By Ed Offley, The News Herald, Panama City, Fla.

Feb. 12–NAVAL SUPPORT ACTIVITY — — PANAMA CITY

It’s a picture-perfect morning on St. Andrew Bay. A cool breeze flows in from the water, bringing with it the soft murmur from the engine of a distant powerboat. Cormorants skim the surface of the bay, and pine needles overhead glitter in the late-morning sunlight.

It’s hell on earth.

Class 06-30-2C is in the sand pit.

Just minutes earlier, the 20 U.S. Navy Dive School students came jogging down Solomons Drive in a tight formation as they concluded a five-mile run. For five hours now, they have been pressed to the limit by their Training Team’s unrelenting schedule: 0430 reveille, 0500 breakfast, 0530 PT exam, then nearly four hours of intense train ing in the pool.

Already they have learned “drownproofing,” technique for staying afloat without the help of life vests or rafts; how to wear and use the standard Navy diving mask, fins and snorkel; the proper procedures for safely entering the water while wearing diving gear; and how to retrieve and clear water from the facemask while remaining sub- merged. They have done pushups until their muscles screamed for relief.

Permeating the tests, exercises and physical training events — and adding mental stress to their already aching bodies — is an unbending, in-yourface regime of military discipline that rises to the level of oppression. The class hasn’t seen this jack-in-the-box routine since the Great Lakes boot camp grinder, or plebe summer at the Academy — if then.

On order, Class 30 forms in two lines of 10 facing Hall, the training team leader.

“This is the eight-count bodybuilder,” he announces, calling off each element by number.

“One,” Hall says, dropping from attention into a squatting position.

“Two,” he barks, throwing his feet back to reach the leaning rest position on hands and feet, back straight and arms locked at the elbow.

“Three … four,” he snaps, doing a full pushup.

“Five,” he adds from the leaning rest position, throwing his legs apart in a leg split.

“Six,” he calls, bringing his legs together again.

“Seven,” he says, jerking his body back into a squat.

“And eight.” Hall ends, jumping back to his feet.

The students wait, still at attention. “We will do ten of these,” Hall announces.

“HOO-YAH TEN!” the students shout.

“Stand to,” Hall orders them. “Are you ready?”

“HELL, YEAH,” Class 30 responds.

On count, 20 bodies drop to a squat. They lunge into the leaning rest, push down, push up, split their legs, close them again, jump back into a crouch, leap back to their feet. And again. And again, eight more times.

Hall continues the litany in a monotone that carries over the sand pit, his 39-year-old body working like a precisely tuned machine. The other instructors, in bright yellow sweatshirts, stand and watch the students.

The sole civilian student, Lucas, catches their eye first. Face stretched with pain, by the end of the third set he can’t keep the pace. His pushups are puny little things that don’t come close to the ground. He jumps back into the crouch with a wobble and teeters instead of snapping to his feet.

“Everyone is doing it except you, Lucas,” an instructor snarls.

Hall leads them through the four sets. Forty of the eight-counts. Class 30 is unraveling badly as fatigue sets in.

Without warning, Hall shifts gear. He intones, “Nineteen, eighteen, seventeen …. “

Class 30 has been briefed.

The 20 bodies race from the sand pit, sprint 30 yards and fling themselves into St. Andrew Bay. The water is all of 6 inches deep, so they must do a full roll to properly soak themselves. The cool water is for an instant wonderful, but now the students must make it back to the sand pit before the countdown ends.

“Four, three, two … ” Hall chants, as the wet bodies throw themselves flat onto the sand.

Hall summons Bibler up front to lead the exercise. Within minutes the 20 sets of canvas UDT shorts, white T-shirts, arms, legs and faces are caked with sand.

Tymofy in the back row, starboard side, is suddenly surrounded by yellow shirts. Their comments are drowned out by Bibler’s hoarse cadence of the eight-count, but Tymofy suddenly bellows, “HOO-YAH, Instructor! I want to be here. I want to be here — really bad!”

Instructors Foster and Pendino stroll through the heaving mass, picking up double handfuls of sand and throwing them on the students’ backs, legs and necks. The eight-count ends.

“Nineteen, eighteen …. ” Hall intones.

Back to the water at full speed, dropping, rolling, on their feet. Moselle is last out of the bay, and Hall is down to “three” as she throws herself head-first into the sand pit like a runner stealing home.

“On your backs –on your bellies,” Hall orders. The students comply instantly and find themselves basted with sand.

Having attracted their ire, Tymofy is next to lead the eight-count cadence.

“Attention to orders,” he chants hoarsely. “The exercise is an eightcount bodybuilder.

“HOO-YAH EIGHT-COUNT BODYBUILDER!” they shout back.

“Stand to” the petty officer croaks.

Squat, lunge, down, up, split, together, squat and up again. And again. And again ….

Instructor Vann steps up. “Some of you people are giving up way too soon,” he says in a stern voice. “When you think you don’t have anything left, you do.”

“Anybody want to quit?” Vann asks.

“HELL NO,” Class 30 shouts in unison.

It goes on forever. And this is just the first real day. Indoctrination day

The first day — only yesterday but seemingly a lifetime ago already — was eerily civil and calm.

Class 30 silently marched down Skylark Drive and Crag Road in the blackness before dawn. The base seemed still asleep, but other groups of students — the Marine Combatant Divers, the Air Force PJs, a pair of earlier Two-Charlie courses — also were up. Here and there they assembled with diving gear, jogged to the PT course, headed for muster and class. Occasional barked commands and Jody calls, chants in cadence, pierced the cool air.

Class 06-30-2C formally meets for the first time in its assigned classroom up on the second deck of the Momsen Building. It’s your basic Navy school setting: two-man tables and hard chairs, whiteboard and overhead projector and harsh neon ceiling lights that cast a pallor over the group. Dressed in Navy blue winter uniforms, they sit quietly, murmuring — about as coherent a team as any 21 strangers waiting to board a plane.

The sound of traffic on Thomas Drive is a low drone outside the two open windows. The sky is just beginning to brighten when the five members of Training Team 6 enter. All conversation instantly halts. The burly team leader strides front and center and introduces himself.

“Welcome to Dive School,” Engineman Chief Timothy Hall says in a brisk voice. The second sentence out of his mouth is a flat warning. “Diving School is not for everybody.”

The students listen silently.

“We will be putting each and every one of you under a lot of stress,” says Hall, his thick forearms crossed across his chest, obscuring five rows of ribbons. “We are going to take you out of your comfort zone.”

He repeats the basic message. “You are all volunteers, but this is not a job for everybody. If you feel ‘This is not for me,’ come and let us know.”

Since Navy diving is inherently more dangerous than other assignments, students are allowed to drop on request (DOR) with no blemish on their records, Hall explains.

There are numerous ways in which a student can get tossed from the program: a single DUI and the student is out; failing a classroom test or key PT exam or swim test and a student will face a review board that can order him back to the fleet. Doing “something stupid” such as an unauthorized absence (UA) or violation of military discipline will bring the walls crashing in.

Hall quickly establishes the parameters for the next 14 weeks.

On the military structure of Dive School: “You may outrank one of your instructors,” he says, glancing at the four commissioned officers in the class. “You do not challenge his authority.”

On the strictness of performance scores: “If you fail the (PT) run by one second, you fail. If on the pull-up your legs are crooked, you fail.”

“You are going to leave here in one of two ways,” Hall continues. “As a DOR or with a Navy Diver pin on your chest.”

After introducing the other four instructors and reviewing a list of housekeeping procedures, Hall again underscores the harsh realities of Dive School by introducing Navy Career Counselor 1st Class Latonya Luter. Her message to the class is short and to the point: “If you are disenrolled from training, I’m the first person you will talk to,” she says.

The instructors set a firm tone from the outset. “We try in the beginning to be very separated from the students,” Hall earlier explained. “If you befriend students it changes things. It’s hard to kick someone out if you’re friends.”

Hall says little about his 20-year Navy career to the class, nor does he waste time discussing his previous assignments as a ship’s husbandry diver with the Shore Intermediate Maintenance Facility (SIMA) in Norfolk or subsequent salvage work at Pearl Harbor. There are no details on his volunteer work as part of a massive Navy diver effort to help in the retrieval of debris and passenger remains from TWA Flight 800 after its crash in New York in 1996.

In fact, he says essentially nothing about himself. “I don’t want you to know much about me,” he tells the class.

One instructor unbends a little.

Boatswain’s Mate 1st Class Joe Pendino steps up. As class proctor, the 34-year-old instructor will be the person who the students can turn to for advice and assistance — the “good cop,” as another instructor later notes. Pendino takes roll call, reviews the daily class procedures and regulations. He gives a very short summary of his 10-year Navy career.

Enlisting in 1992, Pendino served for six years with two Virginia-based diving units before leaving the service in 1998 to work as a heavy equipment operator back in Missouri. In the wake of 9-11, he adds, the Navy called him up and invited him to re-enlist.

After a tour with an explosive ordnance disposal unit that included participation in the salvaging of the Civil War ironclad Monitor, Pendino in late 2002 joined the salvage ship USS Grasp in the Mediterranean. After three years, he returned to Panama City in June 2005 as an instructor at the Dive School.

Pendino ends on a high note: “I wouldn’t do anything else in the Navy,” he says.

Engineman 1st Class Charles Foster, 35, doesn’t talk about himself to the students. Instead, he talks about service as a fleet diver.

Speaking of his own three-year tour on the Grasp, Foster explains, “A junk boat is fine but SIMAs are good places to learn how to dive. They get in the water four to six hours a day — and work and work and work.”

Another instructor tries to nudge Foster to talk about himself.

“Why do you want to be here?” Photographer’s Mate Chief Chad Vann asks Foster.

“I want to be here because if I’m not here, I’m UA,” Foster deadpans.

Both Vann and Hospital Corpsman 1st Class Whitney Chastain then tell the students that, like Hall, they do not care to share their personal backgrounds.

Chastain does tell them that he is the designated class hospital corpsman. Students should come to him if they are having any problems with ailments or minor injuries. “Short of the bones coming out of your leg, come see me first,” he says.

The class then breaks up for a day of bureaucratic chores: mandatory urinalysis, CPR class, drawing PT clothing and swim gear. The pool deck

This is where it starts in earnest.

The training pool behind the Dive School building looks like a normal 33-yard swimming pool, but the steam rising from the water and the heavy stench of chlorine betrays its purpose as a proving ground for would-be Navy divers and not a place for recreation.

It is 0712 on Day 2 of training, and the instructors are spread out around the pool deck, waiting for Class 06-30-2C to mount the stairway from below. The sun rising over Panama City across the bay casts a brilliant orange light in the sky that is reflected on Alligator Bayou just behind the training area and the pool itself. The yard boat Poseidon growls to life 50 feet away and edges out from the pier, taking a diving class out to sea.

This is actually the class’s second visit to the pool today. They were up here at 0530 taking the mandatory 500-yard timed swim before mustering on the far side of the south parking lot for the rest of the PT test: 42 push-ups in two minutes; 50 “Navy curl-ups” in two minutes; 6 full pullups in 10 minutes, and a timed 1.5-mile run.

The students are generally in excellent physical shape, and they go through the reps with little problems.

Hospital Corpsman 3rd Class

—–

Copyright (c) 2006, The News Herald, Panama City, Fla.

Distributed by Knight Ridder/Tribune Business News.

For information on republishing this content, contact us at (800) 661-2511 (U.S.), (213) 237-4914 (worldwide), fax (213) 237-6515, or e-mail [email protected].

SUFFERN, N.Y., Feb. 13 /PRNewswire/ — An important head-to-head study has demonstrated the efficacy and greater tolerability of EUFLEXXA(TM) (highly purified hyaluronan) compared to Synvisc(R)*, an avian-derived hyaluronan and the leading hyaluronic acid (HA) product in its class for the treatment of osteoarthritis (OA) knee pain.(1) In the 12-week trial of 321 patients, EUFLEXXA(TM) showed statistically significant advantages over Synvisc: more patients treated with EUFLEXXA(TM) were symptom-free (p=0.038), there was a lower incidence of joint effusion (p=0.0015), fewer patients required supplemental simple analgesics (p=0.013), and more patients reported being “very satisfied” (p=0.03). The study was published in the February 2006 issue of Osteoarthritis and Cartilage.

EUFLEXXA(TM) is the first and only hyaluronic acid (HA) approved in the U.S. for the treatment of the pain of knee osteoarthritis that is not derived from an avian source** (chicken or rooster combs). This eliminates the risk of related reactions.(2),(3) EUFLEXXA(TM) is a three-injection treatment regimen indicated for patients who have failed to respond adequately to conservative non-pharmacologic therapy and simple analgesics. The goal of HA therapy is to reduce pain and improve physical function by replenishing the HA in human synovial fluid (fluid in joints). In OA, this fluid becomes thinner, leading to a decrease in elasticity and viscosity.

“This study shows that EUFLEXXA(TM) offers better symptom-free relief from OA pain over a 12-week period than the market-leading HA therapy with less use of simple analgesics,” said Wayne Anderson, President, Ferring Pharmaceuticals Inc. “For the growing number of Americans who live with the pain caused by knee osteoarthritis, this study demonstrates the greater tolerability of EUFLEXXA(TM) compared to the leading therapy in its class.”

About the Study

In a prospective, multicenter, randomized, double-blind controlled trial, 321 patients with confirmed knee osteoarthritis were randomized to treatment with either EUFLEXXA(TM) (n=160) or Synvisc (n=161). The Western Ontario McMaster Universities Osteoarthritis (WOMAC) Index pain subscale was the primary efficacy measure. Both products were administered as a course of three weekly injections, with follow-up evaluations at weeks 3, 6 and 12. Both treatment groups experienced statistically significant improvements from baseline (p=0.0001). EUFLEXXA(TM) (WOMAC pain score = 29.8 mm (-61.6%)) was shown to be comparable in efficacy to Synvisc (WOMAC pain score = 28.8 mm (-54.9%)).(1) At the study endpoint, 63% of patients treated with EUFLEXXA(TM) were symptom-free compared with 52% of those treated with Synvisc (p=0.038), as determined by a VAS (100-mm visual analog scale) score of

EUFLEXXA(TM) also showed a significant advantage over Synvisc in the number of joint effusions (p=0.0015), patients requiring supplemental simple analgesics (p=0.013), and patient satisfaction (p=0.03). For patient satisfaction, 50% of EUFLEXXA(TM) patients were ‘very satisfied’ with treatment results compared to 37% for the Synvisc group. A subanalysis performed on patients with unilateral OA found that only 49% of patients treated with EUFLEXXA(TM) used supplemental simple analgesics compared to 82% of those treated with Synvisc (p=0.001).(1)

About EUFLEXXA(TM)

EUFLEXXA(TM) (1% sodium hyaluronate) is the first and only non-avian- derived hyaluronic acid approved in the U.S. for the treatment of pain caused by knee osteoarthritis. The process used to manufacture EUFLEXXA(TM) results in ultra-high-purity HA with properties similar to the HA in healthy human synovial fluid. EUFLEXXA(TM) is also free of chemical cross-linking, which minimizes the risk of related reactions.(2-7)

EUFLEXXA(TM) received approval from the U.S. Food and Drug Administration (FDA) on December 3, 2004, and became available to the public on November 8, 2005. For more information, visit http://www.euflexxa.com/.

About Hyaluronic Acid

HA is a viscous, elastic liquid that is naturally found in many tissues of the body and in high concentrations in joint cartilage and synovial fluid. Within a joint, HA is essential to water balance, viscosity, lubrication and the structure of cartilage.(8) In cartilage, HA binds to other molecules, helping it withstand weight-bearing force and movement of the joint. Inside the knee joint, HA provides a cushion to protect the joint from mechanical damage and acts as both a shock-absorbing fluid and regulator of water and metabolites.

Osteoarthritis and the General Population

The Arthritis Foundation estimates that 66 million Americans are affected by arthritis, half of whom are unaware of available treatments, and that the disease costs the U.S. economy more than $86.2 billion annually. The Foundation also estimates that 21 million American adults suffer from osteoarthritis.(9) Osteoarthritis, a form of arthritis, affects certain parts of the body, most commonly the knee. Over time, articular cartilage in the knee loses elasticity and becomes worn. As a result, the bony surfaces of the joint can grind together and eventually wear the cartilage away entirely. This leads to symptoms of pain, stiffness and impaired joint movement. There are a wide range of treatment options for the pain of knee OA, including behavior modification, drug therapy, injections within the joint and knee replacement surgery.

Non-steroidal anti-inflammatory drugs (NSAIDs) are common first-line pharmacologic treatments for knee pain relief. Serious side effects and risks (i.e. potentially life-threatening stomach bleeding and kidney disease) have been associated with such treatments. The effectiveness of different treatments varies from person-to-person and with the severity of the condition. Treatment options are generally a shared decision between the patient and his/her physician with total knee replacement surgery usually sought as the last option.

About Ferring Pharmaceuticals Inc.

Ferring Pharmaceuticals Inc., part of the Ferring Group, is a privately owned, international pharmaceutical company. Ferring’s line of orthopaedic and urology products includes EUFLEXXA(TM), hyaluronic acid for the treatment of pain from osteoarthritis of the knee and degarelix for prostate cancer (Phase III).

Ferring also markets Menopur(R) (menotropins for injection, USP), Bravelle(R) (urofollitropin for injection, purified), Repronex(R) (menotropins for injection, USP) and Novarel(R) (chorionic gonadotropin for injection, USP) in the U.S. to infertility specialists and their patients. Ferring offers the Q-CAP(TM), the first and only needle-free reconstitution device, for use with its fertility treatments.

Other products include ACTHREL(R) (corticorelin ovine triflutate for injection) for the differential diagnosis of Cushing’s syndrome and generic desmopressin acetate in injectable and rhinal tube forms for the treatment of diabetes insipidus and primary nocturnal enuresis.

The Ferring Group specializes in the research, development and commercialization of compounds in general and pediatric endocrinology, urology, gastroenterology, obstetrics/gynecology and infertility. For more information, visit http://www.ferringusa.com/.

     * Synvisc is a registered trademark of Genzyme Corporation.    ** Derived through bacterial fermentation     (1) Kirchner M, Marshall D. A double-blind randomized controlled trial        comparing alternate forms of high molecular weight hyaluronan for the        treatment of osteoarthritis of the knee. Osteoarthritis Cartilage.        2006;14:154-162.     (2) Schiavinato A, Finesso M, Cortivo R, & Abatangelo G (2002).        Comparison of the effects of intra-articular injections of Hyaluronan        and its chemically cross-linked derivative (Hylan G-F20) in normal        rabbit knee joints. Clin Exp Rheumatol 20, 445-454.     (3) Goomer RS, Leslie K, Maris T, & Amiel D (2005). Native hyaluronan        produces less hypersensitivity than cross-linked hyaluronan. Clin        Orthop Relat Res 239-245.     (4) Leopold SS, Warme WJ, Pettis PD, & Shott S (2002). Increased        frequency of acute local reaction to intra-articular hylan GF-20        (synvisc) in patients receiving more than one course of treatment. J        Bone Joint Surg Am 84-A, 1619-1623.     (5) Puttick MP, Wade JP, Chalmers A, Connell DG, & Rangno KK (1995).        Acute local reactions after intraarticular hylan for osteoarthritis        of the knee. J Rheumatol 22, 1311-1314.     (6) Pullman-Mooar S, Mooar P, Sieck M, Clayburne G, & Schumacher HR         (2002). Are there distinctive inflammatory flares after hylan g-f 20        intraarticular injections? J Rheumatol 29, 2611-2614.     (7) Chen AL, Desai P, Adler EM, & Di Cesare PE (2002). Granulomatous        inflammation after Hylan G-F 20 viscosupplementation of the knee : a        report of six cases. J Bone Joint Surg Am 84-A, 1142-1147.     (8) Abatangelo, G., O'Regan.  Hyaluronan: Biological Role and Function in        Articular Joints.  European Journal of Rheumatology and Inflammation;        Vol15(1) 1995.     (9) Arthritis Rheum 1999; 41(5):778-799  

Ferring Pharmaceuticals Inc.

CONTACT: Tara Fisher of Kovak-Likly Communications, +1-203-762-8833,[email protected], for Ferring Pharmaceuticals Inc.

Web site: http://www.ferringusa.com/http://www.euflexxa.com/

By Luk, Weety S C

Abstract

Aim To examine whether rehabilitation services are provided to patients undergoing peritoneal dialysis in Hong Kong, and the impact of such services on patients’ lives.

Method Semi-structured interviews were conducted with 30 participants. Transcripts were analysed using thematic content analysis. Categories and codes were identified from the first 21 interviews, but guestioning continued throughout the process to saturate the categories.

Findings Rehabilitation is not provided to patients undergoing peritoneal dialysis in Hong Kong. Most support services are initiated by patients themselves.

Conclusion To enable these patients to lead productive lives, efforts should be made to provide them with the reguired medical information to help them make choices. Nurses should provide appropriate training to peer counsellors and regular exercise should be encouraged to allow patients to maintain physical health and mobility. Support for retraining and employment is also important. Counselling on finding a purpose through other roles is beneficial for those who cannot return to work.

Keywords

Dialysis; Kidney disorders; Quality of life; Rehabilitation

These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For related articles and author guidelines visit our online archive at www.nursing-standard.co.uk and search using the keywords.

PATIENTS WHO perform peritoneal dialysis are now expected to take more responsibility for the treatment of their illness. This shift in the provision of care from medical staff to the patient can be effective only if the patient is concordant with the treatment regimen.

For optimal physiological and psychological recovery, rehabilitation programmes complement traditional patient education in helping patients maintain or improve their health and will aid their transfer from the predialysis stage to maintenance dialysis (Lorigef al 1999).

The study reported in this article was the first to investigate the availability of rehabilitation services for patients undergoing dialysis in Hong Kong. The findings will help nurses determine how to improve existing rehabilitation services for dialysis patients.

Literature review

End-stage renal disease is a chronic condition in which the kidneys can no longer regulate electrolytes and the acid-base balance, and excrete waste products and water from the blood. Although haemodialysis and peritoneal dialysis are life-saving treatments, they are only partial replacements for the excretory function of the kidney. Patients are faced with complicated and demanding treatment regimens that include dietary and fluid restrictions, and medication schedules. Prolonged survival in patients with end-stage renal disease is associated with various functional disorders in almost all body systems. This has a negative effect on the patient’s quality of life.

In Hong Kong, haemodialysis is usually undertaken by nurses in a health centre while peritoneal dialysis is undertaken by patients at home. As the pressure to control hospital costs has intensified, the need to deliver the best nursing care in the most economical way has increased.

In a study by Lindqvist and Sjoden (1998), quality of life was perceived as being below average by both groups of patients receiving in-centre haemodialysis and home peritoneal dialysis, although the latter reported a higher quality of life than those receiving haemodialysis. Peritoneal dialysis is the treatment modality preferred by patients. A study of 120 patients with experience of haemodialysis and peritoneal dialysis found that, when given the opportunity to choose, 92 patients listed peritoneal dialysis as their first choice. The reasons given were that this treatment allowed them more free time and more freedom, improved their wellbeing and was less troublesome. They did not like having an arteriovenous fistula implanted and being bound to the haemodialysis machine (Galpin 1992).

In-centre haemodialysis treatment is more expensive than home peritoneal dialysis. In March 2005, the Central Renal Committee in Hong Kong reported that the average amount spent per patient annually on haemodialysis was 17,143 pounds compared with 7,143 pounds for peritoneal dialysis (Judith Siu, access to information officer, Hospital Authority, Hong Kong, 2005, personal communication). Patients are increasingly required to administer treatment themselves using peritoneal dialysis. This shift in the provision of care from medical staff to the patient is seen as a viable way of controlling rising healthcare costs. In March 2005, the Hospital Authority, the health body in Hong Kong, saw 3,200 peritoneal dialysis patients, while those receiving haemodialysis numbered only 690 (Judith Siu, access to information officer, Hospital Authority, Hong Kong, 2005, personal communication).

Dialysis is a crucial treatment on which a patient’s life depends. In transferring treatment from the hospital to the home, it must be considered whether patients can adapt to the intrusions on daily life caused by the treatment.

Peritonea! dialysis requires patients to repeatedly instil and drain sterile dialysate through an implanted catheter into their peritoneum. Physicians can prescribe peritoneal dialysis using manual exchanges of dialysate fluid (continuous ambulatory peritoneal dialysis) three to four times per day, or automated exchanges in which a cycler is used to fill and drain the peritoneum with dialysate fluid every night (continuous cycling peritoneal dialysis) (Rubinei a/2004). By contrast, haemodialysis is only performed two to three times weekly in a dialysis centre for three to four hours. The non-stop nature of peritoneal dialysis makes it more difficult for patients to separate their treatment from the time when they are not receiving treatment. The large volume of fluid contained within the abdominal cavity may be a concern for some patients. Without the direct supervision of staff, patients receiving peritoneal dialysis need to make day-to-day decisions about the management of their illness, and set and maintain their own dialysis schedules. This can be frightening and depressing for some patients (Luk2002).

If the patient has the ability to control his or her own treatment and is willing to follow the treatment regularly, this should have a positive effect on his or her psychological adjustment to the illness while saving medical resources. If the patient views the responsibility for such crucial treatment as a burden and cannot cope with it, he or she will return and require more expensive treatment in hospital (Luk 2002).

The successful transfer of patients to receive dialysis at home demands that they have sufficient knowledge, skill and ability to carry out their treatment regimen. To ensure that this is the case, a rehabilitation programme is an essential aspect of health care.

Klang et al (1998) assessed the physical capacity, nutritional status and psychosocial needs of dialysis patients after they had undergone a rehabilitation programme. Patients who had participated in the programme had fewer disabilities in function and mobility, were happier and experienced less loneliness and lower levels of anxiety than the control group. A better psychological status empowered patients to participate in their healthcare decisions and enabled them to better understand and control disease-specific symptoms.

Aim

The study aimed to examine whether rehabilitation services are provided to patients undergoing peritoneal dialysis in Hong Kong, and the effect such services may be having on patients’ lives.

Ethical approval

The ethics committee of Hong Kong Polytechnic University granted ethical approval for the research. Before the recorded interviews, all of the participants were informed of the purpose of the study, and of the way the data would be collected and transcribed. Confidentiality and the right to withdraw from the study were guaranteed.

Method

The Hong Kong Hospital Authority provides dialysis services in ten hospitals. Each hospital has a renal club, which is run voluntarily by dialysis patients who are treated in that hospital. Members of each club are the patients receiving peritoneal dialysis and haemodialysis at that hospital. Together, these ten renal clubs form the Alliance for Renal Patients Mutual Help Association.

Since each club represents patients of a regional public hospital, to enhance the representativeness of the study, members of each club were invited to participate in the study, using a convenience sampling method.

The selection criteria were that all participants should be Chinese adults with the cognitive ability to read and understand Chinese. They must currently be receiving peritoneal dialysis and have been doing so for at least one month. Those who met the eligibility criteria were first approached by the administrator of the association, and received an information sheet about the project. The administrator approached 40 patients and 33 (about three from each club) agreed to participate in the study.

The researcher then telephoned these 33 patients and provided a second detailed explanation of the purpose and nature of the study. A total of 30 patients (75 per cent) gave their consent for the study, while three refused to participate because of f\atigue.

For the sake of convenience, most patients preferred to be interviewed by telephone. Data obtained from telephone interviews have been deemed to be as reliable as data obtained from face-to- face interviews (Samarel et al 1998 ). Open-ended questions were used, for example, do you have any rehabilitative support, who provides this support and what do you think about your psychological status in relation to the support you are receiving. To put participants at their ease, the researcher developed rapport by speaking in a natural, conversational tone. To prompt reflection or expansion, probing techniques for clarification were used.

The goals of rehabilitation are to promote independence and self- care, and to maximise feelings of self-determination in patients. Rehabilitation involves the management of disability and restoration of roles from a physical, psychosocial and vocational perspective (Pryor and Smith 2002). Thus, participants were invited to explore and elicit information about their life experiences in these areas. They were also asked to report on what kind of rehabilitative support they were receiving, and who was providing that support.

The participants were free to discuss other issues related to the research topic. A pilot study was first conducted with two patients. Closed questions were used to gather demographic information. The questions were on gender, age, marital status, educational level, length of time on dialysis, income level and health status.

Data collection and analysis were simultaneous and continuous. As the number of participants interviewed increased and the data were concurrently analysed, subsequent questions were derived from the emerging responses to further explore the participants’ unique experiences (Tilden et al 2001 ), for example, whether economic status affected participation in exercise. The interviews progressed until no new insights emerged, indicating that the point of saturation had been reached.

To obtain meaning and understanding, thematic content analysis was applied to the narrative text (Burnard 1991 ). Thematic content analysis is an interpretative process whereby the researcher identifies, codes and categorises the descriptive da ta (Graneheimef al 2001).

Guided by the aim of the study units of meaning, a word, sentence or paragraph that reflected meaningful aspects of the experiences, were coded. Most of the categories were identified from the first 21 interviews after multiple analyses of the transcripts, but questioning continued throughout the process in order to saturate the categories (Glaser and Strauss 1979).

Findings

Of the 30 participants, 13 were male and 17 were female. The participants ranged in age from 29 to 70 years, with a mean age of 49.6 years. Three were widowed, 22 were married and the remainder were either divorced or had never married. Nineteen had completed a secondary level of education, while the others were educated to primary level. All of the participants either did not have a job or had retired. The mean number of years during which the participants had undergone dialysis was 8.3, with a range of 1 to 14. Eight commented that their health status was worsening, 14 said that it was static, and eight felt that it was fluctuating.

The interviews lasted between 45 and 80 minutes, but most were about 60 minutes. Table 1 lists the categories derived from the interviews. The underlying dimensions that emerged from the interview texts arc described below.

Rehabilitation support received The participants recalled that before they were discharged for home peritoneal dialysis, the hospitals arranged a training programme lasting between five to 14 days. The main purpose of the training programme was to equip them and/or their caregivers with the skills to perform dialysis. Follow- up home visits were only arranged for those with problems related to performing the dialysis, for example, those with a high recurrence of peritonitis.

All of the participants commented that apart from the training programme, little support was provided by the hospital. Health institutions seldom organised health talks. All of the participants said that if they had problems, they could make enquiries at the ward. The participants commented that the staff were helpful and informative. References to staff characteristics included: The staff were knowledgeable and enthusiastic’ (Participants 2, 4,8,10,13,14,17,20,22,26 and 28).

However, all of the participants said that they usually sought answers from other patients. The tendency for them to first seek help from their peers rather than from staff was because their peers could give them more practical information to deal with issues of daily life, since ‘…they are in the same boat’ (Participants 4,6,7 and 10).

Support for informational needs All participants said that they usually sought answers from other patients. For example, on the day of follow-up they sought the advice of their peers at the service counter organised by the renal club to which they belonged and which was run by patient volunteers, or they spoke to other patients when queuing for the follow-up consultation.

All of the participants said that health talks were occasionally organised by the renal clubs. Comments indicated that they were satisfied with the talks, for example: ‘I had a chance to learn’ (Participant 1), and ‘The session was very informative’ (Participants 3, 8,10 and 14). However, on questions related to diet, all of the participants preferred to seek advice from their peers rather than from a dietician or nurse. Their comments included: ‘If I followed their advice, I would have nothing to eat’ (Participants 3,4,7, 10,11,13,17,20 and21).

TABLE 1

Categories and codes emerging from the data

Support during psychological crises The participants said that the renal clubs regularly arranged activities such as visits to wards and social meetings to provide psychological support for new patients. During the activities, patients volunteered to share their experiences with new patients. Sometimes, ad hoc support was provided to worried patients referred by staff or social workers.

Twenty-three participants recalled the counselling support as being helpful: ‘I can discuss the problem more with people with similar health problems, since they have been there too’ (Participant 5). Nevertheless, these activities were not always well accepted. Three participants said: ‘I do not share with others, nobody can help’ (Participants 4, 7 and 9). Two reported that: ‘It is not so easy to talk with strangers; one cannot be too open’ (Participants 4 and 7). Formal counselling was suggested by three participants: ‘I would like to seek support from a well-trained professional, like a clinical psychologist’ (Participants 9,11 and 14).

Support for physical and social integration Although general fatigue was reported by all participants, to improve their social integration, the majority tried to participate in activities that were occasionally arranged by the renal clubs or by the patients themselves, such as spring festival party, annual celebration, autumn outing, annual dinner, day camp, night camp, group dinner, sports meeting, charity walk and cuttle fishing.

Twenty participants described themselves as physically active. They performed exercises and/or participated in recreational activities at least twice a week, for example, swimming, strolling, jogging, ping pong, dancing, t’ai chi or qi gong, lawn bowling, bush walking and callisthenics. Of these, five reported engaging in exercise three or more times per week, for 30 minutes to three hours each time. The habit of exercise was begun one to six years ago.

Impact of rehabilitation support on patients’ lives PsychologicalstatusTo pass the time, the majority of participants were involved in voluntary work to offer support to other patients in need. Five participants were peer counsellors. Fifteen ran the non-profit counter, which sold accessories to patients receiving dialysis, for two hours per week on the follow-up day. Seven helped with shopping for patients who were very ill. Home visits to other patients were seldom undertaken. The reason was that ‘not so many people like to be visited at home’ (Participants 2 and 7).

The participants concluded that the volunteer work increased their personal growth and wellbeing. Twenty participants said that by helping others to deal more effectively with problems in their lives, they also benefited: One way to enhance the zest for living is to extend a helping hand toothers’ (Participant 12). They increased their levels of self-confidence, enthusiasm for life, feelings of goodwill towards others and social interactions. Ten participants said: ‘I am less home-bound, watch less TV, and go out more often’ (Participants 3,7,9,10,12, 14,15,18,20 and 21 ). Eleven reported that: ‘Having the chance to help others, I have the sense that I am making a contribution, and I feel happier'(Participants 5, 7, 8,1 1, 12,14, 16,17, 18,20 and21).

However, while the experience of being a volunteer was rich and rewarding for most, some of the encounters could have a negative effect. Four participants commented: ‘I was very down when I was dealing with the deterioration in health and finally the death of one peer patient whom I had been helping devotedly’ (Participants4, 7, 1 1 and 13).

Physical, social and financial integration All participants viewed the maintenance of an energetic and social life as a means to ward off stress and loneliness. The participants commented that exercise was a way to stay fit as well as a way to enhance wellbeing: ‘I feel less fatigued’ (Participants 3, 9,14,17and 18). They reported feeling rejuvenated and healthy after undergoing these activities: ‘!feel more relaxed, less bedridden and sick’ (Participants 3,9,14,17 and 18) and’!walk faster'(Participants 3,9,14, 17 and 18). The activities were not only helpfulfor their physical strength, but also for social integration: ‘Practising t’ai chi every morning in the park, I can have a regular chance to breathe fresh air. The whole team usually goes to a tea house afterwards to have dim sum. This is fun. Before, 1 just spent time sleeping at home’ (Participant 18).

Three of the participants had changed their exercise habits. They attributed their progressive reduction in capacity for exercise to the worsening of their health. One stopped practising t’ai chi because he was not physically strong enough to continue. Two adopted less rigorous exercises, from playing ping pong to gate ball (derived from croquet), because of progressive weakness. Three stopped exercising completely because of newly developed physiological problems: two contracted cancer and one had palpitations. Because they were repeatedly hospitalised, they exhibited less of an ability to recover after each episode of inactivity: ‘I found it very hard to rebound after being bedridden’ (Participant 27). Four had never exercised regularly before and after the dialysis became progressively frailer and eventually confined to home.

The patients’ activities were not only affected by their functional level, but also by their financial status. They had no income. All of them were unemployed, except one who was running his own business but claimed to have made no money so far. Their financial difficulty was an obstacle for them to perform physical activities in a group. For example, the t’ai chi class depended on the availability of a volunteer tutor and a subsidised venue. These factors are difficult to control. The participants also indicated that the expense of travelling to and from the venue was another concern.

Discussion

The Hong Kong Hospital Authority does not provide rehabilitation for patients receiving dialysis. Perhaps this is because the disabilities of these patients are relatively invisible compared with the motor deficits associated with paraplegia or stroke. Patients initiate most support services. Little has been done by hospital staff to enable patients to manage chronic diseases long term. The reported level of rehabilitation is far from acceptable.

Patients undergoing peritoneal dialysis are expected to have the discipline to pay close attention to the details required to perform dialysis at home. Such an expectation can cause patients significant stress. To enable these patients to lead reasonably productive lives, it is essential that they are encouraged from the outset to gain control of their lives and to confront and solve some of the problems associated with chronic illness. Tenge? al (2003) stated that as soon as the patient returns home, the government should provide rehabilitation services. This fulfils the aim of a ‘seamless health care system’ promoted by the hospital authority (Hong Kong Hospital Authority 2000).

Lorig et al (2001 ) argued that rehabilitation programmes are beneficial for patients. The hospital authority should integrate rehabilitation into the treatment programme. To conduct a successful rehabilitation programme, healthcare staff should recognise the problems that patients experience, understand and meet their expressed needs and respect their feelings when they are discharged to the community. The following complex concerns revealed in the present study should be considered in the planning of a rehabilitation programme.

To promote the self-care, self-determination and independence of patients, the training programme provided by hospitals should not only focus on giving patients the requisite knowledge of dialysis, but also the ability to cope with other aspects of their condition. For example, regarding dietary restrictions, Chinese people consider eating an important part of life. Many idioms reflect the importance of eating in Chinese culture, for example, the saying that eating is every person’s first priority, a Confucian saying that eating and sex are the most natural of human activities and a Cantonese saying that one works hard for good food (Luk 2001 ). When recommending a therapeutic diet for patients undergoing dialysis, nurses should attempt to provide advice on a diet regimen that is practical and realistic.

The peer counselling discussed in the present study brought together new patients and those already undergoing treatment. The patients shared their emotions and supported each other, and learnt practical tips about self-care from experienced peers. A similar finding was reported in Bruniereia/’s (2002) study. Brunieref al (2002) stated that renal peer support volunteers possibly improved their own wellbeing by helping others with chronic renal failure. One concern is that if peer counsellors do not receive appropriate training, they may not have the skills to deal with the tensions arising during counselling with their peers, as reported in the present study.

Poor physical status and progressively increasing frailty caused by a sedentary lifestyle are common in patients of all ages requiring dialysis (Koufaki et al 2002). Nevertheless, most participants in the present study led active lives, and their physical habits were not correlated to their level of activity before starting dialysis but were determined by their remaining functional ability. This finding differs from that reported in Alien and Gappmaier’s (1997) study, which reported that the physical activity habits of patients undergoing haemodialysis could be predicted based on activity habits before starting haemodialysis.

Regular exercise is important in enabling a patient to maintain physical health and mobility. Fitness can increase the ability of patients to take part in activities that previously brought them pleasure, thus reducing feelings of depression and improving their overall psychological functioning (Koufaki et al 2002). The prevention of frailty will also reduce the costs associated with the loss of employment, loss of independence in activities of daily living and increased risk of hospitalisation. By reducing hospital stays, the government will undoubtedly save thousands of dollars.

In the present study, poverty was a hurdle for participants who wished to continue exercising, with a reported 97 per cent unemployment rate. This rate is much higher than that reported in Luk’s (2001) study. The decline in Hong Kong’s economy in recent years has perhaps had a significant effect on this vulnerable group. It is difficult for a patient on dialysis to find a regular job since employers may be reluctant to hire a worker who needs to spend hours each day having dialysis and to take regular leave for medical follow-ups.

The positive effects of participating in an education programme prevailed during the first six months of dialysis treatment, after which they diminished (Klangeia/1998). Comprehensive and ongoing assessments that identify early warning signs of change and inform early intervention to prevent adverse situations are important (Pryor and Smith 2002). For example, staff should regularly re- examine the dialysis technique of patients. Thus, patient education should be ongoing during the predialysis stage and continued after maintenance dialysis has been established.

To ensure positive outcomes from peer counselling, nurses should provide appropriate training for peer counsellors. Thus, while the recipient can benefit from the counselling, the peer counsellor could cope with the negative psychological impact caused by counselling, if any (Pryor and Smith 2002).

Nurses should co-ordinate the input from all members of the healthcare team as well as the family. Their participation will not only provide a chance for them to exchange ideas, but also provide an opportunity for patients and their families to discuss the patient’s physical and psychological condition with health professionals, peer patients and each other (KlangeiiZ/1998).

Working is an important aspect of life for many individuals, helping them to retain the sense of a meaningful existence. Support for retraining and employment is important. Counselling on finding a purpose in other roles is beneficial for those who cannot return to work (Luk 2001).

When earning capacity is affected, the expenses incurred by exercise represent a tremendous burden to patients. Hospitals should initiate efforts to regularly arrange a regimen of physical activity for patients at their local hospital. It is hoped that this will alleviate the financial burden on patients from having to pay tuition and a venue-booking fee.

Study limitations

Many participants in this study had remained active. When interpreting the results, the researcher had to consider the findings in the light of the convenience sampling method adopted. Those who were willing to be interviewed were probably comparatively fit. Failure to gain access to patients who were confined to home may have excluded those who were not active. Thus, the sampling method reduces the generalisability of the study’s findings.

Conclusion

Hospitals should initiate efforts to provide rehabilitation services for patients undergoing dialysis. The findings of this study will help nurses determine how to improve existing rehabilitation services for patients undergoing continuous ambulatory peritoneal dialysis, especially as the study was the first to investigate the availability of rehabilitation services provided to this group of patients in Hong Kong NS

Acknowledgement

This study was funded by a grant from the Departmental Research Fund, Hong Kong Polytechnic University, Hong Kong.

Luk WSC (2006) Rehabilitation services for patients undergoing peritoneal dialysis in Hong Kong. Nursing Standard. 20, 20, 41-47. Date of acceptance: June 20 2005.

IMPLICATIONS FOR PRACTICE

* Nurses should direct resources to areas where improvements may be required so that patients have a greater chance of leading a life that resembles as closely as possible the one they l\ed before undergoing dialysis.

* This study, although conducted in Hong Kong, has implications for other contexts where rehabilitation is being promoted. The data obtained can provide the basis for further research.

References

Alien K, Gappmaier E (1997) Hemodialysis patients: exercise habits and attitudes. Medicine and Science in Sports and Exercise. 29, 5, Suppl 208.

Brunier G, Graydon J, Rothman B, Sherman C, Liadsky R (2002) The psychological wellbeing of renal peer support volunteers. Journal of Advanced Nursing. 38,1,40-49.

Burnard P (1991) A method of analysing interview transcripts in qualitative research. Nurse Education Today. 11, 6, 461-466.

Galpin C (1992) Body image in end-stage renal failure. British Journal of Nursing. 1, 1, 21-23.

Glaser BG, Strauss AL (1979) The Discovery of Grounded Theory: Strategies for Qualitative Research. Aldine, New York NY.

Graneheim UH, Norberg A, Jansson L (2001) Interaction relating to privacy, identity, autonomy and security. An observational study focusing on a woman with dementia and ‘behavioural disturbances’, and on her care providers. Journal of Advanced Nursing. 36, 2, 256- 265.

Hong Kong Hospital Authority (2000) Annual Plan: Rising to the Challenge. Hong Kong Hospital Authority, Hong Kong.

Klaiig B, Bjorvell H, Berglund J, Sundstedt C, Clyne N (1998) Predialysis patient education: effects on functioning and well- being in uraemic patients. Journal of Advanced Nursing. 28,1, 36- 44.

Koufaki P, Nash P, Mercer TH (2002) Assessing the efficacy of exercise training in patients with chronic disease. Medicine and Science in Sports and Exercise. 34, 8, 1234-1241.

Lindqvist R, Sjoden PO (1998) Coping strategies and quality of life among patients on continuous ambulatory peritoneal dialysis (CAPO). Journal of Advanced Nursing. 27, 2, 312-319.

Lorig KR, Sobel DS, Stewart AL et al (1999) Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial. Medical Care. 37,1, 5-14.

Lorig K, Ritter P, Stewart A et al (2001) Chronic disease self- management program: two-year health status and health care utilization outcomes. Medical Care. 39,11,1217-1223.

Luk WSC (2001) The quality of life for Hong Kong dialysis patients. Journal of Advanced Nursing. 35, 2, 218-227

Luk WSC (2002) The home care experience as perceived by the caregivers of Chinese dialysis patients. International Journal of Nursing Studies. 39, 3, 269-277

Pryor J, Smith C (2002) A framework for the role of Registered Nurses in the specialty practice of rehabilitation nursing in Australia. Journal of Advanced Nursing. 39, 3, 249-257

Rubin HR, Fink NE, Plaiitinga LC, Sadler JH, Kliger AS, Powe NR (2004) Patient ratings of dialysis care with peritoneal dialysis vs hemodialysis. Journal of the American Medical Association. 291. 6, 697-703

Samarel N, Fawcett J, Krippendorf K et al (1998) Women’s perceptions of group support and adaptation to breast cancer. Journal of Advanced Nursing. 28, 6,1259-1268.

Teng J, Mayo NE, Latimer E et al (2003) Costs and caregiver conseguences of early supported discharge for stroke patients. Sirote 34, 2, 528-536.

Tilden VP, ToIIe SW, Nelson CA, Fields J (2001) Family decision- making to withdraw life-sustaining treatments from hospitalized patients. Nursing Research. 50, 2,105-115.

Author

Weety SC Luk is assistant professor, School of Nursing, Hong Kong Polytechnic University, Hong Kong. Email: [email protected]

Copyright RCN Publishing Company Ltd. Jan 25-Jan 31, 2006

By Claudia Parsons

NEW YORK (Reuters) – The gym that brought New Yorkers
“Cardio Striptease” has dreamed up “Stiletto Strength,” a
workout to get women in shape to wear the highest of heels.

At a recent lunch-time session at Crunch gym near Times
Square, dancer Amber Efe demonstrated how to strut like a
cat-walk model, pivoting on six-inch heels that would challenge
even the most ardent follower of shoe king Manolo Blahnik.

“Imagine you’re at the bar, raise one hand high like you’re
holding your drink,” she told the class, music pounding as she
acted the part of a club-goer working through a crowd.

“Don’t spill the drink,” she told the group, a mix of women
who clearly had plenty of experience and others still tottering
on shoes that didn’t show much wear.

Crunch’s class list includes “Circus Sports” and “Cycle
Karaoke” and national fitness director Donna Cyrus said the
most popular nontraditional class in recent years was “Cardio
Striptease,” aerobics with a sexy twist.

“Stiletto Strength” was launched in January in response to
client griping about getting back into high heels for winter.

“They’re businesswomen and they have to wear heels so they
want to understand how to look better in them and feel
confident,” Cyrus said.

Participants wear running shoes for the first part of the
class, which focuses on strengthening lower body and abdominal
muscles and improving balance and posture. The heels come out
for the last 15 minutes.

“I came at the beginning just because I was curious,” said
Andrea Kussack, 27, who isn’t required to dress up for her job
but needs practice wearing “going-out” shoes.

“I recently bought for my boyfriend’s Christmas party these
really high heels. I made it through the night but it wasn’t
the most enjoyable thing and I haven’t worn them since,” she
said.

So what is the secret to walking tall?

“Your abs and don’t look down. Look where you’re going,”
said instructor Kafi Pierre. “And your ankle strength, if you
have weak ankles you’ll tend to roll inward or outwards.”

Cyrus called in a podiatrist to assess the class, which has
been launched in New York, Los Angeles and Miami. “He said ‘You
know, the answer is women shouldn’t wear heels,”‘ Cyrus said.

But she said women will wear them anyway.

“Your feet will probably never recover because it’s not a
position you’re meant to be in all day long,” she said. “This
class will strengthen your legs and your core, it will make it
less painful, but it will never be pain free.”

NEW YORK (Reuters Health) – Menopausal status as well as age at menopause may modify the risk of women developing bladder cancer, researchers suggest in the American Journal of Epidemiology.

The risk in men is greater than that in women. Hormonal factors may be involved, say the Boston-based investigators, because “gender differences in cigarette smoking patterns, occupational exposures and other differences in known risk factor distributions cannot explain the excess bladder cancer observed for males.”

Monica McGrath and colleagues from Brigham and Women’s Hospital and Harvard Medical School used the Nurses’ Health Study to examine hormonal and reproductive factors in relation to bladder cancer risk in women.

During 26 years of follow up, 336 women developed bladder cancer. Compared with pre-menopausal women, those past menopause were nearly twice as likely to develop the cancer.

The team also observed a significant increase in bladder cancer risk with earlier menopause (age 45 years or less) compared with later menopause (age 50 years or more). However, this association was influenced by cigarette smoking status.

The investigators point out that the drop in estrogen levels with menopause has been associated with bladder dysfunction and frequent urinary tract infections.

It may be “that women who experience early menopause are at an increased risk of bladder cancer because they have recurrent urinary tract infections and concurrent inflammation starting at an earlier age.”

Because inflammation and cigarette smoking are likely to act together to increase risk, this hypothesis would also explain the strong interaction with smoking, according to the team.

SOURCE: American Journal of Epidemiology, February 1, 2006.

A 13-year-old British girl who is 6 feet 4 inches tall has been excused from school because of the stress from being bullied for her height.

Caroline Stillman, who has been diagnosed with Marfan syndrome — a hereditary condition that affects the skeleton, eyes, heart, blood vessels, nervous system, skin and lungs — says she has been bullied relentlessly because of her height, the Daily Telegraph reported Saturday.

I am angry and want justice because the people who have done this are still there and getting their education, she said. They would call me names like giraffe, lanky bitch, tree, long-legged bitch, trampy giant. One day two girls held me down while another stuck chewing gum in my hair.

Stillman has been excused from school until the end of March and is receiving weekly counseling sessions, but her parents do not think it is safe for her to go to school.

Even when Stillman is out of school the bullying — including threats — continues via Internet chat rooms, the newspaper said. Police said they were investigating.

By Megan Rauscher

NEW YORK (Reuters Health) – To stay alert behind the wheel
on long road trips, skip the coffee and try sniffing peppermint
or cinnamon. Researchers from West Virginia have found that
getting a whiff of pleasant odors periodically while driving
increases alertness, reduces fatigue, and even lowers drivers’
anxiety and frustration.

Increased driver alertness could lead to fewer accidents on
the highway and decreased frustration could translate into
fewer instances of “road rage,” Dr. Bryan Raudenbush from
Wheeling Jesuit University told Reuters Health.

The current study builds on previous work by Raudenbush and
his colleagues, which suggested that, by stimulating the
nervous system, peppermint and cinnamon odors enhance
motivation and performance, increase alertness, and decrease
fatigue among athletes and clerical office workers.

To test the effects of these odors on drivers, Raudenbush’s
group had 25 college undergrads sniff peppermint, cinnamon, or
a non-odor control for 30 seconds every 15 minutes during
simulated driving conditions.

In general, prolonged driving led to increased anger and
fatigue, and decreased vigor, they report.

However, with the peppermint scent, fatigue, anxiety, and
driver frustration ratings fell significantly, while driver
alertness ratings rose impressively.

Smelling cinnamon also made drivers more alert and lowered
their levels of frustration. Ratings of “workload” associated
with driving also fell with periodic whiffs of cinnamon.

Given these results, Raudenbush said, it is reasonable to
expect that periodic sniffs of peppermint or cinnamon may
produce a more alert and conscientious driver and minimize
fatigue associated with long road trips.

“While we used scents delivered through the nose, our past
research suggests that mints or gums could also provide the
same effects,” Raudenbush added.

BOSTON, Jan. 31 /PRNewswire/ — Crippling menstrual cramps, gastrointestinal problems, and pain during sex are among the most common and distressing symptoms of endometriosis, a gynecological disorder that affects as many as 1 in 10 women. Although endometriosis symptoms are most troubling during the reproductive years, they don’t necessarily disappear once a woman stops menstruating, reports the Harvard Women’s Health Watch.

Endometriosis occurs when tissue similar to the lining of the uterus shows up on the walls of the abdominal cavity and the outer surfaces of the uterus, ovaries, fallopian tubes, bowel, bladder, and nearby organs. Like the uterine lining, this tissue builds up and sheds monthly in response to the menstrual cycle. But rather than exiting through the vagina, the way menstrual fluid does, it remains trapped, triggering inflammation and scar tissue.

Estrogen fuels the growth of endometriosis, so in theory, dwindling estrogen levels at menopause should lessen the symptoms. But even after periods have ceased, the ovaries continue to produce small amounts of the hormone, so endometriosis may continue to cause trouble. “I think of endometriosis as a chronic disease that often — but not always — improves after natural or surgical menopause,” says Dr. Martha K. Richardson, editorial board member of the Harvard Women’s Health Watch.

Women with endometriosis also have a higher-than-average risk of autoimmune disorders and related problems, such as chronic fatigue syndrome, hypothyroidism, and fibromyalgia. They’re also more likely to develop ovarian cancer. The Harvard Women’s Health Watch suggests that if you have endometriosis, be sure to have annual checkups and any tests recommended by your clinician.

   Also in this issue:   * Heart disease risk and family history   * Varicose vein treatments   * Too much magnesium?   * A doctor's advice about the sleeping pill Lunesta   

Harvard Women’s Health Watch is available from Harvard Health Publications, the publishing division of Harvard Medical School, for $24 per year. Subscribe at http://www.health.harvard.edu/women or by calling 1-877-649-9457 (toll free).

First Call Analyst: FCMN Contact:

Harvard Women’s Health Watch

CONTACT: Christine Junge of Harvard Health Publications,+1-617-432-4717, [email protected]

Web site: http://www.health.harvard.edu/

By PETER GOTT, M.D. Newspaper Enterprise Association

Dear Dr. Gott: In your newspaper column, you answered some questions regarding hepatitis. You wrote, “Some forms of chronic, persistent hepatitis are contagious to family members, other types are not. All forms can be spread by blood donation or needle sticks.” This information is wrong!

The only types of hepatitis that are contagious through blood donation and needle sticks are the different viral forms of hepatitis. There are other forms of persistent chronic hepatitis that are never contagious. Autoimmune, alcoholic, genetic and about 15 percent of liver transplants are of unknown origin. I know because I am on the liver transplant list, and the doctors have no idea why I have cirrhosis. You could mix my blood with anyone’s blood anytime, and no one would catch my hepatitis. This disease has a stigma attached to it already, with people believing only drunks and drug addicts get it. Now you are telling people everyone with hepatitis is contagious.

Dear Reader: You are correct that there are other causes of hepatitis that are not caused by viruses, such as cirrhosis of unknown cause (probably autoimmune), alcoholism and the side effects of various medications. I am sorry for the confusion; it is only the viral types of liver inflammation that are contagious. Thanks for writing.

To give you related information, I am sending you a copy of my Health Report “Viruses and Cancer.” Other readers who would like a copy should send a long, self-addressed, stamped envelope and $2 to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title.

Write Dr. Gott c/o United Media, 200 Madison Ave. 4th floor, New York, NY 10016

By Jonathan Maze, The Post and Courier, Charleston, S.C.

Jan. 29–For 16 years, J.C. and Connie Hare invited the residents of Bishop Gadsden’s assisted-living facility to their West Ashley home to watch July Fourth fireworks across the river.

Last month, the Hares became their neighbor.

“We figured we’d go there when we decided we couldn’t take care of ourselves,” Connie Hare said. “I’ve always liked it.”

The Hares moved into a new two-bedroom, assisted-living apartment, one of 40 new units in a nearly complete $12 million expansion at the James Island retirement community. Bishop Gadsden also is working on a $2.5 million chapel that is being paid for largely out of funds raised from community residents.

It’s only the latest in a string of expansions for the community, which in less than 20 years has grown from a single assisted-living facility to a retirement behemoth with 425 residents in 369 units.

Nor will this project be the last. Bishop Gadsden has been gobbling up land next to its facility on Camp Road. The nonprofit now owns 20 acres for future expansion of its 50-acre-plus site.

“When you’ve got a facility this large, you have to continue to work it over,” said Executive Director Bill Trawick. “When you’re finished with one project, you start another.”

The building boom is just the latest chapter in a history that goes back to 1850, when the Rt. Rev. Christopher E. Gadsden, fourth bishop of South Carolina, established the first diocesan ministry for the aging, the Episcopal Church Home. Its original site was on Anson Street in downtown Charleston, and it later moved to Bee Street. The facility was named for Gadsden when it moved to James Island in the 1980s.

Trawick moved to Charleston in 1985 to raise money and oversee development for Bishop Gadsden. The first building, with 70 assisted-living beds, opened in 1987 on 7 acres of land donated by St. James Episcopal Church across the street.

Five years after it opened, the community added a 44-bed nursing center. In 1999, it added independent cottages and apartments in a $55 million project that completed its transition into what is known as a “life care” retirement community.

Such communities are designed to attract younger retirees 62 and older with the prospect of staying there for the rest of their retirement, regardless of the amount of care they need. They typically include a large number of senior apartments with a range of long-term care services on the same campus.

These communities began emerging in retiree-heavy states such as Florida, California and Arizona in the 1970s and have grown in popularity in recent years. Their popularity is expected to increase as baby boomers head toward retirement.

Trawick, however, voiced a note of caution on the prospect of a boomer bonanza for facilities such as his. “I hope they’ve saved,” he said, wondering aloud whether that generation has as much in the bank as the one that now lives in such communities.

Moving into Bishop Gadsden isn’t cheap. Residents pay an entrance fee ranging from $134,700 to $350,900 and enter into a life-care contract for long-term care services. They also pay a monthly fee between $2,020 and $2,750 that, among other things, pays for dining, utilities, security, housekeeping, laundry and maintenance.

As residents need more assistance, they can move into the assisted-living facility or the nursing home.

The community’s rules governing those moves came under fire last year when former resident Blanche Bell filed a lawsuit alleging that the home violated federal disabilities and fair housing laws by requiring her to move into the nursing home.

Bell, who had amyotrophic lateral sclerosis (ALS), hired her own personal caregivers and wanted to stay in her apartment. She died a month after filing the lawsuit but was able to stay in her apartment until then.

The family recently settled the lawsuit after Bishop Gadsden agreed to ease some of their transfer rules.

Still, many residents say they like the on-campus care options.

Put Putnam moved into an apartment at Bishop Gadsden with his wife five years ago from their Kiawah Island home. Last year, Putnam had three major surgeries on his back, kidney and one on his arm after he fell and hit it on a table. “I almost lost it,” he said.

He spent some time in the nursing home for rehabilitation. A month ago, he decided to move into one of the one-bedroom, assisted-living apartments for the extra care.

Demand for Bishop Gadsden is heavy. There is a waiting list to get into the apartments and cottages, as units typically are full.

This enables the community to forgo Medicare or Medicaid for residents’ stays in its nursing home. That’s an approach few communities take: Medicare pays for rehabilitation and Medicaid funds as much as 80 percent of nursing home beds in the state.

But forgoing the government money allows the community to avoid the associated bureaucracy, including many of the regulations and reporting requirements that come with it.

Despite the lack of government payments, or perhaps because of it, the community has enjoyed an enviable financial position that has enabled it to keep expanding and renovating.

In 2004, Bishop Gadsden took in $19.5 million in revenue and earned nearly $1.9 million over expenses. Overall, the nonprofit finished the year with a fund balance of $13.6 million.

“One of Bishop Gadsden’s strengths is its strong financial position,” Trawick said. “It allows us to continually keep facilities fresh and new and appealing to the market.”

The latest expansion may be a perfect example. The expansion replaced 26 modest-size, assisted-living units with 40 larger assisted-living apartments, including eight with two bedrooms, a rarity among assisted-living facilities.

The project cost was $12 million. Bishop Gadsden was able to pay for the project out of its reserve funds.

In addition, the project took 26 units out of commission for two years, a loss of revenue that many communities might not have withstood.

Trawick, however, said the project needed to be done. Market tastes have changed dramatically since the facility was built in the 1980s. Residents, especially those who are more well-to-do, don’t want units that are little more than single rooms.

Few organizations, Trawick said, would have taken the risk of leveling usable units.

“Most people just let facilities age,” Trawick said. “They don’t make the hard decisions.”

BY THE NUMBERS

–$12 million -Cost of expansion of Bishop Gadsden’s assisted-living facility

–$2.5 million — Cost of new chapel

–680,000 — Total square footage of community’s buildings

–425 — Number of residents

–369 — Total number of residential units

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Copyright (c) 2006, The Post and Courier, Charleston, S.C.

Distributed by Knight Ridder/Tribune Business News.

For information on republishing this content, contact us at (800) 661-2511 (U.S.), (213) 237-4914 (worldwide), fax (213) 237-6515, or e-mail [email protected].

By Bangkok Post, Thailand

Jan. 28–Pfizer’s consumer health-care unit has entered into a joint venture with IDS Manufacturing Co to establish a new factory in Pathum Thani to produce Listerine products for both local and overseas markets.

The 160-million-baht factory has an initial production capacity of 50 million bottles of Listerine per year and could rise to 80 million bottles to tap growing demand in the future.

The old Listerine factory in Bangkok, which produced around 20 million bottles of the mouthwash products a year, has already closed.

Worayuth Watcharotayangkoon, general manager (Thailand and Indochina) of Pfizer Consumer Healthcare, said that the mouthwash market in Thailand had grown significantly over the past few years with Listerine holding a 77 percent share of total sales that were estimated at 850 million baht last year.

He said that lifestyle changes and growing emphasis on personal and oral health care had driven the growth of mouthwash products by 24 percent, for a 9 percent share of the entire oral-care market.

Chana Watnakornbancha, Pfizer’s plant manager, said that added capacity of the new plant would enable the company to use Thailand as the production centre for exporting Listerine to other countries in Asia more easily. Currently, 40 percent of the company’s Listerine output is exported to Singapore, Malaysia, Hong Kong, the Philippines, China, Indonesia, South Korea and Japan. Local sales make up the remainder.

He said the plant in Thailand was the largest in the world outside of the United States and Australia.

—–

To see more of the Bangkok Post, or to subscribe to the newspaper, go to http://www.bangkokpost.com.

Copyright (c) 2006, Bangkok Post, Thailand

Distributed by Knight Ridder/Tribune Business News.

For information on republishing this content, contact us at (800) 661-2511 (U.S.), (213) 237-4914 (worldwide), fax (213) 237-6515, or e-mail [email protected].

PFE,

Research and Markets (http://www.researchandmarkets.com/reports/c31478) has announced the addition of Pharmacy Benefit Management Market Overview to their offering.

Pharmacy benefit managers (PBMs) organize the market for prescription drugs. Pharmacy benefit managers secure deep discounts from drug manufacturers and retail pharmacies for large employers or health plans. They try to influence doctors’ prescribing habits and encourage the use of lower-cost drugs, including generic substitutes for brand-name medicines. They strongly recommend certain drugs over others in each therapeutic category. PBMs administer prescription drug plans for more than 200 million Americans with drug coverage provided through the nation’s small and large employers, Taft-Hartley union plans, health insurers, state and federal-employee benefit plans, Medicare Advantage health plans, and state Medicaid plans. Mergers have nearly cut the number of PBMs in half, from more than 100 five years ago to about 55 today. The largest of the recent mergers consolidated Caremark Rx with AdvancePCS. Although the top five PBMs have a market share of nearly 60% when measured by number of covered lives, there are a number of smaller market players that are having a significant impact on the market place. Industry consolidation is likely to continue over the next few years. Our Pharmacy Benefit Management Market Overview, 300 pages in length, provides insight into the trends and issues affecting the market. Our Pharmacy Benefit Management Market Overview also identifies more than 50 of the leading market participants and provides a brief profile on each company, which includes (when available): the company background, strategy, products and services, financial and statistical information, and recent activities.

This Pharmacy Benefit Management Market Overview, published in February 2005 and nearly 300 pages in length, provides insight into the trends and issues affecting the market. This Pharmacy Benefit Management Market Overview also identifies more than 50 of the leading market participants and provides a brief profile on each company, which includes (when available): the company background, strategy, products and services, financial and statistical information, and recent activities.

Topics Covered

Industry Overview/Trends

PBM List by Covered Lives

ACS State Healthcare

Aetna Pharmacy Management

AmeriHealth Mercy

AmeriScript

Anthem Prescription Management

Argus Health Systems

BeneCard Services

BeneScript Services

Caremark Rx

CBCA Rx

CIGNA HealthCare/RxPRIME

PharmaCare Management Services

Envision Pharmaceutical Services

Express Scripts

First Health Services Corporation

4D Pharmacy Management

HealthExtras/Catalyst Rx

Health Information Designs

Health Net Pharmaceutical Services

HealthTrans

Kroger Prescription Plans

MaxorPlus

Managed Pharmacy Benefits/Medicine Shoppe

MedImpact Healthcare Systems

Medco Health Solutions

MIM/Scrip Solutions

Navitus Health Solutions

NBRx

New Benefits

NMHCRX

Northwest Pharmacy Services

Partners Rx Management

PBM Plus

Pequot Pharmaceutical Network

Pharmaceutical Care Network

Pharmaceutical Technologies/NPS

Pharmacy Services Group

Prescription Solutions

Prime Therapeutics

RESTAT

RxAmerica

RxStrategies

RxWest

Safeway-SMCRx

Serve You Custom Prescription Management

Systems Xcellence

Total Script

US Script

Walgreens Health Initiatives

WebMD Prescription Benefit Solutions

WellPoint Pharmacy Management

Sources

Summary

Our Pharmacy Benefit Management (PBM) Market Overview provides the information and analysis you need to gain an understanding of the PBM market and the trends which affect it. Our PBM Market Overview also identifies approximately 40 market participants and provides information on each company which includes (when available): company background, company strategy, products and services, financial and statistical information and recent activities.

For more information visit http://www.researchandmarkets.com/reports/c31478

By So, Dominicus W; Gilbert, Stefanie; Romero, Sergio

Traditionally, African American students display a low-rate of seeking mental health treatment. Issues such as mistrust of White therapists, attitudes toward mental health problems, and African American spirituality affect their help-seeking behavior. The present study examined a sample of 134 African American students at a Historically Black College/University. Using the Attitude Toward Seeking Professional Psychological Help Scale, the present study explored the relationships between students’ year in school, and number of college credits in predicting help-seeking attitudes. Results indicated that the greater the number of course credits students had received, the more confidence in the mental health profession they reported.

Previous studies of the general population’s attitudes and behaviors toward seeking help for mental health problems (e.g. Kushner & Sher, 1991) have documented a general underutilization of mental health services. Factors contributing to such underutilization include limited access to mental health services (Leaf, Bruce, Tischler, & Holzer, 1987), inadequate recognition or acknowledgment of problems (Yokopenic, Clark, & Aneshensel, 1983), fears (Kushner & Sher, 1991), and submissive authoritarianism (Furr, Usui, & Hines-Martin, 2003). Although attitudes toward seeking psychological help have been studied generally, relatively little is known about African American college students’ attitudes towards seeking help for psychological difficulties. Specifically, an examination of the literature addressing help-seeking attitudes revealed that African Americans are underrepresented in this area of research. The lack of knowledge about African American help-seeking attitudes is significant given the contention that ethnic minorities are embedded within unique and different cultural experiences.

The limited extant research in this area suggests that, compared to Whites, Blacks are less willing to visit mental health clinics (e.g. Temkin-Greener & Clark, 1988). Black college students, in particular, (e.g. Gibbs, 1975) report unwillingness to seek help for psychological difficulties and more negative help-seeking attitudes, relative to their White same-aged peers (Gloria, Hird, & Navarro, 2001 ). Much is unknown about the reasons why many African American college students are reluctant to seek help from mental health professionals. Regardless of socio-economic level and mental health needs, African Americans in general are less likely than Whites to receive mental health services (Robins & Regier, 1991; Swartz, Wagner, Swanson, Burns, George, & Padgett, 1998). Instead, they are more likely to seek treatment in primary care setting (Pingitore, Snowden, Sansome, & Klinkman, 2001), emergency facilities (Hu, Snowden, Jerrell, & Nguyen, 1991), or only under coercion or to meet legal obligations (Takeuchi & Cheung, 1998). African Americans in need of mental health services are also more likely than Whites to terminate mental health treatment prematurely (Sue, Zane, & Young, 1994).

To account for people of color’s limited use of mental health services, researchers have suggested that culture may play an important role in contributing to help-seeking attitudes and behaviors. Through socialization, one’s culture sets the subjective standards for determining the levels of tolerance for, and reporting of negative affect and symptoms (Kleinman, 1980). Culture also influences help-seeking through people’s communication patterns, interpersonal relationships, and reaction to the environment (Watanabe, 1973). Using Bronfenbrenner’s (1979) ecological model, Cauce et al. (2002) argued that the ethnic minority pathway into mental health services is itself affected by cultural and contextual influences.

Using a racial identity paradigm, some researchers (e.g., Parham & Helms, 1981) have found that differences in Black racial identity correlated with preferences for Black counselors and that differences in cultural commitment among Blacks and the availability of culturally similar counselors together affects counseling service utilization (e.g., Atkinson, Jennings, & Liongson, 1990). Similarly, Blacks’ cultural mistrust of Whites predicts Blacks’ premature termination from counseling (Terrell & Terrell, 1984) and negative help-seeking attitudes (Nickerson, Helms, & Terrell, 1994). Similarly, a pro-Black orientation tends to relate to more negative attitudes toward professional psychological services (Delphin & Rollock, 1995).

Culture-specific stigma of mental illness also reduces African Americans’ willingness to seek mental health services. African Americans have been found to be less kind toward mental patients, and more likely to reject them and think they are inferior (Suva De Crane & Spielberger, 1981). African Americans are also less likely than Whites to find psychotherapy efficacious (Hall & Tucker, 1985). They are also more likely than Whites to seek help for psychological problems from family members or community or spiritual leaders (e.g. Miller &Weisz, 1996). Cauce et al. (2002) argued that culture might influence behavioral definitions and patterns of acceptance. For instance, supernatural, spiritual, and religious theories of behavior and emotions have been found to be particularly prominent among African American families with strong ethnic affiliations (Cheung & Snowden, 1990). Consequently, prayer and spirituality are used by members of many ethnic minority cultures as coping resources in lieu of counseling or psychotherapy.

Past research has assessed the impact of education and age on predicting attitudes toward help-seeking behavior. Research addressing level of education generally indicates that that a higher level of education predicts more positive attitudes toward seeking help (Surgenor, 1985). In a study by Kligfeld and Hoffman (1979), male medical students exhibited increases in positive help-seeking attitudes as they progressed from the first to the fourth year of medical school. Together, these studies support the notion that help seeking attitudes are associated with a high level of education. However, without studies that control the professional help received during the course of education, it remains unclear whether education alone contributes to positive attitudes toward seeking help for psychological problems since the longer one is in school, the increased likelihood that one will seek help, in turn, may lead to more positive attitudes.

Additionally, several studies suggest that different coping strategies, such as help seeking for problems, are related to age and maturity (Aldwin, 1991, 1994; Aldwin, Sutton, Chiara, & Spiro, 1996; Kliewer, Lepore, Broquet, & Zuba, 1990). For example, an investigation by Gould and Mazzeo (1982) found a positive relationship between students’ age and the likelihood of seeking support, advice, and information about their problems. However, the research in this area has been inconsistent. Yeh (2002) reported that age had no predictive effect on Taiwanese college students’ attitudes toward seeking professional psychological help.

The present study attempted to explore the relationship of education level and help seeking attitude among African American college students. We sought to investigate how the awareness of one’s problems, stigma related to mental health, and trust in professionals are related to a student’s level of education. We expected a positive relationship between personal development and more positive attitudes toward seeking mental health services, as has been previously found in the general population.

Methods

Participants and procedure

Our sample included one hundred thirty-four self-identified African American undergraduate students at a private, historically Black university in an East Coast city. These students were enrolled in an undergraduate psychology course, but were not necessarily psychology majors. The female predominance (84%) of our sample is similar to the 2:1 female-to-male ratio among African-American college enrollment nationally, and highly resembles that of the social science and humanities fields. Slightly more than one-third of the sample was college seniors (37.5%), followed by sophomores (26.8%), juniors (24.1%), and freshmen (11.6%). Although we did not ask for the participants’ age for this survey, the average age of students enrolled at the college is between 18 and 22. All participants were of African descent because we did not include other students in our analyses.

Participants were given the brief measures and were told that the survey sought information for improving psychological services for students. The self-administered measures took approximately ten minutes to complete. Participants were told that their participation was voluntary and anonymous, they could withdraw without prejudice, and they submit the survey before departing the classroom. The response rate of approximately 70% suggests a good representation of the participant pool.

Measures

Brief Demographic Questions. We first asked students about their gender and the number of credits received in college. Due to the limited time for this survey, no other demographic information about participants was obtained. The number of credit\s accumulated prior to that semester was used to determine the participants’ class in college: freshmen (0-30), sophomores (SI60), juniors (61-89), and seniors (90 and higher).

Attitudes Toward Seeking Professional Psychological Help Scale (ATSPPHS; Fisher & Turner, 1970). Participants’ attitudes toward help-seeking were assessed using this scale which consists of 29 Likert items such as, “Although there are clinics for people with mental troubles, I would not have much faith in them (item 1)”, and “Emotional difficulties, like many things, tend to work out by themselves (item 9).” Participants rated the items on a 4-point scale (1 = disagree strongly; 4 = agree strongly). After the reverse- scoring of 18 items (1,3,4, 6, 8,9,10, 13, 14, 15, 17, 19, 20, 21, 22, 24, 26, & 29), a summation of the scores for all the 29 items nets the total score, a composite measure of participants’ help- seeking attitude. A high total score represents a positive attitude toward seeking professional help in mental health services.

In the present study, we chose the ATSPPHS for its reliability and validity. Fisher and Turner ( 1970) reported an internal reliability of .86 for the standardization sample (n = 212) and .83 for a later sample (n = 406). These numbers indicate moderately good consistency of response within the entire scale. Test-retest reliabilities (r) at varying intervals of five days, two weeks, four weeks, six weeks, and two months were .86 (n = 26), .89 (n = 47), .82 (n = 31), .73 (n = 19), and .84 (n = 20) respectively. Overall, the ATSPPHS scores remained consistent over a 2-month period. The ATSPPHS has been among the most widely used and researched tool to measure help-seeking attitudes among people of color (e.g. Delphin & Rollock, 1995; Yen, 2002). This scale has four distinct subscales that measure these following factors.

Factor I – Recognition of need for psychological help. This 8- item factor (4, 5, 6, 9, 18, 24, 25, & 26) taps into the participants’ awareness of need for professional psychological help. Examples of the items include: “Emotional difficulties, like many things, tend to work out by themselves (item 9)” and “At some future time, I might want to have psychological counseling (item 25).” Low- scorers do not see the necessity to seek psychotherapeutic help for emotional problems, expecting psychological problems to resolve themselves. High-scorers believe that emotional stress and troubles should be resolved with psychotherapeutic help.

Factor II – Stigma tolerance. This 5item factor (3,14,20, 27, & 28) estimates one’s forbearance of the shame attached to psychological help-seeking. An example includes “Having been mentally ill carries with it a burden of shame (item 2O)”. This factor assesses participants’ ability to forebear the stigma associated with psychotherapy. Low scorers are less able to forebear such stigma. High scorers are more indifferent to such stigma, indicating a stronger tendency to seek psychological help.

Factor III – Interpersonal openness. This 7-item factor (7, 10, 13, 17, 21, 22, & 29) describes one’s willingness to reveal one’s personal problems to others. For instance, included in this factor are “There are experience in my life I would not discuss with anyone (item 21)”, and “It is probably best not to know everything about oneself (item 22)”. Participants rate their willingness to reveal problems to others, including a mental health practitioner. High scorers on this factor reveal to others their personal problems more readily than low scorers, indicating their belief that one should speak to others about personal problems.

Factor IV- Confidence in mental health practitioner. This 9-item factor (1,2,8,11, 12,15,16,19, & 23) assesses participants’ trust in the mental health profession. Items include “Although there are clinics for people with mental troubles, I would not have much faith in them (item I)”, and “If I believed I was having a mental breakdown, my first inclination would be to get professional attention (item 12)”. Fischerand Turner (1970) noted that Factor IV correlated fairly high (.58) with Factor I and that a combination of these two factors make up the essence of an attitude toward seeking professional psychological help, and would be most directly related to actual help seeking behavior. In other words, one’s inclination to get psychological help requires recognizing the need (Factor I) and trusting the psychologist (Factor IV).

Results

Pearson product-moment correlations were computed to assess the relation between the four ATSPPHS factors, the total ATSPPHS score, and the number of credits accumulated. In our intercorrelational analysis of the ATSPPHS factors (see Table 1), we found the more students recognized their need for psychotherapeutic help, the greater their stigma tolerance, interpersonal openness, and confidence in mental health practitioners. Additionally, the greater the students’ stigma tolerance, the more interpersonally open and confident they were in the mental health profession. Finally, the more students reported being interpersonally open, the more confidence they reported in the mental health profession.

More relevant to the purpose of this study is the significant finding of a positive relation between the Confidence in the Mental Health Profession factor and the number of credits accumulated (r = .64, p = .03). Simply, the more credits students have accumulated or the further along they are in college, the greater is their confidence in the mental health profession.

Table 1

Intercorrelations among the ATSPPHS and its four factors

Discussion

This study has contributed to a small but growing empirical literature that is dedicated to investigating the relation between education level and help-seeking attitudes among African American college students. We replicated Fischer and Turner’s (1970) finding of the high correlation between need-recognition and confidence in the helper: our data showed similar results in our African American college sample that Factor IV (Confidence in Mental Health Professions) correlated fairly high (.66) with Factor I (Need Recognition) and that a combination of these two factors are particularly essential to African American college students’ attitude toward seeking professional psychological help. Our study showed that African American college students’ inclination to get psychological help requires their cognizance of their personal need (Factor I) as well as their trust in the psychological services (Factor IV).

More important, this study was based on the premise that college education and its impact on personal development may help predict a more positive attitude toward seeking mental health services. As our analysis suggested, years in college increase African American college students’ confidence in the mental health profession. These results are consistent with the findings on other populations (e.g. Kligfeld & Hoffman, 1979; Surgenor, 1985). Independently, these researchers offered the hypothesis that over the years, college students acquire more knowledge about mental health services on campus and consequently develop more positive attitudes toward psychological help-seeking. We are able to suggest the same in our African American college sample. In addition, we sepeculate that students who have been in school longer may have experienced greater exposure to university counseling services, including outreach workshops, help for test anxiety, or counseling for personal or interpersonal difficulties. This greater exposure may consequently have contributed to more positive attitudes towards psychological services. Future studies should also ask about students’ contact with psychological services in order for the researchers to ascertain the impact of such exposure.

While African American college students in our study reported greater confidence in the mental health profession, there was no apparent increase in helpseeking stigma tolerance, recognition of need for psychological help, or interpersonal openness over the years. These findings may suggest that although African American college students develop more confidence in the mental health profession, there remains a general apprehension toward seeking psychological help. This is not surprising, given previous research suggesting that African Americans hold less favorable attitudes toward mental health services and are less willing to utilize mental health services (e.g., Gibbs, 1975; SuvaDe Crane & Spielberger, 1981).

Several other precautions should be made for interpreting our results and planning future research. First, our results cannot be generalized to all African American college students since a large percentage of this population does not attend historically Black college or universities (HBCUs). However, it might have under- represented the African Americans attending predominantly White colleges. Additionally, future research on this topic should assess whether students at higher levels of education have been exposed to psychological services to a greater extent than students at lower levels of education to determine the precise factors that contribute to more positive help-seeking attitudes as one’s education progresses.

It is imperative to consider that the measures used in the present study were completed by self-report of respondents’ attitude. Because our attitudinal measures are self-reported, our sample may have under-reported, or not acknowledged, that they hold negative attitudes toward seeking mental health services. In essence, students who were interested in selecting socially desirable responses might have biased the results of the study. Moreover, in future studies, attitudinal measures should be accompanied by objective measurements of help-seeking behaviors, such as report of frequency of use. Future studies may need to include those objective measurements or be conducted in m\ore anonymous settings than a college classroom to circumvent the potential for self-report bias. In our study, because the majority of the counseling staff is African American, we gathered no racial information about the counselors and mental health professionals that serve our African American college sample. This information would be important in other non-HBCU studies because, as may be recalled, many African Americans appear to particularly mistrust White counselors. Thus, the helpseeking attitudes of students attending HBCUs may be influenced, in part, by their expectation of having a counselor with similar ethnic background were they to seek help at the university counseling service. Future research might examine if African American students’ help-seeking attitudes are dependent on whether the counselors’ ethnic background is the same as theirs, and whether the African American college students are enrolled at an HBCU or a predominantly White institution. Future studies must examine factors that continue to maintain negative mental help-seeking attitudes. Research in this area can play an important role in identifying and removing impediments to utilization, and, ultimately, enabling African Americans to utilize mental health services when they need them.

Implications and Conclusion

Despite the interpretive precautions suggested above, our findings nonetheless have contributed to understanding African American attitudes toward seeking mental health services. Although African American college students in our sample gained confidence in the mental health profession during their years in school, their general apprehension about seeking psychological help persisted. Many students may not personalize the potential benefits for themselves. In other words, they may continue to feel that psychotherapy is “good for others, but not for me.” This information is vital to psychologists, health educators, college administrators, and health providers serving college students. Simply offering African American mental health care providers may not in itself increase African American students’ utilization of mental health services.

Based on our finding, we suggest that college personnel use outreach programs specifically targeted toward African American college students when they enter college. We recommend that college personnel expose African American students to the college counseling services early on in the students’ college career, so the students, regardless of their level of seniority, can learn about the importance of mental health services for their success in college. College personnel may outreach to these students in College Freshmen Seminars or Orientation courses and Black student organizations. They may use interactive guest-lectures in classes to build students’ confidence in the counseling staff. They may also use more advanced African American students or alumni who were users of mental health services, to lead peer chat groups / rap sessions or individualadvising programs designed to cover issues facing less advanced students. The key is not only to foster these students social support system and to provide early outreach to prevent issues at the beginning of a college career, but also to help refer new students for psychological services. These peers can also help students to follow through with the recommended counseling services. Other cultural adaptations of existing programs on college campuses may include the use of audio-visual materials, such as multimedia, culturally sensitive promotional material; social and cultural events, such as movie viewing and Black history month celebration; consultation and collaboration with spiritual/religious organization and leaders in identifying/referring students of color to mental health services. These presentations should work together to help younger students recognize the need and confidence for counseling and mental health services on college campuses, so as to enhance the help-seeking behaviors of younger African American college students.

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DOMINICUS W. So* & STEFANIE GILBERT

Howard University

SERGIO ROMERO

Howard University

* Author note

Reprint requests should be directed to Dominicus W. So, Ph.D., Department of Psychology, Room N-269, CB Powell Building, Howard University, 525 Bryant Street NW, Washington, DC 20059; (202) 806- 9462; (202) 806-4873 (fax); email [email protected].

Preparation of this paper was supported in part by one Howard University grant (HU02-13) to the first author (DWS). All opinions expressed are those of the authors. I (DWS) want to express my sincere thanks to my colleagues who gave comments on an earlier version of this paper; and to my students and assistants, especially Karen Saunders, who assisted in the data entry process or participated in the project in many different ways.

Copyright Project Innovation, Inc. Dec 2005

By Singh, Daljit; Kumar, Praveen; Narang, Anil

Abstract

Background. Phenobarbital is one of the oldest, cheapest and most easily available cerebro-protective drugs for the hypoxic brain. It has multiple actions that could be of benefit to the asphyxiated brain. However, its potential has not been fully explored.

Objective. To study the effect of phenobarbital given within six hours of life to term and near-term asphyxiated neonates, on mortality, neurological abnormality at discharge and seizures.

Methods. This was a randomized controlled trial set in a tertiary care referral perinatal centre. Asphyxiated neonates (gestational age ≥ 34 weeks) manifesting with hypoxic ischemic encephalopathy (HIE) in the first six hours of life were randomized to receive either injection of phenobarbital 20 mg/kg IV or to the control group. The primary outcome was death or abnormal neurological examination at discharge while seizures, need for ventilation and multi-organ dysfunction were secondary outcomes.

Results. Twenty-five babies received phenobarbital and 20 were in the control group. The mortality (20% vs. 15%) and abnormal neurological outcome at discharge (30% vs. 53%, p = 0.15) were statistically not different between the two groups. In the phenobarbital group, 8% of neonates developed seizures while 40% of babies in the control group developed seizures (p = 0.01, relative risk (RR) = 0.20 (0.05-0.84)). Phenobarbital was well tolerated and did not increase the need for respiratory support.

Conclusions. Phenobarbital in the dose of 20 mg/kg IV given within six hours of life to term and near-term neonates with HIE, significantly decreased the incidence of neonatal seizures and was well tolerated. However, it did not alter the mortality and neurologic outcome at discharge.

Keywords: Newborn, outcome, phenobarbital, hypoxic ischemic encephalopathy

Introduction

Hypoxic ischemic encephalopathy (HIE) is one of the major causes of morbidity and mortality in term and near-term newborns [1]. In the long run, perinatal asphyxia is responsible for 10-20% of all cases of cerebral palsy [2-4]. There are multiple mechanisms by which neuronal necrosis occurs, and is perpetuated in birth asphyxia. Of them, reperfusion and reoxygenation contribute substantially to birth asphyxia-related brain injury [5].

Reperfusion and reoxygenation leads to excessive production of free radicals. Free radicals can damage or kill cells via several pathways, which include lipid peroxidation of membranes, inactivation of enzymes and DNA and RNA alterations [6]. Of the multitude of drugs, including free radical scavengers, which have been tried in birth asphyxia, phenobarbital is one of the cheapest and most readily available. Apart from its free radical scavenging action, phenobarbital has the additional advantage of controlling seizures, reducing cerebral metabolic rate, inhibiting lipid peroxidation and stabilizing cell membranes [7]. However this drug has not been adequately studied for its potential prophylactic role in the management of birth asphyxia [8]. The aim of this randomized controlled trial was to determine whether intravenous phenobarbital given within six hours of life to term and near-term neonates with HIE would decrease adverse outcomes (death or abnormal neurological examination at discharge).

Methods

Babies with gestational age ≥ 34 weeks were eligible for inclusion if they developed features of encephalopathy in the form of alterations of tone, deep tendon reflexes, primitive reflexes and sensorium (Sarnat and Sarnat [9]) within the first six hours of life, in the settings of low Apgar score (≤6 at 1 min of age) and evidence of fetal distress (fetal bradycardia and/or meconium- stained amniotic fluid and/or cord arterial blood pH ≤ 7.15). Babies with major congenital malformations, meningitis, intracranial hemorrhage and whose mothers were receiving phenobarbital during the last week prior to delivery were excluded.

The study was conducted over a period of 10 months. The enrolled neonates were randomly assigned to treatment or control groups with the help of computer generated random numbers. The assignment was concealed in serially numbered opaque envelopes that were opened only at the time of randomization. The babies in the treatment group were administered an injection of phenobarbital 20 mg/kg IV over 20 minutes within the first six hours of life with monitoring of respiration, heart rate and blood pressure. The babies in the control group did not receive any drug. The rest of the management in both groups was as per the standard protocol for the management of HIE. Seizures were diagnosed clinically by the bedside nurses and physicians who were present round the clock. It was not possible to record electroencephalograms in the neonatal intensive care unit (NICU). If a baby developed seizures in any of the groups, they were managed with additional phenobarbital. Cerebrospinal fluid examination was performed between 10 and 12 hours of life to rule out meningitis and measure products of lipid peroxidation and anti- oxidant enzymes.

A detailed neurological examination was performed daily till the neonate was stabilized and recorded in a structured proforma according to the Sarnat and Sarnat staging system of HIE [9]. The discharge neurological examination was done as per the method described by Amiel-Tison [10]. It was considered abnormal if there were tone abnormalities, disturbances of cortical function and persistent abnormalities of neonatal reflexes. Cranial ultrasound examinations were done at the bedside on days 1, 3 and 7 using a 7.0 MHz probe. The discharge neurological examination and ultrasound examinations were done by neonatologists who were not aware of the group allocation. Administration of phenobarbital was not depicted in the routine nursing charts. The babies were followed up at three months of age. Informed parental consent was obtained before enrolment of the neonates and the institutional ethics committee approved the study.

Outcomes

The primary outcome variable was ‘adverse outcome’ which was defined as death or neurological abnormality at discharge. The secondary outcome variables were seizures, need for ventilation and multi-organ dysfunction.

Sample size

Estimating an incidence of 70% adverse outcome [11,12] among the asphyxiated neonates with HIE, 24 babies per group were required to detect a 50% difference in the primary outcome, with an α error of 0.05 and a power of 80%. Accounting for attrition, it was decided to recruit 60 babies.

Statistical analysis

Continuous, normally distributed variables between the two groups were analyzed using a two-tailed unpaired Student’s t-test. Continuous non-parametric data were analyzed using the MannWhitney ‘U’ test. Dichotomous categorical variables were analyzed using the Chi-square and Fisher’s exact tests. A post-hoc analysis was done for the group of babies with stage II (moderate) and stage III (severe) HIE.

Results

Sixty eligible neonates were randomized to phenobarbital and control groups. Of these, 15 were excluded because of CSF findings suggestive of meningitis (1) and intracranial bleed/traumatic lumbar puncture (14), leaving 25 babies in the phenobarbital group and 20 babies in the control group.

The mean age at administration of phenobarbital was 4.5 0.8 h. The mean birth weight, gestational age and severity of asphyxia as judged by Apgar scores during the first 10 minutes of life, need for intubation, and cord arterial pH were similar between the two groups (Table I). The severity of the neurological syndrome was similar at the time of entry into the study. The proportion of babies developing the various stages of HIE was distributed similarly in the two groups (Table II).

Table I. Baseline parameters.*

The survival rates at discharge were comparable between the two groups (80% vs. 85%). Five babies who died in the study group and the three who died in the control group, were comparable in their characteristics. Their mean gestation, weight, cord pH and median Apgar scores were similar. Four of the five in the phenobarbital group and two of the three in the control group had stage III HIE. All had myocardial dysfunction, hypotension and needed mechanical ventilation.

In the phenobarbital group, neurological examination was normal in 14 (70%) of the 20 babies discharged alive, while in the control group 8 (47%) of the 17 babies were neurologically normal at discharge (p = 0.15). There was no difference in the composite adverse outcome (death or abnormal neurological examination at discharge) in babies who received phenobarbital as compared to controls (44% in phenobarbital group vs. 60% in control group, p = 0.28, Table II).

In the phenobarbital group, only two neonates (8%) developed seizures while eight (40%) babies developed seizures in the control group (p = 0.01, odds ratio (OR) = 0.13 (0.01-0.83)). In the phenobarbital group, one baby had seizures at six hours of life and the other one at 60 hours of life. They were given an additional dose of phenobarbital. In the control group, four babies had seizures at six hours of life, another three babies by 24 hours and one baby had seizures at 36 hours of life. The control group babies also received phenobarbital for control of seizures. The four babies in the control group who developed se\izures by six hours of life received phenobarbital at a mean age of 5.6 0.6 h. Only one baby in the control group required a dose of phenytoin for controlling seizures while no baby needed this in the study group.

Table II. Mortality and neurologic outcomes.

Table III. Mortality and neurologic outcomes in the subgroup with moderate to severe HIE.

A post hoc analysis of the subgroup of babies with stage II and III HIE showed similar results. The incidence of seizures was significantly lower in the babies who received phenobarbital. Other outcomes were not different between the two groups (Table III).

There was no difference in the need for oxygen administration, need for ventilation, myocardial dysfunction, azotemia, coagulopathy, hospital-acquired sepsis and jaundice between the two groups.

Discussion

There is increasing evidence that free radical-mediated reactions, overstimulation by excitatory amino acids and intracellular calcium accumulation are the neurochemical processes that contribute to extension of brain damage after perinatal asphyxia [13-15]. A rational approach to the management of HIE may be directed to prevent or interrupt the biochemical processes initiated during asphyxia [15]. Barbiturates were one of the first agents investigated for the treatment of hypoxic-ischemic brain injury. Studies in asphyxiated human neonates using barbiturates have shown variable results [16-19]. A Cochrane meta-analysis concluded that there was a lack of studies of sufficient size and quality to demonstrate any differences in the risk of death or severe neuro-developmental disability [8]. The relative risk of seizures in this meta-analysis was 0.64 (0.37-1.13). The risk of death and severe disability were 1.06 (0.50-2.27) and 0.61 (0.30- 1.22), respectively.

Data from the present study indicate that early phenobarbital therapy is associated with a significant decrease in the incidence of neonatal seizures (p = 0.01) but that mortality and neurological outcome at discharge are not significantly influenced by phenobarbital therapy. There were no significant side-effects such as hypotension or increased need for ventilatory support. Hall et al. in a similar randomized trial, administered an injection of phenobarbital 40 mg/kg IV to term infants with severe birth asphyxia. They did not find significant effect on seizures; 60% of the treated infants developed seizures vs. 87% of the controls (p = 0.11) [16]. However, neurologic outcome was more likely to be normal (11/15) in the treatment group as compared to the control group (3/ 16) at three years of age (p = 0.003). Goldberg et al., in a randomized controlled trial that used thiopental infusion for 24 hours in babies with HIE, starting at a mean age of 2.3 hours, found no significant difference in the frequency of seizures between the two groups [17]. Early treatment with thiopental also did not improve neonatal mortality or neurologic outcome at 12 months of age. Ruth et al. gave phenobarbital for a period of five days to the study group and did not find any differences in the IQ of survivors at six years of age [18]. Vela et al. compared a 7-day course of phenobarbital with phenytoin but reported only the differences in seizure activity [19].

The reasons for the variability of results seen in different studies could be many. New knowledge of the nature of hypoxic ischemic reperfusion injury indicates that there is probably a ‘window of time’ (therapeutic window) after a hypoxic ischemic insult, during which neuroprotection could be effective. The duration of this therapeutic window is not exactly known but is thought to be in the area of six hours [20,21]. Also, there are a multitude of mechanisms and cascades that are initiated in asphyxia. Different mechanisms may be predominant with different causes of perinatal asphyxia. Hence, a single drug acting on a single step of a cascade may not be effective in all cases of asphyxia [22].

Seizures are associated with increased metabolic demands and may enhance neurologic injury in the hypoxic-ischemic injured brain by themselves [23]. Apart from its other potential actions, phenobarbital, by decreasing the incidence of neonatal seizures, may decrease the brain damage in HIE.

Limitations of our study

We were unable to do blinding for drug administration. However, personnel doing the discharge neurological examination and cranial ultrasound were blinded to the group allocation.

Ideally, long-term neuro-developmental outcome should be the primary outcome, but because of various constraints, we could not incorporate it into this study. Seizures were diagnosed clinically and EEGs could not be done in the NICU, potentially missing electrographic seizures.

Some babies in the control group received phenobarbital for treatment of seizures. However, all babies who received phenobarbital treatment did so at or beyond six hours of life, which probably is beyond the therapeutic window of effectiveness of these agents [20,21].

The sample size was calculated to pick up a 50% reduction in adverse outcomes. Retrospectively, it seems that was too much to expect. Smaller differences would have been missed by the current sample size. To detect a 25% reduction, one would need to recruit about 150 babies.

Conclusions

Phenobarbital given within six hours of life to term and near- term neonates with hypoxic ischemic encephalopathy significantly decreased the incidence of seizures and was well tolerated. The effects on mortality and neurological abnormality at discharge however, did not reach statistical significance. A large multi- centre trial of early phenobarbital therapy in severely asphyxiated neonates, where the drug is administered within first 2-3 hours of life and the primary outcomes are long-term neuro-developmental status, is warranted.

References

1. Vilanova JM, Figueras-Aloy, Rosello J, Gomez G, Gelpi E, Jimenez R. Arachidonic acid metabolites in CSF in hypoxic ischmie encephalopathy of newborn infants. Acta Paediatr 1998;87:588-592.

2. Badawi N, Keogh JM, Dixon G, Kurinczuk JJ. Developmental outcomes of newborn encephalopathy in the term infant. Indian J Pediatr 2001;68:527-530.

3. Gaffney G, Flavell V, Johnson A, Squier M, Sellers S. Cerebral palsy and neonatal encephalopathy. Arch Dis Child Fetal Neonatal Ed 1994;70:F195-200.

4. Perlman JM. Intrapartum hypoxic-ischemic cerebral injury and subsequent cerebral palsy. Pediatrics 1997;99:851-859.

5. Fellman V, Raivio KO. Reperfiision injury as the mechanism of brain damage after perinatal asphyxia. Pediatr Res 1997;41:599-606.

6. Saugstad OD. Mechanisms of tissue injury by oxygen radicals: Implications for neonatal disease. Acta Paediatr 1996;85:1-4.

7. Vannucci RC, Perlman JM. Interventions for perinatal hypoxic- ischemic encephalopathy. Pediatrics 1997; 100: 1004-1014.

8. Evans DJ, Levene MI. Anticonvulsants for preventing mortality and morbidity in full term newborns with perinatal asphyxia. Cochrane Database Syst Rev 2001;3:CD001240.

9. Sarnat HB, Sarnat MS. Neonatal encephalopathy following fetal distress: A clinical and encephalographic study. Arch Neurol 1976;37:696-699.

10. Amiel-Tison C. A method of neurologic evaluation within the first year of life. Curr Probl Pediatr 1976;7:1-50.

11. Annual Livebirth Statistics, 2002. Neonatal Unit, Advanced Pediatric Center, PGIMER, Chandigarh, India.

12. Toh VC. Early predictors of adverse outcome in term infants with post-asphyxial hypoxic ischemic encephalopathy. Acta Paediatr 2000;89:343-347.

13. Palmer CH, Vanucci RC. Potential new therapies for perinatal cerebral hypoxia-ischemia. Clin Perinatol 1993;20: 411-432.

14. Vannucci RC. Experimental biology of cerebral hypoxiaischemia: Relation to perinatal brain damage. Pediatr Res 1990;27:317-326.

15. Biagas K. Hypoxic-ischemic brain injury: Advancements in the understanding of mechanisms and potential avenues for therapy. Curr Opin Pediatr 1999; 11:223-228.

16. Hall RT, Hall FR, Daily DK. High-dose phenobarbital therapy in term newborn infants with severe perinatal asphyxia: A randomized, prospective study with three years follow up. J Pediatr 1998;132:345-348.

17. Goldberg RN, Moscoso P, Bauer CR, Bloom FL, Curless RG, Burke B, Bancalari E. Use of barbiturate therapy in severe perinatal asphyxia: A randomized controlled trial. J Pediatr 1986;109:851- 856.

18. Ruth V, Korkman M, Lkanen A, Paetau R. High-dose phenobarbital treatment to prevent postasphyxia1 brain damage: A 6- year follow up [abstract]. Pediatr Res 1991;30:638.

19. Vela F, Duran JA, Chunga F, Serrano JS, Valls A. Preventive treatment of convulsions in perinatal asphyxia. An Esp Pediatr 1987;27:95-99.

20. Colbourne F, Li H, Bucham AM. Indefatigable CA1 sector neuroprotection with mild hypothermia induced 6 hours after severe forebrain ischemia in rats. J Cer Blood Flow Met 1999; 19:742-749.

21. Thoresen M. Protecting the perinatal brain. Semin Neonatol 2000;5:1-2.

22. Shankaran S. The postnatal management of the asphyxiated term infant. Clin Perinatol 2002;29:675-692.

23. Miller SP, Weiss J, Barnwell A, Ferriero DM, Latal-Hajnal B, Ferrer-Rogers A, Newton N, Partridge JC, Glidden DV, Vigneron DB. Seizure-associated brain injury in term newborns with perinatal asphyxia. Neurology 2002;58:542-548.

DALJIT SINGH, PRAVEEN KUMAR, & ANIL NARANG

Neonatal Unit, Department of Pediatrics, Advanced Pediatrics Centre, PGIMER, Chandigarh, India

Correspondence: Dr Praveen Kumar, Associate Professor, Department of Pediatrics, PGIMER, Chandigarh-160012, India. Tel: +91 172 2747585 ext. 5308. Fax: +91 172 2744401. E-mail: [email protected]

Copyright CRC Press Dec 2005

Week 1

5-minute walk and general warm up exercises.

10 x 30-second walk and 30-second jog l 5-minute walk.

5-10 minutes gentle cool down stretching exercises.

Total jogging time: 5 minutes.

Week 2

5-minute walk and warm up.

6 x 1-minute walks and a 1-minute jog.

5-minute walk.

5-10 minutes gentle cool down exercises.

Jog time: 6 minutes.

Week 3

5-minute walk and warm up.

1-minute jog, 1-minute walk, 3-minute jog, 3-minute walk, 2- minute jog, 2-minute walk, 1-minute jog, 5-minute walk.

5-10 minutes gentle cool down stretching exercises.

Jog time: 7 minutes.

Week 4

5-minute walk and warm up.

2-minute jog, 2-minute walk, 5-minute jog, 5-minute walk, 2- minute jog, 2-minute walk.

5-10 minutes gentle cool down stretching exercises.

Jog time: 9 minutes.

Week 5

5-minute walk and warm up.

2-minute jog, 2-minute walk, 8-minute jog, 5-minute walk.

5-10 minutes gentle cool down stretching exercises.

Jog time: 10 minutes.

Week 6

5-minute walk and warm up.

2-minute jog, 5-minute walk. l 1-mile jog, taking 12 minutes.

5-minute walk l 5-10 minutes gentle cool down stretching exercises

Jog time: 14 minutes.

WHETHER you are fit or flabby, the idea of running a mile in one go can seem daunting.

Images of Sir Roger Bannister sprinting into the record books with his four-minute mile make running look tough.

Yet according to jogscotland, running is for everyone and their jogging programme, above, is an excellent way to get fit.

Provided you have no major health problems and are already walking regularly you should be able to get fit enough to run a 12- minute mile in just six weeks.

From this you can keep training and work up to running a 5km event.

The plan is aimed at complete newcomers to jogging or people who have been inactive for a while.

Getting into exercise can be a difficult and daunting experience.

People wonder how much should they do? How far should they run? What pace should they run at? These are all common questions, so don’t worry – you’re not alone.

The good thing about starting out on a beginners’ programme is that the term ‘walk’ is used quite a lot.

This sample programme lasts six weeks and is aimed at getting you to jog for one mile.

It assumes you are in reasonable shape, and have perhaps done at least some gentle exercise beforehand.

If you have any health concerns about undertaking the programme it is advisable to consult your GP beforehand.

The sessions should be done once, or possibly twice, a week.

They can be done with other people either with friends or family or as part of an organised jogscotland group.

Go to www.jogscotland.org.uk for details of local groups in your area. They also recommend that you try and do another gentle form of exercise – walk, swim, cycle, gym, golf – during the week.

They contain compounds that protected cells in lab study

HealthDay News — Compounds in black currants may help protect against Alzheimer’s disease, according to a study in the current issue of Chemistry & Industry magazine.

Researchers found that these compounds — anthocyanins and polyphenolics — had a strong protective effect in cultured neuronal cells. Darker black currants contain more anthocyanins and are likely to be more potent.

“These compounds also work in hippocampal cells taken straight from the brain,” researcher James Joseph of Tufts University said in a prepared statement. He said these protective effects will likely be reproduced in the human body and that these compounds may prevent or significantly delay the onset of Alzheimer’s.

While previous research found that compounds in black currants acted as antioxidants, this is the first study to demonstrate that they may help protect brain cells. Exactly how they do this remains unclear, the study said.

“We have evidence that the compounds protect against Alzheimer’s by influencing the early gene expression in learning and memory, which influences cell signaling pathways that help neuronal cells communicate with each other,” Joseph said.

More information

The U.S. National Institutes of Health has more about Alzheimer’s prevention.

By Matt Glynn, The Buffalo News, N.Y.

Jan. 23–One of Western New York’s largest nursing home chains plans to sell 11 facilities operating under The Waters name to a California-based company.

East Aurora-based Park Associates said it has signed a purchase agreement to sell the 11 facilities for an undisclosed amount. The prospective buyer is the family-owned ARBA Group, based in Los Angeles.

The deal still needs government regulators’ approval, said Ira Smedra, president of ARBA Group.

Park Associates confirmed it sold, at the end of 2005, 14 nursing home facilities it owned in Indiana. They were operated by Healthcare Centers of Indiana LLC, and were sold to an affiliate of ARBA Group.

Park Associates was formerly led by chief executive officer Neil M. Chur Sr. He died unexpectedly in January 2005 at age 60 while on vacation in Florida.

Smedra said the ARBA Group owns nursing homes elsewhere, but he declined to say where or how many, saying it was “not relevant to the New York state operation.”

“Our family has been in the business for almost 40 years,” he said.

Smedra said his company doesn’t plan any changes in the employee structure at The Waters nursing homes. “We plan to do improvements to the buildings, and we plan to operate them for many years,” he said.

He declined to discuss his own company’s operations. Reports in California newspapers describe Smedra as a developer whose other interests have included retail properties.

The 11 properties operating under The Waters name in New York state are in: Allegany, Dunkirk, East Aurora, Eden, Endicott, Gasport, Houghton, Orchard Park, Salamanca, Painted Post and Westfield. Combined, the facilities have more than 1,700 certified beds, according to state Department of Health data.

Park Associates’ headquarters in East Aurora is not part of the sale and its jobs will not be affected, a representative said.

Gary Grote, executive director of the Greater East Aurora Chamber of Commerce, said he was familiar with the planned sale and likes what he has heard from ARBA Group.

“It seems like it’s going to be a positive thing for both groups and the community,” he said. “ARBA really wants to do some good things in the area.”

Jeffrey Hammond, a spokesman for the state Health Department, said the agency has not yet received an application for the “certificate of need” that would be required for the facilities to change owners.

“It would be premature to speculate on a pending sale,” Hammond said.

Obtaining the certificate usually takes two to three months, if the application materials are complete when submitted, Hammond said.

The state Health Department has a process it follows for such planned ownership changes that includes public commentary and a review of the applicant’s plans. The agency uses the recommendation of the state Public Health Council to decide whether to grant the certificate.

Park Associates declined to discuss in detail its planned sale of the New York state properties, other than to confirm it was working on completing a deal.

Chur (pronounced coor) built up his company after starting in the industry as the half-owner of one nursing home, which his father founded in East Aurora. In 1998, he sold 88 nursing homes in Texas and Illinois for $234 million.

In 2003, Chur agreed to pay $3 million to settle a case with state officials involving allegations of under staffing, falsified records and inadequate patient care at two of his facilities. As part of the settlement, his company made no admission of liability or wrongdoing.

The Buffalo News in 2001 ran a series of investigative articles on nursing homes, and reported that Chur’s nursing homes were repeatedly cited by health inspectors for deficiencies in patient care, sanitation and patient safety.

At that time, Chur and other officials of his company contended that the problems were exaggerated in state inspection reports. Park Associates argued that it was making every effort to improve its care.

Separately, the East Aurora School District is negotiating with ARBA Group to buy back the former South Side School. The district intends to reopen the building, which has been owned by Park Associates. The planned nursing homes deal between Park Associates and ARBA Group has no effect on the ElderWood Senior Care nursing home chain run by Chur’s brother, Robert.

—–

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By DEAN OLSEN STAFF WRITER

Beds, medical instruments and X-ray machines from the former Doctors Hospital will end up in hospitals, medical clinics and veterinarians’ offices around the globe after thousands of items from the bankrupt facility were sold at auction this week.

“American-made is still very sought after,” said Dana Smith, 47, owner of KMA Remarketing Corp., who drove to Springfield from DuBois, Pa., to buy $75,000 worth of medical equipment during the daylong auction Wednesday.

“It’s a big market,” Smith said. “It’s a huge, multibillion- dollar market.”

Doctors Hospital, a former for-profit facility owned by investors in Springfield and elsewhere, competed with the two downtown hospitals for 28 years but closed in 2003. The financial collapse of the 177-bed hospital at 5230 S. Sixth St. put about 400 employees out of work.

The four-story Doctors Hospital building covers 107,000 square feet and is owned by Springfield’s Universal Guaranty Life Insurance Co. Universal, which is trying to find a buyer for the structure, acquired it after buying Doctors’ $10.7 million mortgage loan for a discounted price in 2003.

Universal had hoped to sell the building to Pennsylvania-based Select Medical Corp., which wanted to renovate and reopen it as a long-term acute-care hospital. But that deal fell through in September when the Illinois Health Facilities Planning Board denied Select’s request for a “certificate of need.”

St. John’s Hospital owns the medical office building that’s attached to Doctors. Several doctors still work there, although the building is for sale.

Universal sold the contents of Doctors Hospital to Los Angeles- based Great American Group for an undisclosed price, according to a Universal official who asked that his name not be published.

Great American officials, who wouldn’t reveal the price they paid, travel around the United States selling items from doctors’ practices and hospitals that have closed.

Re-sellers such as Smith, along with central Illinois hospitals, doctors, nursing homes and members of the general public showed up for the auction in the former cafeteria of Doctors.

The prices they paid represented discounts of 10 percent to 90 percent or more compared with what the material would cost new.

Some of the items might have sentimental value to many Springfield-area residents: the beds where a loved one died or the high-back chair where visitors spent many hours sitting patiently with a sick friend.

But thousands of groups of the items – even pots and pans from the kitchen – were flashed on a screen and sold amid the light- hearted, rapid-fire delivery of auctioneers.

Outside, the parking lot contained cars with license plates from Kentucky, Mississippi, Missouri, Indiana and Ohio.

In addition to the 100 people bidding in-person, about 250 bidders participated in a Web simulcast of the auction, according to Great American Group officials who ran the auction.

Some bidders using the Internet were from as far away as Peru and Egypt, and one bidder was planning to use items he bought to furnish a hospital in Puerto Rico, said Roy Gamityan, senior vice president of wholesale and industrial services for Great American Group.

The most expensive item sold was a computerized tomography scanner that went for $40,000 and will be shipped to the Puerto Rican hospital, Gamityan said. The items even included some bone saws for amputating limbs and metal pins for repairing broken bones.

Smith said American medical equipment often becomes unusable in the United States as rapidly changing federal regulations make it obsolete. Overseas medical clinics are more than happy to snap up the stuff at a discount, he said.

The surgical instruments he bought will go to U.S. hospitals and schools that teach operating-room techniques, he said. Some of the instruments and equipment will be resold to buyers in China and the Philippines, he added.

By Dave DeWitte, The Gazette, Cedar Rapids, Iowa

Jan. 19–CEDAR RAPIDS — They arrive on leashes, or crouched in plastic crates, at all hours.

Sometimes they yelp with pain or tremble with anxiety. Not infrequently, they are bleeding.

This is the Cedar Rapids’ only emergency clinic for animals. It’s a place where pets’ lives are saved almost every day, and sometimes, relieving an animal’s pain or ending its life humanely are the only solutions.

The Eastern Iowa Veterinary Specialty Center opened four months ago at 755 Capital Dr. SW, near The Eastern Iowa Airport. Hospital Manager Kristi Murdock said a gradual increase in patients was expected. Instead, the center became busy overnight with referrals from area veterinarians.

Weekends are busiest at the facility, which has digital radiography, laboratory and ultrasound equipment many human clinics would envy.

Between 12 and 15 patients arrive on a typical Saturday or Sunday. Nights are slower, with three to seven patients arriving.

The modern two-story building looks more like a human medical clinic than a vet clinic.

Patients arrive without appointments and are “triaged” by a veterinary technician. If the pet has a life-threatening condition, it is moved ahead of other pets.

Work seldom is dull for the five veterinarians on the center’s 21-member staff.

Veterinarian Sylvia Murphy handled the 8 a.m. to 8 p.m. shift Sunday, often the week’s busiest.

Midway through the shift, she tries to figure out why a miniature schnauzer keeps bleeding from the mouth.

“It’s a little heart-wrenching sometimes, but it’s interesting,” she says of her work.

“It’s always a challenge.”

Murphy’s patients for the day include a Labrador retriever with a probable case of Addison’s disease, a beagle having trouble using its hind legs and two dogs that appeared to be sick from eating bad dog food.

“We’ve had a recent rash of toy dogs with broken legs,” Murphy said, referring to smaller breeds.

One advantage of the 24-hour operation is that at least one vet and one vet tech are on duty at all times and backed up by the latest monitoring equipment.

Veterinarian Bradley Schipper handles the overnight shift from 8 p.m. to 8 a.m.

At 6:30 a.m. Monday, Schipper reports a quiet night: one older dog suffering from seizures, a younger dog with hip problems and one euthanasia. The schnauzer’s bleeding is almost stopped.

An important part of Schipper’s duties comes early Monday when he phones the referring vets about animals that have been admitted. He also updates pet owners, and records his overnight observations of the patient’s conditions for the vet who will take over at 8 a.m.

The center provides overnight vets with a recliner for naps. Schipper rarely uses it.

“You have to be wired a certain way,” says Schipper, who previously commuted to work 25-hour shifts at an emergency vet clinic in New Hampshire.

“It’s a different mind-set than what you see in private practice. I have to do a lot of grief counseling and discussions on potentially significant disease processes. I don’t have as many ‘happy days’ as I had when I was in private practice.”

The relationship between the emergency center and other area vets is carefully defined, according to Murdock. The clinic is owned by a group of Corridor vets who were seeking a better way to provide after-hours services, and by Horizon Veterinary Services of Appleton, Wis., which manages emergency and specialty vet clinics.

Customers must have a referral from a vet, although it may be as informal as mentioning they were instructed to go to the center by an after-hours message on their vet’s phone.

They also pay a premium for receiving emergency service. The center charges a $79 consultation fee to examine a pet, which rises to $99 after midnight and on holidays. Payment is required at the time of service.

But the expense pays for equipment and expertise few clinics can match, such its board-certified veterinary surgeon, Rhonda Aper.

As opportunities permit, the center plans to offer other advanced specialties.

—–

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By Tsujimura, A; Matsumiya, K; Takao, T; Miyagawa, Y; Et al

Abstract

The purpose of this study was to evaluate the efficacy and safety of human chorionic gonadotropin (hCG) for patients with partial androgen deficiency of the aging male (PADAM). Twenty-one patients over 50 years of age with PADAM symptoms were included in this study. Laboratory and endocrinologic profiles were reviewed as appropriate, and PADAM symptoms were judged by means of several questionnaires such as the Aging Males’ Symptoms (AMS) scale, short version of the International Index of Erectile Function (IIEF-5), and the Self-rating Depression Scale (SDS). Laboratory and endocrinologic values and symptom scores were evaluated and compared before and after treatment by hCG injection. The treatment period was 8.0 5.0 months (3.0-24.0 months). Serum concentrations of testosterone, including total testosterone, calculated free testosterone, and calculated bioavailable testosterone, increased significantly. AMS total scores and subscores decreased significantly after treatment. However, IIEF-5 and SDS scores did not improve. With respect to adverse effects, laboratory tests showed that only red blood cell count, hematocrit and hemoglobin level increased significantly after treatment, however, these values remained within the normal range. No adverse effect was identified after treatment. We conclude that hCG injection may be considered as a treatment for PADAM.

Keywords: Partial androgen deficiency of the aging male, human chorionic gonadotropin, Aging Males’ Symptoms scale

Introduction

“Male menopause” and “symptomatic late onset hypogonadism” have received widespread attention in the popular and medical media in the last few years [1]. The International Society for the Study of the Aging Male (ISSAM) coined the acronym PADAM for “partial androgen deficiency of the aging male” to designate this condition [1]. PADAM is defined as a biochemical syndrome associated with advancing age and is characterized by a deficiency in serum androgen with or without decreased genomic sensitivity to androgen [1]. It is well known that the serum androgen level declines with age and that this decline is the main cause of PADAM. Clinical symptoms of PADAM are characterized by: 1) the easily recognized features of diminished sexual desire and erectile quality, particularly nocturnal erections; 2) changes in mood with concomitant decreases in intellectual activity, spatial orientation ability, fatigue, depression and anger; 3) decrease in lean body mass with associated diminution in muscle volume and strength; 4) decrease in body hair and skin alterations; 5) decrease in bone mineral density resulting in osteoporosis; and 6) increase in visceral fat [2-6]. The treatment of PADAM has recently received increased attention with respect to quality of life.

The first-choice treatment for PADAM is usually androgen supplementation. Hormone replacement therapy (HRT) aims to substitute the deficient hormone with a perfect copy of the natural hormone, with a dose schedule that generates physiological hormone levels over 24 hours of the day [3]. Many researchers have recommended HRT with testosterone for PADAM and have reported that HRT can improve sexual function, libido and sense of wellbeing, as well as maintain bone and muscle mass [7-11]. Oral and transdermal testosterone preparations, as well as injections, have been used clinically for PADAM worldwide and their efficacies have been reported. Testosterone is generally administered by injection in Japan because oral and transdermal preparations are not available. Testosterone injections produce a nonphysiologic serum testosterone level that peaks rapidly after injection and declines gradually over 2 weeks [12]. The reduction in serum testosterone is sometimes associated with near normal gonadotropin levels in aging men, suggesting the aging is associated with partial hypothalamic – pituitary dysregulation [13-15]. In addition, testosterone supplementation for long periods of time increases the risk of testicular atrophy, whereas injections of human chorionic gonadotropin (hCG) do not increase the risk of testicular atrophy because it induces the testes to produce endogenous testosterone. Furthermore, hCG has been used safely as a treatment for patients with hypogonadotropic hypogonadism or idiopathic male infertility [16-19]. However, the clinical data of hCG for PADAM has not been reported well.

The purpose of this study was to evaluate the efficacy and safety of hCG for patients with PADAM by comparing endocrinologie and laboratory values, and PADAM symptoms before and after treatment.

Materials and methods

Seventy-seven men over 50 years of age with a chief complaint of decreased libido, erectile dysfunction, depression, general fatigue, or other PADAM symptom, visited one of our special clinics for PADAM at Osaka University Hospital, or an affiliated hospital, between September 2002 and June 2004. Those in whom either total testosterone (TT), calculated free testosterone (cFT) or calculated bioavailable testosterone (cBT) indicated hypogonadism according to the ISSAM’s recommended cut-off levels [1], and in whom serum luteinizing hormone (LH) concentrations were within normal range, were scheduled for hCG treatment. Patients with a serious disease such as malignancy or suicidal depression, those with a high prostate-specific antigen (PSA) level (more than 4.0 ng/ml), and those refusing treatment were excluded from the study. Twenty-one patients received hCG treatment. In these patients, plasma TT was measured on two occasions, once before intramuscular injection of 10,000 IU of hCG and again 4 days later, and adequate production of testosterone in response to hCG was confirmed (3.4 1.4 times) before the entry into hCG treatment (Table I).

Patients ranged in age from 50 to 79 years (55.2 6.4 years). All patients were able to receive the treatment for more than 3 months, and the treatment period was 8.0 5.0 months (3.0-24.0 months). All patients provided written informed consent for participation in this study. General symptoms of PADAM were judged according to the Aging Males’ Symptoms (AMS) scale [20]. Erectile function and depressive state were judged according to the short version of the International Index of Erectile Function (IIEF-5) [21] and the Self- rating Depression Scale (SDS) [22], respectively. SDS is a self- reporting scale composed of 20-item scales and was developed to measure depressive symptoms using 4-point scales. Twenty items include depressed mood, morning symptoms, crying, insomnia, diminished appetite, weight loss, loss of sexual interest, constipation, palpitations, fatigue, clouded reasoning, difficulty with completing tasks, difficult decision making, restlessness, lack of hope, irritability, diminished self-esteem, life satisfaction, suicidal ideation and anhedonia [22]. Endocrinologic variables included serum LH, follicle-stimulating hormone, TT, estradiol, prolactin (PRL), growth hormone and insulin-like growth factor-1 levels. cFT and cBT were calculated on the basis of TT and sex hormone-binding globulin according to the formula included on the ISSAM website (http://www.issarn.ch/freetesto.htm) [1]. Hematopoiesis, liver function, lipid profile, serum PSA, and urinary deoxypyridinoline as an index of bone resorption were also evaluated. Treatment consisted of intramuscular injection of 3,000 units hCG (ASKA Pharmaceutical Co. Ltd., Tokyo, Japan) every 2 weeks. All blood samples were collected at the nadir of serum testosterone concentration (2 weeks after the last injection and just prior to the next injection) between 09:00 and 11:00 hours for monitoring of endocrinologic variables. Laboratory and endocrinologic values and PADAM symptoms were compared before and after treatment to evaluate the efficacy and safety of hCG for PADAM.

Table I. Production of testosterone in response to intramuscular injection of 10,000IU of HCG.

Data are presented as mean SD, and statistical analysis was performed with paired Student’s t-test. A P value of less than 0.05 was considered statistically significant.

Results

Endocrinologic values before and after hCG treatment are shown in Table II. Serum concentrations of TT, cFT, and cBT increased significantly, as expected, and PRL decreased significantly. No other endocrinologie variables, including LH, were altered. With respect to PADAM symptoms, AMS scores decreased significantly after treatment. Furthermore, each of the AMS subscores (psychological, somatovegetative, sexual) decreased significantly. No significant improvement was observed in IIEF-5 or SDS (Table III). With respect to laboratory values, red blood cell count, hematocrit, and hemoglobin level increased significantly after treatment (Table IV). No other laboratory values showed significant alterations. There was also no increase in PSA level. No adverse events of sleep disorders and worsened urinary symptoms such as dysuria, pollakisuria, nocturia and weak stream were identified after treatment.

Discussion

The efficacy of testosterone HRT for patients with PADAM has been reported [9]. With respect to somatovegetative symptoms, lean body mass and lumbar spine bone mineral density increased, and fat mass decreased, after 36 months of treatmen\t with a testosterone patch in 108 men over 65 years of age [23,24]. In addition, older men showed increased muscle volume, and leg and arm muscle strength, after 6 months of HRT treatment [25]. HRT treatment was reported to alleviate depressed mood in men with hypogonadism or symptomatic human immunodeficiency virus illness [26]. With respect to sexual symptoms, frequency of early morning erection, ability to maintain erection and libido, these were reportedly improved by HRT [27,28]. Morley and Tariq have also reported that testosterone restored erections in men who had originally shown no response to sildenafil [29]. However, high-quality testosterone preparations that can maintain a physiologic testosterone level have not been available in Japan. The aging is associated with partial hypothalamic- pituitary dysregulation [13-15]. Therefore, we treated PADAM by hCG injection. We generally performed hCG injections every 2 weeks because it has been reported that the binding capacity of testicular hCG receptors is significantly reduced for 5 days after injection, begins to increase on day 7, and returns to pre-administration levels 14 days after a single administration of 5000IU hCG [30].

Table II. Endocrinologic values before and after HRT in patients who received hCG injections.

Table III. PADAM symptom scores before and after HRT in patients who received hCG injections.

Table IV. Laboratory values before and after HRT in patients who received hCG injections.

Pharmacokinetic studies of hCG demonstrate a usual terminal half- life of about 30 hours, and testosterone levels usually peak between 72 and 96 hours after the hCG administration. In the present study, injection of hCG induced significant increases in serum TT, cFT, and cBT concentrations, even when measured at the nadir of serum testosterone concentration. This finding indicates a good response of the testes in producing endogenous testosterone. With respect to symptom scores, the AMS score decreased significantly after treatment. However, IIEF-5 and SDS scores did not improve significantly. hCG might not improve SDS scores because depression is a complex condition caused by physical, physiological and social factors, and not by hypogonadism alone. Indeed, we previously reported that serum cBT concentrations did not correlate with depression scores [31]. However, our current data showed improvement of the AMS psychological subscore, which indicates that hCG treatment may improve psychological status with regard to wellbeing, mood and cognition. A recent report showed that testosterone can increase positive and decrease negative mood, but has no effect on dysphoria or depression [9]. Our data are consistent with this finding. Likewise, the IIEF-5 score as an indicator of erectile function did not change, even though the AMS sexual subscore improved. We speculate that an increase in testosterone concentration by hCG injection improves libido, sexual arousal and sexual activity, but not erectile function. Our endocrinologie data showed a significant decrease in serum PRL concentration after treatment. It is reported that high serum PRL concentrations inhibit libido [32]. Thus, this significant decrease in serum PRL concentration may be related to improved libido.

With respect to adverse symptoms, we did not find any severe symptoms, e.g., sleep disorders, or worsened urinary symptoms such as dysuria, pollakisuria, nocturia and weak stream. Significant increases in red blood cell count, hematocrit and hemoglobin levels were the only observed adverse effects of hCG injection. Other laboratory values, including PSA level, were not altered. Many studies have found that androgens may be beneficial in the treatment of primary anemia and bone marrow failure. It is well known that testosterone therapy increases whole-body hematocrit values. Despite the short treatment period in the present study (8.0 5.0 months), red blood cell count, hemoglobin level and hematocrit were increased. Another short-term study showed a rise in hematocrit of up to 7% in elderly hypogonadal men undergoing testosterone therapy [33]. Patients undergoing treatment by hCG injection, even for a short period, should be monitored for polycythemia, although our data for red blood cell count, hemoglobin level and hematocrit in our patients remained within the normal range.

We showed that hCG injection can effect a significant improvement in some PADAM symptoms and that it did not have any serious adverse effects. Although hCG injection appeared to be effective for PADAM, particularly with respect to sexual status other than erectile function and psychological status other than depression, a placebo effect cannot be ruled out. Only one double-blind, placebo- controlled, randomized study has monitored the effects of 3 months’ administration of hCG to aging men with plasma testosterone levels in the lower range of normal [34]. It showed that plasma levels of TT increased 50% above baseline and the effects were very similar to those of androgen administration to aging men. Our result is consistent with this well controlled study. However, it was recently reported that none of the AMS subscores (psychological, somatovegetative, sexual) correlated significantly with TT, FT, or BT in a study of 161 healthy, ambulatory, elderly men [35]. Likewise, no correlation between AMS scores (total and subscores) and testosterone levels was reported in a study of 81 self-referred PADAM patients [36]. We have also reported that PADAM symptoms as evaluated by AMS, IIEF-5 and SDS scores were not related to serum testosterone concentration in a study of 90 self-referred PADAM patients [37]. Thus, it remains unclear whether all PADAM symptoms can be explained by a decrease in serum testosterone concentration alone, and whether HRT can improve PADAM symptoms by exerting only an endocrinologie effect. To address these issues, a controlled, randomized study, including a placebo and a large number of PADAM patients, is needed.

Conclusion

Because our study showed a significant increase in the serum testosterone concentration and a significant improvement in AMS scores, we conclude that hCG treatment may be considered a treatment option for PADAM in patients in whom adequate production of testosterone in response to hCG was confirmed.

Acknowledgements

We are very grateful to M. Omune, M. Oki, S. Tanabe, C. Nakamura and T. Enomoto (of our laboratory) for assistance in sample collection and for useful discussions.

References

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11. Morales A, Johnston B, Heaton JP, Lundie M. Testosterone supplementation for hypogonadal impotence: assessment of biochemical measures and therapeutic outcomes. J Urol 1997;157:849-854.

12. Dobs AS, Meikle AW, Arver S, Sanders SW, Caramelli KE, Mazer NA. Pharmacokinetics, efficacy, and safety of a permeation-enhanced testosterone transdermal system in comparison with bi-weekly injections of testosterone enanthate for the treatment of hypogonadal men. J Clin Endocrinol Metab 1999;84:3469-3478.

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15. Veldhuis JD, Zwart A, Mulligan T, Iranmanesh A. Muting of androgen negative feedback unveils impoverished gonadotropinreleasing hormone/luteinizing hormone secretory reactivity in healthy older men. J Clin Endocrinol Metab 2001;86:529- 535.

16. Finkel DM, Phillips JL, Snyder PJ. Stimulation of spermatogenesis by gonadotropins in men with hypogonadotropic hypogonadism. N Engl J Med 1985;313:651-655.

17. Liu PY, Gebski VJ, Turner L, Conway AJ, Wishart SM, Handelsman DJ. Predicting pregnancy and spermatogenesis by survival analysis during gonadotrophin treatment of gonadotrophin-deficient infertile men. Hum Reprod 2002; 17:625-633.

18. Amelar RD, Dubin L. Human chorionic gonadotrophin therapy in male infertility. JAMA 1977;237:2423.

19. Schill WB, Jungst D, Unterburger P, Braun S. Combined hMG/ hCG treatment in subfertile men with idiopathic normogonadotrophic oligozoospermia. Int J Androl 1982;5: 467-477.

20. Heinemann LA, Zimmermann T, Vermeulen A, Thiel C. A new ‘aging males’ symptoms’ (AMS) rating scale. Aging Male 1999;2:105- 114.

21. Rosen RC, Riley A, Wagner G, Osterloh IH, Kirkpatrick J, Mishra A. The international index of erectile function (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology 1997;49:822-830.

22. Zung WW, Richards CB, Short MJ. Self-rating depression scale in an outpatient clinic.Further validation of the SDS. Arch Gen Psychiatry 1965;13:508-515.

23. Snyder PJ, Peachey H, Hannoush P, Berlin JA, Loh L, Lenrow DA, Holmes JH, Dlewati A, Santanna J, Rosen CJ, et al. Effect of testosterone treatment on body composition and muscle strength in men over 65 years of age. J Clin Endocrinol Metab 1999;84:2647- 2653.

24. Snyder PJ, Peachey H, Hannoush P, Berlin JA, Loh L, Holmes JH, Dlewati A, Staley J, Santanna J, Kapoor SC, et al. Effect of testosterone treatment on bone mineral density in men over 65 years of age. J Clin Endocrinol Metab 1999;84:1966-1972.

25. Ferrando AA, Sheffield-Moore M, Yeckel CW, Gilkison C, Jiang J, Achacosa A, lieberman SA, Tipton K, Wolfe RR, Urban RJ. Testosterone administration to older men improves muscle function: molecular and physiological mechanisms. Am J Physiol Endocrinol Metab 2002;282:E601-E607.

26. Rabkin JG, Wagner GJ, Rabkin R. A double-blind, placebo- controlled trial of testosterone therapy for HIV-positive men with hypogonadal symptoms. Arch Gen Psychiatry 2000; 57:141-147; discussion 155-156.

27. Hajjar RR, Kaiser FE, Morley JE. Outcomes of long-term testosterone replacement in older hypogonadal males: a retrospective analysis. J Clin Endocrinol Metab 1997;82: 3793-3796.

28. Kunelius P, Lukkarinen O, Hannuksela ML, Itkonen O, Tapanainen JS. The effects of transdermal dihydrotestosterone in the aging male: a prospective, randomized, double blind study. J Clin Endocrinol Metab 2002;87:1467-1472.

29. Morley JE, Tariq SH. Sexuality and disease. Clin Geriatr Med 2003;19:563-573.

30. Namiki M, Kitamura M, Miyake O, Nakamura M, Okuyama A, Sonoda T, Takeyama M, Fujioka H, Matsumoto K. Reduction of testicular human chorionic gonadotropin receptors by human chorionic gonadotropin in infertile men. Arch Androl 1988;20:45-50.

31. Tsujimura A, Matsumiya K, Matsuoka Y, Takahashi T, Koga M, Iwasa A, Takeyama M, Okuyama A. Bioavailable testosterone with age and erectile dysfunction. J Urol 2003; 170:2345-2347.

32. Graziottin A. Libido: the biologic scenario. Maturitas 2000;34(Suppl 1):S9-S16.

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

34. Liu PY, Wishart SM, Handelsman DJ. A double-blind, placebo- controlled, randomized clinical trial of recombinant human chorionic gonadotropin on muscle strength and physical function and activity in older men with partial age-related androgen deficiency. J CHn Endocrinol Metab 2002;87:3125-3135.

35. T’Sjoen G, Goemaere S, De Meyere M, Kaufman JM. Perception of males’ aging symptoms, health and well-being in elderly community- dwelling men is not related to circulating androgen levels. Psychoneuroendocrinology 2004; 29: 201-214.

36. T’Sjoen G, Feyen E, De Kuyper P, Comhaire F, Kaufman JM. Self- referred patients in an aging male clinic: much more than androgen deficiency alone. Aging Male 2003;6:157-165.

37. Tsujimura A, Matsumiya K, Miyagawa Y, Takao T, Fujita K, Takada S, Koga M, Iwasa A, Takeyama M, Okuyama A. Comparative study on evaluation methods for serum testosterone level for PADAM diagnosis. Int J Imp Res 2005;17: 259-263.

A. TSUJIMURA1, K. MATSUMIYA1, T. TAKAO1, Y. MIYAGAWA1, S. TAKADA1, M. KOGA2, A. IWASA3, M. TAKEYAMA2, & A. OKUYAMA1

1 Department of Urology, Osaka University Graduate School of Medicine, Suita, Japan, 2 Department of Urology, Osaka Central Hospital, Osaka, Japan, and 3 Iwasa Clinic, Osaka, Japan

Correspondence: A. Tsujimura, Department of Urology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan. Tel: 81 6 6879 3531. Fax: 81 6 6879 3539. E-mail: [email protected]

Copyright CRC Press Sep-Dec 2005

By Wai, Mara

Part II of this feature will appear in the January/February 2006 issue of Viewpoint

What Is Complementary and Alternative Medicine?

Complementary and alternative medicine (CAM) is a categorical term used to describe a range of medical and health care systems and/ or therapeutic modalities, practices, and products that are not presently considered to be part of conventional medicine – medicine that is traditionally practiced by physicians and allied health professionals (such as physical therapists, psychologists, and nurses) (Caspi et al., 2003; The National Center for Complementary and Alternative Medicine [NCCAM], 2005). In 1998, the National Institutes of Health (NIH) recognized CAM use as both an alternative medical strategy and a supplemental or complementary health care strategy. CAM therapies used alone are often referred to as “alternative,” whereas when used in addition to conventional medicine, they are often referred to as “complementary” (NCCAM, 2005).

The National Center for Complementary and Alternative Medicine (NCCAM) was instituted by the NIH to address the increasing informational and practical demand for CAM by consumers. NCCAM classifies CAM therapies into five categories described below (Flaherty & Takahashi, 2004). As of 2001, more than 350 therapies met the defining CAM criteria (Milden & Stokols, 2004). The list of what is considered to be CAM is continuing to evolve as new health care strategies become known and as CAM therapies are proven to be safe, effective, and are adopted into conventional health care.

TYPES OF CAM TREATMENTS

Alternative Medical Systems

Alternative medical systems are built upon complete systems of theory and practice that have evolved independent of the conventional medical approach used in the United States. Two of the most popular alternative medical systems are Traditional Chinese Medicine (TCM) and India’s Ayurvedic Medicine. TCM is based on the concept of Chi, which is the life force that is said to run through all of nature. Some TCM treatment strategies include acupuncture, acupressure, and Chinese herbs. Each of these treatment modalities are used to decrease life-force (or Chi) imbalances that are thought to be the cause of specific problems that can manifest in a particular organ system. Other commonly used TCM treatment strategies to balance Chi include Qi Gong (pronounced “chee gung”) and Tai Chi, which are two Chinese movement strategies.

Ayurveda comprises ancient Indian healing techniques that are based generally on the classification of three predominant body types. Ayurvedic philosophy posits that mental, emotional, and physical qualities of an individual can be classified into one of these three body types. Overall, the sum of qualities possessed by an individual are often representative of one or two of the body types. Each body type is associated with specific disease as well as health-promoting treatment strategies. Ayurvedic recommendations for diet and lifestyle regimens differ among the three body types, and Ayurvedic healing strategies emphasize regular detoxification and cleansing of all physiologic systems.

A third example of an alternative system of healing is Homeopathic Medicine. This system employs the use of natural, unsynthesized, herbal remedies that are derived from plants, minerals, and other natural substances. Classical homeopathic treatment is based on the use of minute quantities of natural remedies that in larger doses produce effects similar to those of the disease being treated. Homeopaths define the underlying principle for this matching process as the “law of similars,” which is similar to the principle of immunizations.

Mind-Body Interventions

Mind-body interventions are based on the notion that physical health is influenced by the mind. Mind-body interventions employ various techniques designed to enhance the mind’s capacity to affect physiological symptoms and functions. Meditation and prayer are two widely used mindbody intervention strategies. Other types of mind- body interventions include imagery (use of imagination to visualize goals, relaxing situations) to promote relaxation and healing; biofeedback (employs an electronic device to monitor heart rate, blood pressure, muscle tension, and other parameters via the use of visual or audio feedback, which assists with the conscious control of these physiologic functions); yoga (the practice of physical postures, breathing techniques, meditation, and cleansing techniques); and Tai Chi (slow, mindful movement consisting of a sequence of postures that move smoothly from one to another).

Biologically Based Therapies

Biologically based therapies employ substances such as herbs, foods, and vitamins to promote healing or affect change in health symptoms and/or functioning. Examples of biologically based therapies include therapeutic doses of vitamins, special diets, and herbal products. Macrobiotics is a term for a special diet that adheres to the ancient principle of balance in which TCM is based. Macrobiotic diets include specific dietary and lifestyle regimens. The dietary component of macrobiotics emphasizes the use of whole, unprocessed foods such as whole grains, legumes, vegetables, fruits, nuts, and seeds. This special diet avoids meat, dairy, certain vegetables, and processed foods. The system of macrobiotics also emphasizes the maintenance of a balanced lifestyle that considers the importance of such factors as physical activity and mental outlook. Megavitamin therapy is another example of a biologically based therapy employing large doses of vitamins – sometimes up to hundreds of pills a day – or intravenous infusions of high-dose vitamins, which are used to treat disease. In megavitamin therapy, the use of vitamins is in doses that exceed the Recommended Daily Allowance (RDA), sometimes up to 10 times greater than the RDA dose. Both megavitamin and megadose therapies are often used preventatively based on the belief that intake of certain vitamins and minerals in amounts greater than the RDA approves may reduce the risk of developing some diseases.

Manipulative and Body-Based Methods

Manipulative and body-based methods are based on touching and/or manipulation or movement of one or more parts of the body. Massage therapy is an example of one such method that encompasses a wide variety of techniques that utilize hand manipulation of soft tissue. Massage therapy modalities are aimed at releasing tension in muscles and improving circulation or lymphatic flow. Chiropractic is a system of healing and health maintenance that uses manipulation of the spine, called adjustment, to correct medical conditions and promote health.

Energy Therapies

Energy therapies employ the concept of energy fields that are considered to be surrounding and penetrating the human body. Practitioners aim to balance patients’ energy fields to promote and restore health, and to relieve symptoms such as pain. These techniques are carried out by practitioners who use their own energy field (termed “biofield'”) or “CM” to affect change in their patients’ human energy fields. By way of energy transfer and manipulation of the patient’s human energy field, practitioners can unblock and re-balance the patient’s energy field and thereby promote his or her overall well being. Examples of energy therapies include Reiki and Qi Gong. Reiki is based on the belief that everyone has access to an unlimited supply of “life force energy” to improve health and enhance the quality of life. A simple technique to learn, a Reiki practitioner typically lays his or her hands on a patient (Reiki can also be done without physical contact) to move energy through the affected parts of the energy field and charge them with positive energy. Qi Qong, a TCM energy therapy, is usually defined as “cultivation of the ChL” It is a system involving energy movement-based exercises that are used to balance energy, and are ultimately understood to halt and reverse diseases. Qi Qong combines focused concentration with simple movements and balanced breathing in a controlled way.

APPROACHES TO CAM

Many CAM approaches can be described as emphasizing “holism,” which considers the health of an individual as a reflection of the combination of his or her physical, mental, emotional, social, and spiritual aspects (Caspi et al., 2003). Certain CAM modalities employ treatment interventions that target only one of these aspects of the “whole” system, and the effect of the treatment may or may not be thought to affect the “whole.” Barret et al. (2000) found that patients as well as health care practitioners who employ alternative therapies stressed the importance of a holistic approach to their health care practices; this is in contrast to the conventional medical viewpoint of treating a “composite of numerous biomedical attributes” (Barrett et al., 2000).

CAM USE IN THE UNITED STATES

Emerging literature depicts a dramatic rise in CAM use by individuals (Barrett et al., 2000; Cassileth, 1999; Chatwin & Tovey, 2004). The most comprehensive and reliable findings to date on the use of CAM by adult Americans come from the 2002 edition of the National Health Interview Survey (NHIS), an annual study administered to a representative sample of Americans about their health and illness-related experiences. The 2002 edition of the NHIS survey incorporated detailed questions about CAM including an extensive listof CAM therapies, a wide variety of health conditions and diseases for which CAM therapies may be used, and reasons for CAM use and satisfaction with CAM treatment. Study findings from this 2002 survey reveal an estimated 36% to 62% of adults having used some form of CAM therapy in the 12-month period prior to the survey (Barnes, Powell-Griner, McFann, & Nahin, 2004). Another study regarding the prevalence of CAM use found that alternative medicine use in the United States has increased from 33.8% in 1990 to 42.1% in 1997 – approximately 629 million individuals (Eisenberg et al., 1998). This estimate outnumbers visits to primary care physicians (388 million) by more than 60% (Barrett et al., 2000; Berman, Bausell, & Lee, 2002).

The 10 most commonly used CAM therapies found in the 2002 NHIS survey included:

* The use of prayer specifically for one’s own health (43%).

* Prayer by others for one’s own health (24.4%).

* Natural products (18.9%).

* Deep breathing exercises (11.6%).

* Participation in prayer group for one’s own health (9.6%).

* Meditation (7.6%).

* Chiropractic care (7.5%).

* Yoga (5.1%).

* Massage (5.0%).

* Diet-based therapies (3.5%).

Although CAM was found to be utilized by people of all backgrounds, according to the NHIS survey, CAM use was greater in:

* Women vs. men.

* Older vs. younger adults.

* People with higher educational levels.

* Patients hospitalized in the past year.

* Former smokers, compared with current smokers or those who have never smoked.

When examining the use of CAM more closely, particular patterns of use are noted (Barrett et al., 2000; Sleath, Rubin, Campbell, Gwyther, & Clark, 2001). The largest gender differential has been observed in the use of mindbody therapies, particularly regarding prayer used specifically for health reasons, with women engaging in prayer for health reasons more often than men. Younger women have been found to be less likely to use CAM than older women, suggesting that attitudinal differences or some other preferences may be driving these age differences. In addition, individuals with higher education who were more likely to use CAM were also more likely to have a “holistic philosophy” (Upchurch & Chyu, 2005).

When examining the prevalence of CAM use among Americans over the age of 65, CAM use was found to range from 41 % to 64%, with CAM use greater among older White Americans (61 %) compared with older African Americans (47%) (Flaherty & Takahashi, 2004). The most commonly used CAM therapies reported by this age group (excluding lifestyle, diet, prayer, and vitamins) are herbs, chiropractic, and acupuncture (Flaherty & Takahashi, 2004).

Overall, findings suggest that most patients who use CAM continue to utilize conventional medicine. However, studies of CAM use have shown that they often do not tell their traditional medicine-based providers about their CAM use (Sleath et al., 2001). Physicians attitudes have been revealed to play a crucial role in moderating patients’ beliefs about and use of CAM treatments (Milden & Stokols, 2004). As such, it is becoming increasingly important for primary care physicians and other health care practitioners to take proactive steps to understand and probe for the use of CAM by their patients to improve patient safety by eliminating potential adverse reactions between CAM and conventional medical approaches. Understanding this disconnect and facilitating better communication between patients and their physician about CAM use and the coordination of CAM with traditional medical regimens may fall within the nursing domain and/or other allied health professionals.

PREDICTORS OF CAM USE

Health

Patients are found to be using CAM for a wide array of diseases and conditions. The 2002 NHIS study (Barnes, Powell-Griner, McFann, & Nahin, 2004) findings reveal that Americans are most likely to use CAM for conditions involving chronic or recurring pain (such as back, neck, head, or joint aches), as well as other painful conditions. This is not surprising given that 25 to 33% of the adult population might be suffering from some form of chronic pain in a given year (Lipton, Steward, Daimond et al., 2002; Yelin, Herrndorf, Trupin, & Sonneborn, 2001). Back pain is reported to be the most common reason patients use CAM therapies, with chiropractic and massage as the most frequently used CAM modalities for this purpose (Sherman et al., 2004). There is evidence of the effectiveness and use of various CAM therapies (including the use of relaxation, meditation, gentle yoga, massage, qi gong, guided imagery, herbal and biological-based therapies, and acupuncture) for treating symptoms associated with cancer (Antman etal., 2001; Burstein, Gelber, Cuadagnoli, & Weeks, 1999; Carlson, Speca, Patel, & Goodey, 2003; Cassileth & Deng, 2004; Cassileth & Vicers, 2005; Davidson, Geoghegan, McLaughlin, & Woodward, 2004; Eng et al., 2003; Kinney, Rodgers, Nash, & Bray, 2003; Rosenbaum et al., 2004, Shen et al., 2002; Sparber & Wootton, 2001; Tatsamura, Maskarinec, Shumay, & Kakai, 2003), cardiovascular diseases (Chagan et al., 2005), and for improving post-surgical outcomes (Astin, Shapiro, Eisenberg, & Forys, 2003). Other medical conditions that are associated with the use of CAM include colds, gastrointestinal disorders, and sleeping disorders.

CAM therapies are also used to treat psychological conditions such as anxiety and/or depression. One study reveals that CAM treatments were utilized by the majority of psychiatric inpatients surveyed (63%) within the previous 12-months prior to inpatient treatment (Elkins, Rajab, & Marcus, 2005) Other research has shown that CAM treatments can be used to augment or even replace medications prescribed to individuals to treat anxiety and depressive symptoms (Parslow & Jorm, 2004). Mamtami and Cimino (2002) reported that individuals with psychiatric disorders are more likely to use CAM than those with other diseases.

Current literature (Barnes, Powell-Griner, McFann, & Nahin, 2004) indicates the following as the most commonly reported reasons for CAM use:

* Improve health when used in combination with conventional medical treatments (55%).

* Interest in trying CAM (50%).

* Belief that conventional medical treatments would not help or be inadequate (28%).

* Recommendation by a conventional medical professional (26%).

* Conventional medical treatments are too expensive (13%).

Despite these research findings, the current qualitative research base is limited in terms of the number of in-depth investigations aimed at exploring the actual reasons why patients choose to use complementary therapies (Chatwin & Tovey, 2004).

Ethnic and Cultural Differences

The relationship between CAM use and ethnic and cultural beliefs and practices has not been well-explored. Few studies exist that attempt to analyze this relationship. In one existing review of the literature of CAM use by ethnic and racial minorities, Struthers and Nichols (2004) found that the frequency of CAM use varies depending upon the population of interest. The 2002 NHIS Study revealed that CAM utilization is highest among African Americans (71.3%), followed by Asians (61.7%), Hispanics (61.4%), and Caucasians (60.4%) (Barnes, Powell-Griner, McFann, & Nahin, 2004).

With regard to socio-cultural differences across the use of CAM modalities, African and Native American elders were found to use home and folk remedies more often than European Americans (Arcury, Quandt, Bell, & Vitolins, 2002). Kuo, Hawley, Weiss, Balkrishnan, and VoIk (2004) observed the presence of racial/ethnic differences in herbal use among 322 multiethnic primary care patients. Patients who were most likely to use herbal remedies were nonAfrican American, had immigrant family histories, and reported herbal use among family members. Sleath et al. (2001) collected data revealing that Hispanics and Asians reported the highest rates of herbal use (50%), and were the least likely to disclose their use to health professionals. This study revealed an estimated 83% of minority patients overall who use CAM do not report this use to their physicians.

Culturally distinct worldviews held by different ethnicities can affect health information-seeking behavior and thereby impact the uptake of CAM. For example, Kakai, Maskarinec, Shumay, Tatsumura, and Tasaki (2003) revealed distinct ethnic differences in cancer patients in regard to their preferences in obtaining health information. Survey information collected from 140 cancer patients found that Caucasian patients preferred obtaining objective, scientific, and updated health-related information (including via medical journals, newsletters from research institutions, telephone information sources, and the Internet). In contrast, Japanese patients relied on media and commercial sources for obtaining such information (including via television, newspapers, books, magazines, and CAM providers), and non-Japanese Asians and Pacific Islanders used information sources involving person-to-person communication (such as with physicians, social groups, other cancer patients). These differences in preferences may be related to difference in CAM use between cultural groups.

CONCLUSION

Taken together, these findings suggest that healthcare providers need to understand the role of sociocultural differences and their influence on patterns of CAM interest and uptake. With this understanding, clinicians can assist minority patients in obtaining and synthesizing relevant health information in a meaningful and culturally-sensitive manner.

Objectives

This educational activity is designed for nurses and other health professionals who treat patients using complementary and alternative therapies. For those wishing to obtain CE credit, an evaluation form is available on the AAACN Web site. After studying the information presented in this activity, you will be able to:

1. Define complementary and alternative medicine (CAM).

2. Compare t\ypes of complementary and alternative medicine (CAM) therapies used.

3. Summarize the uses of CAM in the U.S.

4. State which people are most likely to use CAM.

This article, co-provided by AAACN and Anthony J. Jannetti, Inc., provides 1.0 contact hour. Anthony J. Jannetti, Inc. (AJJ) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation (ANCCCOA). AAACN is a provider approved by the California Board of Registered Nursing Provider Number CEP 5336, for 1.0 contact hour. Licensees in the state of CA must retain this certificate for four years after the CE activity is completed.

This article was reviewed and formatted for contact hour credit by Sally S. Russell, MN, CMSRN, AAACN Education Director, and Rebecca Linn PyIe, MS, RN, Editor.

The CE Evaluation Form and Objectives for this article appear on the AMCN Web site (www.aaacn.org). Please complete and submit this form to the AAACN National Office to obtain CE credit.

References

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Arcury, T.A., Quandt, S.A., Bell, R.A., & Vitolins, M.Z. (2002). Complementary and alternative medicine use among rural older adults. Alternative Health Practitioner: The Journal of Complementary and Natural Care, 7, 167-186.

Astin, J.A., Shapiro, S.L., Eisenberg, D.M., & Forys, K.L. (2003). Mind-body medicine: State of the science, implications for practice. Journal of the American Board of Family Practitioners, 16(2), 131-47.

Barnes, P.M, Powell-Griner, E., McFann, K., Nahin, R.L. (2004). Complementary and alternative medicine use among adults: United States. Adv Data, 343, 1-19.

Barrett, B.M., et al. (2000). Bridging the gap between conventional and alternative medicine. Journal of Family Practice, 49(3), 234-239.

Berman, B.M., Bausell, R.B., & Lee, W.L. (2002). Use and Referral Patterns for 22 Complementary and Alternative Medical Therapies by Members of American College of Rheumatology: Results of the National Survey. Archives of Internal Medicine, 162(7), 766-770.

Burstein, H.J., Gelber, S.H., Guadagnoli, E., & Weeks, J.C. (1999). Use of alternative medicine by women with early-stage breast cancer. New England Journal of Medicine, 340(22), 1733-1739.

Carlson, L.E., Speca, M., Patel, K., & Goodey, E. (2003). Mindfulnessbased stress reduction in relation to quality of life, mood, symptoms of stress, and immune parameters in breast and prostate cancer patients. Psychosomatic Medicine, 65(4), 571-581.

Caspi, O., et al. (2003). On the definition of complementary, alternative, and integrative medicine: societal mega-stereotypes vs. the patients’ perspectives. Alternative Therapies, 9(6), 58-62.

Cassileth, B.R. (1999). Evaluating complementary and alternative therapies for cancer patients. CA – A Cancer Journal for Clinicians, 49(6), 362-375.

Cassileth, B.R., Deng, G. (2004). Complementary and alternative therapies for cancer. The Oncologist, 9, 80-89.

Cassileth, B.R., St Vickers, A.J. (2005). High prevalence of complementary and alternative medicine use among cancer patients: Implications for research and clinical care. Journal of Clinical Oncology, 23(12), 1 -3.

Chagan, L., et al. (2005). Use of biological based therapy in patients with cardiovascular diseases in a university-hospital in New York City. BMC Complementary and Alternative Medicine, 5(1), 4.

Chatwin J, & Tovey, P. (2004). Complementary and alternative medicine (CAM), cancer and group-based action: a critical review of the literature. European Journal of Cancer Care, 13(3), 210-218.

Davidson, R., Geoghegan, L., McLaughlin, L., & Woodward, R. (2005). Psychological characteristics of cancer patients who use complementary therapies. Psychooncology, 3, 187-195.

Eisenberg, D.M., et al. (1998). Trends in alternative medicine use in the United States, 1990-1997. JAMA, 280, 1569-1575.

Elkins, G., Rajab, M.H., & Marcus, J. (2005). Complementary and alternative medicine use by psychiatric inpatients. Psychol. Rep., 96(1), 163-166.

Eng, J., Ramsum, D., Verhoef, M., Guns, E., Davison, J., Gallagher, R. (2003). A population-based survey of complementary and alternative medicine use in men recently diagnosed with prostate cancer. Integrated Cancer Therapy, 2(3), 212-216.

Flaherty, J.H., & Takahashi, R. (2004). The use of complementary and alternative medical therapies among older persons around the world. Clinical Geriatric Medicine, 20(2), 179-200.

Kakai, H., Maskarinec, G., Shumay, D.M., Tatsumura, Y., & Tasaki, K. (2003). Ethnic differences in choices of health information by cancer patients using complementary and alternative medicine: An exploratory study with correspondence analysis. Social Sciences Medicine, 56(4), 851-862.

Kinney, C.K., Rodgers, D.M., Nash, K.A., & Bray, C.O. (2003). Holistic healing for women with breast cancer through a mind, body, and spirit self-empowerment program. Journal of Holistic Nursing, 27(3), 260-279.

Kuo, G.M., Hawley, S.T., Weiss, L.T., Balkrishnan, R., & VoIk, R.J. (2004). Factors associated with herbal use among urban multiethnic primary care patients: A cross-sectional survey. BMC Complementary and Alternative Medicine, 4(1), 18.

Lipton, R.B., Steward, W.F, Diamond, S. et al. (2002). Prevalence and burden of migraine in the United States: Data from the American Migraine Study II. Headache, 41, 646-57.

Mamtani, R., & Cimino, A. (2002). A primer of complementary and alternative medicine and its relevance in the treatment of mental health problems. Psychiatric Quarterly, 73(4), 367-81.

Milden, S.P., & Stokols, D. (2004). Physicians’ attitudes and practices regarding complementary and alternative medicine. Behavioral Medicine, 30(2), 73-82.

National Center for Complementary and Alternative Medicine (NCCAM). (2005). Cet the facts: Are you considering using complementary and alternative medicine? (p. 8). Retrieved November 1, 2005, from http://nccam.nih.gov/health/decisions/

Parslow, R.A., & Jorm, A.F. (2004). Use of prescription medications and complementary and alternative medicines to treat depressive and anxiety symptoms: Results from a community sample. Jounal of Affective Disorders, 82(1), 77-84.

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Shen, J., et al. (2002). Use of complementary/alternative therapies by women with advanced-stage breast cancer. BMC Complementary and Alternative Medicine, 2(8), 7.

Sherman, K.J., et al. (2004). Complementary and alternative medical therapies for chronic low back pain: What treatments are patients willing to try? BMC Complementary and Alternative Medicine, 4(1), 8.

Sleath, B., Rubin, R.H., Campbell, W., Gwyther, L & Clark, T. (2001). Ethnicity and physician-older patient communication about alternative therapies, journal of Alternative and Complementary Medicine, 7, 329-335.

Sparber, A., & Wootton, J.C. (2001). Surveys of complementary and alternative medicine: Part II. Use of alternative and complementary cancer therapies. Journal of Alternative and Complementary Medicine, 7(3), 281-287.

Struthers, R., & Nichols, L.A. (2004). Utilization of complementary and alternative medicine among racial and ethnic minority populations: Implications for reducing health disparities. Annual Rev Nurs Res., 22, 285-313.

Tatsamura, Y., Maskarinec, C., Shumay, D.M., & Kakai, H. (2003). Religious and spiritual resources, CAM, and conventional treatment in the lives of cancer patients. Alternative Therapies in Health and Medicine, 9(3), 64-71.

Upchurch, D.M., & Chyu, L (2005). Use of complementary and alternative medicine among American women. Women’s Health Issues, 15, 5-13.

Yelin, E., Herrndorf, A., Trupin, L, & Sonneborn, D. (2001). A national study of medical care expenditures for musculoskeletal conditions: The impact of health insurance and managed care. Arthritis and Rheumatology, 44(5), 1160-1169.

Mara Wai, MEd

Mara Wai, MEd, is a Program Manager, PENN Program for Stress Management, University of Pennsylvania, Philadelphia, PA. She may be contacted via e-mail at [email protected]

Copyright American Academy of Ambulatory Care Nursing Nov/Dec 2005

By Li, J-Y; Li, X-Y; Li, M; Zhang, G-K; Et al

Abstract

Objective. To investigate the age-related change of serum androgen levels in healthy men and to define a cut-off value of serum testosterone for the diagnosis of androgen deficiency in the aging male.

Method. 1080 healthy men aged 20 to ≥70 years old were enrolled in Beijing, Shanghai, Xian and Chongqing. Luteinizing hormone (LH), follicle-stimulating hormone (FSH), total testosterone (T), calculated free testosterone (cFT), sex hormone binding globulin (SHBG), 17beta-oestradiol (E2), the T/LH ratio, and T/SHBG as a free testosterone index (FTI) were all determined.

Results. Serum total T did not significantly decline, but the cFT, T/LH and FTI progressively decreased with aging. To determine androgen deficiency, the 10th percentile value of men 70 years.

Conclusions. (i). While serum total T values do not decline with aging, the levels of cFT gradually decline with aging; (ii) when using the value of cFT of the 10th percentile of men aged 20 to 39 years as the cut-off point, the prevalence of androgen deficiency was

Keywords: Calculated free testosterone, T/LH, aging men

Introduction

In 1940s, Werner was the first to describe a climacteric-like syndrome in men, with symptoms of sexual dysfunction, loss of libido, palpitations, flushing, episodic sweating, loss of energy, depression, and mood swings [1]. Over the past two decades a large number of studies have documented that serum total testosterone decline with aging-particularly free, nonbound testosterone and bio- available testosteronewhile the serum level of sex hormone binding globulin (SHBG) increase with aging [2-6]. Almost all commentaries dismiss the concept of a male menopause or andropause, but rather describe partial androgen deficiency in the aging male (PADAM) [5- 7] or late onset hypogonadism (LOH) [8]. It still remains a point of debate how to define the criteria for testosterone deficiency in elderly men [8-10]. Age-appropriate reference values are lacking; therefore, it has been proposed that the same criteria as for the general male population be used [11]. We conducted a large-scale study of 1080 healthy adult men, aged 20 years and above, in four major cities in China (Beijing, Shanghai, Xian and Chongqing), between December 2002 and December 2003. Depending on this database, the cut-off point for definition of androgen deficiency was set to be the 10th percentile value of men aged 20 to 39 years. We did not observe a decline of serum total testosterone with aging, but in conformity with studies in other parts of the world, there was a progressive decrease of free testosterone levels [2-6].

Subjects and methods

Subjects. Two hundred and seventy subjects were enrolled from each of the following four citiesBeijing, Shanghai, Xian and Chongqing-in China. These subjects were divided in nine subgroups, each comprising 30 subjects, based on age, the categories being: 20- 29, 30-39, 40-49, 50-54, 55-59, 60-64, 65-69, 70-74, and ≥70 years old. Written informed consent was obtained from each participant. Men had to be aged ≥20 years old to participate in this study. Subjects could only be included in this study if there was: (i) no acute systemic disease; (ii) normal functions of heart, liver, and kidney; (iii) no diabetes or other endocrine disease; (iv) no drug addiction; and (v) if they were living independently (not institutionalized).

Anthropometric and hormone measurements. The history of diseases and medication was taken for each subject, and a physical examination performed, with body mass index (BMI, kg/m2), and waist- hip ratio (WHR, cm/cm) being measured. A peripheral blood sample was drawn between 07:30 h to 08:30 h on the morning following the examination, and serum was kept in – 80C until hormone determination.

Luteinizing hormone (LH), follicle-stimulating hormone (FSH), total testosterone (T), and 17betaoestradiol (E2) were determined by Automated Chemiluminescence System (ACS: 180, Bayer) with intra- assay CVs of 4.8%, 3.0%, 6.5%, and 8.3% , respectively, and inter- assay CVs of 6.6%, 4.6%, 7.0%, and 8.6%, respectively. SHBG measurement was performed by ILISA (IBL, Hamburg). The intraassay CV was 5.5%, and the inter-assay CV was 9.0%. The free testosterone (cFT) was calculated using the formula developed by Vermeulen et al. [12], which has been considered to be a reliable method [9]. We further calculated the ratio of T (nmol/L) to LH (IU/L), and the free testosterone index (FTI) to be the ratio of T (nmol/L) to SHBG (nmol/L).

Statistical analysis. The serum androgen values were not normally distributed; therefore percentiles were used for statistical analysis. The 10th percentile value of androgen at age less than 40 years was arbitrarily set to be the cut-off point of androgen deficiency.

As there was no significant difference between hormone measurements in men aged 40 to 49 years and those from the younger group (20-39 years), they were grouped together. Men over 50 years old were regrouped by 10-year intervals. The KruskallWallis test was used to compare differences in hormone levels between age groups, and ANOVA was used to determine prevalence of androgen deficiency, which we defined in this study as being values lying below the 10th percentile of the values obtained from participating males under 39 years.

Table I. Age-related change of serum sex hormones expressed by median (n).

Results

The serum hormone levels, expressed as median values for each age subgroup (in decades), are presented in Table I. The serum level of total T did not change significantly with aging. However, the values for cFT, T/LH ratio (TSI), and FTI significantly decreased with aging, whereas this trend was weak for the ratio of T/E2. By contrast, LH, FSH, SHBG and E2 serum levels increased with aging. Spearman’s analysis (Table II) showed a negative correlation between cFT, T/LH or FTI with age, and with serum levels of LH or FSH.

The 10th and 90th percentile values of T, cFT, TSI, and FTI are shown in Table III. The 10th percentile value of the results of men aged 20 to 39 years were grouped together and were subsequently considered to be the lower limit of normal values for men below middle age. On the basis of this calculation, the lower cut-off value for cFT to define androgen deficiency was 0.3 nmol/L, 2.8 nmol/ IU for TSI, and 0.4 nmol/IU for FTI. For the purpose of this study, the percentage of men (in each age category) with levels above and below this cut-off point of cFT, TSI, and FTI are presented in Table IV. The cFT serum level started to decrease in a small number of men in their fifth decade, and became more profound with aging. The prevalence of androgen deficiency is presented in Table V. Using cFT as a criterion, 13% of adult men showed androgen deficiency between 40 to 49 years, approximately 30% between the ages of 50 to 69 years, and about 45% in those men over 70 years.

Discussion

An age-related decline of serum total testosterone, and particularly serum free- or bio-available testosterone, has been reported by a number of cross sectional and longitudinal studies [2- 6]. Our data fail to illustrate a decline in serum total testosterone with male aging, but do reflect previous findings regarding the decline of serum cFT in healthy men, with a progressive increase of serum SHBG levels with aging [13]. FT or bio- available T is the proportion of circulating T not bound to SHBG or albumin, respectively, and is regarded as the physiologically active fraction of total testosterone [12]. The etiology of the decline of serum T with aging is partly the result of testicular failure, and partly a result of diminished stimulation of the Leydig cell by decreased output of LH [6]. We did not find serum total T to decline with aging, but serum LH levels rose significantly with aging. This is most likely an expression to a certain extent of a compensated testicular failure with aging [14], which sometimes fails [14], but probably not in the sample of men we studied, as evidenced by their stable serum total T levels with aging. The maintenance of relatively stable total T levels with aging is probably largely explained by the simultaneous increase of SHBG serum level. Serum SHBG is suppressed by circulating insulin, a feature of obesity or diabetes type II, which is rather common in aged men [2, 15], but this did not affect our finding of an increase of serum SHBG with aging.

Table II. Spearman’s analysi\s for the relation between androgen and aging.

Table III. The 10th and 90th percentiles for T, cFT, TSI, and FTI.

Table IV. The rate of decline for cFT, TSI, and FTI, expressed as median.

Serum T falls with aging and, as a result of the feedback mechanism, serum LH usually – but not always – rises with aging; we reasoned that the T/LH ratio in elderly men might provide insight in their gonadal status. Our data show that the decline in the value of T/LH with aging parallels closely the value of cFT. Using the T/LH ratio, there was approximately 7% underestimation in two age groups (50-59 years and 60-69 years). It merits further study as to whether the T/LH ratio is an acceptable surrogate for the cFT. In China, SHBG is not routinely measured in clinical practice, although LH is. The introduction of T/LH would be more convenient and cost effective. The FTI is the calculated value of T/SHBG, and is an indirect measure of free testosterone [3]. In our data, the FTI differed more from cFT than T/LH. With FTI there were overestimations of 3% at 40-49, 10% at 50-59, 17% at 60-69, and 25% at ≥70 years. Therefore, in the context of our study, T/LH was a better surrogate marker of cFT, and more useful than FTI in clinical practice.

Table V. The relationship between partial androgen deficiency and aging.

The present study shows a progressive increase in serum levels of SHBG, LH, FSH, and E2 in relation to aging. The increase of SHBG is likely to result from the decrease of androgen and growth hormone system (GH and IGF-1) with aging [16]. The elevations of LH and FSH are an expression of the decline in testicular function [6]. Circulating levels of E2 are mainly derived from the conversion of androgens to estrogens in peripheral tissue by aromatase [17]. As described earlier [17], we found a positive relationship between serum levels of E2 and T (r = 0.1509, p

References

1. Werner A. The male climacteric. JAMA 1939;112:1441-1443.

2. Gray A, Feldman HA, McKinlay JB, Longcope C. Age, disease, and changing sex hormone levels in middle-aged men: results of the Massachusetts Male Aging Study. J Clin Endocrinol Metab 1991;73:1016- 1025.

3. Harman SM, Metter EJ, Tobin JD, Pearson J, Blackman MR. Longitudinal effects of aging on serum total and free testosterone levels in healthy men. Baltimore Longitudinal Study of Aging. J Clin Endocrinol Metab 2001;86:724-731.

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5. Kang YG, Bae CY, Bum MJ, Kirn S, Lee YJ, Seo J, Kim YC. Age- related change in serum concentrations of testosterone in middle- aged men. Aging Male 2003;6:8-12.

6. Jiang-Yuan L. Partial androgen deficiency in the aging male. Reprod Med (China) 2000;9:182-186.

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8. Nieschlag E, Swerdloff R, Behre HM, Gooren LJ, Kaufman JM, Legros JJ, Lunenfeld B, Morley JE, Schulman C, Wang C, et al. Investigation, treatment and monitoring of late-onset hypogonadism in males. Aging Male 2005;8:56-58.

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16. Vermeulen A, Kaufman JM, Giagulli VA. Influence of some biological indexes on sex hormone-binding globulin and androgen levels in aging or obese males. J Clin Endocrinol Metab 1996;1:1821- 1826.

17. Vermeulen A, Kaufman JM, Goemaere S, van Pottelberg I. Estradiol in elderly men. Aging Male 2002;5:98-102.

J.-Y. LI1, X.-Y. LI2, M. LI1, G.-K. ZHANG3, F.-L. MA1, Z.-M. LIU4, N.-Y. ZHANG5, & P. MENG6

1 Department of Endocrinology, PLA General Hospital, Beijing, China, 2 Department of Gerocardiology, PLA General Hospital, Beijing, China, 3 Department of Statistics, PLA General Hospital, Beijing, China, 4 Department of Endocrinology, Changzheng Hospital, Shanghai, China, 5 Department of Endocrinology, Xijing Hospital, Xian, China, and 6 Department of Endocrinology, Xinan Hospital, Chongqing, China

Correspondence: J.-Y. Li, Department of Endocrinology, PLA General Hospital, Fuxing Road, Beijing 100853, China. Tel: 86 10 6693 6222. Fax: 86 10 6816 9817. E-mail: [email protected]\

Copyright CRC Press Sep-Dec 2005

By Patricia Reaney

LONDON (Reuters) – Germans have a word for it —
schadenfreude — and when it comes to getting pleasure from
someone else’s misfortune, men seem to enjoy it more than
women.

Such is the conclusion reached by scientists at University
College London in what they say is the first neuroscientific
evidence of schadenfreude.

Using brain-imaging techniques, they compared how men and
women reacted when watching other people suffer pain.

If the sufferer was someone they liked, areas of the brain
linked to empathy and pain were activated in both sexes.

Women had a similar response if they disliked the person
experiencing the pain but men showed a surge in the reward
areas of the brain.

“The women had a diminished empathic response,” said Dr
Klaas Enoo Stephan, a co-author of the report. “But it was
still there, whereas in the men it was completely absent,” he
added in an interview.

The scientists, who reported their findings in the journal
Nature, said the research shows that empathic responses in men
are shaped by the perceived fairness of others.

“Empathic responses to other people are not automatic, as
has been assumed in the past, but depend on the emotional link
to the person who is observed suffering,” Stephan said.

In the two-part study, 32 men and women volunteers played a
game in which they exchanged money with four other people who
were actors playing a part.

The actors were either fair characters, who returned equal
amounts of cash that have been given to them, or unfair people
who gave little or no money back to the volunteers.

In the second part of the experiment, the volunteers were
placed in magnetic imaging brain scanners as they watched the
actors receiving a mild electric shock, similar to a bee sting.

The scientists measured reactions of the volunteers in
areas of the brain associated with pain and empathy and reward
while the actors experienced pain.

The responses shown in the brain images were backed up with
questionnaires filled in by the volunteers. Men admitted to
having a much higher desire for revenge than women and derived
satisfaction from seeing the unfair person being punished.

“We will need to confirm these gender differences in larger
studies because it is possible the experimental design favored
men as there was a physical rather than psychological or
financial threat involved,” said Dr Tania Singer, who led the
study.

NEW YORK — The recommended daily intake for vitamin B-12 should be more than doubled from the current level, researchers argue in a new report.

In a study of 98 middle-aged and older women, the researchers found that 6 micrograms of B-12 per day seemed to be enough to prevent signs of mild B-12 deficiency. That compares with the current recommended dietary allowance (RDA) of 2.4 micrograms per day.

The findings, along with those from several past studies, “strongly suggest” that the RDA should be raised, the researchers report in the January issue of the American Journal of Clinical Nutrition.

Dr. Mustafa Vakur Bor at the University Hospital of Aarhus in Denmark led the study.

Vitamin B-12 is essential for maintaining healthy nerve cells and red blood cells; a deficiency in the vitamin can cause symptoms ranging from the subtle — including fatigue and mild dizziness — to more severe complications like nerve damage, anemia and even dementia.

Though the typical Western diet provides people with far more than the current RDA for B-12, certain individuals are at risk for a deficiency.

Unlike most vitamins, B-12 occurs naturally only in animal products, including meat, poultry, fish and, in lesser amounts, eggs and dairy. So vegetarians and vegans — who avoid all animal products, including dairy — may have low stores of the vitamin.

The same is true of adults older than 50, as many have a thinning in the stomach lining that prevents the proper release of digestive acids. Stomach acids are essential for “shaking loose” vitamin B-12 from its food source, allowing it to be absorbed. So older adults are advised to get their B-12 from pills and fortified foods like cereal; the synthetic version of the vitamin is more readily absorbed than the natural form.

But there has been debate as to whether the RDA of 2.4 micrograms is too low, Vakur Bor and his colleagues note in their report.

That RDA is what experts believe is the minimum B-12 needed to prevent anemia, nerve damage and mental dysfunction. But it’s not clear that it’s enough to prevent subtler effects, according to the researchers.

In their study, they looked at the relationship between vitamin B-12 intake and certain blood markers of mild B-12 deficiency in 98 postmenopausal women.

Based on diet records the women kept for one week, Vakur Bor and his colleagues separated them into groups according to B-12 intake. They found that overall, 6 micrograms of B-12 per day appeared to be enough to normalize the various blood markers of B-12 status.

This suggests, the researchers conclude, “that this dose might be more adequate for the general population than the current RDA of 2.4 micrograms.”

SOURCE: American Journal of Clinical Nutrition, January 2006.

By Axelrod, David; Kazmerski, Kimberly; Iyer, Kishore

ABSTRACT. Common to all pediatric patients receiving enteral nutrition is the inability to consume calories orally. This is often secondary to issues of inadequate weight gain, inadequate growth, prolonged feeding times, weight loss, a decrease in weight/age or weight/height ratios, or a persistent triceps skinfold thickness

The provision of adequate calories and essential nutrients is vital for childhood growth and development. Although provision of nutrition via oral intake is ideal, in patients unable to eat a sufficient volume, additional nutrition support is necessary. Currently, nutrition goals can be met using either parenteral nutrition (PN), an appropriate mixture of carbohydrate, protein, and fat with essential vitamins and trace elements, or enteral administration of an appropriate tube-feeding formula. When compared with PN, enteral nutrition has numerous potential advantages, including lower costs, reduced infectious complications, reduction in bacterial translocation as a result of improved enterocyte viability, and decreased incidence of PN-associated liver dysfunction (PNALD).1

This review will examine the indications for enteral nutrition in the pediatric population, methods and complications of obtaining and maintaining enteral access, choice of enteral formulas, and approach to long-term feeding. The particular case of patients with decreased intestinal length will be considered, with particular attention given to methods of securing PN independence.

Indications for Pediatric Enteral Nutrition

Common to all patients receiving enteral nutrition is a documented inability to consume adequate calories orally to maintain homeostasis. The common indications for enterai nutrition vary with the age of the patient (Table I).2 In the neonatal period, patients are commonly fed via a nasoenteric route as a result of prematurity and lack of coordination of the sucking and swallowing reflex. Furthermore, the high metabolic demands coupled with gastrointestinal (GI) immaturity and frequent fluid restrictions often render bolus oral feedings inadequate in significantly premature infants. The other principal indications for tube feeding in this period are patients with short gut due to gastroschisis, omphalocele, or a history of severe necrotizing enterocolitis (NEC). In these patients, reduced absorptive capacity requires a slow, continuous feeding regimen if the patient is to achieve early nutrition autonomy from PN.

In early childhood, prolonged enteral access is often indicated for patients with severe neurologic impairment due to a range of conditions, including cerebral palsy, anoxic brain injury, Down’s syndrome, or severe seizure disorders. These patients often had coincidental gastric dysmotility resulting in gastroesophageal reflux (GER) and aspiration. Although children with Down’s syndrome, Prader-Willi syndrome, or myelomeningocele may have decreased metabolic rates leading to obesity during later childhood (oftentimes presenting with failure to thrive in the first year of life), those with cerebral palsy may have increased energy demands as a result of severe contractures or choreoathetoid movements. When 1 or more of the following factors are identified, tube feeding should be considered after other aggressive oral interventions have been tried: (1) inability to consume at least 80% of calculated energy needs by mouth; (2) total feeding time >4 hours per day; (3) inadequate growth or weight gain for >1 month (under the age of 2); (4) weight loss or no weight gain for a period of 3 months (over the age of 2); (5) a change in weight/age or weight/height (length) over 2 growth channels on the Centers for Disease Control (CDC) growth chart; (6) triceps skin folds consistently

TABLE I

Indications for long-term enteral feeding

Acquired conditions of childhood and adolescence, which may result in markedly higher metabolic rates, may necessitate full or supplemental enterai nutrition. Common indications in this group for enterai nutrition include childhood burns, severe sepsis, and advanced human immunodeficiency virus (HIV). Patients with advanced malignancy often require enterai feedings to overcome the decreased appetite that accompanies chemotherapy and tumor cachexia. Finally, children with cystic fibrosis with significant pancreatic insufficiency and increased work of breathing may benefit from nutrition supplementation.

TABLE II

Methods to obtain long-term pediatric enteral access

Methods of Obtaining and Maintaining Enterai Access

Provision of enterai nutrition requires prolonged access to either the stomach or the proximal small intestine. Delivery routes for enterai nutrition include nasogastric, nasoduodenal, nasojejunal, gastrostomy, and jejunostomy (whether direct or through the stomach) feedings. The choice of access depends upon the length of time feeding will be needed, anatomic considerations (eg, inability to access the upper gastrointestinal tract endoscopically), and the presence of coexisting diseases, including GER disease.

In patients with a short-term need for enterai access, including hospitalized patients, nasoenteric access with a thin feeding tube (eg, Dobhoff, Corpak Inc, Wheeling, IL) meets the limited enterai access requirements. Specific to infants and children, soft, small- bore tubes should be used with nasal feedings (5, 6, or 8 Fr). The choice of gastric or small bowel intubation remains controversial. Purported advantages of gastric intubation include ease of tube placement, ability to use bolus feedings, which may be more physiologically appropriate, and reduced cost by avoiding the need for radiographic confirmation. Advocates of small bowel feedings report a reduced incidence of aspiration and improved caloric intake. Recently, several techniques have been introduced that may allow small bowel tube placement without radiologie confirmation including the use of magnets, pH monitoring, or a simple aspiration test. Inability to aspirate 2 mL of air after introduction of 10 mL of air into a nasoenteric tube accurately predicted small bowel placement with 99% certainty in a study of 75 pediatric feeding tubes.3

Although naso-small bowel feeding has been shown to be beneficial compared with nasogastric tubes in single center adult studies, a meta-analysis of adult trials failed to demonstrate a clear advantage of either route regarding infection rates or degree of caloric support.4 In the single randomized trial in acutely ill children, Meert and colleagues5 demonstrated that patients receiving small bowel feedings achieved a higher percentage of daily caloric goal (47% vs 30%) when compared with patients fed into the stomach. In this population, there was no difference in the percentage of positive tracheal aspirates for pepsin (JD = .3) or in the number of tube-related complications between the 2 groups.

Patients who require feedings for longer than 4 weeks are candidates for a surgically, endoscopically, or radiologically placed feeding tube (Table II). Surgical gastrostomy was first introduced by Verneuil in 1876 and remained the standard of care until the introduction of the percutaneous endoscopically guided gastrostomy tube (PEG) by Gauderer et al6 in 1980. A PEG tube is a “blindly” placed gastrostomy tube placed under local, regional, or general anesthesia using endoscopie guidance. During the procedure, the stomach is insufflated and a needle is placed into the gastric lumen and visualized by the endoscopist. A wire is then passed through the abdominal wall into the stomach and used to guide a gastrostomy tube with an internal bolster throughout the abdominal wall. Placement is confirmed endoscopically. Overall success rates range from 91% to 96%. Major and minor complications occur in 4%- 22% of cases but \are principally limited to local wound infections. More serious complications, including colocutaneous fistulas (1.7%), can occur as a result of the blind technique.7 When compared with operatively placed G-tubes, there is a higher risk of developing peritonitis if the tube should become inadvertently dislodged early, as the stomach can fall away from the abdominal wall. Overall, PEG procedural mortality rates are reported to be between 0% and 10%. This technique appears safe even in very small children, including those under 3.5 kg.8 Late complications, although rare, include intragastric buried bumper or extruded gastrostomy, gastric metaplasia, granulation tissue around the PEG site, intragastric pseudotumoral proliferative gastric mucosa, and cutaneous necrosis.9

PEG tubes are reported to be less expensive, safer, and more time efficient to place compared with operatively placed gastrostomy tubes.10 However, operatively placed gastrostomy tubes in conjunction with Nissen fundoplication continues to be recommended for children with severe neurologic impairment. These children have a higher incidence of gastric dismobility, leading to greater GER and aspiration. The need for a combined antireflux procedure and feeding-tube placement is not universal, even in this population. Patients who are likely to require a combined procedure can be accurately predicted using pH probe monitoring. Only 5% of neurologically impaired patients with a normal pH probe study undergoing a PEG required a subsequent Nissan fundoplication compared with 30% of patients with an abnormal study.11

Radiologically placed gastric or gastrojejunostomy (GJ) tubes offer an alternative, minimally invasive method of obtaining enterai access. As originally introduced in 1981 by Preshaw,12 this technique involves distending the stomach and placing the tube under fluoroscopic guidance. One technique, which can be applied to the pdiatrie population, uses a commercially available kit (Carey- Alzate-Soons; Cook, Inc, Bloomington, IN).13 After the introduction of 500-1000 mL of air, lateral and frontal fluoroscopic images are obtained to ensure apposition of the gastric and abdominal wall. Next, the stomach is anchored using 3 percutaneously placed T anchors. Using a 4th puncture, a 6 Fr catheter is introduced and a guidewire is passed into the duodenum. Next a 14 Fr gastrojejunal catheter is inserted and secured with an intragastric mushroom device. The jejunal extension is 10 Fr.

When compared with PEG placement, the radiologie procedures have several disadvantages, including the need for ionizing radiation and increased cost due to the need for the fluoroscopic suite. Hoffer and colleagues13 performed a randomized study involving 135 patients, which demonstrated improved success (100% vs 91%; p = .01) with radiologic gastrostomy placement compared with PEG tube placement, with a lower number of overall complications. The latter did not reach statistical significance. These results were similar to a meta-analysis of cohort studies in which the radiologic techniques were found to be successful and require fewer anesthesias than PEG placement. These advantages may offset the higher cost of the initial procedure.14

The jejunally placed position of a radiologically placed GJ feeding tube may offer a particular advantage to patients with established GER. In these patients, distal feeding may eliminate the need for surgical antireflux procedures without increasing the risk of aspiration pneumonia. Wales and colleagues15 performed a retrospective analysis comparing operative Nissen fundoplication and gastrostomy tube with a radiologically placed GJ tube of 111 patients with established GER. Although patients in the GJ tube group were more likely to require continued medication for reflux, only 8% eventually required fundoplication for symptom control. Furthermore, there was a trend to a reduced incidence of aspiration pneumonia in the patients with a GJ tube.

Each of the initial enterai access placement procedures appears to have advantages and a particular population to which it is best suited. No matter which procedure is performed, long-term maintenance of the gastrocutaneous fistula for feeding is best accomplished with a low-profile device (eg, the MIC-Key button, Medical Innovations Inc, Santa Clara, CA). The button has a lower profile and is more cosmetically appealing, particularly for older children. Conversion from an initially placed PEG tube to a low- profile device generally requires sedation in young children and has been associated with a low incidence of serious complications, including tract disruption, gastrostomy leak, or loss of access. Minor long-term problems include hypertrophie granulation tissue, tube leakage, local yeast infection, and dislodgement (Table III). These problems can, in general, be managed with parent/patient education and simple local interventions. Low-profile devices also require the use of an access tube to engage and open a 1-way valve contained within a low-profile device to allow the instillation of medications, feedings, or fluids.

Tube-Feeding Formulation and Feeding Regimens

Physicians and nutrition specialists caring for patients with long-term enterai feeding requirements now have access to a diverse group of tube-feeding preparations that can be tailored to the needs of the child. Feeding preparations vary by the age or size of the child. Feedings in small infants are beyond the scope of this review and will not be discussed. For children

TABLE III

Management of common complications of enteral access

For most children, tube feeding with a mixture of fat, protein, and carbohydrate is indicated. Examples include Pediasure (Ross Laboratories, Columbus, OH), Peptamen Jr (Nestle Nutrition, Glendale, CA), and Nutren Jr (Nestle Nutrition). The average caloric density of these formulas is 1 kcal/mL. Vitamin and mineral requirements can be met with a total intake of 950-2000 mL per day. The feedings can also be supplemented with free-water bolus to ensure adequate free-water intake. Using these formulas, children will receive appropriate levels of essential fatty acids and trace minerals. Other guidelines to ensure nutrition adequacy in the use of enterai feedings include assessing and calculating the appropriate calorie goal, which will not be discussed in this review; identifying appropriate protein needs (>7% and 30% but age of 10 or >50 kg) may tolerate adult formula, including Osmolite (Ross Laboratories) and Isocal (Novartis Nutrition, Minneapolis, MN).

Several specialized formulas are available for particular disease conditions. In patients with decreased intestinal length, absorptive capacity, or pancreatic function, elemental tube feedings (eg, Neocate [infantl/Neocate Jr/Neocate One Plus [SHS North America, Gaithersburg, MD]; Vivonex Pdiatrie [Novartis Nutrition], and EleCare [Ross Laboratories]) may be particularly useful. Protein content in these feedings consists primary of dipeptides and tripeptides that do not require additional digestion. Additional calories are provided as fat with a blend of mediumchain and long- chain triglycrides and simple carbohydrates. In general, these formulas provide 1 kcal/mL and can be diluted, if needed. Low-fat formulas (ToIerex, 0.15 g fat/L; Novartis Nutrition) may be useful immediately after bowel transplantation or temporarily in patients with chylous ascites or severe pancreatitis.

Feeding delivery regimens vary widely according to the nutrition needs of the child, type of enterai access, and degree of intestinal adaptation. In general, feedings are begun at a low rate and gradually advanced as tolerated. Feeding intolerance is manifested by emesis, diarrhea, or bloating. Rarely, rapid advancement of high- osmolar formula has been reported to precipitate NEC, which can be life threatening. However, a metaanalysis of randomized or quasirandomized trials that examined rapid us slow advancement of feedings in low-birth-weight infants failed to demonstrate a difference in NEC. Patients whose feedings were advanced more quickly, however, reached goal feeding more rapidly and required less time to regain their birth weight. The choice of bolus us continuous feedings depends mainly on the type of enterai access. In general, bolus feeding can be accomplished best with a gastric tube in patients without evidence of GER. In patients with GJ tubes or those who fail to tolerate bolus feedings, continuous infusion feedings must be used. Over time, these continuous feedings can be cycled and the time of administration reduced to evening hours for outpatients.

Weaning from tube feedings is often possible and should be the goal for children with app\ropriate neurologic function. As oral feeding is introduced, total calories can be gradually reduced in the enterai feeding. This can be accomplished by reducing the hours of continuous feeding or the rate of the feedings. After successful weaning (defined as >80% of nutrition needs met orally and consistent/adequate growth), enterai access can, in general, be easily removed and the gastrocutaneous fistula allowed to close on its own.

Approach to Enterai Feeding in Children With Short Bowel Syndrome (SBS)

Patients with severe SBS represent a particularly difficult population to support with enterai feedings. SBS is the end-stage manifestation of a variety of pathologic causes of small intestinal loss in children, including atresias, gastroschisis, malrotation, NEC, and long-segment Hirschsprung’s disease. Nutrients absorbed by the small intestine include fluids, magnesium, zinc, carbohydrates, proteins, fats, iron, calcium, copper, folate, fat-soluble vitamins, vitamin B12, and bile salts, among other micronutrients. Traditionally, patients with severe SBS were managed with PN. Unfortunately, long-term PN is often associated with progressive hepatic dysfunction, loss of mucosal integrity, frequent catheter- related complications, and in some cases, mortality. Aggressive use of enterai nutrition is not only an important factor in promoting intestinal adaptation; it also avoids the numerous complications associated with long-term PN.17 This process, however, may take months to years to complete in some patients. PN is cycled or weaned while adjusting enterai feedings and maintaining appropriate growth. The Children’s Memorial Hospital (Chicago, IL) approach to these children is outlined below.

Initial evaluation is conducted as an inpatient to assure accurate assessment of the child’s intake and output, nutrition status, to facilitate skin care (particularly in the perianal area), and to conduct radiologie investigations. Standard contrast radiography and endoscopy are used to determine the length and caliber of remnant small and large intestine. Particular attention is paid to areas of stricture or significant dilation, which would benefit from surgical intervention. Every effort should be made to recruit all available small and large intestine and restore bowel continuity to improve salt and water resorption. Finally, permanent, noninfected vascular access must be established because line infections impair efforts to increase enterai tolerance.

The type of enterai formula used and the timing of initiation of enterai feedings in the SBS pdiatrie patient are very important. Although residual small bowel length remains an important predictor of the duration of the use of PN, use of breast milk (for infants

Tube feeding should be introduced in a slow and deliberate manner. Dilute elemental tube feeding (15 cal/oz) is initially used to decrease intraluminal residual, facilitate absorption, and decrease the possibility of allergy. Continuous feedings are begun at 5 mL/h and advanced over several weeks or even months to tolerated volumes. Goal enterai feedings are difficult to determine. Goal seems to be the rate at which the child is tolerating the feedings, maintaining consistent weight gain and nutrition status. Feedings are held if the stool output exceeds 30-40 mL/kg/d and slowly reintroduced at a slower rate. Once goal feeding is achieved using dilute, elemental tube feedings, the concentration is gradually increased. Feedings are increased incrementally over a period of time to 18 cal per oz, 20 cal per oz, etc. The addition of protein and calorie modulars has been useful in the nutrition management when increased volumes are not tolerated. Supplements such as Microlipid (Novartis Nutrition; 50% fat emulsion using safflower oil) and Duocal (SHS North America, Gaithersburg, MD), which is a combination of carbohydrate (hydrolyzed corn starch) and fats (corn/coconut oils, MCT/LCT), provide an additional 4.5 kcal/ mL and 4.9 kcal/g respectively. These products have proven to be well tolerated and easy to use in our practice.

Loss of enterai tolerance in short bowel patients should prompt a rapid search for sources of infection. For patients with indwelling lines, blood cultures should be immediately obtained, and if possible, the line must be removed. Other common infections include rotavirus and upper respiratory infections. Finally, bacterial overgrowth in dilated bowel segments may lead to bloating and feeding intolerance. Rotating antibiotics may assist with intestinal decontamination. Children who fail to tolerate feedings despite a persistent effort should be evaluated for intestinal transplantation. Indications for small bowel transplant in these children include impending loss of vascular access, worsening hepatic dysfunction, or recurrent catheter-related infections. Intestinal transplant either alone or with the liver offers the sole definitive therapy for children with refractory intestinal failure. One-year graft and patient survival now exceeds 90% and 70%, respectively.21 After successful small intestinal transplant, patients can achieve freedom from PN and resume linear growth, although few demonstrate catch-up growth.22 Unfortunately, late graft loss remains a problem due to acute and chronic rejection.

Although weaning from PN is important in the management of the short-bowel pdiatrie patient, enterai feedings or oral feedings can pose an increased risk for nutrition deficiencies. A child’s absorptive capacity may continue to be limited and set the stage for subclinical immune deficiencies.23 Many biologic and growth deficiencies are frequently seen in patients with SBS, even after adaptation to enteral/oral feedings. Frequent deficiencies found in these enterally fed children included persistent decreased height for age, a decreased fat body mass, macrocytosis, anemia, and low serum levels of vitamin B12, folate, and ferritin. Many children will develop profound oral aversions as a result of ongoing illness, obnoxious oral stimuli (prolonged ventilation, nasogastric intubation, and suctioning), prolonged periods of not eating by mouth and thereby missing the “window of opportunity” to learn how to eat orally. Although the child is receiving combined PN and enterai feedings, the use of ongoing pleasant oral experiences, in conjunction with speech/feeding therapy by a speech pathologist, should be implemented.

A multidisciplinary approach using pediatric gastroenterologists, pediatric surgeons, transplant surgeons, pediatric dietitians, and an experienced pediatric nurse has been found to improve the care of these patients. After inception of an interdisciplinary team, Koehler et al24 evaluated 103 short-bowel patients. At the beginning of the study, 74% of these patients were PN dependent, 6% enterai feeding dependent, and 20% were eating orally. After intensive management of the 76 PN patients, 29% were weaned to oral, oral- enteral, or enterai feedings. Of the 6 patients who were receiving enterai feedings, 4 (67%) were transitioned to oral feedings.

Conclusions

Enteral nutrition is the preferred method of nutrition support for children unable to consume sufficient calories orally. Both temporary and permanent enterai access can be secured safely. Low- profile buttons improve patient satisfaction without significantly increasing risk. Enterai nutrition support is crucial for patients with SBS, many of whom can be weaned from PN through a careful, stepwise multidisciplinary approach. For patients failing enterai nutrition, small intestinal transplant has emerged as a viable and durable treatment modality.

REFERENCES

1. Kelly D. Liver complications of pdiatrie parenteral nutrition: epidemiology. Nutrition. 1998; 14:153-157.

2. Kleinman RE. Enterai nutrition support. In: Kleinman RE, ed. Pdiatrie Nutrition Handbook. Elk Grove Village, IL: American Academy of Pediatrics; 2004:280-290.

Excellent reference and review for physicians and nutritionists caring for children with enterai and parenteral nutrition needs.

3. Harrison AM, clay B, Grant MJ, et al. Nonradiographic assessment of enterai feeing tube position. Crit Care Med. 1997;25: 2055-2059.

4. Marik PE, Zaloga GP. Gastric versus post-pyloric feeding: a systematic review. Crit Care. 2003;7:R46-R51.

5. Meert KL, Daphtary KM, Metheny NA. Gastric vs small bowel feeding in critically ill children receiving mechanical ventilation: a randomized controlled trial. Chest. 2004;126:872-878.

Excellent study. One of the few, randomized trials in pediatric enteral nutrition which demonstrates that small bowel feeds allow increase nutritional delivery but do not prevent aspiration.

6. Gauderer MWL, Ponsky JL, Izant RJ. Gastrostomy without laparotomy: a percutaneous end\oscopie technique. J Pediatr Surg. 1980;15:872-875.

Original paper describing the technique of PEG placement.

7. Gauderer MWL. Gastrostomy techniques and devices. Surg Clin North Am. 1992;72:1285-1298.

8. Wilson L, Oliva-Hemker M. Percutaneous endoscopie gastrostomy in small medically complex infants. Endoscopy. 2001;33: 433-436.

9. Segal D, Michaud L, Guimber D, Ganga-Zandzou PS, Turck D, Gottrand F. Late-onset complications of percutaneous endoscopie gastrostomy in children. J Pediatr Gastroenterol Nutr. 2001;33:495- 500.

Large case series reviewing the early and late complications of PEG in children.

10. Songster W, Cuddington GD, Bachulis BL. Percutaneous endoscopic gastrostomy. Am J Surg. 1988;155:677-678.

11. Sulaeman E, Udall JN Jr, Brown RF, et al. Gastroesophageal reflux and Nissen fundoplication following percutaneous endoscopie gastrostomy in children. J Pediatr Gastroenterol Nutr. 1998;26:269- 273.

12. Preshaw RM. A percutaneous method for inserting a feeding gastrostomy tube. Surg Gynecol Obstet. 1981;152:659-660.

13. Hoffer EK, Cosgrove JM, Levin DQ, et al. Radiologie gastrojejunostomy and percutaneous endoscopie gastrostomy: a prospective, randomized comparison. J Vase Interv Radial. 1999;10:413420.

Excellent clinical study with appropriate randomization of patients to radiologie or endoscopie techniques. One of the few randomized trials reported in this area.

14. Wollman B, D’Agostine HB. Percutaneous radiologie and endoscopie gastrostomy: a 3-year institutional analysis of procedure performance. AJR Am J Roentgenol. 1997;169:1551-1553.

15. Wales PW, Diamond IR, Dutta S, et al. Fundoplication and gastrostomy versus gastrojejunal tube for enterai feeding in neurologically impaired children with gastroesophageal reflux. J Pediatr Surg. 2002;37:407-412.

16. Kennedy KA, Tyson JE, Chamnanvanakij S. Rapid versus slow rate of advancement of feedings for promoting growth and preventing necrotizing enterocolitis in parenterally fed low-birthweight infants [Review]. Cochrane Database Syst Rev. 2000;2: CD001241.

17. Vanderhoof JA, Young RJ. Enterai nutrition in short bowel syndrome. Semin Pediatr Surg. 2001;10:65-71.

18. Andorsky DJ, Lund DP, Lillehei CW, et al. Nutritional and other post-operative management of neonates with short bowel syndrome correlates with clinical outcomes. J Pediatr. 2001;139:2733.

19. Ksiazyk J, Kierkus PM, Lyskowska M. Hydrolyzed versus nonhydrolyzed protein diet in short bowel syndrome in children. J Pediatr Gastroenterol Nutr. 2002;35:615-618.

20. Weiming Z, Ning L, Jieshou L. Effect of recombinant human growth hormone and enterai nutrition on short bowel syndrome. JPEN J Parenter Enterai Nutr. 2004;28:377-381.

21. Iyer KR, Srinath C, Horslen S, et al. Late graft loss and longterm outcome after isolated intestinal transplantation in children. J Pediatr Surg. 2002;37:151-154.

22. Iyer K, Horslen S, Iverson A, et al. Nutritional outcome and growth of children after intestinal transplantation. J Pediatr Surg. 2002;37:464-466.

This review of the largest institutional experience with pdiatrie intestinal transplant demonstrates improved growth after transplant. However, there was a very limited amount of catch up growth in growth delayed patients.

23. Gonzalez HF, Perez NB, Malpeli A, Martinez MI, DelBuono B, Vileri FE. Nutrition and immunological status in long-term follow up of children with short bowel syndrome. JPEN J Parenter Enterai Nutr. 2005;29:186-191.

24. Koehler AN, Yaworksi JA, Gardner M, Kocoshis S, Reyes J, Barksdale EM. Coordinated interdisciplinary management of pediatric intestinal failure: a 2-year review. J Pediatr Surg. 2000;35:380- 385.

David Axelrod, MD, MBA; Kimberly Kazmerski, MS, RD, CSP; and Kishore Iyer, MBBS, FRCS Eng, FACS

From the Intestinal Rehabilitation and Transplantation Program, Division of Transplant Surgery, Children’s Memorial Hospital, Chicago, Illinois

Received for publication June 1, 2005.

Accepted for publication October 3, 2005.

Correspondence: Kishore R. Iyer, MBBS, FRCS (Eng), FACS, Intestinal Rehabilitation and Transplantation Program, Children’s Memorial Hospital, 2300 Children’s Plaza, Box 57, Chicago, IL 60614. Electronic mail may be sent to [email protected].

Copyright American Society for Parenteral and Enteral Nutrition Jan/ Feb 2006

By Michael Sasso, Tampa Tribune, Fla.

Jan. 18–TAMPA — Gary Kompothecras, the man behind those ever-present 1-800-ASK-GARY commercials, built a small empire of accident clinics partly by urging TV viewers to “call Mr. Gary.”

Now Kompothecras, who’s a Sarasota chiropractor, is fighting in court to keep competitors from using his toll-free “ASK” referral service idea.

On Friday, two of Kompothecras’ companies, 1st Health Inc. and Healthcare Management Enterprises, filed a lawsuit in Hillsborough circuit court against Holiday chiropractor Leonard “Lenny” Linardos and Linardos’ company, West Coast Spine & Injury. Linardos created the 1-877-ASK-KOBY accident referral service in October 2004.

Kompothecras’ companies also filed a federal lawsuit against the company behind the 1-800-ASK-JERY hot line, St. Petersburg chiropractic clinic Spinal Correction Centers Inc.

In each lawsuit, 1st Health accuses the competitors of unfair and deceptive trade practices for creating toll-free “ASK” help lines that are nearly identical to its 1-800-ASK-GARY service.

A fourth hot line, 1-800-ASK-DAVE, is run by Lakeland-based law firm Burnetti P.A. It is not named in the lawsuits.

The 1-800-ASK-GARY commercials are probably known to nearly everyone who has turned on a television set in the past three years. The commercials urge people to call Gary or “Mr. Gary” to find a lawyer, doctor or even a tow truck. In court documents, 1st Health spells out how much advertising it does: more than $4 million per year.

The company makes its money largely by treating auto accident victims, many of whom are referred to 1st Health through the 1-800-ASK-GARY commercials.

The company’s Web site lists 24 accident clinics, including nine in Hillsborough, Pinellas and Pasco counties. However, during a brief discussion last month, Kompothecras told the Tribune he has more than 40 facilities across Florida, from Naples to Jacksonville.

In the lawsuits filed Friday, 1st Health claims that competitors are unlawfully trying to cash in on Kompothecras’ concept. The company claims Linardos created his 1-877-ASK-KOBY hot line “in the hope of creating customer confusion and siphoning off clients from plaintiffs’ businesses.”

The suit also alleges that Linardos bribed an agent of 1st Health to give him information about the company’s business model. Gregory Zitani, an attorney who regularly works on behalf of 1st Health, said Tuesday that he was advised not to comment about the lawsuits.

During an interview last week, Linardos said “Koby” refers to one of his nicknames, although he’s more commonly known as Lenny. He operates two chiropractic clinics in Holiday and Tampa.

On Tuesday, Linardos said his “ASK KOBY” commercials are hardly identical to the “ASK GARY” ads. Among other differences, Linardos’ ads feature a Jamaican-accented pitchman who ends the TV spots by saying, “Koby don’t play that.”

“The only thing similar to Gary’s is the three letters ‘ASK,’ ” Linardos said.

In its federal suit against Spinal Correction Centers, 1st Health makes much the same allegations about its owner, St. Petersburg chiropractor Stephen Steller, and 1-800-ASK-JERY.

“Steller has admitted that [his] actions were illegal, but stated plaintiffs [1st Health] were ‘making a lot of money, and I want a piece of it,’ ” the lawsuit says.

In its lawsuits, 1st Health asks a judge to stop Linardos and Steller from using trade names and advertising similar to 1-800-ASK-GARY.

For his part, Steller, who runs three clinics in Pinellas County, said Kompothecras and 1st Health are going after the wrong person . The “ASK JERY” ads are created by a separate company that is run by Steller’s brother, called Steller Health Inc.

“I don’t own the company,” Steller said. “Make sure you’re suing the right people because he can’t sue me.”

ASKING FOR IT?

The owner of 1-800-ASK-GARY has filed suit against two other chiropractic clinics that use the toll-free concept. Here’s a look at the three companies involved in the lawsuits.

–1-800-ASK-GARY Gary Kompothecras’ 1st Health Inc. has more than 40 accident clinics and other facilities in Florida.

–1-877-ASK-KOBY Leonard Linardos’ West Coast Spine & Injury has two chiropractic clinics in Holiday and Tampa.

–1-800-ASK-JERY Stephen Steller’s Spinal Correction Centers Inc.* has three chiropractic clinics in Pinellas County.

* Steller said he is not responsible for the 1-800-ASK-JERY hot line. He said it is owned by a separate company.

—–

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By Anthony J. Brown, MD

NEW YORK (Reuters Health) – Men who experience few or no
symptoms from an inguinal hernia do not require immediate
surgery; instead, they can be safely followed and treated if
symptoms worsen, new research shows.

If this approach catches on with surgeons throughout the
US, it could markedly reduce the number of hernia repairs
performed.

Inguinal hernias, the most common type, occur in the groin
when tissue that normally resides in the abdomen pushes through
a weak area in the abdominal wall. This bulging mass of tissue,
which may contain intestine, can cause pain, but usually can be
pushed back into the abdomen without difficulty. In some cases,
however, it may become stuck, a potentially life-threatening
complication called incarceration.

Out of fear that incarceration and other problems may
occur, “surgeons are generally taught that all hernias should
be repaired at diagnosis,” lead author Dr. Robert J.
Fitzgibbons, from Creighton University in Omaha, Nebraska told
Reuters Health.

“Our study questioned this conventional wisdom, he
explained, “and found that a ‘watchful waiting’ approach can be
safely applied to men with minimal symptoms. I suspect that 50
percent of patients with hernias could keep them for the rest
of their lives and never have a problem.”

One of the key findings “was that there didn’t appear to be
any penalty for waiting to perform surgery,” Fitzgibbons said.
“The concern had been that waiting could lead to worse hernias
that are more difficult to repair and associated with greater
complications. But in our study, the complication rate for
patients having initial surgery and those having delayed
surgery was exactly the same.”

The study, which is reported in this week’s Journal of the
American Medical Association, involved 720 men with inguinal
hernias that caused minimal symptoms who were randomly assigned
to receive immediate surgery or watchful waiting. With the
latter approach, subjects were seen after 6 months and then
annually to determine if hernia symptoms worsened, an
indication for surgery.

At 2-year follow-up, the rate of pain limiting activities
in each group was comparable, hovering around 3.5 percent.
Likewise, both groups showed a similar improvement in the
physical component of a standard health survey.

Twenty-three percent of patients assigned to watchful
waiting ultimately moved to the surgery group, typically due to
an increase in hernia-related pain. As noted, these patients
were not at heightened risk for surgical complications compared
with men who had their hernias repaired immediately.

One patient in the watchful waiting group developed
incarceration within 2 years. In addition, another patient in
the group had incarceration with intestinal blockage at 4
years.

Fitzgibbons believes the new findings will lead many
surgeons to “discuss nonoperative options with their hernia
patients.” He said that for legal reasons, surgeons may have
been reluctant to adopt a watchful waiting approach in the
past. “But now there is good scientific evidence that it’s a
reasonable strategy and that takes the medicolegal burden
away.”

“If the results of this study are reproduced in other
populations and for other types of hernia, then the era of
preventive hernia repair should go the way of prophylactic
tonsillectomy, (gallbladder removal), and appendectomy,” Dr.
David R. Flum, from the University of Washington in Seattle,
comments in a related editorial.

SOURCE: Journal of the American Medical Association,
January 18, 2006.

By ALISON ROBERTS

IT HAS always struck me that anyone with four children must either be very rich or incredibly, selflessly, committed to a life of grindingly hard work. Or both.

Yet there are plenty of modern quartets around. Four has suddenly become a cool number.

“It’s a real trend,” Chrissie Rucker, founder of The White Company and mother of three girls and a boy, tells me. “I find that more and more of my friends are having four children.” The Blairs, of course, have a nice round four, as do Bono and his wife Ali Stewart, the Gordon Ramsays, Sadie Frost, Sting, Lord Coe and the beleaguered Education Secretary Ruth Kelly.

So how on earth do these modern super-mums (and dads) manage such a houseful? As divorce rates and property prices continue to rise, as schooling in London and the maintenance of twin careers become issues of ever greater complexity, coping with the usual 2.4 kids seems like a task of Herculean proportions to most of us.

Carina Cooper, the Evening Standard’s cookery columnist and author of the Notting Hill Cook Book, has a brood of four aged five to 16, and claims, somewhat counter-intuitively, that in fact it’s far easier with four than one. But then, they are all girls: Ithaka, 16; Flynn, 14; Sidonie, eight, and Zazou, five. “Oh, it’s much easier,” she says. “After a certain age, they start to sort each other out. You can train them quite young and you don’t have to mollycoddle them all the time.”

It looks so enviable, this tribe of four blonde girls, all educated at home.

Can it really be so irritatingly perfect? Not quite, as it turns out – Cooper is in the middle of a divorce and living in a rented house when we meet, and coping with the stress all that involves.

She claims to be fairly disorganised (“It’s been a bit chaotic this morning,” she says as she answers the door in Holland Park at 10am with wet and tangled hair), and loathes the kinds of strict routines advocated by childcare gurus like Gina Ford. “I see some mothers of four who are viciously well-organised, a million times more so than me – with beautifully turnedout kids and tennis lessons after school and so on. My children can look great, but they can also look very scruffy. My days don’t have much rhyme or reason to them, and I don’t have a particular working routine. Quite often I get up very early and work while everyone’s asleep.”

The kids often sleep in till 9am, she says.

Cooper has also taken an unorthodox approach to education, choosing to hire tutors and teach all four girls at home rather than send them to school. She doesn’t impose a structure on their learning. “They’re very precocious and advanced in the creative, arty subjects as a result,” she says, “but quite behind in things like science. That doesn’t bother me, it’s just the way we are.

“I’ve always loved the independence of thought and spirit of home- educated kids. I visited a few schools and I didn’t like the rules, the bullying, the insistence on academic achievement, the hours and hours of homework. I’ve really enjoyed having my kids at home; I love hearing them laughing in the background while I’m in the kitchen.”

Her idea of a stable and loving regime, indeed, involves piling the girls into the back of a car every so often and setting off on a mystery tour with only a map and a vague idea of destination to guide her. “I’m a gypsy at heart,” she says, though it’s also clear that hers is a bohemian lifestyle backed by rather a lot of money. It is very much a W11 existence.

Cooper says she was broody at the age of 15, yet only planned the youngest of her four babies. “The first three just sort of turned up, but I knew I wanted four when I realised that the third was suffering from “middle-child syndrome”. She didn’t have a role like the other two, she was neither the baby nor the leader. Four is such a lovely number, it’s a proper tribe with its own dynamic and energy. I remember, literally half an hour after giving birth to Zazou, feeling very very strongly that now I was complete.”

Many women, of course, don’t find the right man in time to spawn four children.

Cooper met her husband, the director and producer Franc Roddam (Quadrophenia; Auf Wiedersehen Pet), when she was just 22 and had Ithaka five years later. They lived in a beautiful house just off the Portobello Road, a foodie’s heaven. However, Roddam (according to Cooper) subscribed to the ever-so-macho Gordon Ramsay school of fatherhood and never changed a nappy.

“Lots of dads are like that. He was the fun father, into big gestures rather than day- to- day detail.

“But you do have to start young if you’re going to have a big family. And my life in my midtwenties was very different from those of my childless friends, who were out clubbing and having a good time. I used to carry Ithaka around in a sling and chop up vegetables with her on my tummy. It’s strange – now I’ve had my children and I’m in the middle of a divorce and for the first time in ages I’m really free. Quite a few of my friends are only embarking on the whole nappy thing now.”

For women, four children represent a lengthy and draining physical commitment (Cooper, who describes herself as “a bit of an earth mother”, nursed each of her daughters for 18 months each), but for both mum and dad, they also require an extraordinary amount of emotional vigilance. Cooper calls this “keeping them in the circle” and describes the psychological tactics needed to make sure all four are happy and thriving.

“I see it as an imaginary circle that we’re all inside. And if one strays outside the circle – if she’s a bit shy or moody or has dark rings under her eyes – you have to sort her out quickly and bring her back. I’m constantly on the lookout for it.”

Her own childhood in Gloucestershire was itself far from easy. Her mother died when she was 14, and at 16, a teen rebel

who hated studying, she was expelled from school with barely a qualification to her name.

“I had a lot of friends who took drugs in their teenage years, including my two brothers, and really it took 10 years for them to get over it completely and come back to normality. You have to watch your children with eyes like a hawk and, yes, having four does mean four times the worry. But I’m a great believer in the theory that time and attention heal almost anything. The stronger the foundation of love, the stronger they’ll be when they’re older.”

Her girls have already seen a great deal of the world; indeed their childhood reminds one a little of Esther Freud’s fictionalised memoir Hideous Kinky. Cooper and daughters followed Roddam to Morocco, to the US and to Australia, where they lived for months at a time while dad was shooting a new TV series. “For me, the most secure I ever feel is in a car on the road to nowhere with the girls in the back, not knowing where we’re going or where we’re going to stay.” It’s a situation that would terrify most mothers, I say. “Yes, it is bizarre, but that way of life doesn’t bother me at all. I’ve always given them each a backpack and told them to get on with it. Kids are incredibly adaptable, and if you’re relaxed, so are they.”

YES, she has always had the means to employ fulltime help, though her choice has never been conventional.

“The best help I ever had was a French art student – a punk with a gold tooth, lots of piercings and bovver boots. She stayed with us for five years and the girls loved her.”

Cooper also took substantial career breaks while each of her girls was tiny – a deal many women cannot afford – but she was spurred to write the Notting Hill Cook Book in order to generate income while working from home.

If I had four children, I tell her, I’d be constantly afraid of misplacing one of them – leaving them on the bus or in the supermarket by mistake. Has she ever lost or forgotten one? “There are often headcounts at airports or train stations,” she replies. “Sometimes I think I’ve lost one, and then there’s a little tug on my trousers and a small voice saying: ‘Here I am.'” They must be very good girls, then.

“All kids are good,” she says with a charitable shrug of the shoulders.

“If I’d been born 100 years ago, I’m sure I’d have been one of those women with 10.”

. The Working Cook by Carina Cooper, a collection of Evening Standard recipes, will be published this spring.

CARINA’S TWENTY TIPS FOR A HEALTHY FAMILY LIFE

. Take a preventative approach to medicine.

Think about alternative approaches like homeopathy or acupuncture. I never give antibiotics – try the natural solutions first. And children are hardier than we often think.

. Balancing time and effort between children equally is instinctive.

Trying to include them in basic chores, like shopping.

. Shop a little and often.

That way nothing gets left at the bottom of the fridge, and all produce is fresh.

. Never make food a punishment. It becomes less pleasurable if you do.

. A child doesn’t need to eat everything on the plate.

If you involve them in the process of choosing their food, they will want to eat it.

. Puddings are something nice to have at weekends, and our “sweetie” day is on a Saturday. We go out on a special outing and the children choose their own sweets.

. Engage children with what they eat and teach them to like good food.

Making smoothies is a fun and healthy thing to do.

. Things can go awry in life. If you are sad, your children will be sad too.

Be honest with them and tell them what is upsetting you. Make them understand that it is not their fault. A strong foundation of love really helps.

. Instil good manners and respect in the older children; they will teach the younger children those same principles and act as role models for them. Teach the older ones good behaviour and it trickles down to the smaller ones.

. When there are many children in a family, they quickly learn about sharing – and about bargaining, swapping and trading. Sharing a room also helps with this.

. When you have four children, passing clothes on becomes a normal thing.

Don’t worry about the “second-hand Rose” syndrome. The younger ones will relish being like their hip older siblings.

. Children are capable of being reasonable. Try to take the time to explain things to them rather than simply barking out an order. Children will mirror your behaviour. If you are rude and shout at them, they will shout and be rude back.

. If children are naughty, there will be a reason for it.

It is rarely without motivation. Try to work out why they have done something and rather than punish them, try to solve whatever caused the bad behaviour.

. Every so often, do something they don’t expect – serve them and yourself with chocolate ice-cream for breakfast.

They like it when adults are naughty, too.

. Everything is redeemable. Relax around the family. Not everything has to be immaculate all the time. With a large family, perfect organisation is impossible.

. Make some time for yourself. If you make it clear that a certain time in the day is just for you, they will respect that.

This goes for bedtime too. They don’t have to go to bed at a set time, but they do have to realise that you need to relax.

. Once children are five and over they begin to be able to entertain themselves. Rather than you being too hands-on, they like you to just be around while they explore.

On holiday, let them play on their own while you read a book nearby.

. Eighteen months to three years and ages 13 to 15 are the hardest stages.

These are ages that will require a great deal of patience. Be understanding of why they are demanding or grumpy.

. When you have children your whole outlook changes. You won’t get as many manicures and pedicures as you used to.

Don’t expect the same exacting standards of yourself in every minute detail.

. Spending time together needn’t be a chore. Teach the children about things you enjoy – they will learn to enjoy them too.