The Price of Heat ; The Size of the Natural Gas Bill Varies With Location and Weather

By ROSALIE RAYBURN Journal Staff Writer

Just about everyone has seen the heating bills skyrocket in recent years. That’s because increased demand and tight supplies have caused market rates for natural gas to triple since 2002. And by law, utilities pass those costs on to customers without a markup.

Most New Mexico residents are getting a better deal this winter than residents of Colorado but pay slightly more than people in Arizona. As for Texas, it depends on where you live. Houston residents pay more to stay warm than people in El Paso.

Of course the bill ultimately depends on the severity of the climate: Colder weather equals higher bills.

For example, the average household heating bill in balmy southern Arizona is less than $90; it’s more than $150 in Albuquerque or about $250 in parts of Colorado.

Here’s a breakdown on how our natural gas bills compare to others’ bills in the Southwest. Figures include the cost of gas plus the delivery charge to bring it to the consumer. They exclude taxes, franchise fees and service charges.

New Mexico: Public Service Company of New Mexico’s price for natural gas in January is 98 cents per therm. Customers also pay a 19.27 centsper-therm delivery charge. At that price, the average residential bill for 131 therms of gas will be $154.

Arizona: Northern Arizona communities such as Flagstaff and Prescott, which get gas from Unisource Energy Services, will pay a total of $1.12 per therm for gas and delivery. Average January bills will be $116.48 for 104 therms of gas.

In southern Arizona, customers of Southwest Gas living in Tucson or Phoenix pay far more per therm — but use only an average of 73 therms a month. January gas bills will average $80.35.

Colorado: Colorado Natural Gas, which supplies Cripple Creek west of Colorado Springs and rural areas north and west of Denver, charges a total of $1.48 per therm. Average residential customers who live at altitudes of 7,000 to 9,000 feet typically use 171 therms of gas in January and see bills of over $250.

Xcel Energy, which supplies cities such as Denver, Boulder and Vail, charges $1.12. Average bills in January will be $165.

Texas: CenterPoint Energy, which supplies cities such as Houston, Beaumont and Laredo, charges $1.69. For average January gas use of 100 therms, bills will be $169.

Texas Gas Service, supplying El Paso, does things a little differently. It charges 87 cents per therm for gas and customers pay a flat $10.13 per month service charge. Average January bills will total $114.53.

Buying gas

Regulators in all the states allow utilities to make money on what they charge to carry the gas through their pipeline networks and deliver it to the customer.

Utilities say they’re continually tweaking strategies to secure the best price for their customers. But overall, increasing demand and limited supplies mean higher prices are here to stay, industry analysts say.

A utility can help ease the pain by spreading the risk when market prices are volatile. PNM has a department dedicated to securing a diversified portfolio of short- and long-term gas contracts to help keep prices down. PNM has 460,000 gas customers.

Raton Natural Gas with 3,500 customers and Zia Natural Gas with 22,000 say they’ve found it increasingly difficult to compete against large companies for reasonably priced gas contracts.

Changing market

Utilities have faced radically changed market conditions since the mid-1980s, when gas prices were deregulated. From the mid-1950s to the mid-1980s, gas prices were set by federal regulators. Deregulation helped attract more investment into production and brought lower prices in the late 1980s and throughout the 1990s, said Federal Energy Regulatory Commissioner and former New Mexico state regulator Suedeen Kelly.

During that period, gas prices typically rose in the winter in response to higher demand for home heating fuel. Prices fell during the summer.

Utilities took advantage of the seasonal price variation by purchasing winter supplies during the summer when the price was low.

That pattern has faltered over the past five years because demand for gas has increased while production has steadily fallen behind, Kelly said.

The reason: Gas has become the fuel of choice for power plants because it results in fewer emissions than coal. Utilities normally run gas plants during the summer to meet demand for air- conditioners. As a result of this summer demand, the seasonal difference in gas prices is gradually disappearing. Unless consumers reduce their demand or alternative sources of energy are developed, prices will likely remain high, Kelly said.

“It’s a very serious national situation,” she said.

Au Contraire French Women Do Get Fat

By Gillian Bowditch

In heaven, says the old and decidedly non-PC joke, policemen are English, mechanics are German, cooks are French, hotel keepers are Swiss and lovers are Italian. In hell, policemen are German, car mechanics French, cooks English, hotel keepers Italian and lovers Swiss.

National stereotypes were meant to have gone the way of bowler hats and the British Empire. They are a throwback to a less enlightened era when Lord Baden-Powell could unblushingly opine in Scouting for Boys that the way to tell a foreigner was by looking at his shoes. The new empire builders are global brands. Disney, Nike and McDonald’s are meant to have melded into an international soup. We’re all inhabitants of the global village now.

Yet the latest publishing phenomenon plays entirely on the notion that the inhabitants of a country share certain traits. Scots-born writer AA Gill has stirred up huge controversy (and sales) with The Angry Island: Hunting the English, which portrays the English as “a lumpen and louty, coarse, unsubtle, beady-eyed, beefy-bummed herd”. But it is new, positive stereotypes of women that are raking in the cash faster than you can say “German with a beach towel”.

Hot on the kitten heels of Mireille Guiliano’s bestseller, French Women Don’t Get Fat, comes Japanese Women Don’t Get Old or Fat by husband and wife team William Doyle and Naomi Moriyama, hyped as the hit diet book of 2006. So do national stereotypes have an upside? Let’s take a look at the claims.

The Claim French women don’t get fat

The Case For Catherine Deneuve, Edith Piaf, Isabelle Adjani

The Case Against Brigitte Bardot, no end of femmes de la maison

Myth or Reality Myth

Fifteen years ago I went to Paris to write a feature on the now defunct Marks & Spencer on Boulevard Haussmann. Two facts about French women confounded all my preconceptions. The first was that the biggest seller in the food department was the pan loaf – despite all those boulangeries, French women wanted le sandwich because baguettes go stale so quickly. The second was that the average Frenchwoman was a full size larger than her British counterpart. While size 12 was the biggest seller in the UK, in Paris the average woman was a size 14. The secret of French chic, said the head of the store, was that French women were extremely particular about the way they dressed, choosing colours and styles which flattered their figures. More outlandish fashion trends lingered on the shelves while variations on the classic Chanel suit flew off the rails. Guiliano, who is the head of a Champagne house and has homes in France and New York, bases her thesis on the fact that, although French women enjoy a diet rich in butter, cream, meat and pastries, they are slimmer than their American and British counterparts. This is because les portions are tres petites. France is the home of nouvelle cuisine, while America is the home of super-sized Big Macs. “A croissant in Paris is one ounce,” says Chris Rosenbloom, professor of nutrition at Georgia State University, “while in Pittsburgh it’s two.” The French also have less coronary heart disease. According to the World Health Organisation, French women have the second longest lifespans and can expect to live till 82.

Yet, according to the latest French government research, our Gallic neighbours are losing the battle of the bulge. One in ten French adults is obese and the figure is rising, up from eight per cent to 11 per cent in the last five years. Admittedly, the figure is lower than the British obesity rate of 22 per cent or the American 33 per cent, but it isn’t that French women are particularly slim, just that they are getting fatter at a slightly slower rate than everyone else.

According to Anne Barone, author of Chic and Slim: How Those French Women Eat All That Rich Food and Still Stay Slim: “The French woman sees herself as a beautiful woman despite her physical flaws. She is worth the effort of eating well, taking care of herself. She deserves to be slim and healthy.” And their other slimming secret? Magic Knickers. There are as many lingerie shops in Paris as there are boulangeries.

The Claim Good-time girls come from Brazil

The Case For Heloisa Eneida Menezes Paes Pinto (the real girl from Ipanema), Gisele Bundchen, more plastic surgeons per square mile than anywhere else on earth

The Case Against More plastic surgeons per square mile than anywhere else on earth

Myth or Reality Reality

“Of all the places on earth to be stationed,” says Don Black, an executive in the oil industry, “the best is Brazil. The beaches are fantastic, the women are amazing and the whole country loves to party.” It’s not just the girl from Ipanema who is “tall and tanned and young and lovely”; half the women in Rio de Janeiro fit this description. Mikki Taylor, a fashion and beauty writer, says the key to Brazilian sexual attractiveness is an amazing self-confidence. “They just exude self-love,” she says. “In Brazil youth is an attitude. You are as likely to see a 50-year-old walking confidently in a bikini as a 20-year-old. They have a ‘why-settle-for-anything- less’ approach to life.”

Taylor says Brazilian women leave nothing to chance, which would certainly explain their attitude to plastic surgery. That and the fact that before a relationship gets serious, Brazilians will insist on a “beach date” so they can have a look at a prospective lover’s body before making up their minds. In the last five years the number of plastic surgery procedures performed in Brazil has more than doubled, with 400,000 operations performed annually, the highest per capita rate of anywhere in the world.

Not unsurprisingly for the country that invented the G-string, in Brazil plastic surgery is nothing to be ashamed about. Juliana Borges, a former Miss Brazil, admitted to having 23 procedures before her 22nd birthday. Even the dogs go under the knife, with Dr Edgard Brito offering wrinkle-reduction, eyebrow-correction and full canine facelifts. Then there are the weekly manicures, pedicures, facials, peels and waxes which are routine for any fashionable Brazilian (woman, not dog, that is). The growth in plastic surgery may be attributed in part to the fact that, in Rio, life really is a beach.

Brazilian office workers wear their bikinis under their suits so they can pop out at lunchtime and top up their tans. Instead of sweating in a gym, they play volleyball on the beach. From a young age females learn to rub sand and sun lotion into their thighs to prevent cellulite. In an international study of attitudes to health and beauty, sponsored by Dove and co-authored by Susie Orbach of the London School of Economics, Brazilian women were the ones most likely to contemplate plastic surgery – 54 per cent – and to describe themselves as “beautiful”.

For Brazilian women, beauty and love go hand in hand. They were the most likely to say being loved made them feel beautiful and they also scored the highest for overall satisfaction with their lives, perhaps because, despite the image of Brazilian men as macho, it’s the women who are actually calling the shots.

Mary Murray Bosrock, author of Put Your Best Foot Forward, a guide to business etiquette, says Brazilian women can be very aggressive romantically and forward to the point of harassment. “Don’t be surprised if you are in a restaurant or nightclub and a woman sends you a note asking for your phone number, even if you are with your wife or girlfriend,” she writes. “I do think we can learn a thing or two from our Brazilian sisters about owning our bodies and being proud of them,” says Taylor. “Truth be told, the Girl From Ipanema is a state of mind.” And a nifty scalpel.

The Claim Japanese women don’t get old or fat

The Case For Crown Princess Masako, Madame Butterfly

The Case Against Female Sumo wrestlers (yes, they really do exist)

Myth or Reality A bit of both

Naomi Moriyama’s claim that Japanese women don’t get old is contradicted by a single fact: Japan has the largest number of centenarians of any country in the world. There are 25,000 Japanese aged 100 or more and more than 80 per cent of them are women. Japanese women have held the record for longevity for the past 20 years and can expect to live to the age of 83. Yet just four decades ago, the number of Japanese centenarians was a mere 153. The secret? Diet, high standards of health care and close-knit families.

An Australian study of the people of Okinawa, the Japanese community with the highest number of centenarians, discovered that, while genetics played a part, it was only a small part. Lifestyle was of far greater importance. On average the people of Okinawa ate a third fewer calories than their western counterparts. The people of Okinawa eat a huge variety of green leafy vegetables (more than elsewhere in Japan) along with water-based soups and lots of sweet potatoes, a carbohydrate very low in calories. Moriyama’s book should be entitled Japanese Women Don’t Die Young.

It is true that Japanese women often look younger than their years. Moriyama recalls being asked at the age of 42 to produce ID in a US liquor store to prove she was over 21. Yet while Japanese women have an enviable youthful demeanour, they don’t appreciate it. According to the Dove-sponsored comprehensive study of national attitudes to health and beauty (see Brazil, left), Japanese women are the most dissatisfied with their looks.

The study of 3,200 women in ten countries found that while 10 per cent of Americans and 19 per cent of Italians rated themselves as “beautiful” or “pretty”, no Japanese women described themselves in these terms. Women in Japan, in fact, were significantly more likely to rate their beauty and physical attractiveness poorly compared to other women and, despite their longevity, they were the least likely of any of the nationalities studied to believe that women can be beautiful at any age.

“Japanese women are significantly more likely to think of themselves as ‘somewhat less’ or ‘much less’ beautiful than other women,” says the survey. And while only 23 per cent of the Japanese women surveyed were overweight, compared with 60 per cent for the US and 57 per cent for the UK, 52 per cent of Japanese women believed themselves to be too fat, which rather confounds Moriyama’s thesis.

It gives a whole new meaning to “Big In Japan”.

The Claim Italians are the world’s best wives and mothers

The Case For Sophia Loren, Tosca, Raphael’s Madonnas, no end of Dolmio adverts

The Case Against Lucretia Borgia, Messalina (wife of the Emperor Claudius), Nancy Del’Olio

Myth or Reality Myth

For the two most venerated institutions in Rome – the Catholic Church and the Mafia – femininity is synonymous with motherhood and has been for generations. Italian mothers have a reputation, not wholly undeserved, for smothering their male offspring. Two-thirds of Italian men aged 29 are still being looked after by their mothers. The Catholic Church’s stance on contraception and abortion meant that once women had little choice but to accept their role as mothers. This attitude was reinforced by Mussolini, who argued that motherhood was part of a woman’s national duty.

All that is changing, however. Italy now has the lowest birth rate in Europe, at 1.3 children per woman. Italian fathers are the oldest in Europe, with 33 being the average age of a first-time dad. This hasn’t stopped the Italian equality minister, Stefania Prestigiacomo, issuing ten commandments for women, the first of which is: “Consider motherhood a value; it is the greatest, most important, special experience for a woman.”

The big Italian family, a staple Hollywood stereotype, is now a thing of the past. Just as alarmingly, Italian women’s reputation as among the sexiest in Europe is also taking a battering. The Italian Society for Gynaecology and Obstetrics carried out a survey earlier this year which discovered that, despite the low birth rate, contraceptive use in Italy is the lowest in Europe, with 47 per cent of Italian women taking no precautions. “This situation raises the question of whether Italians are having less sex than in the past,” said the society’s Emilio Arisi. A survey by Durex could provide an alternative answer. It discovered that Italian women were the most inventive in bed.

Italian women should, however, be warned. If they don’t want their menfolk, there are plenty who do. In a comprehensive survey of 20 countries for the Wall Street Journal, nearly one in four Europeans said they dreamed of Italian amore, with one in four British women opting for an Italian lover over a British man if they had the choice.

To further shatter the myth, Italian women are divorcing in ever greater numbers and at older ages, according to a study for the Italian Society of Gerontology. So-called “grey divorces” are now a recognised social phenomenon. But that may simply be due to the ageing population. At present there are 35 pensioners for every 100 workers in Italy. By 2050 the proportion will be 75 pensioners for every 100 workers – a case of grandmamma mia, perhaps.

So if the Italians are not the world’s best mothers, who are? Step forward the French. They, along with the Irish, are the Europeans producing the most children, at 1.9 per woman. The French claim it is all to do with their superior health, sexual attractiveness and natural fecundity. Nothing, then, to do with the municipal creches, supervised homework sessions, subsidised holiday camps and GBP 6,500 paid to French women for having a third baby.

The Claim Swedish women have the busiest sex lives

The Case For Ulrika Jonsson, Ingrid Bergman, dodgy films about au pairs

The Case Against Greta Garbo, Abba, the films of Ingmar Bergman

Myth or Reality Myth

According to the United Nations, the Swedes have had more success in producing equality between the sexes than any other nation. The proof? Swedish men do more housework than men anywhere else. The stereotypical Swedish woman, all blonde hair and monokini, is a figment of British men’s fertile imaginations. The biggest surprise about Swedish women is that they are more at home in the boardroom than the bedroom. In a Wall Street Journal survey of 19,000 people in 20 countries, Swedes said a good sex life meant sex once a week or less – bottom of the European league.

According to a survey for the Stockholm Institute for Popular Health, more than half of Swedish men and women are not satisfied with their sex lives and a third of Swedish women say they are simply not interested in sex at all. Despite this, only a third of married men and less than a quarter of married women have been unfaithful. The Institute says Swedes have sex 6.5 times a month on average, with 30 to 35-year-olds having sex less frequently than 30 years ago.

So if the Swedes aren’t winning the bedroom Olympics, who is? According to the Wall Street Journal survey, Greeks are the most insatiable. Nearly one-quarter said a good sex life involved sex five or more times a week – more than double what most Europeans chose. These findings are supported by Durex’s annual survey of 317,000 people in 41 countries. It claims Greece is officially the most amorous country, with the Greeks having sex 138 times a year, well above the global average of 103. Greek goddesses live on, it seems.

So, DO NATIONAL STEREOTYPES TELL US anything? According to Dr Robert McCrae of the US National Institute on Ageing, they are all myths. Yet there is no doubt that cultural influences, and to a lesser extent genetics, can define certain national characteristics. Perhaps the most interesting thing is that winning the international league does not lead to contentedness. Swedish women may be the most liberated but the sexual revolution has ground to a halt. But in “macho” Brazil the women are far from oppressed and among the happiest. And could Italian women’s reputation for being the most stylish be connected to the fact that they are having so few babies? No baby sick on their cashmere sweaters. If Naomi Moriyama has her way we will be turning Japanese in 2006, despite the fact that trim figures and long lives are not making the natives happy. If these surveys show anything, it is that beauty, contentment and sex appeal cannot be produced to a formula. But that won’t stop us searching for the recipe for happiness. Prepare to eat a lot of sushi.

Cold Comfort ; Many Swear By Prevention Medicines, but Do They Really Work?

By TRACY DINGMANN Journal Staff Writer

It’s mid-January, and everywhere you look, family, friends and co- workers are falling victim to the flu or common cold. Then there are those who swear they’ve stayed healthy by using over-the-counter cold-prevention medicines such as Airborne, Zicam, Cold-Eeze and Emer’gen-C. True believers say the products, which contain various formulations of Vitamin C, zinc, echinacea and other herbs and vitamins, actually prevent colds and flu. Many of them contain natural ingredients, running counter to Western medicine. Each week, consumers spend millions of dollars buying them.

But do they really work?

We tried asking Albuquerque doctors that question this past week, but they weren’t exactly champing at the bit to answer. In fact, public relations people at the University of New Mexico and Presbyterian Healthcare couldn’t find any doctors who wanted to take it on.

But one brave Lovelace Sandia Health System doctor — Dr. Allen Adolphe, chairman of internal medicine at Lovelace Medical Center — did step up to the plate to give his opinion.

Simply put, he doesn’t believe over-the-counter medicines that claim to prevent colds and flu work.

“My personal opinion is no, but I’ll add a caveat to that,” he said. “I don’t think they work because haven’t seen any clinical data one way or the other. Let me put it way: If any one of them really worked, it would be in the medical literature and there would be clinical trials that we would all be reading about.”

‘The placebo response’

Adolphe conceded that people who believe cold prevention medicines work may actually get them to work.

“There is something called the placebo response, and it can have a significant effect of some 25 to 30 percent. So if you take something and think it is going to make a difference, then it may make a difference.”

Intel engineer Sabrina Aragon said her husband recently persuaded her to try Zicam nasal spray to ward off a cold. Now she is one of those fervent believers that Adolphe talks about.

“I felt like I was getting sick on Thursday, and it got even worse on Friday. I kept using Zicam and on Saturday it was totally gone,” said Aragon. “My husband had used it before and swears by it. And it actually works! I’ve heard good things about Airborne, too.”

Aragon said she doesn’t care if doctors say cold prevention medicines aren’t medically proven.

“Even if doctors say they don’t work, that would not matter to me. It felt like night and day.”

While there are no definitive clinical studies, there is anecdotal evidence that natural remedies such as zinc and vitamin C can affect colds and flu, said Adolphe.

That’s why school nurse Annette Underhill thinks using cold prevention medicines such as Airborne and Zicam can’t hurt.

“I think they are somewhat helpful as far as prevention, because we know vitamin C helps in warding off colds and helps you sometimes recover more quickly,” said Underhill, who works at Governor Bent Elementary. “I myself take Emer’gen-C. every day, or try to. The more you do to boost your immune system, the better.”

Underhill has been taking Emer’gen-C for about two weeks and has stayed well so far in the face of dozens of sneezing and coughing students.

At any rate, Adolphe said he doesn’t go around discouraging people from using preventive cold preparations.

“I wouldn’t tell anyone who is feeling ill not to try (them), because (they) may help. But there are no clinical studies that would make me recommend (them).”

The magic bullet?

A few years ago an antiviral drug called preconaril was found to reduce the course of colds by 48 hours or so, said Adolphe. It was presented to an FDA advisory panel but was not approved.

“The advisory panel for the FDA didn’t think (reducing a cold by two days) was clinically significant enough to market,” said Adolphe. “That’s the only drug that I know of that can actually reduce the symptoms of a cold, and you cannot get it; it has not been approved.”

But there is a magic bullet for one kind of flu, said Adolphe. A prescription antiviral medicine called amantadine will work on Type A flu if caught in time. People who feel severe muscle aches and other signs of the flu must call their doctor immediately and start on it right away for it to shorten the duration of their illness.

In the end, Adolphe said his advice for people suffering from a common cold is the same doctors have used for years.

“If a patient calls me and says, ‘Dr. Adolphe, I have the following symptoms: a low grade fever, sniffles and a cough; what can I do?’ I would recommend the same things my grandmother told me: Drink lots of fluids, rest and use antihistamines for symptomatic relief.”

TV in the bedroom halves your sex life – study

ROME (Reuters) – Thinking of buying a TV for the bedroom?
Think again — it could ruin your sex life.

A study by an Italian sexologist has found that couples who
have a TV set in their bedroom have sex half as often as those
who don’t.

“If there’s no television in the bedroom, the frequency (of
sexual intercourse) doubles,” said Serenella Salomoni whose
team of psychologists questioned 523 Italian couples to see
what effect television had on their sex lives.

On average, Italians who live without TV in the bedroom
have sex twice a week, or eight times a month. This drops to an
average of four times a month for those with a TV, the study
found.

For the over-50s the effect is even more marked, with the
average of seven couplings a month falling to just 1.5 times.

The study found certain programmes are far more likely to
impede passion than others. Violent films will put a stop to
sexual relations for half of all couples, while reality shows
stem passion for a third of couples.

Judge Dismisses Cancer Lawsuit Targeting Fpl

By SARAH PROHASKA Palm Beach Post Staff Writer

Two sets of Treasure Coast parents – who blame emissions from Florida Power & Light’s nuclear power plant for their sons’ rare cancers – won’t get to present their cases to a jury this month after a federal judge ruled in favor of FPL.

While an FPL spokeswoman said Friday the ruling handed down by U.S. District Judge James Cohn confirms their argument that the suit “had no merit,” the families are disappointed that the judge ended the case before they had a chance to air their allegations in a trial.

“It’s frustrating. We were within days of a trial,” said Jensen Beach resident Scott Finestone, who sued in 2003 after his no-year- old son, Zachary, was diagnosed with neuroblastoma, cancer in his nervous system, in 2000. “More than anything we wanted our day in court.”

Cohn on Monday granted FPL’s request for summary judgment in the case, saying the plaintiffs “shall take nothing from the defendants in this action,” and ordered clerks to close the file.

The Finestones, along with Tish Blake and John Lowe, the Port St. Lucie parents of 13-year-old Ashton Lowe, allege FPL was negligent and breached various duties to limit radioactive releases from its St. Lucie County nuclear plant. Ashton Lowe died in 2001 of a form of brain cancer called medulloblastoma.

However, Cohn ultimately agreed with FPL, saying “there still is no admissible evidence to support” the families’ allegations that FPL exceeded allowable emissions.

“Plaintiffs must do more than present plausible, yet speculative, theories about the amount of radiation released by the St. Lucie nuclear plant,” Cohn wrote in the 38-page ruling.

West Palm Beach attorney Nancy La Vista, who represented the two families, said she plans to appeal the ruling and hopes her clients will one day get a trial.

FPL spokeswoman Rachel Scott said the utility is satisfied with the outcome.

“We have to operate our nuclear plants with a strict focus on safety, not only for our employees, but also for the public,” Scott said. “And we’re very serious about that.”

Both families took part in a state investigation into a possible “cancer cluster” among children in St. Lucie County in the late 1990s. At the time, it was one of the largest investigations of its kind, after officials found 28 cases of brain and central nervous system childhood cancer between 1981 and 1996 in the area. But the investigation offered the families no definitive answers, and officials said there was no pattern or “smoking gun.”

They later participated in a study by a national organization analyzing levels of strontium-90, a fission product, in children and whether radioactive emissions from nuclear reactors raise cancer risks for children. Baby teeth from Lowe and Finestone showed high levels of strontium-90, according to their lawsuit.

While the families alleged the nuclear plant was the source of the strontium-90 in their boys, FPL vehemently denied it.

“Why else would it be here?” Scott Finestone said Friday. “My son was not flying nuclear bomb planes in the 1960s.”

Attorneys for FPL argued that all strontium-90 in St. Lucie County, as well as the rest of Florida, is here as a result of atmospheric weapons testing and the 1986 Chernobyl nuclear plant disaster.

Despite the suit’s dismissal, Finestone and Tish Blake said they still believe the nuclear plant is at the root of their sons’ illnesses. “I blame them more now because of the information we found out,” Blake said Friday.

They point to documents their attorneys dug up from the early 1980s detailing the release of sewage sludge that was accidentally contaminated with radioactive waste in the late 1970s and early 1980s. The waste from a contaminated sink was mistakenly shipped to a cow pasture near Glades Cut-Off Road in western St. Lucie County, and also to the Fort Pierce Sewage Treatment plant, the plaintiffs argued. FPL and the families disagreed on the amount of contamination.

FPL officials say the contamination was “extremely low radiation levels,” and was cleaned up. They said air, soil and water tests showed there was no public health risk.

In his ruling, Cohn said he found the Nuclear Regulatory Commission’s final report on the sludge releases to be “of critical importance.” That report concluded “it is unlikely that anyone received a measurable radiation dose.”

Throughout the litigation, the families’ attorneys complained that FPL did not produce documents about the incident on time, and Cohn in his ruling acknowledged that “certain plant records regarding three days in mid-September 1982, when the sludge incident was first discovered, remain missing and were perhaps destroyed long before this case began.”

But Cohn dealt a blow to the families’ cases when he declared testimony by three of their expert witnesses about the levels of radiation in the sludge as inadmissible. He ruled their theories had not been subject to peer review and publication, and he expressed concern about the potential error rate in their assumptions.

While he said he wants to appeal, Scott Finestone said his family’s focus now is on Zachary, who is about to turn 12 and is in the sixth grade at a private school in Martin County. He is undergoing chemotherapy but is playing soccer in a recreational league, and is doing pretty well right now, his dad said.

“Yes, we would have liked to have had the trial, but right now we have bigger fish to fry,” Finestone said. “We feel lucky we’ve been able to enjoy the quality of life we have with Zachary. We have a lot of friends who have buried their children in the past few years.”

Scott said while FPL has maintained the plant did not have anything to do with the boys’ cancer, it sympathizes with the families.

“Of course, it’s very, very sad when a family is dealing with cancer, especially children,” she said. “We can understand their search for answers.”

[email protected]

The Simple Difference Between Gasoline and Diesel Engines

IN a recent statement by the US Department of Energy, it was projected that by 2012, diesel vehicles could account for 4-7 per cent of the automotive market. When diesel gets 20-30 per cent better fuel economy than gasoline engines it makes sense. Could diesel work for you?

Gasoline engines use pistons to compress a mixture of petrol and air to 10-12 per cent of its original volume within cylinders. Then a high voltage current is sent to each of the cylinders’ spark plugs, which then ignites the petrol-air mixture.

Diesel engines, on the other hand, compress air to 4-5 per cent of its original volume. After compression, diesel fuel is injected into the cylinder. The heat of the compressed air ignites the fuel instantaneously.

The differences between the engines result in vehicles with different advantages and disadvantages. Read the following to see if diesel might work for you.

The Pros of Diesel

* Fuel Economy- Diesels give 20-30 per cent better fuel economy than their petrol counterparts. Sometimes their fuel economy is even better. Take, for example, the Volkswagon Jetta. The diesel version of this car produces 52 per cent better fuel economy than its fuel driven cousin.

* Life – Light-duty diesel engines, when properly maintained and treated well, will easily last over 300,000 miles (about 482,700 kilometres)

* Towing Capability – Diesels produce more drive force (torque) at lower engine speeds than gasoline engines resulting in great towing capability.

* Safety – Diesel fuel is less flammable than gasoline. Try it. A lit match thrown into a pot of petrol will ignite the fuel, but not so if it’s a pot of diesel.

The Cons of Diesel

* Emissions – Though much has been done to better the emissions of diesels they are still dirtier than petrol due to the sulphur content. However, the EPA just announced that US refineries are on target to supply ultra-low sulfur diesel by June 2006.

* Fuel, or more accurately, where to get it? – According to the Diesel Technology Forum only about 30 per cent of all retail service stations in the US sell diesel. (We’re lucky here, all petrol stations in Malaysia sell diesel; it’s not the best quality diesel, but it’ll do for now)

* Choice – Though the number is growing, there are a limited number of vehicles that run on diesel in the US, unlike Europe, where the popularity of diesel passenger cars is gaining ground every day.

* Expense – By and large, diesels are more expensive than petrol powered vehicles, although if you divide that cost over the life of the vehicle, diesel becomes cheaper. Locally, we have become rather spoilt for choice especially in terms of the pick-up truck market, where all are running on diesel, and most if not all are priced below RM100k.

Unbundling the Confusion About "Unbundling" of Charges

By Fedor, Frank

Payers often seem to be looking for ways to give new meanings to their provider contracts-meanings that were never addressed during the contract’s negotiation and are not included in its language.

One approach gaining popularity is to reject individual chargemaster service codes billed by a hospital for services furnished to a commercial patient because the separate billing of this item, and thus the existence of this service code on the chargemaster, constitutes “unbundling” under Medicare’s billing rules.

This service code rejection strategy affects payment only in contracts with percentage-of-charges rates. By rejecting service codes, payers reduce total billed charges. Depending on the rate structure of the contract, this can bring the total billed charges of some claims below the stop-loss threshold and keep payment at relatively low per diems or case rates. In other instances, it may simply reduce the total billed charges to which the contract’s percentage rate of payment is applied.

A limited number of service codes have been rejected on this basis for years during medical record audits as contingency-paid audit companies attempted to increase the payer’s “savings” upon which the auditors were paid. Because audits are expensive and typically performed on only a small percentage of claims, the strategy of rejecting service codes has now moved in-house and is applied at the claims adjudication stage. As moderation in the pursuit of underpayments is no virtue for a payer, the volume of service codes rejected on this basis has increased. Of course, this service code rejection upsets the financial basis on which the contract was made. If a hospital had structured its chargemaster to include the rejected service code X in service code Y, service code Y would have had a higher price because it then would have included the cost and markup for the items and services represented by service code X. However, because the hospital chose to bill for the health care represented by service code X separately, the costs and markup for these services were not included anywhere else in the chargemaster.

Indeed, both parties relied on the existence of the rejected service codes during contract negotiations. In the payer’s financial modeling during negotiations, it accepted the historical charges that included the total costs and markup of the charges it now rejects to estimate what the payer would owe under the contract’s rates. This shows that the real goal of the payer is not to bring the hospital’s chargemaster into conformity with any Medicare “rule,” but to obtain services for free.

“Unbundling” Is Not a Sin Unless a Rule Requires That the Item Be “Bundled”

We start with the simple premise that it cannot be a bad thing to unbundle something unless there is first a rule that requires that thing to be bundled. For example, the Department of Health and Human Services Office of Inspector General says, “‘Unbundling’ is the practice of submitting bills piecemeal or in fragmented fashion to maximize the reimbursement for various tests or procedures that are required \.o be billed together and therefore at a reduced cost.”3 If the cost to the payer is the same whether items A, B, and C are billed together under code “88888” or each is billed separately under its own individual code, there simply is no unbundling.

Most references to unbundling concern the Current Procedural Terminology coding system copyrighted by the American Medical Association and adopted by Medicare. The best case law illustration of unbundling is in United States v. Metzinger, which concerned the separate billing of the components of a lab test panel. The court said, “‘Unbundling’ occurs under circumstances in which the Medicare program prescribes a special reimbursement rate for a group of laboratory procedures that commonly are ordered together. ‘Unbundling’ means billing separately for each component, as opposed to billing at the special rate.”

As Metzinger shows, unbundling is a breach of contract. Every hospital that participates in Medicare has a provider agreement with Medicare. The Medicare fee schedule defines some of the rates under that agreement and establishes the “special rate” for the particular combination of lab tests. That contract rate is breached by the hospital’s unbundling. Unbundling is thus not a circular concept that elevates form over substance. It is a term of art in the healthcare industry that developed from the detailed and precise CPT coding system which, when married to a fee schedule, results in precise contract rates for precisely identified groupings of services.

Of course, managed care contracts never control the content of the hospital’s chargemaster. The chargemaster must be applied to thousands of patients and scores of payers; therefore, for budgetary, regulatory, and practical reasons, there cannot be numerous customized chargemasters in use, each of which conforms to the specific rules of different payers.

However, contracts can address the effect of changes to a chargemaster. For example, a recent trend is to include downward adjustments to the percentage-ofcharges contract rate when chargemaster prices annually rise above specified increments. Here, the hospital retains its discretion to set its prices, but the parties agree on the impact these price increases may have on the contracting payer.

Contracts Do Not Permit Service Code Rejection

The contract between the hospital and the payer shows the mutual intent of the parties at the time of contracting concerning the structure of the charge-master. If the contract has a percentage-of- charges rate, it is likely stated as a percentage of “billed charges” or “covered billed charges,” with no exception for certain types of charges. This alone should be persuasive. If the service code rejection is being applied to an existing contract that was earlier performed on the basis of all the provider’s billed charges, this practical interpretation by both parties will be significant in proving that the parties did not mutually intend to allow service code rejection. If the contract is new, the course of dealing between the parties under earlier contracts will have a similar effect.

Medicare Does Not Control the Structure of a Hospital’s Chargemaster

In the absence of any specific billing rules in the contract, a payer will argue that the Medicare cost apportionment guidelines, which address a distinction between routine and ancillary charges, set an industry standard by which hospitals must set up their chargemasters-and thus an industry standard of what ancillary charges may be billed separately to commercial payers. This argument ignores the language and effect of the cited Medicare rule.

The relevant Medicare cost apportionment “rules” are not found in statutes or regulations, but in Medicare’s Provider Reimbursement Manual. PRM section 2203 (“Provider Charge Structure as Basis for Apportionment”) limits the cost apportionment procedures to Medicare cost apportionment: “While the Medicare program cannot dictate to a provider what its charges or charge structure may be, the program may determine whether or not the charges are allowable for use in apportioning costs under the program.”c

This is not a new position; these Medicare cost apportionment manual provisions were published in the 1970s.d Thus, it was common knowledge in the healthcare industry since the early 1970s that not only did these cost apportionment manual provisions exist, but also that by their own words Medicare disavowed any ability or intent to “dictate to a provider what its charges or charge structure may be.”

These PRM sections also are not intended to eliminate service codes from the chargemaster so that they may be obtained for free. The purpose of the Medicare cost apportionment process is to ensure that costs generated by Medicare patients are not shifted to non- Medicare patients and vice versa. Whether Medicare considers a charge as ancillary (and thus separately billable) or routine (and thus one that should have been included in a routine charge) affects only the methodology by which Medicare attributes the cost of those types of services that were consumed by Medicare patients. Unlike the private payer’s application of this rule to its commercial contracts, Medicare does not cause the cost of an ancillary charge that it thinks should have been included in a routine charge to disappear.

The “industry standard” argument also suffers from the same circularity of reasoning as the “unbundling” argument. If a Medicare rule did create an industry standard, then the interpretation and application of that standard would be for the Medicare program to define and apply. In fact, most if not all of the charges the payer rejects because they violate the Medicare “rule” have never been reclassified or rejected by the hospital’s Medicare fiscal intermediary in the cost apportionment process. Yet the same payer who rejects a service code because it does not meet this “industry standard” deputizes itself-and under its logic every other payer-to privately police how Medicare “should” be applying its rules. This is not done through the adjudicative processes of the Medicare program and the federal court\s so that a truly uniform result can be achieved, but in a series of arbitrations, whose results will remain private and will set no precedent, with the likelihood of conflicting decisions, all without the participation of Medicare- which has the only legal authority to make these decisions.

Simply put, there cannot be two contradictory “industry standards.” In an industry where a contract rate based on a percentage of a hospital’s covered billed charges is a standard term, there cannot also be a standard whereby every payer has the right to tell the hospital how to restructure its charges.

In sum, once the tangled confusion of the payer’s “unbundling” position is itself unbundled, it is clear that the contract between the hospital and the payer, and not Medicare or some hastily manufactured and inconsistent industry standard, controls the obligation to pay for healthcare services. As with so many other underpayment issues, hospitals should not hesitate to enforce the bargain they made in their contracts.

AT A GLANCE

Rejecting service codes on the basis that they have been unbundled has become a popular way for payers to reduce total billed charges. However, the contract between the hospital and the payer, and not Medicare or some hastily manufactured and inconsistent industry standard, controls the obligation to pay for healthcare services.

Managed care contracts never control the content of the hospital’s chargemaster. However, they can address the effect of changes to a chargemaster.

By rejecting service codes, the real goal of the payer is not to bring the hospital’s chargemaster into conformity with any Medicare “rule,” but to obtain services for free.

UNBUNDLING TO MAKE A BUNDLE OFF MEDICARE?

In version 11.3 of its National Correct Coding Initiative Policy Manual for Medicare Services, the Centers for Medicare and Medicaid Services gives the following definition and examples of different types of unbundling:

Unbundling occurs when multiple procedure codes are billed for a group of procedures that are covered by a single comprehensive code. Two types of practices lead to unbundling. The first is unintentional and results from a misunderstanding of coding. The second is intentional and is used by providers to manipulate coding in order to maximize payment….

Examples of unbundling are described below:

* Fragmenting one service into component parts and coding each component part as if it were a separate service. For example, the correct CPT comprehensive code to use for upper gastrointestinal endoscopy with biopsy of stomach is CPT code 43239. Separating the service into two component parts, using CPT code 43235 for upper gastrointestinal endoscopy and CPT code 43600 for biopsy of stomach, is inappropriate.

* Reporting separate codes for related services when one comprehensive code includes all related services. An example of this type is coding a total abdominal hysterectomy with or without removal of tubes, with or without removal of ovaries (CPT code 58150) plus salpingectomy (CPT code 58700) plus oophorectomy (CPT code 58940) rather than using the comprehensive CPT code 58150 for all three related services.

* Breaking out bilateral procedures when one code is appropriate. For example, bilateral mammography is coded correctly using CPT code 76091 rather than incorrectly submitting CPT code 76090-RT for right mammography and CPT code 76090-LT for left mammography.

* Separating a surgical approach from a major surgical service. For example, a provider should not bill CPT code 49000 for exploratory laparotomy and CPT code 44150 for total abdominal colectomy for the same operation because the exploration of the surgical field is included in the CPT code 44150.

a. Compliance Program Guidance for Hospitals, February 1998, fn. 20. Emphasis added.

b. CCH Medicare S, Medicaid’Guide, 44,669 (USDC E.D. Pa., 1996), 1996 WL 530002.

c. See also the following statement in Medicare Intermediary Letter No. 399 (Sept. 1,1969), CCH Medicare & Medkaid Guide, 26,024: “The Medicare program cannot dictate to a provider what its charges or charge structure may be. The provider is free to set its charges and charge its private-paying patients, and others, in any way it sees fit. The Medicare program, however, may determine whether the charges are allowable for use in apportioning costs under the program.”

d. PRM 2206 (“Routine Services”) was adopted in March 1971, and amended by transmittals in September 1972, July 1975, June 1976, and October 1976. CCH Medicare & Medicsid Guide, 6095. PRM 2202.8 (“Ancillary Services”) was also adopted in March 1971, and amended by transmittals in September 1972 and June 1976. CCHMedicare & Medicsid Guide, Sl 6105. PRM 2203 (“Provider Charge Structure as Basis for Apportionment”) was adopted in September 1972, and amended by transmittals in May 1975 and June 1996. The June 1996 amendment did not add or amend the quoted language. CCH Medicare & Medicaid Guide, 6153.

Frank Fedor, JD, is a partner, Murphy Austin Adams Schoenfeld, LLP, Sacramento, Calit., and a member of HFMA’s Northern California Chapter ([email protected]).

Copyright Healthcare Financial Management Association Jan 2006

Unbundling the Confusion About “Unbundling” of Charges

By Fedor, Frank

Payers often seem to be looking for ways to give new meanings to their provider contracts-meanings that were never addressed during the contract’s negotiation and are not included in its language.

One approach gaining popularity is to reject individual chargemaster service codes billed by a hospital for services furnished to a commercial patient because the separate billing of this item, and thus the existence of this service code on the chargemaster, constitutes “unbundling” under Medicare’s billing rules.

This service code rejection strategy affects payment only in contracts with percentage-of-charges rates. By rejecting service codes, payers reduce total billed charges. Depending on the rate structure of the contract, this can bring the total billed charges of some claims below the stop-loss threshold and keep payment at relatively low per diems or case rates. In other instances, it may simply reduce the total billed charges to which the contract’s percentage rate of payment is applied.

A limited number of service codes have been rejected on this basis for years during medical record audits as contingency-paid audit companies attempted to increase the payer’s “savings” upon which the auditors were paid. Because audits are expensive and typically performed on only a small percentage of claims, the strategy of rejecting service codes has now moved in-house and is applied at the claims adjudication stage. As moderation in the pursuit of underpayments is no virtue for a payer, the volume of service codes rejected on this basis has increased. Of course, this service code rejection upsets the financial basis on which the contract was made. If a hospital had structured its chargemaster to include the rejected service code X in service code Y, service code Y would have had a higher price because it then would have included the cost and markup for the items and services represented by service code X. However, because the hospital chose to bill for the health care represented by service code X separately, the costs and markup for these services were not included anywhere else in the chargemaster.

Indeed, both parties relied on the existence of the rejected service codes during contract negotiations. In the payer’s financial modeling during negotiations, it accepted the historical charges that included the total costs and markup of the charges it now rejects to estimate what the payer would owe under the contract’s rates. This shows that the real goal of the payer is not to bring the hospital’s chargemaster into conformity with any Medicare “rule,” but to obtain services for free.

“Unbundling” Is Not a Sin Unless a Rule Requires That the Item Be “Bundled”

We start with the simple premise that it cannot be a bad thing to unbundle something unless there is first a rule that requires that thing to be bundled. For example, the Department of Health and Human Services Office of Inspector General says, “‘Unbundling’ is the practice of submitting bills piecemeal or in fragmented fashion to maximize the reimbursement for various tests or procedures that are required \.o be billed together and therefore at a reduced cost.”3 If the cost to the payer is the same whether items A, B, and C are billed together under code “88888” or each is billed separately under its own individual code, there simply is no unbundling.

Most references to unbundling concern the Current Procedural Terminology coding system copyrighted by the American Medical Association and adopted by Medicare. The best case law illustration of unbundling is in United States v. Metzinger, which concerned the separate billing of the components of a lab test panel. The court said, “‘Unbundling’ occurs under circumstances in which the Medicare program prescribes a special reimbursement rate for a group of laboratory procedures that commonly are ordered together. ‘Unbundling’ means billing separately for each component, as opposed to billing at the special rate.”

As Metzinger shows, unbundling is a breach of contract. Every hospital that participates in Medicare has a provider agreement with Medicare. The Medicare fee schedule defines some of the rates under that agreement and establishes the “special rate” for the particular combination of lab tests. That contract rate is breached by the hospital’s unbundling. Unbundling is thus not a circular concept that elevates form over substance. It is a term of art in the healthcare industry that developed from the detailed and precise CPT coding system which, when married to a fee schedule, results in precise contract rates for precisely identified groupings of services.

Of course, managed care contracts never control the content of the hospital’s chargemaster. The chargemaster must be applied to thousands of patients and scores of payers; therefore, for budgetary, regulatory, and practical reasons, there cannot be numerous customized chargemasters in use, each of which conforms to the specific rules of different payers.

However, contracts can address the effect of changes to a chargemaster. For example, a recent trend is to include downward adjustments to the percentage-ofcharges contract rate when chargemaster prices annually rise above specified increments. Here, the hospital retains its discretion to set its prices, but the parties agree on the impact these price increases may have on the contracting payer.

Contracts Do Not Permit Service Code Rejection

The contract between the hospital and the payer shows the mutual intent of the parties at the time of contracting concerning the structure of the charge-master. If the contract has a percentage-of- charges rate, it is likely stated as a percentage of “billed charges” or “covered billed charges,” with no exception for certain types of charges. This alone should be persuasive. If the service code rejection is being applied to an existing contract that was earlier performed on the basis of all the provider’s billed charges, this practical interpretation by both parties will be significant in proving that the parties did not mutually intend to allow service code rejection. If the contract is new, the course of dealing between the parties under earlier contracts will have a similar effect.

Medicare Does Not Control the Structure of a Hospital’s Chargemaster

In the absence of any specific billing rules in the contract, a payer will argue that the Medicare cost apportionment guidelines, which address a distinction between routine and ancillary charges, set an industry standard by which hospitals must set up their chargemasters-and thus an industry standard of what ancillary charges may be billed separately to commercial payers. This argument ignores the language and effect of the cited Medicare rule.

The relevant Medicare cost apportionment “rules” are not found in statutes or regulations, but in Medicare’s Provider Reimbursement Manual. PRM section 2203 (“Provider Charge Structure as Basis for Apportionment”) limits the cost apportionment procedures to Medicare cost apportionment: “While the Medicare program cannot dictate to a provider what its charges or charge structure may be, the program may determine whether or not the charges are allowable for use in apportioning costs under the program.”c

This is not a new position; these Medicare cost apportionment manual provisions were published in the 1970s.d Thus, it was common knowledge in the healthcare industry since the early 1970s that not only did these cost apportionment manual provisions exist, but also that by their own words Medicare disavowed any ability or intent to “dictate to a provider what its charges or charge structure may be.”

These PRM sections also are not intended to eliminate service codes from the chargemaster so that they may be obtained for free. The purpose of the Medicare cost apportionment process is to ensure that costs generated by Medicare patients are not shifted to non- Medicare patients and vice versa. Whether Medicare considers a charge as ancillary (and thus separately billable) or routine (and thus one that should have been included in a routine charge) affects only the methodology by which Medicare attributes the cost of those types of services that were consumed by Medicare patients. Unlike the private payer’s application of this rule to its commercial contracts, Medicare does not cause the cost of an ancillary charge that it thinks should have been included in a routine charge to disappear.

The “industry standard” argument also suffers from the same circularity of reasoning as the “unbundling” argument. If a Medicare rule did create an industry standard, then the interpretation and application of that standard would be for the Medicare program to define and apply. In fact, most if not all of the charges the payer rejects because they violate the Medicare “rule” have never been reclassified or rejected by the hospital’s Medicare fiscal intermediary in the cost apportionment process. Yet the same payer who rejects a service code because it does not meet this “industry standard” deputizes itself-and under its logic every other payer-to privately police how Medicare “should” be applying its rules. This is not done through the adjudicative processes of the Medicare program and the federal court\s so that a truly uniform result can be achieved, but in a series of arbitrations, whose results will remain private and will set no precedent, with the likelihood of conflicting decisions, all without the participation of Medicare- which has the only legal authority to make these decisions.

Simply put, there cannot be two contradictory “industry standards.” In an industry where a contract rate based on a percentage of a hospital’s covered billed charges is a standard term, there cannot also be a standard whereby every payer has the right to tell the hospital how to restructure its charges.

In sum, once the tangled confusion of the payer’s “unbundling” position is itself unbundled, it is clear that the contract between the hospital and the payer, and not Medicare or some hastily manufactured and inconsistent industry standard, controls the obligation to pay for healthcare services. As with so many other underpayment issues, hospitals should not hesitate to enforce the bargain they made in their contracts.

AT A GLANCE

Rejecting service codes on the basis that they have been unbundled has become a popular way for payers to reduce total billed charges. However, the contract between the hospital and the payer, and not Medicare or some hastily manufactured and inconsistent industry standard, controls the obligation to pay for healthcare services.

Managed care contracts never control the content of the hospital’s chargemaster. However, they can address the effect of changes to a chargemaster.

By rejecting service codes, the real goal of the payer is not to bring the hospital’s chargemaster into conformity with any Medicare “rule,” but to obtain services for free.

UNBUNDLING TO MAKE A BUNDLE OFF MEDICARE?

In version 11.3 of its National Correct Coding Initiative Policy Manual for Medicare Services, the Centers for Medicare and Medicaid Services gives the following definition and examples of different types of unbundling:

Unbundling occurs when multiple procedure codes are billed for a group of procedures that are covered by a single comprehensive code. Two types of practices lead to unbundling. The first is unintentional and results from a misunderstanding of coding. The second is intentional and is used by providers to manipulate coding in order to maximize payment….

Examples of unbundling are described below:

* Fragmenting one service into component parts and coding each component part as if it were a separate service. For example, the correct CPT comprehensive code to use for upper gastrointestinal endoscopy with biopsy of stomach is CPT code 43239. Separating the service into two component parts, using CPT code 43235 for upper gastrointestinal endoscopy and CPT code 43600 for biopsy of stomach, is inappropriate.

* Reporting separate codes for related services when one comprehensive code includes all related services. An example of this type is coding a total abdominal hysterectomy with or without removal of tubes, with or without removal of ovaries (CPT code 58150) plus salpingectomy (CPT code 58700) plus oophorectomy (CPT code 58940) rather than using the comprehensive CPT code 58150 for all three related services.

* Breaking out bilateral procedures when one code is appropriate. For example, bilateral mammography is coded correctly using CPT code 76091 rather than incorrectly submitting CPT code 76090-RT for right mammography and CPT code 76090-LT for left mammography.

* Separating a surgical approach from a major surgical service. For example, a provider should not bill CPT code 49000 for exploratory laparotomy and CPT code 44150 for total abdominal colectomy for the same operation because the exploration of the surgical field is included in the CPT code 44150.

a. Compliance Program Guidance for Hospitals, February 1998, fn. 20. Emphasis added.

b. CCH Medicare S, Medicaid’Guide, 44,669 (USDC E.D. Pa., 1996), 1996 WL 530002.

c. See also the following statement in Medicare Intermediary Letter No. 399 (Sept. 1,1969), CCH Medicare & Medkaid Guide, 26,024: “The Medicare program cannot dictate to a provider what its charges or charge structure may be. The provider is free to set its charges and charge its private-paying patients, and others, in any way it sees fit. The Medicare program, however, may determine whether the charges are allowable for use in apportioning costs under the program.”

d. PRM 2206 (“Routine Services”) was adopted in March 1971, and amended by transmittals in September 1972, July 1975, June 1976, and October 1976. CCH Medicare & Medicsid Guide, 6095. PRM 2202.8 (“Ancillary Services”) was also adopted in March 1971, and amended by transmittals in September 1972 and June 1976. CCHMedicare & Medicsid Guide, Sl 6105. PRM 2203 (“Provider Charge Structure as Basis for Apportionment”) was adopted in September 1972, and amended by transmittals in May 1975 and June 1996. The June 1996 amendment did not add or amend the quoted language. CCH Medicare & Medicaid Guide, 6153.

Frank Fedor, JD, is a partner, Murphy Austin Adams Schoenfeld, LLP, Sacramento, Calit., and a member of HFMA’s Northern California Chapter ([email protected]).

Copyright Healthcare Financial Management Association Jan 2006

Services to Homeless Students and Families: The McKinney-Vento Act and Its Implications for School Social Work Practice

By Jozefowicz-Simbeni, Debra M Hernandez; Israel, Nathaniel

In 1987 Congress authorized the Stewart B. McKinney Homeless Assistance Act to protect the rights of homeless students and to ensure that they receive the same quality and appropriate education that other students receive. This article summarizes key aspects of the 2001 reauthorization of the act, now known as the McKinney- Vento Act, outlines how school social workers can become more involved in the implementation, and offers suggestions for expansion of services and further evaluation of service provision effectiveness.

KEY WORDS: education; homelessness; McKinney-Vento; school social work practice; students

In recent years, research has shed light on the numerous educational barriers that homeless children and adolescents face, including lack of transportation, residency restrictions, lack of personal and school records, guardianship problems, and a lack of resources such as clothing and school supplies (Rafferty, 1995; U.S. Department of Education, 2001; Wall, 1996). Academically, homeless and runaway students face increased risk of school dropout, grade retention, low test scores, low grades, educational disabilities, and school behavior problems (Israel, Urberg, & Toro, 2001; Jozefowicz-Simbeni, 2003; Masten, Miliotis, Graham-Bermann, Ramirez, & Neemann, 1993; Ziesemer, Marcoux, & Marwell, 1994).

Such conditions do not develop in a vacuum, but are nested in a complex web of structural and environmental conditions. Homeless children experience emotional and behavioral disorders, physical health problems, and developmental delays. The problems are compounded by family circumstances of financial troubles, substance abuse, and mental and physical health issues. Furthermore, the nature of homelessness lends disturbingly well to parenting distress. All of these forces conspire to nearly eliminate the homeless child from public school education. Yet, burgeoning research has begun looking into the strengths of homeless students and has found such youths to possess numerous qualities that can lead to positive adaptation to adulthood, including being strong and resilient, as well as possessing spiritual values.

This article looks at the problem of homelessness in the United States, particularly for children and youths and presents the needs and strengths of homeless students. In addition, we explore key provisions of the 2001 McKinney-Vento Act (RL. 100-628), which was designed to address these concerns. Finally, we propose several pathways to greater involvement of school social workers in the implementation of the legislation as well as how they might augment the services they provide and evaluate the efficacy of their work.

HOMELESSNESS IN THE UNITED STATES

Homelessness is an extreme condition of poverty that has been a long-standing concern of the social work profession. Although single adult men make up the majority of the homeless population, growing numbers of children, youths, single mothers, and poor or working poor families are experiencing homelessness in the United States (Swick, 2004; U.S. Conference of Mayors, 2001). In a study of homelessness among urban women of childbearing age, 11.4 percent of the 44,430 women in the study reported at least one episode of homelessness in a seven-year period surrounding the birth of their first child (Webb, Culhane, Metraux, Robbins, & Culhane, 2003). Mothers who were African American, who had less education, and who had more children were much more likely to experience homelessness than other groups. Indeed, more than half (53 percent) of African American women in the study who had dropped out of school and who had four or more children during the seven-year period assessed (either three years before the birth of their first child or within the four years of the birth of their first child) reported being homeless during that period. The results bode poorly for the risk of homelessness of young urban children, particularly African American children.

Older children suffer homelessness in great numbers as well. One recent estimate indicated that more than 900,000 children and youths experience homelessness in a given year (U.S. Department of Education,2001). In a national survey on the annual preva- ( lence of homelessness among youths ages 12 to 17, Ringwalt, Greene, Robertson, & McPheeters (1998) estimated youth homelessness (not including doubling-up with friends or extended family members) at nearly 8 percent. Although boys were more likely than girls to be homeless, they found no other differences in the prevalence of youth homelessness based on race, poverty status, family structure, or region of the country. These findings suggest that youth homelessness is not just a concern for urban, poor youths, but also a broader concern that merits national attention (Ringwalt et al.).

Although prevalence estimates are an empirical indicator of the scope of homelessness, homeless children and youths are likely undercounted and underidentified, in part, because shelters may be inaccessible to them, they are turned away from shelters, or they avoid shelters and other services because of the stigma (Aron & Fitchen, 1996; Swick, 2004; U.S. Conference of Mayors, 2001, 2003). The size of the homeless population, coupled with the fact that severe poverty and homelessness pose significant risks to child development, indicates that homelessness is a pressing social concern for children, youths, and families (Masten et al., 1997; Schmitz, Wagner, & Menke, 2001). Ensuring that homeless children and youths receive an education on par with their peers is necessary in addressing the needs of homeless people in the United States.

NEEDS AND RISK FACTORS ASSOCIATED WITH HOMELESSNESS

Students and their families end up homeless for numerous reasons. Structural factors, such as poverty, lack of affordable housing, and eviction can lead to sudden or prolonged bouts of homelessness (Reganick, 1997). In addition, personal or relationship factors, such as substance abuse, mental health difficulties, abuse and neglect, and family conflict and violence are also reasons that children, youths, and families may find themselves without a place to stay (Reganick; Swick, 2004). The stresses and strains associated with poverty, frequent mobility, and homelessness relate consistently to health, emotional, behavioral, and academic difficulties among homeless students (Hart-Shegos & Associates, Inc., 1999; Masten et al., 1993; Masten et al., 1997; Reganick).

Reganick (1997) categorized the struggles that homeless children and youths face into the following five areas: (1) physical conditions and health problems that result from environmental factors such as poor nutrition, (2) unacceptable behaviors resulting from coping and survival strategies, (3) inadequate social skills and insecurities stemming from frequent moves and self- consciousness about being homeless and lacking resources, (4) psychological trauma resulting from multiple stressors that contributes to negative mental health, and (5) developmental delays due to a lack of stimulating environmental conditions.

Emotional and Behavioral Issues

Homeless children and youths often display higher levels of emotional and behavioral disorders than the general population. They are more likely to experience stress, depression, anxiety, worries, a sense of isolation, withdrawal, aggression, antisocial behavior, and substance use (Hart-Shegos & Associates, Inc., 1999; Masten et al., 1993; Schmitz et al., 2001). For instance, Masten and colleagues (1993) found that homeless children had levels of behavior problems above national norms. They were also more likely to be exposed to recent stressful events and school and friendship disruption than matched, nonhomeless peers. Behavioral problems in both samples were related to parental distress, cumulative risk, and recent stressful events, suggesting that there are significant mediators of emotional and behavioral outcomes for homeless and other low-income students.

Homeless children and youths can also experience shame, self- consciousness, and insecurity about being without a home (Reganick, 1997; Schmitz et al., 2001). These emotional and behavioral problems, as well as negative self-attitudes about being homeless, can lead to academic problems at school.

Academic Achievement

Homeless students are more likely to experience low achievement test scores, poor grades, educational disability, school behavior problems, grade retention, truancy, and school dropout (Israel, Urberg, & Toro, 2001; Jozefowicz-Simbeni, 2003; Mastenetal., 1993; Ziesemer et al., 1994). Ziesemer and colleagues found that homeless students and matched low-income mobile students both have higher levels of academic difficulties compared with other normative samples.This finding suggests that, although homeless students face barriers to educational access and academic success and have unique challenges as a result of not having a home, poverty and resultant high mobility als\o take their toll on students.Yet homeless students, compared with poor students who live at home, are at greater risk of school mobility and related educational challenges (Masten et al., 1993).

Family-Related Challenges

Homelessness is not only associated with child difficulties, but parent and family difficulties as well. Although some studies report lower substance use and mental health disorders among homeless women with children compared with other adult homeless populations, homeless parents are more likely to be single women who have a substance abuse problem, mental health disorder, or physical health problem, and they are less likely than other mothers to receive services (Hart-Shegos & Associates, Inc., 1999).The reality of homelessness can also mean more parental distress, an undermining of views of parents and the parental role, less responsiveness to child needs, and a splintering of the family unit (Reganick, 1997; Schmitz et al., 2001). Thus, several risks and barriers encountered by homeless students can be linked to the struggles of their parents and to family functioning.

Strengths of Homeless Children and Their Families

Finally, although homeless students and families display many struggles and needs, it is important to attend to and emphasize their strengths. Despite the numerous stressors homeless youths face, research has identified significant strengths in these children (Israel & Jozefowicz-Simbeni, 2004; Schmitz et al., 2001). In an interview study of homeless and runaway youths, Lindsey and colleagues (2000) found that the ability to change attitudes and behaviors; personal characteristics, such as being strong; and reliance on spirituality were strengths that contributed to a constructive transition to adulthood for this group.

In response to the needs of homeless children and their families, numerous social services and educational policies have marshaled resources to stem the tide against poor academic achievement and child development, as well as poverty. One piece of legislation, the McKinney-Vento Homeless Assistance Act, has been hailed as a landmark law that explicitly addresses the needs and concerns of homeless students and their families.

THE MCKINNEY-VENTO ACT

In 1987 the Stewart B. McKinney Homeless Assistance Act (P.L. 100- 77) was first authorized to protect the rights of homeless students and to ensure that they receive the same quality and appropriate public school education that nonhomeless students receive by addressing some of the barriers homeless children and adolescents face when enrolling and succeeding in school (U.S. Department of Education, 2004).The act also mandated the designation of a state coordinator whose purpose was to promote educational access for homeless students. In 1990 and again in 1994, the law was amended to expand services to preschool-age children and other student groups, decrease noncompliance, and provide incentives for compliance (Markward & Biros, 2001). Incentives included the allocation of funding to State Educational Agencies (SEAs) for distribution to Local Educational Agencies (LEAs) through granting mechanisms. Such funding not only stimulated the removal of enrollment barriers, but also increased focus on programming and community collaborations for improved academic success of homeless students (Markward & Biros).

In 2001 the McKinney-Vento Homeless Assistance Act was reauthorized as a part of the No Child Left Behind Act of 2001 (P.L. 107-110).The reauthorized act further clarified the definition of who should be considered homeless. Homeless students include those who do not have a fixed, regular, and adequate nighttime residence and find themselves in any of the following situations:

* waiting for a foster care placement or being abandoned in a hospital

* staying in a shelter, abandoned building, or motel

* staying at a campground or inadequate trailer park

* living out of a car or in a bus or train station

* staying with friends or relatives as a result of no housing

* staying in any public or private space not designed for or used as a regular sleeping place for human beings

* staying in any of the described locations because they are from migratory families (U.S. Department of Education, 2004).

It is important to note that McKinney-Vento included reference to preschool-age children, another group of homeless students that are often more difficult to identify and pull into the mainstream educational system. Also, the law refers to special populations of homeless students that may have unique needs, such as those living in domestic violence shelters (U.S. Department of Education, 2004).

McKinney-Vento also increased the scope of policies and potential services to assist homeless students in gaining access to and succeeding in their education. There are explicit prohibitions against segregating students into a separate program or school solely on the basis of homelessness, a presumption of school of origin as the placement in the best interests of the student unless otherwise indicated by the student or family, an immediate and continued enrollment in school of choice regardless of pending disputes, a required designation of a liaison for every LEA, and transportation to and from school of choice (U.S. Department of Education, 2004).

Two main ideas pervade the act. First, school mobility should be minimized to mitigate school disruption and its effect on academic success. Federal guidelines for implementing McKinney-Vento apply a “One Child, One School, One Year” policy and spell out requirements regarding enrollment, transportation, and dispute resolution that include immediate enrollment in school without proof of residency, school records, or immunization records; choice between school attended before loss of housing, last school enrolled, or school affiliated with present living arrangement; and a process for timely dispute resolution (National Law Center on Homelessness & Poverty, 2002). second, McKinney-Vento indicates that services should be provided in a way that allows homeless children to remain in the mainstream setting with their peers to avoid being ostracized, segregated, and harassed (U.S. Department of Education, 2004).

States receive a minimum allotment of McKinney-Vento funding, which was $150,000 in 2003 (U.S. Department of Education, 2004). Grants are given to all states, the District of Columbia, and Puerto Rico depending on the amount of Title I funds they receive. Grants also are given to the outlying areas including the Virgin Islands, American Samoa, Guam, and the Commonwealth of the Northern Mariana Islands. Funds also go to the Bureau of Indian Affairs (U.S. Department of Education, 2004). States with a minimum allotment can spend 50 percent of the funds on state-level activities performed by the state Office of Coordinator for Education of Homeless Children and Youth. States with more than the minimum allotment must award 75 percent of their federal dollars to LEAs through competitive grants.

BARRIERS TO MCKINNEY-VENTO IMPLEMENTATION

Although awareness, implementation, and funding of the McKinney- Vento Act have been expanding, evidence suggests that barriers to its implementation still exist (U.S. Department of Education, 2001). In a 2000 Congressional report based on a survey of state coordinators, respondents indicated that difficulty identifying homeless students, lack of awareness of the needs of homeless students and families, staff turnover, high staff to student ratios, and limited funding were the primary barriers to implementing the act at that time. There is also evidence that low levels of awareness of the act more generally remain problematic. In a study of homeless liaisons in one county in Illinois.Thompson and Davis (2003) found that significant numbers of liaisons were not aware that they were designated as homeless liaisons by their LEAs, and they had little or no knowledge of the McKinney-Vento Act. Such ignorance could reflect school districts’ own lack of knowledge or unwillingness to devote resources to training and outreach. A lack of training and outreach to parents, however, could be viewed as passive ways to deny services to these students and families.

With the exception of some exemplary programs, these barriers mean that homeless students and families continue to be underidentified and underserved, and a program of services to meet their needs is often nonexistent, unrecognized, or inadequate. Increasing awareness of the act, identifying and tracking homeless students, mainstreaming and reducing the negative effect of mobility, and developing and coordinating services to homeless students and their families all require individuals, including the mandated officials and social workers who can educate and prompt school officials to apprehend and comply with the law.

State Coordinators

McKinney-Vento requires each state to have an Office of Coordinator for Education of Homeless Children with a state coordinator whose job is to develop and carry out the state’s McKinney-Vento plan and collect information on the problems faced by homeless students and the ability of programs to address the needs of these students. The coordinator is also responsible for creating and coordinating activities and comprehensive services (including health and social services) for homeless students and families, partly through linking the shelters, schools, and community organizations that serve these students and families. Coordinators are also expected to provide support and technical assistance to LEAs and local liaisons through developed documents.Web sites, newsletters, and other media to increase knowledge, compliance, and activities associated with the McKinney-Vento Act. Finally, state coordinators prepare reports to the U.S. Department of Education about the status of meeting the needs of homeless students as needed (For more information on state \coordinator activities, see Education for Homeless Children andYouth Program: Non-Regulatory Guidance,U.S. Department of Education, 2004).

LEA Liaisons

Each LEA (or school district) must designate a homeless liaison who is responsible for ensuring the smooth matriculation into school and associated school programs that homeless students require, as well as facilitating the education of school personnel and parents regarding the rights guaranteed under the McKinney-Vento Act. The liaison may act as an intermediary between parents and students and the requirements, or felt requirements, of schools and school districts in meeting those needs. As intermediaries, local liaisons may need to assist in document procurement and delivery, dispute resolution, school enrollment, and ongoing education so that all parties understand the law and receive or deliver services. Liaisons can be involved in securing material needs such as food and clothing, as well as transportation to and from schools.They can also be stabilizing forces in homeless students’ and families’ lives through centralized contact and the indirect and direct provision of services.

A Role for School Social Workers

The role and functions of homeless liaisons are so consonant with the role and functions of social work, it is no surprise that school social workers have been recruited explicitly or implicitly into these roles. For instance, homeless liaisons need to be advocates for homeless children and families, need to attain resources for these students and families, and need to connect with community organizations and agencies on behalf of these students and families. School social workers often do this for atrisk and special needs students more generally, and have likely been doing so for homeless students more specifically.

Unfortunately, school social workers’ involvement with homeless students and families, and their positions as homeless liaisons remain largely anecdotal. There is no formal documented accounting of the level of involvement school social -workers have had or are having with this population. As a result, we are only beginning to understand the influence of McKinney-Vento Act on the school social work profession. Markward and Biros (2001) wrote about the implementation of the 1987 act and implications for school social work practice. Recommendations for school social workers then included advocating for adequate housing and funding, identifying preschool and special needs homeless students and linking them to educational programs and services, increasing parental involvement, linking families to services, providing direct services, and evaluating the effectiveness of services (Markward & Biros). Despite such recommendations and the strengthening of the act in 2001, awareness and social -workers’ position in implementation of McKinney-Vento continue to be a challenge.

Overcoming Barriers

To increase knowledge and compliance, schools need to identify local liaisons, educate them about their function and roles, and advocate for training and real support for these individuals.To overcome barriers to appropriate service delivery and facilitate parental involvement, key roles homeless liaisons and school social workers can play are those of parent and staff educator and system advocate.They can educate and sensitize school staff, other families and students, and community agency workers (for example, shelter staff, protective service workers) to the needs and rights of homeless children and families. Concerted awareness-raising efforts would help increase compliance with McKinney-Vento requirements, as well as decrease stereotyping and other negative attitudes toward homeless students and families that impede children’s and adolescents’ emotional and academic growth (Reganick, 1997). Furthermore, a strengths-based approach that emphasizes homeless mothers’ positive views of their children (Israel& JozefowiczSimbeni, 2004) and homeless students’ high aspirations and positive views of themselves (Reganick) could lead to more constructive views, supports, and service provision for this population.

Because of a lack of knowledge and implementation surrounding the McKinney-Vento Act, programs designed to increase knowledge and compliance continue to emerge and expand,and public awareness of such programs is beginning to grow. For instance, an article that appeared in the Chicago Tribune described several programs for homeless students that are run by the Regional Education Office and the Illinois Coalition to end Homelessness (Mastony, 2003). One program involves four social workers who serve as centralized contacts to address student enrollment and problems that homeless students and families face. They also perform outreach to schools and shelters, educate schools about the act, and attempt to identify local liaisons for each local school district (Mastony).

In an attempt to develop and evaluate services to homeless students and families in an urban, high poverty district in Michigan, a quantitative and qualitative needs assessment was conducted with 50 elementary students and their mothers staying in homeless shelters (Israel, Toro, & Jozefowicz-Simbeni, 2003). Preliminary analyses of interview data revealed that these children were highly mobile (moving an average of four times in the past 12 months) and rarely were able to obtain services the law designates. Possibly as a result of this, parents perceived schools as being inadequately prepared to deal with their needs or their children’s needs. However, a strength of the mothers was that they also stated a willingness to become and to stay involved with their children’s education. School social workers could build on such strengths by linking parents with the resources necessary to facilitate their involvement in their child’s education.

Based on the findings, key recommendations to the district included hiring sufficient staff to effectively implement all aspects of the district’s Education of Homeless Student Plan, developing a system to identify and track homeless students and families, providing in-service training to educate staffabout the McKinney-Vento Act, and conducting outreach efforts to local shelters to provide information to homeless students and families regarding the act and their rights (Israel et al., 2003). In addition, the study made recommendations regarding expanded school and social services to improve educational access and the academic success of homeless students from preschool through high school. Key recommendations in such reports have broad applicability and can be used not only to inform local program efforts, but also to inform efforts in other districts and states more generally. Wider dissemination of program descriptions and evaluations, therefore, should be attempted, and school social workers can be instrumental in writing and publishing such reports. In addition to increasing knowledge, staffing, and outreach to shelters, McKinney-Vento and reports on McKinney-Vento also suggest the importance of linking homeless students and families to existing services and school programs, including programs such as the free and reduced lunch program, afterschool programs, tutoring, special education,Title I, and adult and vocational education (U.S. Department of Education, 2001). One important area in need of more attention is the underrepresentation of homeless preschoolers in early education programs (U.S. Department of Education, 2001). Early intervention and education is critical for both remediation of early childhood delays and the promotion of school readiness, particularly for poor preschoolers (McLoyd,2000). Early childhood programs can serve as stable forces in the lives of homeless preschoolers who experience homelessness (Douglass, 1996). Putting families of preschoolers in contact with Even Start and Head Start programs is needed, as well as identifying and developing other options for homeless preschool- age children.

In addition to linking students and families with educational programs, liaisons and school social workers can connect students and families with other services and community agencies. As stated, studies have indicated significant mental health and substance abuse problems for homeless students and their parents. These children and families may also have contact with the public assistance, child welfare, and juvenile justice systems. Thus, school social workers need to be knowledgeable about these systems and how children and families can obtain the appropriate services.

Finally, school social workers can engage not only in risk reduction, but also in resource building (Jozefowicz-Simbeni & Allen- Meares, 2002) for homeless students, families, and the communities and schools they serve.This can occur through persistent outreach, community involvement, and grant-writing activities. Resources can include food, clothing, school uniforms, bus tickets, backpacks, books, school supplies, computers, personal hygiene items, and of course, housing.

FUTURE DIRECTIONS

School social workers have an opportunity to make a significant impact in the lives of homeless school children and youths. The McKinney-Vento Act spells out numerous avenues for involvement that are compatible with social work values, roles, and functions.These include the identification and tracking of homeless students, and the development and implementation of a broad range of interventions and services designed to increase educational access and success for these children and adolescents.

To gain a clearer understanding of the significance of the McKinney-Vento Act to homeless students and families, its implications for school social work practice, and whether its implementation has been successful, more research is needed to determine how many homeless students and families are being served, what their needs are, what types of services are b\eing provided to them, and how effective service provision has been in meeting their needs. Consistent with current models of social work practice, there is a need to identify best practices in this area. In addition, identification of ways in which these efforts can be folded into other efforts to track highly mobile and high-risk children is also needed. Ideally, efforts to address the unique needs of homeless students and families should become part of a comprehensive and seamless service delivery system.This legislation offers a unique opportunity to encourage local human services, community, and business organizations to band together to help a targeted group of individuals who are undeniably in need. It is also an opportunity to develop community awareness of the needs of economically disempowered families and to encourage communities to develop services that rely on integrated service delivery models, such as full-service schools or school-linked services (for exampleJozefowicz-Simbeni & Allen-Meares, 2002). The importance of this legislation to develop and assess the effects of implementing a coordinated system of care has implications for homeless students in particular, and all at-risk students more broadly.

REFERENCES

Aron, L.Y, & Fitchen, J. M. (1996). Rural homelessness: A synopsis. In J. Baumohl (Ed.), Homelessness in America (pp. 81-85). Phoenix, AZ: Oryx Press.

Douglass.A. (1996). Rethinking the effects of homelessness on children: Resiliency and competency. Child Welfare, 75,741-751.

Hart-Shegos & Associates, Inc. (1999, December). Homelessness and its effects on children. Minneapolis: Author.

Israel, N., & Jozefowicz-Simbeni, D. M. (2004, April). Strengths and support needs of homeless students in Detroit. Poster session presented at the Children’s Bridge Conference, Way ne State University, Detroit.

Israel, N.,Toro, P. A., & Jozefowicz-Simbeni, D. M. (2003). An evaluation of homeless children and youth services. Unpublished manuscript,Wayne State University, Detroit.

Israel, N., Urberg, K., & Toro, P. A. (2001, August). Academic performance and maladjustment in housed and homeless adolescents. Paper presented at the annual convention, American Psychological Association, San Francisco.

Jozefowicz-Simbeni, D.M.H. (2003,April). Why do they leave? Why do they stay? Quantitative and qualitative perspectives on high school dropout. Poster session presented at the Biennial Meeting, Society for Research in Child Development,Tampa, FL.

Jozefowicz-Simbeni, D.M.H., & Allen-Meares, P. (2002). Poverty and schools: Intervention and resource building through school- linked services. Children & Schools, 24, 123-136.

Lindsey, E.W., Kurtz, P. D., Jarvis, S.,Williams, N. R., & Nackerud, L. (2000). How runaway and homeless youth navigate troubled waters: Personal strengths and resources. Child & Adolescent Social Work Journal, 17, 115-140.

Markward, M. J., & Biros, E. (2001). McKinney revisited: Implications for school social work. Children & Schools, 23, 182- 187.

Masten,A. S., Miliotis, D., Graham-Bermann, S.A., Ramirez, M., & Neemann, J. (1993). Children in homeless families: Risks to mental health and development. Journal of Consulting and Clinical Psychology, 61, 335-343.

Masten, A. S., Sesma, A.,Jr., Si-Asar, R., Lawrence, C., Miliotis, D., & Dionne.J. A. (1997). Educational risks for children experiencing homelessness. Journal of School Psychology, 35, 27-46.

Mastony, C. (2003, July 2). Education program to aid homeless suburban kids. Chicago Tribune, p. Al.

McKinney-Vento Homeless Assistance Act of 1988, PL. 100-628, 101 Stat. 482.

McLoyd, V. C. (2000). Poverty: Childhood poverty. In A. E. Kazdin (Ed.), Encyclopedia of psychology (Vol. 6, pp. 251-257). Washington, DC:American Psychological Association and Oxford University Press.

National Law Center on Homelessness & Poverty. (2002). Education of children & youth in homeless situations. Washington, DC: Author. Available at http:// www.nlchp.org/content/pubs/Edu- newchildren%20in%20b.omeless%20situations.doc

No Child Left Behind Act of 2001 (NCLB), PL. 107110, 115 Stat. 1425.

Rafferty, Y. (1995).The legal rights and educational problems of homeless children and youth. Educational Evaluation and Policy Analysis, 17, 39-61.

Reganick, K. A. (1997). Prognosis for homeless children and adolescents. Childhood Education, 73, 133-135.

Ringwalt, C. L., Greene, J. M., Robertson, M., & McPheeters, M. (1998). The prevalence of homelessness among adolescents in the United States. American Journal of Public Health, 88, 1325-1329.

Schmitz, C. L., Wagner, J. D., & Menke, E. M. (2001).The interconnection of childhood poverty and homelessness: Negative impact/points of access. Families in Society, 82, 69-77.

Stewart B. McKinney Homeless Assistance Act of 1987, PL. 100-77, 101 Stat. 1425.

Swick, K. J. (2004). The dynamics of families who are homeless: Implications for early childhood educators. Childhood Education, 80, 116-120.

Thompson, J. A., & Davis, S. M. (2003,June). Educating homeless children: Perceptions of school homeless liaisons. Poster presented at the 9th Biennial Conference, Society for Community Research and Action, Las Vegas.

United States Conference of Mayors. (2001, December). A status report on hunger and homelessness in America’s cities,2001:A 27- citysurvey. Retrieved May 18, 2004, from http://www.usmayors.org/ uscm/ hungersurvey/2001/hungersurvey2001.pdf

United States Conference of Mayors. (2003, December). A status report on hunger and homelessness in America’s cities, 2003:A 25- city survey. Retrieved May 18, 2004, from http://www.usmayors.org/ uscm/hungersurvey/2003/onlinereport/ HungerAndHomelessnessReport2003.pdf

U.S. Department of Education. (2001, December). Education for homeless children and youth program: Report to Congress fiscal year 2000. Retrieved October 24, 2004, from http://www.ed.gov/ programs/ homeless/rpt2000.doc

U.S. Department of Education. (2004, July). Education for homeless children and youth program: Non-regulatory guidance. Retrieved October 24, 2004, from http:// www.ed.gov/programs/ homeless/guidance.pdf

Wall, J. C. (1996). Homeless children and their families: Delivery of educational and social services through school systems. Social Work in Education, 18, 135-144.

Webb, D. A., Culhane, J., Metraux, S., Robbins, J. M., & Culhane, D. (2003). Prevalence of episodic homelessness among adult childbearing women in Philadelphia, Pa. American Journal oj Public Hcalih, 93, 1895-1896.

Ziesemer, C., Marcoux, L., & Marwell, B. E. (1994). Homeless children: Are they different from other low-income children? Social Work, 39,658-668.

Debra M. Hernandez Jozefowicz-Simbeni, PhD, is assistant professor, School of Social Work, Wayne State University, 4756 Cass Avenue, Thompson Home, Room 314, Detroit, MI 48202; e-mail: debj- [email protected]. Nathaniel Israel, MA, is Visiting Assistant in Research, Department of Child & Family Studies, Louis de la Parte Florida Mental Health Institute, University of South Florida, Tampa.

Accepted June 7, 2005

Copyright National Association of Social Workers, Incorporated Jan 2006

School Discipline and Social Work Practice: Application of Research and Theory to Intervention

By Cameron, Mark; Sheppard, Sandra M

Research has identified a relationship between school disciplinary actions and poor academic and psychosocial functioning of students subjected to them. The ways in which school discipline is a direct contributor to students’ academic and psychosocial difficulty needs to be further established empirically. Several theories, based in existing research and theory in sociology of education and educational psychology, have been proposed to explain the school discipline-student dysfunction relationship. They generally suggest three pathways: disciplinary actions may contribute to students’ psychological problems; student misbehavior may be encouraged through ineffective and unintentionally paradoxical learning experiences; and disciplinary practices may damage students’ relationship with school. School social workers and others working with children who have been disciplined at school can use these research findings and theories as an assessment framework to guide their interventions. The awareness of the iatrogenic potential of school discipline and informed assessment can support a range of evidence-based alternatives to school discipline.

KEY WORDS: assessment; children; discipline; schools; school social work

Although voluminous research has proven them faulty and ineffective at best and damaging at worst, disciplinary policies and practices in U.S. schools have remained virtually unchanged since the advent of public schooling in the late 18th century (Finkelstein,1989;Katz, 1975; Rothstein, 1984). Schools commonly used methods such as codes of conduct, suspension, corporal punishment, and teachers’ management of students’ behaviors inside the classroom to maintain safe and orderly environments that are conducive to effective teaching and learning.Teachers, however, often must balance the challenges of working in schools that may be lacking resources but have many children with great needs, and sometimes, serious psychosocial difficulties/Teachers need to maintain safe and learning-appropriate classroom environments, and some disciplinary methods are indispensable to accomplishing this task.

Four decades of research, however, have shown that these conventional school disciplinary policies and practices often fail to create the intended environment and appear, in some cases to have a destructive impact on children’s academic and psychosocial functioning. School discipline has been linked with posttraumatic stress disorder (PTSD), depression, anxiety, aggressive behavior in and outside of school, academic failure, and school dropout (for reviews see Cameron (2005); Hyman & Perone, 1998). Furthermore, children of color, boys, and those receiving compensatory services at schools for disabilities are disproportionately and more severely subjected to school discipline (for reviews see Cameron; Hyman, 1990,1995). Most of these studies are correlational, however, and have not conclusively demonstrated that school disciplinary policies and practices directly contribute to the development of these problems in school children.

Using more rigorous methods and statistical analyses, however, Mayer and Leone (1999), Wu, Pink, Grain,and Moles (1982),and Shaw and Braden (1990) found that school discipline directly contributes to the incidence of these psychosocial problems in children. Although their findings accord with the correlational studies, more research is needed to affirm and further specify these findings. The emerging picture, however, strongly suggests that conventional methods of disciplining students may be used prejudicially, and in some cases, to the detriment of the students disciplined.

Research and theories from developmental psychology, sociology of education, and the newer field of the study of school disciplinary practices offer a host of potential explanations for understanding the ways in which students may be adversely affected by common school disciplinary practices. These findings and theories represent the best contemporary conceptualizations of how school disciplinary practices can have paradoxical and iatrogenic effect on some students, and although tentative, can be used to guide professional interventions with children negatively affected by their experiences with school discipline.

School disciplinary practices have received little attention from social work researchers (key exceptions are Dupper, 1994 and Dupper & Meyer-Adams, 2002). Some school social workers and agency or private practice social workers working with children and adolescents may be unfamiliar with extant research on discipline and not know that although discipline may be doled as a remedy of school problems, it may actually harm children. This knowledge gap may limit social workers’ understanding of their young clients and their effectiveness with them. Not being able to consider how school- based factors contribute to young clients’ functioning, practitioners may develop overly narrow intervention plans that may help these clients but miss opportunities for greater and larger systems change efforts.

The literature provides three pathways for understanding the iatrogenic effect of school discipline on school children: (1) research and theory pertaining to student misbehavior and other symptoms as psychological sequelae of harmful school discipline, (2) operant conditioning and social learning theories on the ways students may learn misbehaviors as an unintended product of school discipline, and (3) social and political theories that focus on the problematic nature of students’relationship with school in the wake of exposure to discipline. The research and theory provide fertile ground for recommendations to social workers practicing with school children on how they might differentially assess the multiple ways that school experiences may be contributing to the problems that have brought their young clients in for assistance and design appropriate interventions shaped by these determinations.

PSYCHOLOGICAL SEQUELAE OF SCHOOL DISCIPLINE

Suppressed Negative Emotions

Students who are subjected to school discipline may react to it with strong but unexpressed emotions, including anger, humiliation, shame, and anxiety (Rothstein, 1984). Corporal punishment, for example, may create fear of teachers and administrators that students may never express to anyone directly (Dubanoski,Inaba, & Gerkewicz, 1983).These strong and upsetting but suppressed emotions can provoke reactive misbehavior in the face of incidents that would not normally trigger such reactions, including playful, teasing, or a challenging-but unhostile-remark. In an analysis of the differential treatment of low-income students and others, Brantlinger (1991) found that students perceived peers often subjected to discipline as edgy, defensive, angry, and easily prodded into aggressive acts with others. Brantlinger suggested that the acting out was primarily the product of the humiliation and failure the low-income students experienced and the intense frustrations and social isolation that characterized their lives at school.

Stigmatization and Negative Self-Image

Behavioral confirmation theory, also known as labeling theory or self-fulfilling prophecy, has been used to explain how teachers’ negative expectations for and interactions with their students can have a profound impact on students’ behavior and their identities (fora recent review see Eden, 2003). Receiving discipline suggests to some students that they failed in the eyes of the teacher, a “significant other,” and that they are “bad.” Students internalize the negative messages inherent in the disciplinary interaction (Hyman, 1990), and the messages become part of students’ self- concept. Such experiences can be powerful and aversive enough that some students may develop a negative self-identity. Teachers who attribute students’ misbehaviors to character defects may promote students’ negative self-view (Hart, Brassard, & Germain, 1987). Misbehaving students placed into special education programs as a disciplinary move may also have this reaction.

As a result, students may also experience Stigmatization among their peers. The disciplining of a peer may be off-putting to students, who may shun the disciplined student, leading to another experience of rejection for the disciplined student. Also, students may come to believe that the way they are treated is proper and necessary for them even though it may be overly harsh and damaging to them psychologically (Epp, 1996,1997) .These students, feeling ostracized, may develop closer ties with troubled students (Williams, 1979) and, in some cases, lcse interest in academics and other relationships at school (Costenbader & Markson, 1998).

Trauma

Studies of disciplined school children suggest that punitive disciplinary actions taken by adults are traumatizing for some students. Symptoms associated with discipline-based trauma include anxiety, hypersensitivity to criticism, psychic numbing, poor concentration, somatic complaints, sleep disturbance, flashbacks, and other symptoms associated with PTSD (Hyman, 1990). PTSD symptoms have been identified in students who have been corporally punished or harshly reprimanded in class by their teacher (Hyman, 19\90;Krugman & Krugman, 1984; Maurer, 1991). Students punitively disciplined by teachers may develop symptoms similar to those associated with the use of corporal punishment by adults at home, including anxiety, hypersensitivity to criticism, rumination, diminished social functioning, and school refusal (Hyman, 1990; Krugman & Krugman). Ridicule by teachers exacerbates existing symptoms of children corporally punished at home (Spencer, 1999). Students may cope with the trauma through re-enactment by acting abusively with peers (Hyman, 1995). A key element of the traumatization may be the humiliation of students in front of their classmates, a traditional practice in many public schools in the United States (Rothstein, 1984). Hyman (1995) and Hart and colleagues (1987) have characterized these experiences of punitive school discipline as psychological maltreatment.

OPERANT CONDITIONING AND SOCIAL LEARNING THEORIES

School Discipline as Ineffective Punishment

Teachers tend to not use positive disciplinary approaches with misbehaving students, preferring neutral or negative approaches that may best achieve their short-term objective of ending unwanted student behaviors (Brophy, 1996;Brophy & McCaslin, 1992; Furlong, Morrison, & Dear, 1994; also see Ringer, Doerr, Hollenshead, & Wills, 1993). Operant conditioning theory suggests that punishment- some sort of stimuli aversive to the individual receiving the punishment-as a consequence to actions will discourage the future use of those actions (see Thomas, 2005). Punitive approaches, however, may not be effective as deterrents or methods of eliminating unwanted behaviors, because teachers cannot control all of the conditions required for success. Teachers need to know what a particular student finds aversive to tailor an appropriate response to inappropriate behavior. The punishment needs to be timely, and it needs to be of the appropriate intensity.Teachers also should avoid forewarning the student of an impending punitive action (Bongiovanni, 1979).”[F]rorn an experimental point of view it would prove to be impossible for school personnel to administer an effective punishing stimulus” (Bongiovanni, p. 356). Even if effective in the short term, punishment may only temporarily halt unwanted behavior, not durably modify it (Bear, 1995). When discipline is not effective as punishment, unwanted behaviors are not discouraged, nor are new behaviors encouraged or taught, so no meaningful corrective experience takes place, and behavioral patterns will not be modified.

School Discipline as Positive Reinforcement for Misbehavior

Operant conditioning theory also holds that, although rewards for behavior may not appear as pleasant or positive to others, they may have the effect of increasing the problematic behavior that is the target of the intervention (Thomas, 2005). Unintentionally, school discipline may paradoxically reinforce students’ misbehaviors, especially with students who do not like or have little interest in school (Rutherford, 1978).These students may be motivated to find ways to be away from school, and suspension and expulsion may have the unintended consequences of promoting these students’ use of inappropriate behaviors to provoke disciplinary actions that will allow them to stay out of school (Costenbader & Markson, 1998).This may be especially true for students who are highly aggressive, hyperactive, or lacking in social skills (Atkins et al., 2002). Some students may see the time off from school as a relief from stressful or discouraging experiences in school (Hyman, 1997).These students may experience their time at home as an opportunity for unsupervised recreation, relaxation, and for some, misadventures in neighborhood streets (Neill, 1976). Also, when a student happily becomes the focus of attention when being disciplined by a teacher, or when a student receives praise from peers for the behavior that was displeasing to the teacher, he or she experiences social rewards that may defeat the deterrent effect of the punishment and may exacerbate misbehaviors (Doyle, 1990).

School Discipline as a Model for Aggression and Hostility

Hyman (1995) found that students with verbally hostile teachers may be more likely to act with peers in hostile ways and theorized that these students may have been taking on some of the behaviors exhibited by teachers. Social learning theory (see Thomas, 2005) supports the contention that children develop behavioral habits through observational learning. That is, they add a behavior to their repertoire that they see someone else perform or model. Teachers may have great influence with children seeking to acquire greater mastery and range in their interpersonal behaviors and those who may see the ways more coercive behaviors can help actors achieve their goals. The modeling of punitive discipline may unintentionally suggest to students that the use of aggressive and coercive actions is appropriate (Butchart, 1998; Hyman, 1990).

SOCIAL AND POLITICAL THEORIES

Alienation

Students may become alienated from school if the adults there are, in students’ experiences, insufficiently interested in them. Students may have very limited personal contact with adults during the school day. One estimate is that teachers and students spend less than 10 minutes each day in person-to-person interaction (Goodlad, 1983) .This has been described as a form of neglect- depriving students of personal contact and individualized interest, caring, or affection (Hart et al., 1987). A recent study of teachers coping with the disruptive behaviors of students found that teachers routinely distanced themselves from students whom they experienced as challenging or threatening (Cameron, Sheppard, & Odell, 2005). Sadly, these students may be most in need of increased personal contact with caring adults.

Using Hirschi’s social control theory, Hawkins andWeis (1985) conceptualized students’alienation from teachers as a lack of a social bond between students and school. The break is produced by teacher actions that students perceive as unfair, undemocratic, and non-reinforcing.These students are pessimistic about experiencing success in school and feel little incentive to adhere to the rules and norms of the school and classroom cultures. Students may also disengage from teachers, peers, and others, and from school altogether, if they see school discipline as inconsistent with important life tasks, values, and norms in their lives.These students may not understand or see the advantages in compliance with school rules that appear to be disrespectful or insensitive to their values. Thorson (1996) and Brantlinger (1991), through interviewing students about their views of discipline at school, heard students describing discipline as unfair, insensitive, and overreactive to situations that could not be helped. Rules may not be flexible enough to accommodate the pressing demands of some students’ lives, such as those students who are caregivers of younger siblings before they go to school and risk being late (Thorson). Another example is the prohibition against displays of aggression in school. Adolescents especially may believe that unless they respond aggressively to the challenges and threats of their peers, they may be more vulnerable to future attacks and lose face with their friends (see Andersen, 1999). In a study of interpersonal conflicts among girls in an urban high school (Cameron & Taggart, 2005), girls who had been involved in violence with other girls saw rules and the consequences for breaking them as much less important than taking an appropriately aggressive stand when threatened and avoiding being seen as a coward or “punk.”

Distancing on the part of teachers and other adults at school and rules and methods of enforcement that disregard important student values may be seen by students as a kind of personal betrayal and rejection and may result in a loss of trust and a sense of vulnerability and powerlessness in their relationships with teachers (Hyman, 1990).This disjuncture has lasting repercussions for students: a strong distrust and disengagement from the teacher and instruction, an avoidance of closeness with the teacher, or, for some, a preoccupation with regaining the trust and faith in the teacher (Hyman, 1990). Teachers who overrely on punitive disciplinary tactics in response to student misbehaviors may also create distance between themselves and their students, which may be experienced by students as rejecting, impersonal, and indifferent to them and their needs (Akom, 2001).

Also, when teachers do not understand or appreciate the meaning or importance of students’ behavior, they may be disapproving, distancing, and punitive with those students. This might be especially true when there are cultural differences between teachers and students (Noguera, 1995). Supporting this theory is a substantial body of literature demonstrating that students of color, especially African Americans, are disciplined disproportionately compared with white students and more severely for less serious and less violent infractions of school conduct codes (for example, Children’s Defense Fund, 1975; McFadden, Marsh, Price, & Hwang, 1992; Skiba, 2000, 2001; Skiba, Michael, Nardo, & Peterson, 2002; Skiba & Peterson, 2000).

When students believe that teachers are treating them insensitively, they may seek to punish the teachers by disrupting class and challenging rules (Stanley, 1998). Newmann (1981) found an association between student alienation and vandalism at school. Hyman (1995) found that the chief rationale of disciplined students for misbehaving in school was that they wanted to go after teachers who they believed had belittled them, shown them disrespect, or were disrespectful to their families or their culture. When teachers distance because they fear students and resort to discipline as a way of coping with their anxiety, frus\trated and angry students may retaliate by capitalizing on that fear and fighting to control activities in the classroom (Noguera 1995). Other students may withdraw from classroom activities and relationships with teachers as a passive-aggressive demonstration against those who appear to dislike them (Brantlinger, 1991; Stanley, 1998).

Disempowerment

A related theory, based on the work of Classer (1969), focused more explicitly on the power differential between teachers and students and the ways in which students may experience teachers as domineering and manipulative. A student may be forced to relate to teachers and other school personnel “in ways which emphasize his subordinancy and dependency” (Rothstein, 1984, p. 156). What may be experienced as assaults on personal autonomy may provoke resentment and self-protective resistance in students.Teachers may view these students more simply as misbehaving and inappropriately challenging of their authority (Stanley, 1998). Students need to be able to have and express some degree of power in the classroom. Instruction and classroom management practices that deny this may drive students toward expression of the need for power in self-defeating ways (Henry & Abowitz, 1998). The power imbalance between teacher and student may be exacerbated when some students receive more rewards and are empowered by teachers in ways that their peers are not, leading to conflicts, rejection among peers, and distrust between students and between students and teachers (McEwan, 1998).”Given the realities of many students’ lives outside of schools, as well as the quality of the activities and interactions that are countenanced by mainstream approaches to classroom management and the corresponding view of teaching within the school, we might well see as understandable the kind of ‘deviancy’ and ‘misbehavior’ that management strategies try to root out. Indeed, that sort of deviancy may make good sense, given the internal dynamics of classroom culture and the conditions within which many students live. Misbehavior might even be seen as resistance to authoritarianism masked as behavior management-a resistance to be valued if not encouraged” (Beyer, 1998, pp. 72-73).

School discipline may act as part of a larger organizational system that treats students as untrustworthy and incompetent, suggesting to them that they are best off following directions and conforming to expectations. This may have a diminishing effect on student’s developing autonomy and responsibility, as well as their capacities for independent thought. “The world enacted via mainstream understandings of classroom management is dominated by mistrust-the sense that students, like most of us,’need a taskmaster’if we are to function effectively in or outside of schools; that students must learn to be obedient, which will be facilitated if we can get them to think of others’ directions as their own, resulting in a kind of duplicity. In addition to needing to be led by others, this world is one in which students must be constantly watched and supervised, managed and cajoled into the proper courses of action. The result for students is a decided powerlessness, a ‘followership’ that often results in apathy and a withdrawal of their own interests and investments” (Beyer, 1998, pp. 64-65).

THE SIGNIFICANCE OF SCHOOL DISCIPLINE TO SCHOOL SOCIAL WORK PRACTICE

Greater awareness of how school discipline may be contributing to the difficulties of school children may help school social workers avoid overly restrictive, non-ecologically based problem definitions. Locating the source of a child’s difficulties solely within the child or linked only to family processes will likely limit practice effectiveness and may lead to a worsening of clients’ symptoms. The theories and research findings described here may help assessing social workers consider the multiple ways that school discipline may be experienced by children and how discipline may indirectly or directly relate to the difficulties the child is experiencing. Combined, these theories form a conceptual framework that may be used when considering organization-level and structural factors that must be weighed in a balanced, ecological approach to resolving young clients’ difficulties.

Determinations derived from the use of the framework logically lead to differential interventions for each student. For example, interventions based on an assessment of trauma might clearly be different from those derived from a determination that a student is bored at school and consciously provokes suspension through misbehavior. If an assessment indicates that a student is experiencing stigmatization and diminished self-image as an effect of discipline, that might suggest working with teachers and administrators to use positive disciplinary methods and to avoid humiliating the student in front of his or her peers. A student who expresses alienation from school might be helped by speaking with school personnel about the child’s need for more personal attention or, if relevant, increased sensitivity to the child’s cultural values and norms. A child suffering trauma-related symptoms would likely require more intensive, individual treatment by a social worker or other professional trained in the area.

The use of this framework may also guide school social workers in their efforts to work at the organization level to modify the school’s disciplinary philosophies, codes of conduct, and sanctioned disciplinary procedures and to introduce alternative methods. Alternatives cover a range of evidencebased approaches, including actively involving students in the development of rules of conduct for the school and the classroom; clearly articulating rules to students and enforcing them consistently; using instructional methods that maintain student involvement in exercises that present challenges at the appropriate level; using campaigns against bullying and disrespectful behaviors to improve school culture; using positive reinforcement on a regular basis; trying to avoid humiliating students in front of their peers; preventing distancing between teachers and students; and providing alternatives to traditional disciplinary actions such as suspension, conflict resolution services, drop-in centers and discussion groups, and in- school suspension programs staffed with tutors and counselors (see Bear, 1995; Furtwengler, 1990; Moles, 1990; Olweus, 1993; Sugai & Horner, 1999; Walker, Colvin, & Ramsey, 1995).

Perhaps as important, social workers should advocate to eliminate harmful, punitive, and unfair disciplinary practices in schools, as called for in the NASWs Standards for School Social Work Services (National Association of Social Workers, 2002). Advocacy at the school district level, educating school district administrators and school boards about the potential harm of conventional disciplinary practices, recommending alternatives, and offering training may help prevent the discouragement, upset, and estrangement experienced by many children disciplined at school.

Social workers know well that teachers, administrators, and others working with youths in schools perform critical and courageous tasks under what can be extremely challenging circumstances. Discipline is necessary for their work and for the safety of all school children. Social workers also must realize, however, that common disciplinary practices can be harmful to children and that they must address this problem to effectively help those who may be negatively affected. Additional research and greater awareness of the potential for harm of school disciplinary practices is needed to reform schools’ disciplinary programs so that order, learning, and child safety and well-being are all valued and protected qualities of the school environment.

The modeling of punitive discipline may unintentionally suggest to students that the use of aggressive and coercive actions is appropriate.

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Mark Cameron, PhD, MSSW, is associate professor, Department of Social Work, Southern Connecticut State University, 101 Famhatn Avenue, New Haven, CT 06517; e-mail:. Sandra M. Sheppard, MSW, is a doctoral candidate, School of Social Work, State University of New York at Buffalo.

Accepted June 20, 2005

Copyright National Association of Social Workers, Incorporated Jan 2006

Threats of Violence By Students in Special Education

By Kaplan, Sebastian G; Cornell, Dewey G

ABSTRACT:

We compared threats of violence made by K-12 students in special education (120 cases) or general education (136 cases) in schools that were implementing threat assessment guidelines for managing student threats of violence (Cornell, Sheras, Kaplan, McConville, Posey, Levy-Elkon, et al., 2004; Cornell & Sheras, in press). Students in special education made disproportionately more threats, as well as more severe threats, than peers in general education. Students classified as emotionally disturbed (ED) exhibited the highest threat rates. Nevertheless, use of school suspension as a disciplinary consequence for threats was consistent for students in special and general education, and few students were expelled. Our findings support the use of threat assessment to manage threats of violence by students in special education.

Based on its study of school shooting incidents, the Federal Bureau of Investigation (FBI;OToole,2000)advisedschoolsto abandon efforts to develop profiles of potentially violent students and instead to focus intervention efforts on students who communicate explicit threats of violence. Similarly, a joint report of the U.S. secret Service and the U.S. Department of Education recommended that schools establish threat assessment teams (Fein, Vossekuil, Pollack, Borum, Modzeleski, & Reddy, 2002). In response to these recommendations, the Virginia Youth Violence Project atthe University of Virginia developed detailed practice guidelines for schools to use in conducting threat assessments (Cornell & Sheras, in press). These guidelines were successfully field-tested in 35 schools for one academic year (Cornell, Sheras, Kaplan, McConville, Posey, Levy-Elkon, et al., 2004). The purpose of the present study is to compare the threat behaviors of students receiving special education services and students in general education programs in schools that use these threat assessment guidelines.

Students receiving special education services incur a disproportionate number of school discipline infractions (Skiba, Peterson, & Williams, 1997; Wright & Dusek, 1998). For example, Skiba et al. found that 38.6% of a middle school’s office referrals for discipline violations were for students in special education, even though only 15.6% of the school’s population received special education services. Wright and Dusek found that in a sample of 230 discipline referrals for aggression collected over a two-year period in an elementary school, an average of 26% of students in special education had at least one referral for aggression per year versus only 8% of students in general education.

Students with disabilities are also more likely to receive out- of-school suspensions for endangering others and bringing weapons to school than are nondisabled peers (Rose, 1988). The 1994 Gun-Free Schools Act mandated that schools implement a one-year expulsion, with provisions for a shortened exclusionary period on a case-by- case basis, for any student in possession of a weapon on school grounds. Although the mandated federal report does not include the number of students with disabilities who are expelled, it does provide data on the disabil ity status of those who receive a shortened expulsion. During the 2000-2001 school year, students with disabilities represented 28% of the shortened expulsions under the act (U.S. Department of Education, 2003).

Morrison and D’lncau (1997) found that students with disabilities received recommendations for expulsion at nearly twice the expected rate over a two-year period in a school district that implemented a zerotolerance policy. The authors attributed several risk factors to the 158 students recommended for expulsion, including below-average grades and achievement scores and truancy. In particular, records of students with disabilities often identified chronic emotional and family problems beginning at early ages. Although the authors did not conclude that the students with disabilities were unfairly treated under the school’s discipline policy, they stated that these students’ overrepresentation in the sample recommended for expulsion should not come as a surprise, given the academic and emotional challenges they faced.

Furthermore, McFadden, Marsh, Price, and Hwang (1992) reported differences in the administration of punishment to students with and without disabilities for equivalent offenses. A higher proportion of students with a disability (56%) received corporal punishment for fighting than students without a disability (36%). In fact, corporal punishment was the most common consequence for misbehavior by students with disabilities (40%). Students with disabilities (18%) were less likely to receive in-school suspension for defiance of school authority than were nondisabled peers (45%). The authors concluded, “Commission of the most common school offenses would more likely result in corporal punishment for the handicapped and internal suspension for the non-handicapped” (p. 247).

Zero-tolerance policies are intended as a means of protecting students from threatening or potentially dangerous behavior, but in practice such policies can result in harsh punishment for seemingly minor infractions such as accidentally bringing a plastic knife or toy gun to school (Skiba & Peterson, 1999). For instance, a second grader was suspended and sent to an alternative school for one month for bringing to “show and tell” a watch attached to a one-inch pocketknife (Skiba & Peterson, 1999). Another school division implemented a zero-tolerance policy for all use of threatening statements but had to repeal the policy when it led to 50 suspensions in a period of six weeks, largely of students from kindergarten through third grade (Zernike, 2001). The widespread use of zero-tolerance policies poses particular risk for students whose disabling condition might predispose them to engage in impulsive behavior or make rash statements that are interpreted as threats.

Special Education Classification

Among students in special education, several groups appear to experience higher rates of disciplinary violations. Students who suffer from an emotional disturbance are particularly at risk for discipline violations (McFadden et al., 1992; Conroy, Katsiyannis, Clark, Gable, & Fox, 2002) and often receive harsh punishments for their infractions (Skiba et al., 1997). Research has also shown that students who receive special education services for learning disabilities (LD) also have elevated rates of disciplinary infractions (McFadden et al., 1992; Skiba et al., 1997; Sprague, Walker, Stieber, Simonsen, Nishioka, & Wagner, 2001). Children diagnosed with attention deficit-hyperactivity disorder (ADHD), who may receive services under the other health impaired (OHI) classification, have significantly greater rates of disciplinary violations, suspensions, and expulsions than other students (Barkley, Fischer, Edelbrock, & Smallish, 1990; Murphy & Barkley, 1996). Although these studies identify special education classifications with a higher rate of disciplinary violations, no study has investigated the frequency of threats of violence and the associated disciplinary consequences for these threats.

Discipline and Special Education

What is an appropriate response to a student in special education who has made a threat of violence? According to the Individuals with Disabilities Education Act (IDEA Amendments, 1997) and the Office of Special Education Programs (OSEP), disciplinary decisions for students in special education require that “there must be a balanced approach to the issue of discipline of students with disabilities that reflects the need for orderly and safe schools and the need to protect the right of students with disabilities to a free and appropriate public education” (OSEP, 1997).

Difficulties in maintaining a balance between school safety and the student’s right to a free and appropriate public education have led to confusion and frustration for many school administrators in deciding on appropriate disciplinary consequences for students in special education (Skiba, 2002;Taylor& Baker, 2002). A student with a disability cannot receive standard disciplinary consequences for behavior that is a manifestation of his or her disability. Skiba cited the lack of available measures for the purpose of manifestation determination decisions as a flaw in the IDEA disciplinary requirements. Skiba observed that some school authorities feel that IDEA deprives “schools and school districts of tools-school suspension and expulsion-needed to ensure school discipline” (p. 87).

Threat Assessment

Threat assessment is an approach to violence prevention originally developed by the U.S. secret Service based on studies of persons who attacked or threatened to attack public officials (Fein, Vossekuil, & Holden, 1995). Threat assessment has evolved into a standard approach to analyze many different dangerous situations, such as threats of workplace violence, and more recently, school violence (Reddy, Borum, Berglund, Vossekuil, Fein, & Modzeleski, 2001 ). A threat assessment is conducted when a person (or persons) threatens to commit a violent act or engages in behavio\r that appears to threaten an act of violence. Threat assessment is a process of evaluating the threat and the circumstances surrounding the threat to uncover any facts or evidence that indicate the threat is likely to be carried out.

Threat assessment differs from a zerotolerance approach because of its emphasis on the context and meaning of the student’s behavior. For example, under a zero-tolerance approach, a student would be disciplined for any possession of a weapon, regardless of the reason or circumstances of the behavior. Under a threat- assessment approach, however, school authorities would consider the reason why the student had a weapon, the danger posed by the weapon, and what the student intended to do with it. Threat assessment distinguishes toy guns from real guns and unintentional possession of a weapon from use of a weapon to threaten or intimidate someone (Cornell & Sheras, in press). Threat assessment may be particularly relevant for students in special education who make threats of violence, because administrators are guided to make informed disciplinary decisions based on a careful review of the details and context in which the threat occurred. In contrast, a zero-tolerance policy would impose harsh penalties without consideration of the context and meaning of the behavior, and it thus runs the risk of punishing a disabled student for behavior that is a manifestation of his or her disability.

A literature search identified only one study reporting the frequency of threats made by students receiving special education services. Ryan-Arredondo, Renouf, Egyed, Doxey, Dobbins, Sanchez, et al. (2001 ) reported on the implementation of a risk assessment instrument in the Dallas Independent School District. The authors examined the results of 139 threats, of which 27% were made by students receiving special education services. Presumably, the proportion of threats made by students receiving special education services was higher than the proportion of such students in the school population, although this comparison was not reported. Of those students receiving special education services, 42% were classified ED and 34% LD.

The current study addressed four main questions: (1) Do students in special education make threats more frequently than students in general education? (2) Do students in special education make different kinds of threats than students in general education? (3) Do students in special education and general education receive different disciplinary consequences for their threats? (4) How do students in special and general education differ in their postthreat behavior?

Method

Participants

The core sample for this study was obtained from two school divisions participating in the original demonstration project to field-test threat assessment guidelines (Cornell, Sheras, Kaplan, Levy-Elkon, McConville, McKnight, et al., 2004). These school divisions consisted of 35 schools (22 elementary, 6 middle, 4 high, and 3 alternative schools) with a total student population of 16,273 students, of which 71% were Caucasian, 22% African American, and 7% other groups. Approximately 26% of the students were eligible for free or reducedprice meals. The two school divisions together served a small city and the surrounding county in central Virginia with a combined population of 129,000.

As described in detail elsewhere (Cornell, Sheras, Kaplan, Levy- Elkon etal., 2004; Cornell, Sheras, Kaplan, McConville et al., 2004), each school had a threat assessment team consisting of the school principal or assistant principal who led the team, the school’s resource officer or a liaison police officer, a school psychologist, and a school counselor. A threat was defined as any communication of intent to harm someone. Threats could be spoken, written, or expressed through gestures or possession of a weapon. Threats could be made directly to an individual or expressed to third parties. Whenever school authorities learned that a student had threatened to harm someone, the team leader began a threat assessment and documented the case on a standard form (described in a subsequent section).

The 35 team leaders reported 188 threats of violence during the school year. As shown in Table 1, boys made 78% (n = 146) of the threats and girls made 22% (n = 42). In addition, Caucasian (55%) and African American (43%) students made nearly all threats; a small number were made by students of Hispanic (1 %) and other (1 %) ethnic backgrounds.

To ensure a sufficiently large sample of threats from students receiving special education services, we supplemented the core sample with 68 cases collected over the next two years from the two original school divisions and two additional Virginia school divisions that received threat assessment training. These additional divisions consisted of 14 schools, of which 6 (1 high school, 3 middle schools, and 2 elementary schools) participated in reporting of threats. In these school divisions, 70% of the students were Caucasian, 28% were African American, and 2% were from other ethnic backgrounds. Thirty-nine percent of students received free and reduced-price lunch.

After the initial field-test year, schools were not required to document and report all student threats to the researchers, and as a result, some school principals did not participate in the reporting process. For this reason, the threats obtained in the supplemental sample were not included in analyses intended to measure the rate of threats relative to the general school population. The supplemental cases (also in Table 1 ) involved 53 boys and 15 girls, with an ethnic breakdown of Caucasian (68%), African American (28%), Hispanic (3%), and other (1%) ethnic backgrounds.

Measures

Threat ratings. Threats were coded for seriousness and content. On receiving a report of a student threat of violence, the team leader interviewed the student who made the threat and all available witnesses, guided by a standard set of questions. The team leader then prepared a written summary of the threat and completed a checklist of actions taken in response to the threat (Cornell & Sheras, in press). Based on this initial investigation, the team leader made an important distinction between threats that are serious, in the sense that they pose a continuing risk or danger to others, and those that are not serious, because they are readily resolved and do not pose a continuing risk. Threats that were not serious and were readily resolved were classified as transient threats. Serious threats were called substantive threats.

Transient threats are defined as behaviors that can be readily identified as expressions of anger or frustration-or perhaps inappropriate attempts at humor-but that dissipate quickly when the student has time to reflect on the meaning of what he or she has said. The most important feature of a transient threat is that the student does not have a sustained intention to harm someone. In contrast, substantive threats represent a sustained intent to harm someone beyond the immediate incident during which the threat was made. If there is doubt whether a threat is transient or substantive, the threat is regarded as substantive. Substantive threats were further classified as serious if they involved a threat to assault or beat up someone and very serious if they involved a threat to kill, use a weapon, severely injure, or rape someone.

Threat content was coded by the researchers with six categories: threats to kill, hit, shoot, or stab, vague threats in which the intended action was unclear (e.g., “you’d better watch your back”), and other threats (e.g., bomb threats) that did not fall into one of the first five categories.

Follow-up information. Discipline records were available for 184 out of 188 cases in the core sample, but not for the supplemental sample. Because schools used somewhat different discipline categories, we classified infractions into four categories: violence/ weapons (e.g., fighting, battery, weapon possession), disorderly conduct(e.g., disrespect, using obscene language or gestures), bullying (e.g., bullying, threats, harassment), and other (e.g., tardiness, truancy, vandalism, drug/ alcohol use). Schools also reported whether the student received a suspension (or expulsion) from school for the threat.

For cases in the core sample, research assistants conducted follow-up interviews with principals at the end of the school year. Principals were asked to rate each student’s behavior as improved, about the same, or worse after the threat. Principals provided ratings on 94% of cases, omitting cases involving students who had moved, transferred, or for some other reason left school. Principals also provided ratings (improved, same, or worse) of the students’ relationship with their victims following the threat in 67% of cases.

TABLE 1

Demographic Information

Procedure

All schools received approximately six hours of training on the threat assessment guidelines (Cornell, Sheras, Kaplan, Levy-Elkon, et al., 2004; Cornell, Sheras, Kaplan, McConville, et al., 2004). A research assistant assigned to each school provided consultation on the guidelines throughout the school year. School principals reported cases by completing an electronic form at a secure Web site maintained by the researchers. This form served the dual purpose of providing schools with printed documentation of their response to a student threat and informing researchers of a new case so they could follow up with the principal. The Web site form collected demographic information (i.e., age, gender, grade, race) on the student who made the threat and the intended threat victim and provided space for a description of the threat incident and the classification of the threat as transient or substantive. The form also presented a checklist of actions taken in response to the threat (e.g., suspending the student, contacting parents).

For \the core sample, the research assistant conducted two follow- up interviews with the principals-one at the end of the school year and another the following fall. The average follow-up period from the date of the threat incident to the interview with the principal at the end of the school year was 148 days (range 3 to 282 days). The second follow-up interview occurred an average of 424 days after the threat incident. In the follow-up interviews, researchers asked the school principals to describe their response to the threat incident, whether the student carried out the threat, and whether the student’s relationship with the threat recipient was improved, about the same, or worse than prior to the threat. They were asked to rate the student’s overall behavior at school after the incident as improved, about the same, or worse than prior to the threat.

Results

As shown in Table 1, preliminary analyses found no significant differences between the core and supplemental samples in gender, race, special education status, special education classification, and school level (elementary, middle, and high). Table 1 also contains demographic information for the core, supplemental, and full samples. For the full sample, males committed 78% of threats versus 22% by females. Caucasian (58%) and African American (40%) students committed nearly all threats, with only 2% committed by Hispanic students and 1% by students of other ethnic backgrounds. Grade placement of students committing threats ranged from kindergarten to twelfth grade, with 44% occurring in elementary school, 34% in middle school, and 23% in high school.

Students in general education programs made 53% of threats versus 47% by students in special education. Of those students receiving special education services who committed threats, one-half were classified as ED and onefourth as LD, with the remaining students having OHI (16%) or other (8%) classifications. Those students with other classifications included six with mental retardation, two receiving solely speech and language services, one with autism, and one with developmental delay.

Threat Rates of Students in General and Special Education Programs

The first question investigated whether students in special education exhibited higher threat rates than general education students. These analyses were conducted on the core sample because it represented all of the threats reported to the participating schools for one school year and because data were available for the size of special education population in these schools. Students in special education committed 49.5% of threats versus 50.5% by students in general education.

Students receiving special education services did not make threats at similar rates. Students with an ED classification were most likely to make threats relative to other students in special education programs. Specifically, although students with an ED classification made up only 10% of the special education population in these schools, they accounted for 50% of the threats made by the special education population. In contrast, students with an LD classification made up 37% of the special education population, yet they only accounted for 23% of the threats made by students receiving special education services.

Students with OHI classifications made up 14% of the special education population and accounted for a similar percentage (17%) of the threats made by students in special education. Students with classifications other than ED, LD, and OHI committed disproportionately fewer threats than would be expected; they constituted 39% of all students receiving special education services, but committed only 11 % of the threats made by students in special education.

Comparisons with full school enrollment of the four special education classification groups also revealed disproportionate percentages, particularly for students receiving ED services. Students with an ED classification constituted only 2% of the student enrollment but made one-fourth (46 of 188) of the threats in the core sample. The percentage of students receiving LD services that made threats (21 of 188, 11%) was closer to their proportion within the student population (6%). Students classified as OHI made 9% (16 of 188) of threats and comprised 2% of the student enrollment. The number of students receiving services for other disabling conditions who made threats (10 of 188, 7%) was consistent with the proportion of these students in the core sample (5%).

Of the 188 reported threats, school officials judged 70% to be transient and 30% substantive. Table 2 shows the threat rate for general and special education students, as well as for ED, LD, and OHI classifications, in threats per 1,000 students. Too few students with other classifications were available to enable calculation of a threat rate. We compared threat rates for students in special education using chi-square and z-test formulas from Glass and Hopkins (1996). Students in special education exhibited a significantly higher total threat rate than general education peers, z (1, n = 188) = 4.33, p

There were no statistical differences in threat content between students in general and special education, X^sup 2^ (5, n = 169) = 2.81, p > .70. Overall, the most frequent threat was a threat to hit (41 %), followed by an unspecified, vague threat (15%, e.g., “I’m going to hurt you”) and a threat to kill (15%).

TABLE 2

Threat Rates

Students receiving ED services exhibited significantly higher total threat rates than students receiving LD or OHI services, X^sup 2^ (2, n = 83) = 17.30, p.

In follow-up to the threat rate differences between students in general and special education, we conducted a hierarchical logistic regression analysis to examine whether special education status improved the prediction of principal threat ratings beyond demographics and threat content (see Table 3). At Step 1 we entered student age, gender, race, and threat content, which accounted for 19% of the variance in principal ratings. Age and gender were both statistically significant predictors in this model. At Step 2, special education status accounted for an additional 4% of the variance.

Disciplinary Infractions

The next question considered whether students in special education who made threats committed more disciplinary infractions throughout the school year than students in general education. These analyses were limited to the core sample because disciplinary data were not available for the supplemental sample.

A multivariate analysis of variance (MANOVA) comparing students in general and special education on the four disciplinary categories was statistically significant, f (3) = 5.59, p

TABLE 3

Hierarchical Logistic Regression Analysis for Principal Threat Ratings

A follow-up multivariate analysis of covariance (MANCOVA) tested differences between general and special education students on disciplinary infractions for the 2001-2002 school year using age, threat type, gender, and race as covariates. As shown in table 5, special education students exhibited significantly higher violent and disorderly conduct infractions. General and special education students no longer differed in bullying infractions.

The next analyses considered whether schools administered more severe disciplinary consequences to students in special education than students in general education within the full sample. No statistical differences existed in school use of suspension between the core and supplemental samples. School expulsions were not analyzed because there were only three cases. Students receiving special education services were about as likely to be suspended from school for makinga threat (36%) as students in general education (31%). For those students who received a suspension, we conducted a two-step hierarchical regression analysis to determine whether special education status would predict length of suspension beyond age, gender, race, and seriousness of threat (transient or substantive). As shown in Table 6, age and principal ratings of threat severity were statistically significant predictors of length of suspension at Step 1. Mean length of suspension for substantive threats was 4.7 days (SD = 3.35) versus 2.5 days (SD = 2.45) for transient threats. However, special education status did not significantly con\tribute to the prediction of number of days suspended.

Postthreat Behavior

The next analysis compared behavioral changes of threat perpetrators after the threat incident. School officials were more likely to rate students in general education (53%) than in special education (33%) as exhibiting improved behavior, and more likely to rate special education (28%) than general education (8%) students as displaying worse behavior following the threat, X^sup 2^ (2, n = 188) = 13.6, p

We then conducted a two-step hierarchical regression analysis to determine whether special education status was a significant predictor of postthreat behavior beyond student age and threat severity. At Step 1 we entered age and threat severity, which together significantly predicted principal ratings of postthreat behavior, F (2) = 3.87, p

TABLE 4

Comparison of Discipline Infractions Between Students in General and Special Education

TABLE 5

Comparison of Discipline Infractions Between Students in General and Special Education Controlling for Age, Gender, Race, and Threat Type

Another important question related to postthreat behavior concerns whether any of the threats were actually carried out. For the core sample, we conducted interviews with school principals during the final weeks of the school year and during the following fall. According to the school principals, none of the 188 threats of violence were carried out (see Cornell, Sheras, Kaplan, McConville, et al., 2004 for further information).

TABLE 6

Hierarchical Regression Analysis for Comparison of School Use of Suspension for Threats Made by Students in General Versus Special Education

Discussion

Threats of violence appear to be more prevalent among students in special education than general education. Students in special education made nearly half of all threats reported to school principals, even though students in special education represented only 17% of school enrollment. It should be noted that these were threats that came to the attention of school authorities and do not represent all threats that might have occurred. Although no previous research has compared students in special and general education on threats of violence, our findings are consistent with those of previous reports that find elevated rates of disciplinary infractions among students in special education (Skiba et al., 1997; Wright & Dusek, 1998). These results support further attention to the issue of threats of violence by students who receive special education services.

Students receiving ED services made more threats than any other group. The high rate of threatening behavior by these students is not surprising in light of the criteria used to identify a student as eligible for services under this category. The federal definition of an emotional disturbance recognized by IDEA involves a condition that is present over a long period of time, adversely affects academic performance, and involves one of the following:

* An inability to learn that cannot be explained by intellectual, sensory, or health factors.

* An inability to build or maintain satisfactory relationships with peers and teachers.

* Inappropriate types of behavior or feelings under normal circumstances.

* A general pervasive mood of unhappiness or depression.

* A tendency to develop physical symptoms or fears associated with personal or school problems (Hallahan & Kauffman, 2000, p. 250).

Students receiving services for an ED classification likely experience relationship difficulties and interpersonal conflicts, and they may use inappropriate strategies for dealing with conflicts such as threatening others. As a result, IEP teams could interpret a threat of violence as a symptom of the child’s emotional disturbance.

However, schools must balance the rights of a student classified as ED with school safety. An IEP team has additional options beyond standard disciplinary techniques if a threat is determined to be a manifestation of a student’s disability. A school can place a student with a disability in an interim alternative educational setting (IAES) for up to 45 days if the student possesses weapons or drugs or if “substantial evidence” exists that the student is a danger to self or others (Skiba, 2002). Schools may place the student in an IAES without parental consent in response to weapons or drug violations. However, the school must obtain parental consent for an IAES placement for dangerousness, initiate an expedited due process hearing, and petition a hearing officer (Skiba, 2002). Parents also have the right to appeal any decision that constitutes a change of placement for students with disabilities, although the change in placement can proceed during the appeals process. Furthermore, the school may procure a court injunction to remove a student who is deemed dangerous and whose parents refuse to comply with the removal process, regardless of IDEA protection (see Skiba, 2002, for review).

The high rate of reported threats by students with ED classifications could be a result of their comparatively high rate of disciplinary violations. Students may be more concerned about a threat from a student with an ED classification than a student in general education without a similar history of infractions or peer conflict. Threat recipients or witnesses might perceive a student with an ED classification as more likely to carry out a threat and therefore might be more likely to report the threat to school authorities. Similarly, teachers may feel less able to manage a threat from a student with a history of disciplinary problems.

Students in special and general education exhibited no significant differences in what they threatened to do. This finding is important in light of the significantly higher rates of substantive threats for students in special education. The threat assessment guidelines direct school authorities to place more weight on the context and meaning of the threat than the content of the threat (Cornell & Sheras, in press). For example, threats to kill or shoot someone were frequently judged to be transient threats (Cornell, Sheras, Kaplan, McConville et al., 2004), despite the extreme content of the threat, if it was clear from the context that the student did not mean to carry out the threat.

The guidelines indicate that if the context or meaning of the threat is not clear, a threat should be classified as substantive. Cornell, Sheras, Kaplan, McConville et al. (2004) found that 30% of the 188 threats collected during the 2001-2002 school year were substantive and required more extensive intervention and follow-up. The higher rate of substantive threats by students in special education suggests that school authorities took these threats more seriously. Perhaps students receiving special education services had a more extensive history of violent behavior that increased the likelihood of a principal judging their threats to be substantive. For a more detailed discussion on how schools responded to both transient and substantive threats, please see Cornell, Sheras, Kaplan, McConville et al. (2004).

Students in special education who made threats committed more disciplinary infractions over the course of the 2001-2002 school year than peers in general education. Differences between the two groups also existed for infractions involving violence and weapons, disorderly conduct, and bullying. These results are again consistent with the Skiba et al. (1997) study involving office referrals. However, future research could compare disciplinary infractions between students in special education who do and do not make threats to assess whether the threat group represents a more challenging cohort within the student population.

In light of previous studies, it was surprising that students receiving special education services were not more likely to incur an external suspension than students in general education, or that the lengths of suspensions did not differ between groups. Several studies have identified a disproportionate number of students in special education receiving suspensions (Cooley, 1995; Leone, Mayer, Malmgren, & Meisel, 2000) and other harsh consequences such as corporal punishment (McFadden et al., 1992), even for relatively similar infractions such as endangering others and weapons violations (Rose, 1988). Principals in our study did not appear to apply disproportionately harsh consequences to students in special education for behavior comparable to that of general education students. It is possible that with the threat assessment guidelines, the principals were able to avoid the disproportionate disciplinary consequences found in other studies.

Study Limitations

This study was limited to a sample of schools that were implementing a new procedure for managing student threats of violence. There was no comparison group of schools using a different procedure, so it is not possible to conclude that the outcomes observed in this study were attributable to the use of threat assessment guidelines. The original study was a demonstration project to field-test threat assessment guidelines and show that this approach was a viable procedure and therefore should be followed up with a controlled study (Cornell, Sheras, Kaplan, McConville et al., 2004). Because the schools were participating in the field-test project, it was possible to gather data that otherwise would not be available on threats of violence by students in special education.

Any study of student threats is limited by the nature of threat reporting. This study only examined threats that were reported to school authorities, and undoubtedly there are student threats that never come to the attention of school personnel. Cornell and Loper (1996) reported results from a survey of 10,909 students (g\rades 7, 9, and 11 ) in which more than one-fourth of students replied “yes” to the statement “Someone threatened to hurt you at school in the past 30 days.” Singer and Flannery (2000) found that more than onequarter of elementary school students and more than one-third of high school students reported threatening someone within the past year. It would be useful in future studies to study the incidence of student threats and the distinguishing characteristics of threats that are reported to school authorities. It would also be useful to gather more information on teacher and student perceptions of threats and how they judge the seriousness of a threat.

Conclusion

Can a threat assessment approach reduce the incidence of exclusionary discipline practices and disproportionately harsh discipline among students receiving special education services? This study cannot provide a conclusive answer to this question, but the results suggest that threat assessment is worthy of further study. It is possible that structured guidelines that emphasize the context and meaning of a threat over the content of the threat may be helpful to school authorities in responding to threats by students in special education.

It may be particularly useful to compare schools employing threat assessment with schools following a zero-tolerance approach. Skiba and Peterson (2000) cautione’d that a zero-tolerance environment in schools would clash with IDEA principles and provisions. In particular, IDEA emphasizes positive behavioral interventions for disruptive behavior and increased instructional inclusion of special education students, whereas a zerotolerance policy takes the opposite approach. Skiba and Peterson argued that “without general reform of school discipline practice, increased instructional inclusion for students with emotional and behavioral problems may lead to increased exclusion when those students engage in disruptive behavior in general education settings” (p. 340).

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Sebastian G. Kaplan & Dewey C. Cornell

University of Virginia

NOTES

The authors, with the Programs in Clinical and School Psychology, Curry School of Education, University of Virginia, thank Amherst County, Albemarle County, Appomattox County, and Charlottesville City schools for their participation in this study and colleagues on the Virginia Youth Violence Project for their assistance throughout this project. This study was supported by a grant from the Jessie Ball DuPontfund.

Address inquiries concerning this article to Sebastian G. Kaplan, Programs in Clinical and School Psychology, Curry School of Education, University of Virginia, 405 Emmet Street, Charlottesville, Virginia 22904-4270. Electronic mail may be sent to sgk4j@virginia. edu.

Copyright Council for Children with Behavioral Disorders Nov 2005

Infected Prostitute Back in Jail: Judge Gives Longer Term to HIV-Positive Woman Who Has Multiple Arrests

By Rick Armon, The Akron Beacon Journal, Ohio

Jan. 12–CANTON — Leah Marie Blackburn first got busted for prostitution in Stark County more than four years ago.

Then she got picked up again. And again.

Along the way, the 35-year-old woman learned she was HIV positive. But that — along with stints in jail — didn’t stop her from trying to sell her body for sex.

Blackburn, 5-foot-7 and 231 pounds, was arrested in February 2005 and sentenced to six months in state prison on a more severe felony charge of loitering to engage in solicitation after a positive HIV test. Shortly after being released last year, she was arrested again on the same charge.

On Wednesday, Common Pleas Judge John G. Haas sentenced her to nine months in prison.

Blackburn, whose last known address was in Massillon, offered no comment in court. Neither did Haas — other than noting her lengthy rap sheet.

In both felony cases, police said Blackburn was stopping vehicles in Canton in an attempt to drum up business. Instead, she was picked up by police.

Stark County authorities said it’s uncommon for local prostitutes to test positive for HIV, the virus that can lead to AIDS.

“It is not prevalent but it’s getting worse,” said Canton police Sgt. Victor George, a member of the vice squad. “As time goes on, we’re finding more and more people in prostitution have hepatitis and HIV.”

Last summer, the city experienced a syphilis outbreak among area prostitutes and their customers.

“That was a major issue and continues to be a concern for us,” said Robert E. Pattison, city health commissioner.

Each time someone is arrested, he or she is tested for disease. The Health Department also does outreach with prostitutes to try to test and treat them for illness, Pattison said. But he and George said the prostitutes don’t stop even after testing positive for disease.

“Typically you see them back on the street,” George said. “There’s no real deterrent for stopping them. It’s really a revolving door.”

Pattison estimated that there are about 300 people with HIV living in the county, and another 200 have AIDS.

“We would caution anybody about having sex with people that they don’t know the status of,” he said.

Rick Armon can be reached at 330-996-3569 or [email protected]

—–

Copyright (c) 2006, The Akron Beacon Journal, Ohio

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].

Insect spray may lower testosterone levels in men

By Charnicia E. Huggins

NEW YORK (Reuters Health) – While infertility may be caused
by a number of factors, new study findings suggest that
exposure to nonpersistent, or short-lasting, insecticides may
play a role in male infertility.

“Environmental exposure to chlorpyrifos or its metabolite
(TCPY) may be associated with reduced levels of circulating
testosterone in adult men,” lead study author Dr. John D.
Meeker, of the University of Michigan, Ann Arbor, told Reuters
Health. “A decline in testosterone throughout a population
could potentially lead to adverse reproductive health
outcomes,” he added.

Until 2000, chlorpyrifos was one of the most common
insecticides used in homes. The Environmental Protection Agency
restricted its residential use to reduce children’s exposure to
the chemical after research revealed it can affect the central
nervous system. Just one year earlier, however, up to 19
million pounds of the chlorpyrifos were used in the United
States, and recent investigations suggest that individuals
still experience environmental exposure to the substance,
despite EPA restrictions.

The Second National Report on Human Exposure to
Environmental Chemicals found that more than 90 percent of men
had detectable levels TCPY in their urine.

In a previous report, Meeker and his colleagues found that
higher levels of 1-naphthol (1N) in men’s urine are associated
with decreased sperm concentration and motility and increased
DNA damage in sperm cells. 1N is a breakdown product of
carbaryl, a lawn and garden insecticide known as Sevin, and the
compound naphthalene, which is found in cigarette smoke, diesel
fuel and other combustion byproducts.

Meeker and his colleagues from the Harvard School of Public
Health in Boston and the Centers for Disease Control and
Prevention in Atlanta explored the association between TCPY and
1N, and reproductive hormone levels in 268 men who were
recruited at an infertility clinic between 2000 and 2003.

Men with higher urine levels of TCPY and 1N had lower
levels of the sex hormone testosterone, the researchers report
in the journal Epidemiology. The association with TCPY was
dose-dependent, such that testosterone levels decreased along
with increasing levels of TCPY.

Higher TCPY levels were also associated with a decreased
free androgen index, a marker of lower testosterone
concentrations, the report indicates.

“Although the decrements in testosterone related to TCPY
were relatively small,” Meeker acknowledged, “they may be of
public health concern because of widespread human exposure
among men.”

The researchers also found some evidence that higher TCPY
and 1N levels may be associated with decreased levels of
luteinizing hormone and a decreased free androgen index, but
more studies are needed to confirm this finding.

If TCPY and 1N are associated with decreased levels of both
testosterone and luteinizing hormone, the hypothalamus and the
pituitary gland, rather than the testes, may be involved in the
mechanism by which certain pesticides affect sperm quality,
Meeker speculates. “But there are several other potential
mechanisms as well,” he said.

According to Meeker, “This is the first human evidence of
an association between chlorpyrifos or its metabolite (TCPY)
and testosterone levels, so other studies would be needed to
substantiate our findings.”

SOURCE: Epidemiology, January 2006.

Berlin relives assassination of top Nazi in Prague

By Louis Charbonneau

BERLIN (Reuters) – More than 60 years ago, a group of Czech
and Slovak exiles parachuted into their Nazi-occupied homeland
and assassinated SS-Obergruppenfuehrer Reinhard Heydrich, the
man known as the “Butcher of Prague.”

For the first time since the end of the World War Two, a
German museum is offering a close look at “Operation
Anthropoid,” the codename for the only successful assassination
of a member of Adolf Hitler’s inner circle.

Michal Burian of the Military Institute of Prague, which
presented the exhibition in the Czech capital before it moved
to Berlin, says the assassination ranks among the most
important moments of the last century and is far more than a
footnote.

“The assassination is an ancient tragedy. You can find
everything in this story — bravery, love, betrayal, death. In
my opinion, it is one of the most interesting stories of the
20th century,” he said.

The Heydrich assassination took place on May 27, 1942, on a
quiet street in the Prague suburb of Kobylisy. Two young men —
a Czech and a Slovak — ambushed Heydrich’s black Mercedes-Benz
convertible as he was on his way to Prague’s Hradcany Castle.

Slovak Josef Gabcik wanted to shoot Heydrich, but his Sten
submachinegun jammed at the crucial moment. Heydrich was about
to shoot Gabcik with his pistol when 29-year-old Czech Jan
Kubis lobbed a modified anti-tank grenade at the vehicle.

The bomb exploded. Heydrich died of his wounds a week
later. This sealed the fate of both men and thousands of Czechs
who were imprisoned, tortured or murdered after Hitler ordered
the SS and Gestapo to “wade in blood” to find Heydrich’s
killers.

OVERCONFIDENT HEYDRICH

But it was not Nazi sleuthing that discovered the
assassins’ hideout in the basement of a Prague church. It was
the betrayal of one of the paratroopers who wanted to save
himself.

Kubis, Gabcik and five others died in fierce fighting at
the church or took their own lives to avoid capture by the
Nazis.

The centerpiece of the exhibition, which opened at Berlin’s
German Technical Museum last month, is the Mercedes-Benz
convertible with the license plate “SS-3” that Heydrich was
riding in at the time of the assassination.

Ulrich Kubisch, curator at the museum, went to Prague to
see the original exhibition because of the car and vowed to
bring it to Berlin, the seat of Hitler’s “Thousand Year Reich”
that lasted only 12 years — from 1933 to 1945.

The car is a stark symbol of Nazi hubris. The top is down
because Heydrich, the Reichsprotektor of Bohemia and Moravia,
believed he had successfully pacified the whole Czech nation
and could safely ride in an open, unarmored vehicle.

The exhibition also features a replica of the spectacular
jeweled crown of Bohemia’s King Wenceslas. Legend has it that
Heydrich was doomed the moment he placed it on his head after
arriving in Prague to rule over the “Protectorate.”

Heydrich was more than the “butcher of Prague.” A few
months before his death, he chaired the Wannsee Conference,
where top Nazis began planning the “Final Solution” — the
extermination of Europe’s Jews.

“For us Czechs it was very important that Heydrich be
killed, because he was one of the worst people for us. After he
came to Prague in 1941, he began immediately with his bloody
reign of terror,” Burian said.

ATTEMPT TO KILL HITLER FAILED

Two years after Heydrich was killed, an attempt to kill
Hitler with a briefcase bomb failed. “Operation Anthropoid”
remained the only successful assassination of a top-ranking
Nazi.

But cruel reprisals by the Nazis, who razed two Czech
villages to avenge Heydrich’s death, prompted some historians
to question whether it was worth the carnage that followed.

After Heydrich died, Nazi police surrounded the village of
Lidice, which was believed to be harboring resistance fighters.
The population was rounded up. Most were shot and the remaining
women and most of the children were sent to concentration
camps.

Around 340 people died in Lidice. Two weeks later, the
village of Lezaky received similar treatment.

The decision of Czechoslovakia’s President-in-exile, Edvard
Benes, to assassinate Heydrich while aware the people back home
could face brutal reprisals remains a topic of debate.

“Benes wanted something big. He was aware of the concerns
that there was not much resistance in the Protectorate,
concerns voiced by Stalin, but also heard from the British,”
said Brad Abrams, a history professor at Columbia University.

Accounts of the horrible Nazi reprisals at Lidice were
published on front pages of the New York Times and other key
allied newspapers, raising the profile of the Czech resistance
and the Benes government-in-exile in London.

According to recently released government documents,
Britain’s wartime leader Winston Churchill even suggested
leveling three German villages for every Czech village the
Nazis destroyed.

Abrams said to make a final judgment whether or not the
assassination was worth it “requires a certain moral calculus
that places historians in serious peril.”

But he added: “Other things could have been done.”

Despite the reprisals, Jachym Topol, a prominent Czech
novelist, agreed that Heydrich’s death had a positive impact.

He said it showed Czechs were not all beer-swilling
buffoons like Josef Svejk, the absurdly obedient hero of
Jaroslav Hasek’s classic novel, “The Fateful Adventures of the
Good Soldier Svejk During the (First) World War.”

“Heydrich was evil. He had to be killed and his death sent
a message that the Czechs, too, were ready to fight. It showed
that you didn’t have to just keep your head down and try to
survive. You could be a hero,” Topol said.

Nine States Have Banned Smoking in Public Places

But 40 fail to adequately finance tobacco-prevention programs, report says

The war against tobacco rages on, with some battles won — a growing number of states have banned smoking in public places — and some lost — too little funding has gone toward tobacco prevention and cessation programs.

That’s the assessment of the American Lung Association’s fourth annual State of Tobacco Control Report Card, released Tuesday.

Nine states have now banned smoking in all public spaces and workplaces, according to the association, which is challenging all states to become smoke-free by 2010. And more than 100 municipalities not in smoke-free states have adopted similar laws.

And in 2005, for the first time, the report card had a valedictorian, with Maine receiving an A in all four categories measured, including cigarette taxes.

“It’s one that we would be proud to take home to our parents,” said Edward Miller, chief executive officer of the American Lung Association of Maine.

But the report card also criticized the federal government for not doing enough to combat smoking among Americans.

“We’re disappointed in the lack of action on the part of the federal government. Nothing’s happening. I don’t know how I can put it any other way,” said John Kirkwood, president and CEO of the American Lung Association. “The federal government has been sitting there and watching the world go by.”

The stakes are high, according to the lung association. Each year, 438,000 people die of tobacco-related illness in the United States, costing $167 billion in health-care costs and lost productivity.

The report card rated states on four criterion: cigarette taxes; smoke-free air laws; spending on prevention and control programs; and youth access.

Maine emerged the clear winner. Thanks to various programs, youth smoking rates have plummeted 59 percent since 1997, and adult smoking rates have fallen 6 percent, from 27 percent in 1990 to 21 percent in 2005. The state has come a long way since 1996, when it had the highest rate of young adult smoking.

But the report card called prevention programs across the country generally under-funded, with 40 states, the District of Columbia and Puerto Rico getting Fs for program funding.

Cigarette excise taxes continued to increase, the report said, with 12 states raising their cigarette taxes in 2005. The average state cigarette tax is now 92 cents a pack, up from 84 cents in 2004. Twenty states have a tax of $1 or more and five (including Maine) have a tax of $2 or more. Kentucky increased its tax for the first time in 35 years in 2005.

South Carolina, on the other hand, has the lowest tobacco tax in the country, at 7 cents. “It’s way overdue for them to address this issue,” said June Deen, spokeswoman for the American Lung Association’s Southeast Region. South Carolina, along with Alabama, Kentucky, Louisiana and North Carolina, received all Fs.

Dr. William Hacker, Kentucky’s commissioner of public health, said, “The report documents that Kentucky has a significant public health problem as it relates to tobacco. We are a culture and a state that has had a long history of tobacco. We have not accomplished all of our public health goals, but the report does not capture some of the progress we have made.”

Hacker pointed to a 10 percent decrease in the adult smoking rate from 2003 to 2005, an 18 percent decrease in the youth smoking rate between 2002 and 2004, the recent tax increase, a new 800 telephone quit line, and four communities that have passed clean air ordnances.

“That’s progress. That’s significant progress compared with 10 years ago,” Hacker said. “If the Fs in the report card imply we’re not trying, that’s not accurate. We have a lot of energy involved in this process, and we’re making progress.”

The report card said bipartisan legislation to give the U.S. Food and Drug Administration authority to regulate tobacco products has stalled and the federal government still hasn’t moved to ratify the Framework Convention on Tobacco Control, the world’s first public health treaty, even though more than 100 other nations have done so.

On a positive note, the federal government has agreed to let Medicare cover smoking-cessation counseling for most of its beneficiaries, according to the report.

So how can other states and the federal government match Maine’s standards of success?

According to Miller, there’s no one easy answer. “For a long period of time, Maine has been consistently applying the multiple aspects of a tobacco-control program that we know works,” he said. “It’s not any one piece.”

One sign that might encourage other states to take a tougher anti-smoking stance — tourism to Maine hasn’t been hurt since the smoke-free laws took effect, as critics had predicted.

“This has been marketed as a very positive thing for Maine,” Miller said. “It’s been turned around, and that takes some of the fear out of it for policymakers in other states.”

Smoke-free laws are no longer seen as anti-business and anti-employer. And Maine’s governor, John Baldacci, whose family was in the restaurant business, is now a convert, Kirkwood said.

But there’s plenty of work to be done, Kirkwood said. “The tobacco industry is a very powerful adversary and they are in every corner of the country and every state capital,” he said.

Still, the lung association continues to note successes. Today, just under 21 percent of Americans smoke, compared with 46 percent in 1964, when the landmark U.S. Surgeon General’s report came out.

“Clearly these strategies work, and our objective is to get them implemented in every state in the country,” Kirkwood said. “Our goal is to reduce smoking prevalence to 12 percent by 2010.”

More information

View the full report at the American Lung Association.

Rash, Nausea and a Fever? It Could Be a Case of Strep Throat

By Dr. Helen Minciotti

One of my more dramatic office visits involved a mother rushing into the office first thing in the morning carrying a vomiting and highly feverish child. Fortunately, in this case the drama did not match the disease. The diagnosis that morning turned out to be the common and generally easy to fix strep throat.

Strep throat or streptococcal pharyngitis is a year-round fixture in the school-age population. Strep is always high on my list of possible diagnoses because it can mimic so many other diseases.

Children with strep typically complain of a sore throat, but the full blown syndrome might also feature severe headache, significant fever, abdominal pain with nausea and vomiting, and a fine pink sandpaper-textured body rash.

Some patients don’t actually have sore throats and this might confuse the picture a bit. These children are brought in with other seemingly unrelated complaints such as vaginal discharge (vaginitis), redness around the rectum (proctitis), or clusters of pimples on the face or other body parts (impetigo).

These signs and symptoms are really not all that unusual, and can occur when the child spreads the strep bacteria from the mouth and nose to other areas of the body. Like sore throats, which are because of strep, most of these minor complications resolve when the child is treated with basic, inexpensive antibiotics.

If a child can’t seem to shake a strep infection or suffers from frequent bouts of strep throat, use of more sophisticated antibiotics or a visit with an otolaryngologist (ENT specialist) might be in order.

Parents can help stop the spread of strep simply by keeping their sick children out of school and other activities until they are fever-free and have been on antibiotics for at least 24 hours. I also like to encourage my patients to change their toothbrushes after two full days of antibiotic therapy (who wants to use a germy old toothbrush, anyway?)

On a final note, some of the ugliest throats I see can’t be blamed on strep bacteria at all. White spots in the back of the throat do not necessarily mean that a child has strep throat and are commonly seen in a wide variety of viral infections. A simple throat swab taken during the office visit helps make the diagnosis of strep.

Viral sore throats do not respond to antibiotics, so don’t be disappointed when your doctor does not prescribe them in these cases. Rest, fluids and, most important, time will help as your children cure themselves of these viral illnesses.

– Dr. Helen Minciotti is a mother of five and a pediatrician with a practice in Schaumburg. She formerly chaired the Department of Pediatrics at Northwest Community Hospital in Arlington Heights.

Texas Instruments to Sell Attleboro Unit for $3 Billion

By Neil Downing, The Providence Journal, R.I.

Jan. 10–ATTLEBORO, Mass. — For 47 years, the name Texas Instruments has been synonymous with Attleboro.

The company has run one of the city’s — and the region’s — biggest and best-known manufacturing operations, employing generations of workers from Southeastern Massachusetts and Rhode Island.

That is about to change. Texas Instruments — or TI, as the company is sometimes called — said yesterday that it plans to sell its Attleboro-based Sensors & Controls unit to Bain Capital LLC of Boston in a transaction worth $3 billion.

No job cuts or other changes are planned, spokespeople for TI and Bain said.

If the deal is completed as planned, possibly in June, TI will cede ownership of Sensors & Controls, which has $1.1 billion in annual sales and about 5,400 employees worldwide, including 1,100 in Attleboro.

As a result, Texas Instruments (TXN:NYSE) will end its longstanding association with Attleboro, an association it has had since 1959, when it first acquired the business — then known as Metals & Controls Corp.

TI’s Attleboro operation will once again become an independent, standalone business — much as it was when it was founded by industrialist Rathbun Willard 90 years ago as a gold-plating business to serve Rhode Island’s jewelry industry.

“Now we’re going to have control of our own destiny. . . . It’s extremely exciting,” said Thomas Wroe Jr., president of Sensors & Controls.

A spokesperson for Bain Capital said in a statement that there were no current plans for changes in operations, and that the management team expects the vast majority of Senors & Controls employees to continue in the same job, in the same place, with the same manager.

“We’re going to try to make this as seamless as we can . . . for our customers, our employees and our suppliers,” Wroe said in an interview at the company’s headquarters.

Bain, a private equity investment firm, will become the sole investor in Sensors & Controls. “They’re basically partners” in the transaction, Wroe said. “I don’t see a lot of micromanagement in this.”

The business will remain in Attleboro, and Wroe and other members of the Sensors & Controls management team will stay in place, as will the rest of the company’s Attleboro work force, he said.

“We will stay here. There are no plans for any major changes. We’ve already gone through changes,” Wroe said.

Texas Instruments’ presence in Attleboro is not what it once was. Over the last 10 years or so, TI has gradually reduced the scale of its operations while increasing its presence in other countries.

At one time, the company had about 4,000 employees working in 23 buildings at a corporate campus off Pleasant Street (Route 123). Today, it has about 1,100 employees working in two buildings at the campus, Wroe said, a 100,000-square-foot operations building, and a new, 220,000-square foot facility — a three-story building of brick and glass — that serves as the business’s world headquarters.

The company has manufacturing and other facilities in seven other countries: Holland, Japan, Mexico, Brazil, Malaysia, South Korea and China.

TI formerly owned the Attleboro corporate campus. But in late 2004, TI sold the campus to Preferred Properties, a real estate developer, and agreed to lease back property for its operations, Wroe said.

The Attleboro operation’s customers formerly operated mainly in the United States. But as they have moved their operations to other countries — mainly to Mexico and the Far East — Sensors & Controls has had to adapt, he said. “Essentially, we’ve followed our customers,” said TI spokeswoman Gail Chandler.

Today, only about 150 to 200 of the company’s Attleboro-based employees are directly engaged in manufacturing, mainly in items used by the military, the government and aircraft that typically call for some U.S.-manufactured content, he said.

The rest of the Attleboro-based employees are involved in headquarters, research and development, marketing, engineering and finance operations, he said.

The company will continue to offer the same health, retirement and other employee benefits and compensation packages to its Attleboro work force, Wroe said.

In the short term, the company plans to increase the size of its Attleboro-based work force, adding people in the corporate services area to handle functions now run by the parent company, such as tax, legal, treasury and other functions, he said.

A new name for Sensors & Controls has not been chosen, he said.

Sensors & Controls makes devices used in automobiles, appliances and other applications. For example, its sensors gauge the fluid pressure in a vehicle’s power steering and transmission units, and protect against overload or overheating in refrigerators, recessed lighting and other items in the home, Wroe said.

One of its most recently developed devices senses a passenger’s weight in the passenger-side seat of a vehicle to determine whether an air bag should be deployed, he said.

The sale will allow TI to focus more on its business of chips that run mobile phones, according to Bloomberg News.

Bain Capital said it has more than $27 billion in assets under management. It has invested in more than 225 companies over the last two decades, including Domino’s Pizza and Burger King Corp., the Associated Press reported.

Bain Capital was founded in 1984 by Mitt Romney, who later left the firm to enter politics. (He eventually became Massachusetts governor.) During Romney’s unsuccessful campaign against U.S. Sen. Edward M. Kennedy, Bain was criticized for cutting jobs at a business it acquired; Romney contended that Bain had increased employment at the vast majority of firms it took over.

FYI

More information is available at these company Web sites:

www.texasinstruments.com

www.baincapital.com

—–

To see more of the The Providence Journal, or to subscribe to the newspaper, go to http://www.projo.com.

Copyright (c) 2006, The Providence Journal, R.I.

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].

TXN,

Smoke Gets in Your Pores

You don’t have to be a smoker to suffer from ‘smoker’s skin’: passive smoking causes dry skin and premature ageing in all of us. But what can we do to minimise the damage?

WHEN you look in the mirror, does your skin tell you that you had too much fun this festive season?

Have you got that haggard post-party face that makes you think a good detox is in order? There may be more to blame than a few late nights and a couple (oh ok, half a dozen) large glasses of red wine.

We all know that passive smoking is bad for the lungs, but did you know it’s also bad for the skin? The latest findings from Clinique Laboratories show that there’s a definite link between smoke from someone else’s cigarette and the skin damage we know as ‘smoker’s skin’.

Passive smoking is dangerous because chemicals in smoke are often released into the air in far greater concentrations than experienced by the person smoking. And a non-smoker who lives in a smoky environment will have a blood nicotine level as high as a moderate smoker.

Tom Mammone, executive director of Clinique Biological Research says, ‘Exhaled smoke contains significant levels of nicotine, tar, nitric oxide and carbon monoxide which disrupt and weaken the skin’s barrier, leading to the breakdown of collagen, resulting in the symptoms of smoker’s skin.’

In fact smoke contains around 3,000 different chemicals, most of which are toxic. ‘Passive smoking has a direct toxic effect on the skin,’ says dermatologist Dr Dennis Gross, of MD Skincare. ‘Tars themselves cause free radicals, and they are very harmful to the skin. These free radicals are proven to cause both wrinkles and skin laxity.’

In other words, if you live with a smoker or are often in smoky environments such as pubs and bars, you are at risk of facial lines and saggy skin, not to mention a yellowish, coarse complexion, dehydration and chronic irritation.

The best way to avoid smoker’s skin is simply to avoid cigarettes altogether. ‘The further distance you are from a smoker, the more diluted the airborne toxins become,’ says Dr Gross. ‘Basically, ventilation and distance are the best things you can do.’

But until the Government finally bans smoking in public places or you stop going to bars and pubs, how can you minimise smoke’s toxic effects?

Firstly, remove free radicals from your skin as soon as you get home from the pub, by cleansing and exfoliating, as the harmful particles can continue to do damage even once you leave the smoky environment.

Lorraine Doherty from Skinworks Naturally (www.skinworksnaturally.com) says, ‘The most important issue is to cleanse the skin regularly. A very effective way to do this is by using olive oil, whatever your skin type. The olive oil will cleanse and lift dirt and make-up off the skin without penetrating the epidermis. Dab off the excess with cotton wool and the vitamin and mineral content of the olive oil will benefit the skin greatly.’

And, after cleansing, you should always use a good moisturiser, preferably one containing ingredients like shea butter, ceramides, fatty acids and cholesterol. These strengthen your skin’s natural barrier, and will also plump out the cells, making your skin look smoother.

Another way to help counter the effects of ‘oxidative stressors’ (ie the harmful particles) is with anti-oxidants. ‘Anti-oxidants provide vital protection from not only smoke but also from other internal and external aggressors that are known to cause premature ageing,’ said Dr Karyn Grossman, consultant dermatologist with Prescriptives.

‘Advanced anti-oxidants, including rosemary extract, resveratrol and vitamin E, help skin to neutralise free radicals which boost skin’s ability to defend against environmental damage. Free radicals created by smoke attack skin’s collagen.’

Another great source of anti-oxidants is green tea. ‘Green tea extract not only can fight both environmental and metabolic free radicals but it also repairs DNA,’ says Dr Gross. ‘Damaged DNA promotes ageing, reduces your defence against free radicals, diminishes you cells’ regenerative ability, and can even result in skin cancer.’

But there is another, more direct way to get your anti-oxidants. ‘Ingesting these ingredients cannot compare to applying the ingredients topically( to the skin),’ says Dr Gross. ‘For example, one would have to consume 100 Vitamin C capsules at 250 mg each to get the same level of Vitamin C that could be applied topically in a 10% Vitamin C Gel.’

So make sure to spend as little time as possible in smoky environments and, if you have to, cleanse your face properly, moisturise intensely and stock up on those anti-oxidants. Then simply try to stick to a sensible lifestyle that includes two litres of water every day, a healthy diet and good amounts of rest and exercise, and you should have firm, healthy looking skin for many years to come.

And don’t worry if you’re already showing sign of getting smoker’s skin, or even if you smoke yourself – it’s never too late to start out on a new path, says Noella Gabriel, director of treatment and product development at Elemis. ‘The skin responds very quickly to any adjustments made to our lifestyles, keeping in mind that ‘we are true products of it’. It’s never too late to reverse the damage.’

Clinique Lab Reports are available at Clinique counters. For your nearest stockist go to www.clinique.co.uk

Delaware County’s Mercy Health Hospice Joins Nation’s Leading Hospice Provider

DARBY, Pa. and PHILADELPHIA, Jan. 10 /PRNewswire/ — Mercy Health Hospice, a part of Mercy Fitzgerald Hospital in Darby, Pennsylvania, and Mercy Health System, has been acquired by VITAS Innovative Hospice Care(R), the nation’s leading and largest hospice provider, serving more than 10,250 patients each day from 39 offices in 15 states.

As part of the merger, Mercy Health Hospice will operate within VITAS’ existing Philadelphia program and will be known as VITAS Innovative Hospice Care(R) at Mercy.

Mercy Health Hospice Director, Cathy Franklin, R.N., C.P.H.N., will now run the VITAS interdisciplinary hospice team serving Delaware County.

No layoffs are expected as a result of the merger. Terms of the transaction were not released by either party.

“We are pleased to expand our partnership with VITAS Innovative Hospice Care through this transaction. VITAS is the nation’s leading provider of high quality end of life care services, and we trust they will serve our community with distinction. We are proud of our association with VITAS, and look forward to their continued success in meeting the needs of patients and families,” said H. Ray Welch Jr., President and Chief Executive Officer of Mercy Health System.

“As a vital part of VITAS, Mercy will be able to meet the expanding needs for end-of-life care in the communities it has traditionally served while continuing to grow throughout Delaware County,” said Rosemary Baughn, RN, Senior General Manager of VITAS Innovative Hospice Care of Philadelphia.

Welch noted that, “We at Mercy know VITAS — they’ve been an active partner at two of our facilities in Philadelphia, Nazareth Hospital and St. Agnes Continuing Care Center, for more than 10 years. VITAS operates inpatient hospice units in both facilities and operates those units consistent with the ethical and religious directives for Catholic Health Care Services,” Welch said.

Mercy Health Hospice has served the Mercy Fitzgerald Hospital community for nearly 25 years. The outpatient hospice program became Medicare certified in 1995 and has been an integral part of Mercy’s healthcare community as a dedicated provider of end of life care services. The program is widely recognized for its skilled clinical management and the compassionate care provided by its long tenured team of healthcare professionals.

The origin of VITAS dates back to 1976 in Miami, Florida, when Hugh A. Westbrook, an ordained United Methodist Minister, and Esther T. Colliflower, a registered nurse, saw a void in the treatment of people with terminal illnesses. While affiliated with the local community college, they organized a group of volunteers who also were interested in pursuing betters ways to care for the dying. The group began caring for patients who were willing to be part of a reciprocal agreement: If “the group” would help them to remain comfortably at home until they died, the patients would teach “the group” how to care for them. From caring for its first patient in 1978 VITAS now cares for approximately 55,000 patients each year.

“Delaware County has been a fortunate beneficiary of high quality end-of- life services through Mercy Hospice. That standard of excellence will continue through this partnership,” Baughn said. “VITAS is the largest and one of the nation’s oldest providers of end-of-life care. Mercy Hospice is now part of a family of more than 8,100 hospice advocates who provide care each day to more than 10,250 patients and families in 15 states.”

“VITAS has helped change the face of hospice,” Baughn added. “We were part of the grassroots effort that, in 1982, made hospice care accessible through the Medicare Hospice benefit. We expanded hospice care to include patients with congestive heart failure, lung disease, Alzheimer’s, Parkinson’s and other non-cancer diagnoses. We were among the first to make hospice care available to patients in nursing homes and, later, in assisted living communities.”

The name VITAS (pronounced VEE-tahs) is derived from the Latin word for lives. The name symbolizes the VITAS mission: To preserve the quality of life for those who have a limited time to live. From its founding as an all- volunteer hospice in 1978, VITAS has been guided by four VITAS Values:

     * Patients and families come first.     * We take care of each other.     * I'll do my best today and do even better tomorrow.     * I am proud to make a difference.   

If a family member or friend might benefit from that kind of approach to end-of-life care, call 1-800-664-6334. A VITAS admissions representative can answer your questions and find out more about your family’s concerns.

VITAS Innovative Hospice Care(R), a pioneer and leader in the hospice movement since 1978, is the nation’s largest provider of end-of-life care. Headquartered in Miami, Florida, VITAS operates 39 hospice programs in 15 states (Arizona, California, Connecticut, Delaware, Florida, Georgia, Illinois, Kansas, Missouri, New Jersey, Ohio, Pennsylvania, Texas, Virginia and Wisconsin). VITAS, which has evolved from its founding as a volunteer organization by a United Methodist Minister and an oncology nurse, today employs 8,106 professionals who care for terminally ill patients daily, primarily in the patients’ homes, but also in the company’s 23 inpatient hospice units as well as in hospitals, nursing homes and assisted living facilities/residential care facilities for the elderly. At the conclusion of the third quarter of 2005, VITAS reported an average daily census of 10,259; VITAS served nearly 55,000 patients throughout all of 2004. The name, VITAS (pronounced VEE-tahs), is derived from the Latin word for lives. It symbolizes the VITAS mission: To preserve the quality of life for those who have a limited time to live.

VITAS Innovative Hospice Care

CONTACT: Rosemary Baughn, General Manager of VITAS Innovative HospiceCare(R) of Philadelphia, +1-610-260-6020; or Mark B. Cohen, Vice President ofCorporate Communications and Public Relations of VITAS Healthcare Corporation,+1-305-350-5905

School Tardiness a Growing Problem

By Murray Light

Elementary and secondary schools throughout the nation are adopting various techniques to get children to school on time. Many of these programs are producing positive results, but the evidence still shows disturbing signs of a continuing upsurge in late arrivals to school.

The U.S. Department of Education, in the latest available report, shows that tardiness is a moderate to a serious problem, rising to 32.4 percent by the year 2000, up 7.5 percent over a six-year period. The increase in elementary school tardiness was most disturbing, with 27.1 percent of principals in those schools saying it was a significant problem, increasing 8.6 percent over the same period.

School principals have been concerned about tardiness for many years but didn’t take serious steps to counter the problem. It’s a different story now because of the No Child Left Behind law that results in federal monitoring of school attendance and late arrivals to school. Under that law, schools face a whole range of negative consequences if students don’t meet certain levels on state tests. Students who arrive late to school miss important lessons, because elementary school teachers for the most part begin their day with core subjects such as reading.

Attendance is a major factor that states look at in figuring how much funding the school district gets, and since attendance is taken at the beginning of the school day, late arrivals may be counted as absentees, thereby depriving the district of funding.

The Wall Street Journal in a recent lengthy article reviewed the school tardiness problem and cited some of the reasons it was becoming more and more troublesome. The article, however, failed to mention what I consider to be one of the principal reasons for this increasing tardiness.

A significant number of school-age children have television sets in their bedrooms, and a great many probably are watching a late movie or one of the late-night talk shows when they should be sleeping. When and if they have an alarm clock, they just continue to sleep after it goes off.

I wonder, too, if some tardiness can be attributed to the late arrival of their school bus that then results in their late arrival to school. Many years ago, when youngsters walked to schools in their neighborhoods, this was not a problem. Today, most are bused to school, and if the bus is late, so are those who are on it. This tardiness should not be counted against the students.

Among the devices principals are utilizing to cut back on tardiness include prizes for students who regularly show up on time and after-school movies for those who are always punctual. One school district in Texas has a weekly raffle for students who get to school on time with a watch as the prize.

Three of my grandchildren attend school in Needham, Mass., and the high school gives a day off to those who come on time for an entire semester. I am proud to say that my 16-year-old granddaughter recently enjoyed that day off.

Parents, of course, have responsibilities, too. I recall vividly, even after all these years, the time of a major snowstorm in New York City. My father felt so strongly about my not missing a day at school that he carried me the four blocks from our home to the elementary school I attended. Only a handful of us were present that day in my fourth-grade class.

I have deviated today from my customary approach to this column, which concentrates on local, state and national politics. But I do feel strongly about the need for a strong school system to prepare young people for a meaningful role in our society. I am hopeful that Buffalo’s new school superintendent will be effective in making changes that can considerably enhance that important factor in our community.

Murray B. Light is the former editor of The Buffalo News.

Aldehyde Sources, Metabolism, Molecular Toxicity Mechanisms, and Possible Effects on Human Health

By O’Brien, Peter J; Siraki, Arno G; Shangari, Nandita

Aldehydes are organic compounds that are widespread in nature. They can be formed endogenously by lipid peroxidation (LPO), carbohydrate or metabolism ascorbate autoxidation, amine oxidases, cytochrome P-450s, or myeloperoxidase-catalyzed metabolic activation. This review compares the reactivity of many aldehydes towards biomolecules particularly macromolecules. Furthermore, it includes not only aldehydes of environmental or occupational concerns but also dietary aldehydes and aldehydes formed endogenously by intermediary metabolism. Drugs that are aldehydes or form reactive aldehyde metabolites that cause side-effect toxicity are also included. The effects of these aldehydes on biological function, their contribution to human diseases, and the role of nucleic acid and protein carbonylation/oxidation in mutagenicity and cytotoxicity mechanisms, respectively, as well as carbonyl signal transduction and gene expression, are reviewed. Aldehyde metabolic activation and detoxication by metabolizing enzymes are also reviewed, as well as the toxicological and anticancer therapeutic effects of metabolizing enzyme inhibitors. The human health risks from clinical and animal research studies are reviewed, including aldehydes as haptens in allergenic hypersensitivity diseases, respiratory allergies, and idiosyncratic drug toxicity; the potential carcinogenic risks of the carbonyl body burden; and the toxic effects of aldehydes in liver disease, embryo toxicity/ teratogenicity, diabetes/hypertension, sclerosing peritonitis, cerebral ischemia/neurodegenerative diseases, and other aging- associated diseases.

Keywords Aldehydes, Aldehyde Metabolism, Aldehyde-Metabolizing Enzymes, DNA and Protein Carbonylation, Carbonyl Body Burden, α- Oxoaldehdye

SUMMARY

Although there have been various reviews on particular aldehydes that are of potential carcinogenic concern, such as formaldehyde (CEPA, 2001; Collins and Lineker, 2004; Heck et al., 1990; IARC, 2004; IPCS, 2002b; Liteplo and Meek, 2003), acetaldehyde (CEPA, 2000b; IARC, 1999; Liteplo and Meek, 2003) crotonaldehyde (IARC, 1995a), furfural (IARC, 1995c; IPCS, 2000), and acrolein (CEPA, 2000b; IARC, 1995b; IPCS, 2002a), this review compares many aldehydes and their reactivity to biomolecules particularly macromolecules. Furthermore, it includes not only aldehydes of environmental or occupational concerns but also dietary aldehydes and aldehydes formed endogenously by intermediary metabolism. Also included are drugs that are aldehydes or that form reactive aldehyde metabolites that cause side-effect toxicity. The effects of these aldehydes on biological function, their contribution to human diseases, and the role of nucleic acid and protein carbonylation/ oxidation in mutagenicity and cytotoxicity mechanisms, respectively, as well as carbonyl signal transduction and gene expression, are reviewed. Their metabolic activation and detoxication by aldehyde- metabolizing enzymes are also reviewed, as well as the toxicological and anticancer therapeutic effects of metabolizing enzyme inhibitors. Some of these enzymes are genetically polymorphic so that the susceptibility of the individual to diseases associated with aldehyde accumulation (e.g., diabetes) could be affected. Finally, the human health risks from clinical and animal research studies are reviewed, including aldehydes as haptens in allergenic hypersensitivity diseases, respiratory allergies, and idiosyncratic drug toxicity.

1. SOURCES OF ALDEHYDES

a. Natural and Anthropogenic Aldehydes: Urban, Rural, and Indoor

A trace amount of formaldehyde is present in the air as a result of photochemical oxidation (hydroxyl radicals) of hydrocarbons, for example, methane naturally present in the atmosphere (Atkinson, 1990; Riedel et al., 1999). In rural air, terpenes and isopropene emitted by foliage also react with hydroxyl radicals to form formaldehyde (Atkinson, 1990). In urban areas, motor vehicle exhaust became an important source of aldehydes in air both through direct emission of aldehydes and through the emission of hydrocarbons, which in turn were converted to aldehydes through photochemical oxidation reactions(Cecinato et al., 2002; Destaillats et al., 2002; Grosjean et al., 1996; Maldotti et al., 1980; Rao et al., 2001). The most recent Urban Air Toxics Study results posted on the U.S. Environmental Protection Agency (ERA) web site include formaldehyde, acetaldehyde, and acrolein as significant contributors to the summed risk values for mobile sources of air toxins. These aldehyde air toxins are also regulated under the Canadian Environmental Protection Act (CEPA, 2000a, 2000b). The largest carbonyl emissions were attributed to the oxidation and ring breaking of benzene, toluenes, ethylbenzene, and xylenes in the internal combustion engine or in the exhaust and can be divided into the following four carbonyl classes whose chemical structures are shown in Figure 1:

1. Alkanals: formaldehyde, acetaldehyde, valeraldehyde, hexanal, heptanal, nonanal, dodecyl aldehyde.

2. Alkenals: acrolein, crotonaldehyde, methacrolein.

3. Aromatic aldehydes: benzaldehyde, m-tolualdehyde, 2,5- dimethylbenzaldehyde, 3-hydroxybenzaldehyde.

4. α-Oxoaldehydes: glyoxal, glycolaldehyde, glyoxylic acid.

With the increasing use of alternate and reformulated automotive fuels, an additional source of aldehyde emission is now in evidence. Depending on the type of oxygenates (ethanol, methanol, or methyl tert-butyl ether) added to the automotive fuels, increased amount of formaldehyde or acetaldehyde are now emitted in automobile exhaust(Gaffney and Marley, 2000; Kirchstetter et al., 1996; Maejima et al., 1992). Grosjean et al. (2002) attributed the change in ambient acetaldehyde/ formaldehyde ratio to a change in reliance on ethanol as vehicle fuel in Brazil. The most abundant carbonyls expressed as percentages of Los Angeles air carbonyl content on a parts per billion basis are formaldehyde (24%), acetaldehyde (18%), glyoxal/methylglyoxal (8%), acetone (7%), and acrolein (5%). Furthermore, the two glyoxals exhibit midafternoon maxima probably because they are photochemical oxidation products of aromatic and olefinic hydrocarbons (Ghilarducci and Tjeerdema, 1995; Grosjean et al., 1996; Zervas et al., 2002). Other sources of aldehydes in the air include emissions from forest fire and agriculture burns(Dost, 1991; Materna et al., 1992), and incinerators (Dempsey, 1990). Coal- based power plants (Sverdrup et al., 1994) and diesel engines (Wheeler et al., 1980) also emit aldehydes into the air.

Aldehydes are present in residential and workplace environments, and are detectable in confined spaces such as spacecrafts and airline cabins (James, 1997; NRC, 2002). Aldehyde levels in indoor air were 4- to 10-fold higher than those of outdoor air (Liteplo and Meek, 2003; Shah and Singh, 1988; Willis et al., 2002; Zhang and He, 1994), indicating that indoor sources of aldehydes are from local emissions. The major sources of indoor formaldehyde and acetaldehyde were from furniture, carpets, particle boards, fabrics, and paints (Brown, 1999; Kelley et al., 1966; Pickrell et al., 1983). Cooking fumes contained a variety of aldehydes including formaldehyde, acetaldehyde and acrolein (Lane and Smathers, 1991; Svensson et al., 1999). Woodburning stoves and fireplaces are also a source of aldehyde in homes (Lipari et al., 1984; Ramdahl et al., 1982). Formaldehyde and acetaldehyde were also generated in the indoor environment by the action of ozone on anthropogenic hydrocarbons (Weschler and Shields, 1997). Cigarette smoke is an important source of indoor aldehydes (Mansfield et al., 1977; Rickert et al., 1980). Mainstream smoke analysis of cigarette smoke for aldehydes showed that acetaldehyde constituted the major component at 709 g/ cigarette, followed by acrolein (82), formaldehyde (54), crotonaldehyde (15) (Smith and Hansen, 2000a), diacetyl (207), and methylglyoxal (38) (Saint-Jalm et al., 1980). Sidestream smoke as a result of lower-temperature pyrolysis contains about 12-fold more acrolein than mainstream smoke. Furthermore, the charcoal filters adsorbed the acrolein by 50-80% and decreased the smoker’s exposure (Ghilarducci et al., 1995). Formaldehyde is present in the air of hospitals, mortuaries, and laboratories, where it is used in tissue preservatives, disinfectants, and embalming fluids (WHO, 1989). Dermal and inhalation exposure to formaldehyde is also possible in cosmetic and hair salons, where it is used as a fumigant (Ackland et al., 1980; Olcerst, 1999). Dermal and inhalation exposure to aldehydes may also occur through contact with a wide range of consumer products, such as fabrics, cleaning agents, sun-tan lotions, and many cosmetic products containing formaldehyde or formaldehyde-releasing substances (Flyvholm and Anderson, 1993; WHO, 1989).

FIG. 1. Structures of the most common aldehydes.

Formaldehyde levels have been reported to be as high as 1.38 mg/ L and 6.8 mg/L in rainwater (Kitchens et al., 1976) and fog water (Muir, 1991), respectively, but are generally

Formaldehyde is also generated in vivo from numerous xenobiotics and pharmaceuticals, such as hexamethylphosphoramide bis(chloromethyl)ether, diphenylhydramine, and codeine, to name a few (Dahl and Hadley, 1983; Heck, 1989; Heck et al., 1990). Industrial chemicals such as methanol and methyl tert-butyl ether, a gasoline oxygenater (Hutcheon et al., 1996), are also precursors of formaldehyde. The food preservative hexamethylenetetramine releases formaldehyde and ammonia in the acidic environment of the stomach (WHO, 1974).

b. Endogenous Aldehydes Formed During Biomolecule Metabolism

i. Lipid Peroxidation (LPO)

The accumulation of DNA damage and DNA adducts is believed to play a significant role in genetic diseases, including cancer. Recently, it has been shown that the background levels of exocyclic propano/etheno-DNA adducts in tissues from unexposed humans arise from the endogenous alkenals, hydroxyalkenals, dialdehydes, and alkanal products of lipid peroxidation (LPO) decomposition (Bartsch, 1999). Furthermore, these adducts were increased in subjects ingesting high dietary ω-6 polyunsaturated fatty acids and decreased in subjects consuming vitamin E supplements or having an increased vegetable intake. There is therefore increasing interest in these adducts as possible biomarkers of cancer risk (Hagenlocher et al., 2001). These DNA adducts were also increased in patients with copper storage disease (Wilson’s disease) or iron storage disease (hemochromatosis) associated with liver cancer (Nair et al., 1999). Endogenous carbonylated proteins were also increased in the liver during LPO induced by ethanol or carbon tetrachloride. Using malondialdehyde antibodies, the major adduct was identified as a malondialdehyde adduct with cytochrome oxidase subunit IV (Chen et al., 2000). Cytochrome oxidase was also inactivated and could contribute to subsequent cytotoxicity. This and other LPO aldehyde decomposition products are believed to be responsible for many endogenous protein adducts. Endogenous carbonylated proteins have been shown to increase during aging as well as in various pathological states, including premature diseases, muscular dystrophy, rheumatoid arthritis, metal storage diseases, and atherosclerosis (Chevion et al., 2000). A marked increase in plasma/ urinary aldehydes (by products of LPO and their metabolites) occurred in patients with childhood cancer (Yazdanpanah et al., 1997) or alcoholic liver disease (Aleynik et al., 1998). Plasma heptanal levels increased from 0.1 to 3.5 M (Yazdanpanah et al., 1997).

Besides endogenous LPO products, other contributors to the body carbonyl burden are ingested exogenously and include drugs and environmental agents that undergo biotransformation to form reactive aldehyde metabolites or induce LPO. For instance, there was an increase in plasma LPO derived prostanoids (F^sub 2^-isoprostanes) in smokers (Morrow et al., 1995). Animal experiments also showed increased plasma/urinary aldehydes in rats/mice with iron overload (Bartfay et al., 1999) or following the administration of dioxin, paraquat, carbon tetrachloride, endrin (Shara et al., 1992), or dichromate (Bagchi et al., 1995b). Doxorubicin administered to rats also increased aldehyde levels in the heart and plasma before cardiotoxicity ensued, and both events were prevented with carnitine (Luo et al., 1999). Doxorubicin (10 mg/kg) increased the urinary excretion of formaldehyde from 48 to 158 nmol/kg body weight, acetaldehyde from 2 to 14 nM/kg, and malondialdehyde from 4 to 17 nmol/kg 6 h later. Aldehyde levels were still high 72 h later (Bagchi et al., 1995a). Plasma cytotoxic alkenals (frans-2- heptenal, 4-hydroxynonenal [4-HNE], irani-2-nonenal) were increased up to 3.5-fold (Luo et al., 1999). Formaldehyde, is also formed by oxidative stress (e.g., from polyamine oxidation by ROS) and is increased in tumors. Furthermore it also plays a role in the binding of anthracycline or mitoxantrone anticancer drugs to DNA in vivo (Kato et al., 2000).

Dicarbonyls or oxoaldehydes are of particular concern because of their propensity to covalently cross-link proteins as a result of forming Amadori intermediate products (Figure 1) and advanced glycation end-products (AGEs). Cross-linking of long lived proteins have been found in vivo and were associated with the pathophysiologies of aging and the long-term complications of diabetes and atherosclerosis. The dicarbonyl content of fresh human urine was reported to be glyoxal (41 M), diacetyl (2.1 M), and methylglyoxal (1.5 M) (Espinosa-Mansilla et al., 1998), whereas the concentrations in blood were glyoxal (211 pmol/g), methylglyoxal (80 pmol/g), and lower levels of 3-deoxyglucosone (Thornalley, 1998). The early glycation adduct fructosamine, an Amadori product, is about 140 M in plasma and was increased two- to threefold in diabetes (Thornalley et al., 1999). Plasma glyoxal and methylglyoxal and their derived AGEs and advanced lipoxidation end-products (ALEs) levels were also increased (more than three- to fourfold) in diabetics or patients with renal disease (Odani et al., 1998). A sevenfold increase of deoxyglucosone (to 11 M) was found in the serum of continuous ambulatory peritoneal dialysis patients (Tsukushi et al., 1999). These levels may appear low, but these oxoaldehydes have high reactivity to proteins and nucleic acids.

ii. Carbohydrate or Ascorbate Autoxidation

Glyoxal, unlike methylglyoxal, is a major lipid oxidative degradation product. Glyoxal is also a major DNA oxidative degradation product formed from the oxidation of deoxyribose C4’/ C5′ carbons by ROS and causing a DNA strand break. The amount of glyoxal formed was 17-fold that of 8-OHdeoxyguanosine (Murata- Kamiya et al., 1997). The glyoxal released could then form adducts with neighboring DNA guanine (discussed later). Glyoxal was the only dicarbonyl formed during glucose autoxidation under physiological conditions, presumably formed from the cleavage of the C2-C3 bond of glucosone or another intermediate. Arabinose was also found and presumably arose from the cleavage of the C1-C2 bond of glucose. The AGEs formed with ribonuclease were N^sub ε^- carboxymethyllysine (CML) for glyoxal and pentosidine for arabinose (Wells-Knecht et al., 1995). Dicarbonyl products formed from fructosyl-lysine autoxidation were glyoxal > 3-deoxyglucosone > methylglyoxal (Thornalley et al., 1999). Ascorbate autoxidation is also believed to contribute to age-induced cataractogenesis, which is associated with a buildup of proteins glycated by oxidized catabolites of endogenous ascorbate present in the lens (up to 2 mM). As shown in Figure 2a, the reactive catabolites implicated include diketo compounds and L-erythrulose (Simpson et al., 2000).

FIG. 2a. Endogenous glyoxal formation by autoxidation of glycolaldehyde formed by (left) sorbitol metabolism or (right) ascorbate oxidative degradation or a sugars or DNA deoxyribose or unsaturated fatty acids.

Glyoxal is also formed by the transition-metal-catalyzed autoxidation of the ene-diol tautomer of glycolaldehyde (Benov and Fridovich, 1998) (Figure 2b), hydroxypyruvaldehyde, another oxoaldehyde, is rapidly formed by the autoxidation of the ene-diol tautomers of glyceraldehyde or dihydroxyacetone (Thornalley et al., 1984). Superoxide and hydrogen peroxide are also formed and likely cause the oxyhemoglobin oxidation and cytochrome c reduction that also occurs (Thornalley, 1985). These dicarbonyls are the most reactive carbonyls, as at micromolar concentrations they cross-link proteins, glycate proteins, form AGE, and inactivate enzymes, in contrast to glucose, which requires 20 mA/and very long autoxidation times to cause protein carbonylation and enzyme inactivation (Ukeda et al., 1997).

FIG. 2b. Endogeneous glycolaldehyde and glyoxal metabolic pathways. AKR, aldo-ketoreductase; HPR, hydroxypyruvate reductase; LDH; lactate dehydrogenase.

iii. Carbohydrate Metabolism

Methylglyoxal, unlike glyoxal, is formed enzymatically from the triose phosphate intermediates (glyceraldehyde 3-phosphate and dihydroxyacetone phosphate) produced during the glycolytic metabolism of glucose or from the metabolism of ketone bodies or threonine (Thornalley, 1996). It has been estimated from the triose phosphate and isomerase concentrations that 0.4 mM methylglyoxal is formed per cell per day (Richard, 1991). In Figure 3a, we also show that triose phosphate (i.e., dihydroxyacetone [DHAP] and glyceraldehyde 3-phosphate) formation by the pentose phosphate pathway could also be responsible for methylglyoxal formation from xylitol, ribose, and deoxyribose, which are much more effective than glucose. The endogenous rate of methylglyoxal formation has been estimated at about 120 mol/day, i.e., 0.1% of the glucotriose flux (Thornalley, 1996). Methylglyoxal formation markedly increased when hepatocytes were incubated with glyceraldehyde. Methylglyoxal formation from xylitol also markedly increased when glycolysis was inhibited with fluoride and diamide (Sato et al., 1980). Methylglyoxal formation also increased when glyceraldehyde dehydrogenase underwent oxidative inactivation by ROS generated by hyperglycemia or was inactivated by increased cellular NADH levels (metabolic pseudohypoxia) (Brownlee, 2\001). Cellular methylglyoxal levels were decreased by lowering triose phosphate levels by maximizing transketolase activity with thiamine therapy (Thornalley et al., 2001). On the other hand, thiamine deficiency increased tissue and plasma methylglyoxal levels (and its metabolite glyoxylic acid) (Liang, 1960; Vogt-Moller, 1931). 3-Deoxyglucosone may also be formed as a hydrolysis product of fructose 3-phosphate, a metabolite formed from fructose catalysed by fructose-3-kinase. The fructose of lens and heart could be formed from glucose via the polyol pathway implicated in diabetic complications.

FIG. 3a. Endogenous methylglyoxal and glyoxal formation.

FIG. 3b. Endogenous methylglyoxal metabolism.

It is generally thought that glyoxal is formed almost exclusively nonenzymically (e.g., via oxidation of Amadori products or lipids) and is not formed by intermediary metabolism, unlike methylglyoxal. As shown in Figure 2a, glycolaldehyde is formed by intermediary metabolism from hydroxypyruvate (from glyceraldehyde, fructose, and sorbitol) or D-xylulose 1-phosphate (from xylitol) or glyoxylate (from serine, glycine, and hydroxyproline). Fructose in some tissues could also be formed from sorbitol catalyzed by aldose reductase (the polyol pathway). However, glyoxal was formed from glycolaldehyde by reactive oxygen species (ROS) (Benov and Fridovich, 1998; Okado-Matsumoto and Fridovich, 2000; Vogt-Moller, 1931). In Figure 2b a pathway is therefore proposed for the formation of glyoxal from glyceraldehyde via glycolaldehyde autoxidation, and the identity of the metabolizing enzymes involved is outlined for the first time.

iv. Amine Oxidases-Catalyzed Metabolic Activation

FAD-dependent oxidases include tissue monoamine oxidase (MAO), located in the mitochondrial outer membrane and inhibited by pargyline, quinacrine, or deprenyl, and polyamine oxidase (PAO), located in the peroxisomes and cytosol, and is inhibited by quinacrine or CGP 48664. MAO exists as two isoforms, A (e.g., serotonin substrate) and B (phenethylamine, dopamine substrates), and catalyzed the deamination of tyramine and amine neurotransmitters such as tryptamine, resulting in the formation of H^sub 2^O^sub 2^, NH^sub 3^, and phenylacetaldehyde (Figure 4a). The latter two products are detoxified by the mitochondria. Succinic semialdehyde is formed during the MAO-catalyzed metabolism of the neurotransmitter gamma-aminobutyric acid.

FIG. 4a. Formation of formaldehyde and acetaldehyde by serum amine oxidase (SAO).

In contrast, PAO utilizes diamine and polyamine substrates and forms H^sub 2^O^sub 2^ (detoxified by peroxisomal catalase) but not NH^sub 3^ when it catalyzes the oxidation of spermine to form spermidine and 3-aminopropanal. Acetylspermine and diacetylspermine are even better substrates. The polyamines and PAO are ubiquitous in cells (including erythrocytes) and are involved in cellular growth, differentiation, and carcinogenesis. 3-Aminopropanal is a potent lysomotropic neurotoxin (particularly neurotoxic to neurons) that is formed from polyamines during cerebral ischemia. 3-Aminopropanal and acrolein (spontaneously generated by aminopropanal, Figure 4b) are considered to be the major cytotoxic products of brain injury (Li et al., 2003; Seller, 2000). Hepatic PAO was also induced fourfold in vivo by liver iron loading, and the increased aminopropanal formation by spermine oxidation may have caused the increased LPO and hepatotoxicity (Tipnis et al., 1997).

The copper-dependent amine oxidases such as plasma amine oxidases and diamine oxidases are inhibited by copper chelating agents, semicarbazide, or aminoguanidine, and are thought to “detoxify” xenobiotic amines but form toxic aldehydes, H^sub 2^O^sub 2^, and NH^sub 3^ (depending on the substrate), which have been implicated in vascular damage and advanced protein aggregation found in vascular disorders, such as diabetic complications, atherosclerosis, Alzheimer’s disease, and aging. They include tissue diamine oxidase (DAO) and serum amine oxidase (SAO). DAO is mostly found in the intestinal mucosa and kidney but is also induced by putrescine or injury in the heart, liver, and brain. It utilizes the diamines putrescine and cadaverine as well as spermine to form aminoaldehydes. Acrolein was formed from spermidine, and 3- aminopropanal/malondialdehyde was formed from 1,3-propanediamine (Seller, 2000). SAO exists as membrane or soluble forms in the vascular system for example, the cardiovascular smooth muscle cells, kidney cells, cartilage, and adipocytes, and contain topa quinone as a cofactor. Serum SAO is increased in patients with diabetic complications, vascular disorders, and heart disease. They catalyze the oxidative deamination of the polyamines spermine, spermidine, or the industrial chemical allylamine in the plasma to form the highly toxic acrolein. The aminoaldehyde first formed from spermine undergoes an oxidative deamination to form a dialdehyde. Both the aminoaldehyde or dialdehyde products can then be oxidatively detoxified by aldehyde dehydrogenases or can undergo spontaneous β-elimination to form putrescine and acrolein (Seiler, 2000). The latter is most likely to occur in the extracellular space, as both SAO and polyamines are found in the plasma, unlike aldehyde dehydrogenase. Spermine is synthesized in all eukaryotic cells and is involved in a variety of cellular processes, including the control of cell growth. Rapidly dividing cells such as tumors, bone marrow, and intestinal epithelial cells have elevated levels of poly amines due to enhanced polyamine synthesis by ornithine decarboxylase/S-adenosylmethionine decarboxylase and increased uptake of poly amines. Polyamine uptake is mediated by a transporter, which is also under feedback inhibition by polyamine. Furthermore, polyamine analogs are now being developed as anticancer agents as they underwent an unregulated rapid massive intracellular and intramitochondrial accumulation resulting in tumor cell apoptosis, which was prevented by an amine oxidase inhibitor (Hu and Pegg, 1997). Formaldehyde and methylglyoxal were also formed by SAO from methylamine, a metabolite of epinephrine, sarcosine, creatinine, and also a gut bacteria product. Methylglyoxal was also formed by SAO from aminoacetone, a decarboxylation product of 2- amino-3-keto-butyrate formed by the mitochondrial metabolism of threonine. The formation of acrolein by SAO in the coronary artery was suggested to cause the coronary artery contraction resulting in myocardial necrosis that is induced by allylamine (Conklin et al., 2001). Plasma SAO and methylglyoxal were also increased by the uncontrolled hyperglycemia of diabetics. It has also been proposed that excessive methylglyoxal/formaldehyde formation by SAO from aminoacetone/methylamine causes vascular endothelial cell protein cross-linking and cell injury associated with diabetic atherosclerosis (Yu et al., 1997). Plasma SAO was also increased in patients with congestive heart failure. Human placental SAO has been cloned and sequenced with an identity of about 60% for the cDNA sequence of human kidney amine oxidase. It has two subuits each containing one atom of Cu and one molecule of covalently bound topa quinone (Zhang and Mclntire, 1996). Another member of the SAO family recently discovered is the ectoenzyme vascular adhesion protein-1, an adhesion protein with a dual function that is found on the endothelial cell surface and rapidly deaminates methylamine and aminoacetone (Smith et al., 1998). Spermine oxidized by serum amine oxidase was cytotoxic to tumor cells particularly at 42C, a cytotoxic effect that was attributed to the acrolein formed (Agostinelli et al., 1994). Amine oxidase inhibitors usually prevent the cytotoxicity of polyamine oxidation products. Aminoguanidine is currently the only DAO, SAO inhibitor used in the clinic.

FIG. 4b. Amine oxidases-catalyzed metabolic activation. DAO = diamine oxidase; PAO = polyamine oxidase; SAO = serum amine, oxidase.

v. Cytochrome P-450 Catalyzed Metabolic Activation

Endogenous formaldehyde and and aldehydes with one less carbon atom than the initial alcohol substrate (eg., acetaldehyde) were formed by the cytochrome P-450 (P450) (CYP2E1) catalyzed oxidation of glycerol, ethylene glycol, 1,2-propane diols, or polyhydroxylated alcohols containing vicinal diols likely mediated by a ferryl-type oxidant species involving a radical mechanism or the homolytic cleavage of a dioxetane intermediate (Clejan et al., 1992; Kukielka et al., 1995). CYP2E1 likely catalyzed methylglyoxal formation in vivo from ketone bodies, as acetone can be hydroxylated to acetol (hydroxyacetone), which is then hydroxylated to methylglyoxal (Bondoc et al., 1999). Ketosteroids were also formed during steroid metabolism, and ketoprostaglandins were formed during prostaglandin metabolism.

vi. Myeloperoxidase-Catalzed Metabolic Activation

Plasma contains myeloperoxidase (MPO) and H^sub 2^O^sub 2^ (released from activated neutrophils at sites of inflammation), as well as chloride (0.1 M) and α-amino acids (4-5 mM). Peroxidase/ H^sub 2^O^sub 2^-catalyzed protein arginine, proline, or lysine oxidation by a radical mechanism formed semialdehydes, whereas alanine, valine, and serine oxidation formed HCHO (Headlam et al., 2002). However, acrolein and 2-hydroxypropanal were the major products formed via intermediate chloramines during the myeloperoxidase/H^sub 2^O^sub 2^/Cl- or HOCl-catalyzed oxidation of threonine, and glycolaldehyde was the major product formed from serine via intermediate chloramines (Anderson et al., 1997). Tyrosine formed p-hydroxyphenylacetaldehyde and 3-chlorotyrosine when oxidized by MPO/H^sub 2^O^sub 2^/C1 (Fu et al., 2000), whereas neutrophils/Cl incubated with glycine formed HCHO and alanine formed acetaldehyde (Figure 5) (Hazen et al., 1998). Such aldehyde formation in blood vessels may accelerate diabetic vascular disease. Itis also very likely that the aldehyde yield was much higher than was found, as aldehyde autoxidation is markedly catalyzed by peroxidases. This is toxicologically significant, as the electronically excited carbonyl intermediates (as indicated by chemiluminescence) and hydroperoxy-aldehyde intermediates formed by peroxidases from some aldehydes are reactive DNA oxidants (Adam et al., 1999; Oliveira et al., 1978).

c. Dietary Aldehydes

Methanol is present in fruit and vegetables, fruit juices, and fermented beverages (Kavet and Nauss, 1990), and ethanol constitutes a substantial portion of alcoholic beverages. They are enzymatically converted to formaldehyde and acetaldehyde, respectively, in vivo. However, formaldehyde is also present in fruit and vegetables, meat, cheese, and seafood, but its origin is not known (WHO, 1989). Aspartame, an artificial sweetener, is hydrolyzed in the gut to produce methanol, which is then converted to formaldehyde. Acetaldehyde is a natural component of many fluids including fruits, vegetables, and alcoholic products (Feron et al., 1991). It was also added to food and beverages as a flavoring substance. Thus, acetaldehyde concentrations in vegetables have been reported to be from 0.2 to 400 g/g, and in wine to be from 0.7 to 290 g/g. Acetaldehyde, formaldehyde, and acrolein are also produced during the cooking of fat-containing foods (Lane and Smathers, 1991 ; Svensson et al., 1999). Peas contain traces of acetaldehyde, whereas cinnamon contains high amounts of cinnamaldehyde. Almonds and cherries contain benzaldehyde, the characteristic impact substance, whereas hexanal and 2-hexenal cause the “unripe odors” in fruits and vegetables. Anise and vanilla extracts contain anisaldehyde and salicylaldehyde, respectively. Dietary aldehydes are much more varied and complex, unlike environmental aldehydes, which are dominated by formaldehyde and, to a lesser extent, acetaldehyde, acrolein, glyoxal, and methylglyoxal. These dietary carbonyls are described next under the following four classes:

FIG. 5. Myeloperoxidase-catalyzed metabolic activation.

1. Phospholipid and fatty acid hydroperoxlde decomposition aldehydic products. Over a wide range, alkenals, alkanals, hydroxyalkenals, and glyoxals are products of LPO (Lane and Smathers, 1991; Mlakar et al., 1996; Spiteller et al., 2001 ; Uchida et al., 1998). Recently the pathway for 4-HNE formation from 9- hydroperoxylinoleic acid was shown to involve a Hock cleavage to nonenal followed by oxygenation to form 4-hydroperoxynonenal (Schneider et al., 2001; Uchida et al., 1998). Fruits/vegetables have enzymic pathways involving lipoxygenase-hydroperoxide lyases, as their 2-alkenal and alkanal contents are markedly increased on physical disruption and subsequent processing as a result of these enzymes being brought into contact with their unsaturated fatty acid substrates (Gardner et al., 2004). For instance, the 13- hydroperoxides of linoleic/linolenic acid cleave into hexanal and cis-3-hexenal. The volatile aldehydes and alcohols formed contribute to the characteristic flavor of each fruit or vegetable but could be a primary defense mechanism against microbial infection. For example, hexenal up to 76 ppm can be found in bananas, with up to 25 ppm found in black tea. Hexenal has been approved by the Food and Drug Administration (FDA) to use as a food artificial flavoring additive to generate “green notes” because of its “green” and fruity flavor. Citrus peel can contain up to 500 ppm decadienal and 410 ppm nonadienal (Adam et al., 1999). Glycolaldehyde was the major lipid peroxide decomposition product formed during the ferrous-catalyzed autoxidation of arachidonic acid (Mlakar et al., 1996). Glyoxal is also a threefold more abundant LPO decomposition product than malondialdehyde (Mlakar et al., 1996). Acrolein formation from unsaturated lipids or glycerol dehydration is markedly increased at cooking temperatures. Furthermore, acrolein is likely also formed as a result of cooking other food components, as acrolein was formed when amino acids (or polyamines) and sugars were boiled together. A Strecker degradation (decarboxylation plus oxidative deamination) reaction was proposed (Alarcon, 1976).

2. Monoterpene aldehydes/ketones. These aldehydes/ketones are odoriferous compounds found in the essential oils obtained from plants that are also widely used as flavoring additives for food and beverages, as well as scenting agents in household products. Citral (3,7-dimethyl-2,6-octadienal) is a reactive alkenal found in all citrus fruits and forms up to 80% of the essential oil of Cymbopogon citratus, known as lemongrass (Cimanga et al., 2002), and 2.7% of lemon peel essential oil, where limonene is the major component (Umano et al., 2002). The approved herbal medicine lemon balm contains up to 30% citral and 40% citronellal. Because of its intense lemon aroma and flavor, citral has also been used extensively as an additive/agent in the cosmetic, detergent, and food industries. The FDA included citral on the list of “generally recognized as safe” (GRAS) substances and approved it for food use (GRAS 21, CFR 182.60). It is now a major additive/agent with a world consumption of 1200 tons in 1996. Citral has a low acute toxicity in rats, although short-term use at high doses caused hepatomegaly. However, 60 mg/kg citral given orally to pregnant rats from day 6 to 15 of pregnancy interfered with implantation and caused detectable embryofetal and maternal toxicity with overt toxicity at higher doses (Nogueira et al., 1995). Terpene ketones are the main constituents of the essential oil of the leaves of spearmint, caraway, and mint, which are also used widely, for example, as spearmint and peppermint in food, toothpastes, mouthwashes, chewing gum, aroma therapy, and herbal medicines. Toxic terpene ketones include thujone in wormwood oil, used in absinthe liqueur or herbal medicine but that can cause convulsions and other neurotoxic effects. The direct use of thujone in food is not allowed, but it is present in a number of approved flavorings and additives, as well as in perfumes and Vicks ointments (Hold et al., 2000). Another terpene ketone is pulegone, found in pennyroyal oil (a mint oil), which is still used as an abortifacient, even though pulegone causes life- threatening centrilobular hepatic necrosis, likely as a result of a P450-catalyzed metabolism of the menthofuran metabolite to form a highly reactive y-ketoenal (Madyastha et al., 1993).

3. Aromatic aldehydes, Most of the aromatic aldehydes are substituted benzaldehydes that are abundant in the most commonly used spices. Cinnamaldehyde is formed from cinnamic acid in plants and constitutes up to 90% of cinnamon oil extracted from cinnamon leaves and bark and in essential oils such as myrrh and patchouli. It is also widely used as a flavoring/aroma agent when added to food or beverages, including ice cream, confectionary, baked goods, chewing gums, condiments, and meat preparations, with up to 6400 ppm permitted as an additive to fruits and juices (Friedman et al., 2000). A cinnamaldehyde analysis showed that cinnamon sticks and powder (commonly added to tea or rice) contained 2470 mg/100 g, whereas cinnamon-containing bread, buns, cereals, and cookies contained up to 31 mg/100 g (Friedman et al., 2000). It would therefore be easy to exceed the acceptable daily intake permitted for cinnamaldehyde of 1.2 5 mg/kg. Another flavoring/aroma agent, vanilla, contains the aromatic aldehydes vanillin, 4- hydroxybenzaldehyde, and salicylaldehyde. Both additives act as food preservatives because of their antimicrobial properties. Benzaldehyde is the major constituent of the essential oils of the seeds and kernels of bitter almonds, apricots, peaches, plums, and cherries. Furfural (2-furaldehyde) is also used as a flavor ingredient (maximal use of 63 ppm in meat products) but is formed when polysaccaharides are heated and is therefore highest in coffee and cocoa (55-255 ppm), whereas furfuryl alcohol is highest in heated skim milk (230 ppm) and coffee (90-881 ppm). Intake levels of furfural and derivatives are approximately 0.3 mg/kg/day, whereas furfural intake as a flavor ingredient is 100 times lower (Adam et al., 1999).

4. α-Oxoaldehydes, dialdehydes, and advanced glycation end products formed by protein glycation and lipoxidation. Oxoaldehydes include glyoxal, methylglyoxal, and 3-deoxyglucosone, whereas the dialdehydes include malondialdehyde and diacetyl. As shown in Figure 6, the Maillard reaction, the reaction between reducing sugars and amino groups of proteins (glycation), results first in the conversion of reversible Schiff base adducts to covalently bound Amadori rearrangement products (particularly fructosamine) and is a reversible step. The Amadori products can then undergo multiple dehydration and rearrangements resulting in the release from the protein of 3-deoxyglucosone, and is the major pathway for 3- deoxyglucosone formation in vivo. The deoxyglucosone can then react with more protein amine groups, causing cross-linking, and browning of the proteins via the formation of AGEs in the late stage of the Maillard reaction. Another series of reactions accelerated by oxygen and transition metals in a process called glycoxidation can also cause the glycated protein Amadori product to form AGEs such as N^sub ε^-carboxymethyl lysine (CML), pentosidine, pyrraline, and other unidentified compounds. CML is also formed during metal- catalyzed oxidation of polyunsaturated fatty acids in the presence of proteins in a process called lipoxidation (Figure 7) (Baynes and Thorpe, 2000). Glyoxal and methylglyoxal can also be formed from the degradation of proteins glycated by glucose or the degradation of fructosyl-lysine (Thornalley et al., 1999). Possible intermediates involved in glyoxal formation are suggested in Figure 4. Cooking food at high temperatures mark\edly accelerates these Maillard or browning reactions. Although some food or cooked food has been analyzed for methylglyoxal, the glyoxal content has not been analyzed. The various structures of the AGEs formed from glyoxal, methylglyoxal, and deoxyglucosone are compared in Figure 8.

FIG. 6. Endogenous glyoxal formation by autoxidation of glycoladehyde formed by (left) sorbitol metabolism (right) ascorbate or xylitol oxidative degreadation.

Recently, it has been shown that two-thirds of orally absorbed food AGEs (known as glycotoxins) were retained in tissues. Furthermore, feeding these AGEs to diabetics also triggered changes in inflammation biomarkers that were linked to diabetes and vascular dysfunction and could thus be considered as a risk factor for diabetic angiopathy (Vlassara et al., 2002). Modification of plasma proteins by AGE precursors form ligands that bind to AGE receptors inducing changes in gene expression in various cells.

Hydroxymethylfarfural (HMF) and furaldehyde are common furan AGE hydrolysis products of the Maillard reaction for hexoses and pentoses, respectively, for example, 1% HMF is formed when sugar is heated under household cooking conditions. HMF sometimes exceeds 1 g/ kg in dried fruits and up to 9.5 g/kg in caramel products. The oral LD50 value for the rat is 3.1 g/kg. However, the high concentrations of HMF found in food are not considered to pose a health risk. Two HMF doses of 300 mg/kg po induced aberrant crypt foci, which suggests in rats it may act as a weak initiator and promoter of colon cancer (Zhang et al., 1993). Cellular glutathione (GSH) was depleted by high concentrations of HMF, but GSH conjugates or reactive metabolites have not been identified (Janzowski et al., 2000). Furaldehyde (Figure 1) is found in cocoa, coffee, alcoholic beverages, etc., and is used as a flavor ingredient. Our approximate daily consumption is 0.3 mg/kg/day. The oral LD50 value in the rat is 50-149 mg/kg, with hepatotoxicity occuring at doses above 50 mg/ kg (Adams et al., 1997), and is also a metabolic inhibitor (inhibits pyruvate dehydrogenase (Modig et al., 2002). It is readily metabolized by aldehyde dehydrogenase (ALDH) to furoic acid, but it is not known whether furaldehyde or reactive metabolites deplete cellular GSH (Adams et al., 1997). Furfural is also formed endogenously as an ROS breakdown product of deoxyribose in DNA (Barciszewski et al., 1997). Furan, another Maillard reaction product, is a rodent hepatocarcinogen and hepatotoxin found in many processed foods and beverages, with up to 3900 ppb in brewed coffee extracts (part of the aroma). It is also an environmental toxin and occupational hazard, as it is used as a resin and lacquer solvent and is volatile. The toxicity has been attributed to the major dialdehyde metabolite cis-2-butene-1,4 dial (formed by P450), which reacts with DNA to form mutagenic adducts and forms adducts with deoxycytidine, deoxyguanosine, and deoxyguanosine (Byrns et al., 2002). It also rapidly cross-links protein amino acids to form pyrrole/pyrrolin-2-one derivatives or reacts with glutathione to form adducts (Chen et al., 1997). 2-Methylfuran also found in coffee, cigarette smoke or air pollution (as an SOC) is metabolically activated to acetylacrolein and causes liver, lung, and kidney necrosis in rodents (Ravindranath et al., 1985). As described earlier, lethal hepatotoxicity induced by ingesting the herbal medicine pennyroyal oil for abortifaciant purposes has been attributed to the reactive γ-ketoenal metabolite of menthofuran, the major metabolite of pulegone (Madyastha et al., 1993).

FIG. 7. Mechanism of protein carbonylation and glycation by aldehydes.

FIG. 7. Mechanism of protein carbonylation and glycation by aldehydes.

Glyoxal and methylglyoxal (Figure 1) are major products formed from the reaction of carbohydrates amd amino acids during the nonenzymyatic browning that occurs during thermal processing of foods such as roasted coffee or bread crust. Glycolaldehyde was more effective than glyoxal in generating radicals for the browning reaction with alanine at 98C (Hofmann et al., 1999). Cooking food increases its glyoxal content because, as described earlier, glyoxal (but not methylglyoxal) was formed by glucose autoxidation during heating (Wells-Knecht et al., 1995). Glyoxal/methylglyoxal formation by lipid autoxidation or DNA oxidation discussed earlier would also be expected to increase during cooking. The methylglyoxal content of some foods have been determined but not their glyoxal content. The highest methylglyoxal content of food found was in soy sauce (498 g/ ml) and soybean paste (939 g/ml) (Sugimura et al., 1983). By far the highest methylglyoxal containing beverage is brewed coffee (75 g/ gm). The methylglyoxal content of coffee has been attributed to the roasting process. An estimated 150 g methylglyoxal and 750 g hydrogen peroxide was found per cup of coffee. It was also found that hydrogen peroxide increases methylglyoxal mutagenicity (Fujita et al., 1985). Coffee also contains more furfural than methylglyoxal, but less glyoxal and diacetyl (an aroma component). Because of their reactivity associated with pathophysiological consequences, it is clear that the content of glyoxals as well as AGEs in our food, particularly cooked food, needs to be analyzed.

FIG. 8. Advanced glycation end-products formed by reactive carbonyl products.

Acrylamide, a probable human carcinogen (IARC, 1994), has recently caused some concern, as it was found in fried and oven- cooked food. It also could be formed when glucose was heated with asparagine, which forms 40% of the amino acids of potato and 18% of wheat flour. A Strecker degradation of the amino acid by glyoxal products of a Maillard reaction was proposed (Mottram et al., 2002).

d. Aldehyde Drugs or Reactive Drug Metabolites

Drugs that are aldehydes or form reactive aldehyde metabolites which cause side effect toxicity are summarized in Table 1. The anticancer drugs cyclophosphamide and ifosfamide undergo a P450- catalyzed metabolism to acrolein and chloroacetaldehyde, which cause hemorrhagic cystitis and neurotoxicity, respectively (Maki and Sladek, 1993; Sladek et al., 1985; Sood and O’Brien, 1996). The anticancer drug misonidazole is reduced to DNA-adduct-forming glyoxal, catalyzed by P450 reductase (Heimbrook et al., 1986). The nonsteroidal antiinflammatory drug sudoxicam was also metabolized to glyoxal and was withdrawn because of hepatotoxicity. Felbamate antiepileptic drug therapy has limited use because of hepatotoxicity and aplastic anemia, which has been attributed to atropaldehyde, a major metabolite (Kapetanovic et al., 2002). Abacavir, a reverse transcriptase inhibitor, marketed for the treatment of HIV-I infection, forms a reactive aldehyde intermediate that plays a role in covalently binding proteins (Walsh et al., 2002). Sorbinil, an aldose reductase inhibitor, formed an erythenatous rash in humans and formed a reactive aldehyde intermediate from 2-hydroxysorbinil, its major metabolite (Maggs and Park, 1988).

TABLE 1

Examples of therapeutic drugs and toxic aldehyde metabolites

2. ALDEHYDE METABOLISM AND METABOLIZING ENZYMES

The body carbonyl burden is of concern because aldehydes are reactive electrophiles that form adducts with cellular protein thiols and amines and can therefore cause toxicity. Lipoxidation is the description of the process for forming carbonylated proteins with LPO aldehydes, whereas glycoxidation is used to describe the process for forming cabonylated proteins with carbohydrate-derived dicarbonyls. The protein adducts formed are often reversible, but can undergo degradation to form reactive advanced lipoxidation (ALE) or glycoxidation (AGE) end-products that covalently cross-link proteins that accumulate with aging and increasingly disrupt protein and cellular function. ALEs probably contribute to the pathogenesis of atherosclerosis, whereas AGEs are generally regarded as a cause of the increased risk for microvascular disease in diabetes.

The ability of cells to metabolize and detoxify aldehydes largely depends on the aldehyde and the cellular content of aldehyde- metabolizing enzymes. Thus 4-HNE and methylglyoxal were very rapidly metabolized (within 3 min) by cells, whereas formaldehyde metabolism was slower but more rapid than acetaldehyde metabolism. The rapid metabolism of 3 mM 4-HNE (t^sub 1/2^ of 2 min) by rat hepatocytes (106/ml) was attributed to glutathione S-transferase (GST) and ALDH2 (aldehyde dehydrogenase) activities and to a minor extent alcohol dehydrogenase (ADH), with only 1% binding to proteins (Grune et al., 1991,1994; Hartley et al., 1995; Siemsetal., 1997). Ratenterocytes also rapidly metabolized 4-HNE. The rapid metabolism of 3 mM methylglyoxal (t^sub 1/2^ of 2 min) by hepatocytes was likely due to metabolism catalyzed by glyoxalase (GLOX) and reduction catalysed by aldo-keto reductase (AKR) 1A2. Because of this rapid metabolism, both of these aldehydes were much less toxic than would be expected from their reactivity towards macromolecules. Furthermore, 4-HNE was metabolized by mouse Ehrlich Ascites cells at one-third of the hepatocyte rate and was also more toxic to ascites cells than to hepatocytes (Grune et al., 1991; Niknahad et al., 2003a). The slower metabolism of 3 mM formaldehyde (t^sub 1/2^ of 30 min) by hepatocytes was likely due to metabolism by ADH5 and ALDH2. Furthermore, formaldehyde cytotoxicity was markedly increased by inhibiting the activity of these enzymes or by depleting hepatocyte glutathione levels (Teng et al., 2001).Chloroacetaldehyde cytotoxicity was markedly increased by ADH1 and ALDH2 inhibitors or by depleting glutathione levels (Sood and O’Brien, 1993). While the major in vivo metabolism route for eliminating alkanals and aromatic aldehydes is via oxidation catalyzed by dehydrogenases, the major urinary metabolite for the dicarbonyl 3-deoxyglucosone in \humans or when administered to rats is by reduction catalyzed by aldehyde reductases to 3-deoxyfructose (Kato et al., 1990). Ketones and 2- hydroxy- or 2-carboxybenzaldehyde are also mostly reduced. Conjugation with glutathione catalyzed by glutathione transferase is a major in vivo elimination route for alkenals, while a glutathione- catalyzed isomerization catalyzed by glyoxalase is the major route for the dicarbonyl phenylglyoxal. The following 19 classes of aldehyde-metabolizing enzymes described include 9 aldehyde- oxidizing enzymes, 7 aldehyde-reducing enzymes, and 3 glutathione- dependent enzymes, which function to help the cell detoxify the various aldehydes that the cell is exposed to.

a. Aldehyde-Oxidizing Enzymes

Aldehydes are somewhat unique toxicants in that they are metabolically detoxified by oxidation in vivo (to acids) and/or reduction to alcohols. Alcohol reoxidation can then be prevented by glucuronidation or sulfation of the alcohol, whereas acids often form glycine conjugates (hippuric acids). In general, aldehydes are primarily oxidized usually by NAD^sup +^ and ALDH, whereas some ketones are reduced by NADH and ADH to form secondary alcohols. Alcohol dehydrogenase (described later under Aldehyde-Reducing Enzymes) can also oxidize aldehydes; for example; ADH5 utilizes NAD^sup +^ to oxidize formaldehyde (via its glutathione conjugate) to form formate; ADH1 (particulary γ^sub 2^γ^sub 2^) and to a lesser extent ADH2 but not ADH3 (yeast) catalyzes the dismutation of aldehyde hydrates to form alcohol and carboxylic acid. However, the K^sub m^ for acetaldehyde was 100-fold higher than that for acetaldehyde reduction. Other K^sub m^ values are 1.2mM for butanal and 0.15 mM for 5-hydroxindole 3-acetaldehyde (the major serotonin metabolite) (Svensson et al., 1999). The alcohol dehydrogenase ADH5 also utilizes NAD^sup +^ to oxidize formaldehyde (via its glutathione conjugate) to form formate. ADH catalyzes the oxidation of aldehydes via gem diols. Sixteen aldehyde dehydrogenase (ALDH) genes and three pseudogenes have been identified and their chromosome locations determined in the human genome. Their role in endogenous and xenobiotic metabolism has recently been reviewed (Vasiliou and Pappa, 2000). The toxicologically more significant hepatic ALDHs, other dehydrogenases, and P450s describe by their gene name are as follows.

Aldehyde dehydrogenase superfamily

1. ALDHlA (chromosome location 9q21) is cytosolic in location, which is constitutively expressed in various tissues , with highest levels in the liver. It is the major ALDH that catalyzes the oxidation of retinal to retinoic acid (Ambroziak et al., 1999; Klyosov, 1996) and detoxifies aldophosphamide (the active metabolite of the anticancer agent cyclophosphamide). It is not efficient at oxidizing acetaldehyde but is efficient at oxidizing longer chain alkanals. The aldehydes of naphthalene, phenanthrene, and coumarin are also oxidized (Keung, 1991; Vidal et al., 1998).

2. ALDH2 (chromosome 15 location) is mitochondrial in location, which is constitutively expressed in various tissues, with the highest levels in the liver. The enzyme has two cysteine residues immediately adjacent to the active site thiol and can form an inactive intramolecular disulfide bond with NO or nitroglycerin. Indeed, this process results in the bioactivation of nitroglycerin with ALDH2 acting as a nitrate reductase (Chen et al., 2002). A solubilized purified preparation of mitochondrial ALDH catalyzed aldehyde oxidation at pH 9.5 with the following order of effectiveness as determined by k^sub cat^: formaldehyde > acetaldehyde, heptanal > octanal > 4-nitrobenzaldehyde > benzaldehyde, whereas retinal or alkenals were found to be inhibitors (Klyosov, 1996). However, the order found for mitochondrial ALDH activity using a mitochondrial fraction at pH 8.5 and much lower aldehyde concentrations (10 M) was heptanal, octanal > phenylacetaldehyde > acetaldehyde > retinal [much greater than] formaldehyde, benzaldehyde (Wang et al., 2002). The order found for rat liver mitochondrial ALDH2 activity based on K^sub m^ and V^sub m^ was chloroacetaldehyde [much greater than] propionaldehyde, > dichloroacetaldehyde with no activity for chloral hydrate presumably because it is a strong ALDH2 inhibitor with a K^sub i^ of 150 M (Sharpe and Carter, 1993). The order found for human ALDH was methoxyacetaldehyde > propionaldehyde > acetaldehyde > glycolaldehyde > methylglyoxal > glyoxal > benzaldehyde with no activity for chloral hydrate or glyoxylic acid (Kraemer et al., 1968). Perhaps the best substrate is 4-HNE, as addition of 1 mM 4- HNE to hepatocytes resulted in a very rapid metabolism (half-life of 1 min) that was attributed to metabolism by ALDH2 and GST (Siems et al., 1997; Hartly et al., 1995). Methylglyoxal was a poor substrate (K^sub m^ 8.6 mM) and was also an ALDH2 inhibitor (Izaguirre et al., 1998). Because of the high efficiency of ALDH2 in catalyzing acetaldehyde oxidation, it is likely that ALDH2 plays the major role in acetaldehyde detoxification in humans. It is highly polymorphic in Asians, and individuals with the ALDH2.2 deficient allele exhibit the “alcohol flushing” syndrome as a result of the elevated blood acetaldehyde (Vasiliou et al., 2000). As a result of this discomfort, it is possible that this mutation is strongly protective against alcoholism. However, individuals with this mutation who drink have an increased risk of esophageal and upper aerodigestive tract cancers. Interestingly, although the mutant allele has a marked decrease in activity toward acetaldehyde, formaldehyde, propionaldehyde, or hexanal, its activity toward longer alkanals or aromatic aldehydes was the same as the wild allele (Wang et al., 2002).

3. ALDHlBl, formerly known as ALDH5 (chromosome location 9pl3), is mitochondrial in location and found in the liver, heart, brain, testis, skeletal muscle and fetal tissues. It is active with short- chain aldehydes (acetaldehyde and propionaldehyde) and NAD^sup +^ (not NADP^sup +^) but is insensitive to disulfiram unlike ALDH 1 and 2 (Stewart et al., 1995). It is polymorphic and three variants have been identified (Vasiliou et al., 2000).

4. ALDH3A1 (chromosome location 17pll.2) belongs to a group of homodimeric enzymes tthat are cytosolic in location and utilize NAD^sup +^ or NADP^sup +^ as a cofactor, depending on the isozyme. It is constitutive in the stomach, heart, skin, and corneal epithelium. This enzyme is highly polymorphic in the general population. Although it is not found in the liver, colon, spleen, bladder, lung, and thymus of rodents but can be induced with AhR ligands, it is expressed in hepatoma cells of rats and can be induced along with CYPlAl more than 100-fold in rat liver by AhR ligands, such as the carcinogenic polycyclic aromatic hydrocarbons benzo[a]pyrene and 3-methylcholanthrene. The ALDH3A1 induction is in response to acute-phase proteins induced by an atypical hepatocyte inflammation and can be prevented by NSAIDs (Pappas et al., 2003). It is also overexpressed in the hepatocellular carcinoma tissues of 50% of cancer patients and is associated with ALDH2 downregulation (Park et al., 2002). These patients are also resistant to oxazaphosphorine chemotherapy, for example, cyclophosphamide, ifosfamide, 4-hydroperoxycyclophosphamide, and mafosfamide. Genotyping cancer patients for ALDH3A1 could therefore be useful for selecting the best type of chemotherapy. The chemotherapy resistance is due ostensibly to the enzyme-catalyzed oxidative detoxication of aldophosphamide, the pivotal aldehyde metabolite of these prodrugs. The disulfiram and chloral hydrate ALDH inhibitors do not inhibit this enzyme. However, chlorproamide analogues are inhibitors for this enzyme and may prove useful for overcoming tumor resistance (Rekha et al., 1998). Substrates include LPO aldehydes, such as 4- HNE. The order of effectiveness of other substrates was phenylacetaldehyde > benzaldehyde [much greater than] propionaldehyde. Dicarbonyls have not been reported to be substrates.

5. ALDH3A2 (chromosome location 17pl 1) is microsomal in location utilizes NAD^sup +^ as a cofactor and is considered to perform a housekeeping function in all tissues. A solubilized preparation of microsomal ALDH catalyzed the oxidation of fatty aldehydes to fatty acids, as well as the oxidation of medium- and long-chain alkenals, and alkanals, whereas acetaldehyde, benzaldehyde, retinaldehyde, and crotonaldehyde were poor substrates (Kelson et al., 1997). A genetic deficiency of ALDH3A2 is associated with the SjogrenLarson syndrome, an inherited neurocutaneous disorder, whose symptoms include mental retardation, spasticity, and ichthyosis. ALDH3A2 is also inducible by peroxisome proliferators. The enzyme is polymorphic and seven variants have been identified (Agarwal, 2001).

6. ALDH9 (betaine aldehyde dehydrogenase) is found as cytosolic and mitochondria! isozymes in the liver, kidney, adrenal glands, brain, and plants and utilizes NAD^sup +^ as a cofactor (Pietruszko et al., 2001). ALDH9 catalyzes the oxidation of betaine aldehyde (formed from choline by choline dehydrogenase located in the inner mitochondrila membrane) to betaine (an intracellular osmolyte and methyl donor) and the final step in the conversion of choline to betaine. Betaine aldehyde is the preferred substrate, but aminoaldehydes (e.g., trimethylaminobutyraldehyde, a carnitine biosynthesis intermediate, as well as aldehydes of polyamine metabolism), aliphatic aldehydes (e.g., acetaldehyde [formerly E3]), aromatic aldehydes, and methylglyoxal (and glycolaldehyde) are also substrates (vander Jagt and Hunsaker, 2003). Cimetidine is an inhibitor of this isoform.

7. α-Oxoaldehydedehydrogenase (ODH), NADP^sup +^ dependent, is located in the liver cytosolic fraction and erythrocytes and utilizes NADP^sup +^ for catalyzing the oxidation of methylglyoxal (K^sub m^ 0.\26 mM) to pyruvate but did not catalyse the oxidation of glyoxal or 3-deoxyglucosone. Amines, such as aminopropanol, markedly activate this dehydrogenase (vander Jagt and Hunsaker, 2003). The α-oxoaldehyde substrates are essentially fully hydrated and are not good substrates for ALDHl and -2. It is therefore believed that the role of 2-ODH is to prevent protein glycation (Fujii et al., 1995). The enzymes are monomeric with a 42,000-MW cysteine at the active center and are inhibited by nucleotides and thiol reagents.

8. NAD^sup +^-dependent a-ketoaldehyde-dehydrogenase or pyruvate dehydrogenase. A goat liver cytosol enzyme was isolated that catalyzed the oxidation of methylglyoxal to pyruvate (Ray et al., 1982), whereas methylglyoxal oxidative decarboxylation to acetyl coenzyme A (CoA) and formate was catalyzed by the thiamine pyrophosphatedependent decarboxylase part of the mitochondrial pyruvate dehydrogenase multienzyme complex (Argiles, 1989).

9. P450 or aldehyde oxidase. P450 is located in the endoplasmic reticulum and uses NADPH, oxygen, and NADPH:P450 reductase to catalyze the oxidation of alcohols and aldehydes. Alcohol oxidation is catalyzed by CYP2E1 (alcohol-inducible P450). Alcohols oxidized include ethanol and cyclohexenol. We have also shown that P450, not ADH, is the major metabolizing enzyme in hepatocytes for propargyl alcohol and 2-bromoethanol but not allyl alcohol (Khan et al., 1996; Moridani et al., 2001 ). The ethanol oxidation mechanism involves two one-electron oxidations, with the first forming 1-hydroxyethyl radicals and the second forming acetaldehyde. The mechanism of cyclohexenol oxidation to cyclohex-2-en-l-one, however, involves a radical-mediated formation of a gem-diol intermediate (Bellucci et al., 1996). P450 also catalyzes the oxidation of most aldehydes and includes alkanals (e.g., nonanal), alkenals (e.g., citronellal), benzaldehydes (e.g., 4-nitrobenzaldehyde), terpene-aldehydes (e.g., perillaldehyde), and unsaturated ketones (e.g., cyclohexenone) to products that inactivate P450. The examples given are the most effective aldehyde in that class (Raner et al., 1997). Many of these aldehydes were oxidized by specific P450 isozymes to the corresponding acid, for example, retinal (CYPlAl, 1A2, IBl, 3A4), acetaldehyde, trifluoroacetaldehyde (CYP2E1 ), tolualdehyde (CYP2C), and 9-anthraldehyde (CYP3A4) (Marini et al., 2003). However, the aldehyde oxidation mechanism found when 3phenylpropionaldehyde or cyclohexanal oxidation was catalyzed by P450 involved the formation of peroxyhemiacetal intermediates, which underwent scission (deformylation) to form formic acid and carbonyl carbon radicals. The latter then formed olefins and alkyl P450 heme adducts, which irreversibly inactivated P450 (Kuo et al., 1999). 4-HNE was also metabolically activated by P450 to carbonyl carbon radicals, which were oxidized to 4-hydroxy-2-nonenoic acid or inactivated P450 (Kuo et al., 1997). These reactive radicals also caused mitochondrial toxicity and formed LPO/ROS, which contributed to the aldehyde- cytotoxicity mechanism. Acrolein or allyl alcohol oxidation to glycidaldehyde (a reactive epoxide) and glycidol, respectively, was also catalized by the P450 mixed, function oxidase system (Patel et al., 1980). Furthermore-P450 activation by caffeine has been suggested as an explanation for the caffeine potentiation of allyl alcohol-induced hepatotoxicity (Karas and Chakrabarti, 2001).

10. Molybdenum hydroxylases: aldehyde oxidase (AOX) and xanthine oxidase (XO). Aldehyde oxidase (AOX) is mostly cytosolic with some microsomal activity, primarily in the liver (then kidney and intestine), that utilizes oxygen (or ferricyanide) to oxidize aldehydes to carboxylic acids. AOX has a broad specificity for aldehydes, including all aromatic aldehydes. Aldehyde substrates commonly used include benzaldehydes (e.g., vanillin, 4-hydroxy-3- methoxybenzaldehyde, although steric hindrance occurred with ortho substituted benzaldehydes) or 1- or 2-naphthaldehyde, while butyraldehyde was the best alkanal substrate. Endogenous or biogenic aldehyde substrates included indole-aldehydes, retinal, pyridoxal, and TV-methylnicotinamide. AOX also utilized aldehydes to reduce nitroarene drugs such as nitrofurazone (Wolpert et al., 1973). AOX is a dimeric protein of molecular mass 300 with two identical independent subunits containing molybdopterin, FAD, and two iron- sulfur centers. AOX had a higher affinity for aldehydes than xanthine oxidase (XO), but did not oxidize xanthine as did XO. Superoxide radicals were also formed when acetaldehyde was oxidized by AOX catalysis and seemed to contribute to ethanol hepatotoxicity in vivo or ischemia-reperfusion injury (Mira et al., 1995; Shaw and Jayatilleke, 1990). AOX also oxidized and detoxified lipophilic aromatic compounds, including pteridines, phthalazines, phenanthridine, pyrimidines, and purines. Its activity was higher in guinea pigs and rabbits than in pigs, mice, hamsters, or humans, but is absent in dogs, birds, and some Sprague-Dawley (SD) rat strains, including the one used by most researchers. It was inhibited by isovanillin, menadione, chlorpromazine, promazine, hydralazine, and estrogen receptor modulators (with raloxifene the most effective), but not allopurinol. Other drugs also effectively inhibit AO; therefore, these drugs have the potential to cause drug/drug interactions with other drugs metabolized by AO (Obach, 2004).

XO normally exists in cells as xanthine dehydrogenase (XDH), which differs from XO in having an accessible NAD^sup +^ binding site so that XDH can oxidize xanthine or hypoxanthine to form uric acid, the terminal part of the purine catabolism pathway in humans. Other purines and pteridines were also oxidized. XDH also oxidized ethanol to hydroxyethyl radicals and acetaldehyde (Castro et al., 2001). X-ray crystallography showed that XO was formed from XDH by a reversible oxidation of Cys535 and Cys992 or if the peptide chain was knicked by a Ca^sup 2+^-ac

Long-term Antabuse Keeps Most Alcoholics Abstinent

By Anne Harding

NEW YORK — Alcoholics may have a better chance of staying abstinent if long-term therapy includes drugs such as Antabuse, a new study shows.

Someone on one of these so-called alcohol deterrents will get sick with even a sip of alcohol, with a flushed face, rapid heartbeat, nausea, vomiting and anxiety. But the main power of these pills is their psychological effect, Dr. Hannelore Ehrenreich of the Max-Planck-Institute of Experimental Medicine in Gottingen, Germany, the study’s lead author, told Reuters Health.

Ehrenreich and her colleagues found that more than half of severe alcoholics whose treatment included an alcohol deterrent were not drinking seven years after their program ended. This is far better than the track record seen with typical programs, she said, in which just 6 percent to 20 percent of participants are abstinent two years after treatment.

The program Ehrenreich and her team studied, known as Outpatient Long-term Intensive Therapy for Alcoholics (OLITA), included regular individual therapy, group sessions and other types of social support, as well as frequent urine and blood tests for drug and alcohol use. Patients also regularly took an alcohol-deterrent drug. Patients with conditions that made them ineligible for drug treatment, such as liver or heart disease, were assigned to a placebo.

At the beginning of the study, patients took the drug daily in front of a therapist. The drug gradually was given less often, but still under supervision, until the patient had been in treatment for 13 months, after which he or she could decide whether to continue taking it. Early on patients received the shorter-acting drug calcium carbimide, and were later switched to Antabuse (also known as disulfiram), which is effective for a week or longer.

Of the 180 patients who began the study, 108, or 60 percent, were abstinent seven years after the end of treatment. The longer a patient took an alcohol deterrent, the researchers found, the more likely he or she was to stay sober. And among patients who drank again, the later in treatment the lapse occurred, the more able patients were to return to abstinence afterwards.

One recent study found that only a tiny minority of addiction specialists prescribes alcohol deterrents to their alcoholic patients. This is likely because, Ehrenreich said, Antabuse got a bad reputation when it was first introduced in the mid-20th century. A person’s family members would slip the drug into the alcoholic’s food or drink, believing that it would treat their problem; in fact, the result was sometimes fatal. For alcohol deterrents to work, Ehrenreich said, they must be taken knowingly and willingly.

The findings underscore the fact that alcoholism is a chronic illness and must be treated like one, Ehrenreich added; short-term treatments are rarely enough to keep a person off alcohol.

“We cannot think within a few months everything is over,” she said. “This person needs lifelong attention.”

SOURCE: Alcoholism: Clinical and Experimental Research, January 2006.

Fatigue may persist after breast cancer treatment

By Karla Gale

NEW YORK (Reuters Health) – Approximately one third of women treated for breast cancer experience fatigue for the first five years after treatment, and for about two thirds of those, the fatigue will persist, the results of a long-term study indicate.

“The message is that most women are going to be doing very well, but for those who have persistent fatigue, we think there is an underlying biological syndrome,” co-investigator Dr. Patricia A. Ganz told Reuters Health.

Ganz, from the University of California at Los Angeles, and her associates previously reported that 35 percent of 1,957 women who were diagnosed between with early-stage breast carcinoma between 1994 and 1997 experienced fatigue for the first five years after treatment.

For their current study, published online in the medical journal Cancer, they recontacted the same women in 1998 who were at least five years postdiagnosis. A total of 763 women who remained cancer-free completed the second set of questionnaires.

The results showed that 34 percent were classified as being fatigued. Among those classified as fatigued during the first survey, 63 percent continued to score in the fatigued range.

Further analyses indicated that depression, pain and heart disease were significant long-term predictors of fatigue, as was treatment with combined radiation and chemotherapy compared with either treatment alone.

“When we intensively studied the biological mechanisms of fatigue in smaller groups, we found that women with persistent fatigue have abnormalities” in markers of inflammation, Ganz said. “So it appears they may have some underlying predisposing inflammatory condition” causing the fatigue that is triggered or exacerbated when they develop cancer.

“Like any other subjective complaint,” she added, “we have to believe the patient when she complains of fatigue. Then look for medical problems that may be amenable to intervention, such as anemia or a thyroid condition. If they are on a blood pressure medication, try to put them on meds that don’t contribute to fatigue.”

“And clearly a careful assessment of depression and management of pain are very important,” she added. “If we can get that under control their energy may improve.”

SOURCE: Cancer, February 15, 2006.

The Wolf Ledge: Once a Spot of Natural Beauty, Akron Landmark is Buried in the Past

By Mark J. Price, The Akron Beacon Journal, Ohio

Jan. 9–One of the most beautiful places in Akron’s history is hidden deep in the crevices of a residential neighborhood.

The Wolf Ledge, a natural ravine with 30-foot cliffs and a shallow cave, took centuries for nature to create and years for man to destroy.

Located south of East Exchange Street until the early 1900s, the giant rock formation was a marvel of erosion. A tiny stream — Wolf Run — had gnawed away at its sandstone base, carving out a rocky gulch that raced east to west.

The ravine began near present-day Spicer Street and extended all the way toward the Ohio & Erie Canal near Main and Cedar streets. The exposed ledge rose near Kling Street and cut across Allyn, Sumner and Sherman streets before descending near Grant Street.

Its jagged line followed a rough course between Power Street to the north and Cross Street to the south. In the 1880s, a wooden bridge was built over the chasm at Sumner Street.

“This ravine was a landmark of old Akron,” local historian Cloyd R. Quine (1881-1967) remarked in a 1950 study titled The Old Wolf Ledge. “With its high, overhanging cliffs and cave, and the rippling brook, it was one of the town’s most famous beauty spots.”

The ledge and stream derived their name from the wolves that early settlers used to hunt in the vicinity.

One of the featured attractions of the ravine was a 20-by-8-foot recess at the base of a large outcropping. Area residents referred to it by several names, including Indian Cave, Under the Rocks and Old Maid’s Kitchen (a name also bestowed upon Mary Campbell Cave in the Gorge Metro Park).

“Always the neighborhood children used it as their favorite playground and many were the Indian arrowheads turned up there by diligent searchers,” Beacon Journal reporter Ken Nichols reminisced in 1957.

Kids liked to build bonfires outside the cave and scratch their initials into the soot-blackened walls. In the wintertime, they sledded on southern hills leading to the ledge and skated on Brown’s Pond, a small lagoon formed by Wolf Run. In the summer, they enjoyed picnics.

Young adults visited the cave, too. They brought small kegs of beer purchased at the Wolf Ledge Brewery on Grant Street — better known as the Burkhardt Brewing Co. (and now the site of the Akron Board of Education Maintenance Building). The brewery was at the western end of the ledge, which, come to think of it, may not have been an ideal situation for safety.

It wasn’t all fun and games, though. Four quarries operated along the ledge. The ravine’s sandstone was used in the construction of downtown landmarks, including the Everett Building at Main and Market.

The rapidly growing neighborhood, primarily populated by German immigrants, was nicknamed the Wolf Ledge for the ravine that ran through it. Its general boundaries were East Exchange, Spicer Street, South Street and Washington Street (now Wolf Ledges Parkway).

“The district in recent times has often been called `Goosetown,’ but most Wolf Ledgers resent this term,” Quine noted. “At most it should be applied to the district south of South Street which was settled by Platt Deutsch and Slavs, with a business center at South and Grant streets.”

As Akron’s population surged in the 20th century, the neighborhood began to diversify and lost its distinct flavor. A mixture of nationalities followed the streetcar line down Grant Street.

More housing was needed to meet local needs. City officials began to murmur about all that available land along the ravine.

In 1915, Akron officials pointed out Wolf Run’s “tendency to choke up with refuse and overflow onto adjoining properties” during heavy rains.

In 1916, the City Council proposed building a reinforced concrete bed for the stream.

No, that wouldn’t suffice. In 1917, the city embarked on a $130,000 project to encase Wolf Run in a storm sewer.

Workers funneled the ancient stream into an underground pipe. After all those centuries, erosion would no longer be a factor at The Wolf Ledge.

As local development moved closer, more and more debris was tossed into the gully. Small sections were partially filled.

In January 1921, Akron officials proposed filling in the rest of the ravine to make “public playgrounds, athletic fields and recreation spots.” The council voted unanimously to buy the land on both sides of the ledge.

Trucks began dumping fill dirt and other materials that summer. The cave disappeared, the quarries disappeared, the cliffs disappeared.

Eventually, the ground was raised to an acceptable level.

Akron extended its streets and built new homes along four blocks in the neighborhood. Boss Park is among the landmarks situated over the site.

Today, there’s a noticeable dip in the road on Sumner, Sherman and Allyn. That’s about all that’s left of the famous ravine.

“Its course can be traced by the lowest ground to which the land slopes north and south between Power and Cross streets,” Quine noted in 1950.

The Wolf Ledge is buried and forgotten. Here’s the ultimate insult, though: Hardly anyone calls it by the correct name.

During an urban renewal project in the early 1960s, Washington Street was renamed Wolf Ledges Parkway.

Ledges? Wait a minute.

It should be ledge!

Too late. All the signs had been made.

“Someone apparently made an error,” City Planning Department librarian Louise Morris explained in 1970. “That’s the only explanation we have as to why the `S’ was added to the name.”

Regardless of wrong or right, Akron residents have called it Wolf Ledges ever since.

This year, another big change is coming to the neighborhood.

Spicer Village, a $32 million residential and retail development, is scheduled to break ground south of East Exchange and east of Brown Street.

That’s pretty close to Akron’s former beauty spot.

If construction crews should stray a few blocks over, they just might hit something hard when they begin to dig.

Mark J. Price is a Beacon Journal copy editor. He can be reached at 330-996-3769 or send e-mail to [email protected].

—–

Copyright (c) 2006, The Akron Beacon Journal, Ohio

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].

Selective abortion blamed for India’s missing girls

LONDON (Reuters) – About 10 million female fetuses may have been aborted in India over the past two decades, according to research published on Monday.

A team of scientists who analyzed female fertility figures from a national survey of 6 million people in India found that there were about half a million fewer girls born in the country in 1997 than expected.

Extrapolated over 20 years, the figure would be 10 million, the researchers said in a report published online by The Lancet medical journal.

They added that selective abortion of female fetuses is the most plausible explanation for the skewed sex ratio.

“We conservatively estimate that prenatal sex determination and selective abortion account for 0.5 million missing girls yearly,” said Dr Prabhat Jha, of the University of Toronto in Canada, who headed the research team.

“If this practice has been common for most of the past two decades since access to ultrasound become widespread, then a figure of 10 million missing female births would not be unreasonable,” he added in a statement.

The findings support estimates by the Indian Medical Association which has said that five million female fetuses are killed in India each year.

Jha and his team found that the sex of the previous child was a determining factor in whether a female fetus was aborted. Fewer females are born as second and third children if the first child in a family is a girl.

The researchers said lack of girls as a second or third child is more pronounced in educated, rather than illiterate, women.

“To have a daughter is socially and emotionally accepted if there is a son, but a daughter’s arrival is often unwelcome if the couple already have a daughter,” Professor Shirish Sheth, of the Breach Candy Hospital in Mumbai, India, said in a commentary on the report.

Fetal sex determination and medical termination of pregnancy based on the sex of the fetus have been illegal since 1994, but Sheth said there is published evidence of rampant female feticide in India where daughters are regarded as a liability.

“Female infanticide of the past is refined and honed to a fine skill in this modern guise,” Sheth added.

Dr Rajesh Kumar, of the School of Public Health in Chandigarh in India and a co-author of the report, said missing females is a growing problem.

“Our study emphasizes the need for routine, reliable and long-term measurement of births and deaths,” Kumar added.

Biofeedback cuts urine leak after prostate surgery

NEW YORK (Reuters Health) – For men undergoing prostate
removal for prostate cancer, biofeedback training before the
surgery reduces the duration and severity of urinary
incontinence after the procedure, according to a report in The
Journal of Urology.

Behavioral training has been shown to decrease incontinence
that persists following prostate surgery, the authors explain,
suggesting that training before surgery might also be
effective.

Dr. Kathryn L. Burgio and colleagues from the University of
Alabama at Birmingham evaluated the effectiveness of pre-op
biofeedback to hasten the recovery of urinary control, decrease
the severity of incontinence, and improve the quality of life
in the 6 months following prostate removal.

The intervention consisted of one session of
biofeedback-assisted behavioral training, in which men learned
bladder muscle control and received instructions for muscle
exercises. A rectal balloon probe measured and provided
immediate visual feedback of rectal pressure and bladder muscle
control.

Of the 51 men in the biofeedback group, 70 percent reported
that they were still doing the exercises they learned
preoperatively at the 6-month follow-up.

The time taken to achieve continence in the
biofeedback-training group hovered around 3.5 months, the
investigators report. On the other hand, fewer than half of the
51 men in the comparison group achieved continence by the
6-month follow-up.

At 6 months, men in the biofeedback group reported an
average of 73 days with no leakage, compared with 54 days
reported by men in the comparison group.

Severe or continual leakage was still present in nearly 20
percent of comparison subjects at the 6-month mark, the
researchers note, compared to 6 percent of those in the
biofeedback group.

“The training effect might have been greater had we used
more intensive preoperative training or resumed intervention
after surgery with a more regular program of postoperative
visits to further optimize outcomes,” the team suggests.

SOURCE: Journal of Urology, January 2006.

Birth Complications Linked to Eating Disorders

NEW YORK (Reuters Health) – Children of women who experience birth difficulties seem to be more likely to develop of anorexia and bulimia later in life, Italian researchers suggest.

Previous small studies have implicated complications during pregnancy and childbirth in the risk of anorexia in the offspring, Dr. Paolo Santonastaso and colleagues at the University of Padua note in their report, but only one study considered the role of birth factors in bulimia.

The researchers examined the birthing histories of subjects born at Padua Hospital between 1971 and 1979, including 114 people with anorexia, 73 with bulimia, and 554 comparison subjects.

According to the team’s report in the Archives of General Psychiatry, risk factors for anorexia included anemia and diabetes in the mother, and neonatal heart problems, among others. The presence of two or more of these factors raised the risk of anorexia by nearly sixteen-fold.

Santonastaso’s group theorizes that maternal anemia and diabetes can cause insufficient supply of oxygen and nutrients to the central nervous system of the fetus. Heart problems in a newborn infant can cause low blood flow that results in brain damage.

A finding that the age of onset of anorexia was related to the number of obstetric complications bolsters their theory. Average age of onset was 18.8 years for subjects with no complications, 17.5 for five or fewer complications, and 16.3 for those with more than five complications.

For bulimia, risk factors included low birth weight and early feeding problems, among others. As with anorexia, having two or more of these complications greatly increased the risk of bulimia.

“Future studies,” they conclude, “should try to assess the prognostic impact of the presence of obstetric complications and whether this factor might help in the choice of appropriate and effective treatment.”

SOURCE: Archives of General Psychiatry, January 2006.

For Savvy, Successful, Sexy and Single Women Age 35 and Up, the Shortage of Quality Men is a Problem That Needs an Urgent Fix

By ELAINE HARRIGAN

I recently went to a social gathering after work.

All women; all married. Except for me.

This isn’t unusual; I’m typically the lone, husband-free female in a room. At some point in the evening, the hostess’ other half wandered in to say hello and grab a plateful of goodies. He’s a nice- looking guy, not stop-you-in-your-tracks gorgeous, but attractive for a middle-aged, slightly balding man. For a brief moment, in between the panini and cream puffs, I caught myself thinking, “Gee, he’d be a good one to keep on the back burner if things go sour between him and the wife.”

A second later, I felt skanky about this. Not because I was lusting after a friend’s husband; single or married, we’re all guilty of dabbling in imaginary infidelity. It was more the fact that earmarking a friend’s husband for future reclamation made me realize that I had sunk to a new low in the hunt for eligible, datable men in my age group – generously speaking, between “my biological clock is ticking” and “here comes the AARP application.”

Here’s the sad truth: Quality, available men for women somewhere around age 35 on up are in grievously scant supply these days in the Queen City. Part of the reason, of course, is simple mathematics: After 30, most of the good ones are taken.

And let’s get this on the table right away: There’s nothing wrong with us. We’re a new breed of women – well-educated, successful self- actualized; master home managers and time jugglers. We’re equally adept at managing a company or a birthday party with 20 sugar-hyped first-graders. At the same time, we’ve kept up our Cosmo subscriptions, if you catch my drift.

Do we appreciate men? To quote country music’s Redneck Woman, Gretchen Wilson: “Hell, yeah!”

What we bring to a relationship and our interest in it are not the problems. It’s the times we live in. Even New York Times columnist Maureen Dowd poses questions about the appeal of power between the sexes in her new book “Are Men Necessary?” Women, she contends, are attracted to power in men while the same aura in women tends to scare men off. Women have achieved unprecedented independence and professional success; men haven’t evolved quite fast enough to catch up. We get that. It doesn’t stop us from longing for companionship, love and that spark that comes from mutual attraction.

For women in Rust Belt cities like Buffalo, there’s another influence affecting our datable men resources that’s as pernicious as those pesky zebra mussels proliferating in the Great Lakes, and just as hard to alleviate: the chronic leeching of manpower due to job loss and a stagnant economy.

We can’t blame the men. They’re just responding to a deep- seated, primitive instinct to follow the food supply. More antelope elsewhere equals guarantee of survival. Job decay and economic woes are forcing our mammoth hunters to go where the herds are abundant, so they can raise families, pay taxes, and have plenty of recreational money left over for plasma screen TVs and Jaguars. This is the American male dream.

I know what you’re thinking: With all the real problems facing Buffalo, the decline of date-worthy men is pretty trivial, even irrational. I beg to differ, and so would all my sisters hugging their remote controls instead of boyfriends on these cold Western New York nights.

So where does that leave us? In the middle-aged dating jungle where the only rule is: Do whatever it takes. Yes, scouting out future mate material among our married friends is slightly less distasteful than poking our noses in their medicine cabinets, but extreme times call for extreme measures.

I haven’t been above bribing male friends for inside information on their buddies’ marital woes. Really – what do you think guys talk about between goals and hat tricks? And then there’s the hot new trend of using your body parts as billboards. I’m sure we’re not far from some desperate woman tattooing her forehead with “available” and her Web site address. Just don’t look at me.

There is, of course, the tried and true course: waiting for men to become widowers. Personally, I’m put off by scanning the obituaries. I don’t like the idea of mixing sympathy with an eagerness to be the first woman offering more than a casserole for consolation. Besides, waiting around for the inevitable smacks of passivity. We’re women of the post-feminist age, raised to take a goal-oriented approach to getting what we want.

If we learned anything from last year’s natural disasters, it’s that scarcity drives people to take drastic action. And you know women when it comes to a limited supply of anything, whether it’s the last drop of coffee in the pot or a buy-one, get-one-free table of cashmere sweaters at Kaufmann’s: We’re possessed. Show us a prime available man, and get out of the way, sister! That man, and a convenient parking spot at the mall, will be claimed with equal ruthlessness.

As proof, my friend Steve told me a story about how his mother missed her shot at two available widowers because she wanted to be considerate and give them a bit of grieving time. Apparently, some other women weren’t reading the same Emily Post, and snatched up both men before she had time to bring over the obligatory basket of muffins. Forget politeness. Forget sisterhood. Female hormones are at work here, and there’s no such thing as civilized behavior.

Just as men relate everything in life to sports, women make sense of their world through shopping. As far as we’re concerned, what we’re facing in Buffalo is a surplus of inferior-quality products. Or to put it in consumer terms: Our mate mall has been reduced to a Wal-Mart.

We could tell you stories. A male friend of mine knows a woman around my age who has a long history of “loser men.” One was an accomplished intellectual type. Promising, on the surface, until the end of their dinner date when he discovered he was short of cash, which he borrowed from her. And never paid back.

I, myself, have amassed a catalog of men I call Pants-With-a- Pulse types. These are basically men who have little more to offer than the fact that they’re breathing.

For instance, there is the “Tight Pants” man, which has nothing to do with the fit of his jeans. This is the guy who incessantly brags about his net worth, but is too cheap to buy furniture, replace his wreck of a car, or spring for a dinner that doesn’t come in a take-out bag. I’ve also had a few “Smarty Pants.” These are the geniuses who correct every point you make with enough boring factoids to put the staff at Britannica into a permanent coma.

Other all-time favorites are the ones I dub “Freak-in-Pants.” These are men who creep you out with their weird idiosyncrasies. One was a relatively normal guy – bachelor, good job, decent-looking – who insisted on telling me how much he really, really loved to snuggle with his nieces and nephews. ‘Scuse me? I’m outta here. The other was a guy I called “The Virus.” He would hover around like a nasty flu bug, and no amount of rudeness or insults would drive him away.

The point I’m trying to make is Buffalo’s datable man malaise has led to a competition-free state of affairs. What happens is similar to the real estate market when interest rates soar: Instead of a lot of buyers paying top dollar for prime properties, you end up with a slew of ambivalent buyers who try to dicker down the price.

In a man-depleted environment, the dickerers are the unclaimed men; they know there are few challengers in the field. All they have to do is show up. They’re like the clumsy kid on the baseball team who can’t hit a ball to save his life. And then one day, he steps up to the plate and realizes there’s no one covering the bases, no one in the outfield. Heck, this is his golden opportunity to round all the bases and slide into home without ever picking up the bat. This is what we women end up with when there’s little pressure to compete for female attention.

Look, guys. It’s not that we think you’re all Neanderthals. We love ‘ya. You’re brawny, big-hearted, and can wield a mean snowblower and change tires without even worrying about your manicure. But there are just not enough of you to go around, and we’re getting a little desperate for some good, old-fashioned horn- bashing to show us we’re oh-so desirable creatures. And, besides, when there’s competition for women, men make an effort. They look better. Act better. Smell better. Everyone wins.

I’m thinking it’s time we take a proactive, guerrilla-marketing ap-proach to correct this growing deficit of Grade A testosterone in our city.

Here’s a suggestion: Instead of selling tourists on our great architecture, let’s hawk our reserves of available women. It’s not as if Buffalo would be the first to use the natural attraction between the sexes to save itself. Alaska marketed its excess of burly male mushers to attract more women. Miami rebuilt itself by making thongs and bare chests welcome in every public eatery. Even Las Vegas is putting the sin back in “Sin City.”

At the very core of our humanity, homo sapiens are just upright walking primates. We’re motivated by three basic needs: food, shelter and sex. Buffalo already has the food angle sewn up. Habitat? More than enough is said about the Buffalo environment on the Weather Channel. That leaves selling our sex appeal.

With all due respect, I don’t really think this is a job for Rich Geiger and the Convention and Visitors Bureau. Shriners and busloads of Amway sales reps aren’t exactly what we have in mind. Attracting eager and available members of the opposite sex takes a below-the- beltline kind of strategy. Maybe someone should put gentlemen’s club owner Richard Snowden on this. He seems to know something about how to lure men.

If that’s what it takes to cure the decline of Buffalo’s datable men population, I say: bring it.

Elaine Harrigan is marketing director for a local non-profit arts institution. This is her first article for First Sunday.

Albert Speer Jr emerges from Nazi father’s shadow

By John O’Donnell

FRANKFURT (Reuters) – As the son of one of Hitler’s closest aides who spent much of his childhood at the dictator’s mountain retreat, Albert Speer knows more than most Germans what it is like to live in the shadow of the country’s Nazi past.

Named after his father who was Hitler’s chief planner and favorite architect, Albert Speer Jr. was so traumatized by the war years that he developed a stutter so strong that he could barely communicate.

“I couldn’t string a sentence together,” he said in an interview with Reuters. “The reason was probably my childhood. The stutter is why I left school. I did a carpentry apprenticeship — if you build you don’t have to talk much.”

Speer later chose to follow in his father’s professional footsteps and become an architect, making his professional break by submitting anonymous proposals for building projects.

Now 71, he has learned to live with the name that plagued him as a young man growing up in a post-war Germany that has spent decades trying to come to terms with its Nazi past and World War Two.

Speer can look back on a career that has seen him become one of Germany’s better-known architects and an acclaimed town planner.

Speer’s practice, based in an imposing former factory in Frankfurt’s fashionable Sachsenhausen district, now works on projects worldwide.

Today, Speer tries to play down the significance of his father’s name although he admits that it shaped his career.

“I am the eldest son of that father and don’t see any reason to take another name. But the name certainly didn’t help me.

“Maybe it’s true, however, that with such a name, you really try hard. Perhaps that’s why this office developed with a big focus on ecology, sustainability and compatible architecture, rather than preconceived architectural structures.”

“Maybe one feels especially obliged to produce humane architecture and city planning when you have had such a father. My ambition to do something for other people is something to do with the name.”

GROWING UP AT HITLER’S RETREAT

Speer, whose father started plans to build Hitler’s imperial capital city to be called “Germania,” spent part of his childhood at the dictator’s Obersalzberg mountain retreat.

He moved to a small apartment in Heidelberg when his father was jailed for 20 years at the Nuremberg trials for his role as armaments minister, enslaving millions for the war effort.

Speer senior’s claim at the time that he knew nothing of the Holocaust — which spared him execution — has since been challenged by historians who showed, for example, that he sanctioned material to extend the Auschwitz death camp.

Albert Speer Jr., however, tries to stay out of the past.

“I am not a person who thinks a lot about the past,” he said. “I would rather think about the future.”

He is a vocal opponent of plans to reconstruct further buildings destroyed in the war such as Dresden’s Frauenkirche, saying they have no place in modern Germany.

The church, almost entirely destroyed by Allied bombings in 1945, was resurrected from rubble and rededicated in October. The project, Speer argued, should remain an exception.

He criticized plans to rebuild Kaiser Wilhelm II’s former residence in central Berlin.

Berlin plans to tear down the Palace of the Republic — the former East German parliament building — to rebuild a replica of the Prussian “Schloss,” the Kaiser’s stately residence that stood on the site until it was razed in 1951.

POST-WAR ARCHITECTURE

“When there is something left that’s part of the history of the city, then you should keep it,” said Speer. “But if there is nothing there, to make out as if we would like our old Kaiser Wilhelm back again is absurd. It’s crazy.

“What does the Kaiser’s palace have to do with modern Germany? Absolutely nothing.”

Speer also slated proposals in Frankfurt to rebuild a part of its old town destroyed in bombing raids.

Although he is against rebuilding, Speer is critical of the decision by German planners in the aftermath of World War Two to rip down many old buildings in what he said was the flawed belief that they could create a “new society.”

This policy, together with bomb destruction, transformed many of the country’s once-handsome cities beyond recognition.

“Those in power after World War Two said history doesn’t interest us,” said Speer. “It was not only the history of the Third Reich. They ripped down buildings that were much older.”

“They had hoped that a new society would be created that would be molded by this architecture. But it didn’t work. There was not enough consideration given to the past. People don’t want to live without history.”

West Germany in particular tore down many bomb-damaged buildings quickly after the war and hastily put up modern buildings. Communist East Germany, by contrast, left many of the damaged buildings standing at first because of a lack of funds to demolish them. Many have been renovated since unification.

As his career nears its end, Speer has put his past and his stutter behind him.

“The irony is that today I only talk to politicians, staff, students and others. I never take a pen in my hand.”

Walking in the professional footsteps of three generations of his family before him, does he think he inherited anything from his father that influenced his work?

Speer shrugs his shoulders and laughs. “Hopefully not.”

Moms Who Smoke after Delivery Breastfeed Less

By Charnicia E. Huggins

NEW YORK (Reuters Health) – Women who smoke more than 10 cigarettes a day after giving birth may wean their babies off breastmilk much more quickly than nonsmokers, study findings show.

“A lot of public health programs put lots of attention to smoking cessation during pregnancy, but they do not educate women about not smoking after delivery,” study author Dr. Jihong Liu, of the University of South Carolina, told Reuters Health.

For those who have a “misunderstanding that smoking postpartum is okay” for babies, Liu said the shortened breastfeeding duration among these women is “one adverse consequence.”

Liu conducted the research as a maternal and child health epidemiology fellow at the US Centers for Disease Control and Prevention in Atlanta, Georgia.

Little research has evaluated the association between women’s smoking patterns before, during, and after pregnancy and their duration of breastfeeding. To investigate, Liu and her colleagues analyzed data from more than 3,000 women who were involved in the 2000 and 2001 Oregon Pregnancy Risk Assessment Monitoring System, an ongoing surveillance system that collects information on the behavior and experiences of new mothers in that state.

The team found that while 91 percent of new mothers started breastfeeding, nearly 26 percent had stopped doing so by the time their infant was 10 weeks old.

This pattern was most common among mothers described as persistent smokers, who continued to smoke during and after pregnancy, and among those who smoked heavily – i.e. at least 10 cigarettes per day – after giving birth, study findings indicate.

In fact, both of these groups of mothers were more than twice as likely as nonsmokers to have stopped breastfeeding their infants before 10 weeks, Liu and her team report in the American Journal of Public Health.

The likelihood of early weaning among mothers who quit smoking while pregnant and either did not resume smoking or resumed smoking fewer than 10 cigarettes per day after delivery, was not significantly higher than among nonsmokers.

The shorter duration of breastfeeding among smokers may be partly due to hormonal factors such as lower prolactin levels and decreased breastmilk production among smokers, or to the lower fat content of smokers’ breastmilk, all of which has been shown in previous research.

Mothers who smoke may also stop breastfeeding because of concern about the toxic chemicals in cigarette smoke or because of their baby’s colic or excessive crying, which has been found to be more common among breastfed infants of smokers than among other infants.

Liu advised women who cannot maintain their nonsmoking status after giving birth to cut down on the number of cigarettes they smoke so that they can breastfeed longer.

“I’m still a believer that breastmilk is best for the infant,” Liu said.

She and her colleagues conclude that their “findings suggest that health care providers need to assist and help mothers who have previously smoked before and during (as well as after) their pregnancies to quit smoking during pregnancy and remain nonsmokers after delivery.”

SOURCE: American Journal of Public Health, February 2006.

American Society for Clinical Pathology’s Board of Registry Approves New International Certification Category

CHICAGO, Jan. 4 /U.S. Newswire/ — For the first time since its formation in 1928, the American Society for Clinical Pathology’s (ASCP) laboratory professionals certification body, The Board of Registry, has approved a new category of certification — ASCP-I (the “I” indicating international certification).

This new certification was developed to accommodate requests from laboratorians, laboratory managers and professional associations in other countries who want to ensure that their training programs and practice standards meet U.S. levels of excellence. “Certification by the ASCP Board of Registry (BOR) is universally recognized as ‘the gold standard’ for credentialing lab professionals,” says E. Blair Holladay, Ph.D., SCT(ASCP), the ASCP vice president who serves as the BOR’s executive director.

“There are thousands of well-trained laboratory professionals practicing in other countries — some 2,000 medical laboratory professionals graduate each year in Korea, alone. Those who choose to sit for and pass the ASCP-I exam will benefit in at least two ways,” Holladay says.

“First, they will know that they have passed the same level of testing that laboratorians practicing in the U.S. have. Second, they will likely become more employable in their home countries because the laboratory employment situation overseas is the exact opposite of that in the U.S. Here, there are more openings than there are candidates. In countries such as Korea, Japan, Singapore and the Philippines, there are more laboratorians seeking work than there are openings. Thus, a laboratory professional with ASCP-I credentials will immediately set her- or himself apart from the rest of the market.”

For the most part the ASCP-I exam will duplicate the exam given in the U.S. Where the test questions will differ is in areas of laboratory practice unique to the U.S. such as OSHA, CLIA and other governmental regulatory questions.

“This new designation,” Holladay says, “will not replace the need for U.S.-designed ASCP BOR certification should a foreign national – – whether credentialed or not — seek certification to work in a U.S. laboratory.

KOREA WILL LAUNCH PROGRAM

Starting this month, ASCP will offer three examinations in the Republic of Korea. They are the Medical Technologist (MT), Medical Laboratory Technician (MLT) and the Technologist in Molecular Pathology (MP) exams.

Korean laboratory professionals interested in learning more about the program are encouraged to visit http://www.ascp.org/bor/ international.

While the exams must be taken in one of 120 ASCP-approved international testing sites throughout the world (Pearson Professional Centers), much of the preparation can be accomplished online. Instant registration and practice exams are available online at http://www.ascp.org/bor/international/.

ABOUT THE BOARD OF REGISTRY

The ASCP Board of Registry was formed in 1928 to promote the health and safety of the public by certifying competent laboratory professionals and maintaining a national registry of those who have been certified. It is widely accepted as the most influential leader in the field of certification of medical laboratory professionals in the world.

More than 100 volunteer technologists and technicians, specialists, laboratory scientists, physicians, professional researchers and experts in psychometrics serve on the BOR’s scientific examination committees.

The BOR currently offers 23 certifications and five qualifications in laboratory medicine.

KOREAN CERTIFICATIONS TO BE OFFERED IN JANUARY 2006

Medical Laboratory Technician, MLT(ASCP-I)

The medical laboratory technician performs many routine laboratory tests in blood banking, chemistry, hematology, immunology, microbiology and urinalysis.

Medical Technologist, MT(ASCP-I)

The medical technologist is responsible for the accurate performance of many laboratory tests that determine the presence, absence or causes of specific diseases. A Medical Technologist must be able to conduct a full range of laboratory tests, from routine to complex, with little or no supervision. Medical Technologists also are responsible for the operation of precision instruments and complex medical devices. These individuals may function as supervisors, educators or researchers.

Molecular Pathology Technologist, MP(ASCP-I)

The technologist in molecular pathology is an individual who performs the molecular analysis and diagnosis of acquired, inherited and infectious diseases. This professional is involved in the practice or research of innovative technologies that include histocompatibility/immunogenetics and the diagnosis, treatment and prognosis of infectious diseases, cancer, genetic disorders. This professional plays an important role in the evolving area of medicine known as genomics and proteomics.

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Report says Iran seeks nuclear bomb: paper

LONDON (Reuters) – Iran is secretly trying to obtain
technology and expertise needed to build a nuclear weapon,
according to a leaked intelligence report that threatens to
deepen a rift with the West over its nuclear program.

Tehran’s nuclear purchasing plans stretch from Europe to
North Korea and the former Soviet states, Britain’s Guardian
newspaper said, citing a report by an unnamed European
intelligence agency.

The 55-page report, dated July 1, 2005, draws on material
gathered by British, French, German and Belgian agencies and
has been used to brief European government ministers, the
newspaper said.

The leaked report comes as Iran and the West remain locked
in a standoff over Tehran’s nuclear program.

The United States and the European Union fear Iran’s
civilian nuclear power program is a cover for making nuclear
weapons. Iran says it needs nuclear technology to generate
electricity.

The leaked intelligence report claims Iran has an advanced
program designed to acquire nuclear expertise, training and
equipment.

It also says Syria, Pakistan and North Korea are part of a
global black market in illicit weapons parts.

The document says Iran has built a web of front companies,
middlemen and academics whose job is to find the information
and materials needed for nuclear, biological and chemical
arsenals, according to the Guardian.

“In addition to sensitive goods, Iran continues intensively
to seek the technology and know-how for military applications
of all kinds,” the newspaper quoted from the report.

‘MISSILE DEVELOPMENT’

According to the Guardian, the document details Tehran’s
attempts to build a missile capable of reaching Israel and
southern Europe.

Iranian scientists are building wind tunnels, navigation
technology and acquiring calibration devices needed for
advanced missiles, the document says.

It concludes that Syria and Pakistan have also been buying
technology and chemicals needed to develop rocket programs and
to enrich uranium, according to the Guardian.

The report concludes that scientists in Tehran are shopping
for parts for a new ballistic missile with “import requests and
acquisitions … registered almost daily,” the Guardian said.

The report’s aim is to warn European Union companies from
doing business with the front companies, the newspaper said.
The report does not name Western firms or academics believed to
have worked with Iran, North Korea, Syria or Pakistan.

On Tuesday, Iran said it would resume atomic fuel research
and development next week.

That could lead to renewed calls from Washington and the
European Union for the case to be referred to the U.N. Security
Council, where Iran could face political or economic sanctions.

Apollo Chronicles: Strange Shadows on the Moon

NASA — The moon is utterly familiar. We see it all the time, in the blue sky during the day, among the stars and planets at night. Every child knows the outlines of the moon’s lava seas: they trace the Man in the Moon or, sometimes, a Rabbit.

This familiarity goes beyond appearances. The moon is actually made of Earth. According to modern theories, the moon was born some 4.5 billion years ago when an oversized asteroid struck our planet. Material from Earth itself spun out into space and coalesced into our giant satellite.

Yet when Apollo astronauts stepped out onto this familiar piece of home, they discovered that it only seems familiar. From the electrically-charged dust at their feet to the inky-black skies above, the moon they explored was utterly alien.

Thirty years ago their strange experiences were as well-known to the public as the Man in the Moon. Not anymore. Many of the best tales of Apollo have faded with the passage of time. Even NASA personnel have forgotten some of them.

Now, with NASA going back to the moon in search of new tales and treasures, we revisit some of the old ones, with a series of Science@NASA stories called “Apollo Chronicles.” This one, the first, explores the simple matter of shadows.

Dark Shadows

On the next sunny day, step outdoors and look inside your shadow. It’s not very dark, is it? Grass, sidewalk, toes–whatever’s in there, you can see quite well.

Your shadow’s inner light comes from the sky. Molecules in Earth’s atmosphere scatter sunlight (blue more than red) in all directions, and some of that light lands in your shadow. Look at your shadowed footprints on fresh sunlit snow: they are blue!

Without the blue sky, your shadow would be eerily dark, like a piece of night following you around. Weird. Yet that’s exactly how it is on the Moon.

To visualize the experience of Apollo astronauts, imagine the sky turning completely and utterly black while the sun continues to glare. Your silhouette darkens, telling you “you’re not on Earth anymore.”

Shadows were one of the first things Apollo 11 astronaut Neil Armstrong mentioned when he stepped onto the surface of the moon. “It’s quite dark here in the shadow [of the lunar module] and a little hard for me to see that I have good footing,” he radioed to Earth.

The Eagle had touched down on the Sea of Tranquility with its external equipment locker, a stowage compartment called “MESA,” in the shadow of the spacecraft. Although the sun was blazing down around them, Armstrong and Buzz Aldrin had to work in the dark to deploy their TV camera and various geology tools.

“It is very easy to see in the shadows after you adapt for a while,” noted Armstrong. But, added Aldrin, “continually moving back and forth from sunlight to shadow should be avoided because it’s going to cost you some time in perception ability.”

Truly, moon shadows aren’t absolutely black. Sunlight reflected from the moon’s gently rounded terrain provides some feeble illumination, as does the Earth itself, which is a secondary source of light in lunar skies. Given plenty of time to adapt, an astronaut could see almost anywhere.

Almost. Consider the experience of Apollo 14 astronauts Al Shepard and Ed Mitchell:

They had just landed at Fra Mauro and were busily unloading the lunar module. Out came the ALSEP, a group of experiments bolted to a pallet. Items on the pallet were held down by “Boyd bolts,” each bolt recessed in a sleeve used to guide the Universal Handling Tool, a sort of astronaut’s wrench. Shepard would insert the tool and give it a twist to release the bolt–simple, except that the sleeves quickly filled with moondust. The tool wouldn’t go all the way in.

The sleeve made its own little shadow, so “Al was looking at it, trying to see inside. And he couldn’t get the tool in and couldn’t get it released–and he couldn’t see it,” recalls Mitchell.

“Remember,” adds Mitchell, “on the lunar surface there’s no air to refract light–so unless you’ve got direct sunlight, there’s no way in hell you can see anything. It was just pitch black. That’s an amazing phenomenon on an airless planet.”

(Eventually they solved the problem by turning the entire pallet upside down and shaking loose the moondust. Some of the Boyd bolts, loosened better than they thought, rained down as well.)

Tiny little shadows in unexpected places would vex astronauts throughout the Apollo program–a bolt here, a recessed oxygen gauge there. These were minor workaday nuisances, mostly, but astronauts were jealous of the minutes lost from their explorations.

Shadows could also be mischievous:

Apollo 12 astronauts Pete Conrad and Al Bean landed in the Ocean of Storms only about 600 yards from Surveyor 3, a robotic spacecraft sent by NASA to the moon three years earlier. A key goal of the Apollo 12 mission was to visit Surveyor 3, to retrieve its TV camera, and to see how well the craft had endured the harsh lunar environment. Surveyor 3 sat in a shallow crater where Conrad and Bean could easily get at it–or so mission planners thought.

The astronauts could see Surveyor 3 from their lunar module Intrepid. “I remember the first time I looked at it,” recalls Bean. “I thought it was on a slope of 40 degrees. How are we going to get down there? I remember us talking about it in the cabin, about having to use ropes.”

But “it turned out [the ground] was real flat,” rejoined Conrad.

What happened? When Conrad and Bean landed, the sun was low in the sky. The top of Surveyor 3 was sunlit, while the bottom was in deep darkness. “I was fooled,” says Bean, “because, on Earth, if something is sunny on one side and very dark on the other, it has to be on a tremendous slope.” In the end, they walked down a gentle 10 degree incline to Surveyor 3–no ropes required.

A final twist: When astronauts looked at the shadows of their own heads, they saw a strange glow. Buzz Aldrin was the first to report “”¦[there’s] a halo around the shadow of my helmet.” Armstrong had one, too.

This is the “opposition effect.” Atmospheric optics expert Les Cowley explains: “Grains of moondust stick together to make fluffy tower-like structures, called ‘fairy castles,’ which cast deep shadows.” Some researchers believe that the lunar surface is studded with these microscopic towers. “Directly opposite the sun,” he continues,” each dust tower hides its own shadow and so that area looks brighter by contrast with the surroundings.”

Sounds simple? It’s not. Other factors add to the glare. The lunar surface is sprinkled with glassy spherules (think of them as lunar dew drops) and crystalline minerals, which can reflect sunlight backwards. And then there’s “coherent backscatter”–specks of moondust smaller than the wavelength of light diffract sunlight, scattering rays back toward the sun. “No one knows which factor is most important,” says Cowley.

We can experience the opposition effect here on Earth, for example, looking away from the sun into a field of tall dewy grass. The halo is there, but our bright blue sky tends to diminish the contrast. For full effect, you’ve got to go to the Moon.

Luminous halos; mind-bending shadows; fairy-castles made of moondust. Apollo astronauts discovered a strange world indeed.

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NASA

The Vision for Space Exploration

Japan Baby Boomers Face Late-Life Divorce Risk

By Isabel Reynolds

TOKYO — Newly retired engineer Kotaro Toyohara arrives home for a family celebration after his final day at work, clutching a ring for his wife, Yoko, his head full of plans for the years of leisure ahead.

To his shock, Yoko blurts out that she wants a divorce.

That was the scenario for one of this season’s most popular Japanese television drama series, “Jukunen Rikon” or “Mature Divorce,” reflecting a phenomenon that many commentators fear may balloon as Japan’s baby-boom generation heads into old age.

“We get more and more consultations like this,” said Atsuko Okano, who runs Carat Club, a divorce counseling service. “Women are becoming more independent. When their husbands retire, they realize they have 20 or 30 years of life ahead of them and they don’t want to carry on as before.”

With a new law set to come into force in 2007 allowing ex-wives to claim half their husband’s pension, domestic media are warning of a possible divorce boom.

The number of Japanese couples parting ways has risen rapidly over the past 20 years to a 2002 peak of 290,000, while divorce among those married more than 20 years has increased even faster.

Now figures are drifting downwards, but many commentators speculate that women — who initiate the majority of divorces — are holding out until 2007.

Some Japanese women see their husbands as an obstacle to enjoying their sunset years.

With few hobbies or friends to turn to, many Japanese retirees, often nicknamed “wet leaves” for their tendency to cling to their wives, spend their time at home.

What’s more, they expect their spouses to wait on them as they did when they were bread-winners.

“This was my problem. My husband reached retirement and didn’t know what to do with himself, so he was always in the house,” said Sayoko Nishida, author of a popular book called “Why are retired husbands such a nuisance?.”

“One of the worst things was always having to make his lunch,” she said.

Many men set to retire in the next few years have lived largely separate lives from their families for decades, preferring to devote themselves to their jobs — an arrangement some wives start to like, Okano said.

“I spent virtually all my time on my work,” said one 54-year-old school principal, whose wife divorced him and began a new career five years ago after their children grew up. “All I did at home was sleep. I quite understand how my wife felt.”

NOT ALL ROSY

The drama “Mature Divorce” ultimately paints marital break-up in a positive light, with the couple remaining friends while Kotaro plans to work as a volunteer in South America and Yoko starts a new career with an upmarket retail chain.

Counselors say a rise in similar cases in the real world could be a disaster. Women may face poverty, since the job market is less than welcoming to those who have devoted their lives to their families, while half a meager pension might not provide much of a living. Men often end up lonely and in poor health.

“Japanese men’s life expectancy falls by about 10 years if they divorce late in life,” said Nishida, who now runs regular discussion days to help couples overcome the hurdle of retirement. “That’s because they can’t do anything for themselves.”

She did not divorce but insisted her own husband at least learned to cook for himself.

“Couples need to rebuild their relationship,” Nishida said. “Retired men still tend to act like the lord and master.”

Not all men see a need for change.

“Mature Divorce” star Tetsuya Watari said in an interview on the program’s Web site that he never cooks and has not bothered to give his wife a birthday present in decades.

“I don’t think Kotaro’s way of life is wrong,” he said of the workaholic character he played in the drama.

Some viewers agreed with him.

“I can’t agree with the wife’s point of view,” said one poster on the Web site.

“She says Kotaro works all the time and doesn’t help around the house, but that’s normal for someone devoted to his job — I think it’s admirable. At least he’s not a talentless loser.”

Ovarian Leydig Cell Tumor in a Peri-Menopausal Woman With Severe Hyperandrogenism and Virilization

By Nardo, L G; Ray, D W; Laing, I; Williams, C; Et al

Abstarct

The authors report a case of Leydig cell tumor in a 46-year-old woman who first presented with severe clinical hyperandrogenism and associated complex medical history. Investigations revealed markedly raised serum concentrations of testosterone (28.3 nmol/l) and free androgen index (54.4), whereas sex hormone binding globulin, random cortisol, androstenedione, 17-hydroxyprogesterone and dehydroepiandrosterone sulphate concentrations were all within the normal range. Transabdominal ultrasound and computed tomography scan of the pelvis and abdomen showed a slightly bulky right ovary, but no other abnormalities. An ovarian source of androgens was suspected and surgery was arranged. Following a three-year history of defaulting appointments due to agoraphobia, she underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy and intraoperative selective ovarian venous sampling. Histopathological examination revealed a 2 cm Leydig cell tumor within the right ovary. Successful intraoperative ovarian venous sampling demonstrated significantly elevated testosterone levels (> 260 nmol/ l) from the right ovarian vein. Hyperandrogenaemia normalized post- operatively. The patient showed significant regression of clinical signs and symptoms, including the anxiety disorder. Clinical presentation, biochemistry and imaging modalities should allow to detect androgen-secreting ovarian tumors, while selective venous sampling should be reserved for patients whom uncertainty remains. The present case confirms that androgen-secreting ovarian tumors represent a diagnostic and therapeutic challenge. They have to be considered in the differential diagnosis of severe hyperandrogenism even in peri-menopausal women. Although selective venous sampling is of diagnostic value, however, its impact on future management should be considered on individual basis.

Keywords: Hyperandrogenism, ovarian Leydig cell tumor, peri- menopause, selective venous sampling, virilization

Introduction

Though polycystic ovary syndrome (PCOS) and nonmalignant androgen excess disorders are common causes of hyperandrogenism, other aetiologies such as ovarian or adrenal tumors have to be excluded. Leydig cell tumors and hilus cell tumors are distinctive functioning ovarian tumors that produce testosterone leading to hyperandrogenism and virilization in women [1]. These rare benign tumors are found more frequently in postmenopausal women. Nevertheless, a case of ovarian mucinous cystadenoma with functioning stroma and signs of virilization during pregnancy has been recently reported [2]. The diagnosis can be very difficult because the size of such tumors is often too small to be detected by imaging techniques [3]. The diagnostic role and impact on management of ovarian and adrenal venous sampling in women presenting with symptoms and signs of hyperandrogenism has recently been debated [4]. Bilateral ovarian stromal hyperthecosis is being increasingly recognized as a cause of significant hyperandrogenaemia in perimenopausal women. This is frequently accompanied by marked insulin resistance with other florid features of the metabolic syndrome which include hypertension, obesity, low HDL cholesterol and high triglycerides [5,6]. Such patients are at greatly increased risk for cardiovascular events particularly when coronary heart disease is established. As such they represent an at-risk group for surgical and anaesthetic procedures, and as surgical management of this condition is optional, minimally invasive diagnostic procedures assume increased importance.

We report a rare case of ovarian Leydig cell tumor in a peri- menopausal woman with severe hyperandrogenism and virilization.

Case report

A 46-year-old woman of Caucasian origin was referred to the joint gynae-endocrine clinic with worsening history of hyperandrogenism and virilization. She presented with severe facial and body hirsutism, receding hairline, male-pattern baldness and 7-year history of amenorrhoea. She was gravida 2 para 2 having had 2 spontaneous vaginal deliveries. She had an intra-uterine device in situ as contraception. Her medical history was complicated by ischaemic heart disease, myocardial infarction, hypertension, hypercholesterolaemia, osteoarthritis, asthma and anxiety disorder with prominent agoraphobia. She admitted to be a non-smoker and consumed no alcohol.

On physical examination, her weight was 65 kg and height was 161cm (BMI 25kg/m^sup 2^), and blood pressure was 128/90 mmHg while on medications. Initial biochemistry included baseline hormone profile, amenorrhoea work-up including prolactin, thyroid function test, testosterone, androstenedione, free androgen index (FAI), sex hormone binding globulin (SHBG), dehydroepiandrosterone sulphate (DHEAS), 17-hydroxyprogesterone and random cortisol, full blood count and liver function tests. Testosterone and free androgen index were markedly raised at 28.3nmol/l and 54.4, respectively. Table I shows endocrine parameters at the time of initial referral. Liver function test showed raised cholesterol (8.6mmol/l) and triglyceride (5.1mmol/l), and normal HDL (0.87 mmol/1). Transabdominal ultrasound scan of the pelvis and abdomen showed normal findings, although the right ovary was reported as being slightly larger compared with the left ovary (4cc and 3cc, respectively). These findings were confirmed by computed tomography (CT) scan. An ovarian source of clinical and biochemical hyperandrogenism was suspected. The patient was therefore advised to undergo surgery in the form of total abdominal hysterectomy and bilateral salpingo-oophorectomy. Due to her rather complicated medical history, she was referred for pre- operative anaesthetic and cardiology assessment. Despite continuous attempts in recalling, the patient ended up missing three-year appointments as a consequence of her prominent agoraphobia, for which she was largely house-bound.

Subsequent to a long period of counselling and anti-depressant treatment, she presented again with far worse signs and symptoms of hyperandrogenism. Biochemistry showed elevated serum testosterone levels and FAI. At the time, paired fasting insulin was raised at 13.3 mU/1, while glucose was within normal range (5.4 mmol/1). Urine free cortisol levels were also normal (53 nmol/24-h), with a volume of 1250ml. In accordance with previous imaging investigation, transabdominal ultrasound scan of the pelvis and abdomen demonstrated only an enlarged right ovary at 5 cc volume, but no cystic lesions were seen. The patient was advised to have surgery, and the need for such treatment was highlighted. Pre-operative investigations were arranged and she was operated on four weeks after her last outpatient appointment.

At laparotomy, the right ovary was slightly enlarged showing a pale-brown solid nodule measuring approximately 2 cm in diameter (Figure 1). There were no ascites or peritoneal lesions. No other abnormalities were found. Each ovarian vein was cannulated and blood sampling performed prior to total abdominal hysterectomy and bilateral salpingooophorectomy. Surgery was uneventful and she made a satisfactory post-operative recovery. Biochemistry of right ovarian vein sampling showed markedly increased testosterone levels ( > 260 nmol/1) compared with the contralateral (38.4nmol/1). Histopathology confirmed a 2cm Leydig cell tumor of the right ovary (4.0 1.8 1.5cm), localized in the stroma (Figure 2). Microscopic examination as follows: the cytoplasm was predominantly eosinophilic; rodshaped Reinke crystals were identified; the stroma was fibrotic and hyalinized and blood vessels showed fibrinoid change. The left ovary (3.0 1.8 1.3cm) showed a mild degree of stromal hyperplasia, but no evidence of hyperthecosis. The pre- operative elevated androgen levels normalized following surgery (Table II). Post-operatively, the clinical signs of hyperandrogenism improved significantly. The case was discussed at the multidisciplinary tumor meeting, but no further action was taken. At 6-month follow-up, the patient remains fit and well, with significantly improved signs of virilization and completely resolved anxiety.

Table I. Endocrine parameters at the time of first referral.

Figure 1. Right ovary contains the pale-brown nodule representing the area of tumor.

Figure 2. Leydig cell tumor containing Reinke crystals (arrow) (HJE).

Table II. Androgen measurements pre- and post-surgery.

Discussion

High peripheral androgen levels and virilization may be associated with an androgen-producing tumor of either the ovary or the adrenal. Leydig cell tumors, which account for less than 0.1% of all ovarian tumors, are more often diagnosed in postmenopausal women [7]. These tumors are, whenever suspected, a diagnostic and therapeutic challenge for the clinician. They are small (

Ovarian stromal hyperthecosis is usually associated with a long history of anovulation, amenorrhoea and of slowly, but relentlessly, progressing virilization. However, in peri-menopausal and reproductive age women symptoms of hyperthecosis may be of rapid onset whilst androgen-producing tumors characteristically cause rapidly progressing signs of androgen excess [2,5,6,8]. With all \androgen-producing ovarian tumors, serum testosterone is elevated in conjunction with normal or mildly elevated serum DHEAS levels. The lack of a significant increase in DHEAS distinguishes ovarian from adrenal androgen-producing tumors. In this case, while DHEAS levels were within the normal range, testosterone and FAI measurements were markedly increased, hence suggesting an ovarian origin.

Androgen-secreting ovarian tumors, which are small and often embedded within the ovary, may be missed if no sensitive imaging techniques are used [9,1O]. Transvaginal ultrasonography associated with colour Doppler plays a role in the detection and characterization of ovarian tumors [U]. Our patient did repeatedly deny transvaginal ultrasound, so transabdominal and CT scan were carried out instead. Although not very sensitive, however both these imaging modalities showed a right ovary slightly enlarged compared with the contralateral. Whether the use of transvaginal ultrasonography would allow making a prompt and more certain diagnosis and demonstrating more features cannot be argued.

During the last two decades, several authors have reported the role of selective ovarian and adrenal venous catheterization as investigation for hyperandrogenism [9,10,12,13]. A unilateral androgen gradient allows the localization of the lesion. Nevertheless, successful selective catheterization, even in expert hands, has been achieved in about 27% of cases [4], with the main limitation being anatomical variation in venous size and drainage [14]. In the present case, significantly elevated testosterone levels in the intraoperative sample collected from the right ovarian vein confirmed the site of lesion. In agreement with other authors [14], we sustain that selective venous catheterization should not be performed routinely in women presenting with symptoms and signs of severe hyperandrogenism. On the other hand, it should be reserved for women in whom uncertainty remains, especially after adrenal CT and ovarian transvaginal ultrasonography have failed to demonstrate any pathology [9,10,13]. Clinical presentation in conjunction with the imaging findings lead to a correct diagnosis in the vast majority of women presenting with hyperandrogenism.

The management of hirsutism and virilization should be directed toward its specific causes, aiming to suppress the abnormal androgen secretion. While neoplasms warrant surgical intervention, hyperandrogenism due to stromal hyperthecosis may be medically suppressed with GnRH agonist depending on age and fitness to surgery. Prompt improvement of clinical and biochemical hyperandrogenism following surgery has been reported [15,16]. In our case, clinical symptoms and signs of virilization improved significantly post-operatively. Of relevance, the anxiety disorder presenting as agoraphobia disappeared and the patient ceased pharmacological treatment. Also, the pre-operative markedly increased serum testosterone levels and FAI normalized after surgery.

In conclusion, this case-report confirms that androgen-secreting ovarian tumors have to be considered amongst other disorders causing virilization in peri-menopausal and reproductive age women. Appropriate diagnostic approach encompassing clinical presentation, conventional biochemical and imaging methods (i.e., transvaginal ultrasound) is paramount. Although selective venous catheterization and sampling has good diagnostic value to further investigate an ovarian source or to plan conservative management, however it should be generally reserved for patients whom uncertainty remains. The role of this invasive diagnostic tool to help in selecting the adequate surgical approach remains a matter of much debate.

References

1. Takeuchi S, Ishihara N, Ohbayashi C, Itoh H, Maruo T. Stromal Leydig cell tumour of the ovary. case report and literature review. Int J Gynecol Pathol 1999;18:178-182.

2. Antoniou N, Varras M, Akrivis CH, Demou A, Bellou A, Stefanaki S. Mucinous cystadenoma of the ovary with functioning stroma and virilization in pregnancy: A case report and review of the literature. CHn Exp Obstet Gynecol 2003;30:248-252.

3. Pugeat M, Mirakian P, Dutrieux-Berger N, Forest MG, Tourniaire J. Androgen secreting ovarian neoplasm. In: Azziz R, Nestler JE, Dewailly D, editors. Androgen excess disorders in women. New York: Lippincott-Raven; 1997. pp 555-568.

4. Kaltsas GA, Mukherjee JJ, Kola B, Isidori AM, Hanson JA, Daciet JE, Reznek R, Monson JP, Grossman AB. Is ovarian and adrenal venous catheterization and sampling helpful in the investigation of hyperandrogenic women? CHn Endocrinol 2003;59:34-43.

5. Barth JH, Jenkins PM, Belchetz P. Ovarian hyperhecosis, diabetes and hirsuties in post-menopausal women. CHn Endocrinol 1997;46:123-128.

6. Ayuk P, Stringfellow H, Donnai P, Beardwell CG, Holt A, Laing I. Hirsutism of recent onset with marked hyperandrogenaemia after the menopause. Ann CHn Biochem 1998;35: 145-148.

7. Monteagudo A, Heller D, Husami N, Levine RU, McCaffrey R, Timor-Tritsch IE. Ovarian steroid cell rumours: Sonographic characteristics. Ultrasound Obstet Gynecol 1997; 10: 282-288.

8. Judd HL, Scully RE, Herbst AL, Yen SS, Ingersol FM, Kliman B. Familial hyperthecosis: comparison of endocrinologie and histologie findings with polycystic ovarian disease. Am J Obstet Gynecol 1973;! 17:976-982.

9. Surrey ES, de Ziegler D, Gambone JC, Judd HL. Preoperative localization of androgen secreting tumours: clinical, endocrinologie and radiologie evaluation often patients. Am J Obstet Gynecol 1988;158:1313-1322.

10. Outwater EK, Marchetto B, Wagner BJ. Virilizing tumors of the ovary: Imaging features. Ultrasound Obstet Gynecol 2000; 15:365- 371.

11. Varras M. Benefits and limitations of ultrasonographic evaluation of uterine adnexal lesions in early detection of ovarian cancer. CHn Exp Obstet Gynecol 2004;31:85-98.

12. Moltz L, Schwartz U, Sorensen R, Pickartz H, Hammerstein J. Ovarian and adrenal vein steroids in patients with nonneoplastic hyperandrogenism: Selective catheterization findings. Fertil Steril 1984;42:69-75.

13. Stephens JW, Katz JR, McDermott N, MacLean AB, Bouloux PM. An unusual steroid-producing ovarian tumour: case report. Hum Reprod 2002;17:1468-1471.

14. Sorensen R, Moltz L, Schwartz U. Technical difficulties of selective blood sampling in the differential diagnosis of female hyperandrogenism. Cardiovasc Intervent Radiol 1986;9:75-82.

15. Amato G, Izzo G, Izzo A. A paradoxical inhibition of androgenic hyperproduction by a Sertoli-Leydig cell tumour ovary. Hum Reprod 1995;10:2967-2969.

16. Surbeck DV, Hoesli I, Torhorst J, Almendral AC, Delias A, Holzgreve W. Virilizing ovarian tumour of low malignant potential associated with antecedent tamoxifen use for breast cancer. Gynecol Oncol 1998;68:293-296.

L. G. NARDO1, D. W. RAY2, I. LAING3, C. WILLIAMS3, R. J. McVEY4, & M. W. SEIF1

1Academic Unit of Obstetrics, Gynaecology and Reproductive Health, St Mary’s Hospital, 2 Department of Endocrinology, 3Department of Clinical Biochemistry, and 4Department of Histopathology, Central Manchester and Manchester Children University Hospital, Manchester, UK

(Received 21 December 2004; revised 26 April 2005; accepted 27 April 2005)

Correspondence: Dr Luciano G. Nardo, Department of Reproductive Medicine, St Mary’s Hospital, Whitworth Park, Manchester M13 OJH, UK. Tel: +44 0161 276 6371/6340. Fax: +44 0161 224 0957. E-mail: [email protected]

Copyright CRC Press Oct 2005

Inconceivable: the Spiritual Test of Infertility

By Schlumpf, Heidi

God said, “Be fruitful and multiply.” But millions of couples can’t do that on their own, and their spiritual struggles are often as daunting as the physical and emotional ones.

New parents often describe childbirth and their part in procreation in religious, almost mystical, terms. It’s a “miracle,””awesome,””glorious.” Giving birth to their children is why God put them on this earth, a vocation, more important than anything else they will ever do. Some even see it as sharing in God’s creative power.

So what if you were told you could never have that?

“You do wonder why God is doing this to you,” says Kristin Johnson, whose husband’s infertility led a physician to tell the St. Louis couple it would take a “miracle” for them to get pregnant on their own. “You think it’s going to be so easy, and then you wonder, ‘Why is this happening to me? What did we do wrong? Doesn’t God want us to be parents?'”

Infertility is a medical diagnosis (the inability to conceive after one year of trying or to carry a pregnancy to live birth), and one with serious psychological and emotional ramifications. It also can be, especially for Catholics and other people of faith, a spiritual crisis. Although the moral and ethical issues surrounding reproductive technology are part of it, the even larger questions involve ones image of God, vocation, prayer life, and ideas about God’s role in a persons life.

The spiritual questions raised by infertility are affecting an increasine number of people, in part because many couples are trying to get pregnant later in life. More than 6 million American women age 15 to 33 suffer from infertility, roughly 10 percent of women of reproductive age. Yet infertility is not only a women’s issue: one third of infertility problems are attributed to the male partner, and another third are related to both the man and woman according to the American Society for Reproductive Medicine.

Johnson, who asked that her real name not be used, had drifted from the church but returned to Mass during their infertility problems. “I think I was looking for answers,” she says. The couple got a happy one: With the help of reproductive technology, including in vitro fertilization, Kristin became pregnant and is expecting in March. This, too, she sees as Gods will, a blessing.

“We definitely think God answered our prayers,” she says. And if it hadn’t worked? “We were open to adoption, if that was what God wanted for us.”

But saying “it was meant to be” when treatment is successful can be hard to hear for those who walk away with empty arms. “That’s not particularly helpful to them,” says Dianne Clapp, a psychiatric nurse and medical information director for Resolve, a national infertility support organization. “What people really need is support around the loss.”

And infertility is a loss-not always of a specific child, although multiple miscarriages are common-but usually the less tangible, more difficult loss of a dream: the dream of an easy, unassisted conception; the dream of children who look like you or your relatives; the dream of having a “normal” family.

Infertility also often involves grief and loss on a spiritual level, as old images of God or ideas about how God works don’t seem to fit anymore. “Anger at a supreme being is a normal thing as people wonder ‘Why me?’ ” says Clapp. “But I urge people to reframe it. Rather than searching for answers, I encourage people to pray to God for help in coping and navigating this the best they can.”

Fertile faith

Mary and Sam Nelson of Denver married in their late 30s and spent six years trying to have a child. They tried everything: acupuncture, diet, drugs, prayer, and eventually in vitro fertilization. Not only was it ultimately unsuccessful, but it also was a difficult moral decision and cost tens of thousands of dollars.

“Every time we got a phone call from the doctor it was more bad news. It was heartbreaking,” remembers Mary (not her real name). “My husband was all set on adoption, but I was having a hard time letting go of the dream.”

For Nelson, the deepest grieving involved the genetic connection, as she loved seeing the family resemblance in her nieces and nephews. “It wasn’t about the physical, but more about their personalities and how they’re wired. I also wondered what a combination of my husband and me would be like,” she says.

She eventually found peace by realizing that all children are God’s children-a shift necessary for them to adopt their newborn twins. “I got this whole new way of thinking about it, that I’m more connected to humanity as a whole than to just this gene line, so what does it matter?” she says.

Nelson won’t deny that she was sad and angry-but it was rarely directed at God. “My image of God isn’t of a God doling out rewards and punishments,” she says. “Instead, for whatever reason this was happening to us, and I was trying to understand what to learn from it.”

One lesson was to let go. “It’s hard because the medical side of infertility treatment is so planned and controlled,” she says. “You think that if you just eat the right things or do acupuncture, you can control the situation.”

She also let go of the need for answers. “There are a lot of things we don’t have answers about,” she says. “That brings us back to the mystery of our faith.”

Accepting and living with mystery is necessary, even when the news eventually is good. Jane and Joe Cavanaugh of Minneapolis were told they had a 2 percent chance of getting pregnant on their own. They struggled with the morality of some infertility treatments and were turned off when their doctor pushed egg donation. Finally, with the help of Eastern medicine-such as acupuncture, yoga, and herbal treatments-they beat the odds.

“I do see our daughter as a gift from God, but I don’t know why it happened to us,” says Jane, a spiritual director. “I connect it to the power of prayer, because so many people were praying for us. But what about others who have that prayer behind them, too, and don’t get pregnant? I was afraid it means that God isn’t in charge.”

Her husband, Joe, also doesn’t see God as waving a magic wand. “That’s not a God I believe in,” he says. “I do believe this is a miracle in the sense that God’s love made it happen. But there’s mystery involved. It’s about the constant miracle of possibility and trying to be open to the wonderful possibilities God puts in front of you.”

Jane calls it being open to the “yes/ and”: “One path is not always the right and only way,” she says. “But when it’s not the particular path we were expecting, it’s OK to tell God how you’re feeling. You have to keep God in the equation, even if you’re sad and angry. God can take it.”

Creation spirituality

“Maybe God doesn’t want us to have any more kids.” That’s what Emily HoItel-Hoag of Cleveland initially thought when she and her husband, Mike, had difficulty conceiving when trying for their second child.

“But the more I thought about it, I realized I didn’t really believe God is a micromanager,” she says. “I don’t think God causes infertility or miscarriages, but I do believe God is present and brings grace to the challenges we have in our lives.”

Like most people, Holtel-Hoag used to think of procreation in purely physical terms: she and her husband creating biological children, preferably unassisted by medical intervention. The desire to have children, especially after finding and committing to your partner, is a nearly universal human drive and one that many perceive as Godgiven.

That’s natural, says Jeannie Hannemann, founder of Elizabeth Ministry, which connects women in parishes around issues of childbearing. “Our God is so much a God of creation,” she says. “The first command God gives to humans is to ‘be fruitful and multiply.’ So it’s written deep in our hearts that we want to conceive. It’s how God made us.”

God doesn’t desire for any couple to be infertile, she says. “But when we suffer from infertility, God is grieving with us,” says Hannemann, who experienced infertility herself. “Yes, God wants us to procreate, but God can also bring good out of every situation. If you are suffering from infertility, God will have a plan for you out of all that pain.”

In Holtel-Hoag’s case a trusted mentor challenged her to think more expansively about other ways to bring life to the world. “That really clicked for me,” she says. “Spiritual generativity is more about how we’re going to co-create with God. It helped me see that as human beings we want to be procreators in some sense of the word.”

She and her husband considered “creating” in other ways, such as helping a refugee family or becoming more involved in their parish and community. They eventually decided to adopt an infant from Guatemala.

“We realized we have a lot of love in us and a lot to offer,” she says. “So if we’re not going to have more children, we have a responsibility to share that love and these gifts with the world in some way.”

While an initial response to infertility might be to be angry at God or to question or reject one’s faith, many infertile couples eventually turn to their faith for strength during such a difficult time in their marriage. Prayers range from “Dear God, please give us a baby” to “Not my will but yours be done.”

Mary’s words from the Annunciation-“Let it be done according to your wo\rd”-became Holtel-Hoag’s prayer. “I was trying to open myself up to the possibilities and to God,” she says. “Now I’d probably say, ‘Let it be done, with me, according to your word,’ to show that it’s a partnership between me and God.”

The Prayer of St. Francis is helpful to 27-year-old Katie Malone of Baltimore, who has suffered from early miscarriages in her attempts to get pregnant. “The part about ‘seek not so much to be consoled as o console’ spoke to me,” she says. “I pray to be compassionate toward others and not just focus on this one bad thing that’s happening to me.”

She also tries to emphasize gratitude in her prayer life, thanking God for five things each night. “I try to focus on the things I have,” she says. “It keeps things in perspective.”

But that doesn’t mean she hasn’t struggled with what her inability to carry a pregnancy to term means. “I had a lot of spiritual questions, and I still do, after my two miscarriages. What was it? Was it a baby? Did it have a soul?” she says. “If it has a soul right after conception, then I feel guilty because I couldn’t stay pregnant. But it’s a hard question. I don’t have the answers to that yet.”

What she is sure of is that God is calling her to be a mother. Of course, biological children are what I’ve always pictured myself having, but I’d be very excited about adoption,” she says. “Maybe this is God’s way of saying you have a lot to share and there’s someone out there who needs a home. I feel we have so much and so much to be thankful for.”

Birthing new life

Being able to experience new life-either through a successful pregnancy, adoption, or choosing to remain childless and instead focus on serving the wider community-after the “death” of infertility mirrors the Christian story of Resurrection and redemption. Although the pain is real, ultimately many couples find their faith helps them move through that grief and make life-giving choices for themselves and for others. While they wouldn’t wish it on their worst enemy, some couples see their infertility journey as one that helped them grow into more compassionate, open people.

In the end, Holtel-Hoag ended up feeling grateful after her infertility struggle. “It seems to me that when you say ‘yes’ to God’s possibilities, God says ‘yes’ back to you,” she says, just home from her first visit to 3-month-old Isaiah in Guatemala, one of several trips before the adoption is final. “Once we did that, things just seemed to fall in place-not just the adoption but life in general.”

Mary Nelson’s gratitude and compassion are focused on her twins’ if birthmother, whom they got to know through an open adoption, and on others who suffer from infertility. “You really feel for other people who can’t have children,” she says. “So many people are going through this, but everyone tells me they feel so alone. I think I really grew in compassion.”

The Cavanaughs are grateful for 6month-old Tess but also for the spiritual insights gained through their experience of infertility. Jane says she not only learned to “trust her gut,” but she also expanded her vision of God. “The most interesting thing was the surprise element of God,” she says. “You can’t figure God out. And I love that.”

For more information: www.resolve.org or www.elizabethministry.com.

“I don’t think God causes infertility or miscarriages, but I do believe God is present and brings grace to the challenges we have in our lives.”

We have a lot of love in us and a lot to offer. So if we’re not going to have more children, we have a responsibility to share that love with the world in some way.

“It seems to me that when you say ‘yes’ to God’s possibilities, God says ‘yes’ back to you. Once we did that, things just seemed to fall into place.”

HEIDI SCHLUMPF is managing editor of U.S. CATHOLIC.

Copyright Claretian Publications Jan 2006

Merkel once worked as waitress, biography reveals

By Erik Kirschbaum

BERLIN (Reuters) – Angela Merkel worked as a cocktail
waitress in a disco while studying physics in Communist East
Germany and later moved into an empty East Berlin flat as a
squatter after leaving her first husband.

These are among the illuminating details to emerge about
Germany’s first female chancellor in a new biography entitled
“Merkel, Macht, Politik” (“Merkel, Power, Politics”) by German
journalist Patricia Lessnerkraus.

As a child, Merkel struggled to overcome a fear of walking
downstairs. As a teenager, she was the top student in her
school and wanted to become a teacher but that dream was dashed
by the Communist government, which viewed her family as
suspect.

So she studied physics and worked part-time in a disco.

“I did the barmaid thing,” Merkel said. “I got an extra 20
to 30 pfennigs for each drink I sold and that added up to 20 to
30 extra marks each week. That pretty much paid the rent.

“And considering my allowance was 250 marks (about $15) per
month, that extra income was rather important,” said Merkel,
who studied in Leipzig from 1973 to 1978. She earned her
doctorate in East Berlin in 1986 — under the tutelage of
Professor Joachim Sauer, who later became her second husband.

Merkel, 51, has kept many intriguing details of her private
life under wraps, even after her startling rise from spokesman
of the last East German government in 1990 to the top of the
conservative party in 2000 and into the chancellor’s office
last November.

That is partly a result of the way Merkel and her family
have carefully shielded the privacy of Germany’s first leader
to come from the ex-Communist east.

FASCINATING ANECDOTES

The basic details of Merkel’s career since her drift away
from East Berlin academia and into politics in the heady days
of unification in 1990 are well documented, but little about
her life before then has surfaced.

The book, by a woman who has known Merkel since 1990,
includes profiles of other leaders such as Mary McAleese of
Ireland and Ukraine’s Yulia Tymoshenko but contains fascinating
anecdotes about Merkel’s past.

She describes how Merkel, born Angela Kasner in Hamburg,
moved to the Communist east six weeks after her birth in the
west. Her clergyman father came from the east and his church
work took him back there in the era before the Berlin Wall was
built, when such a move was less unusual.

As a small child, Angela quickly learned to speak but took
longer to walk. She managed by ordering her younger brother
around.

“She turned her brother into an errand boy,” Lessnerkraus
writes. “She gave the orders. He brought her what she wanted.”

Merkel long had a fear of walking downstairs or downhill.

“I was a sheer idiot when it came to moving,” Merkel said.
“My parents had to explain how to walk downhill, from a purely
technical point of view. Something that a normal person can do
automatically I had to think about in my mind and practice.”

Young Angela, who was six when the Wall was built in 1961,
faced problems in the Communist east, an atheist state, because
her father was a pastor, or “Pfarrer” in German.

“Tell people you are a ‘Fahrerstochter’ (chauffeur’s
daughter),” a friend said, urging her to obscure her father’s
job by mispronouncing it in order to avoid problems. “That’s
not lying directly; it just has a slightly different
intonation.”

Her mother had been an English and Latin teacher in West
Germany but was banned from working because of that and her
husband’s work for the church. She implored Angela to excel at
school “otherwise they’ll never let you into university.”

ENJOYED “MONOPOLY”

The young Kasner was a brilliant student, excelling in
Russian. “She graduated from high school with perfect marks,”
wrote Lessnerkraus, who added that Merkel wanted to become a
teacher but that was denied because of her family.

“Angela Kasner not only had to be better than the rest of
her classmates, she also had to keep secret how she and her
family lived at home,” Lessnerkraus added. Among other things,
they enjoyed playing the capitalist board game “Monopoly.”

“They watched west German television, they complained about
Erich Honecker and their shelves were filled with books from
the ‘enemy’ west. It was a terrible burden for a happy girl who
had to learn at an early age to think before opening her
mouth.”

Kasner was allowed to study physics and left her home in
Templin, north of Berlin, for Leipzig where her life changed.

“She didn’t spend all her time studying physics formulas,”
Lessnerkraus wrote, noting she was also a party girl. “She
enjoyed student life with the parties, trips and part-time
jobs”

In 1977, aged 23, she married a fellow student, 24-year-old
Ulrich Merkel.

They had a one-room flat in Leipzig and a year later, after
graduating, moved to East Berlin, finding a run-down flat with
no toilet and no hot water.

Ulrich Merkel spent the next three years fixing up the flat
after work while his wife made progress on her doctorate.

“In 1981 Ulrich was done renovating but at that moment his
wife left him and ‘occupied’ an empty flat,” Lessnerkraus
wrote.

In a rare reference to her marriage to the man whose name
she nevertheless kept, Merkel said: “We got married because
everyone got married. It sounds stupid, but I didn’t go into
the marriage with the necessary amount of seriousness.”

Merkel lived as a squatter in the sparsely furnished flat,
earned 650 marks a month and was a happy single woman who liked
to go dancing. In the early 1980s, she got involved with Sauer,
who was divorced from his wife in 1985.

Only after the Berlin Wall fell in 1989 did Merkel drift
into politics, at first helping to connect computers in the
office of a new democratic party and later joining the
Christian Democrats (CDU), two months before German
unification.

From there, her career took off: first as deputy press
spokeswoman to East Germany’s last prime minister, Lothar de
Maiziere. She won a seat in parliament for the CDU in the
December 1990 election and in January, at 36, was picked by
Chancellor Helmut Kohl as minister for women’s issues.

“She can thank her lightning political career to the fact
that Helmut Kohl needed to have a woman and an east German in
his cabinet in 1991,” wrote Lessnerkraus. “By appointing
Merkel, Kohl killed two birds with one stone.”

Is Tuition Really Necessary?

To enrol or not? With the school year starting soon, a dedicated tuition teacher and a disbelieving parent present their case on this perennial problem.

YES

YES! But not just because I’m a tuition teacher. Our school system is examination-based; from the way the timetable is planned to see how much of the syllabus can be covered before public exams (UPSR, PMR, SPM and STPM). Even non-examination year students are affected.

At the end of the day, it is the results that matter, never mind what people say. When they compare schools, they compare results.

Most education administrators are really politicians. They don’t know or care about education at all. At the end of the day, the authorities only look at how many units you have to decide which course you get into at which university, stressing on paper qualifications, not how good you are at extracurricular activities.

Knowledge by itself is of no use, unless that knowledge can be applied to answering exam questions. You cannot compare the quality and level of school exams to public exams. School exams are full- dress rehearsals. A lot of teachers don’t understand that. They set questions that do not resemble the real thing.

Too many teachers these days are not doing what they are supposed to be doing in school. Don’t get me wrong. There are still good teachers in school but a big portion these days act irresponsibly. To them, dedication is about punctuality and teaching what is in the textbooks, rather than preparing students as best as they can.

The adult world is so competitive today. Say, there are 10,000 students with straight As but only 500 places available for that university course. Can it ever be too early to prepare your child to excel? Tell me, which parent doesn’t want his or her child to have a good start in life? – M.C. Cheah, Maths tuition teacher with 30 years experience

NO

I BELIEVE that tuition is mostly a waste of time. It gives children an excuse not to pay attention in class. Tuition then becomes something to fall back on. It is like in the working world. If you have to work to survive, you will definitely put in the effort because you know that if you don’t, you won’t live.

I’ve experimented on my own children from the time they were in Standard One.

I told them: You better work hard. Any problems, come and tell me, but I won’t send you for tuition unless you really need it; and you come and ask it of me.

My daughter, who finished secondary school just two years ago, has never attended tuition in her life. My son took only one tuition class, and that was for BM (which is a compulsory passing subject), because he said he couldn’t cope.

Anyway, he only took it for five months in Form Five. Now, he speaks like a Malay. Both scored straight As in their exams.

I don’t believe in tuition. It is a waste of money. I’ve never gone for tuition. I studied with brilliant people before and I find that they are inconsistent. They think they are good enough and that makes them too confident. The word is “cocky”.

Studying is like a decathlon – you just have to be hardworking, consistent and organised. It’s better to be a Jack-of-all-trades than master of just one. It will help pull up your overall grade points.

Being disciplined helps a lot. That’s where parents come in. The parents must help them by constantly reminding them to study.

See, children are like clay, you must mould them when fresh, and teach them by example.

A lot of lessons are unspoken. If the parent is disciplined, the child will be too. – Chuah Lip Peng, father of two

Panadol and Aspirin; How Do Anaesthetics Work?; HOW IT WORKS: YOUR BODY

Panadol and Aspirin are brand names for the drugs paracetamol and acetylsalicylic acid. They are both popular analgesics (painkillers) and antipyretic (fever-reducing) drugs, used by millions of people around the world.

They have similar structures but have significant differences. Aspirin is also an anti-inflammatory drug and has an anticoagulant (blood-thinning) effect, so can prevent heart attacks. Panadol does neither but is gentler on the stomach than Aspirin.

Aspirin’s action has long been known but that of Panadol is less understood.

.

How pain works:

Pain is your body’s way of telling you tissue is being damaged. When that happens, chemicals are released at that site and stimulate nerve endings, which send the pain message to your brain. There are two paths we can take to relieve it. One way is to act on the central nervous system – the brain and spinal cord, which is what Panadol does. The other is to act on the nerves that send the pain message to the central nervous system, which is what Aspirin does.

.

Imagine hitting your finger with a hammer. Your finger has nerve endings in it, which register the pain. Damaged tissue also releases chemicals called prostaglandins. Working cells in damaged tissue make them using an enzyme called cyclooxgenase 2 .

Nerves carry the pain signal through your hand, up your arm and into your brain.

Aspirin enters the bloodstream, which carries it through your entire body. Although it is everywhere, it only works where prostaglandins are being made. It blocks COX-2 enzymes, thus reducing prostaglandin production, which in turn reduces pain and inflammation.

.

Panadol works on pain’s pathway in the brain and spinal cord, blocking COX-3 enzymes to decrease prostaglandin production.

.

Aspirin: Inhibits enzymes called cyclooxygenase (COX), which normally help to produce prostaglandins and thromboxanes around the body. Prostaglandins are a hormone found in virtually all tissues and organs. They have various actions, including transmitting pain information to the brain. Prostaglandins also are linked to the inflammation response and to regulating the body’s temperature. Thromboxanes are chemicals involved in helping blood clot.

As a result of decreasing the production of prostaglandins and thromboxanes, Aspirin reduces some of their effects around the body – pain, inflammation, fever and blood clotting. Aspirin blocks two variants of the enzyme, COX-1 and COX-2. Inhibiting COX-1 is bad for the stomach lining, where prostaglandins serve a protective role, and can cause gastric problems.

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Panadol: New research has found paracetamol selectively inhibits a variant of the cyclooxygenase enzyme, called COX-3, that is found only in the brain and spinal cord. Other variants of the COX enzyme are not significantly affected by paracetamol. This explains why paracetamol relieves pain and reduces fever without the side effects of Aspirin.

.

Sources:

www.howstuffworks.com,

www.ch.ic.ac.uk (Imperial College London website), heart.healthcentersonline.com ,

www.assistpainrelief.com ,

www.pharmweb.net ,

www.pa.msu.edu (Michigan State University)

.

How do anaesthetics work?

Anaesthetics depress or numb nerve pathways. If you need surgery, chances are you will have some type of anaesthesia to go along with it. The type you receive will depend on various factors, including the nature, site and duration of surgery, and your health status.

.

How a general anaesthetic works:

Brain and spinal cord: It isn’t completely understood how general anaesthetics work at the cellular level. It is believed they affect the spinal cord, causing the patient to become immobile, and affect parts of the brain, causing unconsciousness. When anaesthetics reach the bloodstream, drugs that affect the brain pass through other blood vessels and organs, so they are often affected too. Patients must therefore be carefully monitored.

.

Inhaled or injected:

General anaesthesia can be administered as an inhaled gas or as an injected liquid. There are several drugs and gases that can be combined or used alone to produce general anaesthesia. Most adults are first anaesthetised with liquid intravenous anaesthetics followed by anaesthetic gases after they are asleep. Children may not like having an injection or drip placed in them while awake so often breathe themselves to sleep with anaesthetic gases given through a mask.

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Reversible: An important property of anaesthetics is reversibility. When surgery is over, the anaesthesiologist shuts off the anaesthetic so the patient can wake from the induced sleep. Once anaesthetic gas is turned off, the bloodstream brings the gas back to the lungs, where it is eliminated. The more soluble the gas is in blood, the longer it takes to eliminate.

.

The four types of anaesthetic

General anaesthesia:

General anaesthesia affects brain cells, causing a loss of consciousness. In this state, a person is unaware of what is happening, is pain-free and immobile, and will not remember anything from the time they are anaesthetised. You can be injected with a liquid anaesthetic drug or breathe an anaesthetic gas to make you sleep, or a mixture of both.

.

Regional anaesthesia:

Local anaesthetic is injected near the major nerve pathways to the part of the body where the surgeon operates. This nerve block numbs that part of the body and is often used for hand, arm, hip or knee surgery, and for caesarean sections to deliver a baby. You can be wide awake or have other drugs to make you relaxed and drowsy. Examples include spinal and epidural anaesthesia, arm blocks and eye blocks.

.

Local anaesthesia:

A local anaesthetic is injected at the site of the surgery to cause numbness. You will be awake. A local anaesthetic is often used when removing small skin lesions.

.

Monitored sedation:

Your anaesthetist uses a special range of drugs to keep you comfortable and sleepy but able to respond to questions if needed.

.

Having an operation:

.

Nil by mouth: Normally, you have to stop eating and drinking about eight hours before an operation because an empty stomach makes you less likely to vomit while under an anaesthetic. When awake, part of the swallowing mechanism involves a reflex that covers the opening into your lungs, which stops you choking.

You lose that reflex when anaesthetised and can inhale vomit into your lungs, which is dangerous.

.

Pre-med: Once changed into theatre clothes, you may be given a “pre-med” before going to theatre. This is a tablet or tablets to relax you if you are nervous or to help with your pain relief after the operation.

.

Anaesthetic: In theatre, you will be attached to a specialised machine that monitors your heart, blood pressure, oxygen level and breathing throughout the operation.

An intravenous infusion, or drip, is placed in your hand or arm to give you the anaesthetic drugs.

.

Sources:

www.howstuffworks.com,

www.anaesthesia.org.nz,

www.cas.ca (Canadian Anaesthesiologists’ Society) en.wikipedia.org

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Untreated Sinus Allergies Affect Sexual Function

NEW YORK (Reuters Health) – Symptoms of itchy, tearing eyes and nasal congestion due to seasonal allergies interfere with individuals’ ability to enjoy sex, results of a study conducted in Turkey suggest. However, successful treatment with an antihistamine can help.

Seasonal allergies are known to interfere with work, school and social life. But up until now, the investigators say, there have been no studies examining sexual function in these patients.

Dr. Cengiz Kirmaz and colleagues at the Celal Bayar University Hospital in Manisa surveyed 27 women and 16 men with seasonal allergies and 40 healthy adults (20 women and 20 men).

They observed that women with untreated seasonal allergies had reduced sexual desire, arousal, ability to reach orgasm and intercourse satisfaction compared with the healthy control subjects. Allergies affected men’s erectile function, intercourse satisfaction, sexual desire and overall satisfaction with sex.

Patients with allergies were treated for 30 days with the oral antihistamine desloratadine for 30 days, after which they repeated the sexual function questionnaires. Results showed that after their symptoms were controlled, their sexual function was not significantly different from that of the healthy controls.

“The impact of allergic symptoms on the sexual functioning of our patients has been under appreciated,” Kirmaz’s team concludes in a report in the Annals of Allergy, Asthma, and Immunology.

SOURCE: Annals of Allergy, Asthma, & Immunology December 2005.

Ranchers can kill wolves harassing livestock

By Laura Zuckerman

SALMON, Idaho (Reuters) – The image of a wolf howling at
the moon has long embodied the American West, but that romantic
symbol is about to get a taste of harsh reality in Idaho.

Next week, Idaho Gov. Dirk Kempthorne and U.S. Interior
Secretary Gale Norton are expected to sign an agreement that
would place management of an estimated 500 gray wolves into
state, rather than federal, hands.

Different Idaho groups, including hunters and livestock
producers, pressured state officials to give them greater
control. Officials in Boise then asked Washington to make the
change.

The agreement would give ranchers permission to eliminate
wolves that harass livestock. It also would empower state
wildlife managers to pick off wolf packs that make a dent in
the state’s deer and elk populations.

The wolf’s revival in Idaho started a decade ago when
officials released 35 wolves into central Idaho. Their numbers
have grown steadily since then.

Federal rules have carefully prescribed when ranchers could
act against wolves, requiring ranchers to catch wolves
attacking or eating livestock before they could kill them.

The new Idaho rules will give locals more latitude, but
some residents would like see an even greater offensive against
the animal.

Ron Gillett, head of the Idaho Anti-Wolf Coalition, wants
to “immediately remove them by whatever means are necessary.”

“They kill everything, all of the game first, then the
predators, then each other,” he said, adding that they are
outsiders.

“These are Canadian wolves,” Gillett said. “The only place
they belong in Idaho is in a zoo, neutered.”

Wildlife biologists say wolves roamed Idaho long before the
region’s settlement and the threatened species was hunted to
near-extinction before strong nationwide support prompted its
reintroduction to the American West.

Carter Niemeyer, self-described “educator, peacemaker,
moderator and referee on wolves” for the U.S. Fish and Wildlife
Service office in Boise, said studies show that the numbers of
livestock and game killed by wolves are low. “But I know they
don’t want to let facts get in their way,” he said of anti-wolf
activists.

Coaching women during childbirth has little impact

By Susan Heavey

WASHINGTON (Reuters) – Pregnant women coached through their
first delivery do not fare much better than those who just do
what feels natural, according to a study released on Friday.

Researchers at the University of Texas Southwestern found
that women who were told to push 10 minutes for every
contraction gave birth 13 minutes faster than those who were
not given specific instructions.

But they said the difference has little impact on the
overall birth, which experts say can take up to 14 hours on
average.

“There were no other findings to show that coaching or not
coaching was advantageous or harmful,” said lead author Dr.
Steven Bloom, the interim head of obstetrics and gynecology at
the Dallas-based university.

“Oftentimes, it’s best for the patient to do what’s more
comfortable for her,” he added.

Bloom and his team studied 320 first-time mothers who had
simple pregnancies and did not receive epidural anesthesia.

About half were given specific instructions by certified
nurse-midwives during the second stage of labor, when they were
fully dilated. The rest were told to “do what comes naturally.”

On average, coached mothers trimmed the final stage to 46
minutes compared to 59 minutes, according to the study
sponsored by the National Institute of Child Health and Human
Development at the National Institutes of Health.

Women in both groups experienced about the same number of
forceps use, Caesarean deliveries and skin tears, among other
complications.

The results were published in the January issue of the
American Journal of Obstetrics and Gynecology.

Less clear was whether extra pushing encouraged by a coach
could lead to bladder trouble.

In an earlier study, the researchers tested bladder
function in 128 of the mothers three months later.

While such problems usually resolve on their own over time,
women who had been coached had a smaller bladder capacity and
felt the urge to urinate more often, they previously found.

Senior author Dr. Kenneth Leveno, a professor of obstetrics
and gynecology at the school, said it was still not clear if
the bladder problems could lead to long-term complications and
more studies are needed.

“We don’t want to alarm patients about this,” he said.

Friday’s finding that coaching “confers neither benefit nor
harm might be pre-empted if it is confirmed that coaching has
deleterious long-term effects,” the study concluded.

President Bush’s “Brownie” quote wins award

By Arthur Spiegelman

LOS ANGELES (Reuters) – Call it the wrong phrase at the
wrong time but “Brownie, you’re doing a heckuva job” was named
on Thursday as U.S. President George W. Bush’s most memorable
phrase of 2005.

The ill-timed praise of a now disgraced agency head became
a national punch line for countless jokes and pointed comments
about the administration’s handling of the Hurricane Katrina
disaster and added to the president’s reputation for verbal
gaffes and clumsy turns of phrase.

Paul JJ Payack, president of Global Language Monitor, a
nonprofit group that monitors language use, says Bush’s
statement in support of the then-director of the Federal
Emergency Management Agency may be remembered for years to
come.

“The ‘Brownie’ quote leads our 2005 list of Bushisms —
memorable phrases or new words coined by the president,” Payack
said, adding that Bush may be the foremost White House creator
of new words, citing such past efforts as “misunderestimate”
(to seriously underestimate) and “embetter” (to make
emotionally better).

Ten days after Bush verbally patted Michael Brown on the
back before the TV cameras, Brown resigned amid a public uproar
over his qualifications and the administration’s failure to get
aid to New Orleans after the devastation of Hurricane Katrina.

Although the president did not originate any new words this
year, he had several notable statements, Payack said, citing
the following:

— “See, in my line of work you got to keep repeating
things over and over and over again for the truth to sink in,
to kind of catapult the propaganda,” Bush said in explaining
his communications strategy last May.

— “I think I may need a bathroom break. Is this possible?”
Bush asked in a note to Secretary of State Condoleezza Rice
during a U.N. Security Council meeting in September.

— “This notion that the United States is getting ready to
attack Iran is simply ridiculous. And having said that, all
options are on the table,” Bush said in Brussels last February.

— “In terms of timetables, as quickly as possible –
whatever that means,” the president said of his timeframe for
passing Social Security legislation in March.

— “Those who enter the country illegally violate the law,”
Bush said in describing illegal immigrants in Tucson, Arizona,
last month.

Global Language Monitor uses an algorithm to track words
and phrases in print, electronic media and the Internet. The
words and phrases are tracked in relation to their frequency,
contextual usage and appearance in global media outlets.

Evista aids bone health in lupus patients

NEW YORK (Reuters Health) – A small study has shown that
the osteoporosis drug raloxifene, sold as Evista, helps
maintain bone mineral density (BMD) in menopausal women with
systemic lupus erythematosus (SLE) who are on corticosteroids.

SLE is a chronic autoimmune disease in which the immune
system can confuse healthy and foreign tissues and sometimes
attacks both. The disorder disproportionately affects women.
SLE may be treated with steroids and long-term treatment with
steroids can result in bone-thinning.

Dr. Chi Chiu Mok of Tuen Mun Hospital in Hong Kong and
colleagues randomized 33 women with osteopenia — a
bone-thinning condition just short of osteoporosis — and
inactive SLE to treatment with either 60 milligrams of
raloxifene daily plus 1,200 milligrams of calcium or to calcium
only. All of the women were taking low-doses of the steroid
prednisolone.

At 1 year, women on calcium alone showed a 2.6 percent
reduction in BMD at the femoral neck — the area where thigh
bone meets the hip — and a 3.3 percent reduction in BMD in the
lower spine. In contrast, there was no change in BMD in the
raloxifene group.

Four patients on raloxifene and six in the control group
had mild to moderate lupus flares, which was not a significant
difference, while none of the women in the study had severe
flares.

Because lupus flares are rare in postmenopausal women, the
researchers note, a much larger study would be needed to
identify any effect of raloxifene on disease activity in this
group. “Thus, close monitoring for disease flares is still
necessary in SLE patients who are receiving raloxifene,” they
write.

It’s also noteworthy, according to the team, that women on
raloxifene also showed an increase in “good” HDL cholesterol
levels and a decrease in “bad” LDL levels, which was not seen
in the control group.

The current study and other recent findings, they write,
suggest that raloxifene could help protect the heart in
addition to treating osteoporosis. “Further multicenter
double-blind placebo-controlled trials are necessary to
reinforce our results,” they conclude.

SOURCE: Arthritis and Rheumatism, December 2005.

Pentagon to kill F-35 back-up engine-consultant

By Jim Wolf

WASHINGTON (Reuters) – The Pentagon has decided to kill a
planned back-up engine for the F-35 Joint Strike Fighter, the
most expensive U.S. warplane program ever, in a boost to United
Technologies Corp. and a blow to rivals, a well-placed defense
consultant said on Thursday.

The decision could mean tens of billion of dollars in extra
sales over 25 years for Pratt & Whitney, a United Technologies
unit, said Loren Thompson, chief executive of the Lexington
Institute, a nonpartisan, Virginia-based research group.

The plan, subject to approval by the White House budget
office and the U.S. Congress, would be a setback for General
Electric Co. and Rolls-Royce Plc, which have been developing a
separate but interchangeable engine.

“They have killed the alternative engine,” said Thompson,
who has close ties to the Pentagon and industry.

A spokeswoman for the Pentagon program office overseeing
the project did not immediately return a phone call seeking
comment. GE said the decision was far from final.

The F-35, which will be the Pentagon’s biggest purchase at
an estimated $256 billion, is a family of three warplane
variants being built by Lockheed Martin Corp. with eight
overseas co-development partners, including Britain, Italy and
Turkey.

The Pentagon plans to buy as many as 2,480 of the aircraft
in three versions being developed for the U.S. Air Force, Navy,
Marine Corps and the British Royal Navy.

Some of the biggest revenue from engines comes in
maintenance and spare parts over their lifetimes. GE and
Rolls-Royce are 60-40 partners in developing their version of
the turbofan engine that would power the single-engine,
radar-evading aircraft.

Thompson said the decision to cancel the back-up engine was
part of a December 23 Pentagon memorandum prepared for the
fiscal 2007 budget that President Bush is due to send to
Congress in early February.

Rick Kennedy, a GE spokesman, said the company was counting
on Congress to restore the engine, pushed by Britain and other
co-development partners.

“The budget process has a long way to go,” he said. “This
isn’t our first struggle. We’ve had them before.”

GE received a $2.4 billion development contract for the
alternative engine in July due to last until 2012, or about
$400 million per year, he said.

Congressional proponents of an interchangeable engine,
along with GE, have cited potential savings through
competition. They also describe it as a hedge against having to
ground the entire fleet in case of trouble with any one engine.
But a second engine has boosted the aircraft’s development
costs, something the Pentagon is under pressure to pare.

United Technologies shares were down 14 cents to $56.73,
while GE added 24 cents to $35.35, both on the New York Stock
Exchange. Rolls Royce shares closed at 429.48 pence in London
trading.

Age No Bar to Clot-busters for Stroke

By David Douglas

NEW YORK (Reuters Health) – Although elderly stroke patients have a greater risk of dying following treatment with the commonly used clot-buster called tPA (tissue plasminogen activator), age is not an independent predictor of outcome, Swiss researchers report in Neurology.

Commenting on the findings, Dr. J. Claude Hemphill III, co-author of an editorial in the medical journal, told Reuters Health, tPA “should not be withheld from acute stroke patients just because they are very old.”

Hemphill, of the University of California, San Francisco, added that while older patients might have a higher risk of bleeding from tPA, “we know that older patients also are more likely to die and less likely to recover from the stroke itself.”

The study, by Dr. S. T. Engelter of University Hospital Basel and colleagues, involved 325 tPA-treated stroke patients. Of these, 38 were 80 years of age or older, whereas the remaining 287 ranged in age from 14 to 79 years and their average age was 63 years.

The team found that the rate of bleeding in the brain did not differ between the two groups and overall there was a favorable outcome in 29 percent of the older patients and 37 percent of the younger patients. At 3 months, 32 percent of the elderly patients had died compared with 12 percent of the younger patients.

Among patients who survived for 3 months, the rate of favorable outcome was similar in the older and younger set — 42 percent and 43 percent, respectively.

According to Engelter and colleagues, stroke severity, time to clot-buster administration, blood sugar level, and history of heart disease — but not age — independently predicted outcome. This study, they conclude, shows that very elderly stroke patients can benefit from tPA administration.

SOURCE: Neurology December 13, 2005.

Dealing Drugs and Mortgages: Despite Indictment, Gang Honcho Secured State License for Loans

By David Jackson, Chicago Tribune, Chicago Tribune

Dec. 29–Last year state officials sent Deangelo McMahan a certificate worth framing–a provisional mortgage loan originator’s license that allowed him to gather financial records from homeowners and submit applications to banks.

A quick background check might have made them think twice about the 31-year-old dealmaker.

Five months earlier, in April 2004, federal prosecutors had indicted McMahan and two of his brothers for running a curbside heroin, cocaine and marijuana market on Chicago’s West Side.

An informant had fingered McMahan as a leader of the Insane Mafia Vice Lords street gang.

The story of McMahan’s metamorphosis from drug dealer to mortgage executive stretches from Chicago’s West Side to its affluent suburbs and all the way to Russia. It involves allegations of using black market credit card information and the identities of dead people.

McMahan’s provisional mortgage license expired in June 2005, a few weeks before he was convicted of drug-dealing and sent to prison for 4 years. But the trail of real estate deals he left behind offers more evidence that gangs are turning to mortgage fraud as a moneymaker.

Called “the new street hustle” by gang members, mortgage fraud is raking cities like Chicago, as con artists use high-tech identity theft and face-to-face scams to secure six-figure bank loans that are never repaid.

A Tribune report in November showed how alleged Black Disciples gang leader Marvel Thompson used fraudulent mortgages to acquire South Side properties and launder money. Sen. Barack Obama (D-Ill.) pointed to that report when he called for Senate Banking Committee hearings on mortgage fraud in 2006.

McMahan has not been charged with mortgage crimes, and his attorney Michael Mann said he believed McMahan worked “honestly and conscientiously” as a home loan originator and real estate investor starting in the 1990s.

But allegations of fraud emerged from land and court records as well as FBI reports made public during McMahan’s drug trial.

Federal authorities have questioned at least one West Side funeral home director to determine whether McMahan helped gang members use the identities of dead people to apply for home loans.

Sheila D. Reid, president of the House of Branch funeral home at 3125 W. Roosevelt Rd., said she believes McMahan did use numerous dead people’s names and information, but she said she told agents that McMahan got the data from another funeral home, not hers.

That was apparently not his only source of stolen identities.

As part of the drug investigation, federal agents intercepted a shipment of 215 black-market credit card holograms from Russia to one of McMahan’s brothers. Holograms, the shiny rectangles on credit cards that contain coded security data, are prized by identity thieves.

Such sophisticated white-collar crime techniques would be a far cry from McMahan’s hardscrabble youth on the West Side.

In a nine-page FBI statement made following his April 2004 federal narcotics arrest, McMahan acknowledged a youth spent with gangs and said he “used to be a drug dealer, but does not deal drugs anymore.”

According to federal court statements by others convicted in the McMahan drug operation, he and his brothers became gang leaders with a reputation for tough justice–one brother allegedly shot an underling in the hand for smoking crack he should have sold.

By the 1990s, land records show McMahan had also launched a career as a real estate dealmaker.

In one of his first significant property acquisitions, McMahan in 1994 bought the storefront and apartment building at 5941 W. Chicago Ave., where he opened a popular hip-hop boutique called 600 Collections.

Another convicted Vice Lords leader told prosecutors that the three McMahan brothers transacted “large weight” drug deals at the boutique, although attorneys for the McMahans deny it.

In the years that followed, McMahan consummated other land deals with criminals and real estate professionals who accrued civil court judgments for fraud, records show.

One example is the ramshackle two-flat at 1216 S. Avers Ave.

McMahan signed a deed as part of a rapid series of deals that inflated the building’s price before using it to secure a $195,000 loan that went unpaid, the Tribune found.

His cohorts in those 2002 deals had shady reputations: Allentino Hayson, a home rehabber convicted in 2004 of passing a forged check; Marek Maka, a property investor convicted this year for holding counterfeit passports; and Maya Jordan, whose state home appraiser’s license was revoked in 2003 amid civil court allegations of fraud.

The Avers Avenue deals also involved a home at 5718 S. Maplewood Ave., in another string of transactions McMahan orchestrated with his girlfriend, a brother and an attorney named Warren Nickel who was disbarred in 2004. After a series of quick exchanges, that building was used to secure a $250,000 loan that went unpaid.

As McMahan continued to acquire city and suburban properties, he moved up to the next tier of the real estate profession, joining the loan executives who finance property deals.

By 2003, he was a loan officer for a growing South Side firm called Express Mortgage Inc., court records show. Such mortgage brokerages do not lend money. For a fee, they assemble loan applications on behalf of homeowners.

Express generated millions of dollars worth of Chicago-area loans before it was shuttered this year amid tax debts and an ongoing criminal probe.

While McMahan has not been accused of mortgage fraud during his time at Express, a number of his co-workers were. Three separate lending companies have won civil court judgments after alleging that the firm used forged documents and inflated home appraisals in loan applications.

And an Express loan officer named Azureeiah O’Connor was indicted in July for allegedly taking part in criminal mortgage fraud schemes. O’Connor, who has pleaded not guilty, declined to comment.

From the ashes of Express, a new mortgage broker company was born, McMahan told the FBI.

The Express office at 1234 S. Michigan Ave. changed names to New Family Mortgage.

Mortgage deals orchestrated at New Family helped that brokerage’s putative owner, Kelly Husband, buy the well-known nightclub Shark Bar.

In a separate action against the nightclub, Chicago police disclosed in December 2004 that Husband’s spouse–allegedly the man in control of New Family Mortgage–was under federal investigation for money laundering and bank fraud.

Around December 2003 McMahan took a new job as a $70,000-a-year loan officer at yet another mortgage firm, based in Homewood, according to bankruptcy papers he later filed.

It isn’t clear where McMahan worked in September 2004 when the state Department of Finance and Professional Regulation issued his provisional loan originator’s license, part of the state’s first required registration.

At the time, the department required no criminal background check for mortgage originators, or loan brokers, as they typically are called.

“Everybody got a provisional license who wanted one,” department spokeswoman Susan Hofer said.

Since June 2005, the department has required loan originators to undergo a fingerprint check conducted by state police or federal authorities. A criminal record does not necessarily disqualify a person, but regulators do have discretion to withhold a license if they deem an applicant unfit.

[email protected]

—–

Copyright (c) 2005, Chicago Tribune

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].

Tokyo:7498,

Wheezing in Infants Requires a Doctor’s Care

By Dr. Helen Minciotti

A mother paged me several hours before our office was due to open. Her infant had been up a good part of the night breathing fast and making noise when she exhaled. The mother astutely recognized that her child was wheezing.

Not wanting to delay, I advised her to head to the closest emergency department.

Most people know someone with asthma, and they understand that asthmatics suffer from wheezing and shortness of breath when exposed to certain environmental triggers. When some infants catch bad colds, they too might wheeze, but their triggers are respiratory viruses.

This viral wheezing is known as bronchiolitis. The bronchiolitic child has a pretty classic appearance, with a clear runny nose, a frequent tight-sounding cough and an expiratory wheeze.

I remember my first bronchiolitic patient during pediatric training. The attending physician described what I would find when I listened with my stethoscope: “When he exhales,” she pointed out, “you’ll hear something that sounds just like paper being crumpled.”

These “bronchiolitic crackles” are wheezing noises made each time the sick infant exhales, and are easiest to hear with a stethoscope. When the wheezing is severe, it can even be heard with the naked ear, an “audible wheeze.” If the baby is really working hard to breathe, you might also see retractions, which are deep- sucking chest movements that cause the chest wall to outline the ribcage with each breath.

Like all wheezing, bronchiolitis can range from mild to severe. It can be life-threatening for infants younger than 6 weeks of age, premature babies and infants with congenital heart disease.

One of the more common respiratory viruses responsible for bronchiolitis is the respiratory syncytial virus, or RSV. RSV is common in the Midwest between October and May.

The American Academy of Pediatrics reports that most children have had at least one bout with RSV before age 2. A majority of these children will just have minor cold symptoms, but some will wheeze. The Academy notes that 125,000 U.S. children are hospitalized each year with RSV, and the infection is fatal in 500 of these cases.

Because bronchiolitis is not truly asthma, many of these little patients will not respond to standard asthma therapy. Then all that’s left is supportive care. Parents are instructed to keep children well-hydrated and to call if they refuse to drink, appear excessively tired or have labored breathing. If patients come into the office already exhausted, breathing hard and in need of oxygen, they will need to be admitted to the hospital for oxygen therapy and close observation.

As with other respiratory infections, the nasty viruses that cause bronchiolitis are best avoided by keeping your child away from sick people and practicing frequent hand washing. During the winter months, certain at-risk infants, such as the extremely premature, might also qualify for monthly RSV preventive shots, such as Synagis or palivizumab, a monoclonal antibody therapy.

– Dr. Helen Minciotti is a mother of five and a pediatrician with a practice in Schaumburg. She formerly chaired the Department of Pediatrics at Northwest Community Hospital in Arlington Heights.

Albany Man Starts Import Business, His Own Vintages to Tap New York Market

By Kevin Harlin, Times Union, Albany, N.Y.

Dec. 27–ALBANY — Joseph Carr believes upstate New Yorkers have a sophisticated palate for wine.

He’s banking on it.

Carr, a one-time sommelier and wine director at The Sagamore Resort and restaurants around Albany, left a career as a wine marketer and executive with large firms to start his own import business in Albany in February.

He now operates Outer Cape Imports out of his Western Avenue home.

But Carr wasn’t content to just sell other people’s wines. So he developed his own labels — Joseph Daniel and Joseph Carr.

“It’s a sophisticated market. There’s a lot of interest in wines here, and we’re taking advantage of that,” he said.

Carr said he expects Outer Cape to import 30,000 cases a year, and be profitable in its first year. He said the wine-making side is profitable as well.

He is a negociant, meaning he buys grapes from growers, or wine already in barrels, and blends it to make his own product. His first wine, a Napa Valley cabernet sauvignon under the Joseph Daniel label, came out earlier this month. Next month he expects to release a 2002 Joseph Carr cabernet.

And he’s working on a merlot from South Africa, and a riesling with a German vintner.

Carr is trying to make a name for his wines. In the meantime, he said he doesn’t want to scare anyone off with a high price tag. His Joseph Daniel label retails for about $18. The eponymous Joseph Carr label will retail for about $21, he said.

He said producing small batches of wine as a negociant is much cheaper than making the same wine with the overhead of a large estate. That allows him to sell wines at $20 a bottle comparable to those sold at $40 or more, he said.

“My philosophy is to over-deliver whatever you do,” Carr said. “So someday, when I release a $35 wine, it would be worth over $70.”

But Carr still needs to be a salesman.

At lunch last week at 677 Prime, a restaurant in Albany, Carr’s table was crowded with numerous bottles of wine — those he imports and those he has created. He offered a bottle to customers at a nearby table. He poured some of his cabernet for two women at another table who were curious.

And he talked wine with 677 Prime’s own sommelier, Ean Egas.

“It carries itself well,” Egas said, tasting an early barrel sample of a South African merlot.

Carr, a Berlin, Rensselaer County, native, began learning about wine as a student at the State University of New York at Geneseo, outside of Rochester. While his friends were drinking the local Genesee beer, he was earning money at a local restaurant.

He was a lousy busboy. So the owner gave him a bow tie, bottle opener and book on wines and made him a wine steward.

After college, he worked as a wine steward in Florida. He returned to the Capital Region, becoming wine director and sommelier at The Sagamore, from 1985 through 1990.

Carr later became a northeast sales manager for Paterno Imports International, a large wine importer. Next, he spent six years at Mildara Blass Wines Inc., an Australian company owned by the Fosters Brewing company. He worked his way up from a regional sales manager to North American president.

Then he became an executive at Knightsbridge Fine Wines, a company that owned vineyards around the world.

But Carr said he wanted to develop his own wine, tailored to what he and his friends enjoy.

“I value quality. There are no shortcuts here,” he said. “I’m also going to drink whatever I make.”

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The Consequences of the Polio Vaccine Batch That Went Wrong

By TERRY ENGLAND

THE CUTTER INCIDENT: How

America’s First Polio Vaccine Led to the Growing Vaccine Crisis

By Paul A. Offit

Yale University Press

238 pages, $27.50

You can blame hortages of flu vaccine on botched batches of polio vaccine in 1955. So says Paul Offit in The Cutter Incident: How America’s First Polio Vaccine Led to the Growing Vaccine Crisis.

By the early 1950s the polio epidemic was in full swing and parents across the country were in a panic. The National Foundation for Infantile Paralysis, founded in 1938 at the urging of President Franklin Roosevelt – a polio victim himself – was raising money by the bucketful to fund research.

One of the researchers was Jonas Salk, who was trying to develop a killed-virus vaccine, one that would inject a virus that has been killed by chemical means (formaldehyde) into a patient to stimulate a immune-system response.

Salk’s name came close to being reviled instead of honored. A large field trial of his vaccine had led the government to declare it safe. But in 1955, cases of immunized children coming down with polio started to show up. These cases came in children inoculated with vaccine from Cutter Laboratories in California. After some fumbling by government officials, the vaccine was pulled from the market.

Too late, because 220,000 people were infected by the virus in the Cutter vaccine; 70,000 developed muscle weakness, 164 were severely paralyzed and 10 died. Investigations pointed to the virus surviving the killing process because of faulty filtering methods.

Cutter was sued, of course; the first trial was Gottsdanker vs. Cutter Laboratories in 1958, brought by the parents of Anne Elizabeth Gottsdanker, who contracted polio through the vaccine.

“The jury had found that Cutter Laboratories was not negligent in the production of polio vaccine, but Cutter was still financially responsible (liable) for harm caused by its product,” Offit writes. “Liability without negligence (fault) was born.”

This has led drug companies to get out of the vaccine-production business.

“We sue pharmaceutical companies because we want them to pay for our health care and we want to punish them,” he writes.

The consequences could be dire, Offit warns. He quotes Anne Gottsdanker as saying she wishes the Cutters, owners of the lab where the contaminated vaccine was produced, could see her now – using crutches to walk, wearing a brace to protect a knee that is easily dislocated, suffering from being treated as a second-class citizen. Offit then says, partly because of the verdict of the Gottsdanker suit, Anne’s grandchildren could face diseases that could be stopped by vaccines but won’t be.

“Ironically, in an attempt to protect children from harm, we have inadvertently exposed them to a greater harm.”

Terry England

England is the Books page editor.