 1947; 213: 598- 602.

23. Fitz-Hugh T, Wolferth CC: Cardiac improvement following gallbladder surgery: electrocardiographic evidence in cases with associated myocardial disease. Ann Surg 1935; 101: 478-83.

24. Vacca G, Battaglia A, Grossini E, Papillo B: Tachycardia and presser responses to dlstention of the gallbladder In the anesthetized pig. Med Sci Res 1994; 22: 697-9.

25. Vacca G, Mary DASG, Battaglia A, Grossini E, Molinari C: Role of vagal afferents in the reflex hemodynamic responses caused by gallbladder distention in anesthetized pigs. Med Sci Res 1996; 24: 41-3.

26. Molinari C, Grossini E, Mary DA, Vacca G: Effect of distension of the gallbladder on plasma renin activity in anesthetized pigs. Circulation 2000; 101: 2539-45.

27. Gilbert NC: Influence of extrinsic factors on the coronary flow and clinical course of heart disease. Bull NY Acad Med 1942; 18: 83-92.

28. Vacca G, Battaglia A, Grossini E, Mary DA, Molinari C: Reflex coronary vasoconstriction caused by gallbladder distension in anesthetized pigs. Circulation 1996; 94: 2201-9.

29. Cullen ML, Howard HL: Myocardial circulatory changes measured by clearance of Na24: effect of common duct distension on myocardial circulation. J Appl Physiol 1952; 5: 281-4.

30. Ryan TJ, Antraan EM. Brooks NH, et al: 1999 update: ACC/AHA guidelines for the management of patients with acute myocardial infarction: executive summary and recommendations: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardlal Infarction). Circulation 1999; 100: 1016-30.

Guarantor: Maj Steven J. Durning, MC USAF

Contributors: 2nd Lt Javed M. Nasir, MSC USAFR*; Maj Steven J. Durning, MC USAF*; Jon M. Sweet, MD[dagger]; Lannie J. Cation, MD[double dagger]

* Uniformed Services University School of Medicine, Bethesda, MD 20814-4799.

[dagger] Department of Medicine, Carillon Health System, Carillon Roanoke Memorial Hospital, Roanoke, VA 24033.

[double dagger] Department of Medicine, University of Illinois College of Medicine at Peoria, Peoria, IL 61605-2576.

The views expressed In this article are those of the authors and do not reflect the official policy of the Department of Defense or other departments of the U.S. government.

This manuscript was received for review in June 2004. The revised manuscript was accepted for publication in February 2006.

Copyright Association of Military Surgeons of the United States Dec 2006

(c) 2006 Military Medicine. Provided by ProQuest Information and Learning. All rights Reserved.

Can I Get Chlamydia By Sharing a Drink?

By ROBERT BENON

Question: There’s a rumor that my friend has chlamydia. I’ve never done anything with him, but I have drunk from his soda. Should I get tested, especially if he’s had oral sex?

Answer: The short answer is “no,” but that wouldn’t do justice to the complexities raised by this situation, so I’m not going to let it go at that. Besides, if you finish reading this column too quickly, you could get the bends. Or you might go on to read something else, like that column on legal issues or an article on how to do laundry, and you might never come back here again.

It’s true that if your friend has chlamydia, one of the most common of all the sexually transmitted diseases, then he might have it in his throat. After all, if he has chlamydia, he got it by having sex with someone (let’s assume a girl) with that germ, and maybe he had oral sex with her, too. Then there’s a chance he got the infection in his throat, not just inside his penis. It doesn’t pass as easily by oral sex on a girl (mouth to vagina) as by vaginal sex, but it’s possible.

These kinds of bacteria are not swimming all over an infected person’s mouth, though. They’re fussy, like all germs, and probably like me and you. After all, we live in our houses but not just anywhere. I can’t survive under the carpet. This turns out to be good on so many levels — not just for me but for guests who need to get through the living room in wheelchairs.

Chlamydia, for as long as it’s able to survive in the mouth, hangs out in the back of the throat around the tonsils. We don’t pass our STDs to each other by kissing. (And when I say “we,” I actually mean anybody but me.) And not by sharing a drink. Even if your friend were the king of backwash and gargled his drink and then spewed it back into the can, I can’t see any STD germs surviving in the soda and establishing a beachhead on your tonsils when you take a swallow afterward.

Of course, your friend might not even have chlamydia. Sometimes the rumor’s out there because someone he’s had sex with has tested positive for chlamydia. If so, whoever tested her would hopefully have given her the choice of telling him herself or having a disease prevention specialist at the Department of Health tell him without using her name. When that procedure works, someone like your friend knows to get tested and, if he has it, get the medicine to cure it.

On the other hand, last week a patient of mine broke up with her boyfriend because he’s been told by three different girls that he’s given them chlamydia and he still refuses to get the medicine for it even though he knows he’s infecting new girls. If it’s true, I guess the jungle that they say is out there has some unattractive specimens swinging from the vines.

My question for you is: Why haven’t you brought this up with your friend? I can think of several reasons ; I’m just wondering which is the case here. Maybe you don’t want him to be embarrassed, which he probably would be to think that people are saying he’s got an STD. If you were in his place, would you rather know or not know about such a rumor affecting your chances of ever finding someone willing to go out with you? You might find yourself wondering why you don’t run out of soda as quickly as you used to. But if you knew about it, you could do something about it. For example, if one were so inclined, one could get tested and then lie about how it came out negative, even if it came up positive. As long as sexual contacts are notified (with or without knowing who the infected person was), does one really care if the rest of the world has the facts straight about test results?

If you want to avoid his associating you with an embarrassing moment, or if you fear he might misinterpret it as a mean-spirited accusation or something, you could send him a note or text message without your name. Sign it with something nice and sappy (and true), like “because someone cares.” Or you could get somebody professional to contact him and let him know what’s what in a most deft manner combining exquisite scientific expertise and nonjudgmental compassion as big as all outdoors with a graceful emphasis on how it could be worse. Like if no one cared enough to make sure he got some help.

Robert Benon is a nurse practitioner with the health centers at Santa Fe and Capital high schools. Questions can be mailed to The New Mexican, For the Health of It, 202 E. Marcy St., Santa Fe, N.M. 87501; e-mailed to [email protected] or phone in to 986-3050.

(c) 2006 The Santa Fe New Mexican. Provided by ProQuest Information and Learning. All rights Reserved.

T. Boone Pickens Launches Charitable Foundation; Dallas Businessman Gives $150 Million in 2006, Establishing a Legacy of Giving

DALLAS, Dec. 22 /PRNewswire/ — Oil and gas industry leader and philanthropist T. Boone Pickens announced today a $135 million donation to establish The T. Boone Pickens Foundation. The new foundation will improve lives through grants supporting educational programs, medical research, athletics and corporate wellness, the entrepreneurial process and conservation and wildlife initiatives.

Coupled with about $15 million in 2006 philanthropic giving to-date, Pickens has contributed about $150 million this year to a wide-range of causes, from health and medical research initiatives to local grassroots organizations in North Texas and Oklahoma. Pickens’ 2005 donations of $220 million earned him the distinction as America’s fifth-largest philanthropist for the year, according to the Chronicle of Philanthropy.

“We’ve always worked to give back to the community, and this continues that tradition and allows us to move forward with a greater philanthropic focus,” Pickens said.

“I feel like I’m starting a new business — one of the most exciting ventures I’ve ever launched — the business of giving and helping. The gifts of this Foundation will be paying dividends and helping people long after we’re all gone,” Pickens continued.

Pickens will serve as chairman of the Foundation. Longtime associate Ronald D. Bassett is president; attorney Robert L. Stillwell is vice president; and Andrew Littlefair, president and CEO of Clean Energy, is vice president, secretary and treasurer.

Pickens is quickly establishing a legacy of giving: his 2005 gift of $165 million to his alma mater, Oklahoma State University, is the single largest gift for athletics in NCAA history, and the $7 million donation to the American Red Cross in 2005 is the largest individual contribution in the 150- year history of that organization.

In 2006, through the Foundation, and in personal charitable giving earlier in the year, Pickens has contributed to the following causes, among others:

    *  $6 million to The Wilmer Eye Research Institute at Johns Hopkins       University.  The gift will help construct a new research and eye care       facility for the Institute, which is long-recognized as an       international leader in ophthalmology.     *  $5 million to Texas Woman's University.  This gift will help fund       construction of TWU's new $32-million T. Boone Pickens Institute of       Health Sciences-Dallas Center.  The state-of-the-art facility will be       built at the TWU Parkland location in the heart of Dallas'       Southwestern Medical District, and will offer programs in nursing,       occupational therapy, physical therapy, healthcare administration and       library science.  The TWU Stroke Center also will be housed in the       facility.  The donation is the largest single gift from an individual       to TWU, the largest public university primarily for women in the       United States.     *  $2 million to Big Brothers Big Sisters of North Texas.  The local       chapter of the oldest, largest youth-mentoring organizations in the       United States is receiving a matching grant for its Campaign for       Children in Crisis.     *  $1.25 million to The Senior Source, Senior Citizens of Greater Dallas,       which is recognized throughout Texas and the Southwest for improving       the quality of life and promoting the independence of older adults.       The Senior Source is one of the few nonprofits addressing a full       spectrum of needs of older adults, from the most active senior to the       very frail, incapacitated elderly.  Through nine distinct programs,       the agency supports nursing home residents, provides eldercare       counseling, coordinates money management, serves as legal guardian,       provides in-home companions, and matches older adults with employment       and volunteer opportunities.     *  $1 million to The Phoenix House, which has been providing substance       abuse services in Texas for nearly ten years.  The gift will fund the       T. Boone Pickens Scholarship Endowment, income from which will pay for       residential drug rehab treatment for from six to eight teenagers per       year.     *  $1 million grant to the Admiral Roy F. Hoffmann Foundation.  The       Foundation helps U.S. veterans wounded in action.  Most initial       contact with recipients for these awards is by "word of mouth" in       federal medical centers.     *  $1 million to M.D. Anderson to support their ongoing cancer research       initiatives, with a particular focus on the early detection, treatment       and prevention of cervical cancer.  Funds are designated to support       Dr. Michele Follen's research and education projects in the Center for       Biomedical Engineering.     CONTACT: JAY ROSSER             214-265-4165             [email protected]  

The T. Boone Pickens Foundation

CONTACT: Jay Rosser of The T. Boone Pickens Foundation, +1-214-265-4165,or [email protected]

Trinity Health Enters Agreement to Sell Care Choices to Priority Health

Trinity Health today announced it has entered into an agreement to sell its Care Choices HMO, Care Choices PPO and Preferred Choices PPO health plans to Priority Health, a Grand Rapids, Michigan based health plan. Priority Health is a non-profit organization locally owned by three health care systems. Spectrum Health (Grand Rapids) is the majority owner. Minority ownership is held by Munson Health Care (Traverse City) and Northern Michigan Regional Health System (Petoskey).

“As we explored strategic options for Care Choices, we knew it was important for all our stakeholders to keep the southeast Michigan market competitive,” said Joseph R. Swedish, president and chief executive officer, Trinity Health. “We’re pleased that we are joining the two top-rated plans in Michigan to provide access to high quality and affordable health care. This is a positive step for Care Choices and the communities we serve.”

“We look forward to expanding our business in southeast Michigan by offering employers and providers increased choice,” noted Kimberly K. Horn, president and CEO of Priority Health. “We share Care Choices commitment to customer service and clinical quality improvement. This acquisition doubles our network of the region’s best hospitals and physicians. These providers will play a very important role in our success in this market.”

The sale is subject to regulatory approval which can take up to 120 days. It is expected the sale will be finalized early in 2007. There will be no immediate changes or interruptions to health benefits for approximately 100,000 HMO members and 43,000 PPO members currently served by Care Choices.

Commenting on the agreement, William Alvin, president and chief executive officer, Care Choices, said, “Care Choices and Priority Health are well-aligned with their vision, values and cultures built around providing excellent service and care. This will provide a strong portfolio of innovative products and new, competitive options for employers, labor, agents, brokers, members and providers in southeast Michigan.”

“We are committed to maintaining an eastern regional office in Farmington Hills,” said Horn. “This will preserve a significant number of jobs, and therefore is good for Care Choices employees and the Michigan economy.”

Care Choices delivers high-quality health care services to its members and providers, as reflected in its selection by U.S. News & World Report and the National Committee for Quality Assurance as the top rated health plan in Michigan and twelfth in the nation. Care Choices HMO offers a variety of traditional HMO benefit and pharmacy plans as well as consumer directed options. The plan’s network includes 40 leading hospitals and 6,200 physicians across southeast Michigan. Preferred Choices PPO is a network of 11,700 physicians, 83 hospitals and other health care providers for self-funded and insured clients. Care Choices PPO is designed to meet the needs of self-insured employers looking for a cost-effective, one-stop shopping solution. For more information about Care Choices, visit http://www.carechoices.com/

Priority Health is a nationally recognized health plan company based in Michigan. It serves more than 460,000 members with a broad portfolio of products including HMOs, PPOs, HSAs, Medicaid, and Medicare. Priority Health is a non-profit organization locally owned by three health care systems. Spectrum Health (Grand Rapids) is the majority owner. Minority ownership is held by Munson Health Care (Traverse City) and Northern Michigan Regional Health System (Petoskey). Dedicated to providing all people access to affordable health care, Priority Health ranks number two in Michigan and thirteenth in the nation by U.S. News & World Report and the National Committee for Quality Assurance. For more information about Priority Health, visit http://www.priorityhealth.com

With hospitals in seven states, Trinity Health is one of the largest Catholic health care systems in the country. Based in Novi, Mich., the system operates 44 hospitals (29 owned, 15 managed), 384 outpatient facilities, numerous long-term care facilities, and home health offices and hospice programs. Employing approximately 45,100 full-time staff, Trinity Health reported $6.1 billion in unrestricted revenue and $307 million in community benefit ministry (excluding cost of Medicare) in fiscal year 2006. For more information about Trinity Health, visit www.trinity-health.org.

Hybrid Marijuana Plant Found in Mexico

Soldiers trying to seize control of one Mexico’s top drug-producing regions found the countryside teeming with a new hybrid marijuana plant that can be cultivated year-round and cannot be killed with herbicides.

Soldiers fanned out across some of the new fields Tuesday, pulling up plants by the root and burning them, as helicopter gunships clattered overhead to give them cover from a raging drug war in the western state of Michoacan. The plants’ roots survive if they are doused with herbicide, said army Gen. Manuel Garcia.

“These plants have been genetically improved,” he told a handful of journalists allowed to accompany soldiers on a daylong raid of some 70 marijuana fields. “Before we could cut the plant and destroy it, but this plant will come back to life unless it’s taken out by the roots.”

The new plants, known as “Colombians,” mature in about two months and can be planted at any time of year, meaning authorities will no longer be able to time raids to coincide with twice-yearly harvests.

The hybrid first appeared in Mexico two years ago but has become the plant of choice for drug traffickers Michoacan, a remote mountainous region that lends to itself to drug production.

Yields are so high that traffickers can now produce as much marijuana on a plot the size of a football field as they used to harvest in 10 to 12 acres. That makes for smaller, harder-to-detect fields, though some discovered Tuesday had sophisticated irrigation systems with sprinklers, pumps and thousands of yards of tubing.

“For each 100 (marijuana plots) that you spot from the air, there are 300 to 500 more that you discover once you get on the ground,” Garcia said.

The raids were part of President Felipe Calderon’s new offensive to restore order in his home state of Michoacan and fight drug violence that has claimed more than 2,000 lives in Mexico this year.

In Michoacan, officials say the Valencia and Gulf cartels have been battling over lucrative marijuana plantations and smuggling routes for cocaine and methamphetamine to the United States. In one incident, gunmen stormed into a bar and dumped five human heads on the dance floor.

The president, who took office Dec. 1, sent 7,000 soldiers and federal officers to Michoacan last week.

Officials have arrested 45 people, including several suspected leaders of the feuding cartels. They also seized three yachts, 2.2 pounds of gold, bulletproof vests, military equipment and shirts with federal and municipal police logos. More than 18,000 people have been searched, along with 8,000 vehicles and numerous foreign and national boats.

“We are determined to shut down delinquency and stop crime in Mexico because it is endangering the lives of all Mexicans, of our families,” Calderon said, calling the operation a “success” so far.

In the past week, soldiers and federal police have found 1,795 marijuana fields covering 585 acres in Michoacan, security officials said.

Officials estimate the raids could cost the cartels up to $626 million, counting the value of plants that have been destroyed and drugs that could have been produced with seized opium poppies and marijuana seeds.

On Sunday, federal authorities announced the capture of suspected drug lord Elias Valencia, the most significant arrest since the operation began.

Calderon’s predecessor, Vicente Fox, started out with enthusiastic U.S. applause for his own fight against drug trafficking. U.S. officials called the arrest of drug bosses early in his six-year term unprecedented, while Fox boasted that his administration had destroyed 43,900 acres of marijuana and poppy plantations in its first six months and more than tripled drug seizures.

Yet drug violence has spiked across the country in recent years, with gangs fighting over control of routes following the arrest of drug lords, authorities say.

Mexico has also continued to struggle with corruption among its law enforcement ranks. Garcia said authorities did not tell soldiers where they were being sent on raids and banned the use of cell phones and radios.

American Medical Systems’ AdVance(TM) Male Sling Positioned to Increase Male Incontinence Market

AdVance™ Male Sling System, an innovative new treatment solution for men suffering from mild stress urinary incontinence from American Medical Systems Holdings, Inc. (NASDAQ:AMMD) was a new technology highlight at the 36th Annual International Continence Society (ICS) meeting held recently in Christchurch, New Zealand.

AdVance was showcased during a symposium on “Minimally Invasive Procedures for Male Stress Incontinence” chaired by Dr. Ajay Singla, Associate Professor, Wayne State University School of Medicine. “AdVance is an exciting new treatment option for men with mild to moderate stress urinary incontinence,” stated Dr. Singla. “It was very well received by the ICS attendees and shows much promise.”

Dr. Peter Rehder and Dr. Christian Gozzi, noted urologists at the University of Innsbruck, Austria and co-creators of the device, presented clinical data and procedural information at the congress. Dr. Rehder stated, “The AdVance sling is truly revolutionary, enabling the treatment of mild male incontinence in an entirely new way.” Dr. Rehder continued, “In contrast to other devices that rely on compression, this device repositions the urethra for optimal functionality. Furthermore, unlike slings designed for female incontinence, the AdVance Male Sling System has been specifically designed to be tensioned in order to facilitate optimal clinical outcomes from this innovative treatment for male stress urinary incontinence.”

More than two million men worldwide suffer from stress urinary incontinence, a condition defined as the uncontrolled leakage of urine due to coughing, straining or some other sudden movement. A majority of these men are prostate cancer survivors, having undergone surgery for the treatment of their cancer with the often unavoidable outcome of a damaged urinary sphincter. Many of these patients experience urethral descent, increasingly recognized by urologists as a form of male prolapse, which impedes the man’s residual sphincteric functionality in ensuring continence. As a result, these incontinent men often restrict their activities, limit their fluid intake or change their lifestyles in an attempt to cope with this humiliating condition. While moderate to severe cases of incontinence in men have been successfully treated through surgical intervention utilizing AMS products for years, the majority of incontinent men, those only mildly incontinent, have had few attractive medical alternatives until now.

Martin J. Emerson, President and Chief Executive Officer of American Medical Systems, stated, “The AdVance Male Sling expands our offering of products for stress incontinence in men, and urologists around the world are eager to offer their patients this exciting technology.” Mr. Emerson added, “AMS continues to bring innovation to our physician customers and their patients. We also place high value on appropriately training physicians on these new procedures. Over 100 physicians have been trained on AdVance and they are thrilled with the outcomes they’re seeing. The interest only continues to grow.”

About American Medical Systems

American Medical Systems, headquartered in Minnetonka, Minnesota and including its recently concluded acquisition of Laserscope, is a diversified supplier of medical devices and procedures to cure erectile dysfunction, benign prostatic hyperplasia, incontinence, menorrhagia, prolapse and other pelvic disorders in men and women. These disorders can significantly diminish one’s quality of life and profoundly affect social relationships. In recent years, the number of people seeking treatment has increased markedly as a result of longer lives, higher quality-of-life expectations and greater awareness of new treatment alternatives. American Medical Systems’ products reduce or eliminate the incapacitating effects of these diseases, often through minimally invasive therapies. The Company’s products were used to provide approximately 170,000 patient cures in 56 countries during 2005.

Forward-Looking Statements

Statements about the Company’s market opportunities, future products, sales and financial results are forward-looking statements subject to risks and uncertainties such as the timing and success of new product introductions; physician acceptance, endorsement, and use of the Company’s products; regulatory matters; competitor activities; changes in and adoption of reimbursement rates; potential product recalls and other risks and uncertainties described in the Company’s Annual Report on Form 10-K for the year ended December 31, 2005 and its other SEC filings. Actual results may differ materially from anticipated results.

For additional information on AdVance, go to www.AMSAdVance.com. More information about AMS and its products can be found at www.AmericanMedicalSystems.com and in the Company’s Annual Report on Form 10-K for 2005 and its other SEC filings.

National Financial Partners to Acquire Balser Companies, A Leading Executive Benefits Firm

NEW YORK, Dec. 21 /PRNewswire-FirstCall/ — National Financial Partners Corp. , a national financial services distribution company, announced today that it has signed a definitive agreement to acquire Balser Companies (“Balser”), a leading executive benefits firm. Balser is NFP’s largest benefits acquisition to date and represents $7.4 million in acquired base earnings. In 2005, Balser’s revenue was approximately $13.2 million. Founded in 1968, Balser serves the Fortune 500 market through its deferred compensation plans and supplemental executive plans, which include life insurance, disability and long term care. NFP has agreed to pay approximately $52.8 million in a combination of cash and NFP common stock to the shareholders of Balser. The transaction, subject to customary closing conditions, is expected to close in the first quarter of 2007.

“We are excited to announce an acquisition with the significant scale and market presence of Balser. Through this transaction, NFP enhances its executive benefits business, potential growth opportunities, and future recurring revenues,” said Jessica Bibliowicz, Chairman and Chief Executive Officer.

Balser’s president, Bud Russell, said “Ron Balser and Barbara Balser see the combination of NFP and Balser as well-suited for the organization’s exceptional client-focused service and its enthusiasm for cutting-edge benefit design. Our senior management team believes that working with NFP will benefit our clients by strengthening Balser’s resources while allowing us to maintain our reputation as an innovative, independent benefits advisor.”

In addition to the acquisition of Balser and since its third quarter earnings release date, NFP has either entered into definitive agreements or completed transactions representing 5 acquisitions. In aggregate, these firms represent $5.1 million in acquired base earnings, of which $3.2 million is effective December 2006 and $1.9 million is anticipated to be effective January 2007. These acquisitions include three estate planning firms, one benefits firm, and one annuity brokerage subacquisition. On a combined basis, these firms generated approximately $13.9 million in total revenue in 2005. NFP has agreed to pay $20.8 million in cash and expects to issue approximately 210,000 shares of NFP common stock for these 5 acquisitions.

“We are pleased that these exceptional firms have chosen to link their future with NFP. This announcement represents total acquired base earnings of $12.5 million, which positions us well with respect to our $20.0 million 2007 objective. This level of acquisition activity is consistent with our 20% cash earnings per share growth target,” said Jessica Bibliowicz, Chairman and Chief Executive Officer.

Defined Terms

The term base earnings represents the cumulative preferred portion of the pre-tax earnings before owners’ compensation of acquired firms that NFP capitalizes at the time of acquisition of a firm. The term cash earnings represents GAAP net income excluding amortization of intangible assets, depreciation and impairment of goodwill and intangible assets. Cash earnings per share represents cash earnings divided by weighted average diluted shares outstanding.

About National Financial Partners Corp.

Founded in 1998, National Financial Partners Corp. (“NFP”) is a leading independent distributor of financial services products to high net worth individuals and growing entrepreneurial companies. NFP is headquartered in New York and operates a distribution network of over 170 firms.

About Balser Companies

Balser Companies has served as a trusted advisor for more than 30 years, specializing in serving the benefit plan needs of Fortune 500 and FT Global 500 public companies and their most talented executives. Balser provides supplemental retirement and insurance plan services to help senior management employees and outside directors create wealth like retirement nest eggs, as well as protect their income through cost-effective insurance programs. Balser Companies’ predecessor company was founded in Georgia in 1976, and adopted the trade name “Balser Companies” in 1999 to differentiate itself in the compensation and benefits marketplace. For more information email [email protected]

Forward-Looking Statements

This release contains certain statements relating to future results, which are forward-looking statements as that term is defined in the Private Securities Litigation Reform Act of 1995. Forward-looking statements include, without limitation, any statement that may project, indicate or imply future results, events, performance or achievements, and may contain the words “anticipate,””expect,””intend,””plan,””believe,””estimate,””may,””will” and “continue” and similar expressions of a future or forward-looking nature. Forward-looking statements may include discussions concerning revenue, expenses, earnings, cash flow, dividends, capital structure, credit facilities, market and industry conditions, premium and commission rates, interest rates, contingencies, the direction or outcome of regulatory investigations and litigation, income taxes and NFP’s operations. These forward-looking statements are based on management’s current views with respect to future results, and are subject to risks and uncertainties. Factors that could cause actual results to differ materially from those contemplated by a forward- looking statement include: (1) NFP’s success in acquiring high quality independent financial services distribution firms, (2) the performance of NFP’s firms following acquisition, (3) competition in the business of providing financial services to the high net worth and entrepreneurial corporate markets, (4) NFP’s ability, through its operating structure, to respond quickly to operational or financial situations and to grow its business, (5) NFP’s ability to effectively manage its business through the principals of its firms, (6) the impact of legislation or regulations in jurisdictions in which NFP’s subsidiaries operate, including the possible adoption of comprehensive and exclusive federal regulation over all interstate insurers, (7) changes in tax laws, including the elimination or modification of the federal estate tax and any change in the tax treatment of life insurance products, (8) changes in the pricing, design or underwriting of insurance products, (9) changes in premiums and commission rates, (10) adverse developments in the insurance markets in which NFP operates, resulting in fewer sales of insurance-related products, (11) adverse results or other consequences from litigation, arbitration or regulatory investigations, including those related to compensation agreements with insurance companies and activities within the life settlements industry, (12) adverse results or other consequences from higher than anticipated compliance costs, including those related to expenses arising from internal reviews of business practices and regulatory investigations, (13) uncertainty in the insurance and life settlements industries arising from investigations into certain business practices by various governmental authorities and related litigation, (14) the reduction of NFP’s revenue and earnings due to the elimination or modification of compensation arrangements, including contingent compensation arrangements, and (15) other factors described in NFP’s filings with the Securities and Exchange Commission including its Annual Report on Form 10-K for the year ended December 31, 2005. Forward-looking statements speak only as of the date on which they are made. NFP expressly disclaims any obligation to update or revise any forward-looking statement, whether as a result of new information, future events or otherwise.

National Financial Partners Corp.

CONTACT: Investor Relations: Liz Werner, +1-212-301-4084, [email protected];and Media Relations: Elizabeth Fogerty, +1-212-301-4062,[email protected], both of National Financial Partners

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

Other Cases Involving Local Doctors

By Kevin Eigelbach

In two other cases involving local physicians last week, the Kentucky Board of Medical Licensure:

Placed restrictions on the license of Dr. Todd S. Carran, a Crestview Hills resident who was authorized to practice in Kentucky and Ohio.

Carran agreed not to practice medicine, but can reapply for a license with a favorable recommendation from the foundation.

A Cincinnati police officer arrested Carran in July and charged him with possession of drugs and carrying a concealed weapon. Carran was accused of having five OxyContin pills loose under the floor mat of his car. That case is scheduled for trial in Hamilton County on Jan. 22.

When Carran was stopped for a red light violation in August in Cincinnati, an officer said he found 21 Cymbalta pills loose in the doctor’s pocket during a pat-down search.

Carran is scheduled for trial in that case Jan. 25, on a charge of possession of a dangerous drug.

He has admitted a substance abuse problem, but maintains his innocence on the criminal charges, the Kentucky board reported.

His Ohio license has been suspended indefinitely pending the resolution of the criminal charges.

Placed restrictions on the license of Dr. Gregory Duma, formerly of St. Elizabeth Medical Center North in Covington.

Duma agreed that he would no longer practice medicine in Kentucky. He can reapply, but only with a favorable recommendation from the Kentucky Physicians Health Foundation, which evaluates, treats and assists doctors with substance abuse problems.

The obstetrics/gynecology specialist admitted that in January, he had been drinking when he answered a page from the hospital and attended the delivery of a baby, according to board documents.

The baby suffered an injury during the delivery, the board reported. Duma’s handling of the case showed gross negligence, a board consultant found.

Duma told the board he had taken leave from the hospital and entered a residential treatment program at Metro Atlanta Recovery Residences.

(c) 2006 Cincinnati Post. Provided by ProQuest Information and Learning. All rights Reserved.

Meretek Announces Change in Georgia Medicare UBT Reimbursement

LAFAYETTE, Colo., Dec. 19 /PRNewswire-FirstCall/ — Meretek Diagnostics announced today that effective January 1, 2007, its BreathTek(TM) UBT (urea breath test) kit for the bacterium Helicobacter pylori (H. pylori) will be entitled to a more favorable Medicare reimbursement rate in Georgia.

The 2007 Medicare Part B clinical laboratory fee schedule for Georgia raises reimbursement for the analysis of the UBT C13 Test (CPT code 83013).

“This effectively opens up the Georgia UBT market for the first time,” said Meretek Vice President for Sales David Walton. “This valuable and beneficial test will now be more readily available in Georgia to help doctors diagnose patients and eradicate H. pylori infections.”

The BreathTek UBT uses C13 urea, a naturally occurring non-radioactive stable isotope. Meretek has the only C13 UBT approved by the FDA for initial diagnosis and post treatment monitoring of H. pylori.

BreathTek UBT is a simple, non-radioactive, non-invasive test for the diagnosis and post treatment monitoring of active H. pylori infection. The test can be administered in doctors’ offices and patient service centers and is well tolerated by patients.

Studies show that 80 to 90 percent of peptic ulcer disease (PUD) cases are caused by an H. pylori infection, and about one in three adults in the U.S. is infected.

In November 2005, the American Gastroenterological Association (AGA) updated its position statement on the evaluation of dyspepsia to recommend testing in patients 55 years of age or younger without alarm symptoms with an active test such as the C13 urea breath test or stool antigen test.

The Meretek BreathTek UBT is CLIA non-regulated, and is covered by Medicare and most major insurance carriers.

Meretek products also include the UBiT(R)-IR300 infrared spectrophotometer and the POCone(TM) infrared spectrophotometer instruments, which are used to analyze the patient’s breath samples.

For a complete listing of features and benefits of the BreathTek UBT, visit http://www.meretek.com/physician_testing.asp.

* The UBT abbreviation is used in Georgia Medicare policy not as a Trademark(R), but as a simple acronym for Urea Breath Test.

About Meretek Diagnostics

Located in Lafayette, Colo., Meretek Diagnostics Inc. is a subsidiary of Otsuka America, a healthcare company engaged in the development of advanced, non-invasive, non-radioactive breath tests and instrumentation. Meretek was founded in 1993 by a group from the Baylor College of Medicine in Houston, Texas. The company holds exclusive licenses to patents involving the C13 urea breath test technologies, and all of the their products are approved by the FDA.

For more information about Meretek Diagnostics, Inc. and the company’s products, including prescribing information, warnings and limitations, visit the Meretek Web site at http://www.meretek.com/.

Meretek Diagnostics, Inc.

CONTACT: Dan Snyders, +1-303-623-1190 ext. 230, [email protected],or Jennifer Hanson, +1-303-623-1190 ext. 239, [email protected],both of Armada Medical Marketing, for Meretek Diagnostics, Inc.

Web site: http://www.meretek.com/physician_testing.asp

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

TPG Completes Acquisition of Aleris International, Inc.

BEACHWOOD, Ohio, Dec. 19 /PRNewswire-FirstCall/ — Aleris International, Inc. announced today the completion of the acquisition of the Company by affiliates of Texas Pacific Group (TPG).

On August 7, 2006, affiliates of TPG entered into a merger agreement with the Company to acquire the Company for a purchase price of approximately $1.7 billion plus the assumption of or repayment of approximately $1.6 billion of debt. Under the terms of the merger agreement, Company stockholders will receive $52.50 per share in cash without interest.

Steve Demetriou, Chairman and CEO of Aleris said, “We are very pleased to complete this transaction with TPG which has created significant value for shareholders while positioning Aleris with a partner committed to our continued growth as a private company.”

Aleris’s common stock will cease trading on the New York Stock Exchange at market close today, and will be delisted. As soon as practicable, a paying agent appointed by TPG will send information to all Company stockholders of record, explaining how they can surrender Company stock in exchange for $52.50 per share in cash without interest. Stockholders of record should await this information before surrendering their shares.

Stockholders who hold shares through a bank or broker will not have to take any action to have their shares converted into cash, because these conversions will be handled by the bank or broker.

About Aleris International, Inc.

Aleris International, Inc. is a global leader in aluminum rolled products and extrusions, aluminum recycling and specification alloy production. The Company is also a recycler of zinc and a leading U.S. manufacturer of zinc metal and value-added zinc products that include zinc oxide and zinc dust. Headquartered in Beachwood, Ohio, a suburb of Cleveland, the Company operates 50 production facilities in North America, Europe, South America and Asia, and employs approximately 8,600 employees. For more information about Aleris, please visit our Web site at http://www.aleris.com/.

About TPG

TPG is a private investment partnership that was founded in 1992 and currently has more than $30 billion of assets under management. With offices in San Francisco, London, Hong Kong, Fort Worth and other locations globally, TPG has extensive experience with global public and private investments executed through leveraged buyouts, recapitalizations, spinouts, joint ventures and restructurings. Visit http://www.tpg.com/

SAFE HARBOR REGARDING FORWARD-LOOKING STATEMENTS

Forward-looking statements made in this news release are made pursuant to the safe harbor provision of the Private Securities Litigation Reform Act of 1995. These include statements that contain words such as “believe,””expect,””anticipate,””intend,””estimate,””should” and similar expressions intended to connote future events and circumstances, and include statements regarding future actual and adjusted earnings and earnings per share; future improvements in margins, processing volumes and pricing; overall 2006 operating performance; anticipated higher adjusted effective tax rates; expected cost savings; success in integrating Aleris’s recent acquisitions, including the acquisition of the downstream aluminum businesses of Corus Group plc; its future growth; an anticipated favorable economic environment in 2006; future benefits from acquisitions and new products; expected benefits from changes in the industry landscape and post-hurricane reconstruction; and anticipated synergies resulting from the merger with Commonwealth, the acquisition of the downstream aluminum businesses of Corus Group plc and other acquisitions. Investors are cautioned that all forward-looking statements involve risks and uncertainties, and that actual results could differ materially from those described in the forward-looking statements. These risks and uncertainties would include, without limitation, Aleris’s levels of indebtedness and debt service obligations; its ability to effectively integrate the business and operations of its acquisitions; further slowdowns in automotive production in the U.S. and Europe; the financial condition of Aleris’s customers and future bankruptcies and defaults by major customers; the availability at favorable cost of aluminum scrap and other metal supplies that Aleris processes; the ability of Aleris to enter into effective metals, natural gas and other commodity derivatives; continued increases in natural gas and other fuel costs of Aleris; a weakening in industrial demand resulting from a decline in U.S. or world economic conditions, including any decline caused by terrorist activities or other unanticipated events; future utilized capacity of Aleris’s various facilities; a continuation of building and construction customers and distribution customers reducing their inventory levels and reducing the volume of Aleris’s shipments; restrictions on and future levels and timing of capital expenditures; retention of Aleris’s major customers; the timing and amounts of collections; currency exchange fluctuations; future write-downs or impairment charges which may be required because of the occurrence of some of the uncertainties listed above; and other risks listed in Aleris’s filings with the Securities and Exchange Commission (the “SEC”), including but not limited to Aleris’s annual report on Form 10-K for the fiscal year ended December 31, 2005, and quarterly report on Form 10-Q for the quarter ended June 30, 2006, the 10-Q for the quarter ended September 30, 2006, and current report on Form 8-K filed with SEC on November 29, 2006, particularly the sections entitled “Risk Factors” contained therein.

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Photo: http://www.newscom.com/cgi-bin/prnh/20050504/CLW056LOGOAP Archive: http://photoarchive.ap.org/PRN Photo Desk [email protected]

Aleris International, Inc.

CONTACT: Michael D. Friday of Aleris International, Inc.,+1-216-910-3503; or Owen Blicksilver of Owen Blicksilver PR, Inc,+1-516-742-5950

Web site: http://www.aleris.com/http://www.tpg.com/

LifeSpan Pharmacy Goes Into Production With Open Source Pharmacy Fulfillment Solution ePostRx(TM)

AdvanceNet Health Solutions (ANSHealth) announced today that LifeSpan Pharmacy Inc. has successfully began dispensing prescriptions with ePostRx(TM) as its primary pharmacy fulfillment solution. ePostRx(TM), the healthcare industry’s only enterprise pharmacy web solution, is licensed under the OSI (Open Source Initiative) approved GNU General Public License (GPL). Additionally, ANSHealth offers commercial services for ePostRx(TM) such as consulting, software customizations, training, support and certification.

ePostRx(TM) is a full featured pharmacy management system that automates the prescription-fulfillment process, from Order/Rx/OTC receipt and insurance adjudication, to DUR and dispensing for most business models, including Electronic Prescriptions, Retail, Chain Retail, Mail-Order Clinical and Central Fill. Developed using the Java programming language and standard web technologies, ePostRx(TM) can serve as a direct open source replacement for current proprietary pharmacy applications.

According to LifeSpan COO Ari Oberman, “We did extensive due diligence and after looking at alternatives we knew that ePostRx(TM) was the best solution for our unique business model. Being open source, ePostRx(TM) will allow us to fully customize the software to meet our business needs freeing us of the normal vendor lock associated with a proprietary solution. Furthermore, as a web application, ePostRx(TM) provides LifeSpan Pharmacy with an enterprise solution that reduces our normal Total Cost of Ownership (TOC).”

ANSHealth President John Strecker is very pleased that LifeSpan Pharmacy has selected ePostRx(TM) as its open source pharmacy solution. “This proves that the open source model is very much applicable to the healthcare industry. We believe ePostRx(TM) offers pharmacy owners a cost effective alternative to that of proprietary software and provides inherit flexibility for business growth. We look forward to a very long and rewarding business relationship with LifeSpan Pharmacy.”

LifeSpan Pharmacy is the third ePostRx(TM) client to go into production for ANSHealth in the past six months. With a growing list of clients, ANSHealth is looking forward towards a successful 2007 as Healthcare IT executives begin to accept the open source model as an alternative to proprietary pharmacy systems.

To learn more about ANSHealth(TM), please visit http://www.anshealth.com.

To learn more about LifeSpan Pharmacy(TM), please visit http://www.lifespanpharmacy.com.

 Contact Information:  AdvanceNet Health Solutions, Inc. http://www.anshealth.com Email: Contact via http://www.marketwire.com/mw/emailprcntct?id=7D531F67D5F2C4F4  LifeSpan Pharmacy, Inc. http://www.lifespanpharmacy.com Email: Contact via http://www.marketwire.com/mw/emailprcntct?id=91C7D1805CD6E3F5  

SOURCE: AdvanceNet Health Solutions, Inc.

Enviromax Introduces a Stimulating Breakthrough in Prostate Massage and Traditional Therapy Alternative

ANCHORAGE, Alaska, Dec. 19 /PRNewswire/ — The Prostate Cradle External Massager, developed by Enviromax, based in Eagle River, Alaska, has been selling on the Internet since last March and the company is struggling to keep up with orders.

   *(PHOTO: Send2Press.com/mediadesk/1206-enviromax_72dpi.jpg)   *(Photo Caption: Prostate Cradle External Massager)  

“I developed the Prostate Cradle out of necessity to help successfully deal with my enlarged prostate,” Adam McVay, said. “The response has been overwhelmingly positive.”

McVay explains that he was faced with a choice of taking expensive prescription drugs, or having a biopsy leading to surgery, and more prescription drugs. He searched for an alternative and read about nutritional healing. During the process, he quit two of his three jobs, as well as sugar and caffeine. He felt better almost immediately and symptoms and aches in his prostate reduced within weeks.

As part of this new lifestyle, McVay sought out a non-invasive prostate massager, but could not find one; he began to research, develop and design a practical and useful model of his own.

“It took years to find the right shape, size and materials,” McVay said, “but, once the Cradle took form, it helped massage my prostate back to health. It also improved the health of my sex life, which was an added bonus.”

Enlarged prostates benefit from massage. The stimulation of blood flow and an increase in oxygen to the gland helps rinse the prostate of harmful bacteria and particles which build up over time, and can lead to tumors. A 10-20 minute prostate massage at least once a month, and as often as once a day, is important for a healthy gland.

The Prostate Cradle works using pressure from body weight which can be focused and controlled on the massager. The Cradle is placed on a chair or firm surface and the user sits on the massager with the two-bump end forward; this cradles and massages the crotch or perineum area between the testicles and tailbone, as well as the pelvic floor muscle group, lymph glands, and prostate gland.

Prostate stimulation can create pleasurable, tingling sensations which travel up the spine for a feel-good experience; the $39 price tag is also a plus and less than a doctor’s visit.

The Prostate Cradle is made from the highest-quality material available. Over the years, many prototypes have been tested to achieve an ideal form of correct universal size, shape, and flexibility, to trigger specific acupressure points, while avoiding others.

Most men are expected to have some type of prostate issue at some point in their lives, if they live long enough. In addition, prostate cancer is a leading form of cancer and has a high casualty rate.

“We need to defend ourselves,” McVay said. “That means powering-up our immune systems through nutrition, exercise, and massage; massage can also be used with other forms of therapy, if needed.”

Research studies report that prostate massage is effective in reduction, and in some cases, curing prostate issues without drugs or surgery. If caught early enough, additional problems are preventable; it is common to have an enlarged prostate before experiencing symptoms.

Healthy prostates can also benefit from massage as preventative therapy. The Prostate Cradle can act as a “trainer” to discover the entire perineum or male “G-spot” area.

A guide booklet accompanies the Prostate Cradle, and discusses not only how to have better orgasms, but, how to have the “right kind.”

Additional benefits of prostate massage include: creating positive energy, burning calories, reducing tension, and eliminating negative emotions like guilt and anger. Prostate massage can also help to release primal, euphoria — inducing chemicals such as adrenaline and endorphins.

The Prostate Cradle works as a natural alternative to prescription therapy by stimulating arousal periods, indefinitely. This can help equal the sensual playing field between partners; if a healthy prostate is massaged correctly, it can become super stimulated and feel like it is glowing.

“Perhaps this is why ancient texts refer to the prostate as the gateway to the universe,” McVay said.

To learn more about the Prostate Cradle, visit: http://www.prostatecradle.com/

This release was issued on behalf of the above organization by Send2Press(R), a unit of Neotrope(R). http://www.send2press.com/

Enviromax

CONTACT: Adam McVay of Enviromax, +1-907-301-8396,[email protected]

Web site: http://www.send2press.com/

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

Mosquitoes May Become Our Allies

Without mosquitoes, epidemics of dengue fever and malaria could not plague this planet.

The skin-piercing insects infect one person after another while dining on a favorite meal: human blood.

Eliminating the pests appears impossible. But scientists are attempting to re-engineer them so they cannot carry disease. If they manage that, they must create enough mutants to mate with wild insects and one day to outnumber them.

Researchers chasing this dream, including an N.C. State University entomologist, know they may court controversy. Genetically modified crop plants such as soybeans and corn have become common in the United States, but an altered organism on wings would be a first.

Critics of bio-engineering, especially in Europe, view some genetic alterations as unnatural, even monstrous. People fearful of so-called Frankenfood could sound similar alarms over Frankenbugs.

But with advances in molecular biology and millions of dollars from the Bill & Melinda Gates Foundation, this quest may be within reach. And its promise is huge, the scientists say.

“We’re looking at a timeline. But this is coming,” said Fred Gould, the NCSU insect expert.

Gould is working on the project with scientists on four continents. They landed $19.7 million under a Grand Challenges in Global Health grant offered by the Gates philanthropy and a National Institutes of Health foundation. The funders selected researchers ready to collaborate rather than compete on risky research aimed at solving massive health threats in poor places.

The genetic tinkering is focused at first on dengue, a tropical virus re-emerging in Asia, Latin America and Africa. While dengue claims a fraction of the million or more victims that malaria kills annually, it strikes 50 to 100 million people each year with severe flu symptoms. Outbreaks disrupt families and communities and overburden health systems.

Dengue is a good starting point because it is transmitted almost exclusively by a single mosquito species (the smallish, striped- legged Aedes aegypti) while the malaria parasite is carried by several. Focusing the effort on just one bug simplifies the science.

To try to build a less dangerous Aedes aegypti, scientists broke a huge job into smaller chunks. First, they needed a means to make female mosquitoes immune to dengue. Only females drink blood (males prefer nectar), and only insects infected with dengue can spread it.

A breakthrough this year at Colorado State University may help. Molecular biologists there stitched laboratory-made DNA into Aedes aegypti that blocks dengue from reproducing in a bug’s gut. That stops dengue from getting into mosquito saliva, which deposits the virus into human bloodstreams.

As important, the change sticks. Bugs pass the trait to their offspring.

“Things keep bearing fruit. So far, so good,” said Anthony James, a biologist at the University of California Irvine, the lead investigator for the mosquito project.

But inserting strings of DNA into laboratory mosquitoes and spreading them in the wild are two different things.

Scientists must convince the government and people of any country they approach that mutant bugs will fight disease without risk to people or the environment, said Sujatha Byravan, president of the Council for Responsible Genetics.

Scientists are trying to harness exotic genes to help slip dengue- fighting DNA into many offspring quickly. One way: piggyback onto so- called selfish genes — unusual stretches of DNA that perform no duties other than tending to their own survival.

Whichever strategy gets picked will require a customized release plan. And it will likely carry a cost. Organisms absorbing altered DNA often take a fitness hit, meaning an altered mosquito may fly slower, weigh less or be less successful finding a mate.

Gould and his team aren’t engineering insects. They are predicting each strategy’s success at passing dengue immunity to future generations. Is it best to release many in a small place or fewer over a neighborhood?

Both jobs require a mix of high-level mathematics and big computing power. But just as important is detailed knowledge of the life cycles and mating habits of Aedes aegypti.

Dengue mosquitoes often are born, live and die in or near a home. They prefer dwellings with no running water, where they can lay eggs in containers people use for cooking, bathing and cleaning. The bugs tend to bite during the day, so mosquito netting over beds offers little protection.

Understanding the life cycles of the insects will give Gould’s group clues on how to infiltrate an entire mosquito population quickly and at a reasonable cost.

“We want to determine what’s the most efficient way to use the fewest mosquitoes to get this done,” Gould said.

Once the scientists select the best strategy, they will test their predictions — but not in the wild. Plans call for experiments in insect-safe cages surrounding mock homes to be built in sparsely populated land in southern Mexico within two years.

The mock home will copy local dwellings. Inside will be clothing, kitchen implements and furniture. Outside will be potted plants and rain barrels like the ones locals use, all potential breeding grounds.

Mexico was selected because it has experience regulating bio- engineering.

Speedel Stops Current SPP301 Phase III Trial in Diabetic Kidney Disease in the Interests of Patient Safety; Data to Be Analysed for Potential New Clinical Trials

BASEL, Switzerland and BRIDGEWATER, N.J., Dec. 19, 2006 (PRIME NEWSWIRE) — Speedel (SWX:SPPN) announced today that in the interests of patient safety it has stopped the current pivotal Phase III clinical trial of SPP301 (Avosentan) in diabetic nephropathy (diabetic kidney disease). This decision was taken by the ASCEND(1) trial’s Steering Committee based on a recommendation from the Data Safety Monitoring Board to stop the trial, following a significant imbalance in fluid retention in patients amongst the study arms. The company is informing health authorities including the U.S. Food and Drug Administration and is in the process of notifying all clinical investigators in the trial. The company also said that the compound will be evaluated for potential new clinical trials in diabetic kidney disease and other indications, and that an announcement concerning the next steps for SPP301 should occur around the middle of 2007.

Giancarlo Viberti, Chairman of the ASCEND Steering Committee, Professor of diabetes and metabolic medicine at Guy’s Hospital London, stated: “We are highly committed to carrying out a thorough analysis of the data from the ASCEND trial to devise the best possible way to continue development of SPP301. There is a need to generate an optimum study design for potential new clinical trials with this compound. Diabetic kidney disease is a large and growing unmet medical need which requires innovative therapies to which SPP301 could make a significant contribution.”

Dr. Jessica Mann, Medical Director of Speedel, commented: “This decision to stop the current Phase III trial is based on data showing that patients taking SPP301 developed higher levels of fluid retention than those on placebo. Fluid retention is not unusual in patients who have severe diabetic kidney disease. However, given the fragility of these patients, the company is being prudent in not continuing to expose them to any further complications in this study.”

Dr. Alice Huxley, CEO, said: “We are disappointed that this promising therapy could not complete the current Phase III trial for diabetic kidney disease. We remain hopeful about the potential therapeutic benefits of SPP301 and we will now use the next 6 months to evaluate the study data and explore possible alternative trial designs for SPP301 in diabetic kidney disease and its potential in other indications. This is a setback to our SPP301 development programme, and it demonstrates the potential risks linked to the pharmaceutical industry’s pursuit of innovation.”

SPP301, a once-a-day oral endothelin-A receptor antagonist (ERA) showed in Phase II trials that it decreases urinary albumin excretion rate (UAER) and total cholesterol in patients with diabetic kidney disease when administered on top of standard treatment. Diabetic nephropathy (DN) represents a large and growing unmet medical need with a high mortality rate affecting an estimated 7.9 million people(2) diagnosed with diabetes in the U.S., Europe and Japan. Speedel has exclusive worldwide development and commercialisation rights to SPP301 under a licensing agreement with Roche.

Web Cast and Conference Call

At 15.00 CET /14:00 London/ 09:00 EST today December 19, 2006, the company will host a web cast which can be accessed at http://www.speedel.com/section/6/subsections/7. In addition participants may join a teleconference facility using the following telephone numbers:

   Switzerland:         +41 (0) 44 580 34 09  UK:                  +44 (0) 845 2450 248  USA:                 +1 866 224 3295   Passcode for all:    4463058 

Slides for the web cast will be downloadable and the web cast will be accessible on the company’s website until January 14, 2007.

Calendar 2007

   Full Year 2006 Results            March 23  Annual Report Published           April 12  Q1 Results                        May 04  AGM                               May 10  Q2 Results                        August 15  Q3 Results                        November 14 

Phase III pivotal trial — ASCEND(3)

The Phase III pivotal morbidity and mortality ASCEND trial, which began in July 2005, was a randomized, placebo-controlled study with over 2000 patients, designed to assess time to doubling of serum creatinine, end stage renal disease or death in type II diabetic patients with nephropathy. It investigated the effects of therapy with SPP301 (25 mg or 50 mg) or placebo, administered once daily on top of standard treatment which consists of angiotensin converting enzyme inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs).The study, which had been discussed and agreed with the FDA and the EMEA, was conducted in Europe, Americas and Asia and was expected to be completed by 2009 but was stopped in December 2006. The FDA has granted Fast Track status for SPP301 in this indication and had agreed a Special Protocol Assessment defining the design and endpoints for this Phase III trial.

Phase IIb results demonstrate strong efficacy and good safety

Results of the Phase IIb trial were presented in November 2005 at the American Society of Nephrology(4). A total of 286 patients were enrolled in this randomized, placebo-controlled, double-blind, parallel design trial. It investigated the effects on UAER of 12-week therapy with SPP301 (5 mg, 10 mg, 25 mg or 50 mg) or placebo, administered once daily on top of standard treatment (consisting of angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs). Compared to placebo, all doses of SPP301 decreased UAER significantly (p less than 0.001), with the highest two doses (25 mg, 50 mg) demonstrating the greatest reduction in UAER. There was also a significant reduction in total cholesterol at all doses (p less than 0.001) compared to placebo.

SPP301 was shown to reduce proteinuria by at least 30% on top of standard treatment for 55% of all patients across all dose groups. This is a remarkable additive effect in patients already receiving ACE-Is or ARBs, since these drugs are known to have strong antiproteinuric-effects on their own. Importantly, data from the U.S. National Kidney Foundation(5) suggests that such a significant reduction in proteinuria by SPP301 could impact morbidity and mortality in patients with diabetic kidney disease.

In this Phase II trial SPP301 also had a good safety profile and whereas other ERAs have previously been associated with liver toxicity, SPP301 has not been associated with this side effect so far. In this Phase IIb trial, no significant increases in liver enzymes, aspartate aminotransferase (ASAT) or alanine aminotransferase (ALAT) were observed with SPP301 compared to placebo.

About SPP301

SPP301 is a once daily oral endothelin-A receptor antagonist that Speedel licensed from Roche in October 2000. SPP301, a second generation ERA, was developed out of Roche’s endothelin research and drug discovery program, and was specifically optimised for improved liver safety. Speedel took the compound through a number of Phase I and exploratory Phase IIa clinical trials before selecting the novel indication of diabetic nephropathy for a Phase IIb clinical trial, the headline results for which were announced in March 2005. The Phase III ASCEND study began in July 2005 and was stopped in December 2006. Speedel has exclusive worldwide development and commercialisation rights under the licensing agreement with Roche.

About Diabetic Nephropathy

Definition: Diabetic nephropathy refers to any deleterious effect on kidney structure and/or function caused by diabetes mellitus. More specifically, diabetic nephropathy is thought of in stages, the first being that characterized by microalbuminuria (30-300 mg urinary albumin per 24 hours). This may progress to overt nephropathy or macroalbuminuria (greater than 300 mg urinary albumin per 24 hours). Later still, progressive renal functional decline is characterized by significant decreases in glomerular filtration rate accompanied by rises in serum creatinine, the final result of which is End Stage Renal Disease.

Current therapies include — amongst others — drugs that work on the renin-angiotensin system such as ACE inhibitors and ARBs, which have an antihypertensive effect as well as a renoprotective effect and have been shown to slow disease progression. However, 20-40% of patients with markers of early disease still progress to advanced kidney damage and eventually End Stage Renal Disease and death(6). Diabetic Nephropathy is a new indication for endothelin receptor antagonists, and the positive Phase II results for SPP301 indicate considerable additional benefit on top of current therapies taken by patients suffering from this chronic disease

Prevalence: According to the WHO in 2000, some 177 million people around the world had some form of diabetes, including undiagnosed cases. About 20-40% of patients with type 1 or type 2-diabetes develop nephropathy.(7) Current treatments (primarily antihypertensive treatment and inhibition of the renin angiotensin system) slow progression of DN, but it remains an unmet medical need, with a high mortality rate.

About Endothelin Receptor Antagonists

Pharmacological blockade of the endothelin system constitutes a relatively new concept for modulating haemodynamic and cellular functions. Substantial evidence from animal testing and clinical studies suggest that endothelin plays a pivotal role in several diseases such as hypertension, chronic heart failure, and chronic nephropathies. Endothelin triggers renal vasoconstriction, decreases glomerular filtration rate and modulates sodium excretion and water balance at the level of the proximal tubule and medullary collecting ducts, by mechanisms that are still unclear. Endothelin also stimulates the renin angiotensin system and atrial natriuretic peptide release and inhibits vasopressin-mediated water re-absorption in the collecting duct. In preclinical testing, chronic administration of Endothelin Receptor Antagonists protected animals, including those with induced diabetes, from developing renal injury.

About Speedel

Speedel is a public biopharmaceutical company that seeks to create value for patients, partners and investors by developing innovative therapies for cardiovascular and metabolic diseases. Speedel is a world leader in renin inhibition, a promising new approach with significant potential for treating cardiovascular diseases. Our lead compound SPP100 (Aliskiren, Tekturna(8)), the first-in-class renin inhibitor, is partnered with Novartis Pharma for development and commercialisation in hypertension; SPP100 was filed with the FDA in the U.S. in Q1 2006 and with the EMEA in the EU in Q3 2006. Our pipeline covers three different modes of action, and in addition to SPP100, includes SPP301 in Phase III (on hold), SPP200 in Phase II, SPP635 in Phase Il, and several pre-clinical projects.

Speedel develops novel product candidates through focused innovation and smart drug development from lead identification to the end of Phase II. We either partner with big pharma for Phase III and commercialisation in primary-care indications, or we may ourselves complete Phase III development in specialist indications. Candidate compounds for development and the company’s intellectual property come from our late-stage research unit Speedel Experimenta and from in-licensing. Our team of approximately 70 employees, including over 30 experienced pharmaceutical scientists, is located at our headquarters and laboratories in Basel, Switzerland and at offices in New Jersey, USA and Tokyo, Japan.

In March 2006 the company raised gross proceeds of CHF 83.95 million (approximately EUR 53m or US$64m) through the public offering of 500,000 treasury shares. Previously, as a private company, we raised gross proceeds of CHF 239 million (approximately EUR 154 million or US$183 million) from private placements of equity securities and two convertible loans and we have had total revenues, principally from milestone payments, of CHF 57.7 million (approximately EUR 37 million or US$44 million). The company’s shares were listed in September 2005 on the SWX Swiss Exchange under the symbol SPPN.

Forward looking statements

This press release includes forward-looking statements that involve substantial risks and uncertainties. These forward-looking statements are based on our current expectations and projections about future events. All statements, other than statements of historical facts, regarding our strategy, future operations, future financial position, future revenues, projected costs, prospects, plans and objectives of management are forward-looking statements. The word “may” and similar expressions are intended to identify forward-looking statements, although not all forward-looking statements contain these identifying words. We may not actually achieve the plans, intentions or expectations described in these forward-looking statements and you should not place undue reliance on them. There can be no assurance that actual results of our research and development activities and our results of operations will not differ materially from these expectations. Factors that could cause actual results to differ from expectations include, among others: our or our partners’ ability to develop safe and efficacious products; our or our partners’ ability to achieve positive results in clinical trials; our or our partners’ ability to obtain marketing approval and market acceptance for our product candidates; our ability to enter into future collaboration and licensing agreements; the impact of competition and technological change; existing and future regulations affecting our business; changes in governmental oversight of pharmaceutical product development; the future scope of our patent coverage or that of third parties; the effects of any future litigation; general economic and business conditions, both internationally and within our industry, including exchange rate variations; and our future financing plans.

   (1) Avosentan on doubling of Serum Creatinine, ENd stage renal disease      and death in Diabetic nephropathy  (2) Decision Resources, October 2004  (3) Avosentan on doubling of Serum Creatinine, ENd stage renal disease      and death in Diabetic nephropathy  (4) The ETA -- selective antagonist SPP301 on top of standard      treatment reduces urinary albumin excretion rate in patients with      diabetic nephropathy. Presented at 38th Annual Meeting of the      American Society of Nephrology, November 11, 2005, Philadelphia.      Rene Wenzel, Jessica Mann, Christiane Jurgens, Ilknur Yildirim,      Heike Bruck, Thomas Philipp, Anna Mitchell.  (5) Keane WF, Eknoyan G. Proteinuria, albuminuria, risk, assessment,      detection, elimination (PARADE): a position paper of the National      Kidney Foundation. Am J Kidney Dis. 1999 May; 33 (5): 1004-10  (6) Diabetes Care, American Diabetes Association 2004  (7) Diabetes Care, American Diabetes Association 2004  (8) Tekturna (SPP100, aliskiren) is a registered trade name of      Novartis Pharma 

Click to access 193683.pdf

This news release was distributed by PrimeNewswire, www.primenewswire.com

 CONTACT:  Speedel           Nick Miles, Director Communications & Investor Relations           +41 (0) 61 206 40 00           D +41 (0) 61 206 40 14           F +41 (0) 61 206 40 01           M +41 (0) 79 446 25 21           [email protected]           www.speedel.com           Hirschgasslein 11           CH - 4051 Basel           Switzerland            Speedel Pharmaceuticals Inc.           Frank LaSaracina, Managing Director           +1 732 537 2290           F +1 732 537 2292           M +1 908 338 0501           [email protected]           www.speedel.com           1661 Route 22 West           P.O. Box 6532           Bridgewater, NJ 08807           United States of America 

Living Coral Reefs Provide Better Protection from Tsunami Waves

Healthy coral reefs provide their adjacent coasts with substantially more protection from destructive tsunami waves than do unhealthy or dead reefs, a Princeton University study suggests.

Initially spurred by the tsunami that devastated the coastlines of the Indian Ocean two years ago, a team of scientists developed the first-ever computer model of a tsunami strike against a reef-bounded shoreline, using a volcanic island as an example. The model demonstrates that healthy reefs offer the coast at least twice as much protection as dead reefs. The finding provides the first quantitative confirmation of a widely held theory regarding the value of living coral reefs as a defense against tsunami waves, which are often generated by powerful undersea earthquakes.

Princeton professor Michael Oppenheimer said his team’s work will give scientists the ability to quantify how much any given reef will benefit its particular stretch of coast.

“Healthy reefs have rougher surfaces, which provide friction that slows the waves substantially in comparison with smoother, unhealthy ones,” said Oppenheimer, the Albert G. Milbank Professor of Geosciences and International Affairs. “Scientists had never before studied this effect by the numbers, nor had they ever analyzed it over a wide variety of coastal shapes. This study provides yet another motivating factor for protecting the planet’s coral reefs from degradation.”

The team’s findings appear in the Dec. 14 edition of the journal, Geophysical Review Letters. In addition to Oppenheimer, other team members include Robert Hallberg, who is head of the Oceans and Climate Group at the National Oceanic and Atmospheric Administration’s Geophysical Fluid Dynamics Lab, and Catherine Kunkel, who is the paper’s lead author. Kunkel spearheaded the work during her senior undergraduate year at Princeton, from which she graduated with a physics degree in June.

Though anecdotal observations of reefs’ effects on tsunami abounded after the 2004 Indian Ocean strike, Kunkel said, it was difficult to form any real conclusions because so many of these observations came after the fact. The goal of this study, which began as Kunkel’s senior thesis project, was to provide a systematic framework by which to examine the assumption that healthy reefs protect shorelines more effectively.

“For our purposes, we assumed that the health of the reef would only be important in terms of the drag it exerted on the wave,” said Kunkel, who is currently working as a research assistant at Tsinghua University in China. “If you have a healthy reef, it has lots of live coral branching out, sticking a lot of small obstacles into the water. A dead reef, on the other hand, is not as rough — it tends to erode and exerts less drag on the wave.”

A turbulent mountain of water crashing over a complicated rough surface presented Kunkel with a number of obstacles for her own study — specifically, how to find a way to express each of these effects with a mathematical formula that a computer could employ to simulate it. Different complex parameters had to be considered one by one: the width and depth of the reef; the roughness of its surface; the size of the lagoon behind it; and the slope of the coast beyond. And the overarching element was the wave itself and its interaction with all these obstacles. Eventually, Kunkel found a set of equations that provided a limited but comprehensive picture of a tsunami strike.

“We had to idealize a number of factors, because we wanted to create a model that could be used for a general shoreline,” Kunkel said. “For example, we had to consider a perfectly even ocean floor, because uneven ones can funnel a wave into a certain area.”

Despite the limitations of the model, Oppenheimer said it provides a sound basis for the team’s conclusions.

“The general conclusion is that a healthy reef might provide twice as much protection as a dead one,” he said. “This could translate into sparing large sections of inshore area from destruction.”

Because coral reefs are dying from rising ocean temperatures, increasing ocean acidity, and direct human damage, Oppenheimer said the findings offer yet another reason to protect these fragile offshore ecosystems.

“This study shows yet another way that protecting the environment relates to humanity in a very tangible way,” he said. “Villages get built behind coral reefs for good reasons, and this is one of them.”

Kunkel said that she hoped the study would inspire other scientists to continue the research by obtaining more observational data. Incorporating such data into the team’s theoretical model, she said, would then allow scientists to plan better for future tsunami strikes along local coastlines.

“We now have a basic idea of what variables are important, but if you want to quantify the effectiveness of a barrier reef around a particular island, you’d want to model that island directly,” Kunkel said.

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Princeton University

Study Highlights Debate Over Drug Expiration Dates

FORT LAUDERDALE, Fla. — If Jane Kreimer’s medicines were library books, she’d be fined for late returns. Her sleeping pills expired in 2000. Her pain pills and excess-fluid pills expired in 2004.

But the Fort Lauderdale retiree said she hasn’t replaced them, because a doctor told her to save the money and take the out-of-date drugs as long as they did the job. “They’re still working,” Kreimer said. “What a terrible waste it is for people to throw drugs away. I bet they’re making millions, if not billions, from people throwing out perfectly good medication.”

A growing body of studies and experts back her, asserting that many medicines remain safe, effective and stable for years beyond government-approved expiration dates set by drugmakers and pharmacists.

The leading evidence comes from a U.S. Food and Drug Administration program that tests drugs for the military. The results through July 2006: 88 percent of tested medicines remained potent for at least a year past expiration, some for up to 14 years.

Many officials from the FDA, drug industry and research community agree that certain medications, such as aspirin, may remain good well past expiration.

Even so, some of those experts discourage taking expired drugs, saying they are not a sure thing. The military stores drugs under ideal cool and dry conditions, these experts say, but consumers may not, creating a risk that old drugs will lose potency.

“After the manufacturer’s expiration, don’t use it, no matter what the government says,” said Skip Lenz, owner of Skip’s Pharmacy in Boca Raton, Fla. “Beyond that, it’s a crapshoot.”

The controversy has waged for more than a decade, dragging Florida drug chains into court and pushing the state to alter its pharmacy rules.

Expiration dates are set by the manufacturer and approved by the FDA based on company tests of a drug. The company guarantees the product will be at least 90 percent potent until the expiration date. Most drugs get a one- or two-year life.

Drugmakers can ask to extend the expiration if they test the drug further. But companies seldom do, industry officials said, because the tests take money and time, and do not lead to extra sales.

So, while aspirin is marked to expire in two or three years, Bayer has found its pills to be 100 percent potent after four years, said Dr. Jens Carstensen, a retired pharmacy professor in Wisconsin who wrote textbooks on drug shelf life. He tested five-year-old aspirin and found it to be “excellent.”

Ormond Beach, Fla., pharmacist Gerald Murphy, who has made the issue a crusade, said companies lowball expiration dates so consumers buy new drugs.

“We should tell people to throw away a $300 bottle of pills because of a marketing scheme?” Murphy said. “Even the manufacturers don’t know when their drugs expire. Here’s the government sanctioning a big lie.”

A spokesman for the pharmaceutical industry denied that drugmakers set expirations to boost sales. The dates must be conservative to ensure drugs work no matter how they are stored, said Alan Goldhammer, vice president for the trade group Pharmaceutical Research and Manufacturers of America.

Many consumers keep their drugs in the bathroom, exposed to heat and humidity that degrade drugs, Goldhammer said.

“I don’t think money is the consideration at all,” he said. “(Drugs) could still be good after the date but there’s no guarantee.”

The FDA does not make manufacturers test drugs for a longer time to find the true life span, because its priority is safety and effectiveness, not saving money for consumers, an agency spokeswoman said.

Certain drugs _ nitroglycerin for heart disease, liquid antibiotics and others _ are prone to degrade fast and must be watched, experts said.

Yet research shows many last for years:

The FDA Shelf Life Extension Program has tested hundreds of drugs for the U.S. military since 1985 and found that, on average, they were good for 5 { years after expiration. The program saved $296 million on drug replacements in 2005 alone, the FDA said.

Anesthetic lidocaine was found to be good past the expiration despite being stored for two years in an Oman warehouse at up to 135 degrees. Antibiotic ciprofloxacin marked to expire in three years was still good after 13. Cyanide antidote sodium thiosulfate was still good after 16 years.

The findings are clouded, the FDA says, because a few batches of long-lived drugs degraded before expiration.

Flu drugs amantadine and rimantadine stored for 25 years under household conditions proved to be fully effective, doctors said in a 1998 study in Antiviral Research.

The asthma drug theophylline proved to be 90 percent potent after 35 years, doctors said in a 2002 study in Human & Experimental Toxicology.

A Massachussetts Institute of Technology researcher, Moshe Alamaro, insists expiration dates are inaccurate, and is lobbying for state approval to collect unopened, expired medicine for the uninsured. Alamaro said supporters may follow suit in other states.

In general, pharmacy experts consider a medicine good at 90 percent potency, but author Carstensen said some drugs _ such as painkillers, cold remedies and others that simply relieve symptoms _ work fine at 85 percent or less. He said he eased a migraine with a drug six years old.

Yet he and others urge caution, saying consumers cannot tell which drugs were stored well enough to be good after expiration.

Some pharmacy specialists call for the FDA or drug companies to test drugs for longer periods, to possibly set longer expirations to benefit consumers, insurers and tax-supported Medicare and Medicaid.

“With medicines being so high, it would be nice if the government would pay for a study. It could save millions or billions,” said Dr. Jay Pomerantz, a Harvard professor who favors recycling expired drugs.

The industry calls the idea a non-starter. Why would a company spend time and money testing a drug’s shelf life when its patent expires after a number of years, Goldhammer said. Most medicines, he added, are given in quantities that should be taken fully to treat the illness, with no leftovers.

Some drug experts argue that aged drugs can break down into harmful byproducts, citing a 1963 study on a death from old tetracycline. But the editor of Harvard Health Letter wrote in 2003 that the old study is in dispute and that cases of old drugs causing harm are “virtually unknown.”

Manufacturer expirations are not the only source of controversy. About 17 states require pharmacists to put a one-year date on a prescription if the pills were removed from a factory container _ even if the official expiration is later _ on the theory that medicine may degrade in drugstore vials. The one-year date is backed by influential U.S. Pharmacopeia, which sets standards for the drug industry.

Florida’s pharmacy board had imposed the one-year rule for years until critics complained. In 2004, the board let pharmacists decide between one year and the factory date. Yet many of Florida’s 22,500 pharmacists don’t know of the change or use computers still programmed for one-year labels, said Paul Elias, owner of the Prescription Pad and president of the Broward Pharmacy Association.

The state pharmacy board doesn’t track pharmacists’ labeling and takes no position on expiration dates, board Director Rebecca Poston said.

Florida’s biggest drug chains, Walgreens and CVS, follow the one-year rule unless pills are in a factory package, company spokespersons said _ and they have been sued.

A 2004 class-action suit in Chicago’s Cook County calls Walgreens’ policy deceptive, said Ben Barnow, an attorney who filed it. A similar suit against CVS was dismissed but another is pending.

Clearly, the issue of expiration dates is far from settled.

“Each drug has to be looked at individually,” said Larry Sasich, a pharmacy professor and consultant for Public Citizen Health Research Group. “It sounds like it should be simple, but it’s not.”

After Taking Blows, Bank Repairs Relations With Lilly Family

By Andrews, Greg

No bank wants to leave a customer steamed, especially when that customer is the mighty Lilly family.

Great news for National City Bank of Indiana: It’s finally back on the family’s good side.

Court papers filed in Marion Superior Court in recent months show the six nieces and nephews of heiress Ruth Lilly are increasingly satisfied with the bank’s handling of her financial affairs.

Lilly, 91, is the sole surviving great-grandchild of the pharmaceutical firm’s founder. The bank, part of Clevelandbased National City Corp., serves as conservator of her estate, valued in 2002 at $1 billion. In a deposition that year, a National City official called the Lilly relationship the bank’s biggest.

It remains a whopper of a client, even though in the intervening years the bank has disbursed millions of dollars to beneficiaries, following the terms of her estate plan. National City continues to oversee accounts and trusts containing hundreds of millions of dollars.

In a court filing last month, the nieces and nephewsrepresented by Eli “Ted” Lilly II of Carmel and George Lilly of Florida-wrote: “During the [six months] covered in this report, the communication, reporting, planning and overall investment performance by the conservator has substantially improved.”

The family used similar language in a report in June and another in November 2005. That was a huge shift from a May 2005 report, in which Ted and George Lilly questioned the bank’s investing and diversification strategies and said they were “extremely disappointed” with its performance.

In that filing, they wrote: “The family designees believe that the conservator is not adequately handling its responsibilities. … The conservator has been particularly uncommunicative and unresponsive to the concerns raised by the family designees.”

What had so irked the family, and how did the bank mend the relationship? The reports, filed in probate court, shed little light. And representatives of the bank and the family would not elaborate.

But papers filed in a separate lawsuit fill in some of the gaps. In that 3-year-old case, two big beneficiaries of Ruth Lilly’s estate, Washington, D.C.-based Americans for the Arts, and Chicago- based Poetry Foundation, charge National City bungled management of her assets, costing them tens of millions of dollars.

At issue are two Ruth Lilly trusts funded in January 2002 with 3.8 million Eli Lilly and Co. shares worth $285 million. The charities say the bank failed to diversify the trusts until the second half of the year, when Lilly shares were slumping, resulting in a $102 million decline for 2002.

A Marion County judge in 2005 shot down the suit, and the Indiana Court of Appeals did the same last month. Attorneys for the charities could not be reached on whether they plan to appeal to the Indiana Supreme Court.

Depositions, e-mails and other records filed as part of that case make clear the nieces and nephews thought the charities’ concerns were well-founded.

After Lilly announced in July 2002 that quarterly profit plunged 20 percent and that federal regulators were demanding 94 fixes at eight manufacturing plants, the company’s shares fell 5 percent in a few hours.

In response, George Lilly fired off an angry e-mail to top bank officials: I continue to insist that rational and prudent management strategies be put in place … so that we do not once again find ourselves exposed like a jackass in a hailstorm. “

The filings show the family and bank were on terse terms even before the diversification uproar.

In a February 2002 e-mail, one bank official wrote to another: “You will rue the day you ever decided to take on this account. … George … has a terrific bark but I am told he usually backs off.”

Copyright IBJ Corporation Nov 13, 2006

(c) 2006 Indianapolis Business Journal. Provided by ProQuest Information and Learning. All rights Reserved.

Cultural Lag: In the Tradition of Veblenian Economics

By Brinkman, Richard L; Brinkman, June E

The purpose of this paper is two-fold: one is to demonstrate that the concept and theory of cultural lag is in the tradition of Veblenian economics; and secondly, that while cultural lag theory delineates and explains problems, it does not necessarily provide for a means of resolution. For example, historically the theory of cultural lag has served as a basis for problem identification and dissent. Veblenian economics, however, can also serve to go Beyond Dissent and promote assent in its relevancy to the processes of institutional adjustment and amelioration. In this respect, in the promotion of assent, there is a need for the origination and innovation of a social DNA to promote a synthesis of the disparate parts of culture via instrumental knowledge. In support of this position this paper is divided into five parts as an analytical whole: (1) a survey of references to cultural lag which have appeared in the literature written by Veblenian economists; (2) a clarification of the concept and theory of cultural lag; (3) a clarification of the “what is” vis-a-vis Veblenian economics; (4) a conflation between cultural lag theory and Veblenian economics; and, (5) the need for synthesis in the formation of a social DNA.

Cultural Lag: A Literature Search among Veblenian Economists

Both Clarence E. Ayres and Allan G. Gruchy, certainly considered bona fide Veblenian economists, were instrumental in keeping alive and maintaining a slender thread of scientific DNA for Veblenian economics during the post-WWII era. A question that arises, however, is how then did these two recognized doyens of Veblenian economics address and treat the concept and theory of cultural lag? Based upon his focus on culture and a holistic and interdisciplinary approach to Veblenian economics, in many instances Gruchy addressed the framework of cultural lag. “Institutionalists from Veblen on have been aware of the problem of cultural lag and in general have favored a policy of some form of collective management of the economic system” (Gruchy 1987, xiii). This position emanates from the fact that Gruchy, along with many other Veblenian economists, gave pride of place to the anthropological, holistic conception of culture.

Specifically with respect to Veblen, Gruchy stated that “Veblen explains that institutions and the culture in which they are embedded change over time in response to changes in science and technology . . . Since all institutions do not change at the same rate, social or cultural lags develop” (Gruchy 1972, 21). Also, “[i]n working out his concept of class organization, Veblen introduced the concepts of the cultural lag and class conflict. According to his theory of culture the most important single factor that alters institutions, and hence human behavior, is technological change” (Gruchy [1947] 1967, 78). Problems arise, though, because not all classes are equally exposed to the changing technological conditions. This causes different rates of psychological adjustment among the classes, leading to cultural lags that affect cultural standards. “Where classes have different institutional standards and mental habits, their members find themselves acting at cross purposes” (78).

Gruchy, in his chapter on “Experimental Economics of Rexford G. Tugwell” discussed the concept of cultural emergence and its association with the concept of cultural lag. Cultural lag has “come to have a prominent place in the thinking not only of Tugwell but also of the other exponents of economic heterodoxy … Cultural emergence is not a gradual, uninterrupted process; instead it is a spotty development in which certain cultural elements, such as institutions and social attitudes, fail to change as rapidly as other elements. This uneven cultural development creates lags which are the source of many serious social and economic problems” (Gruchy [1947] 1967,415).

And on the neoinstitutionalists which include among others John Kenneth Galbraith and Clarence Ayres, Gruchy claimed that “[t]he logic of economic development constructed by the neoinstitutionalists calls attention to the lags in the evolution of society’s institutional structure as this structure responds slowly to changes in society’s technological foundation” (1972, 297). On Galbraith, in particular, Gruchy reported that “[t]he key to an understanding of Galbraith’s economics of opulence or affluence is his concern with technological change and its impact on institutions and the minds of men” and “man is the victim of a cultural lag” (134, 136, and 137, 138, 169).

Ayres certainly emphasized the concept of culture. In fact, his theory of the economy and economic development constitutes a theory of culture evolution. Culture “exhibits two aspects; namely, the institutional (or ceremonial) aspect and the technological aspect. The institutional aspect of human culture … is resistant to change and development. It is restrictive and backward looking, and seeks to preserve existing class arrangements and restrictions . . . the cultural process is continuously affected by the lag between institutional and cultural change” (Gruchy 1972, 95-96). Outmoded institutional arrangements cause many social problems because they become obstacles to a satisfactory adjustment between the institutional and technological aspects of culture.

Other Veblenian economists, as well as Marxian economists, have recognized Veblen as a cultural lag theorist: “The culture of the old generation is devalued and demeaned as a result, creating the generation gap-a kind of cultural lag” (Dugger and Sherman 2000, 55; 1997, 1007; Hodgson 2004, 372,192).

Rick Tilman cited “Veblen’s theory of cultural lag in which institutions and science and technology are perpetually in a state of maladjustment with each other” (1990, 966). ‘ The correspondence between John Dewey and Ayres indicates that they were both concerned with how to address the problem of cultural lag. Tilman, again, in another article reported that “(i]n recent years many political theorists have continued to concern themselves with traditional issues of political philosophy, issues which have less and less relevance in an industrial society undergoing sustained technological innovation and beset by problems arising from cultural lag … problems of adjusting political institutions to a rapidly evolving technical-industrial base” (Tilman 1968, 423).

William Glade noted that “Veblen’s contribution to the theory of cultural lag lies in his keen analysis of the basic dichotomy of the social complex-technology and ceremonialism-an analysis which goes far beyond the usual studies of the phenomenon of cultural lag and deals with the underlying aspects of society” (1952, 436). John Gambs commented on Veblen’s Gestalt in which “today’s Gestalt may contain left-over elements from yesterday’s Gestalt. Thus there can be culture lags, and these culture lags may be of great significance” (1946, 25). Paul Bush, in his article on “The Theory of Institutional Change” introduces three types of ceremonial encapsulation. Bush related cultural lag to the first type, which he labeled “the ‘past-binding’ type. The first type of ceremonial encapsulation for which the term ‘cultural lag’ is most appropriate involves the ‘past-binding’ resistance of the traditions of the community to the absorption and diffusion of technological innovations” (1987, 1094).

Also, “[tjhe concept of culture lag, which Veblen used to analyze social processes, has been widely used by American sociologists to account for both social change and social problems … The cultural lag approach has been one of the master concepts of modern social analysis” (Davis 1968, 304-05). This brief summary of the literature indicates that many bona fide Veblenian economists have addressed the concept and theory of cultural lag. But what then is meant by cultural lag?

Toward a Clarification of the Concept and Theory of Cultural Lag

What follows in this section of our paper is primarily an analysis of William Ogburn’s concept and theory of cultural lag. It appears that “… Ogburn’s analysis was widely used in institutionalist’s circles” (Hodgson 2004, 372; Bush 1987, 1113). But neither Ogburn nor Veblen, nor will anyone else, provide a final or absolute theory of cultural lag. Science in its evolution constitutes an ongoing and continuous process of questioning, critique, and doubt. Consequently, the theory of cultural lag will itself continue to evolve and take on new forms and structures. For example, C. Wright Mills is an obvious supporter of Veblenian economics: “THORSTEIN VEBLEN is the best critic of America that America has produced” (Horowitz 2002, 107; Veblen 1970, vi, Introduction). Yet Mills introduced additional perspectives on the Veblenian as well as the Ogburnian concept and theory of cultural lag.

Mills recognized Veblen as a cultural-lag theorist, but in addition also noted that the theory not only relates to a response to an acceleration of culture that must be considered. “One might say that in terms of the rates of change at which sectors of culture could move, it is technology that is lagging, for the specific reason of the control of patents, etc., by entrenched interests” (Mills 1963, 54\6). Consequently, a problem also relates to the power of power elites that can control the very process of acceleration itself. The acceleration of culture is controlled by social organization and institutions. Such a problem exists in the acceleration of military technology wrought in a crucible of the military-industrial-complex. Or conversely, that the vested interests of power elites in the petroleum industry can also hold back the acceleration of the invention and innovation of solar technology. However, to have a framework as a locus of reference, and as a start, what then is Ogburn’s explicit conception and theory of cultural lag?

While Veblen never used the term, the phenomenon of cultural lag was implied in his writings: “a study of the basic dichotomy- ceremonialism and technology-of Veblen’s analyses reveals the important contribution which Veblen made to the theory of cultural lag” (Glade 1952, 432). However, “while the idea of cultural lag was implied by others, the explicit formulation of the concept and development of the theory awaited Ogburn” (Brinkman and Brinkman 1997, 610; 2005, 230).

Ogburn claimed that cultural lag does not pertain simply to conception alone, but relates to theory as well. “I think it better to say that since it is a concept of a relationship, it is a theory. It is therefore more than merely a new term in the language” (Duncan 1964, 89). In 1922 the concept and theory of cultural lag was specifically addressed in Ogburn’s book on social change. A reason for turning to Ogburn is that clarity of expression was not a Veblenian virtue. In fact, Veblen’s writing style at times makes for difficult reading. According to Gruchy, this is in part, because Veblen “never felt the need to move from the realm of specialized research to that of general or synthetical analysis” (Gruchy [1947] 1967, 613). While some would argue that Veblen’s writings “do not lack unity, unity is never displayed within the limits of one treatise” which leads to difficulty in understanding his theories by reading only one of his works (126). “Veblen thus failed to write at a level that was intelligible to the common man and never presented the bulk of his ideas in a single treatise, which in Gruchy’s view explains the limited scope of his influence” (Tilman 1992, 157). Veblen “could have done much to provide a firm inductive foundation for many of his broad generalizations. But he makes no use of the devices of statistical analysis” (Gruchy [1947] 1967, 127).

Veblen also failed to carry through from theory to policy. “When it comes to concrete suggestions for collective action Veblen has nothing or, at the most, little to say” (Gruchy [1947] 1967, 115). He “was not himself especially interested in problems of economic policy” (124). All this is not to belittle Veblen who had an important influence in both sociology and economics. In fact, Ogburn was “accused of taking the cultural-lag theory from Thorstein Veblen,” which he denied, “because I had never read him on this point” (Duncan 1964, 87; Brinkman 1981, 238, 258; Bush 1987, 1113). Ogburn admitted that he had read Marx on this subject and that this was “a base from which the theory of cultural lag was developed, but certainly neither the materialistic interpretation of history nor economic determinism is the same as cultural lag” (Duncan 1964, 87).

The above criticisms of Veblen are mentioned because it was in these very areas where Ogburn was strong. Ogburn was very interested in social policy and headed up the President’s Research Committee on Social Trends, appointed by President Herbert Hoover in 1929. “For Ogburn the important thing was not the conceptual scheme, but the discoveries to which its application might lead” (Duncan 1964, xv). Ogburn felt the need to prove his theory of cultural lag, and he used his statistical background to that end. “Thus, for proof, a theory evolved into a hypothesis. But the war came along, and it was only after the war that I took up the verification of this hypothesis by considering the adjustment of law to industrial accidents” (89).

With respect to clarity, Ogburn’s writing is clear and intelligible; “it is as clear a formulation of the problem or question of social change and cultural lag as can be found anywhere in the literature on the subject” (Glade 1952, 432). Also, “his writing is clearer than any secondary exposition could make it” (Duncan 1964, xv). Ogburn was “a scholar who could best present the case of the social scientist to the world of nonscientists” (Jaffe 1959, 319-320). Unlike Veblen, the basis for most of Ogburn’s studies, and there were many, may be found in a single treatise – Social Change: with Respect to Cultural and Original Nature ([1922] 1966).

Finally, Ogburn’s influence has been far-reaching. Cultural lag has appeared in almost all sociological textbooks, and has won widespread use, even appearing in dictionaries and encyclopedias, “written with initial lower-case letters and without Ogburn’s name attached” (Duncan 1964, xv). On a conciliatory note, both Veblen and Ogburn concentrated on the dynamics of culture evolution. Ogburn centered attention on social evolution in the context of culture evolution. “Social evolution becomes then cultural evolution” ([1922] 1966, 377). Veblen’s framework was directed toward economic evolution, but was also interrelated to the dynamics of culture evolution. Both emphasized the influence of technology. Ogburn was concerned about the influence of technology on society, as in “How Technology Causes Social Change” (Alien et al. 1957, Ch. 2). Veblen was more concerned with the conflict between technology and the business or pecuniary institutions he addressed in The Theory of Business Enterprise as well as in his other contributions to the literature. Also Veblen did not assume that technology had a completely free reign: “Veblen’s use of ‘lag, leak, and friction’ is a structural analysis of industry versus business enterprise. He focused on where ‘the lag” seemed to pinch; he attempted to show how the trained incapacity of legitimate businessmen acting within entrepreneurial canons would result in a commercial sabotage of production and efficiency in order to augment profits within a system of price and ownership” (Mills 1963, 546). According to Ogburn, then, a basic statement of cultural lag is:

that the various parts of modern culture are not changing at the same rate, some parts are changing much more rapidly than others; and that since there is a correlation and interdependence of parts, a rapid change in one part of our culture requires readjustment through other changes in the various correlated parts of culture . . . The extent of this lag will vary according to the nature of the cultural material, but may exist for a considerable number of years, during which time there may be said to be a maladjustment.2

Ogburn divided culture into material and nonmaterial parts. His aim was to emphasize the material part of culture that he felt was not particularly emphasized in Edward Tylor’s earlier definition as “‘that complex whole which includes knowledge, belief, art, morals, law, custom and any other capabilities and habits acquired by man as a member of society'” (Ogburn (1922] 1966, 4). Nonmaterial culture was broken down into adaptive and non-adaptive parts. An example of this would be the family which is a part of nonmaterial culture. When the factory system provided work away from home, the family had to adapt and adjust to these changed material conditions. At the same time, some of its functions remained constant, and were non- adaptive, as for example to procreate. Culture evolves and accumulates due to “four factors, invention, discovery, diffusion, and adjustment” (377).

There are many reasons to explain why nonmaterial culture tends to lag behind material culture. There are those who cling to the old forms (cultural inertia) for various reasons: settled social habits promoting institutional inertia in the form of vested interests, conformity due to fear of ostracism, and the power of tradition and elites, among many others. Consequently, aspects of nonmaterial culture may present obstacles to change and lag behind the characteristic acceleration of material culture. As a result, there is a period of maladjustment leading to social problems. But Ogburn was adamant that the sequence need not always entail a lag of nonmaterial culture behind that of material culture. On this score, there are four conceivable types of cultural lags interrelating the material with the nonmaterial (Brinkman and Brinkman 1997, 613; 2005, 231). “Indeed, it is conceivable that a change may first occur in nonmaterial culture and later the material culture be adjusted to such a change” (Ogburn [1922] 1966, 268-269). The independent variable “may be technological, economic, ideological, or anything else” (Duncan 1964, 91). The emphasis in most of Ogburn’s studies, however, was on the material culture as prime mover, especially during the modern period.

“What Is” the Veblenian Tradition?

If cultural lag is in the tradition of Veblenian economics, what then constitutes the “what is” of Veblenian economics? This is not an easy task and constitutes a problem that confronts neoclassical, Keynesian and Marxian economists. There have been many attempts by Veblenian economists to deal with this ongoing problem of paradigmatic clarification.3 And further, while many economists make contributions that are considered to be in the Veblenian tradition, they do not always consider themselves to be Veblenian economists, per se (Gruchy 1974, 207). “Not all of these specialists would use the label ‘institutionalist’ to describe their work, nor do they necessarily have an appreciation for the legacy of early institutionalists . . . ,” a clarification of “The Institutionalist Tradition” is addressed by Dell Champlin and Janet Knoedler (2004, 2, 4; B\rinkman 2005). The work of the soolled “new” (neoclassical) institutional economists complicates the issue further by obfuscating the meaning of institutional economics. This leaves traditional institutional economists with the opprobrium of “old” institutional economics. To resolve this conceptual and taxonomic conundrum, that has blurred the meaning of institutional economists, Champlin and Knoedler use institutionalists and institutionalist economics as an alternative.

While this may solve the problem, to some extent, why not call a spade a spade, and simply call traditional institutionalist economics what it really is Veblenian economics. Perhaps it is time to alter Walton Hamilton’s original designation of Veblenian economics as “institutionalism” (Breit and Culbertson 1976, 5; Hodgson 2004, 6, 255-6). This gives deserving recognition to Veblen as “a founder of modern evolutionary economics,” in that “Veblen’s writings constitute the first case of an evolutionary economics along Darwinian lines” (Hodgson 1998b, 183, 170; Hodgson 1998a, xvi, 426). This acknowledgment would place the school of Veblenian economics on par with the other major schools of thought delineated by their founding fathers and known as Keynesian and Marxian economics, and why not?

Given this nomenclaturial or taxonomic switch does not resolve the problem – what then is the “what is” of Veblenian economics? Gruchy offered a definition of institutional economics as “social provisioning” and in the frame of an “ongoing cultural process” (Gruchy 1987, 21-37). Perhaps a brief definition along similar lines might be that the Veblenian framework, in the context of socio- cultural provisioning, serves to analyze and instrumentally evaluate the processes of culture evolution with a reform orientation directed toward social justice in promoting a continuity of an ongoing process of human evolution – the economic life process.4 But this definition is far too brief to provide an understanding as to what constitutes Veblenian economics. The next step toward an increased complexity of conception might be to look at Veblenian economics as a structure, a framework standing on a foundation of three legs: (1) evolution; (2) culture; and, (3) value theory.5

At the outset, this appears to offer the three legs as separate entities; this is legitimate in that some institutional economists might focus on evolution, culture or value theory in isolation. In reality, however, the three legs are obviously interconnected and interrelated – but how? This question moves us from the simple to the more complex in terms of how then to integrate the three legs serving as a foundation for Veblenian economics? What follows constitutes an attempt to delineate some of the salient features of Veblenian economics in terms of its holistic and interdisciplinary nature.6 This will be followed by the Veblenian dichotomy and a further clarification of the conflation of the Veblenian tradition to the concept and theory of cultural lag.

In the first place, what is it that substantively evolves in the context of the economic process? Culture as “that complex whole” is comprised of both the material (buildings, bridges and boats) as well as the nonmaterial (government, corporations, and unions). Together, this gestalt in the overall framework of culture, as an amalgam of the material and the nonmaterial, constitutes the substantive grist for the mill of economic analysis. Veblenian economists “maintain that culture and economy are inseparable – culture is the economy” (Champlin and Knoedler 2004, 4). Culture, however, does not stand still but historically has evolved over time. The process of evolution requires a dynamic in the form of a sequential process of structural transformation7 Veblen frequently alluded to “a cumulative or unfolding sequence . . . a notion of a sequence or complex of change” (Veblen 1961, 70, 32, 77). Such a sequential paradigm, that sociologists address as one of “logistic surges,” presupposes a methodology that embraces the stages of economic evolution.

It appears that Veblen provided a theory for both general and specific cultural evolution (Sahlins and Service 1960, 12-44). General evolution relates to a sequential process of structural transformation. In biological terms general evolution relates to the sequential process of structural transformation in the movement from that of unicellular life, to fish, amphibians, reptiles, and on to mammals. By comparison, specific evolution relates to transformation within a structure such as that of fish. In cultural terms, general evolution relates to structural evolution in transportation, from that of the horse and buggy, on to railroads, to propeller driven aircraft and on to jets and rockets. By comparison, specific evolution relates to transformation within a structure such as that of propeller-driven aircraft in transportation, or capitalism in terms of culture writ large.

In cultural terms, Veblen dealt with both processes. On the one hand, Veblen’s theory comprised the process of general evolution and related to all stages of cultural evolution. “These two divergent ranges of inquiry are to be found together in all phases of human culture. What distinguishes the present phase is that the discrepancy between the two is now wider than ever before” (Veblen 1961, 18). Veblen’s theory related to canoe building, symbolic of primitive cultures, as well as to the construction of the empire state building as a concomitant to modern economic growth.8 But Veblen’s main attention, obviously, was directed toward the processes of specific evolution embedded in the specific overall structure of capitalism. Veblen’s basic dichotomy, juxtaposing the industrial versus the pecuniary, concerned an analysis of late nineteenth-century, robber-baron capitalism. Certainly, Veblen’s theory of economic evolution would not amount to much if it only pertained to nineteenth and early twentieth century America, any more than would Darwin’s theory be a theory of biological evolution if it only related to mammals or Homo sapiens.

Certain points concerning a stage methodology and the role of technology are in need of clarification. One concerns the so-called unilinear or orthogenetic problem. In addressing the stage’s problem there is a need to apply the distinction between general and specific evolution as noted above. The earth as a whole, from the past to the present, has experienced a linear process of general culture evolution. Problems exist in attempts to formulate a precise definition and description of each stage and its given characteristics.9 But it is evident that humankind’s culture has evolved from a very primitive stage to that of an Agrarian Revolution, on to what might be called a Commercial Revolution, and from this stage on to that of an Industrial Revolution and the epoch of Kuznets’s science-fed modern economic growth.

The epicenter of global evolution has shifted and been diffused from one culture to another as a process of general culture evolution for the earth as a whole. That is not to assume that a given culture, such as that of Egypt or Somalia, will necessarily or inevitably evolve into modern economic growth any more than the nautilus will evolve into Homo sapiens. But rather that for the earth as a whole, general evolution has, indeed, taken place in the form of stages and can be depicted as a linear process. That is not to assume that every culture is driven by some inexorable, teleological imperative. Not all cultures will necessarily be able to break out of the bonds of the processes of specific evolution and engage the dynamics of general evolution. Though we know where humanity has been in terms of the path of the general evolution of culture, given the teleological fallacy, this does not enable us to predict where the drift of culture evolution will inevitably lead us in the future. Concerning the future, humankind must transform that enigmatic drift into a design of culture to serve in the promotion of ongoing human needs inherent in a continuity of human evolution.

Interrelating a stage analysis to technology, the technological process accounts for the transformation of one stage of culture to the next. Arguing that technology serves as the factor of causality lends itself to the charge of technological determinism or reductionism. The answer to such a charge depends on the meaning and conception of the technology used in analysis: “Technology-the development and application of scientific or systematic knowledge to practical tasks” (Galbraith 1973, 39). So conceptualized, technology consequently constitutes a process not a thing.10

The technological process, however, does not really cause culture to change and be transformed, but rather that the changes brought about via the technological process, ipso facto, constitute a change and transformation of culture. Culture is made up of the material and social technics emanating from the technological process. “However, no one supposes that the technological process is the whole of culture” (Ayres 1978, 121), but rather that the technological process constitutes the “core of culture” (Veblen 1961, 2, 29; Brinkman 1997, 1033, 1036). Therefore, by inventing and innovating the steam engine, humankind also changed and transformed material culture in the process. Similarly, with the introduction of the factory system as a concomitant social technic to that of the steam engine, nonmaterial culture was also transformed in the process. Such material and nonmaterial technics, as residuals and manifestations of the technological process, constitute a culture- conception of technology (Brinkman 1997).

Consequently, the technological process does not cause culture to change. But rather, that a transformation of the technics of technology, itself, constitutes a transformation of culture. This Janus-faced nature of knowledge, as \a coin of useful knowledge, is depicted in Figure 1, “The Dichotomy of Useful Knowledge.” On one side, technology functions as applied knowledge and on the other, knowledge is stored in culture. Both technology and culture are manifestations of the protean concept of knowledge that appears in many forms. To change one (technology) is to change the other (culture) in that both technology and culture appear as opposite sides of the coin of knowledge. Consequently, this explains culture evolution in terms of its very own substance (knowledge), for to change the dough (technology) is to change the bread (culture).

The processes of invention, discovery and culture diffusion offer new technics, which must be permeable to a given culture to be innovated. Innovation leads to expansion of the technological base, as an overall gestalt of technology, and from this expansion more knowledge begets more knowledge. This expanded base in turn serves to nurture an increased capacity for more inventions. But given such a “Wheel of Economic Development,” as a manifestation of Gunnar Myrdal’s circular and cumulative causation, wherein does one ascertain the locus of the evolutionary impulse?” In such a circle of the technological process, of so many concomitant parts, wherein does one identify a single factor of causality? Further, given the role of humankind as the basic agent advancing the technological process, the conclusion drawn from this discussion is that the technology process, as such, does not serve as the single causal factor of culture evolution. The process of technology constitutes a process of great complexity comprised of many interrelated parts combining humankind’s interaction with culture and the physical world. Technology is not simply relegated to the material – deus ex machina.

The “principle of similitude” states that for growth to experience an ongoing continuum of increased scale and size, there is also a need for an ongoing concomitant process of structural transformation.12 This is another way of stating that evolution and cultural accumulation relate to an ongoing process of structural transformation-that is the process of evolution. The process of economic growth relates to a process of specific evolution and entails growth within a structure. The growth process entails reproduction and replication, as more and more of the same, as in rabbits or more and more automobiles. This appears as a logistic or Gompertz growth curve. Such a sigmoid or “S”growth curve, ultimately, is contained in an asymptotic ceiling. By comparison, economic development, as a sequential process of general evolution, relates to a process of transforming one structure to the next (Brinkman 1995). Consequently, “[a]ny evolutionary science … is a theory of a process, of an unfolding sequence” (Veblen 1961, 58, 77). As such, economic development, as an ongoing exponential process of culture accumulation, and with acceleration, is predicated on what Hornell Hart referred to as an unfolding series of “logistic surges.””Throughout the entire sweep of history and prehistory, the power of human beings to achieve their basic purposes has been increasing at accelerating speed … This long- run acceleration has taken place through a series of logistic and Gompertz surges” (Hart 1946, 281, 290-91). Whereas Ogburn gave us a theory of the exponential advance of culture, Hart noted that the exponential was predicated on an underlying process of structural transformation manifest in “logistic surges.”

Consequently, the ongoing evolution of culture enables humankind to take bigger and bigger bites of the infinity of knowledge. A knowledge that is stored in culture and, in the process of ongoing cultural evolution, can potentially enable humanity to become more human. While technology, as a process, can potentially promote an instrumental function as a necessary condition in the ongoing advance of the human life process, technology need not always serve an instrumental function. The accumulation and store of useful, instrumental knowledge is necessary for ongoing human evolution as a process that is no longer simply biological but is now primarily cultural. “Since change cannot be explained by a constant” (Ogburn [1922] 1966, 377). The process of biological evolution and genetic transformation is gradual and long-term in nature and has changed relatively little for Homo sapiens in the past 25,000 years (132-4, 392, 377). While not discounting the relevancy of the genetic and the biological, ongoing human evolution is now primarily relegated to the dynamics of culture evolution (Ogburn [1922] 1966, 132-33).

Therefore, the exponential acceleration of culture, manifest in a “toolcombination principle,” is viewed by Ayres as a “law of progress” (Ayres 1978, 118-19; Hodgson 2004, 357-8). This position requires a clarification. Using “tools” as the basis for combination infers a focus on material culture arid material technology, granting that Ayres apparently did not conceptualize technology in terms of the material alone but interrelated tools with skills (Ayres 1978, xv). Nonetheless, it is better perhaps to use a “knowledge combination principle,” Invention constitutes a kaleidoscopic process of shaking and combining the existing bits of knowledge into new structures, both material and nonmaterial (social) viewed as new inventions. As a result, more knowledge begets more knowledge and the accumulation is exponential.

A Conflation of Culture Lag Theory to Veblenian Economics

Now to the connection of cultural lag to the overall Veblenian framework and theory embedded in the Veblenian dichotomy. “The ideas of cultural theory as developed by Ogburn and others in sociology later became conflated with Veblen’s cumulative causation and cultural sequence” (Dugger and Sherman 1997, 1007; Hodgson 2004, 372, 192). The advancing exponential juggernaut of general culture evolution has not been a smooth one, but rather has been marked by many periods of maladjustments. These periods have been related to both the long-run as well as the short-run. Ogburn also sought reform, via institutional adjustments, but his focus was directed more to the short-run. To Ogburn, cultural lags tend to disappear in the long run, and therefore are not visible because they “have been caught up” (Duncan 1964, 95; Ogburn [1922] 1966, 388-90). Such a short-term focus precludes an analysis and critique of the overall system of capitalism dating back to the Industrial Revolution, but cultural lags appear in both the long-run, and still many of which have as yet to be resolved, as well as in the short-run.

The dynamic capacity of modern technology is currently controlled by a neoliberal ideology, as a form of institutional sclerosis and cultural lag that assumes an alleged self-regulating, free-market process. This constitutes a powerful resistance to changes not amenable to neoliberal ends in the making of money and -the maximization of profits. Veblen’s theory and critique of capitalism resided in the basic dichotomy that juxtaposed the acceleration of industrial technology to that of the lagging pecuniary or business institutions. The Veblenian dichotomy consequently constitutes a theory of cultural lag, and, perhaps, even more so under the influence of Ayres. “Though he drew on Veblen’s work, Ayres’s thought was closer to some of the cultural lag theories then current in the social sciences” (Dugger and Sherman 2000, 175; 1997, 993;’Hodgson 2004, 366-72). Veblen’s cultural lag was used to critique capitalism and was related to the long-run problems of maladjustment inherent in the system. This long-term lag has yet to achieve ameliorative, instrumental institutional adjustment.

The institutional structure of American capitalism grants elites and the owners of capital control over surplus production in its use and distribution. But further and even of greater concern, over time the elites gained control of what we have designated as the “core of culture”; the cultural capital; the store of society’s technological wealth; and or, the industrial arts; to be used as a usufruct to, in turn, control and direct the path of the process of economic production and evolution. This process reinforces the power and wealth of vested interests. The modus operandi directing that path was, and still is, to accumulate money in the maximization of profits rather than to have production and the overall economic process directed toward the servicing of human needs (Veblen 1996, 51). This tenet constitutes the basic conflation between cultural lag theory and Veblenian economics.

As noted previously, while Veblen implied a concept and theory of the cultural-lag phenomenon, Ogburn later explicitly gave it the title of cultural lag. By comparison and as a distinguishing feature, Veblen’s concept of that phenomenon, in its long-run manifestations, was used to critique the system of capitalism. Ogburn used cultural lag, not pointedly as a critique of the overall system of capitalism, per se, but more so as an analytical framework of its disparate parts-such as workmen’s compensation. If one searches the writings of Veblen, his implicit recognition and theory of the phenomenon becomes evident as a theory of cultural lag: “Institutions are products of the past process, are adapted to past circumstances, and are therefore never in full accord with the requirements of the present. In the nature of the case this process of selective adaptation can never catch up with the progressively changing situation …” (Veblen 1970, 140).

This clearly suggests a process of imperfect institutional adjustment and cultural lag, in which institutions forever adjust towards ‘the progressively changing situation'” (Hodgson 2004, 192; 1998b, 189). The cultural lag phenomenon so delineated is also interrelated to Veblen’s dichotomy. The principles (habits of thought) which govern knowledgeand belief, law and morals, have accordingly lagged behind, as contrasted with the forward drive in industry and in the resulting workday conditions of living” (Veblen 1997, 206, italics added).

Culture as Humankind’s Social DNA

“No charge is leveled more consistently at institutionalism . . . than that it has nothing positive to offer – it is mere dissent” (Klein 1993, 13, 13-47; Klein 1994). The Veblenian tradition, however, goes Beyond Dissent and the critiques associated with cultural lags; it also deals with the positive processes of assent and amelioration. Figure 2, “Three Dichotomies Associated with Veblenian Economics,” is in need of explanation and clarification. Though both Ayres and Veblen dealt with cultural lag as dissent, the dichotomy put forth by Ayres does not represent a continuity of Veblen’s dichotomy. The assumption of such continuity would represent a “false conflation of Veblen and Ayres” (Hodgson 2004, 365, 355-378). Ayres maintained throughout his academic career, even extending to perhaps his last published work in 1973, that his dichotomy represented a continuity of Veblen’s: “Veblen made the dichotomy of technology and ceremonialism his master principle” (Tilman 1990, 976).

However, “(cjontrary to Ayres, Veblen never described the institutional process as ‘ceremonialism'” (Hodgson 2004, 366). To note that business institutions and the pecuniary functioned as the ceremonial, the Veblenian dichotomy does not infer that all institutions served ceremonial functions. Neither does Veblen assume a reductionist position inferring that technology is always positive (instrumental) as to function. By comparison, Ayres also sought to equate technology with instrumentalism, and therefore that technology was always positive as to function in the promotion of human progress. Dewey, “in extreme old age,” was evidently not so inclined: “I’ll stick henceforth to technological” (Ayres 1952, 26; Tilman 1990, 978; Brinkman 1997, 1029).

A search of the literature might reveal instances in which Ayres was unclear in equating all institutions with ceremonialism. However, it appears that the overriding position of Ayres equated all institutions with ceremonialism (Ayres 1952, 43). But, if this Ayresian view is correct, why then make institutional adjustments, if institutions only function as the ceremonial? (Atkinson and Reed 1990, 1096, 1098). This interpretation supported by a book, entitled Science and Ceremony and by many others who evidently endorsed the Ayresian dichotomy and concluded that “Veblen judged social institutions to be evil … all social institutions… are predatory . . . are wasteful.. .” (Breit and Culbertson 1976; Davis 1968, 304, italics added).

After all, one of the most dynamic agents ever originated by humankind, was of the nature of a social institution; we speak here of the institution better known as the institution of science. To disengage from the conundrum of dissent and the cultural lag problem (the dichotomies of Ayres and Veblen) Figure 2 presents a third dichotomy to engage the goal of assent: “The Veblen-Dewey-Kuznets Dichotomy.” This constitutes a paradigmatic shift from that of the empirical world, of the “what is” to that of the “what ought.” As stated earlier, the third leg representing the tradition of Veblenian economics relates to value theory. For while Veblen spoke of “idle curiosity,” his curiosity was obviously not always that idle. Veblen was a whistle blower and social reformer – to the core, “(t]he Veblenian dichotomy is the original and primary source of the neoinstitutionalists’ normative analysis; it undergirds their social value theory… an embryonic normative construct” (Tool 1998, 310- 311).

The Veblenian dichotomy can also be interpreted as a “Dichotomy of Useful Knowledge” (Figure 1). “Under such a bifurcate scheme of culture with its concomitant two-cleft systemization of knowledge . . . these two divergent ranges of inquiry are to be found together in all phases of human culture” (Veblen 1961, 45-46, 18, 39-38). In this context the contribution of Kuznets, to the Veblen-Dewey- Kuznets dichotomy, resides in his concept of a scientific epoch in explaining the dynamics of modern economic growth as The Place of Science in Modern Civilization (Kuznets 1966). And further, that a theory of economic growth will be founded in a “theory of the production and accumulation of empirical knowledge” (Kuznets 1968, 62-84). In addition, in his concept of modern economic growth, Kuznets states that science has come to be applied to economic production and social organization (1966, 487). This then assumes that social structures, not only the material, can be advanced via the application of systematic and scientific knowledge as social inventions.

Both Mitchell and Kuznets are positiviste and provided for the advancement of culture to be led by a ship of science without an ethical rudder. To overcome this normative deficiency, Dewey’s contribution to the Veblen-Dewey-Kuznets dichotomy is manifest in offering both a theory of knowledge as well as a theory of value. Consequently, social institutions and organizations are now assumed to be permeable to instrumental knowledge. It is relevant in this context, that “Dewey did not state that all institutions constrain scientific and or technological advance” (Hodgson 2004, 371-2).

Given the Dewey addendum, we now have in place as depicted in Figure 1, a potential unity of knowledge to embrace a synthesis of knowledge of the hard physical sciences, the soft social sciences, and also to include ethics and philosophy. In drawing attention to Dewey, Gruchy stated: “Institutionalists are pragmatists who believe that where cultural or economic evolution goes depends very largely on the exercise of organized intelligence.”13 Such a synthesis, as “organized intelligence,” embedded in the Veblen-Dewey-Kuznets dichotomy, can then be directed to offer a design of culture fed by the dynamics of instrumental knowledge. It is in this context that we speak in terms of culture as humankind’s social DNA. This constitutes an evolution of culture no longer controlled by a spontaneous drift, but rather by design via the application of instrumental knowledge in the ongoing evolution of culture fed by the dynamics of technological advance. At this juncture we introduce the concept of culture serving as humankind’s social DNA servicing the ongoing advance of human evolution and progress.

Such a social DNA might then serve to synchronize the various disparate parts of culture that move at a variety of rates of acceleration. The function of synchronization of the various parts, in the growth and development of biological organisms, is achieved via biological DNA that serves as a code of life, a blueprint for synchronization. By comparison, potentially, it is culture that can serve as humankind’s social DNA and in the process synchronizes the disparate parts of culture.

[CJulture functions as a storage bank of man’s accumulated knowledge and provides the mechanism or vehicle for passing this knowledge on from generation to generation. Culture provides a blueprint or code for human behavior and in this regard serves as man’s social DNA. (Brinkman 1981, 107, 2, 3, 167, 372-4, and 42527, #74; Brinkman and Brinkman 1997, 621; Dugger and Sherman 2000, 54)

While the current structure of culture provides for a social code of human behavior, it is not always instrumental in content. Culture does not yet function to synchronize the dynamics of its disparate parts. Hazel Henderson has also viewed culture as a code of life and as a blueprint in serving humankind’s potential social DNA. “The real resources at hand for our survival require mining our storehouses of cultural DNA codes . . . CULTURAL DNA AND BIODIVERSITY: CODES THE REAL WEALTH OF NATIONS” (Henderson 1996, 168- 93, 23, 71, 111, 205, 313).

Cultural lags not only exist in culture writ large, but also plague the evolution of science itself, especially in the “Queen” of the social sciences better known as economics. The myth that “one size fits all,” and that a self-regulating, freemarket process actually exists, is still maintained by neoliberal economists. This cultural lag, inherent in mainstream neoliberal policy advocacy, has predictably resulted in many problems indicative of maladjustment. Problems such as that of the nuclear neoplasm of proliferation, the current ecological disaster, the growing inequities of current income and wealth distribution, the current wage stagnation, the destruction of pensions, maladjustments in health care and human rights, and so on, are currently not addressed in the neoclassical framework (neoliberalism). The neoclassical paradigm guiding current megacorporate globalization appears to be irrelevant to the current malaise facing the global and interrelated national economies.

But what is in store for the hope of a future vindicating Dewey’s optimism and “organized intelligence” to guide and design our social DNA, versus Veblen’s cynicism and pessimism? Maybe Veblen’s pessimism was nurtured in his downtrodden situation especially in comparison to Dewey’s status and academic ranking.14 In any event, in what was apparently Veblen’s last article, “Economics in the Calculable Future” published in the American Economic Review (1925) Veblen’s established clairvoyance apparently holds true. “Veblen indicated his belief that economists in the foreseeable future would continue to be apologists for the price system with all that implies in the Veblen lexicon of satire” (Tilman 1990, 969). What Wesley C. Mitchell aptly wrote rings true: “That economists still cling to their traditional analysis is to Veblen merely the latest illustration of the cultural lag theory – a lag readily accounted for by the institutional approach” (Mitchell 1964, xlviii; Kuznets 1968, 80-81).

Notes

1. In a more recent publication, Tilman noted that “Dewey,like Veblen and Mills, subscribed to a similar view of cultural lag and social inertia” (2004, 265), and “Dewey’s social theory . . . was rooted in cultural lag” (196), and “Dewey as a social theorist, often relied on both the theory and phenomenon of cultural lag” (199). In many other instances, Tilman’s 2004 publication draws attention to cultural lag, in relation to Veblenian economics (see for example, 261-63).

2. Ogburn 11922) 1966, 200, a simple diagram is helpful in understanding Ogburn’s cultural lag analysis. For further explanation note: Ogburn 11922] 1966, 206; Brinkman and Brinkman 1997, 615; 2005, 231; and Glade 1952, 428.

3. For a brief compilation of some of this open-ended literature note: Brinkman 2004, 812-13; and 2005.

4. Gruchy’s definition: “A short definition of economics from the institutionalist point of view is that it is the science of social provisioning . . . best viewed as a science of social provisioning” (1987, 22-37), and “[i)t can be said that in their definitions of economics, the institutionalises seek to culturalize the science of economics.” (1987, 37).

5. Harry Trebing in assessing Gruchy’s contribution, offered three basic tenets of Veblenian economics: (1) economics as a cultural science; (2) to include an evolutionary and holistic context; and (3) the social goal of economic planning. Our third leg substitutes the overall rubric of value theory for economic planning, in that instrumental value theory serves to originate specific economic policies, such as that conceivably are contained in the domain of economic planning (Trebing 1991, 409).

6. While noted by many Veblenian economists, the holistic approach was given more pointed attention by Gruchy (1947; 1972; 1987); and Adams (1980).

7. “Structural change was central to our definition of the evolutionary process” (Dugger and Sherman 2000,121,7).

8. On the canoe building (Ayres 1978, 108-9), and on Malinowski, cf., Hamilton 1986, 528.

9. Bert Hoselitz (ed.) drew attention to three problems: (1) the need to delineate the stages of a given economy; (2) description, taxonomy and ideal types; and, (3) the identification of the factors that make for change (1960, 194).

10. “Energy is the capacity to do work” (Marion 1974). “The fact that energy is not a thing in the normal sense of the word does not mean that it does not exist” (Theobald 1966, 177; Brinkman 1981, 12654), neither is the process of economic development a thing, nor is culture as “that complex whole” a thing subject to direct measure as a store of knowledge.

11. For more details related to the “Wheel of Economic Development,” which incorporates MyrdaPs circular and cumulative causation, cf., Brinkman 1981, 198-236.

12. The origins of this principle go back to Galileo, and appear more recently in the contributions of D’Arcy Thompson (1961). The basic literature including the contributions of Talcott Parsons and the process of “structural differentiation” is covered by Daniel Bell (1973, 171-74).

13. (Gruchy 1987, 8, italics added). Gruchy also noted the connection of “organized intelligence” to Dewey (11) and the theory of knowledge vis–vis the future path and dynamics of culture evolution. This is similar to John Kenneth Galbraith’s “collective intelligence” that is applied to the micro-level embodied in the corporate technostructure (1973, 81-91).

14. “Veblen’s last years were spent in modest material circumstances and scholarly neglect, while Dewey lived comfortably and enjoyed every honor that could be bestowed on America’s most influential philosopher” (Tilman 1990, 969); by comparison to Veblen who “lived with his stepdaughter until his death in 1929 amidst furniture that he made with his own hands, wearing rough clothes purchased through mail order houses . . . watching the movements of events with a dull ache of bitterness and resignation” as stated by Max Lerner in Horowitz (2002, 71).

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Sahlins, Marshall D., and Elman R. Service. “Evolution: Specific and General.” 12-44. In Evolution and Culture. Ann Arbor: University of Michigan Press, 1960.

Samuels, Warren J. ed. The Founding of Institutional Economics: The Leisure Class and Sovereignty. London: Routledge, 1998.

Theobald, D. W. The Concept of Energy. London: E &. F.N. Spon, 1966.

Thompson, D’Arcy. On Growth and Form. Cambridge: Cambridge University Press, 1961.

Tillman, Rick..”Insti\tutionalism in the Folklore of Capitalism: A Critique of Thurman W. Arnold.” Journal of Economic Issues 2, no 4 (December 1968): 423-434.

_____. “New Light on John Dewey, Clarence Ayres and the Development of Evolutionary Economics.” Journal of Economic Issues 24 (December, 1990): 963-979.

_____. Thorstein Veblen and His Critics,*189I-1963. Princeton, N.J.: Princeton University Press, 1992.

_____. Thorstein Veblen, John Dewey, C. Wright Mills and the Generic Ends of Life. Lanham, MD: Rowman Littlefield, 2004.

Tool, Marc R., ed.,.”A Neoinstitutional Theory of Social Change in Veblen’s TheTheory of the Leisure Class.” In The Founding of Institutional Economics: The Leisure Class and Sovereignty, edited by Warren J. Samuels, 302-319. London: Routledge, 1998.

_____, ed. Institutional Economics: Theory, Method, and Policy. Boston: Kluwer, 1993.

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Richard Brinkman is a Professor Emeritus in the Department of Economics, and lune Brinlcman is retired Adjunct Faculty at Portland State University. This paper was presented at the AFiT Conference, April 13-16, 2005, in Albuquerque, New Mexico. We thank the anonymous referees for their erudite and helpful suggestions.

Copyright Association for Evolutionary Economics Dec 2006

(c) 2006 Journal of Economic Issues. Provided by ProQuest Information and Learning. All rights Reserved.

Roots and Routes in a Selection of Stories By Alistair MacLeod

By Omhovre, Claire

The fact is that the beginning always begins in-between, intermezzo.

GILLES DELEUZE AND FLIX GUATTARI, A THOUSAND PLATEAUS.

Central to Alistair MacLeod’s Island is the return to the original island or Highlands, phonetic closeness somehow reducing the geographical distance between the two referents. The motif is particularly prominent in four of the collection’s sixteen short stories: “The Return” (1971), “The Closing Down of Summer” (1976), “As Birds Bring Forth the Sun” (1985), and “Clearances” (1999)-a corpus that roughly spans Alistair MacLeod’s writing life.1 Starting from W. H. New’s inspiring remark that “the English-language vocabulary for characterizing landscape (and people’s relationship with land) interconnects with the vocabulary for characterizing language and the use and function of language” (New 1998 164), I propose to analyse the functioning of pairs that combine spatial and linguistic displacement-returning and iteration, but also crossing and analogy. I will then be using a tropical approach to shed some light on the creative tension between roots and routes which lies at the core of Macleod’s fiction. His stories are indeed equally concerned with the centripetal forces of the ethnic culture in which they are embedded and with the centrifugal expansion of writing that announces its scope and concerns as universal, as if immune-or perhaps indifferent-to five decades of post-humanist critique and deconstructive doubt.2

Because MacLeod’s stories foreground the singularity of their Gaelic protagonists and their habitat, analysing the tropes through which the regional is made coterminous with the universal is then likely to throw light on the tacit acceptance evidenced in their reception. In his review of Irene Guilford’s Alistair MacLeod, the only volume of critical essays so far devoted to MacLeod’s writing, Lawrence Mathews pointedly wonders why “no one ever says anything about MacLeod’s work that could be construed as even mildly negative. . . . Despite the slightness of his output . . . and despite the reluctance of academic critics to examine it closely, he has been allotted a secure niche in the Canadian pantheon” (Matthews 119). My hypothesis is that, in MacLeod’s short fiction, the operations of iteration and analogy allow local place to resonate with a national sense of space beyond the immediate insularity, or regional specificity, of their plots and setting. The consonance of MacLeod’s stories with a general, indeed national, response to the particulars of place suggests that their alleged universal value may rest upon the consensual validation of their contribution to the “imagined geographies”3 (Fiamengo 241) in which the nation, fragmented and diverse as it is, grounds its own existence.4

What happened?

What distinguishes the short story as a genre from the tale and the novel, Deleuze and Guattari explain, is the secret that informs its narrative development and orients it towards the past. In a short story, they add, one does not expect anything to happen for everything has already happened:

It is not very difficult to determine the essence of the [short story] as a literary genre: Everything is organized around the question, “What happened? Whatever could have happened?” The tale is the opposite of the [short story], because it is an altogether different question that the reader asks with bated breath: “What is going to happen?” . . . Something always happens in the novel also, but the novel integrates elements of the [short story] and the tale into the variation of its perpetual living present. (Deleuze and Guattari 192)5

Hence, the implacability driving Alice Munro’s “The Time of Death,” or Mavis Gallant’s “Voices Lost in Snow.” As their narratives resist the accomplishment of what has just occurred, they delineate a tear in the fabric of events even as they attempt to mend it. MacLeod’s stories are no exception to Deleuze and Guattari’s principle-nothing takes place in them that did not take place long ago and, one may add, far away. The characters’ individual present is enfolded in the clan’s collective past-the Highland Clearances which, at the end of the eighteenth century, forced them away from their home to Nova Scotia. Six generations later the ancestral culture that was transplanted into the New World is withering under the joint pressures of poverty and progress. The secret MacLeod’s characters share, but will not admit, is constrained within a double bind, staying in Cape Breton being just as impossible as leaving it. The narrative then obsessively recounts the moment of returning, when the home place provisionally coincides with the characters’ longing to dwell there again.

Such is the case in “The Return,” an initiation story built on concentric excursions from and back to home’s still centre: the return of the prodigal son and his family to North Sydney, Alex’s return to his grandparents’ house, the men’s return from the pit, and finally the family’s return trip to Montreal. About to depart for another mining season overseas, the men in “The Closing Down of Summer” are already anticipating their return to Cape Breton and the eventuality that it may be their final journey home to one of the small island cemeteries. In “As Birds Bring Forth the Sun,” a tremendous big grey dog, saved as a pup by the clan’s ancestor, disappears and returns to cause its master’s accidental death. Later on, it will reappear as the big grey dog of death that all the man’s descendants glimpse at the moment of their demise. Likewise, the blanket mentioned five times in the opening of “Clearances” is a synecdoche of a narrative weaving together the past and present of the central character, an ageing widower whose property is coveted by a clear-cutter and a German couple smitten with the ocean frontage. The clashing interests of the tourist industry and those of a local population barely surviving on the island’s depleted resources are set in parallel with the territorial struggles of World War II and the silent eviction of thousands in the eighteenth century, suggesting the constancy of the economic pressures which have beset the Gaelic community and condemned them to poverty and exile.

In all four stories, the narrative is syncopated. It points insistently beyond its own narrow scope, so that even as it explores the present, one feels the story cannot be comprehended outside its relation to the formal dimension of the past (Deleuze and Guattari 237). What happened then may account for a sense of belonging Alex “knows and feels but cannot understand” (R 91; see also 82, 83, 90), an intimation which impresses itself even more brutally upon the characters of “As Birds Bring Forth the Sun.” Both “The Closing Down of Summer” and “Clearances” take this investigation further as their narratives are concerned with liminality, specifically with the interstitial differences and similarities through which the characters define themselves in relation to distant origins but also in respect to other close-knit communities-Highland Scots (CS 185, C 418), French and Irish mining crews (CS 202), the Acadians and neighbouring Mi’kmaq (C 148). In musical terms, a syncopation occurs when the strong note is not on the beat.6 These stories similarly feature a contrast between iteration-the recurrent motifs that encode territory and sustain a sense of belonging-and analogy, a syncopation which cuts short the refrain of home and distends its limits to accommodate intersubjective distance.

The refrain of home

In “De la ritournelle,”7 Deleuze and Guattari observe the territorializing function of repetitive sound patterns, whose effectiveness rests upon the pervasiveness of the sound which irresistibly includes the subject within its reception. In this respect, hearing is to be opposed to sight, a selective sense that requires a separation between perceiving subject and perceived object.8 Both perceptual modes contribute to the tracing and shaping of territory. Visually, or from a discriminating perspective, a territory can be defined as the critical distance between two individuals of the same species (Deleuze and Guattari 319). Aurally, the approach being now inclusive, an interval is induced by expressive sound patterns that mark off space as territorial insofar as they supersede and exclude any other expressive matter: “We call a refrain any aggregate of matters of expression that draws a territory and develops into territorial motifs and landscapes. . . . In the narrow sense, we speak of a refrain when an assemblage is sonorous or ‘dominated’ by sound” (Deleuze and Guattari 323).9 The meaning of territoire, in Deleuze and Guattari’s analysis then diverges slightly from the legal implications of the word territory,10 the French concept containing notions of appropriation and identification associated in English with local, heterogeneous place as opposed to global, homogenous space.11

In their relation to place, Gaelic and, to an even greater degree, song are evident territorial markers. In “Clearances,” they create the distance that ostracizes strangers and trespassers (C 428). And, when during World War II the central character visits the ancestral Highlands, the rustle of Gaelic, its “soft sounds” and “subliminal whispers,” signals his entry into a territory where markers are aural and hapticrather than optic and distant (C 418- 419). Back in Cape Breton, the young man has pups sent in from the Highlands to breed them following the instructions of a Scottish shepherd (C 421). The line of Border collies that later accompanies him into old age also embodies the territorializing function of sound. The man addresses his otherwise nameless dogs with the phrase the shepherd initially uttered to identify the animal and its territorial vigil: “S’e thu fhein a tha tapaidh (It’s yourself that’s smart)” (C 423). From the point of view of reception, the Gaelic fragment also has a definite territorializing value. The reader’s ability to voice the inscription indexes belonging to the island/Highland sound continuum whereas those who need the translation are merely permitted provisional access to it, a limitation materialized visually in the writer’s use of brackets.

The recurrence of a Celtic phrase is more ambivalent in “As Birds Bring Forth the Sun.” The silhouette of the big grey dog also serves as a transition between the clan’s mythic past and the narrator’s present but, instead of suggesting their seamless continuation, the recurring name of the “c mr glas” impresses a punctuation denying the character escape or progress (B 312). The Gaelic refrain suggests that change, whether spatial or temporal, can be checked through the repetition of a set formula, not a language for communication, but signifiers whose musicality moves speaker and listener alike, hemming them in the voicing of territory.12 Gaelic is then only marginally concerned with exchanging information. Instilled in infancy, it partakes of the sacred and its rituals. It is the language used in prayers, to love or to mourn, in lament and in exultation. As one of the characters puts it, Gaelic is the “reflexive” tongue that conveys and causes affects (C 418). As they come in sight of Cape Breton, his father’s tears remind Alex of earlier ceremonies when listening to Celtic music had the double function of commemorating home and inculcating its significance in a child who had never been there:

My mother does not like [my father’s violin records] and says they all sound the same so he only plays them when she is out and we are alone. Then it is a time like church, very solemn and serious and sad and I am not supposed to talk but I do not know what else I am supposed to do; especially when my father cries. (R 80-81)

Focalization upon a ten-year-old’s limited understanding leaves some space for the quiet humour of a mature narrator who recalls the sentimental ritual with mingled feelings; it is hard to tell whether it is genuine concern for his father’s grief, or plain boredom that predominates in the recollection. Equally ambivalent are the revelations as to filiation, masculinity, and their connection to home, that await Alex in Cape Breton. At the ferry landing, their small party is greeted by a drunkard’s obscene song, causing the outrage of Alex’s mother. As a genteel Montrealer, she finds the local filth-at once a class, a gender, and a regional marker-quite insufferable (R 82). A whole story, and a two weeks’ lapse, will be necessary for Alex to begin to fathom what he senses but cannot understand about Cape Breton and its sway upon his family.

In both “The Closing Down of Summer” and “The Return,” the traditional family plot refers both to the grave that awaits the characters in the local cemetery and to the course and purpose of their lives. One of its avatars is “the hereditary salmon net,” another beautiful and cumbersome inheritance in “Clearances.” The characters’ names repeat those of the previous generation and it is expected of their descendants that they will replace those whose untimely death has left a vacancy down the pit, or on the fishing boats. In “The Return,” the narrator’s uncle died “buried under tons of rock two miles beneath the sea.” (R 87). As it combines drowning with the shaft accident, the event epitomizes the suffocation that awaits the men, a prospect only liquor may blunt, male alcoholism turning into another, more insidious but just as fatal, form of drowning (R 87, B 317, CDS 207). Belonging in Cape Breton is rife with contradictions, the home place being at once life-preserving and suffocating as revealed in the climax of “The Return.” Fresh from the ferry, Alex approaches the new environment with the references of any ten-year-old raised on a staple of boy’s magazines and US frontier adventures.13 But it is contact with male dirt and toil that signals his entrance into masculinity and his Gaelic lineage:

[My grandfather] places his two big hands on either side of my head and turns it back and forth very powerfully upon my shoulders. I can feel the pressure of his calloused fingers squeezing hard against my cheeks and pressing my ears into my head and I can feel the fine, fine, coal dust which I know is covering my face and I can taste it from his thumbs which are close against my lips. It is not gritty as I had expected but is more like smoke and sand and almost like my mother’s powder. And now he presses my face into his waist and holds me there for a long, long time with my nose bent over against the blackened buckle of his belt. Unable to see or hear or feel or taste or smell anything that is not black; holding me engulfed and drowning in blackness until I am unable to breathe. (R 93-94)

The grandfather’s gesture evokes the baptism rituals which, to Anne McClintock, are so crucial to male land claiming (McClintock 29). Alex experiences an earthy drowning and rebirth through the matrix of two rough hands that impress their own mark and the physicality of place upon him. The sensation, “almost like my mother’s powder,” is associated with a gentle but definitely smothering affection. And as the fine dust saturates the boy’s five senses it causes a rapture that borders on malaise, an excess perceptible in the insistent use of redundancies-“pressure,””pressing,””presses”-and a string of isocolons culminating in an alliterative outburst of sibilants and plosives. Because it implies that the embrace of kin and place is so overwhelming it is potentially lethal, the scene calls to mind the tragic reunion of the c mr glas with the founder of the line in “As Birds Bring Forth the Sun.”

As the dog’s offspring have never had any contact with people, they misunderstand their mother’s boisterous joy for an attack on the man’s supine body; the wild pack then pounces on him and tears him apart under the eyes of his helpless sons. Although the plot partly recalls the cautionary tales in which a foundling brings disaster into the community that gave him shelter, its concern goes beyond the spatial distinctions ancient myth sought to establish between outside and inside, hastes and hospites (Serres 1983 145- 152). Rather, it addresses the endurance of an archaic articulation between man and the environment framed by the tide and its echo in the denouement, “we are aware that some beliefs are what others would dismiss as ‘garbage.’ We are aware that there are men who believe the earth is flat and that the birds bring forth the sun.” (B 320) The hounds are emanations from the rock and the sea; their conception on the strand results from the pull cosmic energy exerts on the alternation of tides and seasons as well as on the breeding frenzy of animals (B 312). Of the elements that concurred in their birth, the dog’s offspring has retained the colour, the ruggedness and, above all, a formidable force that is both life-giving and devastating. “The ambiguous force of the c mr glas” (B 317) has the characteristic duality of the ecosymbols through which human beings have vested meaning in their surroundings, laying the foundations of the “proto-landscape” (Berque 39-40 and 59-60) that predated the advent of a Western aestheticizing gaze, and the subsequent perception and representation of landscape as distinct because distant from the spectator who assesses his dominion over the view he beholds.14

Neither in “The Return” nor in “As Birds Bring Forth the Sun” is the environment quite objectified into a landscape: there is not enough distance, or distancing, between the characters and the place they inhabit.15 In Alex’s eyes, his grandparents are metonymically related to their surroundings, “My grandmother is very tall with hair almost as white as the afternoon’s gulls and eyes like the sea. . . . My grandfather . . . has a white moustache which reminds me of the walrus picture at school” (R 84). The mine is insistently described as having the characteristics of a living organism-“the black gashes of coal mines . . . look like scabs,” (R 82) “green hills with gashes of their coal embedded deeply in their sides” (R 97). In “As Birds Bring Forth the Sun,” the big grey dog is silhouetted against a land endowed with human attributes as in the dead metaphor “the brow of the hill,” used three times when the old man is crushed by his own creation (B 313-314). Generations later, as the narrator’s father lies in hospital awaiting his vision of the big grey dog of death, his six grey-haired sons sitting around the bed eerily recall the six grey hounds who encircled their ancestor and devoured him, his mangled body materializing the foundation of a line in which genealogy, language, and territory are inextricably interwoven.16

“As Birds Bring Forth the Sun” illustrates in an exemplary fashion the iterative patterns that characterize MacLeod’s stories. Through them, the refrain of home is made consonant with the territory the characters inhabit. It also leads to a temporal inscription which shuns the linearity of chronological progress for the cosmic cycles that regulate life in its manifold forms, an aspect brilliantly analyzed by Simone Vauthier in the essay she devoted to MacLeod’s unconventional use of the present tense.17 At times, the refrain of home may have the weight of a burden. The emplotmen\t of the character’s future limits its accomplishment to the prolongation of a line in which genealogical, linguistic, and territorial strands combine and bind the characters to the island conceived as a verbal extension of the original Highlands.

Conserving / conversing

The continuity of the cultural practices that produce territory, for instance the fashioning of vegetal badges or the ritual sharing of drink and song in “The Closing Down of Summer,” is also manifest in the characters’ concern for their animals. Dogs, in particular, are tokens of permanence. Being descended from the animal companions of the first exiles, or later imported from the Highlands, they are quite literally “from another time” (B 310). Only careful breeding has ensured the preservation of their original traits requiring that they be kept “in pens during the breeding season so that they might maintain their specialness” (C 421). Here man’s control of animal instincts signals a clear line between nurture and nature. No dubious cult of roots can be found in MacLeod’s stories, their narrators being rather wary of the confinement ethnicity may involve.18 In “The Closing Down of Summer,” McKinnon’s miners are distinguished from rival crews who will not leave their province because “they are imprisoned in the depths of their language” (CDS 203). Equating territorial entrapment with unilingualism,19 the metaphor derives its ominous overtones from all the cave-ins recounted in “The Closing Down of Summer.””Clearances” similarly features a dilemma between conservation and conversation. For minorities, the preservation of their language is indeed an asset for ethnic cohesion but it is also a liability that may contribute to their exclusion from wider cultural and economic exchanges:

But in the years between the two world wars they realized when selling their cattle or lambs or their catches of fish, that they were disadvantaged by language. He remembered his grandfather growing red in the face beneath his white whiskers as he attempted to deal with the English-speaking buyers. Sending Gaelic words out and receiving English words back; most of the words falling somewhere into the valley of incomprehension that yawned between them. Across the river the French-speaking Acadians seemed the same as did the Mi’kmaq to the east. All of them trapped in the beautiful prisons of the languages they loved. “We will have to do better than this,” said his grandfather testily. “We will have to learn English. We will have to go forward.” (C 418, my emphasis)

Once again land and language are brought together in a metaphor capturing the isolation caused by ethnic entrenchment. Here the “valley of incomprehension” which renders exchanges impossible finds its counterpart in the “chasm” cutting across generations in “The Return” (R 91). Because it is out of place in the maritime setting, the image jars and draws attention to a decision that links communication with spatial progress. Going forward is indeed emblematic of the dynamics that impel MacLeod’s characters and the awareness that cultivating one’s distinctiveness within the nation is incompatible with a stubborn clinging to the past.20

This paradox is confirmed on two occasions when the return to the Scottish Highlands leads to an encounter with desolation and death immediately followed by the reassertion of Cape Breton’s hold upon the character. In “As Birds Bring Forth the Sun,” one of the grown- up sons is battered to death outside a Glasgow pub by seven large, grey-haired men in a scene that reiterates his father’s fall under the claws and fangs of the island’s big grey dogs. In “Clearances,” the soldier’s excursion to his ancestors’ villages holds no revelation for him either, except perhaps an intimation of his own mortality, some of the gravestones bearing his very name (C 420). The narrator’s resentment surfaces in a description which refers to the discontents of the past only to foreground the constancy of the power politics that, having caused his community’s eviction, brought him back to Europe five generations later, to defend interests in which he still has no part. History is presented as a crushing inevitability, the character’s present a puny re-enactment of past oppressions. The passage of time is then irrelevant or, at least, secondary to the territorial clashes that go on pitting individuals and communities against one another. The Highland shepherd implies just as much when he exclaims, “‘You are from Canada? You are from the Clearances?’ . . . as if it were a place instead of a matter of historical eviction” (C 419). MacLeod then drives the point home when he has his ageing character defend his ocean frontage property against European interests whose financial pressure is presented as far more irresistible than the military expansion he fought as a young man in World War II trenches.

It would therefore be inaccurate to mistake the narrators’ concern with the fractures of long ago for nostalgia. The commemorated past is quite uninhabitable and offers little, if any, refuge against the economic uncertainties of the present. In “The Closing Down of Summer,” descriptions of the drought and industrial decay combine into pervasive evocations of ruin. The representation of the island then splits into two irreconcilable extremes: the parched wasteland of the summer coast or the inland cemeteries of the torrential fall. And the slender beach where the characters are waiting for a change in the weather provides the geographical analogy of all the transitions their community is engaged in. In “Clearances,” the diaphoric use of “clear” allows the narrator to collapse three distinct periods into one territorial struggle fusing the evictions, land clearing in Cape Breton and, finally, the pressure exerted on small land owners by the clear-cutting industry on the coast and the extension of the National Park to the north (C 426). The demonstration reaches its conclusion in a self-conscious doubling of the young soldier’s discovery of the Highlands and their “unpopulated emptiness” when the soldier, now an elderly man, registers a similar desertion in Cape Breton (C 420 and 429).

The consequences of territorial strife-eviction, itinerant labour, and, ultimately, immigration-lead to spatial displacements that assert the link between the story’s agent and its action, indexing the structuring role of the search for employment and its consequence, the journey, identified by Chklovski first in the tale, then in the episodic structure of early novels (Chklovski 194). And yet, for all their departures and returns, MacLeod’s stories do not feature the circularity of the completed quest. Neither do they have the verticality of a picaresque itinerary, the ups and downs of the hero’s fortune delaying narrative progress, exacerbating the reader’s involvement, but never representing any serious threat to the ultimate social ascent of the hero. But MacLeod’s narratives are not impelled by the necessity of an accomplishment. Their trajectory is characterized by its periodicity, their plot occupying the interval between a departure and a home-coming, the intermittence of resources and seasonal labour sending the characters from Cape Breton across the country into the wider world and back. Looking back but moving on, these stories therefore conjoin roots and routes in a lateral dynamics of successive crossings.

Crossings

In MacLeod’s stories, Cape Breton is never pictured as a self- contained, sufficient, and secluded haven. Cut off from the mainland but open and exposed to Atlantic influxes, the island is first and foremost a site of exchanges. In all four stories, insularity transforms any displacement into a crossing of some significance, “a journey on the road to understanding” (CDS 197). In “Clearances,” the middle-aged couple’s trip to Prince Edward Island turns into a profane pilgrimage to the manufacturer where they have been sending their wool production since the early years of their marriage: “Later his wife was to tell her friends, ‘We visited Condon’s Woollen Mill on Prince Edward Island,’ as if they had visited a religious shrine or a monument of historical significance and, he thought, she was probably right” (C 414). The exclamation receives unexpected rhetorical relief, its iambic lilt getting amplified in the sway of the two equal-length segments that frame the preposition on. The wife’s fervour suggests two analogies to the narrator”religious shrine” and “monument of historical significance”- which shun the spectacular or the picturesque to elevate the prosaic and the germane into a local pride.” In MacLeod’s stories, analogy has an informing function that goes well beyond that of decorative artifice. Because it captures an identity which is not essential but relational, the trope establishes a partial equivalence between the local, insular event and a global, plural field of reference.

In its strict Aristotelian sense, analogy fuses comparison and reason, as it formulates a ratio between four items and two sets of relations (a/b = c/d) (Borella 24). The relation therefore allows the conjunction of the similar with the different but also the passage from one plane to another superior sphere, as implied by the idea of elevation contained in the Greek prefix ana.22 Mediaeval theologians then developed complex analogies to approach the ineffability of the divine through a subtle, rigorous gradation of the manifestations of the One in the many. In the secular world of MacLeod’s stories, analogy with its related forms, the simile and the comparison, are repeatedly used to inscribe the singular, insular experience within a wider referential frame. The c mr glas, to cite but one example, is thus related to a Scottish and a West Coast manifestation of the genus loci: “For a while she became rather like the Loch Ness monster or the Sasquatch on a smaller scale. Seen butnot recorded. Seen when there were no cameras. Seen but never taken” (B 316). Bridging the geographical and cultural extremity of its components, the analogy isolates in both an identical response of the human mind to a space alive with intensities that have not been objectified into a stable, external spectacle.

In “The Closing Down of Summer,” several references to the Zulus similarly extend the story’s referential and figurative scope beyond the immediate concerns of the crew and the future of their communal lifestyle. Their impressive physicality and the mastery of skills that shake the earth are not the only traits the Zulus share with the miners. Both communities belong to oral cultures in which group cohesion is achieved through ritual. And both have adapted to a fast- changing, increasingly global world where exotic forms of authenticity are all the more valued as they are becoming extinct. In this respect, the Celtic Revival concert and the Zulu dance performance are analogous in their reception by audiences who, well- intentioned though they may be, are unable to comprehend their profound signification. Communication subsequently aborts and each group remains confined within its linguistic and cultural limits, a seclusion to which the narrator reacts with unease, as evidenced in his choice of the word “archaic,” used recurrently in reference to Gaelic and its speakers.

Beyond an outward likeness, analogy then isolates an intractable core of difference into which the narrator yearns to delve. Intellectual apprehension and physical displacement are expressed in identical dynamic terms, the narrator’s failure “to understand [the Zulus] more deeply” being equated with the impossibility “to enter deeply into their experience” or “to penetrate behind the private mysteries of their eyes.” Tracing the occurrences of the adjective “private” in this short story will highlight the pull within a trope which, even as it brings the disparate together, will not assimilate the similar with the same: “Yet in the end it seemed we too were only singing to ourselves. . . . songs that are for the most part local and private and capable of losing almost all of their substance in translation” (CDS 196). Ultimately, the analogy between the two communities conveys to the outsider the incommunicability of local experience. And yet the trope circumvents the aporia of the untranslatable, the identity it posits being necessarily relative, circumstantial, possibly debatable:

He looked at the land once cleared by his great-great- grandfather and at the field once cleared by himself. The spruce trees had been there and had been cleared and now they were back again. They went and came something like the tide he thought, although he knew his analogy was incorrect. He looked toward the sea; somewhere out there, miles beyond his vision, he imagined the point of Ardnamurchan and the land which lay beyond. He was at the edge of one continent, he thought, facing the invisible edge of another. (C 430)

The unexpected syntactic reversal in “they went and came something like the tide” jars and throws into relief the flawed logic that would derive identity from a mere recurrence. The analogy between spruce and tide is rejected as spurious because it confuses man’s intervention in the vegetal cycle with the cycle itself. In doing so, the analogy naturalizes the clash between competing economic interests, and disqualifies the character’s rebellion. The evocation of the Scottish coast has no elegiac, reconciling virtue. Rather it confirms the narrator’s awareness of the profound, essential difference that lies between the bare Highlands and the land of trees, his commitments to the past and the challenges of the present.

Often undermined by the disparity it seeks to limit, its validity threatened by an intrinsic inaccuracy, analogy is regarded with suspicion by the mathematician and the philosopher alike. For the writer, however, analogical approximation may come close to an approach, the trope triggering the associations and correspondences that open onto the multiplicity and complexity of shared experience. In the case of MacLeod’s bilingual characters, Gaelic and English are frequently paired in translation, one language cleaving into the other’s necessary yet inadequate shadow, “‘M’eudal c mr glas,’ shouted the man in his happiness-m’eudal meaning something like dear or darling” (B 314). Because it engages with an intractable nucleus in signification,23 translation may be regarded as the overarching analogy out of which all the narratorial attempts to convey the bond between the characters and the land proceed. “The Closing Down of Summer,” for instance, repeatedly laments the miners’ failure “to tell it like it is” (CDS 206). The grammatical impropriety of the conjunctional use well captures the narrator’s effort to stretch his argument beyond the literal in order to communicate the elation of the crew’s physical engagement with the elemental world:

I suppose I was drawn too by the apparent glamour of the men who followed the shafts. . . . We are always moving downward or inward or forward or, in the driving of our raises, even upward. We are big men engaged in perhaps the most violent of occupations and we have chosen as our adversary walls and faces of massive stone. It is as if the stone of the spherical earth has challenged us to move its weight and find its treasure and we have accepted the challenge and responded with drill and steel and powder and strength and all our ingenuity. In the chill and damp we have given ourselves to the breaking down of walls and barriers. We have sentenced ourselves to enclosures so that we might taste the giddy joy of breaking through. Always hopeful of breaking through though we never will break free. (CDS 201)

The Conradian overtones of the opening signal the amplification of the miners’ labour into an age-old confrontation between man and the elements. The central comparison-“It is as if the stone of the spherical earth has challenged us to move its weight and find its treasure”-initiates a prosopopeia through which Cape Breton’s mining tradition is elevated into a geste of man’s struggle against a stinting nature, a motif which is not without resonance in the national imagination. The final chiasmus (“breaking down . . . breaking through . . . breaking through . . . break free”), plural abstractions and the syllabic expansion in the series “walls,””barriers,””enclosures,” lead the reader to consider in this miniature mining epic the ambivalence in any confinement, at once an obstacle and an enticement to movement. The contradiction, interestingly, is also present in the formal compression that characterizes the genre, an enabling constraint in terms of narrative efficiency and reader participation.

In MacLeod’s stories, intensity similarly results from the contradictory pull between iteration and analogy, the territorializing impulse of conservation and the deterritorializing force that operates in conversation but also in literature, each participant turned towards the other, text and reader tuned to the other’s reception.24 Such is the assurance I read in Terry Eagleton’s words: “It is not just experience, but language, that takes a writer away from home because there is something curiously rootless about writing itself which is writing only to the degree to which it can survive transplantation from one context to another” (qtd. in Simpson-Housley 123). And MacLeod’s stories have survived transplantation. Territorializing refrains do bind their characters to Cape Breton. Grounded in the island/Highland sound continuum, their iterations of home register the passage of time as a mere intermittence, the pause before a repetition-the oscillation of the tide, the flashes of the lighthouse, the occupation of the land, the rise and fall of cultures-all of them ritomellos. And yet, in these stories permanence is checked by their narrative’s restlessness, an impatience with geographical and temporal constraints, that seeks an outlet in analogical forays into the distance, and the possibilities that lie somewhere, out there. These short stories therefore rely upon a sense of liminality, an in-betweenness to which a Canadian audience is likely to respond because it is emblematic of a shared relation to both region and nation as borderlands, zones of contact but also of interaction (Brown; New 1998), between different communities with competing and yet complementary claims to the land.

NOTES

1 Subsequent page references will appear directly in the text after the following abbreviations: (R) for “The Return,” (CS) for “The Closing Down of Summer,” (B) for “As Birds Bring Forth the Sun,” and (C) for “Clearances.”

2 In her review of No Great Mischief, Dianne MacPhee typically winds up citing MacLeod’s claim that “what makes things universal is that they touch a core, a storehouse of human experience and concerns that transcend regions and transcend time” (qtd. in MacPhee 167). Jane Urquhart concurs when she writes that “MacLeod’s stories have been called albeit with great admiration – traditional, even conservative, by a literary world cluttered with theories and “isms’ (Guilford 37).

3 Janice Fiamengo uses this heading to introduce her chapter on “Regionalism and urbanism” in the 2004 Cambridge Companion to Canadian Literature. The phrase, of course, obliquely refers to the communities of the imagination which, as Benedict Andersen has famously argued, underlie the formation of nations. At a second remove, it also allows Fiamengo to emphasize the vitality of regional writing in Canada and its lasting role in the definition of a Canadian canon and tradition.

4 An anonymous reader has pointed out to me that my field of investigation frequently overlaps with that of David Williams in his Imagined Nations (2003). Contrary to Williams, I did not feel the need to elaborate onthe different positions of the speech community and the writer writing, or MacLeod’s subtle adaptation of a community’s oral fund to the requirements of a written communication, as these various points have been argued in great detail by Williams himself. My own interest rather lies in Macleod’s elaborate written style and the rhetorical strategies his stories develop to bring the local to converse with the distant. My initial intention was to understand why and how MacLeod could be widely read and appreciated by people who do not necessarily feel bound by clan cohesion, a solidarity with, or even a nostalgia for, Cape Breton’s Gaelic past.

5 I have amended Brian Massumi’s translation and restored the word “short story” where he opted for the word “novella,” presumably to foreground the idea of a recent development in the course of events, the latter being implicit in French as nouvelle may refer either to a short story or to a piece of news. The original reads as follows: “L’essence de la ‘nouvelle’, comme genre littraire, n’est pas trs difficile dterminer: il y a nouvelle lorsque tout est organis autour de la question ‘Qu’est-ce qui s’est pass? Qu’est-ce qui a bien pu se passer?’ Le conte est le contraire de la nouvelle, parce qu’il tient le lecteur haletant sous une tout autre question: qu’est-ce qui va se passer? . . . Quant au roman, lui, il s’y passe toujours quelque chose bien que le roman intgre dans la variation de son perptuel prsent vivant (dure) des lments de nouvelle et de conte.” (Deleuze et Guattari 235)

6 The OED defines the word as “the action of beginning a note on a normally unaccented part of the bar and sustaining it into the normally accented part, so as to produce the effect of shifting back or anticipating the accent; the shifting of accent so produced.”

7 The translator of A Thousand Plateaus entitled this essay “Of the Refrain,” an approximation that does not quite capture the melodious and obsessive connotations of the ntornetlo that gave the French ritournelle in the original version.

8 Michel Serres explains that sound does not really take place but rather occupies place: “Though its source may remain ill- defined, its reception is wide and all-encompassing. Sight delivers a presence but sound does not. Sight distances, music touches, noise besets” (Serres 1985 53, my translation). A Thousand Plateaus similarly emphasizes the privilege of the ear, “Colors do not move a people. Flags can do nothing without trumpets. Lasers are modulated on sound. The refrain is sonorous par excellence, but it can as easily develop its force into a sickly sweet ditty as into the purest motif, or Vinteuil’s little phrase” (Deleuze and Guattari 348).

9 “On appelle ritournelle tout ensemble de matires d’expression qui trace un territoire, et qui se dveloppe en motifs territoriaux, en paysage territoriaux. . . . En un sens restreint, on parle de ritournelle quand l’agencement est sonore ou domin par le son” (Deleuze et Guattari 397).

10 “‘Territory’ is a designation of claim over land, of jurisdiction, the power to say the law” (New 21).

11 Place has no satisfactory equivalent in French, its translation as lieu lacking the oppositional articulation place derives from its assonance with space (Staszak 252-253). This may account for the reliance of French geography (and Deleuze and Guattari’s geophilosophy) upon the notion of territoire to address the specificities of the local.

12 In “The Road to Rankin’s Point,” and “Vision,” singing the song “Never More Shall I Return” (Island 158-159 and 346) has an evident metonymic function for the characters. Performing the song together is a clear substitute for inhabiting the lost land, an instance of reterritorialization in song.

13 “I do not know what I’m supposed to do until my cousins come back and surround me like the covered wagons around the women and children of the cowboy shows, when the Indians attack. . . . My almost-attackers wait awhile, scuffing their shoes on the ashy sidewalk, and then they separate and allow us to pass like a little band of cavalry going through the mountains.” (R 89, my emphasis)

14 Analyzing the ambivalence of the ancient Celts’ response to the forest, Augustin Berque draws upon the constitutive duality of Gilbert Durand’s archetypes, their signification being either positive or negative depending upon the diurnal or nocturnal regime in which they are envisaged.

15 I am using the word “landscape” in the restricted sense Augustin Berque has defined to distinguish the notion from any unspecified reference to the natural environment. For Berque, a landscape is not an object per se but a “mdiance,” i.e. the outcome of a series of mediations between a perceiving subject, perceived surroundings and a fund of cultural, social and historical representations (Berque 16-19).

16 This passage is highly reminiscent of the foundational rituals in Ancient Greece and Rome where the fragmented body of the victim was shared by the community, giving birth to a sense of the collective through political representation and art (Serres 1983 118).

17 Although she concentrates upon one specific story, Vauthier’s valuable conclusions throw considerable light on the frequent and spectacular shifts from the preterite to the present that characterize MacLeod’s writing in general. Laurent Lepaludier has also drawn attention to the iterative value of the present tense in his analysis of “The Closing Down of Summer.”

18 “Second Spring,” a story revolving around a young boy’s dream of breeding a prize-winning calf, is a wonderfully comic refutation of ideals of purity. The boy sets off on the island’s roads, determined to take his precious cow to the perfect bull which, he knows, is available in a nearby farm. As Hazard Lepage leading his stallion on Alberta’s tricky roads in Kroetsch’s The Studhorse Man, the boy will have little choice but to adjust to the vagaries of animal desire.

19 By using the adjective “unilingual,” MacLeod ironically suggests that, for many, bi- or multilingualism is the norm, as in the following description: “The real estate agent stood listlessly between them while the July sun contributed to the perspiration forming on his brow. He looked slightly irritated at being banished to what seemed like a state of unilingual loneliness” (C 428).

20 For a fine analysis of the inscription of No Great Mischief within the wider frame of the nation, see David Williams’ “From Clan to Nation.”

21 The narrator’s awareness and implicit refusal of the pastoral alternative is just as interesting: “This was in the time before the Anne of Green Gables craze and they did not really know what people were supposed to visit on Prince Edward Island” (C 414).

22 “La notion analogia . . . exprime l’ide d’un rapport (logos) entre ce qui est haut et ce qui est en bas (verticalit), parce que ce qui est en bas est comme ce qui est en haut (rptition), avec, ventuellement l’ide d’un renversement (le plus petit comme analogue du plus grand)” (Borella 25).

23 “The transfer can never be total, but what reaches this region is that element in a translation that goes beyond transmittal of subject matter. This nucleus is best defined as the element that does not lend itself to translation. Even when all the surface content has been extracted and transmitted, the primary concern of the genuine translator remains ellusive. Unlike the words of the original, it is not translatable, because the relationship between content and language is quite different in the original and the translation. While content and language form a certain unity in the original, like a fruit and its skin, the language of the translation envelops its content like a royal robe with ample folds.” (Benjamin 75).

24 In this respect, it is not indifferent that the etymology of the noun “trope” should be a Greek verb meaning “to turn,” referring to the rhetorical twist given to expression to achieve greater effect and perhaps also, this is my own interpretation, to the pull carefully-wrought statements exert on the reader’s attention.

WORKS CITED

Benjamin, Walter. “The Task of the Translator.” Illuminations. Ed Hannah Arendt. Trans. Harry Zohn. New York: Schocken Books, 1968. 69- 82.

Berque, Augustin. Les Raisons du paysage de la Chine antique aux environnements de synthse. Paris: Hazan, 1995.

Borella, Jean. Penser l’analogie. Genve: Ad Solem, 2000.

Brown, Russell. “The Written Line.” Borderlands: Essays in Canadian American Relations. Selected by the Borderlands Project. Ed. Robert Lecker. Toronto: ECW, 1991. 1-27.

Chklovski, V. “La Construction de la nouvelle et du roman.” Thorie de la littrature. Ed. Tzvetan Todorov. Paris: Seuil, 1965. 170-195.

Deleuze, Gilles, et Flix Guattari. Mille plateaux: capitalisme et schizophrnie. Paris: Editions de Minuit, 1980.

-. A Thousand Plateaus. Trans. Brian Massumi. London, Minneapolis: U of Minnesota P, 1987.

Fiamengo, Janice. “Regionalism and urbanism.” The Cambridge Companion to Canadian Literature. Ed. Eva-Marie Krller. Cambridge: Cambridge UP, 2004. 241-262.

Guilford, Irene, ed. Alistair MacLeod: Essays on His Works. Toronto: Guernica, 2001.

Kroetsch, Robert. The Studhorse Man. 1970. Toronto: Random House, 1988.

Lepaludier, Laurent. “The Everyday in ‘The Closing Down of Summer’ by Alistair MacLeod.” Journal of the Short Story in English (Spring 2002): 39-55.

MacLeod, Alistair. Island. 2001. London: Vintage, 2002.

MacPhee, Dianne. “Tales of the Seannachie.” Canadian Literature 179 (Winter 2003): 165-167.

Mathews, Lawrence. “Atlantic Myths.” Canadian Literature 180 (Spring 2004): 119-120.

McClintock, Anne. Imperial Leather, Race, Gender and Sexuality in the Colonial Contest. London: Routledge, 1995.

New, W. H. Land Sliding: Imagining Space, Presence, and Power in Canadian Writing. Toronto: U of Toronto P, 1997.

-. Borderlands: How we Talk About Canada. Vancouver: UBC Press, 1998.

Serres, Michel. Rome\, le livre des fondations. Paris: Grasset, 1983.

-. Les Cinq sens. Paris: Hachette, 1985.

Simpson-Housley, Paul, and Glen Norcliffe, eds. A Few Acres of Snow: Literary and Artistic Images of Canada. Toronto/Oxford: Dundurn P, 1992.

Staszak, Jean-Franois, Batrice Collignon et al., eds. Gographies anglo-saxonnes: Tendances contemporaines. Paris: Belin, 2001.

Urquhart, Jane. “The Vision of Alistair MacLeod.” Alistair MacLeod: Essays on His Works. Ed. Irene Guilford. Toronto: Guernica, 2001. 36-42

Vauthier, Simone. “Notes sur l’emploi du prsent dans ‘The Road to Rankin’s Point,’ d’Alistair MacLeod.” Ranam 16 (1983): 143-158.

Williams, David. “From Clan to Nation: Orality and the Book in Alistair MacLeod’s No Great Mischief.” Alistair MacLeod: Essays on His Works. Ed. Irene Guilford. Toronto: Guernica, 2001. 42-71.

-. Imagined Nations: Reflections on Media in Canadian Fiction. Montreal/Kingston: McGill-Queen’s UP, 2003

Claire Omhovre is an Assistant Professor of English at University Nancy 2 (France). She has published articles in French and Canadian journals on the novels of Robert Kroetsch, Aritha van Herk, Thomas Wharton, Rudy Wiebe and Anne Michaels. She is currently investigating the metaphoric use of physical geography in contemporary Canadian fiction.

Copyright University of British Columbia Summer 2006

(c) 2006 Canadian Literature. Provided by ProQuest Information and Learning. All rights Reserved.

Man Given Costume Option for Slaying Dog

PAINESVILLE, Ohio – A man who shot his Great Dane in the head may have his jail sentence reduced if he dresses up as a dog.

Municipal Judge Michael Cicconetti offered Thursday to cut Robert M. Clark’s sentence to 10 days in jail if he wears a Safety Pup costume and visits the city’s five elementary schools. The mascot educates children about issues ranging from traffic safety to drug abuse.

Clark, 38, pleaded no contest to an animal cruelty charge and was sentenced to 180 days in jail for shooting his dog.

Cicconetti suspended all but 30 days of Clark’s sentence if he pays the Lake County Human Society for the dog’s veterinarian bills. The judge then offered to cut an additional 20 days if Clark dresses up as Safety Pup.

Clark was arrested July 3 after neighbors reported hearing the dog’s cries and police found the injured animal. The humane society took the dog to an emergency veterinary clinic, but he suffered brain damage and had to be euthanized, the group said.

Clark is appealing the sentence, court officials said.

Swedish Astronaut Breaks Frisbee Record

PHILADELPHIA _ A Swedish astronaut kept a Frisbee in the air for 20 seconds Friday, claiming the new world record for “Maximum Time Aloft”.

Only thing is, it was floating in zero gravity, aboard the International Space Station. And the astronaut, Christer Fuglesang, kept it from bumping into anything _ or going out of range of the camera in a feed to Earth _ by blowing on it.

If the record is accepted by the World Flying Disc Federation, Fuglesang would eclipse the longstanding 16.72-second flight launched over Chester County’s Warwick Park by Don Cain of Haddonfield in 1984.

Fuglesang’s first attempt, during a live web event with Swedish children and Crown Princess Victoria, was a dud.

As fellow astronaut Thomas Reiter, a German pilot, counted down _ “Three, two, one, go!” _ Fuglesang released his white Frisbee.

The two floated together for a bit, but then the Frisbee went askew and Fuglesang caught it, laughing, after a few seconds.

Back on the blue planet, Cain was watching on a computer with co-workers at M&S Electronics in Audubon, N.J. The cheer was tremendous.

Then Fuglesang tried again.

“Ten seconds,” Reiter reported, checking his watch. “15.”

As he announced, “20 seconds,” Fuglesang grinned broadly, let out a triumphant “Aaaah!” and grabbed the Frisbee. The earth-bound audience _ in Sweden _ applauded.

Within 15 minutes, the Swedish tabloid, Aftonbladet, was trumpeting the achievement: “World record was set tonight _ in Frisbee.”

Fuglesang, a physicist who is Scandanavia’s first astronaut, holds his country’s title for Maximum Time Aloft, a record he set in 1978.

But will the rest of the world accept this new record?

Cain was so impressed that he almost wouldn’t mind relinquishing the title.

“It was absolutely mind-blowing to watch that,” he said. “My head is still up in the stratosphere.”

Technically, Cain said, the toss was correct. The Frisbee left Fuglesang’s hand, and he caught it.

Then again, Cain said, in zero gravity Fuglesang “could have thrown a manhole cover and still beat the record.”

And as a lot of his friends are insisting, “doesn’t a world record have to be on the world?”

Dan Roddick, who keeps the world records, saw the space feed, too. “Really, really cool,” he gushed.

Yeah, but did it break the record?

“It seems to me we need a new category for a fabulous performance like this,” Roddick said. “It seems this is clearly the galactic record.”

Then again, maybe Cain won’t give up so easily.

“I’m trying to figure out how to get Bill Gates to buy me a ticket to space. To defend my record, of course.”

Sacramento HeartScan Offers Body Scan Gift Certificates

SACRAMENTO, Calif., Dec. 15 /PRNewswire/ — Sacramento HeartScan has announced that preventive imaging holiday gift certificates for heart, lung and whole body scans are available.

“If you’re having difficulty with last-minute shopping, this is definitely something to consider,” said Dr. Raye Bellinger of Sacramento HeartScan. “As unusual as it might seem, these gifts convey a great deal of care for those that are closest and most important to us. The preventive imaging scans are also quite popular with business people.”

Bellinger said that last year — right before Christmas — one local business executive came in and bought 10 certificates to hand out as gifts at his company. Bellinger said it also gets the message out that early detection is crucial to the successful treatment of heart disease, lung cancer and other conditions.

Gift certificates for the following scans are available, with discounts for multiple certificates:

Coronary artery screen (heart scan) — this fast and painless CT scan measures the amount of calcified plaque in the coronary arteries and provides the patient with a coronary calcium score to help assess the risk of heart disease. $250.00

Lung screen — low radiation, high speed CT scan of the lungs for igh-risk, non-symptomatic patients. Detects lung cancer at an earlier and more treatable stage than ordinary x-ray. $275.00

Brain screen — for the early detection of brain tumors, strokes and other silent diseases. $225.00

Whole body screen — multiple high resolution images which give a detailed look at the vital organs. Includes scans of the heart, lung, abdomen, pelvis, plus a bone density scan. $675.00

Lung & coronary artery screen — coronary calcium score plus lung screen. $375.00

Whole body screen & brain screen — the most thorough anatomical imaging assessment offered at Sacramento Heart. $750.00

Ultrasound carotid/stroke screen — the carotid ultrasound assesses the carotid artery in the neck for fatty deposits or plaque, which may result in stroke. $125.00

CT scans at Sacramento HeartScan, including lung, heart and brain, are performed using the LightSpeed VCT 64-slice scanner, the only one of its kind in the area. Unlike more conventional four-slice scanners, the LightSpeed VCT 64-slice captures clear images of the heart between beats and also provides clear, more precise pictures of other organs and tissue. Physician consultation is available upon request for all procedures.

For more information about Sacrament HeartScan gift certificates, call 916-830-2009.

About Sacramento HeartScan

Sacramento HeartScan is part of the Sacramento Heart Center, the area’s premier integrated cardiac facility, providing complete cardiology and wellness care plus a full range of diagnostic and laboratory services. Sacramento HeartScan is one of a limited number of cardiovascular centers in the United States using the LightSpeed VCT 64-slice scanner for detection of disease. Sacramento HeartScan recently purchased the 64-slice CT scanner, replacing the 16-slice CT scanner, which can uncover early stages of disorders such as: heart disease, lung disease and certain cancers. Sacramento Heart & Vascular Medical Associates, developers of the Sacramento Heart Center, is affiliated with most health care systems in Sacramento. For more information or to make an appointment, visit http://www.sacheart.com/ct/heartscan.html or call 916-830-2009.

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New Study Finds More Than 20 Million Americans Suffer From Blenophobia

More than 15 million American adults and five million children over the age of five suffer from high discomfort or exhibit needle-phobic behavior when faced with getting a blood draw or injection, according to results from a new study, with the overwhelming majority of those studied — 75 percent adults and 91 percent children — naming “pain” as the component they most feared.1

Clinically known as blenophobia, the condition is defined as a fear of needles, and includes the fear of pain felt during injections and blood draws. Pain associated with needle sticks leads directly to fear and anxiety, according to the study. The phobia presents a widespread public health challenge since a patient’s behavior is often influenced by their fears — and in extreme cases — affects their ability to receive necessary medical care.

“Blood tests are one of the most important diagnostic tools modern medicine has at its disposal, but if patients are reluctant, or even actively avoid blood draws, then we need to find ways to alleviate the pain and discomfort or other causes keeping them from getting these procedures,” said Mark Dursztman, M.D., Clinical Assistant Professor of Medicine, Weill Medical College of Cornell University, and Assistant Attending Physician, The New York Presbyterian Hospital, Cornell Campus. “The fear of needles and needle stick pain is a real and significant health problem, one that needs to be addressed.”

The survey, sponsored by Vyteris Holdings, Inc. (OTCBB: VYHN), a leading developer of drug delivery products, was conducted to learn more about the incidence and prevalence of high discomfort and needle phobic behavior around routine blood draws and injections. It found that slightly more than half the general population either had or were requested to have a blood draw or injection in the past six months. Fourteen percent, or approximately 15 million adults, identified themselves as being either needle phobic or having high discomfort around getting their blood drawn.

Of those 15 million needle-phobic adults, approximately 3.5 million indicated they had refused a blood draw or chose not to receive a recommended injection at some point in their life. Twenty five percent indicated that the consequences of these refusals were varied and serious, both from a health and economic standpoint, and directly impacted the patient’s quality of life. Over half of the respondents indicated that they did not receive necessary medical care because of the refusal, or made a change in the kind of care they were receiving. Some lost job offers, others did not receive insurance coverage and some were denied admission to school because of the refusal to get blood work done.

“Needle phobia has a direct impact on my ability to deliver necessary healthcare services, and is an important public health issue,” said Dursztman. “The findings underscore how widespread the issue is, and directly correlate to my personal experience as a physician dealing with patients. Needle phobia can be a significant impediment to understanding a patient’s complete health profile. The healthcare community needs to advance more solutions to deal with needle stick pain.”

The survey also found approximately five million children between the ages of five and 19 were characterized as being needle phobic or having high discomfort around blood draws and injections. Additionally, 26 percent of these needle-phobic children experienced extreme discomfort, the highest level of discomfort, at their last blood draw or injection.

The prevalence of blood draws and injections are high with physician offices and diagnostic laboratories estimated to take more than 900,000 blood draws daily in the U.S.

Despite the high rate of anxiety surrounding procedures, the options for dealing with needle stick pain are limited. The survey found the majority of both adults and children used distraction techniques — such as looking away, humming or focusing on an object — to deal with their discomfort. They found these techniques only moderately effective at best in minimizing their discomfort.

The American Pain Society (APS) and the American Academy of Pediatrics (AAP) set forth guidelines for adequately addressing acute – or short-lived – pain. These guidelines, which apply to the treatment of children and adults, call for healthcare practitioners to eliminate or reduce pain caused by medical treatments whenever possible. In fact, the APS and AAP agree that acute pain experienced with medical procedures can, in most cases, be substantially reduced and even prevented.

About the Survey

On behalf of Vyteris, the survey was conducted by TVG in October and November of 2006. Overall, 11,460 consumers were screened to identify patients with high discomfort levels with venipuncture or injection. A total of 1,010 respondents completed on-line surveys focused on this subject. The national panel from which these consumers were recruited is aligned with the general population across multiple metrics. The overall sampling error for this survey is +/- 3.5%.

About Vyteris, Inc.

Vyteris, Inc., a wholly owned subsidiary of Vyteris Holdings (Nevada), Inc. (OTCBB: VYHN.OB), are the makers of the first active drug delivery patch to receive marketing clearance from the U.S. Food and Drug Administration (FDA). Vyteris’ proprietary active transdermal drug delivery (iontophoresis) technology delivers drugs comfortably through the skin using low-level electrical energy. This active patch technology allows precise dosing, giving physicians and patients control in the rate, dosage and pattern of drug delivery that can result in considerable therapeutic, economical, and lifestyle advantages over existing methods of drug administration. Vyteris’ first product, LidoSite®, which provides dermal analgesia prior to venipuncture (IV catheter insertions, blood draws, etc.) and superficial dermatological procedures, was the first FDA approved active patch. Vyteris has also successfully demonstrated in-vivo, either in animals or in humans, the ability of their active patch technology to deliver drugs transdermally for the following applications: smoking cessation, anti-aging cosmeceuticals, treatments for Parkinson’s disease, and peptides for various indications.

Statements in this press release other than historical statements constitute “forward-looking statements”. Such forward-looking statements are subject to material risks and uncertainties, which could cause the Company’s forward-looking statements to be materially inaccurate. The Company has described such risks and uncertainties under the caption “Risk Factors” in various filings made with the SEC.

1 Statistics represent the number of respondents in the TVG study that had a physician recommended blood draw within the last six months. Full 12-month impact is therefore understated.

New England Journal of Medicine Confirms Replens Moisturizer Relieves Dryness for Menopausal Women; Equivalent to Estrogen

CEDAR RAPIDS, Iowa, Dec. 14 /PRNewswire/ — As reported in a recent issue of The New England Journal of Medicine, women suffering from feminine dryness due to menopause can alleviate symptoms by using Replens Long-Lasting Vaginal Moisturizer, instead of relying on estrogen treatments, which may carry harmful side effects.

“In a randomized trial, a polycarbophil-based vaginal moisturizer available over the counter (Replens) provided relief of vaginal symptoms that was equivalent to that of vaginal estrogen …,” stated the article from the Nov. 30th, issue entitled “Management of Menopausal Symptoms,” by Deborah Grady, M.D., M.P.H. “Oral phytoestrogens have not proved to be effective for the treatment of vaginal symptoms.”

Several studies over the past few years have raised concerns over the use of Hormone Replacement Therapy (HRT) and this article confirmed that women did not need to resort to hormones for the treatment of vaginal dryness as the over-the-counter solution Replens is equally effective.

“By the year 2030, the World Health Organization estimates that 1.2 billion women will be age 50 and older,” said Karin Giblin, founder of Red Hot Mamas (http://www.redhotmamas.org/ ), the nation’s largest menopause-education program offered in 80 hospitals in 29 states. “Few life events affect as many people as menopause. Women and their physicians should discuss the many non- hormonal solutions to combat menopause and age related issues. This New England Journal of Medicine article emphasizes to women that Replens is effective in treating vaginal dryness and it is an effective alternative to hormone therapy for feminine dryness.”

Vaginal dryness is one of the most common concerns of menopausal women. Symptoms of vaginal dryness include irritation, itching, burning, and soreness. If left untreated, this condition can lead to more serious problems such as vaginitis, bleeding, urinary discomfort, bladder infections, and painful intercourse.

Replens Vaginal Moisturizer is an estrogen-free, long-lasting vaginal moisturizer. One treatment delivers continuous moisture for three days, providing safe, effective, and soothing relief and helps vaginal tissues to regenerate.

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Replens

CONTACT: Suzy Ginsburg, +1-713-721-4774, or [email protected] , forReplens

Web site: http://www.redhotmamas.org/http://content.nejm.org/cgi/content/full/355/22/2338

Digital Ads Give Billboards a Jolt

By DIRK LAMMERS, AP Business Writer

SIOUX FALLS, S.D. – They’re large, rectangular and target consumers from high above the nation’s roadways, but these are not your father’s billboards.

Digital billboards, which resemble ballpark jumbo video displays but scroll through several static ads each minute, are helping to draw advertisers back to the outdoor medium as one of the world’s oldest forms of marketing is undergoing a renaissance.

The computer-controlled LED displays allow advertisers to change their message as often as they’d like, unlike their vinyl predecessors, said Christopher Ensley, an analyst at Bear, Stearns & Co. in New York.

“I think that’s what kind of changing the way outdoor is being used by advertisers,” Ensley said.

Bill Ripp, director of Lamar Outdoor Advertising’s digital billboard business, said the flexibility allows companies to place messages such as “sale ends tomorrow” or highlight specific prices that can be changed at any time.

“Billboards have traditionally been a reminder business,” he said. “We do branding and ‘turn left at this intersection’ sort of stuff. This product allows advertisers to drive the message on a much more call-to-action or timing basis.”

The out-of-home market would be healthy even without digital billboards, Ensley said. It’s been able to avoid some of the issues facing television and radio such as audience fragmentation or fast-forwarding of commercials with digital video recorders.

“You may miss it the first time you go to work. But if you’re doing it every day, that message is going to get through,” Ensley said.

Advertisers are also getting more creative with how they use outdoor advertising, said Paul Meyer, global president of Clear Channel Outdoor Holdings Inc.

Clear Channel recently tried interactive bus shelters in some of its European markets, enticing commuters to download information to their cell phones.

“I think you’re going to start seeing, slowly but surely, more and more experimentation with interactive communications between signs and consumers.”

Digital billboards offer many new opportunities, including the ability for companies to sell space in a time-share arrangement and open up high-profile locations to more advertisers. The same billboard, for example, could show a Starbucks ad for a mocha latte during the morning commute, movie listings from the local theater complex during the ride home and a late-night entertainment venue after the dinner hour, Meyer said.

Clear Channel Outdoor’s first foray into digital billboards was in Cleveland, where it launched a network of seven billboards. A local theme park featured its water rides during hotter days and showcased other attractions during cooler temperatures, Meyer said.

The San Antonio-based company made about $380,000 on those seven locations in 2004, and revenues jumped to nearly $2.5 million after they were converted to digital. Clear Channel Outdoor has since added six billboards in Las Vegas and 10 in Albuquerque and is building another network in London.

The Outdoor Advertising Association of America estimates there are 500 digital billboards on U.S. roads, compared to about 450,000 traditional billboards.

The giant screens can cost an initial investment of $300,000 to $500,000 as opposed to between $80,000 and $100,000 for a typical steel billboard structure, said Stephen Freitas, the Washington-based trade group’s chief marketing officer.

Many billboard companies charge the same for a rotation spot as they do for a single static display, so the same location can generate eight to 10 times the revenue that a traditional billboard could deliver, he said.

The new technology is helping the industry take some ad dollars away from other forms of media. Spending on outdoor advertising grew by more than 8 percent during the first half of the year, according to the OAAA’s monthly revenue data. That’s second only to the Internet advertising industry’s rate of growth, Freitas said.

Ensley acknowledged that only a small percentage of signs are digital, but he said it’s probably better to look at their growth as a percentage of revenue, which will be about 2 percent in 2006 but could rise to more than 5 percent by 2008.

Frederick Moran, a Florida-based media analyst with Stanford Group Co., said Lamar has exceeded Wall Street’s expectation for its digital rollout, putting up 10 to 30 more billboards per quarter than analysts thought they would. The company appears on track to have 300 up by the end of the year and 500 by the end of 2007, he said.

Currently, digital billboards are drawing mostly local advertisers such as department stores and automobile dealers, but analysts expect more national clients to jump aboard as the high-tech signs become more pervasive.

“You can’t deliver a national message with the small amount of boards that are digital today,” Moran said. A national advertiser can use digital boards to enhance the message on its static boards, but it will need thousands, if not tens of thousands of digital boards to have a truly national digital message, he said.

Jodi Senese, executive vice president of marketing for CBS Outdoor, said changeable messaging offers tremendous opportunities for the outdoor industry, but there will always be a market for traditional billboards as not all advertisers want to share a prime spot. For some, the real appeal of outdoor advertising comes from owning a spot 24-7, she said.

Freitas said he’s confident that technology will continue to enhance “” not threaten “” the outdoor industry as long as people use cars, trains and planes.

“As long as we need the transportation systems, then outdoor is there,” he said. “It’s omnipresent and technology can only help us become more effective.”

HIP Health Plan Launches New York City’s First Health Plan to Address Diabetes Epidemic Among New York’s Medicare Population

NEW YORK, Dec. 13 /PRNewswire/ — HIP Health Plan of New York is the first to offer a health plan that focuses exclusively on the unique healthcare needs of Medicare beneficiaries with diabetes in the New York City area. More than 500,000 Medicare beneficiaries are eligible to join HIP’s VIP Care Improvement plan, which seeks to help address the epidemic of diabetes in the New York City area.

“The problem of diabetes in New York has reached epidemic proportions,” said Anthony L. Watson, Chairman and CEO of HIP. “As a longtime participant in the New York healthcare market, HIP knows the devastating effect that diabetes has on our senior population. We’ve designed our new health plan to address the special needs of New York’s older residents living with diabetes.”

The prevalence of diabetes in the New York City is nearly a third higher than in the nation overall. It is estimated that more than one in every eight adult New Yorkers has diabetes. HIP is one of a handful of companies throughout the nation chosen by the Centers for Medicare & Medicaid Services (CMS) to offer a Medicare Advantage Special Needs Plan (SNP) for those living with chronic illnesses. In recognition of the fact that some Medicare recipients require specialized care, the Medicare Modernization Act of 2003 allows Medicare Advantage organizations to offer SNPs to Medicare beneficiaries with chronic illnesses. HIP is partnering with XLHealth, one of the country’s leading disease management companies, to provide disease management services under this new plan in New York City, Long Island and Westchester. (See attached overview for details about the plan.)

“This new plan benefits both Medicare beneficiaries living with diabetes, as well as the doctors in our network who treat them,” said Dan J. Dragalin, MD, Executive Vice President for Medical Affairs and Corporate Chief Medical Officer. “With an increased focus on disease management, we can support the work of our physicians with coordinated data collection and improved patient compliance, while offering members the education and support services they need to avoid the serious complications that often accompany this disease.”

“Our experience with disease management-focused health plans has yielded very encouraging results,” said Paul Serini, XLHealth’s executive vice president. “By providing the right kinds of tools to help manage chronic conditions like diabetes, we’ve been able to help those with the disease avoid complications and reduce the need for costly treatments and hospitalizations.”

ABOUT HIP VIP CARE IMPROVEMENT

As a chronic disease management Special Needs Plan, HIP VIP Care Improvement is the first plan to offer a complete Medicare Advantage health plan with prescription drug coverage and comprehensive diabetes disease management services to the more than half a million Medicare beneficiaries in New York who qualify. HIP is partnering with XLHealth, one of the country’s leading disease management companies, to provide disease management services under this new plan.

   To join, members must:   * be eligible for Medicare Part A and enrolled in Medicare Part B   * have diabetes   * reside in the plan's service area: New York City, Long Island or     Westchester   * not have end-stage renal disease   

Each HIP VIP Care Improvement plan member will be assigned a local XLHealth nursing support team who will work closely with the member’s physicians and caregivers to coordinate services and help provide optimal care. Members receive coverage that offers the advantages of traditional Medicare, plus additional benefits, care coordination and services as appropriate, such as:

   * plans options with $0 or no-cost premiums and copays   * no copayment for diabetes self-monitoring training or supplies   * comprehensive prescription drug coverage under Medicare Part D - with a     formulary specifically designed for people living with diabetes   * nursing support in person or by telephone   * medication monitoring and counseling   * medication and appointment reminders   * education to promote self-care   * hospital discharge planning   * tools to help monitor and manage health, such as diabetic protective     shoes and/or blood pressure cuffs for those who qualify   

HIP VIP Care Improvement enrollment began November 15, 2006. Members joining between then and December 31, 2006, will begin receiving plan benefits on January 1, 2007. Medicare beneficiaries with diabetes who are interested in learning more about the plan can call 1-877-PICK-HIP (1-877-742-5447)

HIP Health Plan of New York

CONTACT: John McKeegan, The Marcus Group, for HIP Health Plan of NewYork, +1-201-902-9000, cell: +1-609-571-8510, [email protected]

Recent Changes Seen in Earth’s Freshwater Distribution

Recent space observations of freshwater storage by the Gravity Recovery and Climate Experiment (Grace) are providing a new picture of how Earth’s most precious natural resource is distributed globally and how it is changing.

Researchers are using the mission’s almost five-year data record to estimate seasonal water storage variations in more than 50 river basins that cover most of Earth’s land area. The variations reflect changes in water stored in rivers, lakes and reservoirs; in floodplains as snow and ice; and underground in soils and aquifers.

“Grace is providing a first-ever look at the distribution of freshwater storage on the continents,” said Dr. Jay Famiglietti, professor of Earth System Science, University of California, Irvine. “With longer time series, we can distinguish long-term trends from natural seasonal variations and track how water availability responds to natural climate variations and climate change.”

Several African basins, such as the Congo, Zambezi and Nile, show significant drying over the past five years. In the United States, the Mississippi and Colorado River basins show water storage increases during that time. Such information is vital for managing water resources in vulnerable parts of Africa and Southeast Asia, since increasing populations and standards of living place demands on water resources that are often unsustainable. The data can be used to make more informed regional water-management decisions.

The twin Grace satellites monitor tiny month-to-month changes in Earth’s gravity field that are primarily caused by the movement of water in Earth’s land, ocean, ice and atmosphere reservoirs. Hydrologists are analyzing Grace data to identify possible trends in precipitation changes, groundwater depletion and snow and glacier melt rates, and to understand their underlying causes.

Dr. Matt Rodell, a hydrologist at NASA’s Goddard Space Flight Center, Greenbelt, Md., said the data correspond well with ground observations. As a result, hydrologists can now apply Grace data in ways that will impact regional water management. “Grace data improve our understanding of the water cycle and simulations of soil moisture, snow and groundwater in computer models,” he said. “This is a key step toward better weather, stream flow, flood, drought and water resource forecasts worldwide.”

Dr. Michael Watkins, Grace project scientist at NASA’s Jet Propulsion Laboratory, Pasadena, Calif., said Grace is the only element in NASA’s broad water cycle research program that measures changes in all types of water storage. “Grace detects water storage changes from Earth’s surface to its deepest aquifers. Water can’t hide from it,” he said.

The mission’s abilities to detect water are particularly vital for the emerging field of groundwater remote sensing. “Remote sensing of groundwater has been a Holy Grail for hydrologists because it is stored beneath the surface and is not detected by most sensors,” said Famiglietti. “Outside of the United States and a few other developed nations, it is not well monitored. It’s been speculated that many of Earth’s key aquifers are being depleted due to over-exploitation, but a lack of data has hampered efforts to quantify how aquifer levels are changing and take the steps necessary to avoid depleting them. With additional data, such as measurements of surface water and soil moisture, we can use Grace to solve this problem.”

Grace is also allowing scientists to estimate another key component of the water cycle for the first time: water discharged by freshwater streams from Earth’s continents. Stream flow measurements are often not shared for economic, political or national defense reasons. Grace measurements of the total water discharged by continental streams are important for monitoring the availability of freshwater and understanding how surface water runoff from continents contributes to rises in global sea level.

Scientists from NASA and the University of California, Irvine, are presenting their research today during the American Geophysical Union meeting in San Francisco.

Grace is a partnership between NASA and the German Aerospace Center (DLR). The University of Texas Center for Space Research, Austin, has overall mission responsibility. JPL developed the two Grace satellites. DLR provided the launch, and the GeoForschungsZentrum Potsdam, Germany, operates the Grace mission.

For more information about Grace, see http://www.csr.utexas.edu/grace/ . For more on NASA water and energy cycle research, visit http://watercycle.gsfc.nasa.gov/index.php.

After My Natasha Died, Bingeing on Food Became My Only Comfort. Now I’M Determined to Escape From the Nightmare of Obesity Now I’M Determined to Escape From the Nightmare of Obesity Dad Tells How City Clinic Helped Him Shed Six Stones

By WENDY MILLER

A GRIEVING dad today told how binge eating left him battling obesity after his daughter fell to her death from a tower block in Glasgow.

Heartbroken John Smith resorted to “comfort eating” and piled on the pounds after four-year-old Natasha’s fatal fall from her bedroom window.

The youngster’s death in Easterhouse devastated her family and prompted a successful Evening Times campaign to have safety locks fitted on the windows of council homes across the city.

John, 37, who now lives in Tollcross with his wife Margaret, daughters Louise, 10, and Shannon Louise, 7, and son Daniel, 13, said: “My health problems started after we lost Natasha in 1999.

“We were still in shock and everything just got on top of me. It was a terrible time, a very stressful time. I got depressed and gave up work.

“I had my other children to look after and my wife who was pregnant at the time of Natasha’s death.

“My health was generally okay until after Natasha died. Then I needed my gallbladder removed and I had depression and sleep apnoea.”

As the weight piled on, laziness and binge eating compounded the problem.

John said: “Takeaways, Indian and Chinese meals were a big thing for me. I was a binge-eater. Laziness was an issue too. I would just throw things in the microwave. However, John has now shed six stones – thanks to an award-winning obesity clinic at Glasgow Royal Infirmary.

The former baker has turned his life around since joining Glasgow Weight Management Service 18 months ago.

He said: “Before I went to the clinic I didn’t believe I was able to lose weight at all.

“I’d tried everything – diets, weight-loss tablets – but nothing worked.

“When I came here it was like I got re-educated. Now I know how to prepare fresh foods, how to eat a balanced diet and how to exercise.

“The big thing for me was playing football for the first time with my son Daniel . . . I’d never done that before because of my weight.

“I exercise regularly now. I’ve lost six stones. I’m still attending the group and I’m determined not to gain any more weight.”

Consultant clinical psychologist Dr Susan Boyle, who runs the clinic, said obesity was a “significant problem” in Glasgow.

She is part of a new team dedicated to curing one of the city’s most chronic and lifethreatening conditions.

Scotland’s first-ever obesity clinic was praised last month as the best in Britain by the National Obesity Forum.

The clinic is made up of psychologists, dieticians, physiotherapists and administrators. They try to offer a joined-up approach to a debilitating and complex illness.

Dr Boyle said: “What we do here is look at the whole picture. Obesity won’t go away overnight but we are confident that we’re on the right track.

“Obesity is linked to a number of chronic health problems, including diabetes, bowel cancer and sleeprelated respiratory conditions such as sleep apnoea.”

THE scale of Glasgow’s obesity problem is underlined by the 2500 referrals the clinic has received since its launch in December 2004.

Referrals come from mostly GPs and patients must have a body mass index (BMI) of over 30 – if they have health problems – and over 35 without.

But being clinically obese is not enough to get you into the clinic.

Dr Boyle said: “Every individual is given a comprehensive assessment. We discuss their health and lifestyle and assess their motivations.

“There are sacrifices to be made . . . people have to want to change their lifestyles.”

Patients are encouraged to lose weight slowly, aiming to shed around two pounds each week and keep it off by making permanent lifestyle changes.

Dietician Natalie Jones said: “We give patients a highly nutritious balanced diet, low in fat and high in starchy carbohydrates.

“We also encourage them to eat regular meals, particularly the importance of eating breakfast.”

Initially members embark on a six-month programme, are assessed regularly and attend a group session once a fortnight.

They are also encouraged to go to twice-weekly circuit classes run by resident physiotherapist Kim Ferrier, with exercise programmes tailored to each individual.

During group sessions patients explore their eating patterns and how to change them for the better.

Dr Boyle said: “We look at things like emotional triggers for over-eating, which can be anything from boredom to anxiety.”

wendy. miller@eveningtimes. co. uk

TRAGEDY . . . BECAUSE A GBP12 WINDOW LOCK WAS NOT FITTED

LITTLE Natasha Smith died when she fell 40ft from her bedroom window in Easterhouse in 1999.

The four-year-old had been playing in her room when she fell through a window which had no safety catch . . . which would have cost the council just GBP12 to fit.

Following the tragedy, the Evening Times successfully backed a plea from her devastated parents John and Margaret for window locks to be fitted as standard in council homes.

An investigation revealed 30,000 homes in the city did not have safety catches and 57,000 of Glasgow’s 85,000 council homes needed new windows.

After Natasha’s death, the city council agreed to set aside GBP1.5million to fix windows over a three-year period.

In a damning fatal accident inquiry, Sheriff Linda Ruxton condemned the council for failing to install a safety catch as a “reasonable precaution”, which could have prevented her death.

She said: “I have concluded that the bedroom window through which Natasha fell was such that it presented an obvious danger to children, and in particular to Natasha and the other children in the house.”

Glasgow Sheriff Court heard a GBP12 window lock could have saved Natasha’s life.

The family called for the inquiry so the full facts of the tragedy would be known.

(c) 2006 Evening Times; Glasgow (UK). Provided by ProQuest Information and Learning. All rights Reserved.

‘Plymouth Pharmaceuticals(R) and Dermatologist Launch New Oral Prescription Acne Medication (Acunol(TM))’

TULSA, Okla., Dec. 11 /PRNewswire/ — Plymouth Pharmaceuticals(R), Inc. announced today that it has launched a new oral prescription medication for the treatment of acne and rosacea.

Dermatologist, Dr. Steven A. Smith, MD, FACP, based in Tulsa, Okla. was searching for a better way to treat his acne patients and formulated Acunol(TM) as a result. “Acunol(TM) is a safe biochemical compound with fewer side effects than most prescription acne treatments currently available, and it contains no antibiotics,” Dr. Smith said, a fellow of the American College of Physicians.

“Acunol(TM) is an antibiotic-free, prescription medication for the treatment of mild to moderate acne and rosacea; the tablets can be swallowed, chewed, or dissolved by mouth for easy usage by any person,” Miles Smith, the company’s Vice President, said. Side effects are few and Acunol(TM) has only minimal contraindications (see prescribing insert). Acunol’s price is competitive with other prescriptions acne treatments, as well.

McKesson and Cardinal Health, two of the largest drug wholesale distributors have decided to stock Acunol(TM); pharmacies routinely use one of these distributors to fill a prescription.

A retrospective clinical case study in treating acne and rosacea with Acunol(TM) either in combination therapy or alone has been completed with positive results; 8 out of 10 patients stated that their acne/rosacea had improved at least moderately (data on file).

Acunol(TM) is an effective, inexpensive, safe, and easy to use alternative to less safe, expensive, and largely ineffective prescription acne treatments currently sold by most pharmaceutical companies.

For more information about Plymouth Pharmaceuticals'(R) products, visit http://www.acunol.com/ .

Plymouth Pharmaceuticals(R), Inc.

CONTACT: Miles Smith of Plymouth Pharmaceuticals(R), Inc.,+1-918-664-9882, ext. 102, or [email protected]

Web site: http://www.plymouthpharmaceuticals.com/http://www.acunol.com/

Opiate Addicts Find Fewer Hospital-Run Detox Beds Available

By Andrew Strickler, Newsday, Melville, N.Y.

Dec. 10–Addicts who overdose on heroin or other opiates are likely to land first in a hospital emergency room, where doctors can often save them from brain damage or death.

For many of those who want to get clean, the next step is a hospital-run drug detoxification program. There, patients are physically and emotionally prepared to move into a long-term recovery program.

But with fewer detox beds available, some of Long Island’s hardest-core opiate addicts are finding it harder to take that crucial step. St. Catherine of Siena Medical Center in Smithtown shut its 12-bed unit in July 2005, and Southside Hospital in Bay Shore shut its 10-bed unit in April.

According to the New York State Office of Alcohol and Substance Abuse Services, these closures followed two others at Long Island hospitals in 2002 and 2003. All told, the number of beds reserved for the sickest addicts has dropped 69 percent in the last four years, from 81 beds in 2002 to just 25 in 2006.

Meanwhile, admissions at Long Island’s two remaining medically managed detox units, at Nassau University Medical Center in East Meadow and Eastern Long Island Hospital in Greenport, as well as less medically-intensive programs at two other hospitals, have increased an average of 42 percent over the same period. These detox units provide high-level care for addicts who have especially difficult problems and require more intensive treatment.

The reasons for the decrease in detox beds is part financial, part philosophical. While hospital administrators say they need the beds for more widely used services, drug addiction specialists see the closures as part of a national movement to put more resources into long-term rehabilitation. Many of them agree that’s a positive development.

But the shrinking number of detox beds, many in the field say, also means some addicts at the highest risk of disease or death sometimes are sent to distant hospitals and lose the will to enter before they arrive; others go to programs not prepared to treat the toughest cases.

“There are just not a lot of other places to refer these people to,” said Helen deReeder, director of addiction services at Eastern Long Island Hospital in Greenport. She said the hospital’s five-bed detox unit and 20 spots reserved for addicts with less severe addictions are always at or near capacity.

Patricia Hinken, director of alcohol and substance abuse services at Long Beach Medical Center, says that when detox beds are full, she often tells addicts to go to an emergency room, where they can be admitted for a secondary medical problem and treated for withdrawals.

“At that point it becomes a revolving door. They go … right back to using, and get sicker and sicker,” Hinken said. “If they went straight into detox, you’d have at least three days to motivate them to get into an after-care program.”

—–

Copyright (c) 2006, Newsday, Melville, N.Y.

Distributed by McClatchy-Tribune Business News.

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.

State’s Files on Doctors Fall Short: The State Maintains Public, Online Profiles of Florida’s Doctors and Other Health Practitioners. But How Accurate Are the Profiles

By Jacob Goldstein, The Miami Herald

Dec. 10–IN 2003 — 11 years after he pleaded guilty to 82 felony counts of Medicaid fraud, and four years after New York regulators took away his podiatry license for “gross negligence” — Jack J. Cohen started practicing podiatry in Miami Beach.

Since then, the Florida Department of Health has fined Cohen $1,100 for violating state law by failing to report what happened in New York, according to a deposition that Cohen gave earlier this year.

But you’d never know any of this from Cohen’s online profile, which is posted on a Florida Department of Health website along with those of every podiatrist, medical doctor, osteopath, chiropractor and advanced registered nurse practitioner licensed to work in Florida. According to his state profile, Cohen has no criminal history and has not been disciplined by any state board in the nation in the past 10 years.

Cohen, 45, said he has not hidden anything from state officials.

“Everything’s been reported,” he said. “Everything.”

The online profiles — among the state’s most comprehensive sources of doctor information available at no charge to the public — are mandated by state law. They include basic information such as address, training and hospital affiliation, as well as reports of disciplinary actions, criminal history and malpractice settlements and judgments.

Yet the profiles of hundreds of Florida doctors — including more than 250 in Miami-Dade and Broward counties alone — fail to report malpractice payments as required by state law, an analysis by The Miami Herald has found. The profiles of roughly 1,000 doctors in Miami-Dade and Broward counties do show malpractice payments, suggesting an underreporting rate of about 20 percent.

THE LAW

State law requires doctors to verify their information every two years, when they renew their license, and to update their profile within 15 days after any changes occur. The law also requires the Department of Health to independently verify certain pieces of information, including disciplinary history and malpractice payments.

According to the statute, the profiles must include all judgments and settlements of more than $100,000 for medical doctors and osteopaths, and more than $5,000 for podiatrists, from the past 10 years.

Doctors are supposed to report the payments. In addition, the Department of Health receives regular updates from the Office of Insurance Regulation, which keeps a database of malpractice payments in the state.

Lola Pouncey, a Department of Health bureau chief who oversees the profiles, said there have been problems with this system.

“There have been indicators that the data wasn’t flowing to us,” she said.

The Department of Health recently has begun to check the profiles against the National Practitioner Data Bank, a federal database that tracks doctors’ malpractice and disciplinary history.

“We feel a lot better about the new system that we’re working with now,” Pouncey said.

But gaps remain.

ONLINE PROFILE

The online profile of Dr. Octavio Prieto, a Plantation internist, says he has no liability claims of more than $100,000 in the past 10 years — but in fact he has three, for $500,000 each, according to a malpractice database maintained by the state’s Office of Insurance Regulation.

One claim was for an alleged failure to diagnose a blood clot, and another involved a patient who died of a heart attack, according to the Florida Office of Insurance Regulation database.

The third case, which led to discipline from the state medical board (the discipline is reflected in his profile), arose after Prieto ordered a mammogram for a 37-year-old mother of two. The mammogram was performed in his office on a machine that had not been properly certified, according to a complaint filed by the Department of Health. The mammogram did not reveal anything abnormal in the woman’s left breast.

A year later, when the woman had a mammogram performed at another clinic, doctors found a tumor in the left breast that had begun to spread, according to court documents. The cancer went on to kill her, according to a lawyer who represented her.

Prieto “misled Patient L.D. to believe that Patient L.D. had no evidence of suspicious growth,” the Department of Health alleged in its complaint, which led to a reprimand and $18,000 in fines and fees in 2001.

Prieto, 59, said in an interview last month that he had reported the cases as required. He said he was given bad advice by a state inspector, who told him he did not need to have his mammography machine certified if he was not giving mammograms to Medicaid or Medicare patients. He also said all of the lawsuits were filed at about the same time — in the mid- to late 1990s — because he was carrying a large insurance policy that made him a target.

He added that the discipline by the state medical board was simply a response to the lawsuits.

“The medical board has to act, has to show some discipline,” said Prieto, who is on the staff of Florida Medical Center in Fort Lauderdale, Plantation General Hospital and Westside Regional Medical Center in Plantation. “Unfortunately, sometimes they overshoot.”

In an e-mailed response, Larry McPherson, executive director of the Florida Board of Medicine, said:

“The Florida Board of Medicine carefully reviewed the facts and evidence concerning Dr. Prieto and found that his quality of care fell below the standard we expect from a licensed physician.”

The number of South Florida doctors’ profiles that fail to report malpractice cases could be far greater than 250. The Miami Herald’s analysis included only those cases that were reported to the state’s Office of Insurance Regulation, which spent more than $500,000 to upgrade its malpractice database two years ago and which shares electronic information with the Department of Health.

But the state’s insurance officials say they have no way of knowing whether doctors who do not carry malpractice insurance — and who account for an estimated one-third to one-half of those practicing in South Florida — report their malpractice cases to the database, as required by law.

Cohen, who said he is self-insured, does not appear in the insurance agency’s malpractice database — despite having five malpractice lawsuits against him, at least one of which was settled before going to trial, according to court papers. The four other cases are pending. Some of the other actions reported in the profiles are supposed to be verified by the Department of Health, and some are not. But most have this in common: There is no way for the public to verify the information.

The key categories include:

–Criminal offenses.

When a doctor is first licensed to practice in Florida, the Department of Health is required by law to do a criminal records check with the Florida Department of Law Enforcement and the FBI. Every time the doctor renews his license — every two years — the law requires a statewide criminal records search. In addition, doctors are supposed to report any convictions within 15 days, and are required to verify the accuracy of their profile every time they renew their license.

Cohen — who has been licensed to practice in Florida since 1985, but did not begin to practice here until 2003 — was fined $1,000 and put on probation by Florida officials in 1995, in response to his felony conviction in New York, according to Florida medical board records.

Yet his online profile says he has “NO criminal offenses.”

Department of Health spokeswoman Thometta Cozart said that at the time the 1995 fine was levied, the state office that regulated physicians was not part of the Department of Health. Nevertheless, she said, the omission is “an error on our part.”

–Discipline.

The profiles report several categories of disciplinary actions, all limited to actions from the past 10 years. The practitioners are supposed to update their profiles within 15 days of being disciplined by any hospital, state licensing agency or specialty board.

In the past, the Department of Health relied on doctors to self-report much of this information.

Last year, the Florida Legislature passed a law requiring the department to check profile information against the National Practitioner Data Bank, a database created by the federal government to prevent physicians who get into trouble in one state from moving to another state and practicing there. (The information collected by the data bank on podiatrists is limited to malpractice payments and exclusion from Medicare or Medicaid.)

Pouncey says the Department of Health has requested more than 27,000 reports from the data bank on doctors who renewed their licenses in the past year, and found more than 5,000 cases in which the profile did not match the federal data bank. She expects to complete the updating of those profiles by February.

Hospitals and state licensing agencies can look up a doctor in the data bank, but the public cannot — making it impossible for the public to check the accuracy of the disciplinary information reported in the profile.

SURGEON FINED

As of last month, the profile of Dr. Jon David Donshik, a Plantation surgeon, showed that he had been fined more than $20,000 by the Florida Board of Medicine for operating on the wrong segment of a woman’s spine in 2001.

But the profile did not show that, as a result of the same operation, Donshik, 38, was reprimanded by the state of New York and relinquished his license in California.

The Miami Herald learned of the out-of-state discipline from an anonymous tip, and the Department of Health updated Donshik’s profile to reflect the discipline after a reporter inquired about the matter.

Donshik, who is on the staff of Westside Regional Medical Center, Plantation General Hospital and Aventura Hospital, said he reported the out-of-state discipline to the Department of Health.

But Department of Health spokeswoman Lauren Buzzelli said in an e-mail that Donshik “did not notify licensure services of any additions to his profile.”

Donshik also said the discipline was reported in the National Practitioner Data Bank.

“I’ve complied with the law,” Donshik said.

Miami Herald staff writers John Dorschner and Tim

Henderson contributed to this report.

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Copyright (c) 2006, The Miami Herald

Distributed by McClatchy-Tribune Business News.

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.

Xechem CEO, Dr. Ramesh Pandey to Present at the 10th Annual New York Society of Security Analysts Biotech/Specialty Pharma Industry Conference

Xechem International, Inc. (OTC BB: XKEM), Dr. Ramesh C. Pandey, the Chairman and CEO of Xechem International, will present at the 10th Annual New York Society of Security Analysts Biotech/Specialty Pharma Industry Conference in New York City on Tuesday, December 12th, 2006. He is scheduled to speak at 3:10 pm (EST). Dr. Pandey’s presentation will cover the significant progress in Nigeria for production and distribution of Xechem’s recently approved Sickle Cell drug NICOSAN™. In addition, Dr. Pandey will discuss Xechem’s new Sickle Cell product 5-HMF, a small-molecular compound, which has shown great promise in the preliminary studies with transgenic (Tg) mice, that will be developed as an injectable for acute episodes. Dr. Pandey’s presentation will be webcast live through a link on the Xechem website (www.xechem.com).

About NICOSAN™

NICOSAN™ is an anti-sickling drug developed by Nigerian scientists at the National Institute for Pharmaceutical Research and Development (NIPRD). In clinical studies conducted under NIPRD’s auspices, the drug has shown to substantially reduce the degree of sickling of the red blood cells of those afflicted with the disease. While not a cure, the clinical trials have confirmed that the large majority of patients taking NICOSAN™ no longer experience sickle cell “crises” while on the medication, and even among those whose crises are not eliminated, the number and severity of the crises are substantially reduced.

About 5-HMF

5-HMF is a pure natural compound developed by Professor Donald Abraham and his group at Virginia Commonwealth University (VCU). Studies carried out at VCU and Children’s Hospital of Philadelphia (CHOP) has shown 5-HMF has high affinity for sickle cell haemoglobin and thus the most promising molecule to treat Sickle Cell Disease (SCD). Preliminary animal studies show that 5-HMF is orally active with high bioavailability and has high red cell membrane permeability with very little, if any, toxicity. Xechem has license for 5-HMF from VCU for research, development, worldwide sales and marketing. Xechem received Orphan Drug Designation for 5-HMF from US-FDA on June 6th, 2006.

About Xechem

Xechem International is a development stage biopharmaceutical company working on Sickle Cell Disease (SCD), antidiabetic, antimalarial, antibacterial, antifungal, anticancer and antiviral (including AIDS) products from natural sources, including microbial and marine organisms. Its focus is on the development of phyto-pharmaceuticals (Natural Herbal Drugs) and other proprietary technologies, including those used in the treatment of orphan diseases. Xechem’s mission is to bring relief to the millions of people who suffer from these diseases. Its recent focus and resources have been directed primarily toward the development and launch of NICOSAN™ (to be marketed as HEMOXIN™ in the US and Europe). With the Nigerian regulatory approval now in hand, Xechem is now working on the commercialization of the drug in Nigeria and the pursuit of US FDA and European regulatory approval. In addition to NICOSAN™, Xechem is also working on another sickle cell compound, 5-HMF, which it has licensed from Virginia Commonwealth University (VCU).

Forward Looking Statements

This press release contains certain forward looking statements within the meaning of Section 27A of the Securities Act of 1933, as amended, and Section 21E of the Securities and Exchange Act of 1934, as amended, which are intended to be covered by safe harbors created hereby. Such forward-looking statements involve known and unknown risks and uncertainties.

9 Pasco Cardiologists Sue Hospital, Parent Company

By David Sommer, Tampa Tribune, Fla.

Dec. 8–Nine cardiologists who in effect were fired by a west Pasco County hospital filed separate lawsuits Thursday alleging industry giant HCA Inc. defamed their good names and falsely led the public to believe they were bad doctors.

The heart doctors contend their careers were derailed when the board of trustees at Regional Medical Center Bayonet Point wrongfully suspended them and recommended revoking their privileges to admit and treat patients in December 2004.

Also, the cardiologists allege their reputations were damaged by false and defamatory statements made by a spokesman for the medical center, which is owned by Hospital Corporation of America.

“A summary suspension of hospital privileges or an adverse recommendation for revocation of privileges are considered by the medical community to be the ‘death penalty’ to a physician’s practice and career,” the lawsuits state.

“The suspended physician typically will be severely limited in his professional options. Correspondingly, such adverse events will result in great reductions in the physician’s earnings and earning capacity,” the complaints state.

The nine lawsuits, filed in Pinellas County Circuit Court by lawyers Barry Cohen of Tampa and Anthony Leon of Tarpon Springs, are identical except for the named plaintiffs, said Kevin Kalwary, a spokesman for Cohen’s firm.

The nine doctors, all interventional cardiologists who perform heart surgery, are Sudhir Agarwal, Gopal Chalavarya, Charles Saniour, Adel Eldin, Mahmoud Nimer, Dipak Parekh, Thomas Mathews, Joseph Idicula and Rene “Rudy” Kunhardt.

Named as defendants are HCA Inc., HCA Health Services of Florida, Regional Medical Center Bayonet Point, and HCA executives J. Daniel Miller and David R. Williams.

Kurt Conover, the Bayonet Point spokesman accused of defaming the doctors, said HCA does not comment on pending lawsuits. A call to the company’s headquarters in Tennessee was not returned late Thursday afternoon.

According to the lawsuits, Conover was quoted in news accounts as saying that a review of the nine doctors “identified several opportunities for improvement” and that they did not follow accepted medical procedures.

Cohen said in a written statement that the reason the doctors were banned from the Hudson area hospital was that they were making medical decisions that “resulted in lower profits to the hospital than alternative treatments would provide.”

“Because of a marked shortfall in bypass surgeries compared to the number of angioplasties and the resulting loss of revenue, HCA initiated a review of the interventional cardiology program” that resulted in the nine suspensions, the lawsuit states.

Cohen said the lawsuits aim to restore his clients’ self-respect so that “they and their families will no longer be humiliated by HCA’s actions.”

Reporter David Sommer can be reached at [email protected] or (727) 815-1087.

—–

Copyright (c) 2006, Tampa Tribune, Fla.

Distributed by McClatchy-Tribune Business News.

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:HCA,

Guantanamo Detainees Going to New Prison

By MICHAEL MELIA

GUANTANAMO BAY NAVAL BASE, Cuba – The U.S. military transferred the first group of detainees on Thursday to a new maximum-security prison at Guantanamo Bay designed to restrict contact among the prisoners and prevent attacks on guards.

More than 40 detainees were brought to the $37 million prison perched on a plateau overlooking the Caribbean Sea from another maximum-security facility at the U.S. naval base in eastern Cuba, said Navy Cmdr. Robert Durand.

The 178-cell prison, constructed beside another maximum-security prison built in 2004, will allow the base to phase out an older facility, Durand said.

U.N. human rights investigators and foreign governments have called on the United States to close the entire detention center because of widespread allegations of abuse of detainees by guards. The United States labels Guantanamo detainees “enemy combatants,” which accords them fewer rights than other prisoners.

About 430 men are currently held at Guantanamo on suspicion of links to al-Qaida or the Taliban, including about 100 who have been cleared for release and are awaiting transfer to another country. Fewer than a dozen inmates have been charged with crimes.

The new prison was originally designed as a medium-security facility. But the military made several modifications, citing concerns raised by three suicides in June and a clash in May between guards and detainees armed with makeshift weapons.

It is now one of two facilities reserved for prisoners who are least compliant – an assessment the military says it bases on detainees’ adherence to base rules rather than their cooperation with interrogators.

Detainees will be confined in individual cells with long, narrow windows overlooking areas with metal tables and stools that were meant to be shared spaces but will now be off-limits.

An open-air recreation area has been divided into smaller spaces, which will hold only one detainee at a time. Shower doors were redesigned to allow guards to shackle prisoners’ hands and feet before they leave the stalls, and fencing was installed on second-tier catwalks to prevent detainees from jumping over the sides.

The new prison also has air conditioning, an onsite medical center and two rooms that will allow detainees to meet privately with their lawyers, Durand said.

Air conditioning has not been available at all the camps despite sweltering tropical heat. But the military is now installing it some prisons after detainees used broken fan blades as weapons in the melee in May.

U.S. Navy Cmdr. Kris Winter said the modifications will help make guards safer. In the last year and a half, the military has recorded more than 430 incidents in which detainees have thrown “cocktails” of bodily excretions at guards, as well as 225 physical assaults.

“As a commander, I don’t like my folks being in danger every day,” Winter said this week while leading journalists on a tour of the prison.

Guantanamo officials said the inability of the detainees to communicate with one another will also improve safety. Officials have said the May 18 ambush inside another facility on the base resulted from a plot hatched by detainees as word spread that guards were searching cells for contraband medication following two suicide attempts.

A defense attorney said the melee was sparked when guards tried to search prisoners’ Qurans.

Navy Rear Adm. Harry Harris, commander of the jail, has also described June 10 suicides at a minimum-security facility at the base as a coordinated protest. Lawyers and human rights activists called the suicides an act of desperation.

Vibra Healthcare Acquires Warm Springs Hospital System in a Joint Venture With B.A. Healthcare

MECHANICSBURG, Pa., Dec. 7 /PRNewswire/ — Vibra Healthcare, LLC announced today that it, along with B.A. Healthcare, LLC, has completed the acquisition of the Warm Springs Hospital System, based in San Antonio, Texas. The system owns and operates 3 hospitals, a specialty head injury facility, 8 outpatient centers, and provides Contract Management services to a number of Acute Care Hospitals and Nursing Homes.

The transaction was financed by MPT, Medical Properties Trust. The operating company, Post Acute Medical, LLC, is a newly formed joint venture between a Vibra Healthcare’s subsidiary, Lonestar Healthcare, LLC, and B.A. Healthcare, LLC, a Mechanicsburg, PA-based specialty hospital company founded by Anthony (Tony) Misitano.

Brad Hollinger, Founder, Chairman and CEO of Vibra Healthcare, stated that, “Warm Springs Hospital System has a proud legacy and outstanding reputation of providing medical rehabilitation services to south Texas for more than 60 years. Since its early beginnings, Warm Springs has developed innovative programs and approaches in the treatment of patients with debilitating injuries and illnesses. The Warm Springs management team had the vision to diversify into the long-term acute care hospital (LTAC) business by opening two freestanding LTAC hospitals that complement their flagship hospital in San Antonio. We are excited to be a part of their exceptional legacy.”

Vibra Healthcare, LLC is a specialty hospital provider based in Mechanicsburg, Pennsylvania, focused on the development, acquisition and operation of freestanding long-term acute care and medical rehabilitation hospitals. With the addition of the Texas hospitals, Vibra will operate thirteen hospitals with 732 beds in seven states.

Vibra Healthcare, LLC

CONTACT: Brad Hollinger of Vibra Healthcare, LLC, +1-717-591-5700

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

City of Hope Names Alexandra M. Levine, M.D., Chief Medical Officer

DUARTE, Calif., Dec. 7 /PRNewswire/ — Alexandra M. Levine, M.D., has been named chief medical officer (CMO) of City of Hope. An internationally known expert in lymphoma, Hodgkin’s disease and AIDS-related malignancies, Levine will be the organization’s chief clinician and will oversee all clinical and hospital care programs at City of Hope. Levine was most recently Distinguished Professor of Medicine, chair of the Division of Hematology at the Keck School of Medicine of the University of Southern California (USC), and medical director of USC/Norris Cancer Hospital.

As City of Hope’s CMO, Levine will develop and implement the institution’s clinical strategy and program development. She will serve as the primary liaison with the City of Hope Medical Group and its physician members to promote collaboration across disciplines and ensure effective staff recruitment and retention. Levine will co-lead programs aimed at continually improving the standard of care at City of Hope, including quality of service, patient safety, clinical research, clinical information management and professional education. As chief clinician she will serve as a role model and facilitator for all clinical staff.

“We are thrilled to have Alexandra Levine join City of Hope. She brings both her vast scientific expertise in hematology and HIV, and also her limitless compassion for patients facing cancer,” said Michael A. Friedman, M.D., president and chief executive officer, City of Hope. “Dr. Levine is a noted advocate of bringing more humanism into medicine and can address quality patient care from all angles, managing the needs of patients while also providing guidance for the physicians who treat them.”

Levine is a distinguished professor at Keck School of Medicine, and holds the Ronald H. Bloom Family Chair in Lymphoma. Her research interests include lymphoma, Hodgkin’s disease, and treating and preventing HIV/AIDS among women. She worked for eight years with Jonas Salk, M.D., on the development and testing of an AIDS vaccine. Levine has served as principal investigator or co- investigator on more than 20 major research grants, most funded by the National Institutes of Health.

Levine’s scientific and clinical contributions have received national and international recognition. In 1995, President Clinton appointed her to the Presidential Advisory Council on HIV/AIDS. She also chaired the council’s research committee. Levine has served as a member of the board of councilors of the National Cancer Institute and is currently a member of the Oncologic Drug Advisory Board of the Food and Drug Administration. In addition, she served as HIV/AIDS consultant to the health departments of Chile, Russia, India and China.

“I am delighted and honored to be given the opportunity to work with the City of Hope family. This institution has always distinguished itself by its commitment to quality in terms of patient care and research, and by the kindness and caring that has always been integral to its mission,” said Levine. “City of Hope is now poised to move to the next levels of expertise and national leadership, and I am most thankful to be given the chance to participate in this very exciting future.”

Levine is a member of the American Society of Hematology, the American Society of Clinical Oncology, the American College of Physicians and the International AIDS Society. She has published more than 300 articles and book chapters in noted medical journals such as the New England Journal of Medicine, Blood and the Journal of AIDS. In 1997, she received the Lymphoma Research Foundation of America’s Evelyn Hoffman Memorial Award in recognition for her achievements in lymphoma research and patient care.

Levine received her medical degree from USC in 1971 and completed fellowships at Emory University and Los Angeles County+USC Medical Center.

About City of Hope

City of Hope is a leading research and treatment center for cancer, diabetes and other life-threatening diseases. Designated as a Comprehensive Cancer Center, the highest honor bestowed by the National Cancer Institute, and a founding member of the National Comprehensive Cancer Network, City of Hope’s research and treatment protocols impact care throughout the nation. Founded in 1913, City of Hope is a pioneer in the fields of bone marrow transplantation and genetics and shares its scientific knowledge with medical centers locally and globally, helping patients battling serious diseases. For more information, visit http://www.cityofhope.org/.

City of Hope

CONTACT: Shawn Le of City of Hope, +1-800-888-5323, or [email protected]

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

Analysis: Gleevec’s CML Survival Story

By ED SUSMAN

After five years of treatment nearly 90 percent of leukemia patients treated with Gleevec are still alive — an outcome barely conceivable before the drug was discovered.

The Gleevec story truly is a triumph of science over disease, Brian Druker, the lead investigator of the studies with the anti-cancer drug, told United Press International Wednesday.

Druker, professor of medicine at the Oregon Health and Sciences University Cancer Center in Portland, said, The results we have seen really are astounding. Before Gleevec (generically known as imatinib), patients with chronic myeloid leukemia had about a 50 percent to 60 percent chance of survival for five years and maybe 10 percent survival at eight years.

In a report to be published Thursday in the New England Journal of Medicine, Druker wrote that 95 percent of patients treated with Gleevec were virtually disease-free after five years. Some patients died from other causes over the time period, but death from leukemia has been rare.

Chronic myeloid leukemia was considered a universally fatal disease 30 years ago, said Len Lichtenfeld, deputy chief medical officer of the American Cancer Society in Atlanta. It was called chronic only because it killed people at a slower rate that the acute form of the disease, not because it was a long-term chronic illness such as heart disease or diabetes.

Lichtenfeld told UPI, Gleevec really has turned chronic myeloid leukemia into a chronic disease. We cannot really cure this disease, but we can now tell people that if they adhere to their medical prescription it is likely they will be alive and healthy 5, 10, 15 years later.

In fact, Druker said one impressive finding after five years of treatment is that the relapse rates are actually decreasing rather than accelerating as with previous treatments. Before Gleevec, treatment with interferon and anti-cancer drugs were able to control the disease for short periods before patients relapsed.

Lichtenfeld noted that even in cases where Gleevec fails to control the disease, new compounds have now been discovered that appear to be able to treat those patients who become resistant to Gleevec.

Acute myeloid leukemia is diagnosed in about 10,000 Americans a year, Druker said. What causes the disease — aside from major exposure to radiation (survivors of atomic bomb attacks in Hiroshima and Nagasaki are prone to the disease) — is unknown.

He said some form of accident in the body’s DNA causes fusion of genes. That abnormal gene is part of a molecular cascade that results in a deadly excess proliferation of blood cells.

Druker said he likens the development of Gleevec to fixing a broken thermostat. We identified that the thermostat was running hot. We took it apart and found out what the broken piece was (the fusion gene), and then we found something that could repair the gene (Gleevec).

Of the 553 patients who were originally treated with Gleevec in the clinical studies, at the end of five years 57 of those individuals had died. However, just 23 of those deaths were caused by or were related to chronic myeloid leukemia. The clinical trials with Gleevec, once known as STI571, were sponsored by Novartis.

Gleevec is the model of how we are fighting cancer now and in the near future, Lichtenfeld said. It is an outstanding accomplishment.

NASA Images Suggest Water Still Flows on Mars

NASA photographs have revealed bright new deposits seen in two gullies on Mars that suggest water carried sediment through them sometime during the past seven years.

“These observations give the strongest evidence to date that water still flows occasionally on the surface of Mars,” said Michael Meyer, lead scientist for NASA’s Mars Exploration Program, Washington.

Liquid water, as opposed to the water ice and water vapor known to exist at Mars, is considered necessary for life. The new findings heighten intrigue about the potential for microbial life on Mars. The Mars Orbiter Camera on NASA’s Mars Global Surveyor provided the new evidence of the deposits in images taken in 2004 and 2005.

“The shapes of these deposits are what you would expect to see if the material were carried by flowing water,” said Michael Malin of Malin Space Science Systems, San Diego. “They have finger-like branches at the downhill end and easily diverted around small obstacles.” Malin is principal investigator for the camera and lead author of a report about the findings published in the journal Science.

The atmosphere of Mars is so thin and the temperature so cold that liquid water cannot persist at the surface. It would rapidly evaporate or freeze. Researchers propose that water could remain liquid long enough, after breaking out from an underground source, to carry debris downslope before totally freezing. The two fresh deposits are each several hundred meters or yards long.

The light tone of the deposits could be from surface frost continuously replenished by ice within the body of the deposit. Another possibility is a salty crust, which would be a sign of water’s effects in concentrating the salts. If the deposits had resulted from dry dust slipping down the slope, they would likely be dark, based on the dark tones of dust freshly disturbed by rover tracks, dust devils and fresh craters on Mars.

Mars Global Surveyor has discovered tens of thousands of gullies on slopes inside craters and other depressions on Mars. Most gullies are at latitudes of 30 degrees or higher. Malin and his team first reported the discovery of the gullies in 2000. To look for changes that might indicate present-day flow of water, his camera team repeatedly imaged hundreds of the sites. One pair of images showed a gully that appeared after mid-2002. That site was on a sand dune, and the gully-cutting process was interpreted as a dry flow of sand.

Today’s announcement is the first to reveal newly deposited material apparently carried by fluids after earlier imaging of the same gullies. The two sites are inside craters in the Terra Sirenum and the Centauri Montes regions of southern Mars.

“These fresh deposits suggest that at some places and times on present-day Mars, liquid water is emerging from beneath the ground and briefly flowing down the slopes. This possibility raises questions about how the water would stay melted below ground, how widespread it might be, and whether there’s a below-ground wet habitat conducive to life. Future missions may provide the answers,” said Malin.

Besides looking for changes in gullies, the orbiter’s camera team assessed the rate at which new impact craters appear. The camera photographed approximately 98 percent of Mars in 1999 and approximately 30 percent of the planet was photographed again in 2006. The newer images show 20 fresh impact craters, ranging in diameter from 7 feet (2 meters) to 486 feet (148 meters) that were not present approximately seven years earlier. These results have important implications for determining the ages of features on the surface of Mars. These results also approximately match predictions and imply that Martian terrain with few craters is truly young.

Mars Global Surveyor began orbiting Mars in 1997. The spacecraft is responsible for many important discoveries. NASA has not heard from the spacecraft since early November. Attempts to contact it continue. Its unprecedented longevity has allowed monitoring Mars for over several years past its projected lifetime.

NASA’s Jet Propulsion Laboratory, Pasadena, manages the Mars Global Surveyor mission for the NASA Science Mission Directorate, Washington.

Image Captions

Figure A: This figure shows the southeast wall of the unnamed crater in the Centauri Montes region, as it appeared in August 1999, and later in September 2005. No light-toned deposit was present in August 1999, but appeared by February 2004. The 300-meter scale bar represents 328 yards.

Figure B: This picture is a colorized view of the light-toned gully deposit, draped over a topographic image derived from Mars Global Surveyor’s Mars Orbiter Laser Altimeter data. The color comes from a table derived from the colors of Mars as seen by the Mars Reconnaissance Orbiter’s High Resolution Imaging Science Experiment.

Figure C: The third figure is a mosaic of several Mars Global Surveyor images, colorized using a table derived from Mars Reconnaissance Orbiter camera color data and overlain on a sub-frame of a Mars Odyssey Thermal Emission Imaging System image. The 1-kilometer scale bar represents about 0.62 miles.

Figure D: The fourth figure is a colorized view of the light-toned gully deposit as viewed from an oblique perspective, draped over topography derived from Mars Global Surveyor’s Mars Orbiter Laser Altimeter data. The color comes from a table derived from the colors of Mars as seen by the Mars Reconnaissance Orbiter camera.

Figure E: The first picture shows a pair of gully channels that emerge, fully-born at nearly their full width, from beneath small overhangs on the north wall of Dao Vallis. These overhangs are probably created by the presence of a hard-rock layer. Liquid, probably water, percolated through permeable layers just beneath these harder, more resistant rock layers. The arrow points to the place where one of the two neighboring channels emerges. This is a sub-frame of an image acquired on Jan. 10, 2006, located near 34.2 degrees south latitude, 268.1 degrees west longitude. The 150-meter scale bar is about 164 yards wide.

Figure F: The third picture shows a small crater on the rim of a larger crater. Only a small portion of the wall of this larger crater is captured in the image. Immediately beneath the small crater occurs a group of gullies. The presence of these gullies also supports the groundwater hypothesis because impacting meteors will fracture the rocks into which they form a crater. In this case, there would be an initial set of subsurface fractures caused by the large impact that created the original, large crater. Then, when the smaller crater formed, it would have created additional fractures in its vicinity. These extra fractures would then have provided pathways, or conduits, through which ground water would come to the surface on the wall of the larger crater, thus creating the gullies observed. One might speculate that the group of gullies was formed by the impact that made the small crater, because of the heat and fracturing of rock during the impact process. However, the gullies are much younger than the small crater; the ejecta from the small crater has been largely eroded away or buried, and the crater partially filled, while the gullies appear sharp, crisp and fresh. This is a portion of an image located near 33.9 degrees south latitude, 160 degrees west longitude, acquired on March 31, 2006.

For more information about NASA and agency programs, visit:

On the Web:

http://www.nasa.gov

For more information about images from the Mars Orbiter Camera, see http://www.msss.com/mgs/moc/index.html

U.S. Adults With Diabetes Fear Blindness or Vision Loss More Than Premature Death

CHICAGO and CAPE TOWN, South Africa, Dec. 6 /PRNewswire/ — More U.S. adults with diabetes fear vision loss or blindness more than they fear dying prematurely, according to results from the U.S. portion of a seven-country survey presented today at the International Diabetes Federation’s 19th World Diabetes Congress in Cape Town, South Africa. Many diabetes patients(1) feel they have been or would be affected by emotional challenges due to vision loss or blindness as a result of diabetes.

Forty-one percent of U.S. adults with diabetes cited vision loss — including significant problems not correctible with glasses or contact lenses, or blindness — as what they feared the most; and only 16 percent of U.S. respondents cited premature death as their greatest fear.

Commissioned by Lions Clubs International and Eli Lilly and Company , the survey interviewed 250 U.S. adults with diabetes via telephone and was part of a larger global survey (n=1,458) on the experiences and understanding of diabetes complications of people living with the disease. Lions Clubs International partnered with Lilly, a worldwide leader in diabetes treatment, to commission this international patient survey to show its dedication to treating diabetic retinopathy, which can lead to loss of vision.

“Managing diabetes carefully is essential for the prevention of complications, including vision loss and blindness,” said Jimmy Ross, international president, Lions Clubs International. “This survey highlights the potential significant physical and emotional impact of vision loss on people with diabetes and thus underscores the importance of annual dilated eye exams for people with the disease.”

“While annual dilated eye exams are considered a standard of care for patients with diabetes, in reality, many patients do not get this annual exam. It is through these annual exams that patients at stages of more advanced diabetic retinopathy can be identified, and ophthalmologists have tools today that can reduce the risk of vision loss in these patients,” said Donald Fong, MD, MPH, assistant clinical professor of ophthalmology, University of California, Los Angeles School of Medicine and director of clinical trials research, Kaiser Permanente, Southern California, who collaborated on the survey.

Diabetes is the leading cause of blindness in working-age adults in the U.S. Many U.S. adults with diabetes who say they have not yet experienced vision loss or blindness(2) reported being worried about losing the ability to conduct certain daily life activities, such as driving (65 percent), reading (61 percent) and continuing hobbies or interests (43 percent), as a result of vision loss or blindness due to diabetes. Also, U.S. adults with diabetes feel they would face or have faced emotional issues due to blindness or vision loss, including feelings of frustration (44 percent), depression (34 percent) and loss of independence (34 percent).

Many medical studies have shown that diabetes has been linked to a variety of related complications(3). Nearly seven in 10 (69 percent) U.S. adults with diabetes were aware that vision loss or blindness are potential complications of diabetes. Sixty percent recognized kidney damage as a complication of diabetes, while less than half (49 percent) recognized stroke as a complication.

In addition to the U.S., surveys were administered to adults with diabetes in the United Kingdom, France, Germany, Spain, Italy and South Africa. As in the U.S., the leading fear of people with diabetes in these countries was blindness or vision loss, followed by premature death. With regard to the emotional impact of vision loss due to diabetes, Americans with diabetes who have not yet experienced vision loss or blindness were less worried about losing their ability to continue with hobbies or interests than respondents from the other six countries, particularly South Africa(4) (U.S. 43 percent, U.K. 74 percent, Spain 67 percent, Italy 69 percent, France 66 percent, Germany 70 percent, South Africa 89 percent).

According to the American Diabetes Association, more than 20 million people in the United States, or seven percent of the population, have diabetes. While an estimated 14.6 million have been diagnosed, another 6.2 million people are undiagnosed and have an increased risk of developing diabetes-related complications.(5)

About the Survey

Harris Interactive(R) fielded the telephone survey on behalf of the Lions Clubs International and Eli Lilly and Company between April 21 and May 30, 2006 among nationwide cross-sections of adults age 18+ with diabetes as follows in the following countries: United States (n=250), U.K. (n=200), Spain (n=204), Italy (n=202), France (n=201), Germany (n=201), and South Africa (n=200). The European data were weighted to be representative of the adult population with diabetes of each country on the basis of age, sex and type of diabetes. The U.S. data were weighted to be representative of the U.S. adult population with diabetes on the basis of region, age within gender, education, household income, race/ethnicity and type of diabetes. The South African data was not weighted and cannot be projected to the entire population of South African adults with diabetes.

In theory, with probability samples of this size, one can say with 95 percent certainty that the results for the French, Spanish, Italian, and German samples would have a sampling error of plus or minus 7 percentage points and sampling error for the U.S. and U.K. samples would be plus or minus 8 percentage points. Sampling error for data based on sub-samples may be higher and may vary. However, that does not take other sources of error into account.

About Lions Club International

Lions Clubs International is the world’s largest service club organization with 1.3 million members in nearly 45,000 clubs in 200 countries and geographic areas. In addition to its efforts toward conquering blindness, the organization has made a strong commitment to community service and helping youth throughout the world. Lions Clubs International Foundation provides funding to assist Lions in carrying out humanitarian projects, and has awarded nearly 8,000 grants totaling US $569 million. To learn more about Lions SightFirst initiatives, visit http://www.lcif.org/.

About Eli Lilly and Company

Lilly, a leading innovation-driven corporation, is developing a growing portfolio of first-in-class and best-in-class pharmaceutical products by applying the latest research from its own worldwide laboratories and from collaborations with eminent scientific organizations. Headquartered in Indianapolis, Ind., Lilly provides answers — through medicines and information — for some of the world’s most urgent medical needs. Additional information about Lilly is available at http://www.lilly.com/.

Lilly’s Leadership in Diabetes

Through a long-standing commitment to diabetes care, Lilly provides patients with breakthrough treatments that enable them to live longer, healthier and fuller lives. Since 1923, Lilly has been the industry leader in pioneering therapies to help health care professionals improve the lives of people with diabetes, and research continues on innovative medicines to address the unmet needs of patients.

About Harris Interactive

Harris Interactive is the 12th largest and fastest-growing market research firm in the world. The company provides research-driven insights and strategic advice to help its clients make more confident decisions, which lead to measurable and enduring improvements in performance. Harris Interactive is widely known for The Harris Poll, one of the longest running, independent opinion polls and for pioneering online market research methods. The company has built what could conceivably be the world’s largest panel of survey respondents, the Harris Poll Online. Harris Interactive serves clients worldwide through its United States, Europe and Asia offices, its wholly-owned subsidiary Novatris in France and through a global network of independent market research firms. The service bureau, HISB, provides its market research industry clients with mixed-mode data collection, panel development services as well as syndicated and tracking research consultation. More information about Harris Interactive may be obtained at http://www.harrisinteractive.com/.

   (1) These findings are based on 94% of respondents who reported on the       state of their vision -- those who did not select "don't know" or       "decline to answer" when asked about the state of their current       vision.    (2) Caution should be exercised when interpreting these results as data       are based on small sample size (n=88).    (3) The Centers for Disease Control and Prevention. National Diabetes Fact       Sheet: General Information and  National  Estimates on Diabetes in the       United States, 2000.  Available at:       http://www.cdc.gov/diabetes/pubs/estimates.htm.       Last Accessed November 27, 2006.    (4) The South African data was not weighted and represents only the       opinions of the survey respondents    (5) American Diabetes Association: Diabetes Statistics.  Available at:       http://www.diabetes.org./diabetes-statistics.jsp.  Accessed 10/2/06.     Contact: Nicole Brown                          J. Scott MacGregor            Lions Clubs International Foundation  Eli Lilly and Company            630-571-5466, ex. 386                 317-651-1494 (office)                                                  317-440-4699 (mobile)  

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A Concept Analysis of Voluntary Active Euthanasia

By Guo, Fenglin

TOPIC. Euthanasia has a wide range of classifications. Confusion exists in the application of specific concepts to various studies.

PURPOSE. To analyze the concept of voluntary active euthanasia using Walker and Avant’s concept analysis method.

SOURCES OF INFORMATION. A comprehensive literature review from various published literature and bibliographies.

CONCLUSIONS. Clinical, ethical, and policy differences and similarities of euthanasia need to be debated openly, both within the medical profession and publicly. Awareness of the classifications about euthanasia may help nurses dealing with “end of life issues” properly.

Search terms: Concept analysis, end of life issues, voluntary active euthanasia, terminally ill patients

Introduction

Euthanasia is a very sensitive topic, and the debate surrounding it has intensified since its practice in the Netherlands in the 1980s. Much euthanasia-related articles have been published, but it is often not clear which kinds of euthanasia were being discussed. Debates regarding the right to die issues may be completely different according to voluntary euthanasia, nonvoluntary or involuntary euthanasia, passive euthanasia (PE), active euthanasia (AE), and assisted suicide.

McInerney and Seibold (1995) found that the majority of nurses could distinguish between active and passive euthanasia, but it was only in terms of active euthanasia that the debate was seen as significant. It was considered that the term passive euthanasia, particularly in relation to withdrawal of treatment, has served to confuse the real debate centering on active euthanasia.

The lack of specificity in these terms represents a continuing source of difficulty for understanding and study in this area. Research highlighting these concepts can give impetus to the development of social policy, and raise ethical awareness surrounding right to die issues among nurses and other health professionals.

For the purpose of clarifying the concept of voluntary active euthanasia (VAE), a concept analysis of VAE was performed using the systematic procedure suggested by Walker and Avant (1995). The suggested steps are as follows:

1. select a concept

2. determine the aims or purpose of the analysis

3. identify all uses of the concept that you can discover

4. determine all defining attributes

5. construct a model case

6. construct borderline, related, and contrary cases

7. identify antecedents and consequences

8. define empirical referents

Aims of the Analysis

The aims of the analysis are, first, to develop an operational definition of the theoretical concept of VAE. Second is to define the meaning of VAE in order to clarify the concept and its relevance and use in nursing practice and nursing education. Specific sub- aims were to:

* Determine the definition and critical attributes of VAE

* Identify the antecedents and consequences of VAE

* Identify the empirical referents for the critical attributes of VAE

Definitions of VAE

Euthanasia is a composite term derived from two Greek words-eu, meaning “well,” and thantos, meaning “death”-and means “good death” or “painless, happy death” (Begley, 1998). The Oxford dictionary definition of euthanasia is “the painless killing of a patient suffering from an incurable and painful disease” (Thompson, 1995, p. 465). However, it is classified in various forms, including voluntary, nonvoluntary and involuntary (Thompson et al., 2001). It may be voluntary at the request of the patient. This indicates that it must be carried out at the request of a competent patient. This implies adherence to another prima facie principle, that of respect for autonomy. Euthanasia may also be involuntary, where the views of the patient are disregarded.

It may also be described as active or passive euthanasia. “Passive” describes the withholding of treatment that would be necessary for the continuation of the patient’s life. “Active” implies that something is done or given with the intention of hastening death (Begley, 1998).

VAE is usually the administration of a lethal drug or other methods to terminate the life of a patient who is in a state of constant suffering (Oosthuizen, 2003). In other words, it is active assistance in dying. For example, if the patient cannot act by himself or herself because of his or her terminal illness, the physician or the nurse’s actions directly cause the patient’s death.

Defining Critical Attributes

Walker and Avant (1995) described the “critical attributes” of the concept being analyzed as the characteristics of the concept that appear repeatedly during the literature review. These characteristics help to name the occurrence of a specific phenomenon as differentiated from another similar or related one. Five critical attributes occurring in all cases of VAE have been identified as follows:

* The patient is in intolerable suffering

* The patient asks for a peaceful and painless death to retain dignity in life

* The patient is willing to end his or her life

* The physician or nurse’s actions directly cause the patient’s death

* The patient gives fully informed consent

Constructing a Model case

Walker and Avant (1995) recommended using a model case as the next step of concept analysis, and they described it as a “real- life” example of the use of the concept. The model case should include all the critical attributes and be a pure case example of the concept. Wilson (1963) refers to the model case as an instance in which there is absolute certainty that the model is the concept, “well, if that isn’t an example of so and so, then nothing is” (p. 28).

Patient A was a 95-year-old, very fragile, malnourished woman. She was admitted to hospital with severe abdominal pain under a diagnosis of liver cancer. She was fully dependent. She felt intolerable pain and had a very low quality of life. She told her physician, her daughter, and her niece that she did not want to live and want to die in peace. Why did she have to spend her last few days in pain and misery? She asked the junior doctor on duty, Jane, to give her a lethal morphine injection to die in peace. Jane had witnessed A.’s intolerable suffering many times, and strongly sympathized with her. After she got the consent of A., her family, and the senior doctors, she injected A. with a lethal dose of morphine. A. died shortly afterwards.

All five of the defining attributes of VAE are included in this model case. That is voluntary active euthanasia. Patient A was terminally ill, and was in severe pain. She made a request of dying with dignity and wanted to die in peace. The junior doctor’s action directly resulted in unrecoverable death of patient A.

Constructing Borderline, Related, and Contrary Cases

Borderline, related, and contrary cases are developed to provide examples of “clearly not the concept.” They are very useful to further clarify the analyzing concept and help with understanding (Walker & Avant, 1995).

Borderline Case

The borderline case may have only a few of the defining attributes, or may contain additional attributes. According to Walker and Avant (1995), it is used to promote further understanding of the concept under study. A borderline case of VAE is constructed as follows:

Patient B. was an 89-year-old woman. She had surgery for bowel cancer 2 years ago. She was admitted to hospital under “chest infection.” She was terminally ill, very fragile, malnourished, and fully dependent. She did not want to live in misery. She discussed “to die with dignity” with her daughter, son, and her physician Joe. They could not help her although they understood her feelings, but they said that they would not take any active part in bringing about her death. B. asked for a lethal dose of morphine. Joe gave it to her. B. injected herself with the lethal morphine and soon died.

Most attributes of VAE are presented in this case. For example, the patient was in intolerable suffering; she asked for a peaceful and painless death to maintain the dignity of life, and was willing to end her life. But it was she herself who injected the morphine.

Thus, this must be viewed as physician-assisted suicide (PAS) and a borderline case of the concept of VAE. Physician assisted suicide means allowing a doctor or other person to assist a person who has an invincible and understandable desire to commit suicide (Thompson et al., 2001). The doctor or nurse provided the drug or injection and the patient carried out the act herself.

Related Cases

Related cases are instances that represent a different but similar concept (Walker & Avant, 1995). Generally a different word is used, but the experiences have several features in common. They may involve several attributes (but not all) of the concept under study. These terms are discussed here as related cases. They demonstrate ideas that are very similar to the concept of VAE, but differ from it when examined closely.

Nonvoluntary euthanasia refers to the case of a patient who is not in a position to have, or express, views regarding the continuance of his or her life. For example, a patient in a vegetative state. Another example is the recent American case, the removal of severely brain-damaged Terri Schiavo’s feeding tube.

Voluntary passive euthanasia (VPE) is a concept used to d\escribe the withholding of treatment that would be necessary for the continuation of the patient’s life (Thompson et al., 2001). It is letting a patient die naturally rather than using extraordinary artificial methods (transplant, life-sustaining drugs) or machines (heart-lung machines, respirators) to keep him or her alive in a constant state of suffering or unconsciousness. In this case the patient voluntarily chooses to die “naturally” of whatever ills affecting him or her. Stopping life-sustaining therapies is typically considered passive assistance in dying. Death is more a result of the patient’s will and resolve than an inevitable consequence of the disease.

Another related case is involuntary euthanasia. This is equated with “murder,” although the patient may be in intolerable suffering. The Dr. Shipman’s case in the UK was typically “involuntary euthanasia.” Thus, although the patient may be willing to die, his (or her) informed consent is essential in all cases.

Contrary Case

Contrary cases can often be helpful in an analysis, since it may be easier to say what something is not than what it is. Contrary cases are those which are clear examples of “not-the-concept” (Walker & Avant, 1995). A contrary case of VAE is presented below:

Patient C. is a 35-year-old woman. Because of renal failure, she has to attend dialysis every day. She is independent in activities of daily living. She is optimistic and has never given up her right to live. Her family supported and assisted her to the hospital every day and encouraged the doctors to try every possible treatment for her. The health professionals carried out active treatments, and C. is still alive.

This situation presents the contrary case of VAE. Patient C. is not in intolerable suffering. She did not ask for a peaceful and painless death. She wants to live. Her family also wants her to live, and the health professionals carried out active treatments. The defining attributes of voluntary active euthanasia are completely absent from this case.

Identifying Antecedents and Consequences

Walker and Avant (1995) stated that identifying antecedents and consequences focuses on the social contexts of the analyzing concept, and helps to further refine the critical attributes.

Antecedents of VAE

Antecedents are situations or phenomena that precede the concept (Rodgers, 1993). Walker and Avant stated that it can be identified from the previous presentation of material, and identity incidents that must occur prior to the occurrence of the concept (Walker and Avant, 1995). Therefore, the proposed antecedents of VAE are

* The individual suffers from a disease

* Two or more individuals are involved

* The patient expresses intolerable pain

* The patient is mentally competent and autonomous

* The patient has a poor quality of life or meaningless life

* The patient has the desire to end life

Consequences of VAE

Consequences, on the other hand, are those events or incidents which occur as a result of the occurrence of the concept (Walker & Avant, 1995). Rodgers (1993) refers to situations, events, or phenomena that follow the analyzed concept. Therefore, the proposed consequence of VAE is the patient’s unrecoverable death.

Empirical Referents

The empirical referents are measures of the defining attributes of the concept, and are specific behavioral signs which indicate that the concept has occurred. In many cases the critical attributes and the empirical referents are identical (Walker & Avant, 1995).

However, in the concept of VAE with its abstract defining attributes, the empirical referents indicating the presence of VAE proceed from communication to discussion, to solemn expression, to positive action. Following this action, the individual’s heartbeat stops. Vital signs disappear (no response, no pulse, and no respiration) and pupils are dilated.

Conclusions and Implications to Nursing Practice

Among health professionals, nurses have the most contact with and are often involved in caring for terminally ill patients. They intimately witness the devastation of life-threatening illness and struggle to provide humane care. Professional conduct and respect for patient’s autonomy sometimes are contradictory, which places the nurse in an ethical dilemma.

Schwarz (2004) pointed out that “even nurses with many years experience in providing end-of-life care may be uncertain about identifying and doing the ‘right thing’ for dying patients” (p. 233).

As the largest group of healthcare professionals, nurses must learn to deal with the ethical, legal, and social consequences of euthanasia practices. Clinical, ethical, and policy differences and similarities of VAE need to be debated openly, both publicly and within the medical profession. However, failure to acknowledge the risks of accepted practices may also undermine the quality of terminal care and put patients at unwarranted risk. Hidden, ambiguous practices and inconsistent justifications should be avoided.

Therefore, the analysis of the concept of VAE indicates the importance of achieving conceptual clarity prior to joining any debates. Awareness of the classifications about euthanasia may help nurses dealing with “end of life issues” properly, and may also provide valuable references for nurses who continue to be asked for assisting in dying.

Research highlighting these concepts can give impetus to the development of social policy, and raise ethical awareness surrounding right to die issues among nurses and other health professionals.

Among health professionals, nurses have the most contact with and are often involved in caring for terminally ill patients. They intimately witness the devastation of life-threatening illness and struggle to provide humane care. Professional conduct and respect for patient’s autonomy sometimes are contradictory, which places the nurse in an ethical dilemma.

References

Begley, A.M. (1998). Beneficent voluntary active euthanasia: A challenge to professionals caring for terminally ill patients. Nursing Ethics: An International Journal for Health Care Professionals. 5(4), 294-306.

Mclnerney, F., & Seibold, C. (1995). Nurses’ definitions of and attitudes towards euthanasia. Journal of Advanced Nursing, 22(1), 171-82.

Oosthuizen, H. (2003). Doctors can kill-Active euthanasia in South Africa. Medicine and Law, 22, 551-560.

Rodgers, B.L. (1993). Concept analysis: An evolutionary view. In Rodgers, B.L., & Kanfl, K.A. (Eds.), Concept development in nursing: Foundations, techniques, and application (pp. 73-92). Philadelphia: WB Saunders.

Schwarz, J.K. (2004). Responding to persistent requests for assistance in dying: A phenomenological inquiry. International Journal of Palliative Nursing, 10(5), 225-235.

Thompson, D. (Ed.) (1995). The concise Oxford dictionary (9th ed.). Oxford: Oxford University Press.

Thompson, I.E., Melia, K.M., & Boyd, K.M. (2001). Nursing ethics (4th ed.). Edinburgh: Churchill Livingstone.

Walker, L., & Avant, K. (1995). Strategy for theory construction in nursing (3rd ed.). Norwalk, CT: Appleton & Lange.

Wilson, J. (1963). Thinking with concepts. New York: Cambridge University Press.

Fenglin Guo, PhD, MSc, BSc, RGN

Fenglin Gou, PhD, MSc, BSc, RGN, is a Fellow at De Montfort University, Leicester, UK.

Author contact: [email protected], with a copy to the Editor: [email protected]

Copyright Nursecom, Inc. Oct-Dec 2006

(c) 2006 Nursing Forum. Provided by ProQuest Information and Learning. All rights Reserved.

Appendiceal Cancer and Peritoneal Carcinomatosis: A Report of 29 Cases/DISCUSSION

By Esquivel, Jesus; Merriman, Barry; Davis, Sallie; Manning, Darrell; Et al

JESUS ESQUIVEL, M.D., F.A.C.S., BARRY MERRIMAN, SALLIE DAVIS, M.D., DARRELL MANNING, M.D.

From the Department of Surgery, Division of Surgical Oncology, Kaiser Permanente of the Mid-Atlantic States, Washington, District of Columbia

Peritoneal surface malignancies of appendiceal origin arise from a perforated neoplasm with gradual expansion of the tumor within the abdomen. We report our experience with 29 patients. Between February 2000 and November 2004, 29 patients were classified into one of three groups based on the features of their peritoneal dissemination. Group 1 included those with extracellular mucin with little cellular atypia (disseminated peritoneal adenomucinosis/low- grade mucinous adenocarcinomas). Group 2 included those with peritoneal mucinous carcinomatosis/high-grade mucinous adenocarcinomas, and Group 3 included those with nonmucinous carcinomatosis. There were 17 patients in Group 1, 9 in Group 2, and 3 in Group 3. The majority had cytoreductive surgery and intraperitoneal chemotherapy. There were no operative deaths. Mean follow-up was 21 months. Median survival for Groups 1 and 2 has not been reached. Group 3 patients were more likely to die than Group 1 patients, with a hazard ratio of 48.0 (P = 0.001), and Group 2 patients with a hazard ratio of 7.8 (P = 0.029). Median survival for Group 3 was 5 months. These data add to the growing evidence that supports cytoreductive surgery and intraperitoneal chemotherapy in a selected group of patients. Those with mucinous peritoneal dissemination are more likely to benefit from this approach. It appears that in patients with nonmucinous carcinomatosis, the biology of the tumor predicts their outcome.

PERITONEAL SURFACE MALIGNANCIES represent a spectrum of diseases characterized by a rupture of the primary tumor with wide dissemination in the intraperitoneal cavity. This dissemination is governed mainly by three factors: the flow of the peritoneal fluid, which is clockwise, results in frequent accumulations of tumor underneath the right hemidiaphragm. Another factor is the phagocytic activity of the greater and lesser omentums and the appendices epiploicae in the sigmoid colon. Accumulation of tumor in these anatomical sites gives rise to the classic omental caking associated with these types of tumors. The third factor, gravity, leads to tumor accumulation in the culde-sac region with subsequent pelvic outlet obstruction. The paradigm of peritoneal surface malignancies is represented by the rupture of an appendiceal adenoma. After the tumor ruptures, large amounts of mucus and tumor will redistribute throughout the entire abdomen, giving rise to the Pseudomyxoma peritonei syndrome with its characteristic “jelly belly.”1 In the past, this term was used for any peritoneal dissemination of a gastrointestinal mucin-producing adenocarcinoma, a primary mucinous ovarian tumor, and even peritoneal carcinomatosis from nonmucinous tumors. In some of these cases, the peritoneal dissemination consists mostly of solid tumor and serous ascites, and their clinical presentation can vary from intestinal obstruction, intractable ascites, or even a manifestation of a hypercoagulable state like a deep vein thrombosis or a pulmonary embolus.

Pseudomyxoma peritonei was once treated with repeated operative debulking procedures with the goal being to evacuate as much tumor and mucus as possible. Even though it is a minimally aggressive tumor with limited capability of invasion, few patients lived beyond 5 years.2 Invariably, the tumor would continue to grow and the patients would succumb to intestinal obstruction. Sugarbaker et al.3 have previously reported greater than 80 per cent 5-year survival rates in patients with appendiceal adenomas with Pseudomyxoma peritonei syndrome treated with a comprehensive cytoreductive surgery and intraperitoneal hyperthermic chemotherapy. The use of peritonectomy procedures, better perioperative management, and strict selection criteria have allowed this systematic approach to be used for the treatment of high-grade appendiceal cancers and other mucinous and nonmucinous peritoneal surface malignancies of gastrointestinal origin. Long-term success with this particular approach has also been reported in patients with peritoneal dissemination from colorectal cancer. In a recent report, the median survival in patients with colorectal cancer with peritoneal dissemination in whom a complete cytoreduction was achieved was 32 months.4

The aim of this study was to report a detailed analysis of 29 patients with peritoneal dissemination from an appendiceal neoplasm evaluated by the Kaiser Permanente MidAtlantic Region Cancer Center.

Materials and Methods

The research records of all the patients with peritoneal surface malignancies evaluated by the Kaiser Permanente MidAtlantic Region Cancer Center from February 2000 to November 2004 were reviewed. There were 57 patients with peritoneal surface malignancies. Of these, 29 patients had the diagnosis of a peritoneal surface malignancy of appendiceal origin. Four patients were excluded from the study because of the following reasons: two refused surgery, one had an appendectomy only, and one had not had surgery at the time of this report. An analysis of the remaining 25 patients constitutes the basis of the study. No patients were lost to follow-up.

All 25 patients were taken to the operating room with the intention of performing cytoreductive surgery and intraperitoneal hyperthermic chemotherapy. A completeness of cytoreduction score (Table 1) was assigned to each patient at the end of their surgical procedure. A summary of selected clinical and histopathological features regarding these 25 patients was gathered from the clinical records. An analysis of these features and their prognostic impact was performed using survival as an endpoint.

Results

There were 15 men and 14 women. The mean age of presentation was 59 years. The most common presenting sign or symptom overall was increasing abdominal girth, with 34 per cent of the patients presenting this way. Fifty per cent of women presented with an ovarian mass (Table 2). There were 14 (56%) patients in Group 1 and the vast majority of those had disseminated peritoneal adenomucinosis. There were eight (32%) patients in Group 2 and there were three (12%) patients in Group 3 (Table 3). The standard surgical approach consisted of a very generous midline incision, usually removing the umbilicus. The peritoneum of the anterior abdominal wall was usually stripped to get access to the intraperitoneal cavity. Mechanical retraction was achieved with a Thompson retractor and the abdominopelvic regions were then evaluated. High-voltage electrosurgery with a 3-mm ball tip was used to perform the peritonectomy procedures necessary to remove as much tumor as possible. After all of the resections were done, the abdomen was prepped for the intraperitoneal hyperthermic perfusion with the open coliseum technique. The majority of patients (84%) had cytoreductive surgery, and 76 per cent of those patients had intraperitoneal chemotherapy with mitomycin C (12.5 mg/m^sup 2^ in men and 10 mg/m^sup 2^ in women) heated at 42 C for 90 minutes (Table 4). There were four (16%) patients that had only an exploratory laparotomy and were closed because a cytoreduction could not be performed because of the extensive involvement of the small bowel. There were no operative deaths. The overall morbidity was 32 per cent. Six (24%) patients had a Grade III complication and two (8%) patients had a Grade IV complication. There were 17 patients with no Grade III and no Grade IV complications (Table 5). Mean follow-up was 21 months. Cox Proportional-Hazards regression was used to measure and test the impact that a number of factors had on survival. Age, gender, and length of hospital stay were not statistically significantly related to survival. The completeness of cytoreduction score approached but did not reach statistical significance, with patients with a CC score of 3 being 7.9 times as likely to die as a patient with a CC score of 1 (P = 0.068). The group that a patient was in was statistically related to survival. Patients in Group 2 were 6.1 times more likely to die than patients in Group 1 (P = 0.028), and patients in Group 3 were 48.0 times more likely to die than patients in Group 1 (P = 0.001). Similarly, patients in Group 3 were 7.8 times more likely to die than patients in Group 2 (P = 0.029). Median survival for Group 1 and Group 2 has not yet been reached, but it is greater than the 22 months in Group 1 and greater than the 20 months but less than the 2 years in Group 2. Median survival for Group 3 patients was 5 months.

TABLE 1. Surgical Scoring

TABLE 2. Clinical Presentation

TABLE 3. Pathology

TABLE 4. CC-Scores

TABLE 5. Morbidity and Mortality

Discussion

Cytoreductive surgery and intraperitoneal hyperthermic chemotherapy are playing an ever-increasing role in the treatment of patients with peritoneal carcinomatosis of gastrointestinal origin. Results of this treatment modality are being reported from centers around the world. In addition, the morbidity and mortality from this procedure has improved significantly and is no different than any other major gastrointestinal \or hepatobiliary operation for cancer.

This study reports the results of our peritoneal surface malignancy center treating peritoneal carcinomatosis of appendiceal origin. A critical review of our early experience warrants further discussion.

There were four (16%) patients that were opened and closed, and only 56% of the patients (14/25) were able to have the cytoreductive surgery and the intraperitoneal hyperthermic chemotherapy. These numbers represent a combination of inadequate patient selection criteria and that cytoreductive surgery with intraperitoneal hyperthermic chemotherapy is a complex procedure with a very steep learning curve. None of those four patients that were opened and closed survived 24 months.

In Group 1, there were 8 of 14 (57%) patients with complete cytoreductions, CC-1. Five of those 8 patients had a massive cytoreductive surgery (operating room time greater than 10 hours) with intraperitoneal hyperthermic chemotherapy. All five patients are alive and four of five (80%) are with no evidence of disease at a follow-up greater than 24 months. It is important to mention that of the four patients that were excluded from the study because they did not have surgery, three had the diagnosis of a low-grade mucinous adenocarcinoma and were still alive at the time this article was written. The other patient had a high-grade mucinous adenocarcinoma and died 4 months after diagnosis.

Also, recurrence of low-grade mucinous adenocarcinomas of the appendix even after a complete cytoreduction is not an uncommon event.5 This relapse has been correlated with a number of clinicopathological parameters, including extent of initial disease, histology, adequacy of cytoreduction, the use of intraperitoneal chemotherapy, and other factors. Still, the ability to inhibit mucin reaccumulation would transcend all of these prognostic factors. As pointed out by O’Connell et al.,6 they can think of no setting more appropriate for new translational approaches than that offered by Pseudomyxoma peritonei where MUC2 is the clear target and is the cause of the disease’s morbidity and mortality.

Our current approach for patients with low-grade mucinous adenocarcinomas of the appendix is to perform the best ostomy- sparing cytoreductive surgery with intraperitoneal hyperthermic chemotherapy followed by systemic chemotherapy if gross disease was left behind. However, sometimes the only way to achieve an adequate cytoreduction will be to perform a total abdominal colectomy with an end ileostomy.

When it comes to high-grade mucinous and nonmucinous appendicial cancer, our current review shows that we were able to achieve a complete cytoreduction in only two of eight patients in Group 2. At a mean follow-up of 21 months, these were the only two patients from Group 2 that were alive. In Group 3, all patients had only surgical debulking and no intraperitoneal hyperthermic chemotherapy because of bulky disease left behind. None of these patients lived more than 9 months. It is clear that this group of patients did not benefit from our surgical procedure.

As a result of these experiences, we have refined our selection criteria, making every possible effort to take patients with high- grade tumors of the appendix to the operating room only if we think that an adequate cytoreduction can be achieved. That has decreased our open and close rate for peritoneal carcinomatosis from appendicial cancer to 3 per cent in our latest 33 cases.

Also, there has been significant improvement of the armamentarium with systemic chemotherapy. The combination of cytotoxic chemotherapy with biological agents has resulted in a median survival of more than 20 months in patients with metastatic colorectal cancer.7 Unfortunately, there is no data regarding the use of these therapeutic combinations in the treatment of peritoneal carcinomatosis from appendicial cancer. Whether these new regimens should be used in a neoadjuvant or adjuvant setting in asymptomatic patients with high-grade appendicial cancer warrants further evaluation.

In summary, it appears that the prognosis of patients and the responses to cytoreductive surgery and intraperitoneal hyperthermic chemotherapy depend on the histology, the degree of malignant transformation that is present in the appendiceal tumors, and the adequacy of the cytoreductive surgery, and only with a continuous interaction between medical and surgical oncologists will we be able to identify the right sequence of our therapeutic treatment modalities.

REFERENCES

1. Esquivel J, Sugarbaker PH. Clinical presentation of the Pseudomyxoma peritonei syndrome. Br J Surg 2000;87:1414-8.

2. Gough DB, Donohue JH, Schutt AJ, et al. Pseudomyxoma peritonei. Long-term patient survival with an aggressive regional approach. Ann Surg 1994;219:112-9.

3. Sugarbaker PH, Chang D. Results of treatment of 385 patients with peritoneal surface spread of appendiceal malignancy. Ann Surg Oncol 1999;6:727-31.

4. Glehen O, Kwiatkowski F, Sugarbaker PH, et al. Cytoreductive surgery combined with perioperative intraperitoneal chemotherapy for the management of peritoneal carcinomatosis from colorectal cancer. A multi-institutional study. J Clin Orthod 2004; 22:3284-92.

5. Esquivel J, Sugarbaker PH. Second-look surgery in patients with peritoneal dissemination from appendiceal malignancy. Analysis of prognostic factors in 98 patients. Ann Surg 2001;234: 198-205.

6. O’Connell JT, Tomlinson JS, Roberts AA, et al. Pseudomyxoma peritonei is a disease of MUC2-expressing goblet cells. Am J Pathol 2002;161:551-64.

7. Hurwitz H, Fehrenbacher L, Novotny W, et al. Bevacizumab plus irinotecan, fluorouracil, and leucovorin for metastatic colorectal cancer. N Engl J Med 2004;350:2335-42.

Presented at the Annual Scientific Meeting and Postgraduate Course Program, Southeastern Surgical Congress, Lake Buena Vista, FL, February 18-21, 2006.

Address correspondence and reprint requests to Jesus Esquivel, M.D., F.A.C.S., Surgical Oncology, St. Agnes Hospital, 900 Caton Avenue, Baltimore, M.D. 21229.

DISCUSSION

EDWARD A. LEVINE, M.D. (Winston-Salem, NC): This paper represents an initial experience with cytoreductive surgery and intraperitoneal hyperthermic chemotherapy for peritoneal carcinomatosis from an appendiceal primary.

The absence of mortality is quite impressive with this initial experience of 25 patients undergoing this arduous procedure. Distributions of patients with low-grade versus high-grade tumors is quite similar to that of larger centers, and the major morbidity rate of 32 per cent is quite reasonable for operative procedures of this magnitude. However, the rate of complete, or nearly complete, CC-1 cytoreduction was only 40 per cent, which is significantly lower than that seen in other centers.

I have several questions for the authors. First, in the paper, the authors describe limiting cytoreductive procedures to perform the “best ostomy sparing cytoreduction.” Having worked for some time in this field and having spent significant efforts in trying to quantify quality of life in these patients, I certainly understand the desire to avoid a stoma. However, the adverse impact of a stoma pales in significance to unsalvageable recurrent peritoneal disease. How are patients chosen for resection mandating a stoma or a stoma sparing procedure?

Second, the authors seem to suggest that only with CC-1 procedures was the intraperitoneal chemotherapy delivered. We, and others, have wrestled with perfusion of selected patients with R2a, or as the author calls them, low-volume CC-2 disease. Our patients with residual disease less than 5 mm in size are perfused and not simply observed. How much residual disease will the authors tolerate and continue with the chemoperfusion?

Finally, the authors suggest, and I would agree, that systemic therapy is needed for patients with high-grade lesions whether mucinous or not. Although patients with appendiceal tumors treated with cytoreductive surgery and intraperitoneal hyperthermic chemotherapy have survivals three times that of those with colorectal cancers, the high-grade lesions behave very much like colorectal adenocarcinomas in this setting. That being the case and with the recent improvements in systemic chemotherapy for colorectal carcinomas with the availability of agents such as oxaliplatin, irinotecan, and avastin, I ask the authors: would procedures be best performed before or after initial systemic therapy?

Dr. Esquivel and his colleagues bring significant experience to this vexatious problem, and I look forward to their responses.

JESUS ESQUIVEL, M.D. (Clarksville, MD; Closing Discussion): Regarding the first question, what we are currently doing for patients with low-grade mucinous tumors is to try to perform what we call “The Boss,” the Best Ostomy-Sparing Surgery. That is only for patients with a true pseudomyxoma. We have been able to spare many of the right colon resections for pseudomyxoma. We do not believe that a right colectomy is necessary for patients with pseudomyxoma. We have been able to remove the peritoneum from the right colon and the pelvic peritoneum, including the cul-de-sac in patients who have small-volume disease in these regions. If the patient has disease that is extensive, there is no way to remove that peritoneum. Previously, our approach was to do a resection, and some of those patients ended up with an ostomy, whether it was temporary or permanent. Now, we try very hard to eliminate the tumor without having to do an ostomy. For high-grade tumors, there is no way you can remove the cul-de-sac and remove the pelvic peritoneum without having to do a resection.

Regarding the second question of when do we decide to do a perfusion, in our most recent review, we had about 97 per cent perfusion rate for appendicial cancer on our last 33 cases in Baltimore.

In terms of whether you should do systemic chemotherapy before or after, I do not know the answer to th\at. I think that if the patient presents to us with a very large abdomen and having repeated paracenteses, preparing the patient for the best systemic chemotherapy will be a more reasonable approach rather than giving the patient, who is not even able to eat, a combination of cytotoxic and biologic agents.

Copyright The Southeastern Surgical Congress Aug 2006

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