House Panel Approves Pension Bill

WASHINGTON (Reuters) – U.S. companies would get another year, until 2007, before they have to start following stricter pension funding rules under legislation approved on Wednesday by a U.S. House panel.

The House Ways and Means Committee approved the bill on a vote of 23-17. It aims to repair the underfunding of traditional pensions and avoid a possible taxpayer bailout of the federal agency that insures pensions, the Pension Benefit Guaranty Corp. (PBGC).

Unlike a version in the Senate, the House bill contains no special relief for distressed airlines with underfunded pensions. Ultimately both chambers must approve the same legislative language before a bill can become law.

The House bill previously had cleared the House Education and Workforce Committee with a 2006 starting date. But Ways and Means Chairman Rep. Bill Thomas, R-Calif., said on Wednesday that a year’s postponement was needed “given the difficulties of putting these (pension funding) rules into effect.”

Thomas proposed the one-year delay as part of a package of changes to the bill which the committee approved before voting to send the entire measure to the House floor.

Also added was a provision penalizing companies shedding traditional pensions on the PBGC while in bankruptcy. They would have to pay $1,250 per plan participant to the PBGC in each of the first three years after emerging from bankruptcy protection.

The Senate has already approved such a penalty as part of that chamber’s budget legislation.

First seconds of a quake can show size: study

By Jeremy Lovell

LONDON (Reuters) – With the devastation of last month’s Pakistan earthquake still fresh in the mind, scientists said on Wednesday they have developed a way of predicting the size of a tremor even as it starts.

Seismologists have tried and failed for years to predict where and when quakes will happen and how big will they be.

Now there is a glimmer of light on the horizon — at least for the latter goal, according to scientists at the University of California, Berkeley.

“We can determine the magnitude within a couple of seconds of initiation of rupture and predict the ground motion from seconds to tens of seconds before it is felt,” said lead researcher Richard Allen.

Although that time frame would be far too short for people to react and evacuate, it could be enough to tell local emergency services almost instantaneously the scale of the disaster they are likely to be facing when the dust settles.

It could also set off alarm bells in far flung centers who could begin to mobilize support earlier.

Up to now, the cascade theory of earthquakes that portrays them as acting like a row of dominoes with one action triggering another in sequence, has meant it has been impossible to gauge the scale of the quake until it has ended.

By that time, communications could well have been destroyed leaving local emergency services in an information black hole.

But the study led by Allen and co-author Erik Olson, published in Thursday’s edition of Nature science journal, uses a different theory.

It suggests that the size, type and depth of the first break on the fault line — that can be measured as it happens — gives a very good indication of the earthquake’s eventual reach.

“Most seismologists are surprised, and frequently skeptical, that you can predict the magnitude of an earthquake before it has ended,” Allen said in a statement from Berkeley.

“But this is telling us that there is something very different from what we thought about the physics of the processes involved in the rupture,” he added.

In a commentary on the research also published in Nature, Rachel Abercrombie of Boston University said the new theory had crucial implications but that more work was needed.

“We are far from understanding how onset, propagation and state of stress of the surrounding fault interact to determine the final size of a seismic event,” she wrote.

“Olson and Allen’s study advances that understanding and thus our ability to predict an earthquake’s size before it reaches its peak,” she added.

Parasites Sour Appetite for Peppered Pickle

By Jon Herskovitz

SEOUL — Take a cabbage. Pack it in a large clay pot with garlic, ginger, fish sauce and fiery red peppers. Add some other goodies and let it ferment.

What do you get? The pungent Korean dish called kimchi — and a scare about parasite eggs that has ignited a trade dispute between two of Asia’s largest economies.

Kimchi is served at almost every meal and made in most homes. But increasing imports of the spicy cabbage from China have raised a ruckus about a foreign country eating away at the market for a national dish that is at the essence of Korean identity.

Last month, the Korea Food and Drug Administration (KFDA) banned the sale of kimchi imported from China because samples contained parasites’ eggs that likely came from the use of human feces as fertilizer in Chinese agricultural production, it said.

The KFDA then added more spice to the trade pickle last week, releasing a report saying parasite eggs had also been found in 3.2 percent of South Korean-made kimchi.

“I’m really worried about the state of kimchi these days,” said Yoon Ji-sun, a graduate student who went on a tour of a kimchi factory in order to get tips on pickling her own at home.

“We cannot trust anyone but ourselves when it comes to kimchi,” she said by telephone.

KIMCHI SCIENCE

Some of the South Korean kimchi producers cited as having a tainted product have sent kimchi to markets such as Japan — and even supplied South Korea’s presidential Blue House, the KFDA said.

Typically, the science of kimchi has been less about findings in the lab and more about claims such as warding of the SARS virus and preventing cancer.

One Seoul pharmacist said consumers are worried.

“We have sold five times the amount of anti-parasite medicine in recent days than we normally do, said Yoo Ha-na.

Demand for kimchi had not dropped over fears about Chinese imports, South Korean officials said. But they are not sure what will happen after the revelation the domestic product may also be tainted.

According to the Korean Food Research Institute, the average South Korean each year consumes about 75 pounds of kimchi, which is mostly made with cabbage, though a variety of vegetables can also be used.

The kimchi worries started in September with a report that Chinese-made kimchi had a higher lead content than South Korean-made kimchi. Scientists later said the content did not present a significant health hazard.

China complained about the lead-content report and when South Korea banned the import of Chinese-made kimchi last month, Beijing slapped import bans on several South Korean food products.

In 2004, China became South Korea’s leading trading partner, with two-way trade totaling $79.35 billion, up 39.2 percent from the year before, South Korea’s trade ministry said.

This year’s imports of kimchi from China to October 20 reached 94,128 tons, up by about 30 percent from the same period last year. The 2005 imports had a value of about $40 million, South Korea’s food administration said.

Although the dispute will not be on the menu of official talks at an Asia-Pacific summit in Pusan, South Korea, later this month, kimchi could make its way into informal chats among the leaders, foreign ministers and business leaders — and is almost certain to be served during official functions.

The foreign ministers of China and South Korea have said they want to avoid a trade war over the kimchi spat.

Five years ago, South Korea imposed a 10-fold increase in tariffs on Chinese garlic partly over health concerns, partly to protect its farmers. China retaliated with restrictions on Korean mobile phone imports.

MIRACLE FOOD

Over the years, kimchi has been billed as a miracle food with an amazing, and perhaps exaggerated, array of health benefits.

Kimchi cuts cholesterol, prevents obesity, diabetes and stomach cancer, constipation and colon cancer, and to top it off, keeps a person young and their skin healthy, according to the Korea Agro-Fisheries Trade Corp.

Most of these claims, however, have not been supported through extensive scientific testing.

Kang Sa-ouk, a professor at South Korea’s prestigious Seoul National University, is testing to see if an extract from kimchi can be used as an additive for chicken feed to prevent bird flu.

“The feed has been shown to help improve the fight against bird flu or other types of flu viruses,” said Kang.

Another scientist, who specializes in kimchi, said that even though claims such as cancer prevention have not been proven through substantial study, the food staple does help health.

“There are a lot of ingredients in kimchi, as well as microbes produced during the fermentation process that help a person’s immune systems and circulation,” said Lee Myung-ki, a senior researcher at the Korea Food Research Institute who leads its kimchi task force.

(With additional reporting by Lee Jin-joo and Frances Yoon)

Hospital Infection Rates Hit Web

By Carol Gentry, Tampa Tribune, Fla.

Nov. 9–TAMPA–Tampa General Hospital and six other Bay area hospitals received among the worst ratings in the state for patient infections in a study released by state regulators Tuesday.

Administrators at hospitals that received low ratings argued the study is flawed.

With the release of the study, Florida became the first state in the nation to begin publicly rating hospitals for their infection rates, a move praised by some consumer rights advocates.

“It’s a really historic first step,” said Lisa McGiffert, director of a hospital infection project at Consumers Union. “This is the kind of report that gives consumers what they want.”

The report, which lists charges, caseload, and length of stay, in addition to infections and other measures of patient safety, was issued Tuesday by Florida’s Agency for Health Care Administration.

It can be viewed online at: www.floridacomparecare.gov or floridacomparecare.org.

Four hospitals in the area — Pasco Regional Medical Center, Spring Hill Regional Hospital, Manatee Memorial Hospital, and Blake Medical Center in Bradenton — did better than average on measures of infections acquired from medical care.

Seven in the region did worse. Those include three in Hillsborough County: Tampa General, Memorial Hospital of Tampa, and Brandon Regional Hospital.

Administrators at Tampa General and others that received worse ratings argued the methods the state used weren’t appropriate and that the study could mislead people.

Tom Danzi, chief medical officer at Tampa General Hospital, said the hospital works hard to prevent patient infections. “Believe me, we’re striving every day to get to 100 percent” infection-free, he said. “We’re very proud of the excellent care we provide.”

The state study showed that Tampa General’s infection rates, adjusted for risk, was less than 1 percent.

The report was compiled using hospital billing codes, rather than patient medical records. Once data on infections were obtained, researchers adjusted the results to allow for the fact that some hospitals treat sicker patients who are more prone to infections.

Tampa General’s situation, for example, is complex. It has unusually large numbers of immune-suppressed patients because it has a burn unit, a heavy trauma caseload, a neonatal intensive care unit, and one of the nation’s largest heart transplant centers.

A number of government and private organizations that measure hospital performance have rated Tampa General above-average on a number of performance standards. For example, the Joint Commission on Accreditation of Healthcare Organizations recently gave Tampa General awards for heart patient care.

All Children’s Hospital in St. Petersburg is another local hospital that fell into the higher-than-expected group for infections. Like Tampa General, All Children’s is a teaching hospital affiliated with the University of South Florida.

Its patients include some of the sickest children in the region. The measures used to draw up the comparison were designed for adult facilities, not pediatrics, said physician Jack Hutto, vice president for quality for All Children’s. It will be another year before appropriate measures are designed for children’s hospitals, he said.

The measures used in the report, called patient safety indicators, were devised by the federal Agency for Healthcare Quality and Research in Rockville, Md.

Marybeth Farquhar, that agency’s senior adviser on quality initiatives, said that it might be wise for the state to note on the Web site that ratings can be misleading for hospitals such as Tampa General and All Children’s.

“We want to promote quality initiatives,” Farquhar said, “but we don’t want to set up a perverse incentive that would punish hospitals that take the riskiest cases. That scares me to death.”

Hospital-acquired infections are typically caused by professionals and other staff forgetting to wash their hands when they move from one room to another.

Infections can occur from catheters, intravenous lines and other tubes in the body, and from organisms invading a surgical wound. Tampa General and All Children’s scored in the expected range for risk of post-surgical infection.

The Centers for Disease Control and Prevention estimates that 2 million patients a year catch infections after they check in to the nation’s hospitals. Of those, the CDC says 88,000 patients a year die from those infections. Hospital infections rank as the nation’s sixth-leading cause of death.

Patient advocates and state officials said it is important to give the public tools to evaluate health care, even if the ratings system isn’t perfect. The state’s Web site allows users to compare hospital safety rates by procedures or conditions as well as by infections and complications.

However, even the site’s biggest supporters agree it still has room for improvement.

Alan Levine, secretary of the state agency, said he expects people to squabble over the way the study was done. He urged the public not to compare one hospital with another, but to compare a hospital’s results this year with its results next year, when the report is updated.

“This does not determine which hospitals are good and bad,” he cautioned.

The author of the bill that led to the study and Web site, Rep. Frank Farkas, R-St. Petersburg, said it’s important to give consumers information on health care safety .

“This stuff is monumental,” Farkas said. “It’s ground-breaking. The rest of country should follow.”

—–

To see more of the Tampa Tribune — including its homes, jobs, cars and other classified listings — or to subscribe to the newspaper, go to http://www.tampatrib.com.

Copyright (c) 2005, Tampa Tribune, Fla.

Distributed by Knight Ridder/Tribune Business News.

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

LabCorp Launches More Advanced HIV Test

By Times-News, Burlington, N.C.

Nov. 8–LabCorp has launched a new HIV screening test that allows for earlier detection of the virus.

The test is designed to help identify newly infected HIV patients by using nucleic acid testing on antibody samples that have come out negative.

A test is negative when no or few antibodies that defend against the virus are detected in the patient’s blood. However, this doesn’t mean the person has not contracted the virus.

If a person was infected with the virus shortly before the test was conducted, there is a chance that the person hasn’t developed detectable levels of HIV antibodies.

During this period, infected individuals are considered significant contributors to the spread of the virus since they are unaware of their HIV status.

“There are nearly one million people in the United States infected with HIV, with approximately 40,000 new infections every year,” said Myla Lai- Goldman, a LabCorp executive vice president. “Earlier diagnosis leads to earlier referral for appropriate care.” The new test combines antibody screening with HIV nucleic acid testing using pooled samples. Although it has not been cleared by the Food and Drug Administration for diagnosing HIV infection, this method can help identify the virus up to six weeks sooner than standard HIV antibody screening.

With more than 3,200 local employees and 24,500 employees nationwide, Labcorp is Alamance County’s largest employer and the second-largest clinical laboratory in North America.

The laboratory offers clinical tests ranging from blood analyses to HIV and genomic testing to more than 220,000 clients.

—–

To see more of the Times-News, or to subscribe to the newspaper, go to http://www.thetimesnews.com.

Copyright (c) 2005, Times-News, Burlington, N.C.

Distributed by Knight Ridder/Tribune Business News.

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

LH,

Skin Deep New Cosmetic Treatments Mean You Can Improve Your Look Without Drastic Measures

By Susan Stevens Daily Herald Health Writer

For you, maybe, a face lift is off the table. You don’t want to spend weeks recovering and dislike the idea of such a radical change.

But the march of decades has left its mark across your brow. Too many hours in the sun have stolen your bright complexion. And lately you’ve noticed your jaw line looks a little, well, indistinct.

“All of us eventually look in the mirror and realize our skin just doesn’t look the same any more,” said Dr. Mary Massa, a dermatologist and director of the cosmetic program at Rush University Medical Center in Chicago. “Everyone is getting a little older, their skin is getting a little bit duller, there’s unevenness of color, irregular brown spots, lines in the upper face.”

A host of new cosmetic skin treatments can fulfill those cravings for a skin fix. In many cases, they are less painful, less risky and more effective than what was available a decade ago, so you can see significant improvement without ever going under the knife.

Before you pick and choose, most experts recommend you see a physician trained in these techniques to evaluate what’s best for you.

“It’s important to match the right technique with the right patient,” said Dr. Stephen Bloch, a plastic surgeon and founder of Skin Deep Medical Spa in Glenview and Highland Park.

Fraxel

A new resurfacing laser treatment can help fade wrinkles around the eye, erase age spots and improve skin texture.

The innovation: Unlike traditional laser treatments that remove the top layer of skin, the Fraxel laser treats thousands of tiny points of skin in a checkerboard pattern, leaving surrounding areas untouched. The laser heats the deeper dermis layer of skin to stimulate the production of collagen and new skin cells.

About 20 percent of the skin is treated at one time. This “fractional” approach results in a much quicker, less-painful recovery than ablative treatments like the CO2 laser.

What you get: For $750 to $1,500 per treatment, you’ll see fresh skin in a few days. Usually four to six 30-minute treatments are required. Even with anesthetic cream, you will feel mild prickling or a burning sensation. Afterward your skin will feel tight and swollen, and you’ll look like you have a sunburn. In a couple of days your skin will look bronzed. After a week the top layer will start to slough off as new skin emerges.

Patient experience: After four Fraxel treatments at Skin Deep Medical Spa, Rosalind Alvarez, 60, of Mundelein said dark spots have disappeared and her skin texture has improved. She retired most of her cosmetics, keeping just a little concealer and her eye makeup. “It’s truly like when you first started wearing makeup,” she said.

Alvarez scheduled her treatments for Friday morning and said she was red and swollen enough that she appreciated the downtime over the weekend.

Expert opinion: Fraxel is new – it won FDA approval last year – so long-term results are unknown. Doctors who perform Fraxel say the results are not as dramatic as the more aggressive lasers, but neither do you suffer through two weeks of crusting and oozing.

“It’s good for sallow complexions, irregular pigmentation, some fine lines,” said Dr. David Van Dam, a dermatologist in Barrington. “In some cases it’s fairly dramatic, but in most cases it’s just a nice improvement in the quality of the skin.”

Dr. Val Fugali, who performs Fraxel treatments at Skin Deep Medical Spa in Glenview, said Fraxel is also good for the delicate skin of the neck, chest and hands. It’s also an option for people with darker skin who are not candidates for ablative lasers.

“It does really great things for patients who have acne scarring,” Fugali said. “Every patient I’ve treated has commented on how fresh her skin looks.”

Where to find it: At dermatologists’ and plastic surgeons’ offices. To find a doctor near you, visit www.fraxel.com.

Thermage

If you’re not ready for a facelift, Thermage might offer the tightening you need.

The innovation: Using radiofrequency energy, Thermage ThermaCool penetrates to the dermis layer of your skin to tighten existing collagen and stimulate new collagen.

What you get:

For roughly $2,500, Thermage can tighten skin around the jaw and neck and smooth out wrinkles. The hourlong treatment feels like a rubber band snapping against your face. Redness and swelling might last a few hours to a few days. Your skin continues to build new collagen for up to six months, so doctors recommend waiting at least that long before considering another treatment.

Patient experience: Joyce Gonnerman, 55, of Barrington had Thermage at Skin Deep Medical Spa five months ago, when she noticed the skin under her chin had started to sag. But surgery scared her, and she didn’t want to leave work for a long recovery.

Since her treatment, Gonnerman said her skin is tighter.

“Since I have had it done, I’ve had people look at me and say, ‘God, you look great,’ but they don’t know what the difference is,” she said. “I look five to seven years younger, easy.”

Expert opinion: According to the American Society for Dermatologic Surgery, Thermage results in mild to moderate skin tightening in most patients. But some patients complain it hurts too much, and at least 20 percent see no benefit. Some doctors say that percentage is actually higher.

Bloch said the technique has evolved in the past four years. Physicians are performing more passes at lower energy levels, which reduces pain and achieves better results with less risk of blistering or pitting.

Not everyone is a good candidate, Bloch said. It’s best for those in their 50s or 60s who are starting to see their skin loosen.

“I’ve had the treatment, and there’s no doubt in my mind that it works,” he said.

Where to find it: In dermatologists’ and plastic surgeons’ offices. Visit www.thermage.com to find a doctor near you.

Titan

Newer than Thermage, Titan has similar goals: tightening loose skin.

The innovation: Using infrared light, Titan heats up the deeper layers of the skin to stimulate collagen to contract while leaving the top surface unharmed. Titan can be used on loose flesh from your face to your knees, including areas not helped by surgery.

What you get: Depending on the area treated, Titan costs $1,000 to $3,000 per treatment. You could see firmer, tauter skin immediately, but final results might take several months as new collagen fills in. Doctors often recommend two or three treatments. You will feel a warming sensation followed by mild swelling and redness. Some areas, such as the abdomen and thigh, tend to be more painful. Recovery is minimal.

Expert opinion: Since Titan has only been around a year or so, doctors aren’t sure how long results will last. Titan is a good choice for a patient with little fatty tissue but some skin laxity, such as after pregnancy, Bloch said.

“The results are a little bit variable,” he said. “Rather than treating the entire face, we tend to just spot treat.”

Other manufacturers are developing similar devices, which could become available next year.

Where to get it: At dermatologists’ and plastic surgeons’ offices. Visit Titan’s manufacturer at www.cutera.com to find a physician near you.

Intense pulsed light

Intense pulsed-light treatments can lighten redness, age spots and freckles.

The innovation: Pulses of visible light in specific wavelengths are directed at the skin and are absorbed by pink and brown discolored areas. The unwanted pigments become fragmented and absorbed by the body.

What you get: Treatments cost $350 to $500 each for a full face, and you might need several sessions. Treatment feels like tiny pricks on the skin and does not require anesthesia. Dark spots disappear in the weeks after treatment. The effects last for years – unless you go back to your sun-worshipping ways.

Patient experience: Joyce Gonnerman of Barrington had a FotoFacial for freckles and dark spots on her face.

“These dark spots turn darker right after the treatment, and then all of a sudden they just start flaking off,” she said. “I had one really dark spot that was as big as a pencil eraser, and it’s gone. I’m delighted.”

Expert opinion: Intense pulsed light treatment is not a good option for people with darker skin, Bloch said, but it’s an excellent treatment for sun-damaged skin in fair patients.

When combined with prescription medication, the pulsed light can also be used to treat precancerous areas on the skin.

The treatment carries a low risk of side effects, but be choosy. Van Dam said he is seeing more patients who suffered scars and burns after treatment in a salon or other facility with less training in the device.

Where to get it: Intense pulsed-light treatments have been around long enough that several manufacturers offer slight variations. Brand names include FotoFacial, Lumenis and Palomar. They’re available at many dermatologists’ and plastic surgeons’ offices.

LED rejuvenation

A quick, pain-free light treatment can give your skin a nice glow.

The innovation: Light-emitting diodes cause subtle changes in tissue at the molecular level to stimulate collagen.

What you get: After exfoliating your skin, you sit in front of an LED panel that flashes light on your face for about 30 seconds. Twice-a-week treatments for four weeks might be needed to see effects, including brighter, smoother skin. Later maintenance treatments might be spaced out to once a month.

If you are receiving another treatment such as microdermabrasion, laser treatment, chemical peel or even a facial, dermatologists often add LED photo rejuvenation for free. A la carte treatments range from $50 to $150.

Expert opinion: The American Society for Dermatologic Surgery found LED photo rejuvenation can achieve “incremental improvement” of sun-damaged skin, but the results might not be dramatic enough for LED to stand alone. Patients could get similar results with creams that contain retinoids, according to the ASDS.

“It’s a good procedure for those folks who have really good skin and just want to get a little glow going,” Massa said. “It’s good for people who are very frightened to do anything more aggressive.”

Where to get it: LED photo rejuvenation is marketed under several brand names, including Gentlewaves, Dermillume, Lumiphase, Omnilux and Soli-Tone. Most dermatologists offering cosmetic treatments offer LED treatments.

Microdermabrasion

This widely available treatment is a popular way to improve your complexion.

The innovation: A technician blasts the skin with aluminum oxide particles, salt or a jet of water to slough off the outermost, dulling layer, leaving your complexion brighter and more even- toned.

What you get: For $125 to $200 per session, you’ll see some improvement in texture, pore size and color. A dermatologist or medical spa can be more aggressive than home kits, so you likely will see a bigger impact. Your skin might be pink for several hours.

Patient experience: “They get in every nook and cranny,” said Joyce Gonnerman. “I think they have a lot more consistency. When I did it myself I would rub some areas until I was raw and there were other areas I missed.”

Expert opinion: Doctors often recommend a course of microdermabrasion sessions combined with other treatments and skin products.

“I feel very strongly that patients can get more out of microdermabrasion if they’re using an effective skin care program at home,” Massa said.

Where to get it: Dermatologists’ offices, medical spas and salons.

Chemical peels

A variety of chemical peels can revitalize your skin.

The innovation: The most popular “lunchtime” peels use glycolic or salicylic acid to dissolve the top layers of sun-damaged or thickened skin, stimulating the growth of healthy new skin. Tricholoracetic acid, or TCA, penetrates deeper into the skin and offers a more dramatic improvement, but with more risks and longer recovery.

What you get: Glycolic or salicylic acid peels cost $125 to $200. For each peel, a doctor or technician applies an acidic solution to your face. Depending on its strength, you will feel a mild stinging or a strong burn for the few minutes it remains. Recovery varies. “Some people are very pink, some people are red, some people will flake like coconuts for a week,” Massa said.

Doctors might recommend a series of lighter peels, or, if the patient doesn’t mind the longer recovery, a single TCA peel that penetrates more deeply. For $500 to $650, the TCA peel will turn your face red, shiny and flaky for a week, revealing fresher skin underneath. The full effect could take months to emerge.

Expert opinion: “It’s really good for texture and that spotty sun damage,” Massa said. “It does nothing for red.”

Like microdermabrasion, chemical peels work best when paired with a good skin care regimen.

Where to get it: Dermatologists’ offices, medical spas and salons. Physicians offer higher- strength peels than aestheticians.

Cosmeceuticals

Creams and lotions containing retinoids, alpha hydroxy acids and antioxidants can help erase all that time you spent in the sun.

The innovation: While drugstore aisles display dozens of products promising skin miracles, only a few ingredients have stood up to scientific study.

Numerous studies have shown that retinoids – synthetic derivatives of vitamin A – improve skin color, elasticity and wrinkling. Alpha hydroxy acids have also been well-tested and can improve skin appearance.

The newest trend is antioxidants like green tea and grape seed extracts, vitamin C and a recent product called idebenone, which is sold as Prevage in doctors’ offices. Antioxidants aim to control free radicals that may lead to premature aging. Unfortunately, proof that antioxidants work often rests in small studies, Van Dam said.

“People need to understand the scientific evidence of their effectiveness is lacking,” he said.

What you get: The products you buy in the drugstore or at the cosmetics counter will typically be a weaker concentration than what is available at a dermatologist’s office. The alpha hydroxy acid creams at a drugstore are about 10 percent solutions; physicians’ formulas go as high as 30 percent.

Doctors usually recommend a combination of products tailored to a patient’s skin problems. Prices can range from $22 to $250 for a two- month supply.

“If someone comes in and they have a really limited budget, you can pick one or two things you think will make the biggest difference for them,” Massa said.

Expert opinion: You’ve got to actually use what’s in those pretty bottles to see the effects. It might take a few months of regular use to see results.

“It took 20 years to make the skin the way it is. Give us four months to make a change,” Massa said.

And dermatologist agree the most important skin care product is one you probably already own: sunscreen.

Where to get it: Physician’s offices or drugstores.

Hmong killer of Wisconsin hunters sentenced to life

By Eileen Nimm

HAYWARD, Wisconsin (Reuters) – A Hmong immigrant convicted
of killing six hunters was sentenced on Tuesday to life in
prison without the possibility of parole.

“These were six horrific crimes,” Sawyer County Judge
Norman Yackel told the same courtroom where a jury found Chia
Soua Vang, 37, guilty in September.

Vang opened fire last November after being confronted by
deer hunters who threatened him for trespassing on private land
near Rice Lake in Wisconsin’s North Woods. Vang chased down
some unarmed victims and shot them in the back.

Vang, who emigrated from his native Laos as a child and
joined Minnesota’s large Hmong ethnic group, was given six life
sentences and will never be paroled, the judge said.

“Mr. Vang has a history of anger, violent anti-social
conduct and his low moral character shows that he is unable to
be rehabilitated,” Yackel said.

“The method he used to kill his victims was unspeakable and
brutal. He even executed them when they were crying out for
help,” he added.

Vang first lied to investigators about who did the
shooting, then claimed he was fired at first as he tried to
leave and shot those who tried to flee because he thought they
were going for their guns.

One of the victims was Jessica Willers, whose fianc© Craig
Schuh told the courtroom the couple had planned a July wedding
and had bought a house together.

“We had hope for a future that was taken away,” Schuh said.

Vang, appearing much less animated than his shouted trial
testimony, said: “My life is over. But all of you out there
still have your life and I hope everyone learns something from
this tragedy, to live in peace with one another.”

Vang, a truck driver who won respect in his St. Paul
community for taking on the role of a shaman, told
psychologists before his trial that an evil shaman had entered
his head. He also related visions of running other drivers off
the road.

The murders underlined frictions between native hunters and
the Hmong, who were avid hunters in their Southeast Asian
homeland and were enlisted by the United States to fight the
Vietnamese during the war.

“I hope this doesn’t turn into a racial issue,” said
Wisconsin Attorney General Peg Lautenschlager, who helped
prosecute the case. “I hope that life will get back to normal
in the North Woods.”

COVER STORY – Hasbro’s Doctor of Hope – How Dr. Edwin Forman Revolutionized Children’s Cancer Care in Rhode Island

By LAURA MEADE KIRK Journal Staff Writer

Three-year-old Connor Hennessey was sicker than his parents had ever seen him: he had been complaining of pain in his legs, then spiked a temperature of 105. His pediatrician thought it was the flu. But two days later, Connor still had the fever and couldn’t walk because his legs hurt too much.

His parents brought him to the emergency room at Hasbro Children’s Hospital, figuring Connor had some sort of nasty virus. But the blood tests showed something much worse: Connor had leukemia.

Tracy and Brian Hennessey burst into tears when they heard the news. “We were in complete shock and hysterical,” Tracy recalled. “Did this mean he was going to die?”

As they sat on the edge of Connor’s hospital bed, morphine pumping through their child’s tiny body, they felt helpless. Then, they said, this “grandfatherly man” walked into their room.

Dr. Edwin Forman, the head of pediatric hematology and oncology, patiently explained “what it meant and what he could do,” Tracy said. “He was calm and comforting — grandfatherly — very reassuring. You’re talking about your three-year-old, who could possibly die, and this man comes in and gives you the strength and the confidence in him to know that he’s going to do everything he has in his power to make it better.”

They believed him.

Connor turns 8 later this month, with no signs of the cancer that could have killed him.

The Hennesseys credit Forman.

“He’s just an amazing individual who really cares and really knows his job and mission — to help save children’s lives,” Tracy said.

And he’s been doing it in Rhode Island for nearly four decades.

“ED FORMAN, 30 YEARS AGO, changed the face of pediatric ‘hem- onc’ (hematology-oncology) in Rhode Island,” said Dr. Wilson Utter, a Rhode Island’s pediatrician for more than 40 years, until he retired two years ago. “Prior to Dr. Forman, for example, we automatically sent a child with leukemia to Boston. Then, suddenly, wonderfully, we didn’t need to. The children could stay in Providence, it was much easier for the parents, and they got just as good care.”

It all started when Forman teamed with Dr. Louis Leone back in 1968. But Leone specialized in treating adults. Until then, no one had focused on kids.

That’s not surprising, Forman noted, because a diagnosis of cancer was usually a death sentence for a child. The cure rate then was an abysmal 25 percent.

But Forman believed it didn’t have to be that way. He was among the first to conduct “clinical trials” of new cancer-fighting drugs on kids. He pushed for the creation of Hasbro Children’s Hospital to replace the children’s wing at Rhode Island Hospital, which state health officials had declared “an embarrassment.” And he recognized that there’s more to treating cancer than treating the disease.

He helped launch supportive services for young patients and their families, from programs designed to help schools deal with students who have cancer to the Tomorrow Fund, which provides financial and emotional support to families.

That’s why so many people know and love him – they say it’s obvious he cares.

“In a world where specialists are often out of touch, he is always available, always answers quickly or returns calls, gives advice or sees patients,” Utter said. “All my patients who have seen him over the years have found him to be warm and caring and informative, (which is) so important when dealing with a child who is often — in his business — seriously ill.”

HIS EMPATHY IS BORN of his own experiences, Forman says. His father died in a car accident when he was 12. Soon after, a neighborhood child died of cancer “in a matter of weeks” after being diagnosed. Later, a college classmate who went to the hospital for bleeding gums was diagnosed with leukemia and died. Then, his mother succumbed to breast cancer.

“That made me want to go for a cure” for cancer, he said.

Oncology has to be one of the saddest specialties in all of pediatrics, he admits. It’s never easy telling parents that their child has cancer, and it’s even harder to be there when the child dies.

But he’s also found it challenging — trying to come up with a cure where once there was none. He has watched children’s survival rate soar. And he has had what he describes as “miracle” cases, such as that of Corey Fox of Cumberland.

Corey had a tumor like that of biking champion Lance Armstrong; it can be cured 60 to 70 percent of the time. But Corey was in the 30 to 40 percent failure category. “He just kept relapsing, no matter what (drugs) I put him on,” Forman recalled.

About that time, Forman read an article called “Dying Words.” It was written by a doctor about telling a woman who has breast cancer there is no cure.

Forman decided to be up-front with Corey’s family. He told them he’d try to “cage the tiger” — to prevent the cancer from spreading, but there was no longer hope for a cure. That wasn’t good enough for Corey’s family. They said: “We have faith, Dr. Forman. Between you and God, we’re going to cure him.”

Inspired, Forman decided to try a different tack: a drug that was used to treat this type of cancer years ago. It worked.

“It’s been four years now, and there’s no sign of the disease anymore,” Forman said.

He chucked that article about “Dying Words.”

FORMAN WAS BORN on Christmas Day in 1934, a Jewish baby in a Catholic hospital in Brooklyn, New York. He was the youngest of three children and grew up a diehard Brooklyn Dodgers fan. He remembers listening to the games blaring through every open window during his three-block walk home from school.

The Dodgers were a scrappy team, he recalls, unlike the dreaded New York Yankees, who looked as though they belonged on Wall Street with their pin stripes and huge salaries. The Yankees never would have hired Jackie Robinson, the first black man to play major league baseball, Forman said. But the Dodgers did.

Forman was 12, and Robinson was his hero.

It was around that time that his father was killed in a car crash while being driven home by his uncle from a Dodgers game.

Yet it would be his father who led him to Rhode Island. His father had graduated from Brown University, and his family received the Brown alumni magazine long after his death. When Forman graduated from high school, he decided to go to Brown, too.

Brown was followed by the University of Pennsylvania medical school, and Johns Hopkins in Baltimore for a residency in pediatrics. He experienced the highs of medicine — he and another intern solved a medical mystery that ended up being published in the prestigious American Journal of Medicine — and the lows — his first time telling a family that their little boy’s cancer had spread “and there’s no hope for your son.”

Forman eventually joined the Air Force, in large part to avoid the post-Korean War draft, and he found himself in England, where he was the only pediatrician on his base, responsible for 2,500 kids.

But he was still searching for a pediatric specialty. He wrote to his former professor at Johns Hopkins, asking for advice. Should he pursue a career in infectious disease or hematology?

The professor wrote that there was no future in infectious disease because of the advances in antibiotics over the years.

Forman took up hematology, focusing on the nearly hopeless children with leukemia. “Every kid died in a couple of months” after diagnosis, he said.

Forman traveled to the University of Illinois in 1966 for a fellowship, about the time that treatments were being developed to combat some forms of leukemia. The cure rate for leukemia by then had risen to 25 percent.

In that climate of hope, Forman would find his niche.

BY THEN, HE’D MET and married his wife, Sylvia, in what he calls a “romantic story.” While at Brown, he’d befriended a fellow student from Providence, Herb Rakatansky, who often invited classmates to his home. Rakatansky had two younger sisters. One had a tremendous crush on Forman, though she didn’t reveal it at the time.

After Brown, Forman and Rakatansky went separate ways, but met up later while each was in medical school. Rakatansky said to his sister: “Guess who I saw? Ed Forman.” She immediately demanded details: Where was he? What was he up to? Was he married or seeing anyone? Then, she wrote to Forman, saying: “Hi, remember me?” Forman wrote back, and four or five months later, they were engaged.

She persuaded him to move to Rhode Island to be near her family, Forman said. Here he became a Red Sox fan, since, like the former Brooklyn Dodgers , they were arch-enemies of the Yankees.

Forman started with a part-time practice in pediatrics in Providence, while working part-time at Rhode Island Hospital in the oncology department, which dealt primarily with adults.

By 1968, though, there had been so many breakthroughs in the treatment of kids with cancer that Forman gave up his pediatric practice to concentrate on bringing care for children with cancer and diseases of the blood to Providence.

Even then, it was clear to Forman that it would take more than medicine to cure these kids. During his fellowship in Chicago, he participated in a study on the effects of stress on families dealing with traumatic illness. He would interview the families to find out what was happening with the marital and sibling relationships. It was eye-opening.

“When parents get a life-threatening diagnosis, all the focus is on that child,” he said. The parents don’t get any attention. Nor do frightened siblings, who often wonder if they will get the disease too.

He proposed hiring a family consultant for Rhode Island Hospital, someone who’d already gone through treatment — or the death — of a child, to help families when their children were diagnosed with cancer.

He recalls how the first family consultant reminded him of his priorities. Forman was on rounds with a medical student and was talking about a child’s case. The consultant pointed out that the family had waited 45 minutes to talk to Forman while he was tied up with the resident. He realized he was sending the wrong message: “that patients can wait.” It reminded him and the resident that patients and families should come first.

Then he turned his attention to the schools, because most kids are eager to get out of the hospital. But returning to class can be traumatic.

“When a kid with cancer goes back to school, they look puffy (because of steroid treatments) and they have no hair. The word goes out: that kid has cancer and is going to die.” So other kids tend to stay away — or make fun of him. So Forman established a program where he would talk with teachers, school nurses and the child’s classmates to help ease the transition back into school.

He recalls the case of one young boy who had a brain tumor. “He really wanted to go back to school. He was puffy from steroids and was walking with difficulty. Other families didn’t want him in the school. He was frightening to look at, and it was scary knowing he was going to die.”

But he finally was allowed back in school, and Forman talked to the students. The boy’s classmates rallied. Two boys volunteered to help him in the bathroom. He even had a girlfriend. Lots of kids came to his aid before he eventually died, and each of those kids felt like a hero to that little boy, Forman said.

He also lobbied for a social worker and a child life specialist, people to make a child feel at ease in the hospital. One of the specialists corrected him when he suggested that she was a “play therapist.” She retorted: “Play isn’t therapy. Play is like oxygen. Children can’t survive without it.”

It’s now an integral part of treatment, he said.

MEANWHILE, ALTHOUGH CHILDREN’S cancer treatment in Rhode was making great gains, Forman longed for a program like the highly successful Jimmy Fund in Boston that provided money for research and family support for patients at the Dana-Farber Cancer Institute.

He didn’t have the time to do it on his own. Then along came Robert Trudeau, a Providence College professor whose daughter, Julie, had succumbed to cancer in 1984 at age 17.

Twenty years ago, they co-founded the Tomorrow Fund, a nonprofit organization that offers financial and emotional support to families who have children with cancer. It provides the obvious — support groups and counseling — but it also addresses the often hidden costs of cancer treatment. The fund, unique in the nation, is tapped for everything from paying parking fees at the hospital to helping out with mortgage payments when parents have to take time off from work. (See story on Page 8.)

Four years later, he co-founded the local Ronald McDonald House, which provides low-cost housing near the hospital for families while their children are undergoing treatment.

And he lobbied for a children’s hospital.

Forman pointed out that children were shoehorned into the Potters Unit at Rhode Island Hospital, where six patients often shared a single room and each shower served 25 kids. There were strict visiting hours, and parents were discouraged from staying with their kids. There was no place to talk to families except at the child’s bedside or in the hallway. What an awful place to convey bad news, he said.

He invited the state’s Joint Commission for the Accreditation of Health Care Organizations to check out the Potters Unit, and they reported back: “Your children’s area is an embarrassment.”

That blunt statement was just what Forman’s campaign for a new hospital needed: “We were made.”

Hasbro Children’s Hospital opened in 1994 with a special treatment center for kids with cancer.

The Tomorrow Fund helped create the Tomorrow Fund Clinic, with its brightly colored murals in the treatment rooms, video games, arts and crafts — and its own child life specialist and family consultants.

Forman also reached out to kids and their families in other ways, such as creating Camp Dottie, a summer camp for sick kids and their siblings, and initiating a Remembrance Day: a day in December when family members could gather with staff members to remember the kids who didn’t make it.

It’s important to the families — and to the staff, Forman said.

“One of the things that was so sad is that we work (with a family) for a couple of years and a kid dies and we say goodbye. It’s a kind of brutal ending for the staff. You see the family in grief, and then you never see them again.”

Now, families submit photos of their children, and they’re made into a slide show on a big screen, with pictures fading in and out with the date of birth and date of death. There’s music in the background, and a candle-light vigil, and a special speaker, and then an open microphone for families to talk about their loved ones.

He wipes a tear from his eyes as he describes it.

“You might make (these parents) cry if you bring up their child,” Forman said. “But they don’t want their child forgotten. So the tears are good.”

Beyond his own patients, Forman was busy sharing his ideas and expertise with Rhode Island’s medical community.

He spent more than 25 years overseeing a pediatric residency program at the children’s hospital. He tested drugs and treatments and he wrote books, including The Parents’ Handbook on Childhood Leukemia. He was named director of pediatric hematology and oncology, where he built a team of specialists.

Where once there was only him, now a child with cancer sees a team of more than a dozen people, including six faculty doctors, two nurse practitioners and several nurses. Many are specialists in such fields as leukemia, brain tumors or Hodgkin’s disease.

When he arrived in Rhode Island, only about a quarter of kids with cancer who lived in southeastern New England came to Providence for treatment. Today, nearly 90 percent do.

They know that the team at Hasbro Children’s Hospital is among more than 100 children’s cancer centers nationwide, all sharing information, research and techniques. The only procedures not performed in Providence are transplants, which are done at a handful of hospitals nationwide.

“If we can’t do it,” he said, “it’s our job to find the right place.”

On Aug. 1, Forman stepped aside as Hasbro’s director of hematology/oncology, turning over his post to Dr. Cindy Schwartz, an expert on “late effects” of treatment. One out of four kids who undergoes treatment for cancer and other serious blood disorders develops other problems, ranging from learning disabilities to lost limbs, he explained. Schwartz’s expertise, Forman said, adds another dimension to the hospital’s care.

Forman is quick to note that he’s not retiring, he simply wants to spend more time with patients.

Schwartz concurred: “He’s going to be a doctor forever. He loves it too much.”

WHAT FORMAN LIKES absolutely best, he says, is taking care of kids. Spend a day with him at the hospital, and that’s obvious.

Two months after stepping down as administrator, his new hospital office is still filled with unpacked boxes of books, files and papers. He’s too busy with patients to worry about the mess on his desk. Whether he’s at work or at home, he’s always on call.

“One of my patients is dying right now,” he said one recent day. “I’m not on call, but if anything happens, I’ll have to be with that family.”

It’s as important for him, he says, as it is for them.

On a walk through the hospital corridors, everyone knows Dr. Forman. He’s the guy straight out of central casting, with a thick shock of white hair and matching moustache, and a shirt pocket crammed with pens underneath his white lab coat. He ‘s known for his calm demeanor and the easy smile of television’s Marcus Welby, M.D.

His longtime secretary, Donna Burke, says she’s never seen him ruffled. “He’s in a good mood every single day. And if he’s not, no one would know.”

His lofty status at the Tomorrow Fund Clinic is clear from his portrayal on the “Wall of Hope” mural leading into the clinic. The painting is of a jungle scene, with donors’ names written on each leaf and blade of grass. Forman is the wise owl at the top of the “Tree of Life,” the centerpiece of the mural.

That’s how he’s viewed inside the clinic, as well.

“He’s a legend,” said secretary Joanna Winn. “He’s our own little legend.”

HOW MANY LEGENDS, though, can do magic tricks? That’s Forman’s secret weapon to put kids at ease.

One recent day, 4-year-old Victoria “Tori” Beck was curled up against her mother, sobbing. Her mother explained she was suffering from terrible back pains. Forman approached her in the waiting room, asking if she needed Tylenol for the pain. But Tori was tired of medicine. And she didn’t want a snack from the treat basket, or to make a treasure box, as the other kids were doing. She just sobbed.

So Forman pretended to pull a coin from her ear. Sure enough, Tori cracked a smile. Then, he showed her his magic light: a pen light that appears to go out each time he blows at it. Tori smiled again.

And he puts parents at ease as well.

He was recently on rounds at Hasbro Children’s Hospital, checking on an 11-year-old girl with an aggressive tumor on her leg. She was due to be discharged after her first round of chemotherapy. She was curled up on the bed, her leg in a bright green cast, watching Arthur on television while her mother told Forman she didn’t understand what was happening with her daughter’s treatment.

She wasn’t one of Forman’s patients, but he patiently explained the entire process, from diagnosis through treatment, and how the team of doctors worked together and with other doctors nationwide to come up with the best course of treatment for each child. Sometimes, tests show that a cancer is more aggressive than initially thought – – as happened in this case — so they simply need to treat it more aggressively.

The mother said, “So I’m still going to be positive.”

With good reason, Forman told her. The prognosis was still very good.

Hope is critical, he later explained. “Parents can’t live without it.” But it has to be tempered with reality.

EVEN WHEN CHILDREN ARE NOT his own patients, Forman sticks to his philosophy: take every patient personally.

He says that at diagnosis, “I can get a little wet in the eyes,” but that’s okay. Parents in crisis won’t remember a doctor’s words, he says, but they will remember, “Does he care? Can I trust him?”

He’s involved with families for months, even years, and so “at a deathbed, I see no reason why a physician shouldn’t cry.”

He pulls a quotation from his wallet. It’s from the book Praying for Gail Hodges: “People don’t care how much you know until they know how much you care.”

Patrick Lynch knows. Diagnosed with leukemia at age 15, he’s been Forman’s patient ever since.

“He’s always been like the grandfather I never had,” said Lynch, 26, of Pawtucket, who recently “graduated” to the adult treatment center. “He’s so much more than a physician. He is a friend, and he is someone who cares — not just about the physical well-being of the patient, but about this kid — or this teenager — the patient, and his family.”

One day when Lynch had been at the Tomorrow Fund clinic for what should have been a routine blood test, he had to wait much longer than usual for the results.

Finally, Forman walked in. “He was much more quiet than normal. His eyes were watery and he said, ‘Patrick, I don’t know any other way to tell you this, but your cancer may have relapsed.’ Normally, when you hear those words, you think, ‘Oh God, not me.’ But when I heard them from Dr. Forman that day, I already knew everything was going to be okay.”

And, after a bone marrow transplant in Seattle in December 1997, everything has been okay — just as he’d expected.

FORMAN INSISTS THAT despite his 10-hour days at the hospital and clinic, he tries to make time for fun. He plays tennis. He used to play softball on the over-40 then over-50 leagues, pitching and playing outfield. “I had a heck of an arm — a rifle arm. My arm’s like Johnny Damon’s,” he boasts playfully. But a rotator cuff injury put him out of commission.

Instead, he enjoys tending his vegetable garden at his home on Providence’s East Side. “I love compost,” he said. “I love all that crap turning into black gold.”

He says he enjoys everything about living in the city, from easy access to shopping to the Rhode Island Philharmonic Orchestra. His wife is now a psychotherapist, and his three kids are grown.

His oldest son, Joel, is a pediatrician at Mount Sinai Hospital in New York, directing the residency program there while specializing in environmental medicine. His daughter, Lisa, is a pediatrician at City Hospital in Queens, a multi-ethnic area of New York City where “she sees everything — she’s diagnosed diseases I’ve never even heard of.”

Another son, Daniel, lives in New Orleans and is on the lieutenant governor’s staff, working to interest kids in the environment.

None had the heart to follow in Forman’s footsteps. His kids think his profession “is too sad,” he said.

His brother-in-law, Rakatansky, agreed: “It takes a special kind of person to do pediatric oncology, and Ed is that special kind of person.”

But it’s his patients who appreciate their doctor most. Just last week, Forman wept when he received a letter from the parents of a boy who’d died of leukemia.

“There have been many doctors that we’ve come across in the past seven years since Stefan was first diagnosed with leukemia, and we feel that you’re definitely an exceptional work of God,” the parents wrote.

“We cannot thank you enough for loving Stefan with us, through thick and thin. . . . The power of your love for your field has touched so many lives, including ours. We will forever have a special place for you in our hearts, as we know you have for Stefan.”

* * *

The Tomorrow Fund Helping families cope

When a child is diagnosed with cancer, a family’s life turns upside-down. Parents are frightened by the diagnosis, confused by the complex world of treatment, and stunned by how financially draining it is to care for a son or daughter with cancer.

That’s where the Tomorrow Fund steps in. For individual families, it provides emotional support and, if needed, pays bills. For all families of kids with cancer, it helps pay the salaries of specialists at the Tomorrow Fund clinic who make this medical crisis more bearable.

”We literally adopt families,” said Barbara Ducharme, executive director of the non-profit program that was created 20 years ago to help families cope with the financial and emotional strain of cancer. ”We give them whatever support they need.”

Helping parents meet basic financial needs is the component of the program that makes The Tomorrow Fund unique in the country, Ducharme said. It spends about $800,000 a year, aiding about 200 families and supporting the hematology and oncology division at Hasbro Children’s Hospital.

So many cancer costs ”fall through the cracks,” said Nancy Isabel, director of development. Most people don’t realize, she said, that a child diagnosed with cancer is likely to undergo at least two years of treatment, including 100 days in the hospital. An average of 100 kids a year are diagnosed.

For parents, the hidden costs mount: Daily parking fees at the hospital. Meals in the hospital cafeteria when parents stay around the clock. Co-pays for cancer drugs that cost as much as $2,000.

And if a parent has to take time off from work or even quit a job to care for a child, mortgage, utilities and grocery bills must still be paid.

The Tomorrow Fund helps with all of it.

In addition, the fund sponsors support groups for parents and patients — especially teenagers — who feel as though no one else knows what they’re going through.

And the fund helped pay for Hasbro’s Tomorrow Fund Clinic, where kids come for their frequent blood tests, examinations and outpatient chemotherapy. It paid artists to create bright murals in each treatment room, and it provides televisions, video games, toys, and arts and craft supplies.

It helps pay for staff members at the clinic, including a child- life specialist who helps kids feel comfortable at the hospital, and parent consultants — who’ve had a child with cancer — who serve as a liaison between the hospital and a patient’s family.

Still, even after 20 years, the Tomorrow Fund is often confused with the Make-A-Wish Foundation, which grants wishes to terminally ill children. That’s a wonderful organization, Ducharme said, but with a completely different mission.

The Tomorrow Fund, she said, doesn’t make just one wish come true: ”We’re with you forever.”

— LAURA MEADE KIRK

* * *

* CARICATURE by LEONARD SHALANSKY

* Dr. Forman cheers up patient Tori Beck, below, with a disappearing-coin magic trick, above, as her grandmother, Gloria Laurie, looks on. A humorous sketch, left, portraying Dr. Forman and his love of baseball hangs by the clinic reception desk.

JOURNAL PHOTOS / SANDOR BODO

* Michael Donovan holds his four-month-old son, Brian, with the animals of the mural at the Tomorrow Fund Clinic peering over them.

JOURNAL PHOTO / SANDOR BODO

* Patient Beth Wyman of Wakefield reacts as the staff of the Tomorrow Fund Clinic at Hasbro make their rounds on Halloween dressed

as a wedding party.

Dr. Edwin Forman wore a T-shirt tux, as the father of the bride. They won first place for group costumes in Lifespan’s employee contest.

JOURNAL PHOTO / GRETCHEN ERTL

Hope stirs in Angola 30 years after independence

By Karen Iley

LUANDA, Angola (Reuters) – Angola won independence from
Portugal 30 years ago but the southwest African country is only

celebrating properly now, as a cautious optimism takes hold
after the end of a devastating civil war.

Peace, signs of recovery, the prospect of political change
through elections scheduled for next year and even the soccer
team’s qualification for the World Cup for the first time mean
this year’s independence party promises to be bigger than ever.

Angola fought for 14 years against the Portuguese but
celebrations on November 11, 1975 to mark its liberation were
marred by fighting that was to last another 27 years.

“The war dashed all hopes that came with independence,”
said Cornelio Caley, professor in African sociology and history

at Luanda’s Agostinho Neto University, named after the
president who led the independence fight and died in 1979.

“In theory, we should be celebrating 30 years of
independence, but in practice, we’re only beginning celebrate
it now,” he told Reuters. “It has been delayed.”

This year’s anniversary is “not just a round number,” said
Ari de Carvalho, the director of Angola’s national private
investment agency ANIP.

“For me, independence marks the beginning of our rights as
citizens, as people of this country. It marks the end of a
painful and extremely destructive period in our history,” he
said. “This tastes a lot better because we are no longer
embroiled in conflict.”

DREAM OF FREEDOM

When Angola won its independence, people dreamed of
enjoying freedom for the first time since the Portuguese landed

on Angolan soil almost 500 years before.

But those dreams were short-lived. Civil war erupted and
over the next 27 years, around 1 million people were killed,
roads and bridges were destroyed and Angola’s health and
education systems fell to pieces.

“Angolans have suffered so much. There are parts of Angola,

and some Angolans, who will never recover physically,
spiritually and emotionally. But we have to leave that to a
chapter of history,” Caley said.

With the signing of a peace accord in April 2002, there was

a glimmer of hope that life would begin to improve.

But it took time for Angolans to believe that the weapons
had been silenced for good. Now, three years after the end of
the war, oil-rich Angola is finally taking some small steps on
the road to recovery.

The economy is booming and is expected to grow by almost 16

percent this year. Inflation is being brought under control
and oil output is set to reach 2 million barrels per day by
2008, cementing Angola’s position as a major crude supplier and
the second-largest producer in sub-Saharan Africa after
Nigeria.

Roads are being rebuilt, thanks largely to $2 billion
Chinese credit line, bullet-scarred buildings are being
refurbished and other industries outside of oil and diamonds
are beginning to prosper.

Foreign entrepreneurs involved in copper, granite,
agriculture, finance and construction, among others, are lining

up to grab a share of Angola’s anticipated growth.

SOCCER BOOST

Even the country’s sports teams are adding to the climate
of hope — the soccer squad has qualified for the World Cup
Finals in Germany next year and the basketball team was this
year crowned African champion for the eighth time.

“Most of the world looked on us as a bunch of people who
fought and are corrupt, but I can say this very proudly: We
achieved peace on our own when everyone told us we would
continue to fight,” de Carvalho said.

There is much still to be done. Angola languishes at or
near the bottom of almost every development index.

Government figures show that around two-thirds of Angola’s
13 million people still live on less than $1.70 a day and the
country has one of the world’s worst child mortality rates with

the U.N. children’s agency UNICEF estimating that one child
in

four will die before their fifth birthday.

Half the population does not have access to clean, safe
drinking water and preventable diseases like malaria and
tuberculosis continue to claim lives.

Yet, the green shoots of recovery are showing and plans for

parliamentary elections in 2006 — the first national
ballot in more than a decade — are adding to a mood of
cautious optimism.

With around 70 percent of Angola’s population under the age

of 24, young people will play a huge part in rebuilding the
country and everyone shares the responsibility, said Emanuel
Castro, who studied business in Lisbon.

“Our country is still like a child — it needs help from
people who know better, it needs to learn, it needs to be fed
and it needs to grow. It needs all kinds of people, people with

capital, people with good ideas, people who want to work,”
Castro said.

“This is not something we can do alone. Each one of us —
each and every Angolan — has to play his or her part.”

ABC Launches Anti-Smoking Ad Campaign

By Paul J. Gough

NEW YORK (Hollywood Reporter) – It isn’t just ABC News that’s being enlisted in the battle against smoking and lung cancer in the Quit to Live series, which began airing this month on “World News Tonight.”

A public service campaign launched late last week features President Bush, Sen. Hillary Clinton, D-N.Y., former Secretary of State Colin Powell, actress Geena Davis, Microsoft mogul Bill Gates and sports stars Lance Armstrong and Tom Brady. ABC News employees including Ted Koppel, Charles Gibson, Diane Sawyer, Elizabeth Vargas, Bob Woodruff and Barbara Walters also are taking part, along with former ABC News correspondent (and Fox News star) Bill O’Reilly.

“World News Tonight” launched Quit to Live in part as a response to the death of longtime anchor Peter Jennings, who succumbed to lung cancer in August. That sparked an interest on the part of “World News Tonight” and ABC News to launch an anti-smoking public-service campaign that includes information on how to stop smoking and the treatment and prevention of lung cancer, as well as its toll on the public health system.

The Quit to Live campaign runs through November, Lung Cancer Awareness Month, on a number of ABC News platforms including “World News Tonight,” “Good Morning America,” ABCNews.com and ABC News Radio. It’s in partnership with the Centers for Disease Control and Prevention, the National Cancer Institute and the North American Quitline Consortium.

Reuters/Hollywood Reporter

$19 Million State Hospital Near Milledgeville, Ga., Sits Empty

By Don Schanche Jr., The Macon Telegraph, Ga.

Nov. 6–MILLEDGEVILLE — A few miles south of Milledgeville on Ga. 112, a brand new $19 million state hospital building sits vacant and unused.

State officials say they need it to treat mentally ill people who are charged with committing crimes.

But even though construction was completed in 2003 and the construction branch of Georgia’s state government accepted the structure from the contractor and architect, the building has been deemed “nonfunctional” in its current condition.

Since 2003, according to state records, a host of problems have turned up. Among them:

–Electronic locking and fire alarm systems that didn’t work properly.

–Roof leaks throughout the building, and ceilings that weren’t properly attached to the structure.

–Air vents that could be pushed out, allowing access to the space above the ceilings.

–An exterior security fence that had to be completely taken down and rebuilt.

A Department of Human Resources official wrote in an Aug. 29 e-mail that he and his colleagues were “amazed as more lack of construction/poor workmanship issues are found. However, thank God they are being found before we attempt to put forensic patients and staff into this building.”

The construction division chief of the Georgia State Financing and Investment Commission says the state will take legal steps to go after the surety bond that the contractor put up before beginning the project. The money would be used to pay for completing the work.

The contractor says his company built the building according to the design specifications and addressed all the problems that were brought to his attention. If state officials are dissatisfied with the design, he said, that’s not the contractor’s fault.

The architect declined to comment at all.

Sen. Johnny Grant, R-Milledgeville, said, “I haven’t been able to track down all of the details going into this, but it does sound like somebody dropped the ball somewhere along the way. The contractor looks like he skimped on a number of items. And it does look like the GSFIC may not have picked up on that early enough. There’s probably lots of blame to go around. The bottom line is we’ve got a building sitting there and it has been ready for a year and we have a tremendous need for it but yet we haven’t been able to occupy it.”

State Rep. Bobby Parham, D-Milledgeville, said, “That building is a perfect way not to build a building.”

The Payton B. Cook Building is supposed to be a maximum-security “forensic hospital” — a place where criminal defendants can be evaluated for mental competency and treated if found incompetent or “not guilty by reason of insanity.” In a mental health system that tries to treat most clients in the least restrictive environment appropriate to their needs, a forensic hospital stands out as a small but important high-security exception.

The Georgia Department of Human Resources’ statewide mental health plan says there is a growing need for forensic beds, “but the numbers needing services are far greater than the system has the capacity to serve.” As evidence, the plan cites the large numbers of mentally ill inmates now in county jails.

Several regional hospitals around Georgia offer forensic services, but traditionally the largest and most heavily used forensic center has been in Milledgeville.

Forensic patients at Central State are currently housed in the Binion Building, which has a capacity of 84. Built in 1946, it is a grim prison-like facility with hard tile interiors and a walled-in courtyard in the center. Since at least the 1970s, state officials and mental health advocates have recommended replacing it.

In the 1990s, the state Legislature agreed. The Georgia General Assembly authorized construction of a 196-bed forensic hospital. Estimated cost: $15.2 million.

In 1998, the Atlanta architectural firm of Nix Mann Perkins & Will was hired to design the hospital and oversee construction. LPS Construction Co. of Statesboro, a company with a long track record of building large commercial and industrial projects, submitted the low bid of $16.2 million and was hired in August 2000. Ground-breaking was held three months later.

In May 2003, the architect issued a letter accepting the completed project, with the exception of a few “punch-list” items that still needed work.

GSFIC accepted the building.

Gena Abraham is director of Georgia State Financing and Investment Commission’s construction division. The GSFIC manages state construction projects. Abraham was not in the chief’s job when the hospital was being built, but she inherited the challenge of bringing the Cook building to completion.

Abraham said the architect’s 2003 letter indicated that the building was ready to go.

“We received that document from the architect, so we believed at the time we had the grand opening for the facility that things were OK,” she said. The architectural firm, now called Perkins & Will, declined to make any comment for this article.

As state officials and consultants took a closer look, Abraham said, “We started to discover problems. That’s where this thing took off to a whole new degree.”

The DHR refused to accept the building.

Joe Watkins in the DHR’s Office of Facilities and Support Services said in a July 29, 2003, e-mail to the GSFIC, “DHR refused to accept it since the building was nonfunctional for our designed program to serve state (mental health) clients and staff.”

He continued, “Security system was nonfunctioning including the exterior fence and interior doors, sallyport, etc. … too many to list here.”

Watkins wanted to know “if and when the project will be turned over to the bonding company to get it ready for our usage and occupancy.”

He added that the project, officially called DHR-62, “has caused a lot of concern for us all.”

The GSFIC’s project manager, Jason Williams, replied a week later that his agency was working out the bugs. The contractor said all punch-list items would be complete by the end of August.

But by December 2003, there were still problems. And month after month, new ones kept turning up. According to GSFIC records:

–Two days before Christmas, Watkins reported problems with an outer security fence. Concrete footings were not poured to the required depth. He asked if it should be torn down and replaced. Eventually it was.

–In January 2004, a security consultant reported problems with the fire alarm system. He said, “Due to the extent of problems encountered, there is some concern as to whether a proper initial certification was ever performed for this system.”

–By June 2004, there were reports of leaks throughout the building, and the fire alarm system still could not be certified.

–In September 2004, a hospital employee discovered that some of the air vents could be pushed up, giving access to the space above the ceiling. They were supposed to be security fixtures that were fastened in place.

–By November 2004, there were still leaks.

–By last July, work on the fire alarm was nearly complete, but the system had been damaged by a lightning strike.

–In August, Watkins reported the electrical system was not properly grounded, the elevators weren’t working right, and that “hard and soft drop ceilings were not installed to design specifications and are a health/safety issue due to potential falling.”

He added, “Please note, this is not all of the Cook (building) issues, but the major ones known about at this time.”

Abraham said last week that many of the problems have been solved.

“The fence has been completely fixed. That was with the help of the contractor and the subcontractor,” she said.

But some problems remain. Abraham said they include: the installation of a fuel tank; grading to control stormwater runoff; ceilings not properly anchored to the structure; electrical system grounding; and a possible problem with a boiler.

She estimated it will cost of $800,000 to $1 million to make the fixes.

That’s on top of the $19.2 million now estimated to be the total project cost.

GSFIC has been spending money out of its own operating budget to make repairs, but Abraham said it does not have enough funds to finish fixing all the problems. To get the money, she said, the state will go after the contractor’s surety bond.

LPS Vice President Terry Fletcher said, “We kind of find that really confusing to us, because we haven’t had any correspondence from GSFIC about ceiling problems or other problems. They can’t show us anything in writing that we have not responded to and sent people up to check on.” He said several of his letters to GSFIC asking for more information have gone unanswered.

He and LPS President Wallace Wiggins acknowledged there were some problems with the construction, and say they addressed all the problems that were brought to their attention. But they said the real problem seems to be that DHR is not happy with the design.

“All we understand is we were required to build the job per our contract, which we did,” Fletcher said. “If GSFIC didn’t direct us to build it the way DHR wanted that’s not LPS’s fault. … We fulfilled our contract.”

Abraham said the legal process of collecting the bond is lengthy and the outcome uncertain.

In the meantime, she said, the state will try to fix all the problems.

“We think we could probably fix the remaining problems within about six months,” Abraham said. But she cautioned, “In the past, every time we thought were close to finding a light at the end of the tunnel we literally opened up the building and found a new problem.”

—–

To see more of The Macon Telegraph, or to subscribe to the newspaper, go to http://www.macon.com

Copyright (c) 2005, The Macon Telegraph, Ga.

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].

Scooter Libby novel becomes hot online item

NEW YORK (Reuters) – A steamy novel by Lewis “Scooter”
Libby has become a hot item now that Vice President Dick
Cheney’s chief of staff is under indictment.

An inscribed copy of “The Apprentice: A Novel,” which Libby
wrote in 1996 when he was a relative unknown outside
Washington, was on sale on online bookseller Amazon.com on
Monday for $2,400. Unsigned hardcover copies were going for
$700.

Now out of print, the novel tells the story of an innkeeper
apprentice in a bizarre coming-of-age story set in Japan in
1903. It is littered with edgy sexual material and strong
language.

“Wow, who would have thought that clean living, family
values man Scooter Libby was capable of writing such filth,”
said one reviewer on Amazon. Another Amazon reviewer noted its
“lavish dollops of voyeurism, bestiality, pedophilia and corpse
robbery.”

Libby was charged last month with perjury in a special
prosecutor’s probe into how a CIA operative’s identity was
leaked to journalists.

Libby’s writing skills also happened to be displayed in a
widely published letter to reporter Judith Miller of The New
York Times that showed a flair for literary allusion and
ambiguity.

“Out West, where you vacation, the aspens will already be
turning. They turn in clusters, because their roots connect
them,” he wrote to Miller as she sat in jail earlier this year
for refusing to reveal Libby’s identity as a source.

Recreating ‘Flowers for Algernon’ with a happy ending

In a surprise twist that recalls the film classic “Flowers for Algernon,” but adds a happy ending, UCLA scientists used statins, a popular class of cholesterol drugs, to reverse the attention deficits linked to the leading genetic cause of learning disabilities. The Nov. 8 issue of Current Biology reports the findings, which were studied in mice bred to develop the disease, called neurofibromatosis 1 (NF1).

The results proved so hopeful, that the Food and Drug Administration approved the use of the drugs in three clinical trials currently under review to test the effect of statins in children and adults born with NF1. The findings could help the estimated 35 million Americans who struggle with learning disabilities.

“Learning disabilities and mental retardation each affect five percent of the world population,” said Dr. Alcino Silva, professor of neurobiology, psychiatry and psychology at the David Geffen School of Medicine at UCLA. “Currently, there are no treatment options for these people. That’s why our findings are so exciting from a clinical perspective.”

In an earlier study, Silva and his colleagues linked NF1’s learning problems to a protein called Ras, a protein that regulates how brain cells talk to each other. This communication is what enables learning to take place. The NF1 mutation creates hyperactive Ras, which disrupts cellular conversation and undermines the learning process.

“The act of learning creates physical changes in the brain, like grooves on a record,” said Silva. “But surplus Ras tips the balance between switching signals on and off in the brain. This interrupts the delicate cell communication needed by the brain to record learned information.”

The UCLA team began searching for a safe drug that would zero in on Ras and overcome its hyperactivity without causing harmful side effects over long-term use.

“It became something of a Quixotic quest — an impossible dream,” Silva admitted. “We thought, ‘Wouldn’t it be nice to find a drug that is already FDA-approved, safe for lifetime use and could be tested in mice and humans with NF1?’ Fortunately, our optimism was rewarded.”

It took a medical student in Silva’s lab to identify the drug and connect it with NF1. Steve Kushner, a scholar in UCLA’s MD/PhD program, learned in a clinical rotation about statins, the drugs already prescribed to millions of people worldwide to lower cholesterol.

“Steve raced into my lab and shared what he’d learned: statins work on the Ras protein that is altered by NF1 and play a key role in learning and memory,” recalled Silva. “It was the researcher’s equivalent of finding a suitcase stuffed with a million dollars.”

Statin drugs lower cholesterol by blocking the effects of certain fats. Because Ras requires fat to function, less fat results in less Ras. With reduced Ras activity, the brain cells are able to communicate properly in mice with NF1, allowing normal learning to take place.

“NF1 interrupts how cells talk to each other, which results in learning deficits,” said Silva. “Statins act on the root of the problem and reverse these deficits. This enables the process of learning to physically change the brain and create memory.”

Silva’s lab tested the effects of statins on mice that were bred with the NF1 mutation. The animals displayed the same symptoms as people with NF1: attention deficits, learning problems and poor physical coordination.

First author Weidong Lee, a UCLA postdoctoral fellow, ran three tests to compare the behavior of NF1 mice treated with statins to NF1 mice who received a placebo. Then he compared both groups to normal mice.

First, he trained the mice to follow a blinking light in order to find a food reward. The NF1 mice on statins showed a 30 percent improvement in their ability to pay attention, outperforming the normal mice.

Second, he trained the mice to memorize spatial clues in order to navigate a water maze and swim to a platform. The normal animals learned to find the platform in seven days; the NF1 mice took 10. After receiving statins, the NF1 mice outraced the normal mice.

Third, Lee tested coordination by training the mice to balance while running on a rotating log, which gradually increased in speed. At first, the NF1 mice would jump off as the log spun faster. But statin therapy enabled the NF1 mice to perform as well as their normal counterparts.

“This is mind-blowing ““ we think we have a real fundamental reason to be optimistic,” explained Silva. “Here is a drug that affects a key learning and memory pathway, and completely rescues the most common genetic cause for learning disabilities. We don’t have to do extensive clinical trials for toxicity or safety ““ these were already completed for other uses.”

On the World Wide Web:

University of California – Los Angeles

Columbia University Study Suggests Benefits of Zyflamend(R) in the Early Treatment of Prostate Cancer

Data from the Columbia University Department of Urology demonstrates that Zyflamend(R), a unique herbal extract preparation, suppresses the growth of prostate cancer cells and induces prostate cancer cells to self-destruct via a process called “apoptosis.”

The data, published in the October edition of Nutrition and Cancer, showed Zyflamend(R), a patented formulation from New Chapter, has the ability, in vitro, to reduce prostate cancer cell proliferation by as much as 78 percent and to induce cancer cell death or apoptosis.

The research confirms Zyflamend(R) has COX-1 and COX-2 anti-inflammatory effects, although its anti-cancer affects against prostate cancer were independent of COX-2 inhibition, supporting the postulation that some prostate cancer cells are not affected by COX-2 inflammation.

“These results were particularly surprising and show great promise in the fight against prostate cancer,” said researcher Dr. Debra L. Bemis of the Columbia University Department of Urology. “We hope that the magnitude of benefits shown in this research will be confirmed in the larger scale trial already in progress.”

Based on this research, Zyflamend(R) shows value in early therapy for prostate cancer patients. COX inhibitors have also shown value for prostate cancer patients, but data from recent trials of selective COX-2 inhibitors such as sulindac (Clinoril(R)) and celecoxib (Celebrex(R)), suggest that use of these drugs might have adverse cardiovascular effects. The more widely utilized general COX inhibitor, aspirin, is not associated with these negative side effects and, instead, has well-established beneficial effects for individuals with cardiovascular disease. Zyflamend(R) has a biochemical action profile that resembles aspirin more than these selective COX-2 inhibitors.

Dr. Bemis added: “Zyflamend(R) is derived from natural herbal sources and is readily available in health food and nutritional supplement stores. Given the impressive data we’re reporting, Zyflamend is a potentially more convenient and desirable means to target the enormous population that is susceptible to prostate cancer.”

On the strength of this laboratory research, Columbia University’s Department of Urology has commenced a Phase 1 human clinical trial testing Zyflamend’s ability to prevent prostate cancer in patients with prostatic intraepithelial neoplasia (PIN).

PIN is a clinical precursor for prostate cancer. Without intervention, men diagnosed with PIN have a 50 to 70 percent likelihood of developing prostate cancer. Although there are tools that detect the early signs of prostate cancer, such as PIN or elevated prostate specific antigen (PSA) levels, there is no consensus as to the optimal therapy for these patients.

“We are very encouraged about the early results of this phase 1 trial,” said Aaron E. Katz, M.D., associate professor of urology at Columbia University College of Physicians and Surgeons, Director of the Center of Holistic Urology at Columbia University Medical Center and principal investigator of the study.

“We are encouraged that this study provides additional scientific evidence that specific herbal preparations can produce a positive impact on prostate health,” said Mark Blumenthal, founder and executive director of the non-profit American Botanical Council. “With so many people using herbal supplements for their health, new research documenting their safety and benefits is encouraged and welcomed.”

About New Chapter, Inc.: New Chapter is a widely respected producer, formulator, packager and distributor of organic probiotic nutrients and herbal formulations selling over 90 products to approximately 3000 retail locations. Its three main categories include Probiotic Nutrients, Supercritical Therapy and MycoMedicinals. Bear Growth Capital Partners recently provided equity capital to support the company’s anticipated growth plans. More information about New Chapter can be found at http://www.newchapter.info

The Herbal Supplement

Zyflamend is a patented formulation from New Chapter, Inc. of Brattleboro, VT. It includes proprietary extracts of rosemary, turmeric, ginger, holy basil, green tea, hu zhang, Chinese goldthread, barberry, oregano, and Baikal skullcap.

Columbia University Medical Center provides international leadership in pre-clinical and clinical research, in medical and health sciences education, and in patient care. The medical center trains future leaders in health care and includes the dedicated work of many physicians, scientists, nurses, dentists, and public health professionals at the College of Physicians & Surgeons, the School of Dental & Oral Surgery, the School of Nursing, the Mailman School of Public Health, the biomedical departments of the Graduate School of Arts and Sciences, and allied research centers and institutions. Columbia University Medical Center researchers are leading the discovery of novel therapies and advances to address a wide range of health conditions. www.cumc.columbia.edu

About Bear Growth Capital Partners: Bear Growth Capital Partners (“BGCP”) is an affiliate of BSMB, the private equity arm of Bear Stearns & Co. (NYSE:BSC). BGCP focuses on making investments in middle market companies valued between $10 and $100 million. BGCP will invest in compelling growth capital opportunities, traditional buyouts, recapitalizations, co-investments, and control and minority ownership positions alongside superior management teams and other private equity sponsors. More information about BGCP can be found at http://www.bsmb.com.

Benefits of Probiotic Drinks

By Cahal Milmo

They are advertised with hyperactive parents maniacally monopolising the playground in front of their cringing children and geeks whose dinner- party repartee on the subject turns them into sex gods.

The none-too-subtle message behind the adverts for Britain’s pounds 213m market in probiotic or ‘friendly bacteria’ drinks, from Actimel to Yakult, is: drink me and you will become a sleeker, healthier or fitter human being.

But with vague promises that they ‘may benefit overall well- being’ by transplanting six billion microbes into the stomach in two gulps, the proliferation of probiotic products has provoked suspicion that the only thing at which they are highly effective is siphoning cash from consumers’ wallets.

Think again.

Research by Swedish scientists has found that the yoghurt-type drinks are indeed beneficial by apparently boosting the immune system and shortening the effects of minor ailments such as cold or stomach upset.

The researchers gave 94 workers for the packaging giant Tetra Pak a daily probiotic drink and found they were 2.5 times less likely to take time off work for sickness than a group which was given a placebo.

The findings published this week will provide a further boon to the burgeoning market in ‘neutraceuticals’, foods produced with a health-improving additive and sold at a suitable premium, which is now worth nearly pounds 1bn a year in Britain.

From Benecol spread ‘proven to reduce cholesterol’ to Flora ProActiv yoghurt drink containing dairy peptides to ‘actively help control blood pressure’, a trip to the supermarket increasingly involves deciding on a health priority as much as what to eat for dinner.

Experts predict that spending in the sector will double by 2010 as Britons fill their shopping baskets with products ranging from milk containing omega 3 fish oils to SkinCola, an ‘oxygen-enhanced’ mineral water to be launched soon which claims to boost the immune system.

But while nebulous promises to improve well-being have not dissuaded people from buying probiotic drinks ” the fastest-growing part of the neutraceuticals industry ” there has been little evidence of their vaunted benefits.

Probiotics are harmless bacteria which occur naturally in the large intestine, where they perform a role in stopping unpleasant pathogens such as E.coli or campylobacter entering the bloodstream.

The theory is that by ‘topping up’ these friendly bugs with a probiotic drink, conditions in the gut ‘micro-flora’ are improved, with an knock- on benefit for the immune system.

The Swedish researchers focused on Lactobacillus reuteri, one of the family of bacteria most commonly used in probiotic products, and gave 180 Tetra Pak workers a daily dose containing 100 million of the bugs or a placebo over 80 days.

Of those taking the placebo, 23 fell ill with colds or a stomach upset. Among those given the bacteria, just 10 fell ill.

The effect was most obvious among shift workers, whose irregular hours often lead to a weakened immune system. None of the 26 employees given the L.reuteri fell ill, while nine out of the 27 taking the placebo did. It is thought that the bacteria succeed in stimulating the immune system by attracting white blood cells, which help to combat infection.

Dr Py Tubelius, the author of the study, which was published in the journal Environmental Health, said: ‘Although the exact mechanism of action cannot be defined from our study, it is likely that such an immune stimulation lies behind the reduced illness in the subject taking L.reuteri.

‘This stimulation may also explain why the beneficial effect of L.reuteri in our study was specifically apparent among shift workers. [They] are known to be at risk for having a weaker immuno- defence as compared to those working daytime shifts only.’

When added to research suggesting that some probiotic bacteria have anti-carcinogenic properties and may be able to regress or reduce tumours, while others can help protect against diarrhoea, it seems that the arguments in favour of investing in a daily dose of Yakult, Danone’s Actimel, Muller’s Vitality or any other of their competitors are incontestable.

The sale of the drinks has increased by 50 per cent in the past year, with Danone saying that its product has increased sales by 73 per cent in the past 12 months. The food company said that of the 9.5 million people who bought Actimel during one month last year, only 45 took up its offer of a full refund to anyone who did not feel a ‘difference’ within two weeks.

Crucially, however, Danone declined to define what that difference might be.

Some experts believe that there is a risk that probiotics are being wrongly touted by some as a panacea. Dr Simon Cutting, an international expert in probiotics at the University of London, said: ‘The health claims made for oral probiotic supplements are generally acceptable. But claims made for yoghurt drinks are often too wishy-washy and general.

‘Some marketing is downright misleading and involves meaningless phrases such as ‘feelgood bacteria’ to generate an unrealistic picture of unobtainable health benefits.

‘For the consumer this may all be very frustrating, as they want a more specific claim, for instance that using the probiotic will reduce the symptoms of irritable bowel syndrome.’

Experts are also divided on just how much of the useful bacteria contained in probiotics actually reaches the gut. One study estimated that as much as 90 per cent of one probiotic bacteria was killed by stomach acid, meaning that each drink needed to contain at least one billion of the bugs to be useful.

While the most high-profile brands have measures to ensure that the correct ‘dose’ of bacteria is produced, others simply do not.

A survey by Belgian researchers found that just 20 per cent of 55 probiotic products they tested contained all the organisms that were listed on their labels. Nine of the products had no bacteria in them at all.

But there is no sign that such problems are doing anything to dampen the rampant growth in probiotics and other parts of the neutraceutical industry.

Probiotic cheese and fruit juice are already on supermarket shelves, while ice-creams and sorbets are soon to follow.

Which is to mention nothing of the dizzying array of ‘functional foods’ containing health-boosting additives which give new meaning to the word ‘doctored’.

Waitrose earlier this year introduced bread enriched with selenium, the mineral found by some studies potentially to protect against heart conditions.

There are also plans to launch TipTopUp bread, an Australian brand containing omega 3 oils, while Flora, which has seen its fortunes transformed by the arrival of dairy and plant extracts designed to reduce cholesterol and blood pressure, has had to colour- code its ranges to avoid confusing consumers: blue for blood pressure and green for cholesterol.

If combating heart disease by popping a couple of slices into the toaster were not enough, manufacturers are also offering foods that claim to improve beauty. Unsurprisingly, they have been labelled ‘cosmeceuticals’.

Nestl, the Swiss-based conglomerate, and the cosmetics giant L’Oreal recently launched Inneov, a dietary supplement which claims to improve the look of skin, hair and nails.

A Japanese company has launched a range of foods containing a fatty acid derived from shark skin and whale cartilage which claims to help retain moisture, while the new Emmi yoghurt range contains aloe vera, designed to improve the skin.

Experts point out that such targeted hi-tech nutrition is a positive ” and lucrative ” response from a food industry battered by criticism that it has fuelled ill-health and obesity with high fat, salt and sugar levels.

But critics claim that some products are based on unproved science or make assertions so bland as to be meaningless.

One marketing expert involved in the launch of a probiotic drink said: ‘You have to be very careful indeed about what you say this little bottle of sweet liquid will do to improve your life. The blurb has to seduce the consumer but at the same time you can’t say drink this and you’ll live to 100 because it’s just not true.’

Whether the lure of science will continue to seduce shoppers into paying extra for a loaf of bread which might come with a promise to cure baldness remains to be seen.

But others point out that the real path to good health lies in a discovery made long before probiotics and omega 3 ” the Mediterranean diet of fresh fruit and vegetables, whole grains, olive oil and a small amount of meat and oily fish.

Catherine Collins, chief dietician at St George’s Hospital in Tooting, south London, said: ‘Functional foods containing positive additives are no substitute for a naturally balanced diet. If pursued, there’s no need for functional foods.’

LEADING ARTICLE, PAGE 32

n BURGEN BREAD

A bread containing soybean and linseed, both sources of plant oestrogen. Researchers say the phyto-oestrogens can ‘reduce symptoms of menopause- balance hormones’ among women. In Japan, where soya is the staple diet, rates of breast cancer are thought to be the lowest in the world.

n DHA EGGS

Omega-3 fatty acids maintain the heart and circulatory system. DHA is one of the most elusive acids of the Omega-3 family. It is thought to be vital for brain and eye structure in adults. Hens fed on natural Omega-3 DHA then go on to lay these eggs, making the acid palatable for human consumption.

n BENECOL

Contains ingredients that may reduce cholesterol levels by up to 14 per cent. These are traces of plant stanol ester often found in corn, wheat and rye. Plant stanols block the body’s absorption of cholesterol. Critics say the product will only help reduce cholesterol levels. It will not prevent the build-up of cholesterol altogether.

n YAKULT

A Japanese researcher discovered Lactobacillus casei Shirota in 1933. Since then the product has become known across the world. Each 65ml bottle is said to contain around 6.5 billion colonies of bacteria that help the natural balance of the digestive system.

n NUTRILAW SELENIUM ENRICHED BREAD

The levels of nutritious elements from soil have steadily fallen with the rise of intensive farming. This bread aims to redress the balance by using wheat specially grown in selenium-enriched soil. According to the maker, four slices a day maintain a healthy immune system. Selenium is also thought to help the heart by acting as an anti-oxidant.

n FLORA PROACTIVE

Contains AmealPeptide, a combination of two peptides derived from milk protein. Consumed daily for two to four weeks, tests have shown it to help in controlling high blood pressure.

n ACTIMEL

L. casei Imunitass is a probiotic bacteria.

It reinforces resistance to salmonella and increases protection against dysentery. According to studies, it aids in the prevention of certain kinds of diarrhoea.

n PROBIOTICS

The makers say that Omega-6 this contains is an essential fat that comes from vegetables, helping the body to conserve carbohydrate while shedding fat. Omega-6 supports healthy skin and hair and also aids in the regulation of joint inflammation.

n PROBIOTICS ACTIVA

Contains Bifidus digestivum that has been selected, the makers say, because of the positive effects it has on the digestive system. It is a live culture that tests have shown can improve the performance of the digestive tract when eaten every day.

n FLORA SEMI-SKIMMED MILK WITH PLANT STEROLS

The makers say the plant sterols this contains are clinically proven to lower cholesterol and maintain a healthy heart. They say cholesterol reduction begins within two weeks of drinking the milk regularly.

Kunal Dutta and Tom Pettifor

Antibiotics Don’t Always Work

By Dr. Allen Douma

Q: I have been struggling with vaginitis for years. My doctor says it is caused by bacteria and needs to be treated with antibiotics. But it comes back within a few months, and sometimes the antibiotic treatment doesn’t work.

What can I do?

— Buffalo, N.Y.

A: Inflammation of the lining of the vagina is called vaginitis. It’s one of the more common problems faced by women of all ages.

The primary symptom of vaginitis is abnormal vaginal discharge. Vaginal discharge is considered abnormal if it occurs in large amounts, has an offensive odor, or is accompanied by vaginal itch or pain. The characteristics of the discharge depend on the cause of the vaginitis.

Inflammation of the vaginal lining can be caused by many agents and conditions. They include infections, physical irritation, allergic reactions, tumors, drugs, radiation, hormonal changes and the friction of sexual intercourse.

Vaginal infections can be due to bacteria, fungi, protozoa and viruses. Poor personal hygiene can contribute to the growth of bacteria and fungi, but in most cases it’s not known why some women have a greater problem than others.

The most common vaginal infection is due to the fungus called candida. It typically causes a white, curd-like discharge with little to no odor. Diagnosis is often made by the woman herself and treated at home. But resistant cases need to be examined and the discharge looked at under a microscope.

Vaginitis caused by bacteria is also called vaginosis. It typically produces a grayish, frothy or cloudy discharge with a fishy odor. The odor may become stronger after intercourse or washing with soap, both of which reduce vaginal acidity and encourage bacterial growth.

It’s important to confirm the suspicion of bacterial infection by looking at the discharge under a microscope and testing the acidity of the fluid to see if it is more acid than normal.

Although the most common culprit is a bacterium called Gardnerella, many different bacteria can cause vaginosis. Often more than one can be responsible at the same time. In most cases the lactobacillus bacteria that normally inhabit the vagina, without causing problems, are absent. Culturing the discharge usually doesn’t help in determining the best treatment.

Sometimes making the vagina less acid may be enough to treat the problem. It will at least help in the treatment and help prevent the problem from returning. The easiest way to do this is to use a pre- measured vinegar and water douche. Excess douching, however, especially without using vinegar, can increase the problem.

The recommended antibiotic treatment for bacterial vaginitis has been metronidazole, taken orally, or either clindamycin vaginal cream or metronidazole gel applied topically. However, these treatments work only about two-thirds of the time, and the recurrence rate is greater that 50 percent. A recent study found that using chlorhexidine-based bioadhesive vaginal gel (Clomirex) or clotrimazole vaginal cream was even more effective.

The next time you see your doctor, make sure you talk about what you can do besides taking different antibiotics to help keep the problem from returning.

Treating Levator Ani Syndrome

By Dr. Allen Douma

Q: Recently a member of my family was diagnosed with levator ani syndrome. The colorectal specialist who saw him said there is no cure for this painful and embarrassing ailment! Perhaps you have bumped into a cure for levator syndrome.

— B.

A: I haven’t bumped into a cure. But, in researching the problem, I found some approaches that may help. A number of conditions cause pain in and around the perineum, which is the area between the tail bone and pubic bone. These include abnormalities of the anus, colon, vagina and testicles. But often the source of pain cannot be identified.

Three of the most common disorders that cause anorectal and perineal pain are levator ani syndrome, coccygodynia and proctalgia fugax. Making the diagnosis of levator ani syndrome requires tenderness when pressing on the levator ani muscles.

These are two muscles that stretch across the bottom of the pelvic cavity. They act like a hammock and support the organs in the bottom of the abdominal cavity. They also provide support so that when organs such as the bladder and colon contract they have something to pull against.

The pain comes and goes over a few minutes to days without anything that seems to set it off. Some people can lessen the pain with relaxation; for others, eating may decrease it.

People with this problem are also much more likely to have irritable bowel syndrome.

Presumably, the pain and tenderness is due to spasm or cramping of part of the levator ani muscles. But the cause or causes of the cramping are not known.

Most people with levator ani syndrome will be able to live with the condition without specific treatment. For many others, training themselves to relax the pain away can make the condition much more comfortable.

Research reports indicate that four types of treatment help some people: massage, electrostimulation, injection of botulinum toxin, and injection of a combination of a steroid and anesthetic. No research has compared these approaches for effectiveness (except for one study that compared electrostimulation to steroid injection and found that similar results were obtained).

One study found that about half the people were helped by massage of the perineal area, especially toward the tail bone. In this study, people who also had irritable bowel syndrome showed improvement in the symptoms of that condition as well, for completely unknown reasons.

Unfortunately, only about half of those treated with any of the approaches to levator ani syndrome will be helped. And the effects and benefits wear off within a few months to years.

In summary, levator ani syndrome must be diagnosed with care after other physical causes have been ruled out. Treatment should then be focused on trying to manage it using relaxation techniques during times of pain. And if this is not satisfactory, specialist care should be sought to discuss the risks, benefits and costs of various other approaches.

Write to Allen Douma in care of Tribune Media Services, 2225 Kenmore Ave., Suite 114, Buffalo, NY 14207; or contact him at [email protected].

Fit After 45!

By ANNE RODGERS Palm Beach Post Staff Writer

Shari Brenner, 52,

Palm Beach Gardens

5′ 7″ (she would not divulge weight)

Her fitness secret? Practices yoga, takes vitamins, stays active.

This third-grade teacher takes vitamins daily, practices yoga and Pilates weekly and does water aerobics. She plays tennis once a week and takes a body sculpting class. She goes on yearly skiing vacations and yoga retreats. She also kayaks, hikes and goes horseback riding.

Dvera Berson, 93,

Boca Raton

5′ 2 1/2″, 128 pounds

Her fitness secret? Developed the Berson Water Exercise Program.

After contracting severe arthritis in her mid 50s, Dvera was crippled for years until she discovered the benefits of water exercise. Over a period of nine months she became pain-free, and along the way she discovered what exercise movements and principles work best to relieve arthritic pain. She emerged with a series of 35 water exercises done five times a week. She’s been pain-free for 30 years on the program.

Vickie Easson, 77,

Singer Island

5′ 5″, 125 pounds

Her fitness secret? Walking barefoot on the beach.

Vickie takes action if she gains 5 pounds; that’s when she starts eating half portions of her meals, losing 2 pounds a week. She eats out most of the time, and always takes home a doggy bag to enjoy the next day. She walks barefoot on the beach for an hour five times a week. She also loves dancing.

Carol Best, 58,

Lake Clarke Shores

5′ 2″, 110 pounds

Her fitness secret? Leslie Sansone’s Walk Away the Pounds program.

Carol gained weight as she approached middle age, and by 48, she was up to 180 pounds. With Sansone’s program, she lost 70 pounds and has appeared in 20 tapes and two infomercials for the program. Now she’s a master walk instructor, spin instructor and Pilates instructor.

Janice Ferraiolo, 51, Boynton Beach

5′ 7 1/2″, 150 pounds

Her fitness secret? She made the fitness industry her line of work.

She’s held other jobs, but Janice says being a fitness instructor is by far the most fulfilling. ‘It not only makes me glad that I keep myself in shape, but the success of the women I teach – all over 45 – could fill every page of this newspaper.’

Maureen Sullivan, 55, Tequesta

5′ 8 1/2″, 145 pounds

Her fitness secret? Bikram yoga.

A check of her mineral status three years ago showed that Maureen had poor calcium uptake, wasn’t getting enough good water and was eating way too much protein. (She was an Atkins-type diet advocate at the time.) She began taking proper minerals and joined a Bikram yoga class three times a week. The first 10 times she had to leave the room and rest. Now she’s at the front of the class. Her stamina, strength and balance are much better – and she can hit her golf drives farther.

Jane Illsley, 49, Boynton Beach

5′ 5 1/2″, 144 pounds

Her fitness secret? Taking the Bible at its word that fasting is a needed cleansing.

Jane skipped two meals two days a week, and one meal the other days. After six months, she lost the 10 pounds she’d gained around the middle with menopause. She takes vitamins, listens to her doctor, goes to a Christian kinesiologist and believes retaining one’s youth is an internal fight.

Jane Burge, 70, Jupiter

5′ 4″, 173 pounds

Her fitness secret? Got involved in water aerobics, then became certified to teach it herself.

After a second heart attack at age 65, Jane left behind her sedentary lifestyle. She takes classes in water aerobics at North County Aquatic Center in Jupiter three days a week, and teaches two days a week at North Palm Beach Country Club. She eats lots of vegetables and fruits and very little red meat, and says she feels better than she has in years.

If you’re fit and over 45, chances are it’s no accident. The forces of fitness almost seem to line up against women of a certain age: you’re battling the effects of menopause, plus you’re contending with the natural loss of muscle to fat and the increased difficulty of losing weight. No wonder a pear is the most identifiable shape for midlife women.

It doesn’t have to be this way. Plenty of women have taken control of their weight and health, opting to put themselves on the winning side of the formula for fitness.

What works for one woman may not be right for another, but sensible eating and some form of exercise are must-haves in the war against excess weight. So is the initiative to get started. No matter how small your effort feels, do it. It’s likely to lead to more, and soon you’ll have a program to be proud of.

To look at Jane Burge today, you’d never guess she had heart attacks at age 60 and 65. Her exercise consisted of a little bike riding – until a friend at her heart surgeon’s office recommended water aerobics. She started slowly, but fell in love with the activity, and now the Jupiter woman is in the water five days a week, both teaching and taking classes.

“I say get up off your duff, get moving, get with people you love and do something you enjoy. Don’t let the soap opera people become your friends,” she said.

Jane points out the evidence is mounting that physical activity not only preserves but improves cognitive abilities in adults 60 to 75 years old, “so my advice is eat well, keep moving, laugh a lot, believe in yourself and love life. The alternative does not seem like much fun to me.”

Dvera Berson is another woman who took to the water to cure her ills. At 93, the Boca Raton resident is a winning advertisement for the Berson Water Exercise Program, which she developed.

After contracting severe arthritis in her mid 50s, Dvera’s condition deteriorated to the point that she had to wear a neck collar, a back support and a surgical corset. She was crippled for years until she discovered the benefits of water exercise. Over a nine-month period she became pain-free, and along the way she discovered what exercise movements and principles work best to relieve arthritic pain. She emerged with a series of 35 water exercises that are done five times a week with increasing frequency until the person becomes pain-free.

“I still have arthritis,” she said, “but I no longer have pain. That’s because most arthritis pain comes from muscles that atrophy, spasm and contract around the joints. My program of water exercise is designed to strengthen, stretch and relax the muscles of the entire body, thus relieving pain.”

She shares her secrets in her 1978 book, Pain-Free Arthritis. (Arthritis sufferers might want to visit www.becomingpainfree.com.)

Taking to the water is hardly the only way women find health. For Janice Ferraiolo of Boynton Beach, the ideal way to stay in shape after 45 was simple: She made it her job.

“As we age, it becomes harder to stay fit and in shape,” said the 51-year-old fitness instructor. “We really must make the decision to eat properly – I dislike the word diet – and we must get some form of physical activity daily. It’s that simple!”

Other women find their road toward fitness to be a more internal process. Jane Illsley, who visits a Christian kinesiologist whenever she gets sick, decided to take the

Bible at its word – and lost 10 pounds by fasting.

“I read Discover and Scientific American, I watch television news programs and listen to my doctor about what works to keep us young,” said the 49-year-old Boynton Beach mother of three. “I

believe, as many say, that it is an internal fight.”

Jane said that being fit can require anything from “a certain vitamin E to keep our cholesterol down, to something that keeps our cells young, to making sure we get Omega 3 in our diet and less Omega 6, to using natural ingredients for cancer, such as carrots, or a plant called graviola.

“All I know is that when I don’t take the vitamins, I wake up with wrinkles and bags around my face. When I do, I’m OK, as in a face like a 20-year-old, only no zits.”

Developing a healthy lifestyle takes many forms, and Maureen Sullivan found her journey to be a very sweaty one. At 52, she was 170 pounds, post-menopausal, fatigued, depressed and having several bouts of heart palpitations a day.

“I found a way to get my mineral status checked and my levels were all out of whack,” she said.

Maureen began taking proper minerals and joined a Bikram yoga class three times a week. The first 10 times, the heat forced her to leave the room and rest. Now, three years and 25 pounds later, the

Tequesta golf enthusiast is at the front of the class.

Her stamina, strength and balance are better – and she can hit her drives farther, 240 yards plus.

“Granted, I am not the most flexible, but my stamina, strength and balance are 100 times better than before I started,” Maureen said. “It has not been easy, but all the changes I have made – well I feel like I’m 45 again instead of 55!”

If sweating intimidates you, perhaps walking is your highway to health. It was for Carol Best.

A decade ago, Carol was facing menopause, along with all the tiredness and malaise that comes with it. “I was so blessed to live in New

Castle, Pa., the home of Leslie Sansone’s Walk Aerobics. At her fitness center, I learned to move more as I age.”

After losing 70 pounds, Carol, now 58, said she sleeps better, wakes up earlier and has more energy. She says walk aerobics is good for the Baby Boomer generation because your body doesn’t have to take a pounding when you exercise. She even got her 80-year-old parents started on it.

Carol frequently comes to visit her daughter Nadine in Lake Clarke Shores and was here so often that she joined Ladies of America in Palm Springs.

“Let me tell you, women of a certain age, to join these beautiful places, learn from the wisdom of other women, young and aged, and get up and move,” she offered.

“I take no medication for any of the diseases related to my age: no high blood pressure, no cholesterol medications, no meds for hormones. Please know you can welcome this beautiful second half of life with open arms.”

[email protected]

The big problem of obesity

With approximately one-third of U.S. women classified as obese, obesity is the fastest growing health problem in the United States. Obesity is different from being overweight. Obesity is defined as a Body Mass Index greater than 30. It is viewed within the ob-gyn specialty as one of the leading health problems confronting women today and is associated with increased health problems, including type 2 diabetes, hypertension, infertility, heart disease, gallbladder disease, osteoarthritis, and a variety of cancers, including breast, uterine, and colon cancers. In addition, obese women are five times more likely than non-obese women to develop endometrial cancer.

– Source: The American College of Obstetricians and Gynecologists

Berlin’s pre-war Jewish life captured at exhibit

By Sarah Marsh

BERLIN (Reuters) – Germany’s thriving pre-war Jewish
community as captured on black and white photographs went on
display in Berlin’s Jewish Museum on Friday with an exhibit of
90 stirring images by photographer Roman Vishniac.

The portraits of lively street scenes, artists and
intellectuals in Berlin taken just before the Holocaust recall
a vibrant Jewish culture in the German capital. The previously
unpublished pictures were only found after Vishniac died in
1990.

Jewish culture flourished in Berlin before the Nazis took
power — it was one of the world’s 10 largest Jewish centers
and many of Germany’s top scientists, such as Albert Einstein,
were Berlin Jews. There were about 160,000 Jews in Berlin in
1933, but only 1,400 in 1945.

“These photos show a city where everyone was involved in
culture, art, politics and philosophy,” said Sarah Kushinsky,
25, whose grandfather was taken to a concentration camp but
survived and later emigrated to Australia.

“They show the Jewish culture at its peak before the
crash,” said Kushinsky, who is a student in Switzerland and
went to the exhibit’s opening on Friday with her grandfather.
“I don’t think there will ever be anywhere like Berlin was then
again.”

Vishniac, known for his pictures of pre-war Jewish life in
Eastern Europe, was a Russian-born Jew who went to the United
States. He was a biologist, linguist, art historian and
philosopher as well as a photographer.

His pictures of Jewish communities of Eastern Europe taken
on the eve of World War Two are included in his most famous
collection of pictures called “Vanished World.”

David Prince, who survived Auschwitz and emigrated to
Melbourne, said he was delighted by the exhibit.

“Germany was recognized as the most cultural country at the
time, and suddenly turned into the horror of mankind,” said
Prince, 80. “We take great pride though in the knowledge that
the cultural wealth shown in these photos is part of Jewish
history, and that we survived and continued tradition.”

“My favorite photo is the one of workers breaking into an
impromptu Jewish dance in a work camp in the Netherlands,” said
Alana Honigman, a 20-year-old student from the United States.
Her father had lost most of his family in the Holocaust.

Germany now has the world’s fastest-growing Jewish
population. Though still a fraction of the half-million strong
community when the Nazis came to power in 1933, it has more
than doubled in a decade to about 100,000 with immigration from
the former Soviet Union and eastern Europe.

Despite Germany’s history as the nation that carried out
with grisly efficiency the murder of some six million European
Jews, thousands of Jews have elected to emigrate to Germany
because they want to stay in Europe.

Madonna steals the show at MTV Europe awards

By Ian Simpson

LISBON (Reuters) – Madonna stole the show at the MTV Europe
Music Awards on Thursday with the first live televised
performance of her new single “Hung Up,” emerging from a giant
glitter ball wearing purple leather boots and matching leotard.

The 47-year-old queen of pop rocked the Atlantic Pavilion
on one of the music industry’s most important nights outside
the United States, and said she still got a kick out of playing
to a crowd.

“After I fell off my horse it was amazing to be able to get
up and dance,” she told Reuters backstage, referring to a
riding accident in August when she cracked three ribs and broke
her collarbone and a hand.

She confessed she had feared that energetic performances
like the one in Lisbon would no longer be possible because of
the injuries.

“Being in front of all the people, waiting for it to come
up, and waiting to see the audience, my heart was just pumping
out of my chest,” Madonna said in a brief interview.

Madonna will be hoping “Hung Up,” the first single from her
new album “Confessions on a Dancefloor,” puts her back on top
of the charts after her last album failed to sell well.

“I’ve been making records for over 20 years. I’ve had an
incredible run, highs and lows, but I keep going.”

Scooping two awards were as pop-punk idols Green Day, who
won Best Album and Best Rock categories. Their record “American
Idiot” also won at the Grammys this year.

Best Male category went to Robbie Williams, beating
competition from 50 Cent and Eminem. Gorillaz was named Best
Group and Coldplay took Best Song for “Speed of Sound.”

Best Female category went to Colombian-born Shakira, Snoop
Dogg snagged Best Hip-Hop, Best R & B was won by Alicia Keys,
Best Pop by the Black Eyed Peas, and the Chemical Brothers were
awarded Best Video for “Believe.”

System of a Down were crowned Best Alternative, and James
Blunt took away the Best New Act gong.

COLDPLAY, CARTOONS, COMEDY

Irish rocker Bob Geldof was given the humanitarian Free
Your Mind Award after staging what was billed as rock music’s
greatest day with Live 8, a global anti-poverty concert watched
by hundreds of millions of people.

Madonna, handing Geldof the prize, called him “my hero.”

Gorillaz “appeared” using hologram-style technology to beam
three-dimensional, performing cartoon characters on stage.

Billed as the world’s most successful virtual band, the
human artists behind Gorillaz traditionally appear at live gigs
as silhouettes on a giant screen combined with images of their
cartoon alter egos.

U.S. actor Jared Leto had the crowd booing, whistling and
turning their thumbs down at U.S. President George W. Bush, in
a moment of political controversy.

“If you can’t criticize the president in our country, who
can you criticize?” he said.

Williams was in typically exuberant form, taking a dive
into the crowd during his performance and joking at the expense
of none other than Madonna.

“She’s amazing. She’s an absolute legend. I can’t believe
she’s 89 and looks like that,” he said.

Hosting the event was spoof Kazakh television presenter
Borat, a guise adopted by British comedian Sacha Baron Cohen
who is renowned for his risque, politically incorrect humor.

His opening gag on the night was no exception.

“It was very brave of MTV to start the show with a
transvestite,” he joked, referring to Madonna.

(Additional reporting by Jeffrey Goldfarb and Mike
Collett-White in London)

Liberian orphanages steal, exploit children

By Katharine Houreld

MONROVIA (Reuters) – When social workers found the starving
children at the Hannah B. Williams orphanage in Monrovia, they
were eating frogs because the owner had sold the food donated
by aid agencies at a market in Liberia’s capital.

“Sometimes, we went into the swamp to eat chicken green
weeds (swamp weeds) because of hunger,” said 17-year-old
Michael, who was beaten if he was caught outside the orphanage.

“Some children, 7 or older, would go outside to ask for
help from anybody,” he added.

When authorities closed the building earlier this year, 89
of the 102 so-called “orphans” were reunited with their
families. Many parents believed they had sent their children to
a boarding school and some were even paying fees.

Such tales are becoming increasingly common as a
U.N.-backed task force tries to clean up Liberia’s orphanages
and reunite thousands of families across the West African
country, crippled by 14 years of sporadic civil war.

The war displaced nearly a third of Liberia’s 3.4 million
people and caused more than 250,000 deaths. As terrified
families fled bush battles, children were lost. Some joined the
ranks of drugged-up child soldiers, either by choice or
coercion; others were taken into orphanages, but there, too,
some were exploited.

Many rogue orphanages are “recruiting” Liberian children
from their families and keeping them in appalling conditions in
order to increase the aid they receive, authorities say.

“We have this problem all over the country,” said Vivian
Cherue, Liberia’s deputy minister for health. “So far, we have
only assessed two out of 15 counties and we have found 35
orphanages that need to be closed.”

Children from closed orphanages would be moved to
accredited institutions if their families could not be found,
Cherue said.

Laurie Galan, a child protection worker in the north of
Africa’s oldest independent republic, said she had had problems
with two out of three orphanages where families had been
traced.

“I’ve come across orphanages that have just taken kids and
the families have no idea what happened to them,” said Galan.
“They know the task force wants to do family tracing, but some
are deliberately obstructing it.”

POST-WAR CHAOS

Last month, Liberia held its first elections since the 2003
peace deal, a vote meant to bring stability to a country
founded by freed American slaves in 1847.

A presidential run-off on November 8 pits soccer star
George Weah against former World Bank economist Ellen
Johnson-Sirleaf.

Slowly, people are rebuilding their lives in a country
where the capital is still without piped water or mains
electricity.

However, some children in orphanages are still waiting to
start new lives. Some institutions are reluctant to give up
children they cared for when their parents were missing.

United Nations police intervened earlier this year after a
nun, who ran an orphanage in the northeastern town of Saclepea,
refused to give back children she gathered from refugee camps
in neighboring Guinea. Eventually 57 of 61 children were
reunited with their parents.

In another institution in the northern city of Ganta, Galan
said she saw severely malnourished children forced to sell
bulgur wheat by the side of the road. Bulgur wheat is the
staple food supplied to the orphanages by the U.N. World Food
Program.

“It’s a shame because there are genuine orphanages that are
losing out (on aid),” Galan said.

LIVED IN GRAVEYARD

Sometimes, it is difficult to tell whether conditions are
the result of poverty and years of war or corruption.

At the Teemas Orphanage on the outskirts of Monrovia, 46
boys sleep in one room on a urine-stained concrete floor with
six thin foam mattresses between them.

Conditions are barely better in the girls’ room. The roof
of the derelict building has collapsed and plastic tarpaulins
stretched over sticks protect the children from the rain and
fierce sun.

In a tattered tent outside, an epileptic girl lives by
herself. She says she is 15, although she has the high fluting
voice and the stature of an 8 year old.

“I thank God for this,” said the orphanage’s director,
Doris Weefar, gesturing to her shabby surroundings. “For three
weeks we lived in a graveyard. It was terrible.”

The children have been displaced four times by war, most
recently by the battle known by local residents as “World War
Three” where rebel LURD forces and child soldiers loyal to
then- President Charles Taylor laid waste to central Monrovia.

Yet here, too, many of the “orphans” were left by their
parents. Weefar found at least two of them wandering the street
while Monrovia was under attack and collected them as she fled.

The orphanage has records for 57 of its 79 children. Of
those, half had a living relative, often their mother or
father.

“Father left in war,” reads one hand-written form. “No
assistance.” “Needs educational help,” says another.

Weefar insists that, despite the poor living conditions,
her children are fed three times a day — more than many
families can afford — and she is doing her best to educate
them.

She says she is using a grant from the former U.S.
ambassador to build a new institution. But the Ministry of
Health is not satisfied: the orphanage is slated for closure.

“She has had a year since we first inspected her,” said
Cherue. “Ten other orphanages have made improvements in that
time and the point remains, an orphanage is not a school. If
these children have parents, then they belong at home.”

Circumcised men less apt to transmit Chlamydia

NEW YORK (Reuters Health) – Female sexual partners of
circumcised men are less likely to contract Chlamydia
trachomatis infections than are those of uncircumcised men, a
study shows.

The most common bacterial cause of sexually transmitted
infections, C. trachomatis can cause severe reproductive
complications in women and is associated with increased risk of
cervical cancer.

The relationship between male circumcision and C.
trachomatis infection in the female partner has not been
explored, Dr. Xavier Castellsague, at Institut Catala
d’Oncologia in Barcelona, and colleagues point out in the
American Journal of Epidemiology for November.

They therefore evaluated this relationship among 300 female
subjects enrolled in studies in Colombia, Spain, Brazil,
Thailand and the Philippines and their male partners. Blood
samples from the women were tested for C. trachomatis.

According to the report, the overall prevalence of
circumcision was 37 percent among the men, ranging from 1.8
percent in Spain to 92 percent in the Philippines.

Women whose partners were circumcised were significantly
less likely to be infected with C. trachomatis. This was true
across all five countries.

Only among younger women and women with a history of
consistent condom use was there no association between
circumcision and C. trachomatis detection.

The researchers speculate that a penis with retained
foreskin is perhaps more likely to retain infection for a
longer duration than a penis with no foreskin, “subsequently
increasing the likelihood of infection to the penile urethra
and transmission to the vagina during intercourse.”

SOURCE: American Journal of Epidemiology November 2005.

Pennsylvania company recalls 94,400 lbs of beef

WASHINGTON (Reuters) – Quaker Maid Meats Inc. on Tuesday
said it would voluntarily recall 94,400 pounds of frozen ground
beef panties that may be contaminated with E. coli.

The beef products were produced by Reading,
Pennsylvania-based Quaker on July 19 and shipped to retail
stores in Connecticut, Florida, Georgia, Maine, Maryland,
Massachusetts, New Jersey, New York, Pennsylvania, South
Carolina, Virginia and Wisconsin.

The beef products have an establishment code of “Est 2748”
inside the USDA mark of inspection. A Quaker official could not
be reached on the recall.

E. coli O157:H7 is a deadly bacteria that can cause
diarrhea and dehydration. Children, the elderly and people with
weak immune systems are most susceptible.

The following products were recalled:

-Three-pound boxes of “Philly-gourmet, 100% Pure Beef,
Homestyle Patties,” with the packaging code of “2005A,”
“2005B,” “2005C” or “2005D”;

-Five-pound boxes of “Philly-gourmet, 100% Pure Beef,
Homestyle Patties,” with the packaging code of “2005A,”
“2005B,” “2005C” or “2005D.”

Liberian orphanages steal and exploit children

By Katharine Houreld

MONROVIA (Reuters) – When social workers found the starving
children at the Hannah B. Williams orphanage in Monrovia, they
were eating frogs because the owner had sold the food donated
by aid agencies at a market in Liberia’s capital.

“Sometimes, we went into the swamp to eat chicken green
weeds (swamp weeds) because of hunger,” said 17-year-old
Michael, who was beaten if he was caught outside the orphanage.

“Some children, seven or older, would go outside to ask for
help from anybody,” he added.

When authorities closed the building earlier this year, 89
of the 102 so-called “orphans” were reunited with their
families. Many parents believed they had sent their children to
a boarding school and some were even paying fees.

Such tales are becoming increasingly common as a
U.N.-backed task force tries to clean up Liberia’s orphanages
and reunite thousands of families across the West African
country, crippled by 14 years of sporadic civil war.

The war displaced nearly a third of Liberia’s 3.4 million
people and caused more than 250,000 deaths. As terrified
families fled bush battles, children were lost. Some joined the
ranks of drugged-up child soldiers, either by choice or
coercion; others were taken into orphanages, but there, too,
some were exploited.

Many rogue orphanages are “recruiting” Liberian children
from their families and keeping them in appalling conditions in
order to increase the aid they receive, authorities say.

“We have this problem all over the country,” said Vivian
Cherue, Liberia’s deputy minister for health. “So far, we have
only assessed two out of 15 counties and we have found 35
orphanages that need to be closed.”

Children from closed orphanages would be moved to
accredited institutions if their families could not be found,
Cherue said.

Laurie Galan, a child protection worker in the north of
Africa’s oldest independent republic, said she had had problems
with two out of three orphanages where families had been
traced.

“I’ve come across orphanages that have just taken kids and
the families have no idea what happened to them,” said Galan.
“They know the task force wants to do family tracing, but some
are deliberately obstructing it.”

POST-WAR CHAOS

Last month, Liberia held its first elections since the 2003
peace deal, a vote meant to bring stability to a country
founded by freed American slaves in 1847.

A presidential run-off on November 8 pits soccer star
George Weah against former World Bank economist Ellen
Johnson-Sirleaf.

Slowly, people are rebuilding their lives in a country
where the capital is still without piped water or mains
electricity.

However, some children in orphanages are still waiting to
start new lives. Some institutions are reluctant to give up
children they cared for when their parents were missing.

United Nations police intervened earlier this year after a
nun, who ran an orphanage in the northeastern town of Saclepea,
refused to give back children she gathered from refugee camps
in neighboring Guinea. Eventually 57 of 61 children were
reunited with their parents.

In another institution in the northern city of Ganta, Galan
said she saw severely malnourished children forced to sell
bulgur wheat by the side of the road. Bulgur wheat is the
staple food supplied to the orphanages by the U.N. World Food
Program.

“It’s a shame because there are genuine orphanages that are
losing out (on aid),” Galan said.

LIVED IN GRAVEYARD

Sometimes, it is difficult to tell whether conditions are
the result of poverty and years of war or corruption.

At the Teemas Orphanage on the outskirts of Monrovia, 46
boys sleep in one room on a urine-stained concrete floor with
six thin foam mattresses between them.

Conditions are barely better in the girls’ room. The roof
of the derelict building has collapsed and plastic tarpaulins
stretched over sticks protect the children from the rain and
fierce sun.

In a tattered tent outside, an epileptic girl lives by
herself. She says she is 15, although she has the high fluting
voice and the stature of an eight year old.

“I thank God for this,” said the orphanage’s director,
Doris Weefar, gesturing to her shabby surroundings. “For three
weeks we lived in a graveyard. It was terrible.”

The children have been displaced four times by war, most
recently by the battle known by local residents as “World War
Three” where rebel LURD forces and child soldiers loyal to
then- President Charles Taylor laid waste to central Monrovia.

Yet here, too, many of the “orphans” were left by their
parents. Weefar found at least two of them wandering the street
while Monrovia was under attack and collected them as she fled.

The orphanage has records for 57 of its 79 children. Of
those, half had a living relative, often their mother or
father.

“Father left in war,” reads one hand-written form. “No
assistance.” “Needs educational help,” says another.

Weefar insists that, despite the poor living conditions,
her children are fed three times a day – more than many
families can afford – and she is doing her best to educate
them.

She says she is using a grant from the former U.S.
ambassador to build a new institution. But the Ministry of
Health is not satisfied: the orphanage is slated for closure.

“She has had a year since we first inspected her,” said
Cherue. “Ten other orphanages have made improvements in that
time and the point remains, an orphanage is not a school. If
these children have parents, then they belong at home.”

Joseph F. O’Neill, M.D., Former Director of the Office of National AIDS Policy, Joins The Immune Response Corporation As CEO and President

The Immune Response Corporation (Nasdaq Capital Market:IMNR) announced today the appointment of Joseph F. O’Neill, M.D., M.P.H. as its new Chief Executive Officer and President, succeeding John N. Bonfiglio, Ph.D. Dr. O’Neill comes to The Immune Response Corporation after a distinguished career leading federal AIDS policy at the White House, the Office of the U.S. Secretary of Health and Human Services, and the Office of the Global AIDS Coordinator at the U.S. Department of State. Dr. O’Neill was chief architect of the President’s 2003 Emergency Plan for AIDS Relief, known as PEPFAR, a $15 billion U.S. Government-led global initiative to combat the HIV/AIDS epidemic. He will leverage his extensive experience and relationships in public health initiatives to lead the Company in the ongoing development of its products for HIV and multiple sclerosis (MS). Dr. O’Neill will also serve on the Company’s Board of Directors.

“I am thrilled to take on this challenge and dedicate my efforts to the development of Immune Response’s products, which represent a powerful new therapeutic approach,” said Dr. O’Neill. “I am acutely aware of the need for new HIV therapies. An effective immune-based therapy would make an enormous contribution in the fight against HIV/AIDS, enabling entirely new approaches to treatment. Similarly, there is a great need for new MS treatments. After careful review of the Company’s recent scientific developments, I believe that we can successfully complete the necessary clinical trials and form the public and private partnerships required to advance these important new treatments.”

The Immune Response Corporation’s products for HIV are based on its patented whole-inactivated virus technology and are intended to help restore a patient’s immune system to fight the HIV infection. REMUNE(R), currently in Phase II clinical trials, is being developed as a first-line treatment for people with early-stage HIV. A new HIV immune-based therapy, IR103, which incorporates a Toll-like receptor (TLR) agonist-based adjuvant from Idera Pharmaceuticals Inc. (AMEX: IDP), is currently in Phase I/II clinical trials. Further, the Company is developing NeuroVax(TM), an immune-based therapy for MS, which is also in Phase II.

Dr. O’Neill has an extensive record of public service spanning multiple administrations. He served as Deputy U.S. Global AIDS Coordinator and Chief Medical Officer for the Office of the Global AIDS Coordinator at the U.S. Department of State. During his tenure, the Office of the U.S. Global AIDS Coordinator oversaw the disbursement of $2.4 billion to over 100 countries in the first year of operations. Prior to that position, Dr. O’Neill was the Director of the White House Office of National AIDS Policy where he spearheaded the development of PEPFAR, and coordinated the successful legislative strategy resulting in the passage by Congress of the U.S. Leadership against HIV/AIDS, Tuberculosis, and Malaria Act of 2003.

Previously, Dr. O’Neill also served as the Acting Director of the Office of HIV/AIDS Policy in the Department of Health and Human Services, coordinating the Department’s $30 billion HIV/AIDS program. He also served as Director of the HIV/AIDS Bureau of the Health Resources and Services Administration, responsible for management of the $1.9 billion Ryan White CARE program, the nation’s largest healthcare program serving people living with AIDS.

“I can’t think of a more capable and accomplished person than Joe O’Neill to lead our Company into its next era,” said Bob Knowling, Chairman of the Board of The Immune Response Corporation. “Joe brings a unique perspective from his work on the front lines treating patients and his understanding of the plight of those suffering from this epidemic, combined with unparalleled experience implementing global health initiatives. We are honored that he will put that same passion, dedication and experience to work at the Immune Response Corporation.”

Dr. O’Neill is a practicing HIV/AIDS physician and a member of the faculties of the Johns Hopkins School of Medicine and the University of Maryland School of Medicine. He was also previously on the medical staff of the Chase Brexton Clinic, a community-based AIDS clinic in Baltimore. A graduate of the School of Medicine of the University of California at San Francisco, Dr. O’Neill also received Master’s degrees in public health and medical sciences and a Bachelor’s degree in business administration from the University of California at Berkeley.

About The Immune Response Corporation

The Immune Response Corporation (Nasdaq Capital Market: IMNR) is a biopharmaceutical company dedicated to becoming a leading immune-based therapy company in HIV and MS. The Company’s HIV products are based on its patented whole-inactivated virus technology, co-invented by Company founder Dr. Jonas Salk to stimulate HIV immune responses. REMUNE(R), currently in Phase II clinical trials, is being developed as a first-line treatment for people with early-stage HIV. The Company has initiated development of a new immune-based therapy, IR103, which incorporates a Toll-like receptor (TLR) agonist-based adjuvant and is currently in Phase I/II clinical trials in Canada, Italy and the United Kingdom.

The Immune Response Corporation is also developing an immune-based therapy for MS, NeuroVax(TM), which is currently in Phase II clinical trials and has shown potential therapeutic value for this difficult-to-treat disease.

Please visit The Immune Response Corporation at www.imnr.com.

Required NASDAQ Disclosure

To further align Dr. O’Neill’s interests with those of Immune Response stockholders, the Company’s Board of Directors granted Dr. O’Neill an inducement stock option award. NASDAQ rules require disclosure of the terms of such awards. Dr. O’Neill received an option to buy 6,000,000 shares of Immune Response common stock at an exercise price of $0.32 per share. The option is subject to vesting requirements, as follows: 3,000,000 of the options shall vest quarterly over two years subject to Dr. O’Neill’s continuation of service as CEO; and the remaining 3,000,000 options shall all vest in 2012, subject to Dr. O’Neill’s continuation of service as CEO, unless they vest earlier based upon attainment of performance milestones which may be mutually agreed upon in the future by the Company and Dr. O’Neill.

Forward-looking Statements

This news release contains forward-looking statements. Forward-looking statements are often signaled by forms of words such as should, could, will, might, plan, projection, forecast, expect, guidance, potential and developing. Actual results could vary materially from those expected due to a variety of risk factors, including whether the Company will continue as a going concern and successfully raise proceeds from financing activities sufficient to fund operations and additional clinical trials of REMUNE(R), NeuroVax(TM) or IR103, the uncertainty of successful completion of any such clinical trials, the fact that the Company has not succeeded in commercializing any drug, the risk that REMUNE(R), NeuroVax(TM) or IR103 might not prove to be effective as either a therapeutic or preventive vaccine, whether future trials will be conducted and whether the results of such trials will coincide with the results of REMUNE(R), NeuroVax(TM) or IR103 in preclinical trials and/or earlier clinical trials, and any transition issues related to the hiring of Dr. O’Neill. A more extensive set of risks is set forth in The Immune Response Corporation’s SEC filings including, but not limited to, its Annual Report on Form 10-K for the year ended December 31, 2004 and its subsequent Quarterly Reports filed on Form 10-Q. The Company undertakes no obligation to update the results of these forward-looking statements to reflect events or circumstances after today or to reflect the occurrence of unanticipated events.

REMUNE(R) is a registered trademark of The Immune Response Corporation. NeuroVax(TM) is a trademark of The Immune Response Corporation.

Singapore not ashamed of low rank for press freedom

SINGAPORE (Reuters) – Singapore should not be embarrassed
by its lowly ranking on the international press freedom index
because it has achieved top ratings for economic freedom and
prosperity, its senior minister said.

Defending the city-state’s model of press control, former
prime minister Goh Chok Tong said the country should not
subscribe to the Western model of a free press that favors
criticism and opposition.

Instead, Singapore should develop a non-adversarial press
that reported accurately and objectively.

“I do not favor a subservient press. An unthinking press is
not good for Singapore. But press freedom must be practised
with a larger sense of responsibility and the ability to
understand what is in, or not in, our national interests,” Goh
said late on Monday, at the anniversary dinner of the Today
newspaper.

Goh’s comments come a week after an annual index produced
by Reporters Sans Frontieres, a Paris-based media monitoring
group, ranked Singapore 140th out of 167 countries — up four
notches from last year but still faring worse than tightly
governed states such as Russia and Yemen.

In a report accompanying the publication of the latest
index, Reporters San Frontieres (RSF) said Singapore’s low
ranking was due to the complete absence of independent media,
the application of prison sentences for press offences, media
self-censorship and the opposition’s lack of access to state
media.

The report also cited instances where the government used
heavy fines or distribution bans on international newspapers
such as the Asian Wall Street Journal, the Economist and the
International Herald Tribune to “silence Singaporeans or
foreign journalists” who wrote articles that embarrassed the
political elite.

Goh said the RSF report was a “subjective measure computed
through the prism of Western liberals.”

He cited other surveys such as the Transparency
International Index and the US-Based Heritage Foundation’s
Economic Freedom Index, in which Singapore received top
ratings.

“My simple point is this: it has not been proven that
having more press freedom would result in a clean and efficient
government or economic freedom and prosperity,” Goh said.

Singapore is known for heavy-handed censorship in the media
and arts, largely enforced through a system of issuing
publication and performance licenses.

Run by the People’s Action Party for 40 years, Singapore
often gets top marks for its sound economic policies but lags
other Asian countries when it comes to freedom of expression.

Last month, outgoing U.S. ambassador Franklin L. Lavin
slammed the city-state’s curbs on freedom of speech. In the
same month, Britain’s Warwick University dropped plans to set
up a campus in Singapore because of concerns about academic
freedom.

Railway connects Welsh past to the future

By Kevin Plumberg

CAERNARFON (Reuters) – With a whistle and a hiss, the
47-year-old Beyer-Garratt steam locomotive lurched out of
Caernarfon station, sending plumes of smoke into the air and
obscuring the Welsh town’s 13th century castle.

The glistening black train chugged along one of Britain’s
oldest narrow gauge railways, winding through blackberry bushes
and the jagged crags of northern Wales to Rhyd Ddu, a village
at the foot of Snowdon, the highest peak in England and Wales.

For the people of northern Wales, the Welsh Highland
Railway acts as a link to a long-dead industrial past, when
mining and slate quarrying dominated in this hilly region.

Many now hope plans to extend the track will help shape the
future, by luring more tourists to places like Caernarfon, a
seaside town where most people speak Welsh.

The railway was opened in 1923 to haul slate from the
foothills of Snowdonia’s purple saxifrage-covered mountains but
it closed down in 1936 because of a decline in the mining
industry and a lack of passengers.

For some, the railway was one of the greatest white
elephant schemes of British industrial history: by 1927, the
growing popularity of road transport and the declining slate
industry pushed the slow and infrequent railway into
receivership.

The latest drive to revive the line dates from 1989 and was
initially supported by rail enthusiasts who won backing from
local authorities and community groups.

Now, the $62 million (US) initiative is in its final stage.
Track work has begun on a final extension and is expected to be
completed by the end of 2008. The finished line is due to open
to the public early in 2009.

“The impact of this project will be pretty big,” said Paul
Lewinn, general manager of the Ffestiniog Railway Co., which
operates the line.

SOMETHING TO DO

The railway is being extended around 10 miles from Rhyd Ddu
to Porthmadog where it will link up with a line traveling on to
Blaenau Ffestiniog, once the capital of the slate quarrying
industry, for a 40-mile total trip.

Ffestiniog Railway, the oldest independent rail company in
the world, put up 25 million pounds for the extension, with the
remainder coming from donations of money and equipment.

The gauge refers to the width between train rails. Most
railways use a standard gauge of more than 4 feet but the Welsh
Railway has a gauge of slightly less than 2 feet, which was
cheaper to make and made turning corners easier.

Lewinn, who was a narrow gauge train driver for almost two
decades, said he believed the finished line could contribute
between 15 and 20 million pounds to the economy each year by
drawing as many as 250,000 tourists a year to the region.

He was speaking as he drove along the train route from Rhyd
Ddu to Porthmadog. He parked near Dinas station where a
shipment of rolled track had just arrived from Poland for the
extension.

The extended line will be a boon to Caernarfon, the town’s
mayor said.

“When people come here it’s something for them to do, and
that’s what we want,” Mayor Tudor Owen said.

But not everyone is happy about the prospect of more people
coming to visit their picturesque region.

“Caernarfon is a town with a glorious past and an uncertain
future … the Welsh Highland Railway might be of use in
bringing in a few short-stay visitors, but it should not be
looked upon as a salvation to cure all the town’s ills,” said
T. Meirion Hughes, a local historian.

Caernarfon’s jobless rate is around twice as high as
Britain’s overall 4.7 percent rate. The town relies heavily on
drawing tourists to see the castle, built by King Edward I on
the site of a Norman stronghold.

SCENIC ROUTE

The railway has long had its detractors, not least because
it fell so spectacularly out of favor just after its creation.

In 1934, Ffestiniog Railway attempted unsuccessfully to
revive the line by taking over its lease.

But during World War Two, tracks were pulled up and trains
were demolished as part of the war effort.

The railway, which had operated at a loss since opening to
the public, fell into disuse for the next 50 years until the
Ffestiniog Railway once again came to the rescue with a plan to
rebuild the line from Caernarfon to Blaenau Ffestiniog.

Train enthusiasts are excited by the latest expansion
plans.

“This is one of the best scenic routes we’ve been on. It’s
excellent,” said Bill Swindell who drove with his wife for 2
1/2 hours from their home in Derbyshire to ride the rail to
Rhyd Ddu from Caernarfon.

The class NGG16 Beyer-Garratt locomotive he rode was the
last to be manufactured out of Manchester, once the cradle of
English heavy industry, and was then exported to South Africa.

Eight years ago, Ffestiniog Railway bought back the train.

“It’s the last to be built. It’s really something,” said
Mike Jewell, a driver for the Welsh Highland Railway.

Linking Medicare Reimbursement to Quality Outcomes

By Lusis, Ingrida

Congress Considers “Pay for Performance” Legislation

A new Medicare reimbursement system based on performance and outcomes has been proposed in legislation recently introduced in Congress.

“Pay for performance” has emerged in the context of staggering federal deficits and severe cuts that are expected in the Medicare Fee Schedule issued annually by the Centers for Medicare and Medicaid Services (CMS). An overall decrease of 4.5% is anticipated in the 2006 fee schedule, with subsequent cuts that could reach 24% over the next five years.

In this harsh budget environment, Congress has proposed this new system as a way to customize payment of outpatient services. Currendy, the fee schedule under which most Medicare outpatient providers are reimbursed is updated yearly through a formula-the sustainable growth rate or SGR-which links the fee to the total volume of Medicare services paid the prior year. Under SGR, providers are reimbursed equally regardless of the quality and efficiency of service delivery.

Hurricane Rita tore through parts of Louisiana and Texas. See related article, page 35. Articles about Hurricane Katrina aftermath on pages 32-33.

Under pay for performance, providers could either receive additional payment for submitting outcomes data or be penalized for not submitting data during the first years after the system is implemented. In later years, as CMS collects data, a portion of the Medicare reimbursement could be tied to the individual provider’s ability to meet quality standards.

ASHA believes that passage of pay for performance must be preceded by legislation establishing the right of direct billing of Medicare by SLPs. (Audiologists already have the right to bill Medicare directly).

Legislative Goals

The first, crucial step toward reimbursement equity for SLPs who treat Medicare patients is to gain the legislative right to directly bill Medicare for services. SLPs are not yet recognized as suppliers under the outpatient Medicare law and would not be able to directly report quality measures to Medicare, if pay-for-performance legislation passes.

Bills have been introduced in the House and Senate (S. 657 and H.R. 3795) to remedy this inequity and to view SLPs as private practitioners under Medicare and enable direct reporting of quality measures. Grassroots advocacy is underway, and SLPs are encouraged to contact their members of Congress through ASHA’s Take Action site at www.asha.org/takeaction.htm and urge them to support S. 657 and H.R. 3795.

Pay for performance legislation has also been introduced in both chambers. Rep. Nancy Johnson (R-CT), Chair of the House Ways and Means Health Subcommittee, introduced H.R. 3617, which would repeal the current SGR payment system and implement a pay-for-performance program. The legislation would penalize providers and suppliers for not reporting quality measures by withholding the annual updates in reimbursement for their services.

The Senate bill (S. 1356), the Medicare Value Purchasing Act, would tie a portion of Medicare reimbursement to quality outcomes. Under this bill, CMS would be charged with developing performance measures through a new standard-setting group that would work with stakeholder organizations.

Both House and Senate committees have held hearings on their bills, which will likely be considered as part of a larger Medicaid or Medicare omnibus bill this fall.

The concept of pay for performance also is being discussed as an alternative to the Medicare outpatient therapy caps. With the moratorium on implementing the caps set to expire on Dec. 31, ASHA is lobbying aggressively for an alternative that would replace the caps with a pay for performance system. Although CMS does not yet have the data to develop this system, ASHA is working with CMS and Congress to gain recognition of ASHA’s National Outcomes Measurement System (NOMS) as the data collection and benchmarking tool for speech-language pathology services.

Demonstration Projects

CMS has initiated demonstration projects that would gauge the feasibility of adopting a Medicare pay for performance system. These projects primarily focus on hospital and physician services. Health care systems participating in the five-year “Medicare Health Care Quality Demonstration” will be permitted to modify payment systems and provide incentives for better quality and lower costs.

Participants in the demonstration program will have the opportunity to adopt and use decision support tools (e.g., evidence- based guidelines, shared decision-making tools), reduce unwarranted variation in practice, measure outcomes and enhance cultural competence in the delivery of care. Details on CMS demonstration projects can be found at www.cms.hhs.gov/researchers/demos.

For more information contact Ingrida Lusis at [email protected] or [email protected].

Copyright American Speech-Language-Hearing Association Oct 18, 2005

Long Island’s Top 50 Private Companies – Part 1

By Jeremy Harrell

Quality King Distributors Inc.

2060 9th Ave., Ronkonkoma 11779

(631) 737-5555

www.qkd.com

Revenue: $2.3 billion

Industry: Distribution of pharmaceuticals, health and beauty products, fragrances and groceries.

CEO: Glenn Nussdorf

Employees: 1,350; 1,200 local

The secret to Quality King’s business? Sell low and buy lower.

That formula has worked since 1961, when Bernard Nussdorf founded the company in Queens.

In addition to fragrances, foods and beauty aids, the company’s QK Healthcare subsidiary sells branded and generic pharmaceuticals to retailers and pharmacy benefit programs.

The more than 10,000 products stocked by the company are sold through drug stores, supermarkets and wholesale clubs.

The firm, headed by one of the founder’s sons, CEO Glenn Nussdorf, was rated No. 86 nationwide on Forbes’ 2004 ranking of the largest private companies.

Bellco Health

5500 New Horizons Blvd., Amityville 11701

(631) 789-6900

www.bellcohealth.com

Revenue: $1.3 billion

Industry: Pharmaceutical distribution

CEO: Neal Goldstein

Employees: 220; 200 local

Bellco Health, which distributes pharmaceutical products and serves the dialysis market, once again ranked as the second-largest private company on Long Island.

The company saw revenue jump 8 percent to $1.3 billion by sticking to its knitting. Overall, we’re continuing our national pharmaceutical strategy, selling to retail pharmacies and to kidney dialysis, said CEO Neal Goldstein. Those are our two primary markets.

P.C. Richard & Son

150 Price Parkway, Farmingdale 11735

(631) 843-4300

www.pcrichard.com

Revenue: $1.1 billion

Industry: Appliances and electronics

CEO: Gary Richard

President: Gregg Richard

Employees: 2,500; 1,725 local

It was a bittersweet year for the 96-year-old appliance, electronics and computer giant. Sadly, A.J. Richard, who turned the company into the behemoth that it has become, passed away in December at the age of 95.

It was A.J., son of Peter Christiaan Richard, who pushed the company beyond its roots – a Brooklyn-based hardware store.

On the bright side, under the leadership of Gary Richard, the company continues to grow. It added warehouse space – it now has about 1 million square feet of it in Farmingdale. P.C. Richard also continues to see revenue rise, thanks to sales of high-end electronics such as flat-panel plasma screen televisions.

Those televisions used to cost thousands of dollars, Richard said. Now we have them for $1,200. They’ve come down in price quite a bit, and with football season here, they’re selling quite well.

P.C. Richard has 49 stores in New York and New Jersey, 19 of which are on Long Island.

Levitz Home Furnishings Inc.

300 Crossways Park Drive Woodbury 11797

www.levitz.com

Revenue: $1 billion

Industry: Furniture retailing

President and CEO: C. Mark Scott

Employees: 4,000

Gone is the Seaman’s Furniture name, absorbed recently into Levitz Home Furnishings, one of the country’s largest furniture retailers.

The company that dates back to 1910 has more than 100 shops in the Northeast, West Coast and St. Paul, Minn. It is now exploring using the Brooklyn-born Seaman’s name within Levitz shops, according to a spokesman.

In May, Levitz got $20 million in additional financing – increasing the facility to $80 million – money that will help build stronger and growing position in the home furnishings market in the Northeast and on the West Coast.

Despite the availability of new funds, the company raced to beat the institution of new bankruptcy regulations and filed for Chapter 11 earlier this month – its second time in eight years.

Harold Levinson & Associates

21 Banfi Plaza, Farmingdale 11735

(631) 862-2400

www.hladistributors.com

Revenue: $980 million

Industry: Wholesale distribution of tobacco products and food items

CEO: Edward Berro

Employees: 420; 400 local

Diversification is the name of the game for Harold Levinson & Associates.

Started as a cigarette distributor to convenience stores, the company has gradually moved more and more into supplying food products.

We’re becoming less dependent on our cigarette business, said Marty Glick, the Farmingville company’s vice president of sales. We’re still a cigarette company, but less so than we were three or four years ago.

That’s partly because state and local taxes have made cigarette distributing a tough business, Glick said. But it’s also because consumer habits are changing.

Even within the world of tobacco, Harold Levinson is filling out its lineup, finding financial success by distributing roll-your-own cigarettes, high-end cigars and other tobacco products that are gaining market share, Glick said.

And it’s also a distributor’s responsibility to figure out what the consumer wants and bring that message to customers. Anyone could sell you Marlboros and M&Ms, Glick said. They always taste the same.

Harold Levinson plans to expand its forays into food service, especially as cigarettes become harder to sell and for a more fundamental reason: better margins. The company also expects to capitalize on its recent investments in information technology, allowing the firm to attract higher-end customers, Glick said.

King Kullen Grocery Co.

185 Central Ave., Bethpage 11714

(516) 733-7100

www.kingkullen.com

Revenue: $880 million

Industry: Supermarkets

CEO: Bernard D. Kennedy

Employees: 4,700; 4,625 local

King Kullen continues to remodel and open supermarkets. In June, a 40,000-square-foot store was completed in East Setauket’s Three Village Shopping Center. Also this year, King Kullen renovated and upgraded supermarkets in Bridgehampton, Mineola, Levittown and North Babylon. Nearing completion is the renovation of the King Kullen in Bellmore.

The company operates 47 stores, all but one of which are on Long Island; the other is in Staten Island. The food retailer also runs two Wild by Nature stores, one in East Setauket, the other in Huntington.

The Smithsonian Institute recognizes King Kullen as America’s first supermarket. It was launched in Queens by Michael J. Cullen in 1930. Seventy-five years later, it’s run by a third-generation of the Cullen family.

Rallye Group

1600 Northern Blvd., Roslyn 11576

(516) 625-1600

www.rallyegroup.com

Revenue: $524 million

Industry: Car sales

CEO: Julia Terian

Employees: 488, all local

The Rallye Group’s sales of luxury cars and light trucks proved a winning formula again in 2004, as the company’s annual revenue continued to climb.

Rallye’s 2.3 percent revenue increase in 2004 didn’t match the double-digit jump of 2003, but the company added employees and sales volume during a turbulent year for automobile sales.

It was a slow start for 2004, but it’s picked up since then, and we’re on an upward trend, said Joe Stanco, company vice president and CFO. Rallye’s BMW Group posted its most successful year ever in 2004, as did the Acura Group, making it one of the top 15 Acura dealerships in the country.

There’s promising growth potential for Rallye’s other groups. Lexus still leads luxury auto sales nationwide, and the company recently unveiled its first hybrid model. Mercedes-Benz, Rallye’s fourth make, is also experiencing strong nationwide sales.

Publishers Clearing House

382 Channel Drive, Port Washington 11050

(516) 883-5432

www.pch.com

Revenue: $450 million

Industry: Direct marketing

President and CEO: Andy Goldberg

Employees: 400

This company may be known for its giant cardboard check and its big money sweepstakes, but Publishers Clearing House is more than that, says President and CEO Andy Goldberg.

As the name hints, the 52-year-old company sells discount magazine subscriptions, more than 250 titles, including People and Maxim. It also operates a classic direct-mail business with 2,000 wares, including household products, books and music. That revenue has grown 13 percent so far in 2005, Goldberg said.

Even more rapidly growing is revenue for the bright-orange pch.com, the company’s online channel, which is projected to double this year. That youth-oriented site offers the same things with the click of a mouse.

PCH takes a chance by delivering products without requiring payment first.

It’s not that risky because we’re very experienced at managing credit risk, Goldberg says. Our challenge is to identify those people who will go on to pay.

For those who can’t, the next $1 million prize drawing is on Thanksgiving.

Bamberger Polymers Inc.

2 Jericho Plaza, Jericho 11753

(516) 622-3600

www.bambergerpolymers.com

Revenue: $412 million

Industry: Plastic resin distributor

CEO: Lawrence Ubertini

Employees: 120; 50 local

The future is now for Bamberger Polymers, which supplies plastic resins to a wide range of manufacturers, primarily in the United States, Canada and Mexico. The firm’s revenue jumped in 2004 primarily due to increases in costs for resins, which are made using oil.

Bamberger’s resins are used in everything from toys to garbage bags to cups to cars, isolating them from the vagaries of each industry.

Unit sales also rose 10 percent for Bamberger, which in 2004 sold about 775 million pounds of plastic resin, up from about 700 million the prior year.

Bamberger, which buys resins from giants such as Dow Chemicals, Innovene (BP’s plastics group) and Eastman Chemicals, said companies aren’t stocking up on large backlogs due to the higher cost for the product as a result of rising oil prices. They’re buying only what they need, said Chief Financial Officer Paul Coco.

And, following the Gulf Coast hurricanes, supply shortages and cost pressures have led to further price increases throughout the plastics industry.

Sam Ash Music Corp.

278 Duffy Ave., Hicksville 11801 (516) 932-6400

Revenue: $390 million

Industry: Music instrument retailing

CEO: Richard Ash

Employees: 1,900; 320 local

Schools have changed their tune and Sam Ash Music Corp. is dancing to the melody.

Many school districts that eliminated music programs in recent years have been restoring funding, bolstering business for the music- store chain, explained President Paul Ash.

One of the biggest trends is the resurgence in school music, he said. School music departments that closed – many are being reinstated. Low-end instruments are being sold in our stores around the country.

Ash said that demand also is strong for recording equipment for rock bands.

You can make your own CD for fairly low money, he said. Before, you used to have to go to a studio. A couple of kids can get together with a synthesizer. We sell synthesizers and recording equipment.

The business, founded in Brooklyn in 1924 by Ash’s parents, remains in family hands.

Marchon Eyewear

35 Hub Drive, Melville 11747

(631) 755-2020

www.marchon.com

Revenue: $363 million

Industry: Manufacturer, distributor and marketer of designer and patented eyeglass frames and sunglasses.

CEO: Al Berg

Employees: 1,000; 500 local

Marchon Eyewear may be in the eyewear business, but it also is part of the fashion industry, rolling out designer eyewear for couture houses known around the world. The firm – whose eyewear brands include Nike, Nautica, Calvin Klein and Coach – has been bringing new fashion names into the fold.

In 2004, the company signed a deal to sell Michael Kors branded eyewear. And earlier this year it took over global distribution for the Fendi eyewear and sunglass collections after distributing Fendi in the Western Hemisphere for more than a decade. The firm’s Flexon flexible eyewear frames also gives it a technological edge.

Marchon is a prime example of global vision in sales and sourcing. In addition to its U.S. base, the company distributes products through regional headquarters in Amsterdam and Tokyo and sales offices serving customers in more than 80 countries. It also has production facilities in Italy, China and Japan.

For kids’ glasses, Marchon is the company behind the mouse: They make and market Disney eyewear.

Quality of Life, Physical Disability, and Respiratory Impairment in Duchenne Muscular Dystrophy

By Kohler, Malcolm; Clarenbach, Christian F; Bni, Lukas; Brack, Thomas; Et al

Rationale: Duchenne muscular dystrophy (DMD) leads to progressive, generalized paresis, and to respiratory failure in the second decade of life. The assumption that severe physical disability precludes an acceptable quality of life is common, but has not been specifically evaluated in DMD.

Objectives: The purpose of this study was to investigate the quality of life in relation to physical disability, pulmonary function, and the need for assisted ventilation in DMD.

Methods: In 35 patients with DMD, aged 8-33 yr, we assessed physical disability by a score ranging from 9 (no disability) to 80 (complete dependence on care and technical aids), pulmonary function, and health-related quality of life by Short-Form 36 of the medical outcome questionnaire.

Measurements and Main Results: All patients required a wheelchair and help for dressing and eating. Fourteen patients were on long- term noninvasive positive-pressure ventilation. In ventilated patients, mean SD FVC was 12 10 % predicted, and the physical disability score was 65 7. Corresponding values in spontaneously breathing patients were 48 25 % predicted, and 51 7, respectively (p

Conclusions: Quality of life in DMD is not correlated with physical impairment nor the need for noninvasive positive-pressure ventilation. The surprisingly high quality of life experienced by these severely disabled patients should be taken into consideration when therapeutic decisions are made.

Keywords: chronic respiratory failure; hypoventilation; muscular diseases; noninvasive ventilation

Duchenne muscular dystrophy (DMD) leads to progressive muscle weakness of legs and arms, and respiratory and cardiac failure (1). Most patients become wheelchair-bound and dependent on others for their daily activities during the second decade of life (2). In advanced stages of the disease, chronic respiratory failure develops, and assisted mechanical ventilation is administered. Compared with historical controls, noninvasive positive-pressure ventilation (NIPPV) has increased the median survival of patients with DMD by several years to currently more than 25 yr (3-5). Only a few studies have addressed the health-related quality of life (HRQL) in patients with DMD. In an early investigation, 80 severely disabled patients with DMD on long-term assisted ventilation via a tracheostomy or a mask had a positive affect, and their life satisfaction was greater than anticipated by their caregivers (6). In a more recent study, 13 of 23 patients with DMD treated by nasal mask ventilation for chronic respiratory failure completed an HRQL questionnaire within 3 to 72 mo after starting assisted ventilation (3). Their health perception was superior to that of patients with chronic obstructive lung disease on noninvasive ventilation. Similarly, the mental component summary of the Short-Form 36 of the medical outcome questionnaire (SF-36) in 17 patients with DMD on noninvasive ventilation was higher than corresponding values in patients with chronic obstructive lung disease in another study (7). Although knowledge of the perceived quality of life in patients with chronic illness requiring a high level of care is essential because it may influence therapeutic decisions (8), a detailed analysis of quality of life in patients with DMD in relation to their physical performance, pulmonary function, and need for assisted ventilation has not previously been performed. Therefore, we investigated HRQL, physical disability, and respiratory impairment in stable patients with DMD with and without requirement for assisted ventilation. Some of the results of these studies have been reported in the form of an abstract (9).

METHODS

Patients

All patients with DMD living or attending school in a facility specialized in the care of patients with muscular dystrophies, the Mathilde-Escher-Heim, Zurich, were prospectively enrolled. According to the concepts of the Swiss health care system, patients with advanced neuromuscular disease are generally cared for by their relatives at home as long as feasible. Patients requiring a level of support that cannot be provided at home are admitted to one of the few institutions that offer services comparable to those of the Mathilde-Escher-Heim. The latter provides schooling and lodging as needed. School graduates have the opportunity to undergo professional training in information technology using special computer equipment. Some patients living in their parents’ homes are brought in for daytime care. Others are full-time residents in the institution, and live together in groups of three to five patients who share a flat. They are attended by social workers, nursing staff, and physiotherapists.

In all patients, the diagnosis of DMD was based on standard criteria comprised of progressive symmetrical muscle weakness and other signs and symptoms starting before the age of 5 yr, elevated serum creatinin kinase activity, muscle biopsy and genetic analysis, and, in some, a family history consistent with X-linked recessive inheritance (10).

Informed consent of patients and their parents was obtained. The protocol was approved by the ethics committee of the University Hospital of Zurich.

Measurements

A physical examination, including measurement of body weight and body length, was performed. Body length was used for calculation of body mass index and reference values of pulmonary function. It was measured by a flexible ruler fitted along the contours of the body, from the head, along the vertebral spine and the backside of the legs, to the heels to account for kyphoscoliosis and leg contractures.

Spirometry was performed in sitting position with a flow meter attached to a flanged rubber mouthpiece with the nose occluded (Vmax; SensorMedics, Yorba Linda, CA) (11). Sniff nasal pressure (SNIP) at functional residual capacity and maximal expiratory pressure (MEP) at total lung capacity were measured (Pmax mouth pressure monitor; P.K. Morgan, Rainham-Gillingham, Kent, UK). Reference values for ages up to 17 yr (12, 13) and above (14, 15) were computed. Arterial blood gas analysis was performed on a sample drawn in sitting position during spontaneous room-air breathing, with the exception of patients requiring continuous ventilatory support (AVL Medical Systems AG, Diessenhofen, Switzerland).

Cardiac function was assessed clinically by ECG and echocardiography. Cardiac involvement was assumed if there were rhythm or conduction abnormalities, abnormal repolarization, a decreased left-ventricular ejection fraction, or abnormal ventricular cavity dimensions or wall motion (16).

Physical disability (i.e., the inability to perform activities of daily living [ADL] and the dependence on support by others and on technical aids) was evaluated with a score specifically developed by one of the authors (L.B.) for assessment of the course of illness in DMD. Some aspects are similar to the index of independence in ADL described by Katz and colleagues (17). Disability was evaluated by assessing the following eight aspects of daily life in a standardized way (see online supplement): mobility without technical aids, mobility with technical aids, transfers (e.g., from bed to wheelchair), static body control, changes of body position, dressing, feeding, and breathing. Each aspect was rated with up to 10 points, with higher scores reflecting greater disability. The sum score of all eight domains was computed as a measure of overall disability and of dependency on care; its maximal value was 80 points. The score had been prospectively applied over several years in a subset of the patients. These data are presented with the evaluation of all patients at the time of this study to illustrate that the score reflects the progressive disability in DMD.

The SF-36 was completed during an interview with each patient (18). Transformed scores for each domain and the physical and mental component summaries were computed (19). Reference values from an age- and sex-matched U.S. population (18), and from a German population (20), were used for comparison.

Data Analysis

Data are expressed as means SD. Comparison of results between groups was performed by unpaired t tests. A probability of p

RESULTS

Thirty-five male patients with DMD were enrolled. Of these, 18 patients spent the nights in the home of their parents and attended school at the Mathilde-Escher-Heim, whereas 17 full-time residents lived at the institution and went to school or worked there. All were wheelchair-bound due to advanced paresis of the legs and arms. Thoracolumbar scoliosis w\as apparent in 34 patients (97%), and spinal stabilization surgery had been performed in 24 patients (69%). Some patients required intermittent treatment for musculoskeletal pain with nonsteroidal antiinflammatory drugs, but none received narcotic, psychotropic, or antidepressant drugs.

Fourteen patients were on chronic NIPPV by nasal or face mask. Long-term assisted ventilation had been initiated in patients with chronic hypoventilation (daytime Pa^sub CO^sub 2^^ ≥ 50 mm Hg with appropriately compensated pH, or mean nocturnal transcutaneous PCO^sub 2^ > 50 mm Hg and oxygen saturation 5% of the night) and consistent symptoms, such as headaches, restless sleep, and excessive sleepiness (21). At the time of the study, none of the patients met criteria for invasive ventilation via tracheostomy (uncontrollable airway secretions, repeated aspiration [21]) or preferred this intervention over mask ventilation. The VPAP II ventilator (ResMed, North Ride, Australia) was used in the bilevel positive airway pressure S/T or T-mode, with inspiratory pressures of 12-22 cm H2O, expiratory pressures of 3-5 cm H2O, and respiratory rate of 12-20 breaths/min. Six patients applied NIPPV during the night only, two patients during the night and occasionally during the day (

Spirometric volumes (FVC, FEV^sub 1^) in patients not requiring NIPPV were reduced to about one-half of the predicted value, whereas the corresponding values of patients on NIPPV were only about one- tenth of the predicted value. In patients without NIPPV, the reductions of maximal respiratory pressures (SNIP and MEP) from predicted values were more pronounced than the reductions of lung volumes, but SNIP and MEP (% predicted value) were still significantly greater than in patients requiring NIPPV (Table 1). Spirometry and measurement of maximal respiratory pressures were not feasible in all patients due to ventilator dependency or difficulty in cooperation.

Cardiac evaluation had been performed clinically and by ECG in all 35 patients, and in 28 patients by echocardiography. No cardiac abnormalities were found in 25 patients (71%). In 10 patients (29%), cardiomyopathy was suspected in the ECG, and confirmed by echocardiography (mean SD left-ventricular ejection fraction, 36 12%). The age of patients with and without cardiomyopathy was not statistically different (mean age, 21.3 5.8 vs. 18.2 5.7 yr; p = 0.12). The scores of the SF-36 domains and of the disability scale were similar in patients with and without cardiomyopathy (p > 0.05 for all comparisons; data not shown).

Disability and dependence on others and technical aids was assessed in 34 patients (Table 2). The disability sum scores were plotted over time for 29 patients in whom at least two assessments, separated by at a least 1 yr, were available (Figure 1A). The relentlessly progressive course of the illness is evident. At the time of the current evaluation of respiratory function and quality of life, patients on NIPPV were more disabled in each evaluated aspect of daily living (Table 2) and had higher disability sum scores than patients without NIPPV (although there was some overlap; Figure 1B). Due to the advanced generalized paresis, the scores reflecting reductions in mobility, transfer, and body control were particularly high. The “mobility without technical aid” scores of 10 and the “transfer” scores of ≥ 8 in all patients on NIPPV reflected their need for a wheelchair and their complete dependency on others for mobility. Similarly, they were all entirely unable to dress without help. The need for assistance in eating and drinking was more variable (Table 2).

TABLE 1. ANTHROPOMETRICS AND RESPIRATORY FUNCTION

TABLE 2. DISABILITY AND DEPENDENCE ON OTHERS AND TECHNICAL AIDS

TABLE 3. HEALTH-RELATED QUALITY OF LIFE

As expected, HRQL was low in the SF-36 domains representing physical function (the physical functioning scores were near zero) and, to a lesser extent, in domains representing problems with work and everyday activities as a result of physical health (moderate reduction in role-physical values; Table 3). Other aspects of well- being, such as general and mental health, emotions, social functioning, and pain, were not impaired according to the patients’ judgment, and corresponding domain scores were close to the values observed in populations without chronic illness (Figure 2) (18).

Figure 1. (A) Disability scores of 29 patients, with at least two observations obtained at yearly intervals before the main data acquisition for the current study, clearly illustrate the progressive limitation in activities of daily living, and the dependence on others and technical aids. Lines connect data in individual patients without noninvasive ventilation (NIPPV; open circles) and with NIPPV (closed circles). (B) The disability scores at the time of assessment of pulmonary function and quality of life are plotted for patients without (open circles) and with NIPPV (dosed circles).

Figure 2. For each of the Short-Form 36 (SF-36) domains, the mean deviation (and SD) from sex- and age-matched U.S. reference values is displayed for 21 patients with Duchenne muscular dystrophy (DMD) without NIPPV (open bars), and for 14 patients with NIPPV (hatched bars). The dashed line represents the deviations of a German male reference population (20) from the U.S. reference (18). BP = bodily pain; GH= general health; MH = mental health; PF = physical functioning; RE = role-emotional; RP = role-physical; SF = social functioning; VT = vitality.

To compare the health profile of patients with DMD with values of a reference population, the scores of U.S. males, ages 18-24 yr (18), were subtracted from the measured scores in patients with DMD, and these differences are plotted in Figure 2. Thus, this figure illustrates the deviations in the domain scores of the studied population from the reference. German reference values (20) are also shown in Figure 2. Despite their greater limitation in pulmonary function and in ADL, the patients on NIPPV rated their HRQL similar to patients without NIPPV (Table 3 and Figure 2). To further evaluate a potential effect of physical disability on HRQL, correlation analysis was performed on the SF-36 physical and mental component summaries versus the disability summary score. The Pearson correlation coefficients were r = -0.326, p = 0.06, and r = -0.031, p = 0.862, respectively. The correlation of the physical and mental component summaries versus FVC (% predicted) as a measure of respiratory impairment also revealed no statistically significant correlation (Pearson correlation coefficients, r = 0.084, p = 0.646, and r = -0.268, p = 0.138, respectively). The course of respiratory impairment and HRQL as a function of age is illustrated in Figure 3.

DISCUSSION

The main finding of our study is that patients with DMD of various ages with advanced general muscle weakness and paresis perceive a high quality of life despite their chronic progressive illness, which makes them highly dependent on others and technical aids. Patients believe that the problems with ADL due to their health status are relatively minor, although they are aware of their major limitation in physical functioning. With the exception of domains directly linked to the loss of muscle strength, the HRQL of patients with DMD is independent of the degree of physical disability and respiratory impairment, and similar to that in reference populations (18, 20). Our observations have important clinical implications, as they contradict the still common assumption of a low HRQL of patients with advanced disability and respiratory impairment, an assumption that may influence therapeutic decisions (8).

This study provides the first detailed account of the quality of life in patients with DMD of various ages and degrees of disability and respiratory impairment. The use of a generic HRQL questionnaire allows comparisons with other populations with and without chronic illnesses. Simonds and coworkers (3) assessed HRQL with the SF-36 questionnaire in 13 patients with DMD on nasal mask ventilation. Because no numeric data were provided, a quantitative comparison with our study is not feasible. In a survey of HRQL in patients with chronic lung disease, kyphoscoliosis, and various neuromuscular diseases on domiciliary NIPPV, data on 17 patients with DMD were not reported separately, with the exception of the SF-36 mental component summary (7). The mean value of that component was 59.6, similar to the values of 60 and 62 that we found in patients without and with NIPPV (Table 3). Compared with patients with chronic obstructive lung disease and kyphoscoliosis in the cited report (7), patients with DMD in the current study had much lower physical functioning scores, but perceived less role limitation by physical and mental problems, and scored higher in mental health and social functioning (Table 3). The scores in all SF-36 domains, except physical functioning, in the patients with DMD studied in the current investigation were also considerably higher (by 7 to 52 points) than corresponding scores we had obtained in patients with severe pulmonary emphysema undergoing lung volume reduction surgery (22). This may relate to better coping abilities in patients with DMD adapting themselves to a progressive limitation since early childhood (Figure 4); patients with chronic obstructive lung disease may experience greater difficulties \in handling the limitations imposed by a chronic illness acquired in adulthood. Another possibility is the very supportive and empathetic care given to the younger patients with DMD by their parents and their caregivers. Furthermore, perception of health status, and expectations on achievable goals in life, may differ between patients according to their illness and the time of its manifestation. Mental retardation as a possible confounding factor was not specifically examined in the current study, but was not prominent, as all patients attended at least primary school, and some underwent professional education in information technology. HRQL might also be influenced by certain medications, but none of our patients received psychotropic, antidepressant, or long-term analgetic drugs. An easy access to technical aids and activities that provide social contacts and independence might have contributed to the high HRQL perceived by the patients. Most of them own an electro-wheelchair, and some own a cellular phone. They have the opportunity to participate in electro- wheelchair hockey training and tournaments (Figure 4), participate in excursions, holiday camps, and other leisure time activities.

Figure 3. Respiratory impairment, represented by FVC values, progresses with advancing age. (A) The dashed line represents an exponential decay function (f = a . e^sup -b.time^). There is little variation in the physical as well as in the mental component summaries of the SF-36 questionnaire (B and C, respectively). Open circles, patients without NIPPV; closed circles, patients with NIPPV.

Figure 4. Patients with DMD on wheelchairs playing land hockey, one of their favorite leisure time activities (reprinted by permission from Reference 25).

The lack of a correlation between physical disability scores, lung function impairment, and SF-36 mental and physical component summaries in patients with DMD of a broad age range (Figure 3) is in accordance with the notions discussed above. It corroborates data from a longitudinal evaluation of 45 patients, aged 25-60 yr, with various distal and proximal muscular dystrophies other than Duchenne, showing only moderate correlations between dependence with regard to ADL (17) and quality of life (23). The score we used for assessment of physical disability in DMD shares some similarities with the ADL, which was designed to evaluate disability and effects of rehabilitation in the elderly (17). However, our score incorporates some aspects typical of DMD (i.e., the consequences of progressive generalized muscle weakness). The score tracked the course of illness well, and asymptotically approached maximal values corresponding to the complete loss of mobility, ventilator dependence, and requirement of care by others (Figure 1).

Evaluation of pulmonary function revealed that the SNIP and MEP were relatively more reduced than spirometric lung volumes (Table 1), a finding consistent with an early impairment of SNIP preceding reductions in vital capacity in motoneuron disease (24).

In 80 severely disabled patients with DMD on long-term ventilation via tracheostomy or mask, the hardship associated with chronic ventilator dependence was significantly overestimated by health care professionals compared with the patients’ own assessments, demonstrating a relatively positive attitude and health perception of patients with DMD, despite their physical dependence, and underlining the subjective nature of quality of life (6). Although our cross-sectional study allows no definitive conclusion with regard to the effect of NIPPV on HRQL, the nearly normal values of SF-36 scores in domains other than physical function and physical role limitation (Table 3) suggest that assisted ventilation does not adversely affect the perceived health status.

In conclusion, patients with DMD perceive a high HRQL independent of the degree of their physical disability, their respiratory impairment, and their dependence on NIPPV. Because medical professionals tend to underestimate the high HRQL perceived by the patients with DMD, these observations should be taken into consideration when decisions on mechanical ventilation and other life-sustaining therapies are made.

Conflict of Interest Statement: None of the authors have a financial relationship with a commercial entity that has an interest in the subject of this manuscript.

References

1. Smith PE, Calverley PM, Edwards RH, Evans GA, Campbell EJ. Practical problems in the respiratory care of patients with muscular dystrophy. N Engl J Med 1987;316:1197-1205.

2. Brooke MH, Fenichel GM, Griggs RC, Mendell JR, Moxley R, Florence J, King WM, Pandya S, Robison J, Schierbecker J. Duchenne muscular dystrophy: patterns of clinical progression and effects of supportive therapy. Neurology 1989;39:475-481.

3. Simonds AK, Muntoni F, Heather S, Fielding S. Impact of nasal ventilation on survival in hypercapnic Duchenne muscular dystrophy. Thorax, 1998;53:949-952.

4. Eagle M, Baudouin SV, Chandler C, Giddings DR, Bullock R, Bushby K. Survival in Duchenne muscular dystrophy: improvements in life expectancy since 1967 and the impact of home nocturnal ventilation. Neuromuscul Disord 2002;12:926-929.

5. Yasuma F, Konagaya M, Sakai M, Kuru S, Kawamura T. A new lease on life for patients with Duchenne muscular dystrophy in Japan. Am J Med 2004;117:363.

6. Bach JR, Campagnolo DI, Hoeman S. Life satisfaction of individuals with Duchcnne muscular dystrophy using long-term mechanical ventilatory support. Am J Phys Med Rehabil 1991;70:129- 135.

7. Windisch W, Freidel K, Schucher B, Baumann H, Wiebel M, Matthys H, Petermann F. Evaluation of health-related quality of life using the MOS 36-Item Short-Form Health Status Survey in patients receiving noninvasive positive pressure ventilation. Intensive Care Med 2003;29: 615-621.

8. Gibson B. Long-term ventilation for patients with Duchenne muscular dystrophy: physicians’ beliefs and practices. Chest 2001;119:940-946.

9. Kohler M, Brack T, Clarenbach CF, Russi EW, Bloch KE. Quality of life in patients with respiratory impairment due to muscular dystrophy. Eur Respir J 2004;24:3375.

10. Lin S, Liechti-Gallati S, Burgunder JM. New advances in muscular dystrophy: an up-to-date diagnostic plan. Schweiz Med Woehenschr 1999; 129:1141-1151.

11. American Thoracic Society. Standardization of spirometry: 1994 update. Am J Respir Crit Care Med 1995;152:1107-1136.

12. Zapletal A, Samanek M, Paul T. Lung function in children and adolescents: methods, reference values. Prog Respir Res 1987;22:113- 217.

13. Stefanutti D, Fitting JW. Sniff nasal inspiratory pressure: reference values in Caucasian children. Am J Respir Crit Care Med 1999;159:107-111.

14. Quanjer PH, Tammeling GJ, Cotes JE, Pedersen OF, Peslin R, Yernault J-C. Lung volumes and forced ventilatory flows: report working party standardization of lung function tests European Community for Steel and Coal. Eur Respir J Suppt 1993;16:5-40.

15. Uldry C, Fitting JW. Maximal values of sniff nasal inspiratory pressures in healthy subjects. Thorax 1995;50:371-375.

16. Finsterer J, Stollberger C. The heart in human dystrophinopathies. Cardiology 2003;99:1-19.

17. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged. The index of ADL: A standardized measure of biological and psychosocial function. JAMA 1963;185:914-919.

18. Ware JE Jr, Snow KK, Kosinski M, Gandek B. SF-36 health survey: manual and interpretation guide. Boston: The Medical Outcome Trust, New England Medical Center; 1993.

19. Ware JE Jr, Kosinski M. SF-36 physical and mental health summary scales: a user’s manual. Boston: The Health Institute, New England Medical Center; 1994.

20. Kurth BM, Ellert U. The SF-36 questionnaire and its usefulness in population studies: results of the German Health Interview and Examination Survey 1998. Soz Praventivmed 2002;47:266- 277.

21. Make BJ, Hill NS, Goldberg AI, Bach JR, Criner GJ, Dunne PE. Mechanical ventilation beyond the intensive care unit: report of a consensus conference of the American College of Chest Physicians. Chest 1998; 113(Suppl):289S-344S.

22. Harnacher J, Buchi S, Georgescu CL, Stammberger U, Thurnheer R, Bloch KE, Weder W, Russi EW. Improved quality of life after lung volume reduction surgery. Eur Respir J 2002;19:54-60.

23. Natterlund B, Gunnarsson LG, Ahlstrom G. Disability, coping and quality of life in individuals with muscular dystrophy: a prospective study over five years. Disabil Rehabil 2000;22:776-785.

24. Fitting JW, Paillex R, Hirt L, Aebischer P, Schluep M. Sniff nasal pressure: a sensitive respiratory test to assess progression of amyotrophic lateral sclerosis. Ann Neurol 1999;46:887-893.

25. Roffler J. Mathilde Escher Heim und Stiftung, Jahresbericht 2001. Zrich: Mathilde Escher Stiftung; 2001.

Malcolm Kohler, Christian F. Clarenbach, Lukas Bni, Thomas Brack, Erich W. Russi, and Konrad E. Bloch

Pulmonary Division, Department of Internal Medicine, University Hospital of Zrich, Zrich, Switzerland

(Received in original form March 1, 2005; accepted in final form June 8, 2005)

Supported by grants from The Lung League of Zurich, Switzerland.

Correspondence and requests for reprints should be addressed to Konrad E. Bloch, M.D., Pulmonary Division, Department of Internal Medicine, University Hospital of Zrich, Raemistrasse 100, CH-8091 Zrich, Switzerland. E-mail: pneubloc@ usz.unizh.ch

This article has an online supplement, which is accessible from this issue’s table of contents at www.atsjournals.org

Am J Respir Crit Care Med Vol 172. pp 1032-1036, 2005

Originally Published in Press as DOI: 10.1164/rccm.200503-322OC on June 16, 2005

Internet address: www.atsjournals.org

Copyright American Thoracic Society Oct 15, 2005

Skull Valley’s Nerve Gas Neighbors

By Brenda Norrell, Indian Country Today, Oneida, N.Y.

Oct. 26–SKULL VALLEY GOSHUTE NATION, Utah — The Nuclear Regulatory Commission has approved a license for a nuclear storage facility on Skull Valley Goshute tribal land, prompting new questions about the federal government’s use of the area as a U.S. Army test site for biological and chemical weapons, including nerve gas and anthrax.

Margene Bullcreek, Skull Valley Goshute tribal member and among those protesting nuclear and toxic dumping on Indian lands, said it is time for the government to stop dumping its nuclear waste on Indian people and stop treating them as if they are expendable.

“There is no gain to our prosperity when there is poison spilled. The radioactive waste would bring harm to our medicine wheel in four areas: physical, mental, emotional and spiritual,” said Bullcreek, founder of the community group Ohngo Gaudadeh Devia Awareness.

The Goshute group, along with the state of Utah, is opposing the Private Fuel Storage Limited Liability Consortium’s current plan to store more than half of the nation’s high-level nuclear waste on 17,444 acres of tribal land.

Goshutes, whose native language is Shoshone, are protesting the proposed nuclear dump now referred to as “Utah’s Yucca Mountain,” after the proposed high-level nuclear waste repository in southern Nevada. Meanwhile, Western Shoshone in Nevada continue to oppose the Yucca Mountain nuclear dump on ancestral lands.

“Indigenous people within this nation have always been victimized to provide national security,” said Bullcreek, criticizing the BIA’s approval of the nuclear waste dump of Goshute land.

Already, Goshutes have been unwilling neighbors of the U.S. Army’s biological and chemical weapon open-air testing at the Dugway Proving Ground in western Utah.

The Federal Emergency Management Agency recognizes the risks those weapons pose to Dugway’s neighbors, the Skull Valley Goshute.

On its Web site, FEMA quotes from Jicarilla Apache researcher Veronica Tiller’s “Guide to Indian Country”:

“South of the reservation is the Dugway Proving Grounds, where chemical and biological weapons have been developed and tested by the government. In 1968, chemical agents escaped from Dugway, killing approximately 6,000 sheep and other animals on the reservation; the government buried at least 1,600 of the contaminated sheep on the reservation. —

“East of Skull Valley, in the Rush Valley area, is a government nerve-gas storage facility. Northwest is the Envirocare Low-Level Radioactive disposal site. North of the reservation is a large magnesium production plant, which has been identified by the Environment Protection Agency as the most polluting plant of its kind in the U.S.”

Referring to the proposed nuclear dump, the FEMA site states that flash flooding and earthquakes along the Wasatch fault pose additional risks.

The operations at Dugway Proving Ground were classified for most of the 20th century. In March 1968, following a VX nerve agent experiment, 6,000 sheep died in Skull Valley and Rush Valley.

“Agent VX was found to be present in snow and grass samples that were received approximately three weeks after the sheep incident,” said the 1970 report by researchers at the Army’s Edgewood Arsenal in Maryland, as revealed by the Salt Lake Tribune in 1998.

The document was declassified in 1978, but not until 30 years after the deaths of the sheep did it become public. Still, the commander of Dugway said the Army does not accept responsibility for the death of the sheep or admit negligence.

VX, which was found in the bodies of the dead sheep, is a nerve agent so powerful that a single drop on the skin can result in death within about 15 minutes. It disrupts the nervous system and causes breathing to stop. GB, another common form of nerve agent known also as sarin, vaporizes quickly when exposed to air and forms a deadly gas.

International publicity about the incident contributed to President Nixon’s decision to ban all open-air testing of chemical weapons in 1969.

Meanwhile, Goshute tribal leaders often question whether the deaths of several tribal elders, who died shortly after the sheep, were the result of the nerve gas accident.

At the time, in 1968, Dugway conducted aerial nerve gas testing. In one of its experiments, VX was sprayed from a jet to a ground target 27 miles west of Skull Valley. At the time of the accident, when the nerve agent escaped the target area, any animals or people who ate the grass or snow would have become contaminated.

Besides the sheep deaths in 1968, there were at least 1,174 other tests of chemical agents at Dugway, which spread nearly a half million pounds of nerve agent to the winds, according to documents revealed by Deseret News in Utah. There were 328 open-air germ warfare tests; 74 radiological “dirty bomb” tests and the equivalent of eight intentional meltdowns of small nuclear reactors.

Along with biological and chemical testing at Dugway, open-air nuclear weapons testing at the Nevada Test Site in the 1950s and 1960s sent radioactive fallout drifting into Utah.

Currently, Dugway is in the market for mass quantities of anthrax, according to contract requests discovered by the Sunshine Project, a U.S.-German organization that opposes the use of biological and chemical weapons.

New Scientist magazine reported that the controversial move is likely to raise questions over the United States’ commitment to treaties designed to limit the spread of biological weapons, pointing out that even though the nation renounced biological weapons in 1969, Dugway was still producing quantities of lethal anthrax as recently as 1998.

The Dugway contract request is for companies to bid for the production of bulk quantities of a non-virulent strain of anthrax and equipment to produce significant volumes of other biological agents.

Besides contracts for anthrax, other contracts are for equipment to produce an unspecified biological agent and sheep carcasses to test the efficiency of an incinerator for the disposal of infected livestock.

—–

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Copyright (c) 2005, Indian Country Today, Oneida, N.Y.

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].

Study shows most Australian women are overweight

A new study by global market research firm, TNS, reinforces growing alarm among health and nutrition professionals that Australia is in the grips of rising levels of excess weight, risking future diabetes, heart disease and cancer epidemics and increasing mental illness in the community.

The on-line study of 506 Australian women aged 15 or more shows an alarming two thirds (67%) are overweight based on their height and weight (BMI), with four in ten (39%) obese.

Eight in ten women (79%) think they are overweight, indicating that the 12% whose weight is right for their height have body image issues.

TNS General Manager, Tania Kullmann, said the survey shows two thirds of Australian women are trying to lose weight, primarily focusing on reducing the amount of fatty foods they eat, snacking less and exercising.

“Worryingly, however, only 17% of women undertake regular exercise ““ a symptom of not enough time in modern society for important priorities,” she said.

The TNS study reports that 25% of the women surveyed are members of a slimming company, 21% are following an international weight-loss program like the Atkins and South Beach diets and 22% are using weight loss pills.

It also highlights the pressure on teenage girls to be thin. More than a quarter (26%) of 15 to 19 year olds involved in the study consider they are overweight when their BMI indicates they are not. Thirty percent are in fact underweight.

“Being underweight is also unhealthy for our bodies,” said Ms Kullmann. “It is very concerning that almost one in three teenagers surveyed weigh too little. This points to growing levels of anorexia and bulimia.”

The study was conducted by TNS throughout Australia in September using its managed on-line access panel which has 325,000 active members. Based on the sample size TNS is 95% confident in the accuracy of the results which have a margin of error of +/- 4%.

On the World Wide Web:

Research Australia

Iran president wants Israel “wiped off the map”

By Parisa Hafezi

TEHRAN (Reuters) – Iranian President Mahmoud Ahmadinejad
said on Wednesday that Israel should be “wiped off the map,”
the official IRNA news agency reported.

Support for the Palestinian cause is a central pillar of
the Islamic Republic which officially refuses to recognize
Israel’s right to exist.

“Israel must be wiped off the map,” Ahmadinejad told a
conference called “The World without Zionism,” attended by some
3,000 conservative students who chanted “Death to Israel” and
“Death to America.”

Under reformist President Mohammad Khatami, whose
eight-year tenure ended earlier this year, Iran had shown signs
of easing its implacable hostility toward Israel. Officials
said Tehran might not object to a two-state solution if that
was what the Palestinians wanted.

But Ahmadinejad, a former member of the hard-line
Revolutionary Guards and traditional religious conservative,
said there could be no let-up in its hostility to Israel.

“The Islamic world will not let its historic enemy live in
its heartland,” he said.

White House Spokesman Scott McClellan said Washington took
such remarks seriously.

“It underscores the concerns we have about Iran’s nuclear
intentions,” he told reporters.

The United States accuses Iran of seeking nuclear arms,
whereas Tehran says it needs atomic fuel only for power
stations. Iran has developed ballistic missiles able to hit
Israel.

Tehran denies accusations it trains and arms Palestinian
militant groups, saying it offers only moral support.

French Foreign Minister Douste-Blazy said that he had been
informed of the reported remarks and had summoned Iran’s
ambassador to the Foreign Ministry to explain the comments.

“If these (reported) comments are true, they are
unacceptable. I condemn them with the greatest firmness,” he
said in a statement.

(Additional reporting by Swaha Pattanaik in Paris)

Delayed Childbearing: Underestimated Psychological Implications

By Schardt, Dana

ABSTRACT

Delayed childbearing is, for various reasons, a current societal trend, Literature reports the physical risk to women thirty-five and older is higher than for their younger counterparts. Typically psychological responses to pregnancy have been focused on women under age thirty-five. Several psychological issues are identified in women choosing to delay childbearing. Women over thirty-five years of age are often underestimated in consideration of their psychological needs. The dynamics of infertility, perinatal loss, or high-risk pregnancy may create psychological distress, resulting in disappointment, guilt, anger, and jealousy, and often doubt as to one’s own abilities. This paper will explore the psychological impact of delayed childbearing and implications for childbirth educators and health professionals.

At age 47, I had almost run out of time. For the two weeks after insemination, I tried not to let my Imagination run away with me. Again and again I reminded myself it would not work. We began another round of fertility… A few weeks later, on the 3 Jsi day of my cycle, I hadn’t started my period yet – but I’d been fooled before, many times, and I no longer trusted my body. The pregnancy test is positive. I could hardly believe it and I was thrilled.

I was lying on the examination table in the ultrasound room. I had been there forty minutes now. Now it came: words that both surprised me and yet seem familiar, as if I’d already heard them. “Do you want me to give it to you straight?” he asked, and with these words, he already had. “Of course I do,” I said in a firm voice. So he said it: “I don’t believe the pregnancy is viable.”

Now I become the sad receptacle of miscarriage stories. Women bring them to me, in sympathy and comfort, like flowers.

In a few weeks we met with the geneticist. I want to know what has gone wrong and if it is age-related. She tells us the egg would have been defective all along. She talks on and on, but I come to when she refers to “her.” Her? I think. Who? That’s right, she says. Of course there was no fetus yet – the tissue – had 2 χ chromosomes. It would have been a girl.

Excerpt from Crossing the Moon: A Journey Through Infertility,

Paulette Bates Alden

INTRODUCTION

Today an increasing number of women are choosing to have their first baby after age 35. The number of first births per 1000 women 35-39 years of age has increased by 36% between 1991 and 2002, and the rate among women 40-44 years of age has increased by a remarkable 70% (Heffner 2004). In recent years, the trend of conceiving at an older age continues to increase.

Many factors contribute to this trend, including effective birth control methods, expanded career options, increasing number of women with advanced education, later marriages, high cost of living, delaying childbearing until financially stable, and increased availability of specialized fertility procedures which offer opportunities for infertile couples (Heffner 2004).

Interestingly, other factors that contribute to delayed childbearing are the “celebrity and media factor.” Couples’ expectations of delaying childbearing have been altered due to the heightened public awareness from media exposure (Burrage 1998) and the reported rate and ease of celebrities having healthy babies at a later age. Media attention paid to older childbearing women has been favorable and inspiring (Heffner 2004). In 2003, most media reports were on successful pregnancies in women between the ages 50-54 (Burrage 1998). While strong media attention is being given to the successful pregnancies, and inspiring women to share their stories of success, what are the implications for the general population regarding delaying childbearing?

It is often assumed that women over 35 years old have made a conscious decision, have planned the pregnancy, and will enjoy the benefits of a good support system. At least half these women experience various difficulties emotionally, physiologically, psychologically, and socially. Although childbearing at an older age is widely socially accepted, it does present with many psychological factors and conflicting emotions (Sheiner, et al. 2001). If problems occur within the pregnancy, emotions such as guilt, anger, sadness, resentment, helplessness, and fear may develop (Burrage 1998).

The purpose of this paper is to provide information to childbirth educators and health professionals on current knowledge about the psychological impact of pregnancy and its outcomes in women over 35 years of age. While the scope of this paper is limited to psychological implications, it should be noted that there are biophysiological risks of childbearing in women over 35, along with advantages of pregnancy at a later age that will not be discussed.

DEFINITION OF ADVANCED MATERNAL AGE

Advanced Maternal Age (AMA) is defined as the childbearing woman over the age of 35. This has been considered in the literature as relatively more hazardous from both maternal and fetal perspectives. Although AMA is traditionally defined as age greater than 35 years at time of delivery, new definitions such as Very Advanced Maternal Age (VAMA) is reported as age greater than or equal to 45 years of age at delivery (Dildy, et al. 1996). AMA designation suggests that a woman’s fertility rapidly declines after the age of 35. Approximately one-third of women who delay pregnancy until their mid- thirties and beyond will find it difficult to conceive (Burrage 1998), or have physical maternal or fetal complications. These women may experience an increased incidence of miscarriage or stillbirth resulting in significant emotional and psychological trauma (Burrage 1998).

AMA RISKS: A REVIEW OF THE LITERATURE

For most women, pregnancy is a period of intense emotion that ranges from excitement, anticipation, and fulfillment of their life, to disappointment and fear (Blickstein 2003). AMA women share the same concerns of younger women; and they may experience additional stress, believing they have placed their own and their baby’s health at risk because of their age (Kee, Jung, and Lee 2000). Professional recognition of mothers’ fear of childbearing in later life has been reported as early as 1929. Schulze, a physician in the early 1920s, reported that her older primiparous patients had a “fear of labor.” This fear came from beliefs among the lay population that older childbearing women are prone to more difficulties. In the 1930s many women avoided childbearing, fearing they were too old to have children due to anticipated dangers. In 1949, physicians Randal and Taylor (Katwijk and Peeters 1998) reported that elderly primiparous women presented with a “different mental attitude.” In the 1950s it was recognized that AMA women’s worries required extra support and supervision during pregnancy (Blickstein 2003).

The effects of both maternal age and outcome of pregnancy may be assessed by examining specific factors that can negatively affect pregnancy outcome. These factors include increased infertility rate, miscarriage, chromosomal anomalies, and physical complications to mother, such as hypertension and stillbirth (Heffner 2004). Maternal death, although rare, does increase with maternal age (Heffner 2004). These outcomes carry psychological implications which can negatively affect the woman’s emotional health. A woman with a history of infertility or perinatal loss may have unresolved grief, guilt, or uncertainty about becoming a mother (Levy-Schiff, et al. 2002), especially with advancing age and limitations of conceiving.

IDENTIFIABLE STRESSORS: INFERTILITY, PERINATAL LOSS, AND THE CONTEXT OF CULTURE

Infertility has been considered a potent source of stress for most AMA couples (Kee, Jung, and Lee 2000). The diagnosis of infertility can seriously undermine self-esteem and may reveal underlying marital or psychosexual problems (Burrage 1998). Although recent fertility methods are available with new opportunities for couples, this can also prolong the agony of disappointment if conception does not occur (Kee, Jung, and Lee 2000). Some couples are not willing to exhaust all their available treatment options, for various reasons; this may lead to additional emotional conflict between the couple and stress related to their decisions. For other couples, the difficult decision-making process of discontinuing active treatment may also contribute to additional stress and conflict in the couple’s relationship (Burrage 1998).

Distress may be exaggerated by prolonged infertility workup and treatment. Women who were evaluated or treated for psychological causes related to infertility reported the highest amount of distress affecting their daily living (Kee, Jung, and Lee 2000; Sjogren and Uddenberg 1990). Distress and decision conflict occurs with risky or uncertain situations such as diagnostic testing recommended for the AMA couple. Research indicates that women in this group experience increased anxiety at several points in the process of prenatal testing (Kaiser, et al. 2004). In addition, acute stress reaction occurs with the initial diagnosis of infertility; then chronic strain and tension develops with infertility treatment superimposed on work, family, and social life. Thus, both negative physiological and psychological responses escalate with longer treatment (Kee, Jung, and Lee 2000).

The literature reports tha\t couples perceived that the most stressful experiences were at various times in the treatment process (Goacher 1995) and when family issues were raised (Burrage 1998). During treatment couples have little control, such as whether fertilization has occurred and waiting for a positive pregnancy test (Goacher 1995). Couples who decide to have fertility treatment fear stigma and ridicule from their family or close relatives. The couple may choose to keep it a secret, which can be destructive and place considerable strain on their own relationship as well as with their families (Burrage 1998).

One study reported an increased risk of fetal loss with increasing maternal age over 30 years (Andersen, et al. 2000). At age 42, more than half of all pregnancies resulted in spontaneous abortion or stillbirth. case reports regarding AMA women with fetal loss describe experiences of unresolved grief, guilt, or uncertainty about their ability to become a mother. These dynamics create psychological distress resulting in disappointment, guilt, anger, and jealousy (Levy-Shiff, et al. 2002). In attempting to conceive, women experience diminished confidence, hope, eagerness, exhilaration, and pleasure (Levy-Shiff, et al. 2002). The incidence of multiple pregnancy is significantly increased in women who do become pregnant through fertility treatment. Multiple pregnancy and its associated risks often expose the woman and couple to further stress due to physical factors and difficult decisions, even ethical dilemmas, at a time when they want to feel joy that they have conceived (Heffner 2004).

Although this paper focuses on women in the United States, it is noteworthy to examine a cross- section of infertile women in other cultures. For example, traditionally if Korean women were infertile it was regarded as one of the “seven largest sins.” These women were subjected to mistreatment by family. The emotional response has been characterized as grief, feelings of anxiety, anger, alienation, guilt, and depression (Kee, Jung, and Lee 2000). Further research is needed in cross-cultural advanced maternal age to understand similarities and differences in psychosocial stressors and coping.

COPING STRATEGIES AND COUNSELING

Coping is defined “as the cognitive and behavioral efforts used to manage specific external and or internal demands that are appraised as taxing or exceeding a person’s resources” (Levy-Shiff, et al. 2002). Two main strategies of coping in couples have been identified. The first, problem-focused coping strategies, attempts to confront the source of the stress. The second, emotion-focused coping strategies, attempts to regulate emotion by suppression, venting, or directing negative feelings (LevyShiff, et al. 2002). In problem-focused coping strategies, couples develop strategies to help them through the infertility diagnostic and treatment processes. The emotional-focused coping strategies in AMA couples exposed to prolonged stressors can cause the couple to become desensitized to the distress, and actually result in them perceiving less distress as a means of coping with long-term exposure to emotional stress (Kee, Jung, and Lee 2000). The outcomes of these coping methods in AMA couples is not well-documented in the literature.

When AMA women were asked about their coping strategies for unsuccessful fertility treatment, the majority (93%) said they would continue to pursue treatment or pursue other options; 26% considered adoption; 26% were not sure how they would cope. None of these respondents considered remaining childless as an option, although they did express that taking a holiday from continued fertility treatment would help them cope (Goacher 1995). For those with VAMA, taking time away from fertility treatment may not be a reasonable option, secondary to age. Thus these couples are denied a break and the opportunity to refresh or renew their coping skills in facing the emotional and physical stressors (Heffner 2004).

Research clearly indicates the beneficial nature of counseling for AMA couples (Burrage 1998). Additional social support resources are thought to moderate the effects of stress as well as increase effective coping methods of the couples. Studies indicate that access to social support and counseling can increase the sense of wellbeing in the expectant mother and reduce distress symptoms such as depression, anxiety, or burnout caused by infertility or pregnancy loss (Levy-Shiff, et al. 2002). Professional support is a key intervention in the psychological management of AMA women. Since the women are at risk for iatrogenic stress, reassurance by providers can improve their emotional state by reducing excess worry. Providers must be realistic in their assessment of the patients’ concerns and give them an opportunity to express their concerns. The health care professional can provide accurate, personally-focused information, creating a positive perception of the process and/or the pregnancy (Heffner 2004).

ATTITUDES AND IMPLICATIONS OF HEALTH PROFESSIONALS

It can be difficult for health educators and professionals to remain impartial or non-judgmental if it conflicts with their personal beliefs and values. In an overcrowded world, some believe that infertility treatment should not be offered to anyone, regardless of age or circumstance. The medical profession and society in general favor younger women and pregnancy even with serious medical issues versus the AMA woman (Burrage 1998). This judgment may have psychological implication on the couple in regards to working with health professionals. To effectively work with AMA couples, the individual educator must assess their own values and morals and needs to be comfortable in working with this specialty. The American Society for Reproductive Medicine has begun an effort to educate the public on risks of delaying childbearing. Generally speaking, the decade between 25-35 years of age seems ideal. For women between 3545 years of age, where historically childbearing was not an option, it appears to remain safe enough and should not be considered a contraindication for childbearing (Heffner 2004). Information to professionals is vital to be effective in treatment with the AMA couple.

The majority of couples feel the provisions of information regarding medical procedures and treatment options are excellent (Goacher 1995). Such extensive preparation is viewed by some physicians as undesirable because it provides too much information to the couple and is apt to heighten their stress considerably. This fearful burden detracts from the pregnancy experience. Information regarding psychological and emotional aspects of infertility and the risk of perinatal loss have been reported to be limited. This indicates a clear opportunity for health educators to develop and implement additional instruction (Goacher 1995). Education and interventions regarding psychological and emotional aspects of the AMA couple may make a difference in the choices couples make, the standards of client care, and perhaps ease the psychological burden associated with AMA.

CHILDBIRTH EDUCATION

Childbirth education classes are important during pregnancy for couples of any age. Older couples’ needs may be unique, requiring a change in childbirth education. Although AMA couples are still in the minority, these couples may feel uncomfortable in classes where participants are younger. The older couple’s special psychological needs and concerns may not be met in the class. Educators should try to anticipate the informational needs for the older couple, while at the same time not drawing attention to or making them uncomfortable. As the number of AMA couples increases, class accommodations must be met for the specific needs of the older couple. Research indicates that individualized, personally focused information provides a positive influence on a women’s perception of the pregnancy, her “pregnancy lens.” Also apparent in the literature is the compelling evidence for childbirth educators to take an active role in the psychological education of AMA women as well as educating younger women who are contemplating delaying childbearing.

CONCLUSION

What significance can we derive from insights of the AMA client? First, we can confirm from research literature that later childbearing is associated with a number of physical, psychological, and emotional complications. This does not mean that an AMA pregnancy is not in the best interest of the couple. Many of these identifiable complications can be treated during pregnancy. Cross- cultural AMA is limited in the literature, making it difficult for a provider and educator to understand similarities and differences in psychosocial stressors. AMA is a specialty requiring alternative options to women, including professional emotional and psychological support along with identifying coping strategies. Emphasis should be placed on counseling AMA couples about the physical, psychological, and financial implications of treatment. Childbirth education trends may require additional accommodations for the needs of the AMA couple. It is clear that additional resources are needed to support the AMA specialty.

References

Andersen, A., J. Wohlfahrt, P. Christens, J. Olsen, and M. Melbye. 2000. Maternal age and fetal loss: Population based register linkage study. British Medical Journal Vol. 320 (7251): 1708-1712.

Blickstein, I. 2003. Motherhood at or beyond the edge of reproductive age. Int J Fertil Womens Med Jan-Feb, 48 (1): 17-24.

Burrage, J. 1998. Infertility treatment in women aged over 40 years. Nursing Standard 13 (5): 43-45.

Dildy, G., G. Jackson, G. Powers, B. Oshiro, M. Varner, and S. Clark. 1996. Obstetrics: Very advanced maternal age: Pregnancy after age 45. American Journal of Obstetrics and Gynecology 175 (3): 668- 674.

Goacher, L. 1995. In vitro fertilization: A study of clients waiting for pregnancy test results. Nursing Sta\ndard 10 (2): 31- 34.

Heffner, L. 2004. Advanced maternal age – How old is too old? The New England Journal of Medicine 351 (19): 1927-1929.

Heffner, L. 2004. Advanced maternal age – How old is too old? The New England Journal of Medicine 351 (19): 1927.

Kaiser, A., L. Ferris, R. Katz, A. Pastuszak, H. Llewellyn- Thomas, J. Johnson, and B. Shaw. 2004. Psychological responses to prenatal NTS counseling and the update of invasive testing in women of advanced maternal age. Patient Education and Counseling 54 (1): 45-53.

Kee, B., B. Jung, and S. Lee. 2000. A study on psychological strain in IVF patients. Journal of Assisted Reproduction and Genetics 17 (8).

Levy-Schiff, R., M. Lerman, D. Har-Even, and M. Hod. 2002. Maternal adjustment and infant outcome in medically defined high- risk pregnancy. Developmental Psychology 38 (1): 93-103.

Porreco, R., L. Harden, M. Gambotto, and H. Shapiro. 2005. Expectation of pregnancy outcome among mature women. American Journal of Obstetrics and Gynecology 192 (1).

Sheiner, E., I. Shoham-Vardi, R. Hershkovitz, M. Katz, and M. Mazor. 2001. Infertility treatment is an independent risk factor for cesarean section among nulliparous women aged 40 and above. American Journal of Obstetrics and Gynecology 185 (4): 888-892.

Sjogren, B., and N. Uddenberg. 1990. Prenatal diagnosis for psychological reasons: Comparison with other indications, advanced maternal age and known genetic risk. Prenat Diagn, Feb; 10 (2): 111- 20.

Van Katwijk, C., and L. Peeters. 1998. Clinical aspects of pregnancy after the age of 35 years: A review of the literature. Human Reproduction Update 4 (2): 185-194.

* Dana Schardt, MS, WHNP, ICCE, is a Nursing instructor and Women’s Health Nurse Practitioner specializing in obstetrics and complementary and alternative therapies. She has served as faculty for ICEA Basic Teacher Workshops and Conventions. She is the author and producer of Pregnancy Relaxation: A Guide to Peaceful Beginnings, available through the ICEA Bookcenter. Dana is the owner of Childbirth Celebrations, a consulting firm.

Copyright INTERNATIONAL CHILDBIRTH EDUCATION ASSOCIATION Sep 2005

Philippines says arrests Islamic militant leader

MANILA (Reuters) – Philippine security forces on Wednesday
arrested the leader of an Islamic militant group suspected of
involvement in the sinking of a ferry that killed more than a
100 people last year, an army general said.

Ahmad Islam Santos, the head of a radical Muslim convert
group with ties to the Abu Sayyaf terror group, and eight
suspected militants were caught from a house in Zamboanga, one
of the largest cities on the southern island of Mindanao.

“We’ve got a very big guy,” Lieutenant-General Edilberto
Adan told reporters and added that weapons, explosives and maps
of the capital, Manila, were seized from the hideout.

“He’s still undergoing tactical interrogation. We believed
the group was up to something big during the long holiday,” he
said, referring to next week’s holidays to mark the Roman
Catholic All Saints Day and the end of Ramadan for Muslims.

Santos, also known as Hilarion del Rosario, is believed to
have founded the Rajah Solaiman Movement in the late 1990s
after he converted to Islam and attended military training in a
Muslim rebel camp in Mindanao’s Lanao province.

The Abu Sayyaf group claimed responsibility for the sinking
of the ferry near Manila in 2004 that killed more than 100
people, the country’s worst terror attack.

Intelligence authorities said Santos’s group was also
involved in the attack.

One of the self-confessed ferry bombers was a Muslim
convert that belonged to the Rajah Solaiman Movement. Rajah
Solaiman was the last Muslim ruler of Manila whose kingdom was
destroyed by Spanish colonizers in the 16th century.

Adan said that Santos and his companions did not resist
arrest when a combined team of soldiers and police officers
stormed the hideout early on Wednesday. The rebels were
sleeping when the raid began, said a soldier involved in the
assault.

Abbott’s discontinued ADHD drug too risky-US FDA

WASHINGTON (Reuters) – Liver problems linked to Abbott
Laboratories Inc.’s discontinued attention deficit drug Cylert
and other generic versions make the drug too dangerous for the
U.S. market, the Food and Drug Administration said on Monday.

“The agency has concluded that the overall risk of liver
toxicity from Cylert and generic pemoline products outweighs
the benefits of this drug,” the FDA said in a warning posted on
its Web site.

In March, Abbott said it would no longer make the
30-year-old drug due to declining sales, but consumer advocates
had argued it was too dangerous to be sold. Generic makers also
agreed to halt sales, according to the agency.

“The decision to discontinue Cylert was based on commercial
reasons. Usage of pemoline products has declined significantly
over the years,” Laureen Cassidy, a spokeswoman for Abbott,
said.

FDA officials said Cylert would remain available until
current supplies ran out. Doctors who prescribe it or its
generic counterparts “should transition their patients to an
alternative therapy,” they said in a statement.

The agency said it received 13 reports of liver failure
that led to patient death or an organ transplant. The rate
involving patients taking pemoline was 10 to 25 times higher,
it said.

The fact that there are “multiple other drug treatments”
for Attention Deficit Hyperactivity Disorder, or ADHD, also
factored into the agency’s decision, the statement said.

The FDA’s warning was posted online at
http://www.fda.gov/cder/drug/InfoSheets/HCP/pemolineHCP.htm

Abbott shares were up 29 cents, or less than 1 percent, at
$43.03 in midday trading on the New York Stock Exchange.

(Additional reporting by Julie Steenhuysen in Chicago)

Cherry products must drop disease claims – FDA

WASHINGTON (Reuters) – The U.S. Food and Drug

Administration said on Monday it warned more than two dozen

companies to stop selling cherry products that claim to
help

treat or prevent cancer, heart disease, arthritis and other

diseases.

The agency sent warning letters earlier this month to 29

companies, ordering them immediately to stop making the
health

claims on their Web sites and product labels.

“The companies cited are marketing dried fruit, fruit
juice,

and juice concentrate for treating or preventing of a
variety of

diseases, including cancer, heart disease, and arthritis,”
the

FDA said in a statement.

If the companies fail to take corrective measures, they may

face FDA enforcement actions such as seizure of their
products

or criminal sanctions.

The following companies were sent the warning letters:

* Amon Orchards, Acme, Mich.

* Brownwood Acres, Eastport, Mich.

* Cherry Lands Best, Appleton, Wis.

* Cherry Republic, Glen Arbor, Mich.

* Cherry Rx, Genoa City, Wis.

* Chukar Cherry Co., Prosser, Wash.

* Coloma Frozen Foods, Coloma, Mich.

* Country Ovens, Ltd., Forestville, Wis.

* Eden Foods Inc, Clinton, Mich.

* Flavenoid Sciences, Traverse City, Mich.

* Friske Orchards, Ellsworth, Mich.

* Heritage Products International, Livonia, Mich.

* H & W Farms, Belding, Mich.

* King Orchards, Central Lake, Mich.

* Leelanau Fruit Co., Suttons Bay, Mich.

* Leland Cherry Co., Leland, Mich.

* Obstbaum Orchards, Salem, Mich.

* Orchard’s Harvest, Traverse City, Mich.

* Overlake Foods Corp., Olymica, Wash.

* Payson Fruit Growers, Inc., Payson, Utah

* Rowley and Hawkins Fruit Farms, Basin City, Wash.

* Rowley’s South Ridge Farms Inc., Santaquin, Utah.

* Royal Ridge Fruit & Cold Storage, Royal City, Wash.

* Seaquist Orchards, Sister Bay, Wis.

* Skyview Orchards, Ludington, Mich.

* Sunrise Dried Fruit Co., Northport, Mich.

* TPG Enterprises Inc., Othello, Wash.

* Traverse Bay Farms, Bellaire, Mich.

Simple Method Can Predict Child’s Adult Height

By Amy Norton

NEW YORK — Canadian researchers have devised a low-tech method they say can predict a child’s ultimate height within a couple inches.

Parents who are curious about their children’s future stature can perform the calculation themselves, with the help of little more than a tape measure.

Also, according to the researchers, their prediction method could prove practically useful in sports. A problem in youth sports is that there is a bias toward kids who have already begun their adolescent growth spurt, study co-author Dr. Adam D. Baxter-Jones told Reuters Health.

But if, for example, a short adolescent boy is merely a late bloomer and destined to top 6 feet, then volleyball may indeed be his game.

“We wanted to give coaches, teachers and other professionals working in this area a non-invasive technique to distinguish the late maturers from the early maturers,” explained Baxter-Jones, an associate professor of kinesiology at the University of Saskatchewan in Saskatoon, Canada.

He and his colleagues arrived at their height-prediction formula by studying 224 boys and 120 girls between the ages of 8 and 16. They found that a calculation based on a child’s age, height, weight and sitting height — which gauges leg length in relation to total height — could predict boys’ adults height within 2 inches and girls’ height within 2 to 3 inches.

The prediction tool is available online at http://www.usask.ca/kinesiology/research_index.php.

Baxter-Jones and his colleagues report their findings in the October issue of the Journal of Pediatrics, where they point out that there have long been other methods for predicting a child’s future height, but they have drawbacks.

Measuring “bone age,” for instance, is expensive and exposes a child to radiation. There are less intrusive methods, too — such as using the average of both parents’ heights — but Baxter-Jones said his team’s formula seems to be more accurate than other non-invasive measures.

Specifically, the tool’s use of sitting height gives an estimate of a child’s current biological maturity — that is, how far he or she is from a growth spurt. On average, girls have a growth spurt at about age 12, while boys’ heights tend to take off at age 14; there are, however, early and late “bloomers,” and the new prediction tool takes this into account.

However, Baxter-Jones pointed to some limitations of the method as well. While the method is low-tech enough for parents to perform themselves, they do need to be precise in taking the measurements that are to be plugged into the formula.

In addition, the tool is intended only for healthy children between the ages of 8 and 16, and not those with any medical condition affecting growth. And because all of the children in the study were white, it’s not clear yet whether the formula is accurate for other racial groups.

SOURCE: Journal of Pediatrics, October 2005.

Roundup: Uganda Makes Achievements in Universal Primary Education

Roundup: Uganda makes achievements in universal primary education

by Ssekandi Ronald, Chen Cailin

KAMPALA, Oct. 23 (Xinhua) — The Ugandan government is making remarkable progress in implementing Universal Primary Education ( UPE) in the country, Education Minister Namirembe Bitamazire said recently, adding the program has had a positive impact on the access to education in the country, especially in poor rural areas.

According to Ministry of Education statistics, the number of school going age children enrolling for the program is rapidly increasing every year. Since the introduction of the program in 1997, gross enrollment rose from 5.3 million pupils in 1996 to 7.6 million children in 2003.

It is this remarkable success that makes the country a model for other countries that want to start the UPE program. LET ALL CHILDREN GO TO SCHOOL

The Ugandan government declared in 1997 the policy of UPE, which entitled up to four children per family to receive free education in government and government aided schools.

Because many parents who had more that four children simply allocated them to relatives or pleaded with the program implementors to register them, this forced the government to announce free access to primary education to all school going children.

Ministry of Education statistics indicate that because of the introduction of UPE, gross enrollment increased by 73 percent in one year from the pre-UPE total of 3,068,625 pupils in 1996 to 5, 303,564 in 1997. By 2003, gross enrollment in primary schools was 7,633,314 children representing an increase of 149 percent of the pre-UPE enrollment.

This resulted in the available facilities to be stretched to breaking point. In some places especially in the rural areas, the ratio of pupils to teachers exceed 100 to one. The reality of a teacher trying to teach a class of over 100 pupils under a mango tree was common.

The Ugandan government increased funding of the education sector. The funding of the sector as a whole increased significantly from 2.1 percent of GDP in 1995 to 4.8 percent in 2000. The share in the national budget went up from 13.7 percent in 1990 to 24.7 percent in 1998.

The country’s education sector strategic investment plan makes mandatory that not less than 65 percent of the education budget fund primary education, which is one of the key poverty reduction priority areas.

Some money saved through debt forgiveness under the Heavily Indebted Poor Countries Initiative of the International Monetary Fund and the World Bank was also used to boost the UPE program.

The government also liberalized the education sector which enabled the setting up of private schools. ALL STAKEHOLDERS INVOLVED IN UPE

To ensure the proper implementation of the program from the government down to the village level, the government adopted an all inclusive policy. In this policy, all stakeholders from the ministry of education and sports, local authorities, school management committees that are elected by parents actively participate in the implementation of the program.

The Ministry of Education and Sports provides two types of grants: capitation grant and school facilities grant.

It pays capitation grant on the basis of the number of students enrolled in a school and depending on the level of education. The monthly rate per child was fixed at 5,000 shillings (2.7 US dollars) per pupil for classes P1-P3 and 8,100 shillings (4.4 dollars) per pupil for classes P4-P7, payable for a fixed period of 9 months per year.

The ministry disburses the money to districts which in turn send the money to the schools.

The ministry is also responsible for training and retraining of teachers, providing and developing policies and policy guidelines and planning for quality education including assessment and monitoring of learning and teaching process.

Local authorities also play a crucial role in the implementation of the program. Under the leadership of the Chief Administrative Officers, who is the accounting officer of a district, districts ensure that all UPE funds reach schools. POSITIVE IMPACT

According to Minister Namirembe Bitamazire, the UPE has impacted positively on access to education in the eastern African country.

“Education quality as measured by standard indicators such as pupil/teacher ratio, pupil/classroom ratio and pupil/ textbook ratio point to improving quality of primary education in UPE schools from the time UPE was introduced,” said Bitamazire.

Ministry of Education statistics indicate that the period of 1996 to 2003 witnessed massive increase in the number of primary schools from 8,531 in 1996 to 13,353 in 2003, representing an increase of 4,822 schools in only seven years.

By 2003, there were 10,460 government owned primary schools compared to 1,705 private primary schools, and 1,121 community schools.

The number of primary school teachers almost doubled in seven years from 81,564 in 1996 to 145,587 in 2003 representing an increase of 64,023 or 78 percent yet, in the decade preceding the introduction of UPE, the number of primary school teachers increased by only 8,594 or 12 percent.

The gender inequalities have also been addressed. For a long time, enrollment of females at all levels of education has lagged that of males. However, the gap is narrowing after among other things, the introduction of primary education.

In 2003, enrollment of girls in primary schools was slightly over 49 percent of total, falling behind that of boys. This is significant improvement compared to 44 percent and 44.5 percent for 1990 and 1993 respectively. The post UPE period witnessed a narrowing gap between the number of girls and boys enrolled in primary schools.

These successes notwithstanding, Uganda’s remarkable progress to the successful implementation of the UPE program has not been easy. It has faced key challenges but the government’s and parents ‘ continued commitment to the program will make it possible to address any challenge that comes along the way.

Tanzania’s witch-doctors cast spells for votes

By Helen Nyambura

BAGAMOYO, Tanzania (Reuters) – The witch-doctors in the
former slave port of Bagamoyo on Tanzania’s coast are busy
concocting spells to help the east African country’s
politicians win votes in this month’s elections.

“Some (politicians) started making regular visits five
months ago. Others come at the last minute and expect me to
help them win,” said Pandu, an almost toothless witch-doctor
who boasts that he is one of the best in town.

Usually Pandu sees around 10 patients a day, mostly people
looking for help with illnesses they believe are caused by
demons. The politicians come at night or send a representative.

“One comes and asks, ‘Will I win or lose?’ If I say he will
lose, he asks me to make his opponent fail,” Pandu said.

“I can’t say their names, why do you think they come at
night?” he said, declining also to give his own last name.

Tanzania holds presidential and parliamentary elections on
October 30, with fears running high of violence in
semi-autonomous Zanzibar, an opposition stronghold that has
already been shaken by bloody clashes between rival supporters.

Tanzanian President Benjamin Mkapa will step down after the
poll and most analysts expect Foreign Minister Jakaya Kikwete,
55, of the ruling Chama Cha Mapinduzi (CCM) to win the vote and
replace him. It’s a prediction Pandu supports.

“Kikwete has already been chosen. I saw that a young person
would win this election,” he said.

A majority of Tanzania’s 35 million people are either
Christian or Muslim, but most also respect the animist beliefs
of their ancestors and often consult witch-doctors for help
with money problems, affairs of the heart and illnesses.

The coastal region of Bagamoyo northeast of the capital Dar
es Salaam is renowned for the quality of its witch-doctors.

DON’T LEAVE IT TOO LATE

Pandu’s spells usually involve sewing a few verses written
with a sharp stick dipped in red ink into the clothes of an
aspiring legislator. The floor of his tiny consulting room is
littered with unused pens and white paper strips.

But seeking other-worldly help to secure political victory
should not be left to the last minute.

“You have to come even before the party nominations begin
and make frequent visits after that if you have any hope of
winning,” he said.

Other witch-doctors backed his prediction of victory for
Kikwete, who is from the Bagamoyo district.

“(The age) 55 is a good number as he has crossed from 4
which is a negative number,” witch-doctor and astrologer Sheikh
Yahya Hussein said in a weekly television program

.

Hussein said the number 55 signified that Kikwete would
help develop Tanzania, a poor country that has nurtured its
image as one of Africa’s most stable countries despite what
critics call a record of brutality and electoral dirty tricks
in Zanzibar.

Others were less optimistic, echoing the gloom of analysts
who say the elections could trigger more violence in Zanzibar,
where dozens of opposition supporters were killed in clashes
with police in 2001.

“Where we are going is not good,” said Rajab Kibuna. “I
have predicted that there will be fighting after the elections
up to June next year. What I see is that this election doesn’t
offer peace. I don’t know how many of us will survive.”

Already, two people have been killed and scores more have
been injured in pre-poll clashes between supporters of the
opposition Civic United Front (CUF) and the ruling CCM in
Zanzibar, which will elect its own president and parliament.

The CUF has promised Ukraine-style protests if it deems the
October 30 election to be unfair.

WISDOM

A majority of Tanzania’s witch-doctors are Muslim. Their
magic includes recited verses from the Koran — a practice that
Muslim leaders say is acceptable if carried out respectfully.

“There are some verses in the Holy Koran that should be
read out when praying,” Mzee Ruga Mwinyikai, a leader of the
Council of Imams in the Dar es Salaam suburb of Kinondoni,
said.

“But it is forbidden that they should write down any of
these verses in blood, whether of animal or human beings.”

In poor Tanzania, witch-doctors can enjoy a good living
thanks to their popularity. Hussein said he got clients from as
far away as Washington and London.

Kibuna, who is the leader of a local branch of the CUF and
says he has 12 clients in positions of power, does not ask for
payment. Instead, his clients give him what they think is a
appropriate amount for his services.

They seem to be quite generous: the witch-doctor lives in a
stone-brick building with a corrugated iron roof in his dry and
dusty Mlingotini village with his two wives and 14 children. A
CUF flag sways in the wind outside.

His neighbors live in mud huts covered with palm fronds.

But with the relative wealth comes responsibility,
especially when dealing with requests from politicians.

“You have to evaluate whether the candidate is right for
the people,” Kibuna said. “You can help the wrong person go up
and earn money for yourself but create problems for everyone
else.”

The Naked Truth: Tucked Away in Hampshire County, A Clothing- Optional Resort Caters to Needs of Stressed-Out City Dwellers

By Ford, Christine Miller

PAW PAW – Despite a lineup of activities ranging from fishing, swimming and nature hikes to tennis, yoga and dancing, it’s easy to pack light for a trip to Avalon Resort.

You’ll need shoes, but forget about bringing your swimsuit, eveningwear or sports clothes. Avalon is a clothing-optional resort, the only such vacation spot in all of West Virginia.

“There’s a wonderful sense of freedom that comes back to you as you spend time nude,” explained Phyllis Gaffney, the North Carolina native who founded Avalon 10 years ago along with her husband, Patrick. “It’s really just very natural, very relaxing, very freeing.”

The Gaffneys have been hooked on the lifestyle since they first went skinny dipping at an abandoned quarry in Northern Virginia as grad students in 1975.

Two decades later, they came across the property near Paw Paw, which was on the market after having served as a church conference center.

Today the site includes a full-service restaurant called La Belle Pomme, two bars, two heated pools, a gaming room with video lottery machines (a spot known not as a casino, but the “nude-sino”), a sauna, tennis courts, sand volleyball courts, horseshoe pits, an exercise trail, a stocked pond for fishing, three hot tubs and more.

Overnight guests can choose from hotel-style rooms, one- or twobedroom condos with kitchens or camping sites for tent or RV. For Avalon visitors who plan to spend a week or longer, Gaffney’s staff stands ready to offer assistance in planning off-site trips to nearby attractions including the historic Paw Paw Tunnel, the outlet mall in Hagerstown, Md., nearby Civil War sites such as Antietam and Gettysburg, antiques shops white water rafting, wineries, golf and other pursuits.

Though Avalon is described as a “clothing optional” resort, nudity is the absolute rule in Avalon’s pools, sauna, hot tubs and the nude-sino.

“People are expected to be nude whenever weather and health permit,” reads the mailer sent to prospective Avalon visitors. “No one is forced into being nude; you may get undressed at your own pace. If one member of your family does not wish to get undressed, they will not be required to disrobe except for using the pools, sauna, hot tubs or gaming room.”

Avalon’s location at the edge of the Eastern Panhandle allows it to attract visitors from all over the Northeast, particularly from Baltimore and Washington, D.C. A small advertisement for Avalon recently appeared in The Washington Post’s Sunday travel section.

From inside the Beltway, it takes about two hours to get to remote, bucolic Paw Paw.

“It’s close enough to get to easily, but also far away enough to feel as if you’re truly getting away,” Gaffney said.

Nude recreation is an ideal antidote to fast-paced city life, Gaffney said.

“Everybody today is dealing with so much stress,” she said. “It seems like the closer you are to D.C., the more stressed out you are. People tell us they can feel their stress level decreasing as they drive out.”

Autumn in Paw Paw, when the surrounding mountain ridges are full of vibrant color, is something to see, Gaffney said.

“Early fall and Indian summer offer a beautiful time to experience nature in the nude,” she said.

Some of the special events slated for the coming weeks: an Autumnal Equinox Celebration and Dance (Sept. 24), Hunter’s Moon Dance with the band Living Out Loud (Oct. 15) and the popular All Hallow’s Eve Party (Oct. 29).

As the weather cools, Gaffney said, the aquatic center will put up its space-age roof and sliding glass walls to become an indoor facility. Massage workshops also help guests ease into the cold- weather months, she said.

Any time of year, Gaffney said, nude recreation delivers an opportunity to “just be your true self” and to turn off the messages sent by the culture’s perfectionist image makers.

“We face these impossible standards of appearance,” she said. “Most people can’t begin to imagine how good it feels to just accept your natural body.

“It’s a too-well-kept secret how relaxing and safe a clothes- free getaway can feel. Once you try it, you find yourself wondering, ‘Wow. What took me so long?'”

Copyright State Journal Corporation Sep 23, 2005

Microbial Biomass Estimation

By Madrid, R E; Felice, C J

ABSTRACT The development of a fully automated on-line monitoring and control system is very important in bioprocesses. One of the most important parameters in these processes is biomass. This review discusses different methods for biomass quantification. A general definition of biomass and biovolume are presented. Interesting concepts about active but not culturable cells considerations are included as well as concepts that must be taken into account when selecting biomass quantification technology. Chemical methods have had few applications in biomass measurement to date; however, bioluminescence can selectively enumerate viable cells. Photometric methods including fluorescence and scattered light measurements are presented. Reference methods including dry and wet weight, viable counts and direct counts are discussed, as well as the physical methods of flow cytometry, impedancimetric and dielectric techniques.

KEYWORDS biomass, biovolume, bioprocess control, physical methods, chemical methods, photometric methods, classical methods.

I. INTRODUCTION

A. General Concepts

The development of a fully automated on-line monitoring and control system is very important in bioprocesses. Biotechnology development has been very vertiginous and required new probes and sensors for optimal control of these processes (Schgerl, 2001; Locher et al., 1992; Liu et al., 2001).

Sensors of different types may be used, such as amperometric, potentiometric, fluorescence and chemiluminescence detectors as well as photometers. Miniaturized sensors for the in-situ measurement of pH, pO^sub 2^ are well developed for biotechnological measurements (Steenkiste et al., 1997; Voigt et al., 1997). In recent years, the number of research groups dealing with sensors for on-line bioprocess control has increased dramatically and many groups have developed biosensors for this specific purpose.

When designing sensors, it is important to fully exploit the potential of modern measurement instrumentation and advanced control methods. It is very important to classify and to properly process the great amount of information given by the sensors and control devices of a bioreactor. Some papers integrate all of this information for monitoring and controlling a bioprocess through an expert system in real time (Cimander et al., 2003) or special control software (Zelic et al., 2004; Liu et al., 2001; Turner et al., 1994).

Biomass is a critical parameter in the fermentation process, and it is difficult to measure. It is important because it is a key variable to optimize a specific process, or to reach a maximum efficiency to obtain a certain product, i.e. an antibiotic.

Through the years, a number of methods have been developed to detect and quantify biomass, which are useful in different cases, depending on the application. At present maximum possible automation is desired in every bioprocess, so that this can be carried out more efficiently and, at the same time, monotonous and boring tasks are avoided (Sonnleitner, 1997). Automation allows us to control processes safely and reliably, 24 hours a day and 365 days a year, with minimum errors and maximum safety. The processes turn out to be quite reproducible and the products obtained observe quality and standard regulations. But such an automatic control requires devices for on-line monitoring of different variables needed in every process, such as temperature, pH, aeration or biomass (Locher et al., 1992). This is why a large number of researchers are continuously looking for methods and devices that can provide fast on-line and in-situ results. Generally, these devices take part in control loops, and the faster and more accurate they are, the more efficient the control performed in the bioreactor will be. There are control programs (Liu et al., 2001) and even expert systems (Cimander et al., 2003), or neural nets (Leal Ascencio and Aguilera Galicia, 2000; Vanek et al., 2004) for process regulation.

In the case of biomass measurement, there are only a few sensors, generally based on the measurement of physical, chemical and photometrical variables and occasionally on biological ones (Sonnleitner, 1999). In other cases, the measurement of other variables might drive to the measurement of biomass (Hrdlicka et al., 2004; Couriol et al., 2001; Bai et al., 2005). Couriol et al. (2005) estimated biomass concentrations from the measurement of CO2 production during batch cultivation of Geotrichum candidum (Couriol et al., 2001). The work of Bai et al is particularly interesting. They estimated floe biomass concentrations on-line using an optical detecting technique to measure floc chord length distribution (Bai et al., 2005). This technique was useful for flocculating microorganisms, but presented problems due to disturbances resulting from CO2 in the case of ethanol fermentation and air bubbles in the case of aerobic cultivations.

Methods that measure physical variables are generally better adapted for on-line, in-situ biomass measurements (Harris and Kell, 1985; Vicente et al., 1998; Hoffmann et al., 2000; Neves et al., 2000; Arnold et al., 2002). One of these is dielectric spectroscopy, which is a direct technique useful only with high cell concentrations, i.e., higher than 2-5 . 10^sup 5^ cell/ml for yeast or animal cells (Ducommun et al., 2002; Guan and Kemp, 1998). The minimum measurable concentration is higher for bacteria, typically 1010 (Harris et al., 1987).

Until now, the most universally applicable in-situ devices for on- line biomass monitoring are the photometric methods, including optical probes such as turbidimetric or nephelometric sensors (Strk et al., 2002). For example, a sensor for on-line determination of biomass in a microalgae bioreactor was reported by Meireles et al. (2002). This measured optical density of the culture using a Flow Injection Analysis (FIA) system with two loops to provide two dilution factors, coupled with a spectrophotometric detector. They obtained good results with a simple and economic system, which could be applied to unicellular microorganisms such as bacteria.

There are a few chemical methods to measure biomass. One of them, bioluminescence, is applied in biotechnology to monitor a bioprocess product, by introducing a reporter gene which codifies for this product (Roda et al., 2004). In microbiology, bioluminescence is a very rapid and sensitive method for detection and quantification of bacteria (Hobson et al., 1996).

Biomass is defined below from the microbiological and biotechnological point of view. Furthermore, biovolume is described as a more useful way of quantifying biomass.

B. Biomass in Microbiology and Biotechnology

Biomass sensu stricto is the amount of cell material that is able to grow and multiply, and this quality distinguishes it from necromass (Postgate, 1969). However, this definition is old and does not include metabolically active microorganisms, which are unable to grow in-vitro under ordinary culture conditions and methods.

The existence of “viable but not culturable” microorganisms (VBNC) made several authors analyze the subject in depth to try to clarify this concept. The need arose as the expression “viable but not cultivable” is contradictory since that definition of viability states that a bacteria is “viable” if it is able to grow and proliferate. Some authors define the term VBNC as an oxymoron or a misnomer (Bloomfield et al., 1998; Kell et al., 1998; Barer and Hardwood, 1999), because these cells are not non-culturable since we fail to provide the adequate culture conditions (Bloomfield et al., 1998).

In 1998, Kell et al. published a paper where they analyzed this subject and they clarified the concepts. They proposed operative definitions of viability and culturability instead of conceptual ones.

According to the conceptual definition, a viable cell is an organism able to grow and multiply. This definition does not consider that there are cells able to grow and multiply, but do not grow axenically, because we cannot provide them with the proper growth environment.

The operative definition considers that all metabolically active cells are viable. This definition includes as viable cells the ones excluded in the previous definition.

Kell et al. proposed that the cells can be characterized in four main categories: i) culturable, ii) nonculturable, iii) (metabolically) active, and iv) (metabolically) inactive. In Figure 1, the different categories are presented.

They proposed that the terms viability (viable) and culturability (culturable) are operative synonyms, and that nonviable = nonculturable. They also proposed that the term “active but not culturable” (ABNC) should be used instead of VBNC. “Dormant” cells are metabolically inactive but capable of making a transition to a growing state.

FIGURE 1 Major physiological states of non-growing microorganisms and their interrelationships (From Kell et al., 1998, reproduced by permission of Kluwer Academic Publishers.)

The term “dormancy” refers to cells with negligible activity but which are ultimately culturable. The VBNC cells have exactly the opposite properties: they are (metabolically) active but “nonculturable” (ABNC). Examples where the terms VBNC and dormant cells are used as synonymous can be found in the literature despite the fact that they are exactly the opposite (Steinert, 1997). The concept of VBNC state arises from the existence of ba\cteria capable of causing diseases but that can not be quantified through ordinary culture procedures.

ABNC cells can become a major public health problem since they cannot be detected by traditional culture methods. That is why several cases of pathogenic bacteria in the ABNC state have been studied. Whether or not all human pathogens remain virulent when entering the ABNC state has not been definitively demonstrated. Besnard et al. determined environmental and physico-chemical factors, that induce the ABNC state in a food-borne pathogen of public concern such as Listeria monocytogenes (Besnard et al., 2002). In order to evaluate the cell activity, they used the Direct Viable Count technique and CTC-DAPI double staining.

Wang and Doyle (1998) studied the survival of enterohemorrhagic Escherichia coli O157:H7 in water and proved that they can survive in water in the ABNC state, but they have not studied the possible pathogenic activity of this state, or after resuscitation. Another investigator who studied the pathogenic activity of bacteria in the ABNC state, suggested with his data that cells of V. vulnificus (an estuarine bacterium responsible for 95% of all seafood-related deaths in the United States) remained virulent, at least for some time, when present in the ABNC state and are capable of causing fatal infections following in vivo resuscitation (Oliver and Bockian, 1995).

These are only a few examples, but there are numerous research groups working on this subject, and in almost all of the cases the methods used for the determination of microorganisms in the ABNC state are being carried out through molecular methods, fluorescent labelling (AODC, DAPI, DTAF double staining), epifluorescence microscopy or flow cytometry (Steinert et al., 1997; Bunthof et al., 2001; Chaveerach et al., 2003; Kaeberlein et al., 2002; Keer and Birch, 2003).

Daugelavicius et al. (2001) provided a method to distinguish “viables” from “dead” based on the amount of lipophilic anions (PCB”) taken up by the cells. The cell membrane is permeable to lipophilic ions due to the ability of these ions to bind and even translocate the lipid membrane. The amount of ions taken up by the cell allows the quantification of cells in a sample with a previous calibration measurement. Biomass can be monitored in-situ by this method, and only an ionometer (pH meter), a PCB^sup -^ sensitive electrode (commercially available) and the addition of PCB^sup -^ salts are needed. One problem with this technique is that it is not sensitive enough for the detection of a low concentration cells.

The limit of detection is 6 10^sup 6^ cell/ml for S. cerevisiae, and approximately 10^sup 7^ cell/ml for bacteria such as E. coli or B. subtilis. The method is repeatable and the results are obtained in 10 minutes.

Direct microscopic methods are adequate to show the total number of cells (non-viables and ABNC) and they can be differentiated by epifluorescence microscopy. The latter may be considered adequate to quantify microorganisms in samples where the presence of cells in the ABNC state is suspected.

Molecular methods are also used to determine ABNC bacteria. These methods offer velocity, sensitivity and specificity with respect to the classic methods. They determine DNA or RNA by staining or molecular amplification, since any method which requires microorganism growth will fail to provide accurate results. Polymerase chain reaction (PCR), reverse transcriptase (RT-PCR), and nucleic acid sequence-based amplification (NASBA) are the most frequently used. Keer and Birch performed a comparative study of these methods for the assessment of bacterial viability (2003).

The determination of ABNC microorganisms is highly relevant in clinical and/or environmental samples since their presence may be potentially dangerous.

However, these dormant or ABNC states are not common in biotechnology, where the cultures generally have the proper nutrients and the cells are not starved. The exception to this rule are high density cultures where the main cell state is ABNC (Andersson et al., 1996); in other words, the bacteria maintain their metabolic activity but they do not multiply.

In the previous paragraphs, the ABNC microorganisms were not included in the biomass definition. In 1990, Harris et d. introduced a new operational definition, the biovolume, which includes ABNC microorganisms. This is the volume fraction enclosed into the cell cytoplasmic membrane in a suspension (Harris and Kell, 1985; Harris et al., 1987). This is a definition of biomass to be used strictly in fermentations.

C. Biovolume as a Biomass Estimator

Biovolume is defined as the product between the cell volume and the total number of cells. This value can be converted to biomass using a proper conversion factor.

On the assumption that the microorganism is a sphere, ellipsoid or cylinder, its volume can be estimated by measuring its radius, diameter or length with a microscope. This estimation includes the volume enclosed by the cytoplasmic membrane (Kell et al., 1990).

This measurement can be carried out through different methods, including electronic sizing, flow cytometry (Bouvier et al., 2001), and different microscopic techniques (Bratbak, 1985). The main disadvantage of the methods that enumerate and measure cell length to estimate microbial volume is their deficiency to differentiate active microorganisms from inactive ones (Bolter etal, 2002). This deficiency becomes even more significant when Kell and Young’s classification is used, where microorganisms are considered as active and culturatte, metabolically active and not culturable, or metabolically inactive and not culturable cells (Kell and Young, 2000).

Complementary methods can be used to overcome the limitations mentioned in the previous paragraph. These methods include activity measurements (e.g. respiration, growth velocity) or biomass (e.g. ATP, ergosterol). This is particularly important for nutrient-poor environments such as soils and habitats for oligotrophic organisms (Bolter et al., 2002).

Biomass in biotechnology is referred to cell material, which is able to grow and multiply. This condition is not applied in real time applications because of the problem of having to wait until cells grow and multiply.

The real-time alternative for biomass estimation is biovolume measurement, which can be carried out through physical methods such as dielectric spectroscopy (DE) (Harris et al., 1987; Kell et al., 1990). This technique measures the dielectric permittivity variation of a cell suspension in the radio frequency range of the electromagnetic spectrum. This variation is related to the biological volume fraction present in a fermenter (Pauly and Schwan, 1959).

The main advantage of using biovolume to estimate biomass in fermenters is that it allows the measurement of the content of cells with an intact membrane in real time, making use of dielectric measurements of the suspension. It also allows one to differentiate these cells from those with a lysed membrane (Davey et al., 1993).

The disadvantage of using dielectric estimation is that the biovolume is always lower than the total volume fraction, because the cell wall is not included in the theoretical basis of the method. It can represent from 25% to 50% of the total cell volume (Orlean, 1997). If DE measurements are calibrated against methods that include the cell wall, this underestimation will not be a problem.

Another subject to be considered is that the biovolume estimated by DE does not differentiate among the four main categories proposed by Kell (Kell et al., 1998). Nevertheless, in a review (Yardley et al., 2000) it is stated that this underestimation is not significant under fermentation conditions. Whether this may become a problem or not depends on the analysis of each particular situation, such as in high cell density fermentations, where the active but non culturabk cells may represent a significant part of the cell population (Andersson etal., 1996).

II. METHODS FOR THE QUANTIFICATION OF BIOMASS

There are diverse methods for the quantification of biomass. These methods must be fast, and if it is possible, in-situ, in order to control the systems in real-time. The measurements in a reactor may be as follows (Sonnleitner, 1999):

* off-line: when the result is manually obtained and cannot be automated. The time delay of the results impedes a real-time control of the system.

* on-line: when the result is obtained immediately after the measurement. These kinds of measurements are fully automatic, and they allow a real-time control of the system.

* in-situ: when the sensors are located inside the system to be measured.

* ex-situ: when the sensors are located in a bypass or in an exit line.

* continuous: when the measurements are continuous in time.

* discrete: when the measurements are performed at regular intervals.

These classifications may be used in reactors for the determination of biomass. In the next sections some examples of these methods can be found, such as a capacitive biomass measurement (in-situ, on-line, continuous), sensors in FIA systems (ex-situ, on- line, discrete), or dry weight (ex-situ, off-line, discrete).

The quantification of biomass in samples of environmental and clinical origin, as well as in reactors, where a determined product is expected to be obtained, is of great concern. The term is generally associated with samples that have a high cell concentration such as reactors, where the concentration may be higher than 10^sup 7^ cell/ml.

The microorganism concentration expected in samples coming from a clinical environment or the food industry is low (

The following five sections describe different methods for biomass quantifica\tion, including reference, physical, chemical, photometric, and non-conventional methods. Both in chemical and physical methods, only the most common techniques are taken into account.

A. Reference Methods

1. Dry and Wet Weight

The dry weight method is the most widely applied for biomass estimation. It is also used as a reference method.

The cell density can be quantified in two basic ways: as grams of dry or wet weight per liter of sample, or as a number of viable/ dead cells per ml. The cells in a sample can be separated from the broth and weighed while they are wet, or the cells may be thoroughly dried before weighing. The dry weight measurement usually gives a much more consistent result than the wet weight and is usually used as a reference method. It is simple but laborious and takes a lot of time. Although it is a widely used method it can be erroneous if the broth contains other insoluble material as is commonly found in a practical fermenter. In addition, these methods cannot distinguish viable cells from dead cells.

2. Viable Counts

Another way to quantify microorganisms is concentration measurement, defined as the number of viable cells per volume unit. The Plate Count, the Membrane Filtration and the Most Probable Number Method (MPN) are examples of these techniques.

In the plate count method, the number of cells can be counted by successively diluting the original sample and plating on a Petri dish. This plating method detects only the viable cells. This technique requires elaborate preparations, is laborious, and takes 24-72 hours for the cells to be incubated and counted. Therefore, it is useless as a feedback control of a fermentation process and is used mainly industrially to countercheck other measurements, especially optical density. Despite the fact that other more recent techniques have surpassed it, the plate count method is still one of the basic techniques in microbial quantification.

The filter membrane method simply consists of collecting bacteria from a sample on a highly porous cellulose acetate membrane of different pore sizes, with high volumes of water passing through under pressure. The membranes generally employed have pores of 0.45 m. This membrane is placed on a plate with growth medium, incubated at an appropriate temperature and the number of colonies counted.

When the number of microorganisms is low, this method is used to concentrate the sample, and it is generally applied for the quantification of water samples. The versatility of this conventional method also allows the membrane to be incubated in the presence of different compounds in order to quantify specific microorganisms, such as coliforms. This technique can also be combined with other techniques such as epifluorescent microscopy (previously staining the sample with an appropriate stain) and using the epifluorescence filter technique.

The MPN method allows for the estimation of the number of viable microorganisms in a sample, capable of growing in liquid growth medium. A selective growth medium is usually employed. It is based on a 10-fold dilution series and a calculation is made of the number of bacteria present in the highest dilution. These procedures can be carried out with 3 or 5 tubes. The number of dilutions required for the sample and the number of tubes that show positive growth (tubes that shows turbidity) are required for the determination of the most probable number of microorganisms, and these numbers are referred to probability tables (Hobson et al., 1996). This method is used to quantify coliforms and sulphate reducing bacteria (SRB) and the main disadvantage is the time required to obtain results. SRB may take up to 28 days. It is not a very accurate method, but it could be improved by increasing the number of replicates, but this also increases the material used and handling difficulties.

B. Direct Count Methods

1. Epifluorescence Microscopy

This is one of the Direct Count (DC) methods. Direct Count is a general term that involves all the direct microscopic methods for enumerating bacteria. It is based on the same optical principles of common microscopy, but differs in sample handling and in the design and operation of the microscopes used.

When designing the generation systems and wave transmissions of these microscopes, adequate wavelengths for the fluorochromes to be visualized must be taken into account. A fluorochrome is a fluorescent dye used to label biological material. The excitation processes generally require short wavelengths, in the near UV (halogen-quartz lamps, mercury arc lamps, etc.). The lens must be made of a special material (generally fluorite) that is able to transmit these wavelengths. The immersion oil must be non- fluorescent.

McFeters et al. (1999) made a useful revision of rapid direct methods for enumeration of bacteria in water and biofilm. Fluorescence microscopy has provided a very rapid method for microbial enumeration, and one which does not require an incubation period. It allows the direct observation and total enumeration of viable and non-viable organisms in less than 30 minutes as compared to traditional culturing methods that may require incubation times of up to 72 hours. Traditional culturing methods used with environmental samples also underestimate the total number of microorganisms due to the selective nature of the media employed, lack of detection of ABNC microorganisms, and failure to count microorganisms that are present as aggregates or associated with particles. Acridine orange, the most commonly used fluorochrome, has a high affinity for nucleic acids, and is used as a viable cell stain, since nucleic acids are rapidly degraded upon cell death. Thus a total bacterial count can be accomplished using this method. Under UV light, acridine orange stains deoxyribonucleic acid (DNA) green and ribonucleic acid (RNA) is stained orange. Actively growing bacteria can therefore be distinguished from inactive bacteria on the basis of their higher RNA content (Hobson at al., 1996).

The most successful technique of this nature is the epifluorescence filter technique (DEFT) (Hobson et al., 1996). By using this technique, bacteria are filtered to be retained in an appropriate membrane. The filter is treated with detergents to destroy the somatic cells which may be retained together with the microorganisms, and afterwards the fluorescent agent is added (e.g., acridine orange or diamidino-2-phenylindole) in order to stain the bacterial cells. Microorganism detection is carried out by fluorescent microscopy or by other methods capable of measuring epifluorescence. In some cases, the membranes are incubated to produce colonies, which are more easily detectable. The detection limit of the method is 5 . 10^sup 3^ microorganism/ml.

Solera et al. (2001) described the determination of a microbial population in a thermophilic anaerobic reactor using different counting methods. This case is different from the environmental samples. Cells are growing inside the reactor and therefore conclusions are in accordance with what is expected (a good correlation between direct counts by DAPI (4′,6-diamidine-2- phenylindole) epifluorescence microscopy and viable plate counts). They also found that it was equivalent in this case to measure microorganisms and biomass because they obtained a high correlation between DAPI epifluorescence microscopy and biomass. This biomass was determined by measuring the volatile suspended solids contained in the digester medium according to “Standard Methods” (Solera et al., 2001).

Another extremely sensitive cytochemical staining method, is the fluorescent antibody (FA) technique. This method consists of labeling an antibody with a fluorescent molecule and incubating it with cells in the sample. Cells to which the FA is attached are detected by epifluorescence microscopy. This is a widely used technique to enumerate bacteria in public health, water microbiology, microbial ecology and environmental biotechnology. The result was a successful on-line estimation of bacterial or yeast biomass in aerobic fermenter cultures (Hobson et al., 1996; Beyeler et al., 1981).

In practice all these techniques are labor intensive, difficult to automate and susceptible to various forms of interference, which may cause errors.

2. In-Situ Microscopy

In-situ microscopy (ISM) is another method reported for the on- line estimation of biomass but it is not widely used for the determination of biomass in fermenters. In a paper by Bittner et al. (1998), a measurement system is reported. It consists of a direct- light microscope with a measuring chamber, integrated in a 25-mm stainless steel tube, two CCD-cameras and two frame-grabbers. The data obtained are processed by an automatic image analysis system.

They applied this system for the estimation of Saccharomyces cerevisiae biomass concentration in a reactor, within a measurement range of 10^sup 6^-10^sup 9^ cells/mL (equivalent to a biomass of 0.01 g/L to 12 g/L). They concluded that biomass concentrations up to 80 g/L can be determined with the ISM from the image area occupied by the cells. The calibration curve obtained between the cell volume per image and biomass had a good correlation. The system was simple and made with components commercially available, but it was necessary to adapt the optic for other types of cells such as bacteria or animal cells. Nevertheless, the bonus was that one could examine the cells microscopically during the process.

C. Physical Methods

1. Flow Cytometry

Cytometry refers to the measurement of the physical and chemical characteristics of cells. The technique is based on a procedure where the cells pass one by one from a suspension through a detection system, which may be a detector or a group of detectors that are able to measure different parameters (different types of fluorescence, absorbance, light dispersion, etc). This allows one to identify and \characterize bacteria while they are passing through the detector. This is the most important characteristic of this method, since it allows the rapid measurement of individual cells and gives a population distribution for each of the characters of interest. This information is useful to quantify the heterogeneity of a population (Davey and Kell, 1996).

Throughout the last 20 years a great number of papers have been published describing various applications of flow cytometry in the field of microbiology (Betz et al., 1984; Steen, 2000; Winson and Davey, 2000; Malacrino et al., 2001; Bradner et al., 2003).

Several attempts to assemble flow cytometers for online determinations in fermenters have been made. But the handling of the samples and waste and the qualified staff required has limited the use of flow cytometry to research laboratories (Bittner et al., 1998).

Flow cytometry is a widely popular method and it allows one to carry out on-line biomass estimation as well as revealing additional data about the population. Zhao et al. (1999) have designed a flow injection flow cytometry system for on-line monitoring of bioreactors. The system includes a specially designed microchamber, which allows not only an accurate on-line dilution but also on-line cell fixation, staining, and washing. These features allow the system to measure a wide range of cellular components after appropriate sample processing. The system can also measure biomass on-line by automatically carrying out dilutions of the sample to keep absorbance readings in the linear range using a spectrophotometer (Zhao et al., 1999). It is an interesting method, but it is a complex technology when compared to technologies such as dielectric spectroscopy or turbidity.

2. Impedancimetric Methods

In this section the basis of impedance microbiology is presented as well as typical applications in low, medium and high microorganism concentrations. Conductivity measurements for monitoring biomass in fermenters are included.

Electric impedance as a transduction principle (Geddes and Baker, 1989) is a tool provided by electrical engineering and is widely applied to study biological materials (Valentinuzzi et al., 1996). It has been used for the detection and quantification of bacteria, yeast, animal and vegetal cells, as well as in clinical, industrial and research fields (Alexandrou et al., 1995; Dang et al., 2003; Duran and Marshall, 2002; Felice and Valentinuzzi, 1999; Felice et al., 1999; Glassmoyer and Russell, 2001; Moore and Madden, 2002; Owens etal, 1992; Ramalhor et al., 2001).

The impedancimetric technique has been particularly successful in microbial quality control of foods and has been reviewed in detail by other authors (Wawerla etal, 1999; Silley and Forsythe, 1996). An interesting application was the monitoring of conductivity changes of soil solutions as a method for detecting extraterrestrial life (Silverman and Muoz, 1974). Electrical impedance is complex, composed of a resistive and a reactive part. The inverse values of both parts are generally measured, that is the conductance and susceptance (or capacity if constant frequency is used). When the interface component is not included, the conductance and capacity are respectively physically associated to the suspension media and the measurement electrodes.

Impedance Microbiology (IM) is defined as the collection of methods applied in microbiology, which use impedance measurements to detect, monitor and quantify active and viable microorganisms (Kell et al., 1998). Capacity and permittivity measurements of cellular suspensions are not included in IM, but they are described in another section of this paper (Dielectric Spectroscofy).

The methods used in IM can reflect different phenomena depending on the concentration of the microorganisms present. When the concentration is under 107 cells/ml, the impedance or its components reflect only the effect of the microbial metabolic activity in the culture media and/or the measurement electrodes (Noble et al., 1999; Felice and Valentinuzzi, 1999; Firstenberg-Eden and Eden, 1984). These methods are considered classic in IM.

On the other hand, when the cell concentration exceeds 10^sup 7^ cells/ml (Davey et al., 1992), the conductance measurements of a cell suspension can reflect the biomass and its metabolic activity simultaneously and instantaneously or on-line (Yardley et al., 2000; Fehrenbach et al., 1992; Harris et al., 1987).

This ability to reflect two phenomena without discrimination makes this application one not commonly used in biotechnology. In addition, the measured value is affected by the presence of bubbles (Connolly et al., 1988).

The concentration that produces a detectable change in the impedance curves is defined as the concentration threshold (CT). It is 10^sup 7^ cells/ml for yeast and 108 cells/ml for bacteria such as Micrococcus luteus (Davey et al., 1992). The conductance signal is only incorporated as a bonus in the Biomass Monitor(TM) (BM, Aber Instruments Ltd., Science Park, Cefn Llan, Aberystwyth, SY23 3AH), an instrument that allows one to estimate biomass on-line, and in- situ using dielectric permittivity measurements (Yardley et al., 2000).

The classical techniques used in IM require that the microorganisms grow, multiply and reach a concentration of approximately 10^sup 7^ CFU/ml to produce a detectable impedance signal (Firstenberg-Eden and Eden, 1984). The estimation of viable biomass using these techniques for concentrations lower than 10^sup 7^ cells/ml is deduced indirectly from the relationship between the threshold detection time (TDT) and the initial cell concentration present in the inoculated culture media. In these cases, the lower the initial concentration, the higher the TDT, since the microorganisms need to grow for a longer time to produce significant changes in the initial ionic content of the culture media. In practice, a time measurement in an impedance curve replaces the concentration measurement made with a classical method such as a plate count (Felice et al., 1999). By using these techniques, concentrations between 101 and 10^sup 7^ CFU/ml can be quantified without any additional special processes (Noble et al., 1999).

Impedance Microbiology has two main areas of application. The first one is direct impedance technology, where the change in the conductivity of the liquid culture medium or the change in the impedance of the measurement electrodes serves as measuring parameters. The other one is indirect impedancemetry, where the change in the electrical conductivity of a reaction solution is measured. This change occurs through the absorption of gases originating in the inoculated microbial culture.

There are several microbiological applications using direct impedance measurement. The factors for medium optimization are analyzed in these applications to obtain better quality growth curves (Glassmoyer and Russel, 2001; Edmiston and Russell, 2000; Colquhoun etal, 1995).

There is less information in the literature about indirect impedancemetry, since it is a more recent technique. Devices for indirect monitoring of microbial growth are still appearing. The technique consists of measuring the impedance in one of two linked and hermetically sealed cells. In the first one there is an inoculated medium without electrodes and the second one contains potassium hydroxide with a pair of electrodes. When microorganisms grow, they produce CO2, which is absorbed by the potassium hydroxide, lowering the interelectrode impedance. This method is used when culture media with high concentrations of salts are needed as commercial equipment measurements may be out of range (Sawai and Yoshikawa, 2003; Riveiro et al., 2003; Owens et al., 1989).

Both techniques, direct or indirect impedancemetry, are faster for the quantification of microorganisms than the classical methods such as CFU counts. They can also be implemented for massive analysis of samples. For example, some of the commercial technologies available can simultaneously evaluate up to 512 samples.

In order to distinguish which technology could be employed in the quantification of biomass, the concentration range to be measured must be taken into account. There are also some questions to be answered. Which microorganisms are of interest? Viable or ABNC? Are the concentrations to be measured lower or higher than 10^sup 7^ CFU/ ml? It is very important to answer these questions before a method is selected.

3. Dielectric Methods

The dielectric method is the only one which allows a continuous, on-line and in-situ biomass measurement. The next paragraphs describe dielectric spectroscopy fundamentals, the relationship with biomass, and some applications thereof.

The electrical properties (or dielectric) of cell suspensions are given by conductivity and permittivity (dielectric constant ε). They change with the frequency of the applied electric field, where each frequency region is characterized by a specific mechanism, such as cell membranes, organelles inside cells, double layer counterions relaxation, etc. These regions correspond to the α, β, δ and γ dispersions (Schwan, 1957). They are typical for the majority of tissues and suspensions, but despite that the magnitude and frequencies may vary (Foster and Schwan, 1989; Schwan, 1957; Schanne and Ruiz-Ceretti, 1978). Dispersion is generally shown as a sigmoid change between a low and a high value or vice versa and with a determined time constant.

β dispersion is of general concern for biomass determination, since its amplitude is intimately related to the volume fraction occupied by the cells in a suspension. It is in the range of the radiofrequencies and its origin is still a matter of opinion.

One useful example to make clear the information given by the dielectric permittivity and the conductance of a cell suspension is the real-time monitoring of th\e accretion ofRbizopus oligosporus biomass during a solid-substrate tempe fermentation (Davey et al, 1991). In this case, capacity and permittivity provided the same information.

Figure 2 shows the time course of the fermentation of lupins, where two phases can be clearly distinguished: a growing phase, in which capacitance increases monotonically; and a second one, a nongrowing or lytic phase, characterized by a continuous decrease of capacitance with time. At the same time, the conductance increases slowly during the growing phase and sharply in the lytic phase, when cytoplasmic material is released into the medium thereby changing its conductivity.

FIGURE 2 Time course of lupin tempe fermentation. Y axis: Capacitance C of culture broth, Conductance Ge of culture broth. X axis: time in hours. C=(ε. ε^sub 0^. A/d) where ε: permittivity, ε^sub 0^: vacuum permittivity. A: transversal area of the sample, and d: distance between electrodes. (Adapted from Davey et al., 1991, by permission of Kluwer Academic Publishers.)

Up to now, a great number of papers have reported on the use of the dielectric permittivity methods to measure biomass. There are two commercial systems using dielectric spectroscopy to measure biomass: the Biomass System(TM) (Fogale Nanotech, Nimes, France) and the Biomass Monitor(TM) (Aber Instruments Ltd., Aberystwyth, U.K.), which is available in different models. The former is a three- frequency capacitance analyzer that computes the biomass concentration (Sarrafzadeh etal., 2005) from the difference between measurements made at two frequencies. The latter is suitable for precise on-line monitoring of homogeneous (unicellular) and heterogeneous (mycelial) cultures in bioreactors as reported by Fehrenbach etal. (1992). The measurements were performed on bioreactors of up to 2000 liters on cultures of Saccharomyces cerevisiae, Pichia pastoris and the filamentous bacterium Streptomyces virginiae. The capacitance signal measured was stable, with a slight influence of external parameters such as agitation speed and strongly influenced by medium conductance above 20 mS. However, they concluded that this instrument was useful for monitoring mycelial and yeast growth under industrial conditions.

Recently, a new probe has been described. The prototype was an annular probe, which was evaluated in realtime monitoring of the concentration of viable cells during an industrial pilot-scale fermentation to produce an active pharmaceutical ingredient (Ferreira et at, 2005). The new probe used the same measurement principle as the four-pin probe of the Biomass Monitor(TM), but was reported to be easier to handle and more robust than the latter.

Mishima et al. (1991a) studied other kind of cells such as E. coll, Aspergillus niger, human leukemia (K562) cells and a culture of Mardin-Darby bovine kidney (MDBK) cells. They were cultured in different ways, immobilized, aggregated or suspended. Rather than the Biomass Monitor(TM) they used a measuring chamber that was a parallel plate condenser with two electrodes. The dielectric measurements were made using a Hewlett-Packard 4194A Impedance/Gain Phase Analyzer controlled by a microcomputer. They have obtained very good results with very high correlation coefficients, more than 0.99 for all the cells and type of growth tested (Mishima etal, 1991a). In other work of the same group, they developed two types of electrodes for measuring the dielectric properties of a suspending medium of S. cerevisiae, obtaining the same results (Mishima et al., 1991b).

Using a HP4192A impedance analyzer, Bragos et al. (1999) presented two biomass estimators derived from a generic cell suspension model and parameters from the Cole-Cole impedance model (Davey et al., 1992). They also obtained good correlation coefficients for all cells tested and found that the concentration threshold of E. coli was higher than the concentration threshold of yeast, or inclusive of other bacteria such as R. capsulata (Brags et al., 1999).

a. Permittivity Measurement Using the Inductive Method

A relatively recent technological development, which avoids all the obstacles generated by electrode polarization, was the design of a biomasss sensor based on the indirect determination of permittivity of a biological suspension by measuring inductance. The HP inductive permittivity probe E5050A was presented in the market in 1995 by Hewlett-Packard. It was then applied to dielectric spectroscopy of colloidal suspensions, including the biomass measurements of yeast, bacteria and mammalian cells (Wakamatsu, 1997; Asami et al., 1996; Siano et al., 1996). The E5050A was also applied to the dielectric monitoring of cell growth in whisky and beer fermentations (Asami et al., 1996; Asami and Yonezawa, 1995).

The E5050 sensor consists of two coaxial toroidal coils, between which the microbial suspension is located. Both coils are covered with an epoxy resin. When voltage is applied to the primary coil, a current is induced in the secondary one, which depends on the sample admittance, that is, on the conductivity and permittivity of the microbial suspension. Admittance is determined by the rate between the voltage applied to the primary coil and the current in the secondary one.

This sensor avoids the use of electrodes and therefore eliminates all the polarization impedances in the measurement. The probe was not sterilizable and requires the HP4285A precision LCR meter to function. At present, the E5050A colloid dielectric probe is no longer being sold or supported by Hewlett-Packard.

D. Chemical Methods: Bioluminescence

Chemiluminescence occurs when a chemical reaction produces an electronically excited species, which emits a photon in order to reach the ground state. These reactions are encountered in biological systems and the effect is called bioluminescence. Bioluminescence is a very rapid and sensitive method for bacterial detection. Assuming that living cells of a given type, contain a reasonable constant amount of adenosine 5’triphosphate (ATP), which is lost rapidly upon cell death, it can be a good parameter to measure to quantify cells. The reaction of ATP with luciferin catalyzed by the luciferase enzyme is the principle of the bioluminescence method.

One photon of light is produced per molecule of hydrolyzed ATP and this can be measured using a photometer (Hobson et al., 1996), giving a sensitivity of about 10^sup -4^ mol of ATP. The light emitted is proportional to the amount of ATP present. By knowing the concentration of ATP in the sample, an estimation of microbial content can be made.

In some cases, when a variation of cellular ATP content occurs, the measurement of the total concentration of adenine nucleotides (ATP, ADP, and AMP) is used.

These variations are due to incomplete extraction, activity ofATPases or kin ases, or variation in physiological conditions, among others. The total concentration of these three nucleotides remains essentially constant. It is not possible to measure biomass on-line with this method because it is necessary to remove the sample from the fermenter with the corresponding delay before the results are available (Harris and Kell, 1985).

Billard and DuBow (1998) considered that luminescence-based assays to detect bacteria were better compared to traditional methods such as microscopy, immunological and nucleic acid-base detection assays because the method uses reporter genes that enable selective viable cell enumeration. That is, the use of molecular marked cells offers more versatility to the assays because of the number and types of genes that can be introduced.

There are many papers dealing with bioluminescent biosensors in the literature. Most of them were developed to study the toxicity of different chemical compounds or heavy metals (Kim and Gu, 2003; Kim et al., 2003; Horsburgh et al., 2002; Billard and DuBow, 1998; Premkumar et al., 2002). Other biosensors were developed to be incorporated inside a FIA system for the determination of ATP and NADH (Blum et al., 1993). However, it was not stated that these biosensors could serve as biomass determinators, although if a calibration through any software or expert system were made, ATP concentration could be related to biomass.

E. Photometric Methods

1. Fluorescence

Fluorescence is the result of a three-stage process that occurs in certain molecules (generally polyaromatic hydrocarbons or heterocycles) called fluorophores or fluorescent dyes. The process responsible for the fluorescence of fluorescent probes and other fluorophores is related to the levels of energy of a molecule and the jump of an electron from a high energy state to a lower one, emitting a photon at the same time.

Absorption of UV radiation by a molecule excites the electron from a vibrational level in the electronic ground state to one of the many vibrational levels in the electronic excited state. This excited state is usually the first excited singlet state (all electrons in the molecule are spin-paired). A molecule in a high vibrational level of the excited state will quickly fall to the lowest vibrational level of this state by losing energy to other molecules through collision. The molecule will also partition the excess energy to other possible modes of vibration and rotation. Fluorescence occurs when the molecule returns to the electronic ground state, from the excited singlet state, by emission of a photon. This process distinguishes fluorescence from chemiluminescence, in which the excited state is populated by a chemical reaction.

If a molecule which absorbs UV radiation does not fluoresce it means that it must have lost its energy. These processes are called radiationkss transfer of energy and may be collisional quenching, Fluorescence Resonance Energy Transfer (FRET) and intersystem crossing.

Four essential elements of fluorescence detection systems are identified from the preceding di\scussion: 1) an excitation source, 2) a fluorophore, 3) wavelength filters to isolate emission photons from excitation photons, and 4) a detector that registers emission photons and produces a recordable output, usually as an electrical signal or a photographic image. Regardless of the application, compatibility of these four elements is essential for optimizing fluorescence detection (Abelson et al, 1997).

Fluorescence is the most widely used method for on-line biomass determination in a bioprocess. The intensity of the fluorescence is affected by the amount of viable biomass concentration and by abiotic factors such as air bubbles or other fluorescent components in the medium. Different complicated fluorometer devices were developed over the years to be used in fermenters, and based on these devices, different biomass estimation experiments were performed (Stark et al., 2002; Parsys et al., 2005). Zabriskie and Humphrey (1978) applied for the first time culture fluorescence for the estimation of biomass in fermenters. The logarithm of fluorescence was found to be generally linear with the one of the biomass, but the relationship depended on the culture environment, making the technique slightly reliable for in situ monitoring of biomass. This is a good technique only under strictly controlled cultivation conditions.

Honraet et al (2005) obtained good results with fluorescence measurements with different dyes for the quantification of Candida biomass in suspension. This technique could be applied for the quantification of biomass in fermenters. However it requires extraction of the sample from the reactor making the method less practical.

Recently, different spectroscopic techniques have been studied intensively for potential application in bioprocess monitoring (Wolfbeiss, 2002). Optical techniques using fiber technology are of particular interest. They provide the possibility for non-invasive monitoring of bioprocesses. Fluorescence spectroscopy is one of these techniques and offers the possibility to directly follow different analyte concentrations and even the metabolic state of the biomass.

Fluorescent spectroscopy and chemometric methods are able to monitor on-line bioprocesses parameters, including biomass, with good results (Boehl et al., 2003).

2. Scattered Light Measurement

Biomass estimation based on the optical properties of the medium is traditionally used in fermenters. The Huygens basic measurement principle says: “When the light energy cannot be absorbed, a light quantum of the same energy (color) must be re-radiated. This light can emerge in any direction. This means that all atoms in a physical body serve as secondary sources of light.”

The light scatter measurement methods can be classified according to the position of the light detector as:

* Turbidimetry-measures the primary beam of light that passes into the sample without deviation to reach the detector. Not recommended when used in fermenters in a conventional way, since the signal-to-noise ratio is too low.

* Nephelometry-measurement of the scattered light. Recommended for low biomass concentration. The signal is directly proportional to biomass. Typically nephelometers detect light scattered usually at 90 to the incident beam. Backscattering optical probes use light scattered at 180 and are useful for high cell concentrations.

Detectors with optimized path lengths are available to improve the signal-to-noise ratio and they are used in extremely dense microbial cultures.

III. CONCLUSIONS

Biomass measurement continues to be a critical parameter in bioprocess control. The methods now need to be faster, on-line and in-situ, to yield greater technological progress. The physical methods for biomass determination prevail in terms of practicality. These methods are closer to the ideal, but they still need to solve problems such as biofouling or the electrode-electrolyte interface interference. In the case of dielectric spectroscopy specifically, it is necessary to achieve a lower resolution when bacterial cultures are measured.

Fluorescence is the most widely used method and it is a good technique only under strictly controlled cultivation conditions, because it depends on the culture conditions. In practical terms, fluorescence sensors for biomass determination are well developed. Another widespread physical method is dielectric spectroscopy, but although it is an efficient method, the necessary equipment is onerous. Flow cytometry is very promising but too complex at this time. Other methods are successful only in specific cases.

ACKNOWLEDGMENTS

E. Treo contributed the “Dielectric Methods” of the “Physical Methods” portion of this article.

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Progestin Only Contraceptives and Their Use in Adolescents: Clinical Options and Medical Indications

By Burkett, Amy M; Hewitt, Geri D

This article reviews progestin only contraceptives and their use in adolescent women. Young women requiring hormonal contraceptives for birth control or medical indications may prefer or require a nonestrogen containing product. This article reviews the products currently available, those soon to be released, and those under development. Many relatively common clinical situations preclude the use of estrogen-containing contraceptives or combination hormonal contraceptives, and those also will be outlined.

Progestin only hormonal contraceptives

Depot medroxyprogesterone acetate

Depot medroxyprogesterone acetate (DMPA) is discussed in detail in another section, but warrants brief mention here because it is used so widely. DMPA is given intramuscularly every 12 weeks and works by suppressing the luteinizing hormone (LH) surge and inhibiting ovulation [I]. Failure rate is less than 1% over 1 year of perfect use, but with typical use, the failure rate is 3% [2]. The most commonly experienced adverse effect is menstrual irregularity, including amenorrhea [I]. Other potential adverse effects include depression, weight gain, and a longer interval of return to baseline fertility when compared with oral contraceptives [3]. There is also increasing concern regarding bone mineral density loss with use in patients younger than 14 and with long-term use. This concern has led the manufacturer to change the package insert to limit the duration of use to 2 years unless no other hormonal contraceptive method is available [4,5].

Progestin only pills

Progestin only pills come in three separate formulations in the United States. Micronor and Nor-QD each contain 0.35 mg of norethindrone; Ovrette contains 0.075 mg of norgestrel. Progestin only pills are all active pills, with no inert pills or placebos, and they need to be taken daily, at the same time (Table 1) [I]. This required level of diligence can be a challenging obstacle for adolescent use. Progestin only pills have a perfect use failure rate of 0.3%. Because it must be taken at the same time every day, its typical use failure rate is upwards of 10% [2]. The progestin only pill works by suppressing ovulation, thickening cervical mucus, and causing atrophy of the endometrium [1,6], thus creating an inhospitable uterine environment to the sperm and ovum. Like all oral contraceptives, the progestin only pill will not disrupt an implanted pregnancy, cause miscarriage, or birth defects [7]. Adverse effects include amenorrhea, intermenstrual spotting, and altered menstrual flow. Up to one-third of women who are using these pills while not lactating will experience an abnormal bleeding pattern. Patients should be counseled regarding longer cycles and intermenstrual spotting, as these are the most common complaints leading to discontinuation. Patients using them while lactating are more likely to experience amenorrhea. This effect likely is related to lactational amenorrhea and is well tolerated, as the discontinuation rate in the lactating population is lower. Although menstrual irregularities may be more common in nonlactating patients using progestin only pills compared with estrogen-containing pills, headaches and breast tenderness are less common [6].

Table 1

Difference between progestin-only and combined hormonal contraceptives

Implanon

Implanon is a plastic polymer rod implant containing etonogestestrel that is available only in Europe [8], but it has received Food and Drug Administration (FDA) approval [9] and will to be released in the United States soon [I]. Implanon is inserted by a health care professional underneath the skin to provide long-term (up to 3 years) contraception [8]. Like other forms of hormonal contraception, the mechanism of action with the contraceptive rod is inhibition of ovulation [I]. Implanon is an excellent hormonal contraceptive option for young women, because there is little need for ongoing patient compliance after insertion, and the pregnancy rate is remarkably low. An initial study published in 1999 reported no pregnancies in its study population, which included over 1200 woman-years. Norplant was a contraceptive rod system with six silastic rods containing levonorgestrel. When inserted under the skin, it was effective for up to 5 years [1O]. Researchers feel comfortable projecting Implanon’s contraceptive efficacy to be comparable to Norplant’s, which had a 0% to 0.6% failure rate in the first 3 years of use and a 0.6% to 1% failure rate at 5 years of use [11,12]. Implanon has distinct advantages over Norplant directly related to its development into a single rod with a different plastic polymer that will allow greater ease of insertion and removal [8].

Implants are well accepted by women. In a study looking specifically at an adolescent population, 93% were satisfied with Norplant. Implanon should be as well accepted as Norplant or even more so given its ease of insertion and removal. Adolescents tend to choose an implant after a contraceptive failure, particularly one resulting in pregnancy. They also switch to an implant when they experience adverse effects from other methods. Some simply choose implants because they like the device’s convenience and ease of use [13]. Patients need to be counseled to expect altered bleeding patterns ranging from amenorrhea to prolonged and heavy menstrual flow; these are the most common reasons sited for early removal of Implanon. Other reasons sited include desired pregnancy, worsening of acne, weight gain [10], breast tenderness, and headache [14]. Most adverse effects experienced by patients using Implanon were not bothersome enough for the patient to have the device removed [14].

Emergency contraception

Up to 30% of patients have never heard of emergency contraception, and only 10% know how to obtain it [15]. Emergency contraception is described in detail elsewhere in this issue; this article briefly describes the progestin only method. There are three common pill regimens available, the Yuzpe Method, Plan B, and low- dose mifepristone [16,17]. Plan B is the progestin only method of emergency contraception. It contains two 0.75 mg doses of levonorgestrel, which are to be taken 12 hours apart. It is highly effective in preventing pregnancy after an act of unprotected intercourse. When used in the first 24 hours after unprotected intercourse, one study found only 2 of 450 women became pregnant. Although the method is most effective in the first 24 hours, it can be used up to 72 hours after unprotected intercourse [18]. Emergency contraception can be very helpful to young women who experience rape, sexual abuse, contraceptive failure, or a spontaneous, unpredictable sexual encounter where contraception was not used or planned for in advance. Although progestin only emergency contraception will not harm an existing pregnancy, the only contraindication to its use is pregnancy [7]. Therefore if a clinician is contacted regarding a patient’s need for emergency contraception, they can simply have the patient do a home urine pregnancy test and, if negative, call in a prescription to a local pharmacy for “Plan B, to use as directed.” It is important to initiate the therapy as soon as possible after the act of intercourse. The young woman can follow up in the office at an appropriate interval for contraception counseling, sexually transmitted infection (STI) testing, and a follow-up pregnancy test. Adverse effects are less common with plan B than the other methods, but they include nausea, vomiting, breast tenderness [18], and irregular bleeding patterns [19]. These patterns include spotting, shortened interval to menses, and lighter or heavier menses [19]. Teenagers should not mistake spotting for a light menses, as spotting does not always indicate success of emergency contraception [18,19]. Studies show that adolescents who are given emergency contraception before a method failure (advance provision) are more likely to use it than those who have to obtain it after unprotected intercourse has occurred. These data support providing all sexually active adolescents prescriptions for emergency contraception [20].

Intrauterine devices

Intrauterine devices (IUDs) have a long and mixed history as contraception in the United States, much of which stems from the now obsolete Dalkon Shield [21]. IUDs often are not considered a viable method of contraception in the adolescent population, but research shows that in a carefully screened population, the device can be successful. Adolescents should be mutually monogamous, placing them at low risk for STIs. They do not have to be parous, but there is a higher expulsion rate in the nulliparous patient [22]. The Mirena IUD (Table 2) contains a progestin. It works by slowing releasing levonorgestrel into the endometrial cavity over a 5-year period and has a failure rate of 0.1% [2]. The device works locally, causing thickened cervical mucus and an atrophie endometrium. This environment is toxic to sperm because of local inflammation [23]. The ParaGard IUD is not hormonally active but contains copper, again causing endometrial inflammation that is toxic to sperm (Fig. 1). Both IUDs are spermicidal. The copper IUD is effective for up to 10 years after insertion [24] and has a failure rate of 0.8% per year with typical use [2]. Most women experience a decrease in menstrual bleeding whil\e using the Mirena IUD, but bleeding profiles when using the nonhormonally active IUD can be heavier than a patient’s preinsertion menses [24]. Because both devices are very effective in preventing pregnancy, the rate of ectopic pregnancy is lower than that seen in the general population [24,25]. The Mirena IUD is not recommended for patients with a history of ectopic pregnancy, as these patients were not included in the clinical trials [25]. Complications associated with IUDs include uterine perforation during insertion, insertion-related endometritis [24], and increased dysmenorrhea that usually responds to nonsteroidal anti- inflammatory drugs (NSAIDs). The most common reasons patients request IUD removal are bleeding and pain [22]. Antibiotic prophylaxis at the time of insertion is recommended only for patients who receive prophylaxis for other procedures, such as dental work [24].

Table 2

Comparison of copper and progestin containing intrauterine devices

Fig. 1. ParaGard is made of soft white plastic in the shape of a small “T.” It is 1.375 inches long, with small amounts of copper wrapped around the stem and arms. The copper enhances effectiveness. (From www.paragard.com.)

Future methods

Researchers continue to strive for hormonal contraception that is simple, effective, and user friendly. To that end, there are efforts to create an implant that is biodegradable when exposed to body fluids. Such a device is Capronor, a capsule consisting of levonorgestrel, which slowly dissolves. A second device consisting of four to five pellets of norethindrone is in early development [1,2]. If successful, both devices would alleviate the uncomfortable process of removing a device, while still providing the long-term, effective, and effortless contraception many adolescents desire.

Vaginal rings as alternative delivery system are receiving attention also. A combination contraceptive ring containing both estrogen and progestin is already available in the United States. A progestin only ring is available in South America, indicated currently only for use during lactation. Further use and development of progestin only rings had been halted in the 1980s because of concern over adverse lipid profiles and vaginal lesions. There is a phase II trial underway looking at a nestorone-containing ring that could stay in place for 6 to 12 months in lactating women [26].

Clinical indications for progestin only contraceptives

Lactation

Some adolescent mothers are very interested in breastfeeding, and with appropriate education and support, they are successful at breastfeeding exclusively. Most clinicians are familiar with the use of the progestin only contraceptive methods during lactation. Because estrogen-containing hormonal contraceptives affect breast milk production, progestin only options are the preferred choice. Controversy exists regarding when to initiate progestin only contraceptives in the postpartum period. Most authorities, including the National Medical Community of Planned Parenthood Federation, agree that it is acceptable to begin them immediately postpartum, but the World Health Organization (WHO) and International Planned Parenthood Federation recommend waiting until 6 weeks postpartum [27]. Some clinicians prefer to wait until the 6 week postpartum visit to decrease the likelihood of abnormal bleeding [28] and to secure lactogenesis [29]. The authors’ practice has been to initiate progestin contraceptives before discharge from the hospital for several reasons. First, a significant proportion of teen mothers in their practice have initiated sexual activity before their 6-week follow-up appointment. second, few of their young mothers breastfeed exclusively, and third, compliance at the 6-week postpartum examination is often less than 100%. DMPA, progestin only pills, and contraceptive rods can be initiated before discharge from the hospital (Fig. 2). The progestin IUD is not approved by the FDA for use in lactating women [25]. Latino women with gestational diabetes are at increased risk of developing diabetes in the first year after delivery if they are lactating and using progestin only pills [3O]. Although this is not a contraindication to using progestin only pills in this population, it emphasizes the need for diabetes screening during this period (Fig. 3).

Fig. 2. Plan B. (From http://ec.princeton.edu/Pills/planb.html.)

Gynecologic disorders

Often times an adolescent may present to the pediatrician with gynecologic complaints, including dysmenorrhea, pelvic pain associated with endometriosis, polycystic ovarian syndrome, and anovulatory bleeding. Progestin only contraceptives may play a role in managing these common gynecologic complaints.

Medical problems

Although most adolescent women are healthy and without medical risk factors or disease, there are numerous health problems that can preclude a young woman from using estrogen-containing birth control methods (Table 3) [7,31]. Approximately 10% of adolescents are diagnosed with a major medical condition by the time they are 18 [32]. Therefore, practitioners should screen their patients for personal and family medical conditions that could affect their contraceptive choice. Screening questions should include personal or family history of neurological disorders, cardiovascular disease, sickle cell anemia, liver dysfunction, and diabetes. It should be noted that there are no medical conditions that preclude the use of progestin only emergency contraception [7].

Fig. 3. The implantable contraceptive rod.

Table 3

Medical conditions and their impact on hormonal contraceptive choice

Cardiovascular disease

Adolescents should be asked about cardiac disorders and cardiovascular risk factors when considering hormonal contraception. These risk factors include [34]:

* Smoking

* Diabetes

* Hypertension

* Family history of premature cardiac events

* History of cerebral vascular accident

* Low high-density lipoprotein (HDL) (less than 35)

* Elevated triglycerides (greater than 250)

* Elevated low-density lipoprotein (LDL) (greater than 160)

* Cardiac anomaly

Young women may not remember the specific disease entity, but one can screen for medication use, emergency room visits for chest pain, use of antibiotics during dental procedures, chest surgery, or a history of having an echocardiogram. Young women with asymptomatic mitral valve prolapse (MVP) can use combination hormonal contraception safely [7,33]. Patients with symptomatic MVP or MVP associated with smoking, history of thromboembolic events, or coagulopathy should not use combination hormonal contraception but can use progestin only birth control methods safely [33]. Teenagers with other uncomplicated cardiac valvular syndromes may use combination hormonal contraceptives [7]. Cardiac valvular syndromes complicated by pulmonary hypertension, risk of atrial fibrillation, or history of subacute bacterial endocarditis preclude the use of combination hormonal contraceptives. These patients can use progestin only methods safely [7]. Patients with valvular disease other than asymptomatic MVP require antibiotic prophylaxis against bacterial endocarditis at the time of IUD insertion [7,33].

Current WHO recommendations suggest that women with hypertension should avoid combination hormonal contraception and would be served better with the use of progestin only contraceptive methods. Young women with a history of hypertension limited to pregnancy can use combination hormonal contraception safely. Patients with uncontrolled hypertension (systolic blood pressure greater than or equal to 160 or diastolic blood pressure greater than or equal to 100) or multiple cardiac risk factors should avoid DMPA, but they may use any other progestin only methods safely [7].

More infants born with cardiac anomalies are living well into their reproductive years and require counseling about choosing acceptable methods of birth control. Pregnancy can expose these patients to significant risk of maternal morbidity and mortality. Many of these disorders, even when repaired, are complicated with other cardiac diseases, which preclude the use of combination hormonal contraceptives. Although there is an array of cardiac syndromes, generally the use of progestin only contraceptive methods is safe [32]. Both IUDs are also an acceptable choice in this patient population [7,32].

Box 1. Inherited hypercoagulable disorders

Teenagers with an active or resolved DVT (deep vein thrombosis) or PE (pulmonary embolus) cannot use combination hormonal contraceptives. In the patient with an active DVT or PE, progestin only methods should be avoided also, but they can be used safely after resolution of the acute event. Family history of DVT or PE does not preclude a teenager from using combined hormonal contraceptive methods unless a clotting disorder also was diagnosed [7].

Patients diagnosed with hereditary thrombogenic mutations (Box 1) should avoid combination hormonal contraceptives, but they can use all types of progestin only methods safely. Current WHO recommendations maintain that routine screening tests for thrombogenic disorders are not required before prescribing combination hormonal contraceptives [7]. If a young woman reports a family history of acute thromboembolic events or thrombogenic mutations, however, appropriate screening tests should be done [7,34]. These tests include [36] (personal communication with P. Samuels, MD, December 2004):

* Genetic testing for factor V Leiden

* Genetic testing for prothrombin gene 2021OA

* Plasma levels of protein C, protein S, antithrombin

* PT/INR

* PTT

* Plasma levels of homocysteine (if elevated, consider genetic testing for methyleneterahydrofolate reductase homozygosity and cystathionine β-synthase deficiency

The most prevalent disorder diagnosed is factor V Leiden mutation, affecting 7% of Caucasians [34]. Young patients with a personal history of thrombosis in less comm\on places or without trauma should be screened for the acquired hypercoagulable disorders in addition to the heritable thrombogenic disorders. The American College of Obstetrics and Gynecology (ACOG) specifically suggests screening for antiphospholipid antibodies and anticardiolipin antibodies in this patient population, as these disorders can complicate pregnancy outcomes and are a contraindication to combination hormonal contraception [35]. In adolescents diagnosed with hypercoagulable disorders progestin only birth control methods can be used safely so long as the patient does not currently have a DVT or pulmonary embolus (PE). Combined hormonal contraceptive methods should be avoided [7].

The WHO does not recommend routine lipid profile screening in healthy adolescents before prescribing combination hormonal contraception [7]. If a screening lipid profile is done for other reasons and identifies a dyslipidemia, there are specific recommendations for the use of hormonal contraception. Adolescents with controlled dyslipidemias have no limitations on their contraceptive choice as estrogens have a positive effect on HDL and LDL. If a young woman has an LDL greater than 160 or other cardiac risk factors, however, she should not use combined hormonal contraception, because estrogens elevate triglycrides [32]. These patients may use progestin only methods safely [32,36]. Patients with dyslipidemias on combination hormonal contraceptives should have their lipid profiles followed closely [32].

Neurologic conditions

Screening questions for neurological disorders should focus on headaches and seizures. Teenagers with nonmigrainous or migrainous headaches without aura are not limited from use of combined hormonal contraceptives [7,37,38], Migraines with aura lasting longer than 1 hour or accompanied by neurological symptoms such as numbness, weakness, or tingling preclude the use of combined hormonal contraceptives. Additionally if patients with migraines have stroke risk factors, they should not use combined hormonal contraceptives [31,37,38]. If a young woman begins to experience auras while using a progestin only method, it should be discontinued [7].

Young women with seizure disorders need reliable contraception because of the teratogenicity of most anticonvulsants [31]. No seizure disorder precludes the use of combined hormonal contraception. Many anticonvulsants, however, decrease the efficacy of combined and progestin only hormonal contraception, primarily through enhanced liver activity [7,31]. DMPA is the least affected by this process, likely because the serum concentrations are higher compared with other methods [31]. Although some clinicians increase the dose of the hormonal contraceptive prescribed in patients taking anticonvulsants, it is uncertain whether this will increase its efficacy [7]. Patients on anticonvulsants may choose barrier methods and either IUD, as their efficacy is not affected by liver metabolism.

Diabetes

Adolescents with type 1, type 2, or a history of gestational diabetes mellitus can use any method of hormonal contraception safely unless there is end organ damage (nephropathy, retinopathy, or vascular disease). The presence of end organ damage precludes the use of combined hormonal methods, but these patients can use progestin only birth control methods, barrier methods, or either IUD safely [7,38]. Young mothers who had gestational diabetes should be screened for impaired glucose tolerance after delivery [39]. All diabetic women should be counseled about the importance of glycemic control, because hyperglycemia is related directly to an increased risk of birth defects. This illustrates the need for glycemic control when attempting conception and emphasizes the need for good, reliable contraception in patients with diabetes [4O].

Sickle cell disease

Sickle cell disease is not a contraindication to the use of combined hormonal contraceptives. Small controlled trials suggest that patients using DMPA experience fewer crises, and therefore ACOG considers it the method of choice in these patients [38].

Hepatobiliary disease

Some types of gallbladder and liver disease preclude the use of hormonal contraceptives. When screening for these disorders, clinicians should ask about jaundice after the newborn period, history of cholecystectomy, presence of gallbladder disease, medically imposed dietary restrictions, intravenous drug abuse, current and past sexual practices, and history of blood transfusion before 1992 or transfusion of clotting factors before 1987 [41]. Active hepatitis precludes the use of all hormonal contraceptives, but these patients may use barrier methods and copper IUDs. Patients with chronic hepatitis can use progestin only options, barrier methods, and both IUDs. Adolescents with liver tumors or mild cirrhosis should not use combined hormonal contraceptives, as they can exacerbate these disorders. These patients can use progestin only methods safely [7,42]. Young women with decompensated cirrhosis should avoid all hormonal contraception but may consider a copper IUD [7]. Patients with active gallbladder disease are candidates for progestin birth control, but they should not use combination hormonal contraceptives until after cholecystectomy [7]. Adolescents with Wilson’s disease should avoid the copper IUD and combination hormonal contraceptives but may use progestin methods safely. Any young woman who has received a liver transplant can use the progestin only methods safely, but the use of combined hormonal contraception is controversial. Patients taking combined hormonal contraceptives need to have liver function tests and cyclosporine levels monitored closely. Use of IUDs in liver transplant patients is also controversial because of their immunosuppression, which may cause an increased risk of ascending infection. There is also concern that the immunosuppressive agents may lessen the efficacy of the copper IUD, as its affects are thought to be exerted partially through the immune system [42].

Patient choice

Patient lifestyle always plays a role in the choice of contraceptive. Although choosing a contraceptive method, counseling adolescents, and sexual activity are addressed elsewhere in greater detail, it should be noted that DMPA and implantable devices often are chosen by young women simply because of ease of use. These methods do not require the adolescent to remember a pill every day, and they provide discreet, long-term contraception with minimal hassle.

Summary

Most adolescents are healthy and can use combined hormonal contraception safely. In clinical situations that preclude the use of these agents, the patient often can be served well by a progestin only method. The progestin only contraceptive options include pills, a long acting intramuscular injection, an implant, and a progestin IUD. Although the options vary in their efficacy, they are generally safe and well tolerated by adolescents. In particular, implants are suited well for adolescent use because of their low need for compliance and high efficacy and continuation rates. Pregnancy is the only contraindication to progestin only emergency contraception, and studies show advanced provision enhances its appropriate use in the adolescent population.

Acknowledgments

The authors would like to thank Ms. Laura Trout-Molton for her help in preparation of the final manuscript and Ms. Megan Dailey for her assistance in accessing numerous reference articles.

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[29] Kennedy KI, Short RV, Tully MR. Premature introduction of progestin only methods during lactation. Contraception 1997;55:347- 50.

[30] Kjos SL, Peters RK, Xianq A, et al. Contraception and the risk of type 2 diabetes mellitus in Latina women with prior gestational diabetes mellitus. JAMA 1998;280:533-8.

[31] Neinstein L. Contraception in women with special medical needs. Compr Ther 1998;24(5): 229-50.

[32] Heroux K. Contraceptive choices in medically ill adolescents. Semin Reprod Med 2003;21(4): 389-98.

[33] Sullivan JM, Lobo RA. Considerations for contraception in women with cardiovascular disorders. AJOG 1993;168(6S):2006-11.

[34] Rao AK, Sheth S, Kaplan R. Inherited hypercoagulable states. Vase Med 1997;2(4):313-20.

[35] American College of Obstetricians and Gynecologists. ACOG Educational Bulletin 224: antiphospholipid syndrome, February 1998. In: 2004 Compendium of selected publications. Washington (DC): ACOG; 2004. p. 149-58.

[36] Knopp R, LaRosa JC, Burkman Jr T. Contraception and Dyslipidemia. AJOG 1993;168(6S): 1994-2005.

[37] Evans RW, Lipton RB. Topics in migraine management: A survey of headache specialists highlights some controversies. Neurologic Clinics 2001;19(1) NP. Available at http://home. mdconsult.eom/das/ article/body/41197932-2.

[38] American College of Obstetricians and Gynecologists. ACOG Practice Bulletin 18: The use of hormonal contraception in women with coexisting medical conditions, July 2004. In 2004 Compendium of Selected Publications. Washington DC: ACOG; 2004. p. 674-87.

[39] American College of Obstetricians and Gynecologists. ACOG Practice Bulletin 30: Gestational Diabetes, September 2001. In 2004 Compendium of Selected Publications. Washington DC: ACOG; 2004. p. 398-411.

[40] Mestman JH, Schmidt-Sarosi C. Diabetes mellitus and fertility control: contraception management issues. AJOG 1993;168(6S):2012-20.

[41] Adams PC, Arthur MJ, Boyer TD, et al. Screening in liver disease: report of an AASLD clinical workshop. Hepatology 2004;39(5):1204-12.

[42] Connolly TJ, Zuckerman AL. Contraception in the patient with liver disease. Semin Perinatal 1999;22(2):178-82.

Amy M. Burkett, MD, Geri D. Hewitt, MD*

The Ohio State University College of Medicine and School of Public Health, 516 Means Hall, 1654 Upham Drive, Columbus, OH 43210, USA

* Corresponding author.

E-mail address: [email protected] (G.D. Hewitt).

Copyright Hanley & Belfus, Inc. Oct 2005

Natural Contraception

By Breuner, Cora Collette

Among consumers and health professionals, complementary and alternative medicine (CAM) has become sought after and integrated into mainstream provision of medical services. CAM, known as nonallopathic, unconventional, holistic, or natural therapy, encompasses many types of healing practices [1,2] From the Cochrane Collaboration, CAM is a “a broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health systems in a particular society or culture in a given historical period” [3].

A 1993 Harvard study documented that in 1990, more than one- third of Americans used unconventional therapies [4]. In a second study, this number increased by 38%, from 60 million to 83 million people per year between 1990 and 1997. Expenditures for visits to alternative medicine providers were estimated at $21.2 billion, $12.2 billion of which was paid out-of-pocket. Nearly one in five individuals taking prescription medicines also was taking herbs or highdose vitamin supplements [5]. CAM use is considerably higher in specific groups of children and adolescents, such as in those with cystic fibrosis, cancer, arthritis, and in those undergoing surgery [6-12]. Use in homeless adolescents was noted to be 70% and was felt to be caused, among other things, by a need to use something natural and a mistrust of mainstream health care. These youth faced medical and mental health illness on an acute and chronic basis yet felt more confidence in a system that embraces CAM [13]. From a Detroit study, 12% of the pediatrie patients were using CAM [14]. A significant predictor for CAM use in the pediatrie populations is the use of CAM by parents.

Primary care providers are resources for advice and recommendations about using CAM. Adult primary care providers maintain an open attitude toward CAM and may make referrals to CAM providers, or use CAM themselves [15-21]. Similar findings were seen within a study of pediatricians [22].

There are multiple effective contraceptive medical allopathic choices available for women and men in the form of the birth control pill, injectables, barrier methods, intrauterine devices, and sterilization. Yet these may not be the only options that people use, as made clear from studies on CAM use. The contracepting community, of which adolescents may be active or passive members, includes those who seek alternative choices for many chronic illnesses, for prevention or health maintenance, and as an adjunct to the medical services provided by allopathic providers. This article discusses some of these options for contraception, including natural family planning and plant- derived hormonal contraception. The discussion will include medical evidence to support or refute these methods, potential dangers of these interventions, and additional resources for those who want to learn more.

Natural family planning-historical view

The concept of regulating fertility is not a new one. The decline in fertility among the white middle class was noted in Europe and then the United States in the 19th century [23]. The gospel of self sovereignty and fewer children and healthy, happy maternity was coincident with reproductive control and drew considerable support around the time of the Civil War. Fertile times, when sexual activity needed to be curtailed, were documented in diaries and in the medical literature and were discussed at length in the higher social circles.

Family planning has belonged to a highly discordant and not necessarily peaceable clan [24,25]. Family planning to many has been the cornerstone of feminism, redefining the role of women from their patriarchal-defined role as child bearers and household managers. For others, the term is synonymous with abortion. The criminalization of abortion during the latter half of the 19th century drove reproductive services and dissemination of information underground until the middle of the 20th century. Only recently has it become apparent that discussion of contraception is less of a taboo and more of an ethical right for women and men.

From the historical perspective in island and native cultures, sexual taboos against premarital and adolescent sexual union did not exist, as observed and recorded by anthropologists. One reviewer noted that in these cultures where sexual experimentation among adolescents was allowed, there was a general absence of pregnancy [26], Ethnographic reports are highlighted in the next section.

Regarding the Triobriand islanders in Oceania

Since there is so much sexual freedom, must there not be a great number of children bom out of wedlock? If this is not so, what means of prevention do the natives employ? .. .it is very remarkable to note that illegitimate children are rare. The girls seem to remain sterile throughout their period of license.. .until they marry; when they are married they conceive and breed sometimes quite prolifically.. .1 was able to find roughly a dozen illegitimate children recorded genealogically throughout Triobriands, or about 1 %. Thus we are faced with the questions: why are there so few illegitimate children? .. .they never practice coitus interruptus [27].

In the textbook Medical History of Contraception, Himes postulated that desire for contraception is a universal social phenomenon; every society possesses some knowledge of birth control, even if the methods are not always effective. Ethnographers in the era along with Himes rejected the idea of medicinal plants, roots, and barks as commonly used contraceptives. Female researchers who visited these cultures, however, were able to establish trust with the native women in Peru, the Pacific islands, and the Pacific Northwest Native American Shoshone and learned of contraceptive plants grown in small secret gardens and used by these indigenous women.

The questions from the past remain pertinent today. Women want to know: when am I the most fertile? When am I the least fertile? And for adolescents, what is the perfect (easiest) way to keep from getting pregnant? (tonight)? For many, natural birth control answers these questions and helps women to be more in control of their fertility.

In the United States, approximately 4% of women of reproductive age use natural family planning (NFP) to avoid pregnancy. In one study, a questionnaire was mailed to 1500 women, aged 18 to 50 in Missouri in 1992. Almost 25% stated that they would probably use NFP in the future to avoid pregnancy, and 37.4% indicated that they would likely use NFP in the future to become pregnant [28]. A woman’s decision regarding her desires for a family are planted well before her actual first pregnancy, most likely during her adolescent years [29]. Women are seeking out information on natural birth control as a method to prevent pregnancy [30],

Can adolescents learn information needed for natural family planning?

The correspondence of cervical mucorrhea with elevated concentrations of serum and 24-hour urinary estrogens has been established [31-33]. Can this information be disseminated to the adolescent population? Many would think that this is a concept far from the grasp of an adolescent. Yet Klaus and Martin evaluated this and concluded that ethnically and socioeconomically diverse perimenarchal girls can be taught to recognize their cervical mucus patterns and distinguish anovulatory from ovulatory cycles [34].

Young women can take an interest in the physiology of their own bodies. In a study on the pathophysiology of polycystic ovarian syndrome, women performed menstrual charting in an attempt to understand ovulatory disorders. Although this article focused on polycystic ovary syndrome and hypothalamic dysfunction, information gained from a paper such as this can be used in future research on the reproductive health education of the young woman. With knowledge of fertility and menstrual cycle function, adolescents and young women are in a stronger position to make informed decisions about how they wish to manage their reproductive and sexual health [35].

Fig. 1. Marquette model chart. Most commonly patients color code the interpretation: red for menses, green for infertile day, blue for fertile day. The amount of flow is also described is the space allotted for comments. This chart represents a luteal phase deficiency. Note the shortened luteal phase of only 8 days. (From: Barron ML. Proactive management of menstrual cycle abnormalities in young women. J Perinat Neonat Nurs 2004; 18(2):81-92.)

There are many types of NFP, including the Billings Method (the ovulation or mucous method), named for Australian doctors Jon and Evelyn Billings. This method charts the presence and description of cervical fluid [36]. The mucous method describes three different cervical fluids during the menstrual cycle: (1) sticky, tacky, and dry occurring after menstruation, (2) creamy, milky, and smooth, which occurs right before the most fertile period, which is (3) slippery, egg white, stretchable, clear, and yellow /pink or red tinged. Women are taught to avoid intravaginal sexual activity when the cervical mucous reflects the most fertile time [37]. An example of this method is noted in Fig. 1.

Herbal contraception

Herbal products historically have been the cornerstone of much of the pharmaceutical armamentarium. Active segments of the plant include leaves, flowers, stems, roots, se\eds, and berries. Plant- derived products used by health care providers include the statins, which are derived from the fungus Aspergillus terreus; cephalosporins, derived from a marine fungus (Cephalosporium acremonium); digoxin from foxglove (Digitalis lanata), progesterone (Dioscorea villosa, Mexican yam); and cromolyn sodium, a khellin derivative from the Ayurvedic herb Ammi visnaga [38].

From the Harvard studies on CAM use in 1990 and 1997, the use of selfprescribed herbal remedies within the United States increased from 2.5% to 12.1% [4,5]. The proportion of individuals consulting practitioners of herbal medicine rose from 10.2% to 15.1%, and they spent around $5 billion on herbal medicines. In 1998, Brevoort estimated the total retail sales of herbal medicines close to $4 billion [39].

Experts in the field of naturopathy and medicine do not support herbal contraception because of the lack of scientific evidence of efficacy and the possibility of adverse outcomes. With that in mind, it is known that the plant kingdom contains numerous bioactive substances that may affect the regulation of reproduction. Many herbs have been used to reduce fertility with little or no scientific evidence supporting this claim [4O]. Berman, an expert in CAM, does not recommend contraceptive herbs in that they may be abortifacients that work by poisoning the woman [41]. Fifty-seven poisonings from attempts at herbal abortion, including two deaths, were reported in a 1900 to 1997 review [42]. The German Commission E Monographs issued repeated warnings that many herbs can cause pregnancy termination as a side effect and so are not recommended in the pregnant patient or in one desiring pregnancy [43]. Importantly, many of these herbal supplements may be substandard both in content of active constituents and in lack of contamination. Health professionals need to educate their patients on the lack of stringent federal regulation of these products. There have been recent attempts at improving the standards [44,45].

The following herbs and other compounds have been evaluated predominantly in the laboratory with mixed results. If available, information on typical doses is cited. Techniques used for extraction of the bioactive ingredients of these herbs are noted to use ethanol or methanol, which may cause some of the anticontraceptive effects. Except for the isolated occasion, many of these herbs have not been studied in people. Despite this, usage may be higher in women and men than previously thought judging by the high volume of people accessing herbal contraception on the Internet (eg, www.sisterzeus.com). It is not known how many adolescents use these products.

Ovulation inhibition, anti-implantation

Queen Anne’s lace seeds/Wild carrot fDaucus carotaj

Women have used seeds from Daucus carota for centuries; the earliest written references dates back to the late 5th century BC appearing in a work written by Hippocrates. Many view Queen Anne’s lace as a promising postcoital agent, and Internet discussion recommends use similar to emergency contraception, although there has been little or no scientific evidence to support this claim. Typically, one teaspoon of the seeds are chewed and then swallowed with water or juice. The claim is that the volatile oils from the seeds prevent implantation, and thus the seeds must be chewed before swallowing [46].

Stem bark extracts

Multiple studies on the stem bark extracts of Combretodendron macrocarpum, Cola nitida, Afrormosia laxiflora, and Pterocarpus erinaceus have shown that they block the estrus cycle of female rats. It is thought that these compounds may bind to steroid receptor sites with resultant antigonadotropic activity. The most potent competitor for steroid receptors was C macrocarpum extract, followed by P erinaceus, C nitida and A laxiflora [47-49].

Rivea plant (llivea hypocrateriformisj

The plant Rivea hypocrateriformis was tested for anti- implantation effects and as an abortifacient in female rats using petroleum ether, chloroform, ethanol, and distilled water extracts. The ethanol extract was found to be most effective in causing significant anti-implantation and interruption of early pregnancy. The active ethanol extract contained alkaloids, glycosides, saponins, tannins, and phenolic compounds. Whether the contraceptive effects of this plant are caused by the constituents of the extract or an active ingredient of the plant is unclear [5O].

Castor plant (Hicinus communis,)

This plant is a native of India with 17 species that produce large seeds containing the active constituent ricin, a glycoprotein. The castor oil from the seed has been used as a purgative and traditionally is accepted as a contraceptive by women throughout India and Africa. Ricin also is found in smartweed leaves (Polygonum hydropiper). In a study looking at mechanism of action of this compound, female laboratory animals were injected with ricin, placed in cages with males of the same species and then had laparotomies looking for fetus implantation. Controls were injected with estradiol. The findings from this study indicated that Ricinus communis might possess estrogenic and anti-implantation activity [51].

Contraception was evaluated in people using the seeds of Ricinus communis (RICOM-1013-J) in two separate studies. In both trials, women were given one single oral dose of 2.3 to 2.5 g. No pregnancies were detected in subjects for 1 year in one study and for 8 months in the second study. Adverse effects included headache, nausea, vomiting, weight gain, loss of appetite, increased blood pressure, and dysmenorrhea. The results of the liver and renal function profiles in women volunteers showed that there were no significant (P

Wild yam (Dioscorea villosa)

It has been hypothesized that wild yam contains dehydroepiandrosterone-like properties and may act as a precursor to estrogen and progesterone. In the 196Os, progesterone, androgens, and cortisone were chemically manufactured from Mexican wild yam, and this has led many to believe consumption of this plant can lead to the same chemical conversion in the human body. It is used for dysmenorrhea and as an alternative to hormone replacement therapy to treat the symptoms of menopause [56]. It is not recommended as a contraceptive agent [57].

Marshmallow plant (Malvaviscus conzattii,)

The methanol extract of the flowers of Malvaviscus conzattii was administered to rats orally and was found to be effective in inhibiting ovulation. From these data, the researchers suggested that there might be an interference with the synthesis or release of gonadotropins from the pituitary gland [58].

Asparagus (Asparagus pubescens,)

The methanolic extract of Asparagus pubescens root was investigated for its contraceptive activity in mice, rats, and rabbits. Fetal implantation was inhibited in a dose-dependent manner [59].

Other herbs

In India, many antifertility herbs are used by indigenous peoples living in the hills (Drynaria quercifolia) [6O]. Ayurvedic traditional herbs are used by those in more urban environments (Pippaliyadi vati, Molluga stricto, Ruta graveolens, Derris brevipes variety coriace). Studies are preliminary on mechanism of action and efficacy of these herbs [61-64]. In one laboratory study using Ferula jaeschkeana, uterine implantation was inhibited by ingesting an extract of this herb [65]. Similar studies of Ethiopian indigenous medicinal plants traditionally used as antifertility agents appear in the literature [66].

Abortifacient

Every indigenous pharmacopeia contains some type of herbal abortifacient, and these plant products are among the oldest of herbal medicines. Anecdotal evidence suggests that use of herbal abortifacients declines when safe, legal, and affordable clinical abortion and contraception is available.

Pennyroyal (Hedoema pulegiodes)

Pennyroyal traditionally has been used as an abortifacient, yet its toxicity is well documented [67,68]. Doses required for abortion can cause irreversible kidney damage, hepatic disease, and death. It is not recommended and is considered unsafe by Natural Medicine Comprehensive Database.

In a retrospective study of 86 cases of herbal infusion ingestion with abortive intent reported to the Poison Control Center Uruguay between 1986 and 1999, 35 plant names representing 30 species were used. Most frequently used were rue (ruda; Ruta graveolens), cola de quirquincho (Lycopodium saururus), a type of parsley (Petroselinum hortense), and an over-the-counter herbal product called Carachipita, which contains pennyroyal (Mentha pulegium), yerba de la perdiz (Margiricarpus pinnatus), oregano (Origanum vulgre), and guaycuru (Statice brasiliensis). In 23 cases, patients ingested homemade brews made from two to six different species. Rue and parsley were among the more successful abortion agents; they were also among those producing the most toxic symptoms [69].

Spermicidal

Sedum praealtum

Intravaginal ethanol extracts of Sedum praealtum in mice decrease spermatozoa viability for 24 hours after administration [7O].

Cotton plant (Gossypium hirsutum)

Gossypol has been studied in women as an effective spermicide and has been found to immobilize spermatozoa when inserted intr\avaginally. It also has been shown to have an inhibitory effect on herpes simplex virus in vitro [71].

Neem oil (Azardirachta indica)

Neem oil pressed from the bark of Azardirachta indica, a native Indian plant, is considered a spermicidal agent when used intravaginally. It also has antimicrobial and antifungal properties [72]. Orally, neem oil caused arrest of spermatogenesis in male rats along with a decrease in sperm motility and density [73]. Intrauterine neem oil administered to rats and monkeys caused a block in fetal implantation [74].

Zinc acetate and Aloe barbadensis

In a study using 20 samples of fresh ejaculate from volunteers (age 20 to 30 years), zinc acetate was noted to be spermicidal. Lyophilized Aloe barbadensis also was noted to be spermicidal because of the spermatozoa tail toxicity from multiple elements present in small amounts (boron, barium, calcium, chromium, copper, iron, potassium, magnesium, manganese, phosphorus, and zinc). In the laboratory animal, these compounds did not irritate the vaginal epithelium. It was suggested that zinc acetate and lyophilized Aloe barbadensis warranted further study as a vaginal contraceptive [75].

Male antifertility herbs

Cotton plant (Gossypium hirsutum)

Gossypol (Gossypium hirsutum) is a polyphenolic extract of the seed of the cotton plant, and, when taken orally, it may suppress sperm concentration by inhibiting spermatogenesis [76,77]. Gossypol can cause fatigue, hypokalemia, persistent oligospermia. and can interfere with digoxin or other diuretics. It typically is taken as 15-20 mg/d [78].

Papaya (Carica papaya,)

Papaya has been used as a male contraceptive. In adult male rabbits receiving an aqueous extract of papaya seeds orally, no contraceptive effects were noted contrary to the observations made in previous studies [79].

Piperine

Piperine has been used as an oral male contraceptive agent. Histological studies in male rats receiving piperine revealed a partial degeneration of germ cell types, damage to the seminiferous tubule, decrease in seminiferous tubular and Leydig cell nuclear diameter, and desquamation of spermatocytes and spermatids. A 10 mg dose of piperine caused a marked increase in serum gonadotropins and a decrease in intratesticular testosterone concentration. The clinical implications of this study are unclear [8O].

Nicotine

Nicotine causes a reduction in the weight of epididymis and vas deferens in rat studies. The clinical implications of this finding are unclear [81].

Thunder god vine (Lei Gong Teng,)

Thunder god vine has been used for rheumatoid arthritis, menorrhagia, multiple sclerosis, and as a male contraceptive. There is insufficient evidence of efficacy for use as a male contraceptive, but it is postulated that in thunder god leaf and root, the triptolide and tripdiolide inhibit sperm transformation, maturation, and motility. Fertility may return to normal 6 weeks after cessation of use. Adverse effects include gastrointestinal upset, diarrhea, headache, hair loss, and immunosuppression [82].

Tripterygium hypoglaucum

Tripterygium hypoglaucum is a plant used in southern China for renal, liver, skin, and rheumatoid diseases. It also is considered a male antifertility herb. In 24 males aged 20 to 43 years who were given a daily concoction for 2 to 48 months, sperm motility and concentration were lower than in control subjects. These sperm changes were reversed 6 to 12 months after cessation of treatment. Follicle-stimulating hormone, luteinizing hormone, testosterone levels, and libido were similar in treated and control groups [83].

Solanum xanthocarpum

Solarium xanthocarpum is being studied in the laboratory in India as an inhibitor of spermatogenesis [84].

Anacardium occidentale

β-sitosterol, a phytosterol isolated from the leaves of Anacardium occidentale, can cause estrogenic effects and reduce the number of implantation sites in rabbits [85]. It also can inhibit the process of spermatogenesis in male rats [86]. Two doses were studied in rats for 16, 32, and 48 days. High-dose treatment reduced sperm concentration and weights of testis. Further studies were recommended [87].

Summary

The field of CAM is broad and diverse [88-9O]. CAM therapies may be viewed as an adjunct to conventional treatment or as a primary source of medical service [91,92]. Understanding patient choices, and supporting them if safe, reflect respect for the health care choices made by patients [93]. Health care providers must be aware of the safety and efficacy of alternative treatments and know how to access resources to help guide the patient methodically through a decision tree on CAM use for contraception.

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[62] Padma P, Khosa RL. Identity of Mollugo stricta roots: a potential antifertility drug for future. Ancient Science of Life 1995;15(2):97-101.

[63] Gandhi M, LaI R, Sankaranarayanan A, et al. Postcoital antifertility activity of Ruta graveolens in female rats and hamsters. J Ethnopharmacol 1991;34(l):49-59.

[64] Badami S, Aneesh R, Sankar S, et al. Antifertility activity of Derris brevipes variety coriacea. J Ethnopharmacol 2003;84(1):99- 104.

[65] Prakash AO, Pathak S, Mathur R. Postcoital contraceptive action in rats of a hexane extract of the aerial parts of Ferula jaeschkeana. J Ethnopharmacol 1991;34:221-34.

[66] Desta B. Ethiopian traditional herbal drugs. Part III: antifertility activity of 70 medicinal plants. J Ethnopharmacol 1994;44(3):199-209.

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[72] SaiRam M, Ilvavazhagan G, Sharma SK, et al. Antimicrobial activity of a new vaginal contraceptive NIM-76 from neem oil (Azardirachta indica). J Ethnopharmacol 2000;71(3):377-82.

[73] Purohit O. Antifertility efficacy of neem bark (Azadirachta indica Aa. Juss) in male rats. Ancient Science of Life 1999;19(2):21- 4.

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Further readings

Blumenthal M, Busse WR, Goldberg A, et al. The complete German Commission E monographs: therapeutic guide to herbal medicines. Boston: American Botanical Council; 1998.

Brinker F. Herb contraindications and drug interactions. Sandy (OR): Eclectic Medical Publications; 2001.

Hudson T. Women’s encyclopedia of natural medicine. Lincolnwood (IL): Keats Publishing; 1999.

Kass-Annese B, Danzed H. Natural birth control made simple. Alameda (CA): Hunter House; 2003.

McGuffm M, Hobbs C, Upton R, et al, editors. Botanical safety handbook. New York: CRC Press; 1997.

Murray M, Pizzorno J. Encyclopedia of natural medicine. Roseville (CA): Prima Publishing; 1998.

Riddle J. Eve’s herbs. Cambridge (MA): Harvard University Press; 1997.

Schulz V, Hansel R, Blumenthal M, et al. Rational phytotherapy. Heidelberg (Germany): SpringerVerlag; 2004.

Tyler V. The honest herbal. New York: Pharmceutical Products Press; 1993.

Wechsler T. Taking charge of your fertility. New York: Harper Collins; 2002.

www.consumerlab.com.

www.herbalgram.com.

www.naturaldatabase.com.

www.naturesherbal. com.

www.sisterzeus.com.

Cora Collette Breuner, MD, MPH

Adolescent Medicine Section, Department of Pediatrics, Children’s Hospital and Medical Center, 4800 Sand Point Way NE, Seattle, WA 98105, USA

E-mail address: [email protected]

Copyright Hanley & Belfus, Inc. Oct 2005

Etanercept Injection Site Reaction

By Clelland, Susan; Hunek, Jeffrey R

The “Clinical Snapshot” series provides a concise examination of a clinical presentation including history, treatment, patient education, and nursing measures. Using the format here, you are invited to submit your “Clinical Snapshot” to Dermatology Nursing.

History: A 20-year-old female presented with a history of psoriasis and psoriatic arthritis since childhood. She started treatment with etanercept (Enbrel) 1 month previously. One day after a subcutaneous injection into the left thigh, she developed a mildly pruritic eruption on the right thigh, at the site of a previous injection.

Description of Skin Lesion: There is an erythematous, slightly indurated plaque on the anterior right thigh. There is adjacent ecchymosis (see Figure 1).

Hallmark of the Disease: Etanercept (Enbrel) is an injectable fusion protein that competitively inhibits the pro-inflammatory cytokine TNF-α. It is approved for use in rheumatoid arthritis, juvenile rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, and adults with chronic moderate-to-severe plaque psoriasis. In clinical trials, the most common adverse effect of this treatment was injection site reaction (ISR). This can occur in up to 49% of patients and usually presents as erythema, pruritus, pain, or edema. At least 7% of patients develop “recall ISR,” or reaction at a prior treatment site with subsequent injections.

Normal Course: Injection site reactions to etanercept usually occur within the first month of treatment. They most commonly occur 1 to 2 days after an injection, and the duration is usually 3 to 5 days. ISRs decrease in frequency with continued treatment in the vast majority of patients, although a persistent or worsening reaction has been described.

Treatment: Most ISRs resolve without treatment, but symptomatic eruptions can be treated with cold compresses, topical corticosteroids, oral antihistamines, or acetaminophen. Discontinuing treatment with etanercept is rarely indicated.

Patient Education: Instruct patients to avoid administering etanercept to the area of ISR. Future injections should be given at least one inch from the periphery of the ISR. Rotation of injection sites should also be encouraged. Recommended sites include the anterior thighs, outer upper arms, and the abdomen two or more inches from the navel. Injections should not be administered into psoriasis skin lesions. Signs and symptoms of infection should be reviewed with the patient.

Figure 1.

An erythematous, slightly indurated plaque on the anterior right thigh with adjacent ecchymosis.

Nursing Measures: Make sure patients understand that an ISR will resolve and that it is not related to the disease process. The proper injection technique should be reviewed, and patients should be instructed to contact their physician if they exhibit severe itching, pain, swelling, or signs of infection.

References

Edwards, K.R., Mowad, C.M., & Tyler, W.B. (2003). Worsening injection site reactions with continued use of etanercept. Journal of Drugs in Dermatology, 2(2), 184-187.

Immunex Corporation. (2005). ENBREL prescribing information. Thousand Oaks, CA: Immunex Corporation.

Murphy, F.T., Enzenauer, RJ., Battafarano, D.F., & David-Bajar, K. (2000). Etanercept-associated injection site reactions. Archives in Dermatology, 136, 556-557.

Werth, V.P., & Levinson, A.I. (2001). Etanercept-induced injection site reactions: Mechanistic insights from clinical findings and immunohistochemistry. Archives in Dermatology, 737, 953- 955.

Zeltser, R., Valle, E, Tanck, C, Hoylst, M.M., Ritchlin, C., & Gaspari, A.A. (2001). Clinical, histological, and immunophenotypic characteristics of injection site reactions associated with etanercept. Archives in Dermatology, 137, 893-899.

Susan Clelland, BSN, RN, is a Nurse Supervisor, Henry Ford Hospital, Detroit, MI.

Jeffrey R. Hunek, MD, is a Dermatology Resident, Henry Ford Hospital, Detroit, MI.

Copyright Anthony J. Jannetti, Inc. Oct 2005

Job Stress and General Well-Being: A Comparative Study of Medical- Surgical and Home Care Nurses

By Salmond, Susan; Ropis, Patricia E

The purposes of this study were to examine job stress among medical-surgical and home care nurses, and determine if high job stress predicted general well-being. A comparative, descriptive design was used. Findings support the need to examine workplace stressors and implement strategies to reduce overall job stress among medical-surgical nurses.

Stress is pandemic in today’s society. Results of an occupational stress survey in the early 1990s (Northwestern National Life, 1991) showed that the proportion of workers who reported feeling “highly stressed” more than doubled between 1985 and 1990 (Speilberger & Vagg, 1999). Since that time, the work environment has become more stressful due to mergers, downsizing, and intense competition. Health care and nursing have not been spared. Increasing patient acuity and decreased length of stay in both acute and home care settings, a composite of new technology, managed care, increased supervisory responsibilities, risk and fear of litigation, and the current nursing shortage all place increased stress on today’s nurses. Other key factors contributing to workplace stress include team conflict, unclear role expectations, heavy workload, and lack of autonomy (Calnan & Wainwright, 2001; Huber, 1995; Peterman, Springer, & Farnsworth, 1995; Taylor, White, & Muncer, 1999).

The Occupational Health and Safety Survey (National Institute for Occupational Safety and Health [NIOSH], 1995) confirmed the deleterious effects of stress in certain occupations. An examination of more than 22,000 health records of employees from 130 occupations showed 40 occupations had higher than expected incidences of stress- related disorders. Along with six other health professions, nursing was among the occupations experiencing the negative impact of stress.

Failure to acknowledge and take action to reduce nursing occupational stress has potential physiological, psychological, spiritual, occupational, and economic effects. In an early study, Harris (1989) compared stress-related symptoms in surgical nurses to the general population and found that nurses presented with higher mortality rates, stress-related disease, high blood pressure, anxiety, and depression. Even more alarming, Metules and Bolanger (2000) reported that suicide is among the top five causes of death among nurses – a much higher rate than the general population.

High stress leads to negative work environments that rob nurses of their spirit and passion about their job. Low job satisfaction in nurses is linked empirically to chronic absenteeism, decreased morale, reduced job performance, burnout, increased tardiness, high turnover, and substance abuse (Lancero & Gerber, 1995; Laschinger, Wong, McMahon, & Kaufmann, 1999; Lobb & Reid, 1987). Moreover, high stress affects overall quality of care. Loss of compassion for patients, and increased incidences of mistakes and on-the-job injuries are consequences of high stress levels (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Laschinger et al., 1999; Laschinger, Finegan, Shamian, & Wilk, 2001; Lusk, 1997).

Some authors have attempted to estimate the impact of stress in terms of economic consequences. Stress has been estimated to cause half of workplace absenteeism and 40% of turnover, which is projected to cost the U.S. economy $200 – $500 billion annually (Department of Health and Human Services [DHHS], 1999; Matteson & Ivancevich, 1987; Maxon, 1999). Discussing the negative impact of psychological stress resulting from downsizing, Wright and Smye (1996) quoted an earlier estimate by Spielberger and Vagg (1991) projection the overall costs to business and industry of burned out or dispirited employees at $150 – $180 billion a year.

Job stress combined with the stress from everyday life can lead to detrimental physical and emotional outcomes for nurses and their families. This awareness has been responsible for growing attention to employee well-being. There are two common components to well- being: the actual physical health of workers and the mental, psychological, or emotional aspects of workers (Budge, Carryer, & Wood, 2003; Geiger-Brown et al., 2004; Pomaki, Maes, & Ter Doest, 2004). Well-being comprises the various work/job-related satisfactions (for example, satisfaction and/or dissatisfaction with pay, the job itself, co-workers, and supervision), as well as life/ non-work satisfaction enjoyed by individuals. There are personal and organizational consequences of well-being. Nurses’ and other health care providers’ experience of constant stress may affect their well- being and lead to disengagement, poor judgment, distress, and burnout. Stress and concomitant decreased well-being are contributing factors to organization inefficiency, high staff turnover, absenteeism because of sickness, decreased quality and quantity of care, increased costs of health care, and decreased job satisfaction (Abu Al Rub, 2004)

Recognizing the clearly established relationship between high levels of stress and adverse employee and organizational effects, nurse leaders must begin to examine levels of workplace stress and factors contributing to stress. Proactive interventions then can be used to decrease the target stress and/or help nurses adopt strategies to cope with stressors. Hence, the purpose of this study was to identify stressors and the intensity of stressors for nurses employed in medical-surgical and home care units, and to determine the relationship between stress and mental well-being. It was hypothesized that nurses employed on medical-surgical units would report higher stress levels and that nurses reporting high job stress would have negative affect scores.

Methodology

A comparative, descriptive study was designed to explore the causes and the severity of stress in hospital-based medical- surgical and home care nurses, and to examine the relationship of occupational stress to nurses’ affective mood. The target population was drawn from RNs and LPNs in two hospitals from a Northeast health care system (one urban and one suburban location) and three area home care agencies, representing both freestanding and hospital- based agencies. Convenience sampling was used.

Instrumentation

The majority of quantitative measures of stress, such as the Work Environment Scale (Moos, 1994), Occupational Stress Indicator (Cooper, Sloan, & Williams, 1988), and NIOSH Generic Job Stress Questionnaire (Hurrell & McLaney, 1988), focus on identifying job stressors and determining the intensity of each stress. Measurement of stress is generally not discipline-specific. Rather, these measures focus on commonly known aspects of work situations that result in job strain. Thus they address items such as “making critical, on-the-spot decisions” or “conflict with other departments” instead of specifically identifying “decision making in a code situation” or “conflict with a physician.”

Focusing on job stressors themselves in the absence of frequency assessment may not provide a full picture of the work environment (Spielberger & Vagg, 1991). The impact of stress is influenced not only by the severity of the stressor but also by the frequency of its occurrence. For example, a “code situation” in either home care or in the acute care environment may be considered highly stressful; however, if one nurse experiences that stress weekly and another experiences the stress annually, the stress phenomenon is different. Consequently, measures of occupational stress that evaluate both the perceived severity of specific sources of stress and the frequency of occurrence of that stressful event within a preset time period may provide a more accurate measure. The method of measurements prevents overestimating the effects of highly stressful events that rarely occur in a particular work setting, as well as underestimating the impact of moderately stressful events that occur quite frequently (Spielberger & Vagg, 1991).

Job stress survey. In this investigation, occupational stress was measured by using the Job Stress Survey (JSS) (Speilberger & Vagg, 1991). The JSS measures the perceived severity (intensity) and frequency of occurrence of 30 general sources of work-related stress that are experienced commonly by both men and women employed in a wide variety of business, industrial, and educational settings. The JSS has been used to provide information about specific work- related stressors that adversely impact employees, as well as to evaluate and compare the stress levels of employees in different work departments and settings. The instrument contains 30 items. Each item is rated twice by the participant on a 9-point scale, first for perceived severity and then for frequency of occurrence within the last 6 months. The JSS yields scores for three scales and six subscales. The three scales are total scores for job stress severity (JS-S), job stress frequency (JS-F), and job stress index (JS-X). The JS-X combines the severity and the frequency ratings of the 30 items and is an overall indicator of perceived stress level.

Factor analysis of the JSS has demonstrated consistently two major components of job stress: job pressure (JP) and lack of organizational support (LS). Ten-item subscales for each of these components provided additional information on pressures associated with the job itself (JP) and lack of support (LS) from supervisory personnel, fellow wo\rkers, or an organization’s administrative policies and procedures. Three scores are reported for JP and LS, yielding the six subscale scores. These scores are similar to the overall job stress scale scoring and provide information on the severity of the stress within the category, the frequency of occurrence, and the overall index score.

The JSS has been used extensively in professional health care settings. Data have been normed on 1,873 individuals drawn from managerial, professional, health care, and clerical employees. Cronbach’s alpha for the overall job stress scale, the severity subscale, and the frequency subscale all were reported above the 0.80 level. Cronbach’s alpha for this study was high, with a severity index alpha of 0.96 and a frequency index alpha of 0.92. The overall total reliability score for the stress index in this investigation was 0.95.

Affect balance scale. The Affect Balance Scale (ABS) (Bradburn, 2001) was employed to measure mental well-being or overall affect. This 11-item questionnaire contains two subscales, a five-item positive affect scale (PAS) and a five-item negative affect scale (NAS). The 11th question asks participants to rate their general happiness. Each question is scored on a 3-point scale assessing the frequency of occurrence of the positive or negative feeling. The ABS score is computed by subtracting NAS scores from PAS scores and adding a constant of 5 to avoid negative scores. The model specifies that an individual will be high in psychological well-being to the degree to which he or she has an excess of positive-over-negative affect and will be low in well-being in the degree to which negative predominates over positive (Bradburn, 2001).

The original instrument was normed on a probability sample of 2,006 adults ages 29 to 49 living in four small Illinois communities. The test-retest reliability was reported by Bradburn to be 0.76. Positive affect was correlated with social participation, companionship, and sociability. Negative affect was correlated with tensions, worry, and difficulty adjusting to work or marriage (Boyd & McGuire, 1996).

Interview guides. An interview guide designed of five openended questions was used to elicit in-depth responses to overall job stress, workplace stressors, support, and perceived well-being. The interview guide was prepared by the researchers and reviewed by two nursing administrators who had an active program of stress research. After completion of the quantitative survey, nurses who indicated a willingness to be questioned for a broader look at workplace stress were contacted by the researchers in either phone or face-to-face interviews, or through focus group interviews.

Data Collection

Institutional review board approval was obtained through both the hospital system and the academic facility where the researcher was employed. Permission from the vice president of nursing also was obtained at each of the home care sites. The participating acute care organization was selected conveniently and the home care agencies were selected to represent the main referrals from the agency. The participating acute care units were designated by the agency to be medical-surgical units. A site resource manager assisted with on-site survey distribution and collection, and kept the completed research packets in a locked cabinet until returned to the investigator. Research packets consisted of a cover letter advising the nurses of the purpose of the research, an informed consent, the Job Stress Survey, the Affect Balance Scale, a demographic sheet, and an envelope for returns. All packets were numerically and color-coded to differentiate by unit. No personal identifiers were used. A total of 142 research packets were distributed to all eligible RNs on the five participating units/ sites. Data collection proceeded over a 1-month period. Qualitative interviews were conducted after completion of the quantitative portion of the study with a purposive subsample of nurses who agreed to be interviewed.

Data Analysis

Independent sample t-tests were used to determine differences in stress cores between medical-surgical and home care nurses. One- sample t-tests were used to compare the group results with known normative scores for professional women. A significance of 0.01 was set because the analysis would require multiple t-tests and this would reduce the likelihood of a type 1 error.

Results

Sample and setting. Of the research packets distributed, 95 packets were returned (67%); however, only 89 were used for analysis because of missing data. Table 1 provides the demographic characteristics of the sample by age, work status, position, education, and years in nursing. The majority of respondents were middle-aged, female, and employed as staff nurses with many years of nursing experience.

Job stress. Table 2 shows that the total stress score and subscale scores for nurses employed on medical-surgical units were higher than for those employed in home care. To test the hypothesis that medical-surgical nurses would have higher stress scores than home care nurses, authors performed independent sample ttests. These findings showed there was no difference in mean scores for job stress severity (JSS), but there was for job stress frequency (JS- F) (t [78] = 4.04, p

Table 1.

Demographics of Survey Respondents

Figure 1 converts the mean scores into percentile rankings to illustrate the scores obtained in this sample compared to normative scores provided by the Job Stress Survey. The overall job stress index score of 28.49 for medical-surgical nurses placed this group in the 79th percentile of stress rankings as compared to home care nurses whose job stress index was in the average range (50th percentile).

Examination of the 10 most stressful items (the item index scores) showed that there were five common top stressors for both medical-surgical and home care nurses, and five unique stressors per environment. Table 3 presents these top stressors. Excessive paperwork was the top stressor for both groups of nurses. The other stressors, although ranked differently by each group, included meeting deadlines, frequent interruptions, insufficient personnel to handle an assignment, and insufficient personal time. For medical- surgical nurses, all other top-10 stressors fell in the “lack of support” category and included events involving other people. For home care nurses, the additional stressors related to job factors such as travel, the weather, and work environment.

Job pressure. Table 2 summarizes job pressure scores. Medical- surgical nurses reported higher job pressure severity and frequency (and thus a higher pressure index) than home care nurses; however, independent sample t-tests did not meet the significance criteria of p

Lack of organizational support scale. Table 2 presents the mean scores for organizational support among medical-surgical and home care nurses. Independent t-test results showed that lack of support severity scores did not differ between the two groups, but medical- surgical nurses had significantly higher lack of support frequency (t [82] = 5.03, p

Table 2.

Job Stress Scores

Figure 1.

Percentile Profile

Relationships between demographics and job stress scales and subscales. Pearson Product Moment Correlation was calculated to determine relationships between job stress index scales and demographic variables. Years employed in nursing was related negatively to the lack of support index (r = -0.27, p

Table 3.

Top-10 Stressors

Affect balance scores. Descriptive statistics were used to determine frequencies of n\urses with negative and positive moods. Scores were grouped as negative, moderate (neither negative or positive), and positive. A negative affective mood was found in 21.3% (n=19) of the sampled group of nurses, 44.9% (n=40) had moderate scores, and 33.7% (n=30) had positive mood scores. Comparison of general affect according to site worked showed no difference between mood scores for medical-surgical and home care nurses on an independent sample t-test. Data were then analyzed as total sample data.

To test the hypothesis that those with higher job stress would have negative affective moods, researchers used a one-way ANOVA. ANOVA results across the three mood groupings showed that job pressure index varied by mood grouping (f = 4.464, p

Qualitative findings. Qualitative interviews were used to gather in-depth information of the areas of stress identified by nurses employed on medical-surgical units and in home care departments. A small subset of five home care nurses and five medical-surgical nurses was interviewed. It was found that “paperwork” was the biggest source of stress for both home care and medical-surgical nurses, corroborating quantitative findings. Nurses found the paperwork to be redundant and time-consuming, and completing paperwork took away from what they perceived to be time with the patients. “Lack of cooperation” among co-workers was also a common theme to both groups of nurses in the qualitative findings; however, the medical-surgical nurses discussed this in greater breadth and depth. The final common theme was “time stress associated with workloads” that were perceived at times to be unrealistic. Both groups of nurses remarked that time management is an essential skill but that even with strong time management skills, the work demand often superceded the designated shift time. One medical-surgical nurse commented, “I spend a few minutes at the beginning of the shift organizing myself, setting priorities, and reviewing what I need to get accomplished. Then I can work more efficiently. But all the planning and all the efficiency doesn’t matter. At times the workload is so overwhelming, it just can’t be accomplished in the allotted time. The sad thing is that quality suffers.”

Home care nurses identified work-related stressors, such as maintaining their schedule, driving/traffic, bad weather, noise in the office in the morning, and decreased decision making secondary to third-party payer guidelines. Despite these stressors, home care nurses felt they were less stressed than in their previous medical- surgical work environments. Further, the home care nurses expressed a feeling of greater control over their practice and over the environment than they did when they were working in acute care. One home care nurse remarked, “As a case manager in home care, you can control your stress by shifting your environment to keep things from getting way out of control.” This shift was not seen as possible in the acute care environment. Although the home care nurses believed that they had good job control, they did identify that third-party reimbursement and changed Medicare regulations had decreased their autonomous decision making or decision latitude. Lack of patient/ family support was identified as a stressor for the home care nurse. This was well articulated by one nurse, “If there is no family support in the home, then your role extends, and this is stressful.”

Medical-surgical nurses identified competing demands of equal priority and frequent interruptions to be significant stressors. Interruptions included phone calls, other personnel needing assistance, emerging priorities, and need for collaboration when physicians made rounds. Stressors related to personnel were of prime concern. Lack of teamwork, lack of independent initiative among staff, problems with delegation, and problems with laziness were discussed by most of the medical-surgical nurses. Verbal abuse by physicians, colleagues, and on occasion family members were cited as stressors in the medical-surgical environment, as was the lack of respect for the medical-surgical nurse by other specialty nurses and by many physicians. Additional discussion involved identified changes in job expectations of the staff nurse that required more involvement in leadership and independent decision making on the unit; they were less able to rely on a nurse manager for problem solving and assistance because the role of the nurse manager had assumed more hospital-wide responsibility. Excessive paperwork, fellow workers not doing their job, frequent interruptions, poorly motivated co-workers, and inadequate support by the supervisor were quantitative stressors substantiated in the qualitative findings.

Discussion

In the last several years, abundant research has addressed the work environment and the need to create organizational cultures more supportive of nurses (Adams & Bond, 2000; Aiken et al., 2002; Aiken, Havens & Sloane, 2000; Aiken & Patrician, 2000; Aiken & Sloane, 1997; Laschinger et al., 1999). Findings of the current study showed that workplace stress was significantly above the norm for medical- surgical nurses as compared with home care nurses and a normative group of professional women. What was especially noteworthy in these findings was that the job stress severity was similarly high for both work settings. It was the fact that this severity was significantly more frequent for medical-surgical nurses as compared to home care nurses that resulted in an overall higher job stress index or total job stress score. Job pressure severity scores also were similar for medical-surgical nurses and home care nurses, but the frequency of that pressure was significantly higher among medical-surgical nurses. The sharpest contrast in findings was in the difference in “lack of support” scores. Medical-surgical nurses had much higher ratings on severity, frequency, and the over-all index score, indicating that medical-surgical nurses perceived significantly less organizational support than their home care counterparts or the normative group of professional women. Eisenberg, Bowman, and Foster (2001) cited lack of available support systems as a cause of stress among health care workers. In their study, lack of support from colleagues appeared to be a major factor contributing to the lack of support. Review of the top-10 stressors among medicalsurgical nurses revealed that five were items involving lack of support specific to interaction with other personnel. These items, “fellow workers not doing their jobs,””poorly motivated co- workers,””covering work for another employee,””conflicts with other departments,” and “inadequate support from the supervisor,” all reflected the interdependency of the role of the medical- surgical nurse.

Results in this study were compared to the normative data of the Job Stress Data. This normative group consisted of women in professional careers. Medicalsurgical nurses’ job stress, job pressure, and lack of organizational support were significantly higher than the normative data of professional women. For home care nurses, job stress scores and job pressure severity scores were similar, but job pressure frequency was higher and lack of support was in fact lower than the normative data. The results showed that overall the medical-surgical work environment was more stressful. The home care environment had similar stress severity and more frequent job pressure; however, some of this was offset by the low lack of support scores, indicating that home care had more supervisory and peer support.

Qualitative findings were consistent with the top-10 stressors identified in the survey. Difficulties managing the expanded workload discussed in the qualitative findings were consistent with the priority items of “paperwork,””insufficient personal time,” and “insufficient personnel to handle an assignment.” Managing the workload was intensified by “frequent interruptions,” and “meeting deadlines” was a major stressor in light of the work to be accomplished within a designated shift. Medical-surgical nurses spoke of the significant stress associated with teamwork and collaboration with other disciplines and departments. This was consistent with the five “lack of support” stressors among the top- 10 stressors for medical-surgical nurses and dramatically different than the home care nurses who did not rate “lack of support” items in their top 10 stressors.

For the medical-surgical nurse, accomplishing his or her work required others to be doing their jobs. It also required effective working relationships and communication with others. The emphasis on this category of stressors pointed to the need for ongoing team- building efforts, as well as examination of the interdependency of systems and the need for efficiency and cooperation across systems/ departments.

Medical-surgical nurses identified inadequate support from supervisors as a priority stressor, whereas home care nurses did not. This lack of support may have been due to increased demands placed on managers and supervisors in hospitals. Role changes for managerial personnel moved them away from the bedside and even away from the unit, which may have contributed to a sense of lack of support. In contrast, home care organizations were small health care “ecosystems” in which supervisors had greateravailability and visibility to nurses and could afford help to staff if needed on a one-on-one basis, thus contributing to the lower stress score for this specialty of nurses. Nursing staff in home care were more autonomous and appreciably less dependent on each other to get the work done. This contributed to the overall reduction in stress in the home care environment.

The most common job stress factor in both groups of nurses was paperwork, with mean scores of 6.7 and 6.9 respectively for home care and medical-surgical nurses. This egregious amount of paperwork may be due to increased governmental demands, accrediting regulations, and the constant threat of litigation for nurses and institutions leading to the need for more forms and more documentation. Computer-based documentation using “intelligent” systems is predicted to result in a major decrease in paperwork demands; however, because the cost of these systems is high, many nurses have no promise of a reprieve.

Nurses who were older and more experienced had lower stress levels. This finding was consistent with the findings of Aiken and Sloane (1997). Their study of stress and emotional exhaustion in over 800 nurses in magnet and nonmagnet hospitals on medical- surgical units and on AIDS-dedicated units also found older, more experienced nurses had less stress. This may have been due to a larger repertoire of coping reactions, drawn from an expanded nursing experience and leading to greater confidence in nursing practice than the younger nurses.

The hypothesis that nurses who indicate high job stress will report a negative affective mood (decreased well-being) was supported in this study. This finding was similar to those of Bourbonnais, Comeau, Vezina, and Dion (1998) and Bourbonnais, Comeau, and Vezina (1999). Both groups of researchers found significant relationships between nurses’ job strain, and symptoms of psychological distress and emotional exhaustion. Cheng, Kawachi, Coakley, Schwartz, and Colditz (2000) used data from the Nurses Health Study to link job strain similarly to decline in functional health status over a 4-year period. Findings of this study suggest that assessment of working conditions that produce job strain is needed to identify priorities for workplace intervention in order to reduce job strain and negative-well-being.

Recommendations

A limitation of the study was the use of a small convenience sample. The study needs to be replicated using a larger number of nurses, a wider geographic distribution, and random sampling methods. This replication should attempt to survey nurses from institutions and units of varying size and specialty areas in order to see whether stress varies based on specific characteristics (teaching versus non-teaching hospital, specialty versus nonspecialty unit, large versus small hospital, etc.).

Clinical Implications

This study suggests that job stress in the clinical environment is related to general affect or well-being. What can be done to sustain well-being? Attention to the work environment and key areas of stress within the job likely will improve job satisfaction, well- being, and organizational effectiveness. The higher job stress scores and job pressure scores among medical-surgical nurses creates a compelling impetus for more attention to the workplace environment. Moving toward computerized medical records may alleviate stress due to paperwork. The lack of staffing is a more difficult problem to tackle and may require long-term strategies, such as sponsoring individuals in RN education.

In the interim, this study directs attention to providing support for nurses. Medical-surgical nurses had higher “lack of support” scores and qualitatively, this was a major theme. Support needs to be provided in ongoing team development so there is attention both to competency and interpersonal relations. Older, more experienced nurses in this study experienced less stress. These nurses should be used as mentors to the younger, less-experienced nurses, but caution must be taken not to overload them and put them into higher stress categories. Team building is needed to enhance cooperation and minimize conflict. This cannot be a one-time intervention but an ongoing strategy. Use of unit-based clinical nurse specialists or clinical experts to serve as mentors and team builders may provide the necessary support to practicing nurses even in the face of short staffing. Perhaps the best approach to providing support would be to begin with focus groups of the staff, listening to the areas where support is needed, but listening by itself will be insufficient. The information from the focus group can provide data for unit-based priorities so support can be provided where it is needed most.

Conclusion

The experience of stress at work has undesirable effects on the health and safety of the workers and on the health and effectiveness of their organizations. Nursing is, by its very nature, a stressful profession; however, the stress is exacerbated by a range of organizational issues. This study identified job stress for medical- surgical nurses as significantly above the norm and significantly greater than nurses working in home care. Workload issues and lack of support (team building and collaboration issues) were major stressors. Attention to these priority stressors is critical in order to maximize the quality of nurses’ working lives, and contribute to the general health and well-being of the nursing workforce. Job stress can be evaluated periodically using a combined qualitative/quantitative approach similar to this study. This would allow identification of high-risk areas along with a qualitative explanation of specific stress factors. As a generic approach, a focus on providing support and conditions that support professional nursing practice may yield high returns. Job stress and job pressure are high in nursing, especially medical-surgical nursing. It may not be possible to eliminate or even minimize this stress, but changes definitely can be made in level of support.

Job stress and job pressure are high in nursing, especially medical-surgical nursing.

References

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Susan Salmond, EdD, RN, CNAA, CTN, is Associate Dean and Associate Professor, University of Medicine and Dentistry of New Jersey, School of Nursing, Newark, NJ.

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Copyright Anthony J. Jannetti, Inc. Oct 2005

Blue Cross and Blue Shield of Florida, Walgreens Partner To Promote Medicare Part D Education

JACKSONVILLE, Fla., Oct. 20 /PRNewswire/ — Blue Cross and Blue Shield of Florida (BCBSF) today announced a new marketing alliance with Walgreen Co. (Walgreens) to inform and educate Florida Medicare beneficiaries about the new Medicare Part D prescription drug program. The initiative will address the needs of Medicare beneficiaries through proactive outreach and education and distribution of Part D information.

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“As a Florida-based company, Blue Cross and Blue Shield of Florida is uniquely positioned to help Florida seniors take advantage of the new Medicare Part D benefit program,” said Lowell Sterler, vice-president, pharmacy programs, Blue Cross and Blue Shield of Florida. “Our Part D plans offer choice and convenience options that are complemented by Walgreens unparalleled local and national presence and capabilities.”

BCBSF recently announced that it will offer BlueScript for Medicare Part D drug plans to all eligible Medicare beneficiaries in Florida beginning Jan. 1, 2006. BCBSF and Walgreens will collaborate to educate Medicare beneficiaries about BlueScript for Medicare Part D and other Part D plans through in-store materials available at more than 600 Walgreens locations in Florida. BCBSF representatives will also be on hand to provide support at more than 150 Part D information sessions held at Walgreens Florida retail pharmacies in October and November.

Blue Cross and Blue Shield of Florida is a leader in Florida’s health industry. BCBSF and its subsidiaries serve more than 7.1 million people. Since 1944, the company has been dedicated to meeting the diverse needs of all those it serves by offering an array of choices. BCBSF is a not-for-profit, policyholder-owned, tax-paying mutual company. Headquartered in Jacksonville, Fla., BCBSF is an independent licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield companies. For more information concerning BCBSF, please see its Web site at http://www.bcbsfl.com/ .

Walgreen Co. is the nation’s largest drugstore chain with fiscal 2005 sales of $42.2 billion. The company operates nearly 5,000 stores in 45 states and Puerto Rico. Walgreens also provides additional services to pharmacy patients and prescription drug and medical plans through Walgreens Health Initiatives, Inc. (a pharmacy benefits manager), Walgreens Mail Service, Inc., Walgreens Specialty Pharmacy and Walgreens Home Care, Inc.

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Blue Cross and Blue Shield of Florida

CONTACT: Bruce Middlebrooks, Blue Cross and Blue Shield of Florida,+1-904-905-3400, or cell, +1-904-803-6795

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

Wound Care for Patients With Darkly Pigmented Skin

By Bethell, Elaine

Summary

This article examines the main skin or wound assessment parameters used for patients with darkly pigmented skin. Differences in skin pigmentation are discussed along with the challenges health professionals encounter in clinical practice and why linking theory to practice is vital.

Keywords

Diversity; Pressure ulcers; Transcultural care; Wounds

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

THE SKIN PIGMENTATION continuum varies from light ivory, deep brown, black, yellow to olive, light pink to dark, ruddy pink, or red (Baranoski and Ayello 2004). Lyder (2005) describes patients with skin pigmentation as having ‘diversity in skin tones’. This can pose a challenge to clinicians when they assess patients with wounds or grade 1 pressure ulcers. In patients with darkly pigmented skin the assessment of skin changes for erythema, which is indicative of inflammation, is difficult especially for healthcare professionals and carers who lack training and experience (Bennett 1995, National Pressure Ulcer Advisory Panel (NPUAP) 1998). The usual signs of redness that characterise blanching and non-blanching erythema are difficult to detect. Erythema is characteristic of many skin conditions other than pressure ulcers (Alterescuand Alterescu 1988).

This article examines the key skin or wound assessment parameters necessary for patients with darkly pigmented skin admitted to any healthcare setting. It explores how clinical practice relating to skin or wound assessment incorporating a patient history and physical examination is the same for any patient regardless of age, sex, race or skin colour. However, it is important that an assessment is made by trained practitioners who are a ware of the differences between lightly and darkly pigmented skin. The clinical implications and relative risks are that failure to assess skin adequately and to detect signs of inflammation or non-blanching erythema may lead to the development of a severe pressure ulcer or a life-threatening wound infection.

Assessment provides the key elements regarding the current status of a wound and is essential to the development of all healthcare interventions (Baranoski and Ayello 2004). The management of acute and chronic wounds has evolved into a highly specialised area of practice and this is apparent in the assessment of patients with darkly pigmented skin (Baranoski and Ayello 2004).

Background

The Office for National Statistics (ONS 2002) found that the UK’s minority ethnic population, most of whom have darkly pigmented skin, rose from 3.1 million in 1991 to 4.5 million in 2001-2002 – this equates to 7.6 per cent of the population. It is envisaged that the minority ethnic population in the UK will continue to increase (Bethell 2003a). The ONS also found that many members of this population have lower incomes than other populations and experience ill health, thus placing them at risk of developing pressure ulcers and wound infections. Salcido (2002) states that health care in the United States is beginning to experience a shift in racial and ethnic demographics. In the US, the black and Latino/Hispanic populations are the fastest growing among those aged 85 years and older and are often in poor health (Lyder et al 1998).

The problem for clinicians when assessing patients with pigmented skin is the lack of guidance and/or evidence. A search of Medline, the Cumulative Index of Nursing and Allied Health Literature (CINAHL) and other sources including the European Pressure Ulcer Advisory Panel (EPUAP), NPUAP, the Tissue Viability Society (TVS) and the National Institute for Health and Clinical Excellence (NICE) websites, in addition to conversations with colleagues, demonstrated that guidance cited in the literature primarily relates to pressure ulcers with little on skin and wound assessment (Lyder 1991, Witkowski 1993, Bennett 1995, Flanagan 1996, Lyder 1996, Lyder et al 1998, NPUAP 1998, NICE2001, Bethell 2002, Salcido 2002, Baranoski and Ayello 2004, Scanlon and Stubbs 2004).

Diversity in skin tones

Skin colour or tone depends on four factors: various carotene pigments in the subcutaneous fat, concentration and state of oxygenation of haemoglobin, the presence of other pigments, for example bile, and the amount of melanin present in the epidermis. Melanin is synthesised by melanocytes. These cells are of neuro- ectodermal origin and migrate during development to the epidermis where they remain scattered in the basal layers. The cell bodies of the melanocytes are located between the basement membrane and the basal epithelial cells. The ratio of melanocytes to basal epithelial cells varies from about one in five to one in ten in different regions of the body. They are highest in the skin of the face and external genitalia.

Sunlight promotes melanin synthesis and causes darkening of previously synthesised melanin. Melanin has biophysical and biochemical properties related to its functions in skin. It protects against the damaging effects of ultraviolet (UV) radiation. Tanning or pigment darkening can occur in minutes, probably due to photo- oxidation of pre-existing melanin. There are fewer melanocytes in freckles than in adjacent paler epidermis, but they are larger and more active (Bannister 1995).

Within melanocytes, melanin accumulates in secretory vesicles known as melanosomes. These are disseminated throughout long cytoplasmic processes from where they are transferred to surrounding epithelial cells. The rate of production and the size and shape of melanosomes vary between individuals of one race and between racial groups. Consequently, the pigmented cells of skin are both the melanocytes, which synthesise melanin, and the epithelial cells, which have taken up melanin; commonly the epithelial cells contain much more melanin than the melanocytes. The number of melanocytes is relatively constant between different individuals irrespective of race. Racial variations and differences in skin colour and tone are due to melanocyte morphology and activity, that is, the amount of melanin produced rather than the number of melanocytes present (Bannister 1995).

Wound assessment

A wound is a disruption of normal anatomic structure and function (Lazarus et al 1994), and may be classified as acute or chronic. Baranoski and Ayello (2004) purport that there is no written standard that outlines the type and amount of information to include in a wound assessment; also, no single documentation chart or tool has been designated as the most effective. However, it is accepted generally that a total patient assessment, inclusive of any co- morbid conditions and lifestyle, must form part of a comprehensive wound assessment. A patient history irrespective of skin colour must be systematically documented. A wound assessment is a written record or picture of the progress of the wound, and a cumulative process of observation, data collection, and evaluation. It is a vital component of patient care. An individual wound assessment should include a record of initial assessment, ongoing changes, and treatment interventions (Baranoski and Ayello 2004 ). The effectiveness of interventions cannot be ascertained unless baseline assessment data are compared to follow-up data.

A minimal wound assessment should include a thorough patient examination, aetiology or wound type and wound characteristics such as location, size, depth, exudate, and tissue type. Wounds can be classified using several different approaches, however, this is not within the scope of this article and has been covered elsewhere (Lazarus et al 1994). The pathology or cause of the wound must be determined before appropriate interventions can be implemented. Wounds may have a surgical, traumatic, neuropathic, vascular, or pressure-related aetiology. These factors do not change whatever the patient’s diversity in skin tone.

Physical examination

To accurately detect skin changes in patients, visual assessment must be followed by a thorough physical assessment of the wound and its surrounding skin. The skin surrounding a wound can provide the assessing clinician with valuable information regarding ongoing evaluations and future wound care management (Baranoski and Ayello 2004). Asking patients and/or carers about skin changes can also prove useful. Baranoski (2001 ) advises that a minimal skin assessment should include the following five parameters: colour, temperature, moisture, turgor, and intact skin or presence of open areas.

Palpation should be carried out with the fingers around a wound surface. This may reveal a temperature difference compared with the surrounding skin. Induration and oedema indicate abnormal fluid accumulation, which may suggest further tissue damage, abscess or a wound infection (Baranoski and Ayello 2004).

Changes in normal skin colour and increase in temperature are due to the inflammatory process (Hart 2002). Failure to observe the above may increase the risk of a patient developing a pressure ulcer or wound infection. Therefore, it is important for practitioners to recognise and understand the clinical implications of inflammatory changes.

Inflammation Inflammation is a normal physiological response to tissu\e insult or injury and is integral to microbial resistance (Gardner and Frantz 2004). In surgical wounds, inflammation occurs following an incision and wounding, but should subside within five days post-operatively (Stotts 1998). The inflammatory process is triggered by endogenous (host sources) and exogenous (microbial) mediators. The release of inflammatory mediators results in localised vasodilation and increased blood flow to the injured area. These chemical mediators are key to the inflammatory process. The accompanying increase in vascular permeability promotes a rapid influx of phagocytic cells and antibodies to the wound site. Collectively, these events cause the removal of micro-organisms, debris and bacterial toxins and enzymes. These physiological responses to injury are demonstrated by the signs of inflammation including erythema, heat, oedema and pain (Gardner and Frantz 2004).

Inflammation is either acute or chronic. Acute inflammation is the initial response to tissue invasion or in] ury. Chronic inflammation occurs if the invasion or injury of tissue is not resolved and persists over a long period (Gardner and Frantz 2004).

Erythema The change in usual skin colour results from the dilation of capillaries near the skin’s surface, which is mediated by polymorphonuclear leukocytes, monocytes and macrophages. This phase usually occurs from the time of initial insult to about two to five days’ post-injury. Colour is a proven indicator of a physiological response to injury and a good indicator of a stage 1 pressure ulcer (Lyder 1991). In patients with darkly pigmented skin, erythema is difficult to detect (Bennett 1995). In lightly pigmented skin the presence of erythema is detected by bright or dark red skin, and by darkening in patients with darkly pigmented skin (Gardner and Frantz 2004).

Most clinicians agree that colour and temperature play a major role in the identification and assessment of stage 1 pressure ulcers (Agency for Health Care Policy and Research 1992, Parish et al 1997, EPUAP 1999), and almost all pressure ulcer classifications include erythema as a category (Lyder 1991). However, erythema is not only difficult to detect in darkly pigmented skin, but it is also characteristic of many skin conditions other than pressure ulcers, including allergic reactions and excoriation from faecal incontinence caused by alkaline enzymes in the stool which irritate the skin (Alterescu and Alterescu 1988).

Lyder (2005) suggests using a pen torch to observe changes in skin colour. However, this is a subjective assessment (Matas et al 2001 ). Lyder et al ( 1998 ) report that caregi vers who are not of the same ethnic background as patients may be less sensitive to slight changes in skin colour. This is an important factor to consider in the assessment of patients with darkly pigmented skin (Lyder 1991).

Temperature Skin is usually warm to touch. If it is warmer than usual this could be a sign of inflammation, and an indicator of infection or pressure damage. Increased local blood flow and oedema are followed by engorgement of surrounding vessels and tissues resulting in warmth and redness in the area. Histologically this is due to oedema of the papillary dermis, platelet aggregation in the microcirculation (Barton and Barton 1981), and erythrocyte engorgement of the superficial blood vessels (Witkowski 1993).

Pale and cool skin may be a sign of poor perfusion or ischaemia and may indicate the end stage of non-blanching erythema (Lyder 1991, NPUAP 1998). Histologically this is due to endothelial cell damage, and activation of haemostatic mechanisms that decrease blood flow and potentiate endothelial cell damage which increases the degree of platelet thrombosis and hence ulcer size and severity (Barton and Barton 1981). Witkowski (1993) and Bliss (2000 ) report that a grade 1 pressure inj ury is more likely to have a bluish tinge than reactive hyperaemia, and that this is evidence of irreversible tissue damage. Lyder (1991) reasons that non-blanching erythema must be considered a true criterion of stage 1 pressure ulcers.

Both extremes in temperature are included in the definition of stage 1 pressure ulcers (Lyder 1991). Education and training are required to avoid inaccurate assessment and negative patient outcomes. An increase or decrease in skin temperature is usually detectable by touch (Parish et al 1988, Bliss 2000). Flanagan (1996) states that these temperature changes are slight and detection can be made easier by avoiding the use of gloves. However, Lyder (2005 ) challenges this and argues that in clinical practice a rise in temperature of 1 -2 degrees is difficult to assess with or without gloves; practitioners’ fingers are not usually that sensitive. However, this assessment is important in patients with darkly pigmented skin because of the difficulty in observing colour changes.

Oedema Oedema is one of the physiological signs of inflammation, and is also indicative of heart, liver and kidney failure and venous insufficiency. In the case of suspected pressure ulceration, wound infection, or abscess formation, oedema can be palpated in areas of suspected damage, irrespective of skin pigmentation. Gardner and Frantz (2004) state that shiny, taut skin or pitting impressions in the skin adjacent to any wound but within 4cm of the wound margin indicate oedema. This can be assessed by pressing firmly within 4cm of the ulcer margin with a finger, releasing and waiting five seconds to observe for any indentation (Gardner and Frantz 2004).

Oedema and induration occur because pressure causes separation in the skin layers and allows interstitial fluid to accumulate (Longe 1986). Therefore, both oedema and induration are good indicators of tissue damage. Parish et al (1988) found that at this stage there is engorgement of capillaries and venules in the papillary dermis.

Turgor Skin should quickly return to its original state when it is assessed and palpated. A slow return may indicate dehydration or the effects of ageing. Soft tissue may indicate an underlying infection. Tense skin may indicate lymphoedema and cellulitis. Palpation is useful to assess skin temperature, oedema and turgor of suspected damaged areas.

Moisture It is important to note whether skin is moist or dry during assessment. If it is dry look for hyperkeratosis (flaking and scales). Observe for eczema or dermatitis, psoriasis rashes, leaking oedema, or exudate. These signs may aid diagnosis in patients with cellulitis, lymphoedema or wet gangrene.

No consensus as to what constitutes a minimal skin assessment exists in the literature (Baranoski and Ayello 2004). A skin assessment differs from a wound assessment as it should include observation of the patient’s entire body, not only areas with wounds. Lesions, bruising, absence of hair, shiny skin, callus formation, scars (hypertrophie and keloid scars are more prevalent in patients with darkly pigmented skin (Placik and Lewis 1992)) and signs of venous insufficiency such as haemosiderin deposits (reddish- brown colour), ankle flare and atrophy blanche can be identified. Haemosiderin deposits are often seen on the lower legs of patients with venous ulcers and lightly pigmented skin. However, in patients with darkly pigmented skin the signs of venous insufficiency are difficult to detect and patient history becomes the key to aid diagnosis.

Arterial ulcers often present with the classic signs of hair loss, weak or absent pulses, and thin, shiny, taut skin. Patients with diabetes are prone to callus formations. All of these diagnostic features can be detected during an assessment (Baranoski and Ayello 2004). Physical examination and patient history should reveal why the patient has a wound and, if it is not healing, why healing is not taking place irrespective of age, race or skin colour.

Scarring

Epithelialisation is the regeneration of the epidermis across the surface of a wound ( Bryant 1992 ). As wound migration occurs from the wound edges, the area covered with epithelium is pearly or silver and shiny (Figure 1 ). In darkly pigmented skins the colour of the epithelium will be tonally relevant to normal skin but as with scar tissue in lighter skins it will be different from surrounding undamaged epidermis ( Gray et al 2004 ).

Hypertrophie and keloid scars Hypertrophic (Figure 2) and keloid sears (Figure 3) are abnormalities associated with the maturation phase of healing. Hypertrophic scars occur directly after initial repair, tend to follow the line of the incision and are more common in young patients. Careful placing of incisions along Langer’s lines (incisions are made in natural creases) and fine suture material can avoid excessive scar formation (Centre for Medical Education 1992, Leaper and Gottrup 1998).

Keloids result from formation of large amounts of scar tissue around the site of the wound. This is due to an increase in collagen synthesis and lysis and is also thought to be linked to melanocyte- stimulating hormone (MSH). Often these scars are larger than the wound itself, and even if the scar is excised it is likely to recur (Bale and Jones 2000). Keloid scars may occur some time after healing (Eisenbeiss etal 1998) and are often red (darker in pigmented skin) and prominent. The scar continues to grow and spread, invading surrounding healthy tissue, whereas hypertrophie scars do not. Black AfroCaribbeans are ten times more likely to develop keloid scarring than Caucasians (Lee 1982). The reasons for this are not fully understood. Theories include a deficiency or an excess of MSH, decreased percentages of mature collagen and increased soluble collagen, or blockage of small blood vessels which results in lack of oxygen and contributes to keloid formation (Placik and Lewis 1992). While the lack of a definitive theory demonstrates lack of understanding of the condition, it also indicates that work is being done to find the cause. Determ\ining the cause should mean better preventive medicine and more effective treatment in the future, but there are many problems with inadequate follow up of people with the condition, lack of a clear cut-off from treatment and too few studies, which hamper the search for a cure.

FIGURE 1

Epithelial tissue

FIGURE 2

Hypertrophic scar

FIGURE 3

Keloid scar

The role of MSH in humans is not fully understood (Bennett 1995). However, Mehendale and Martin (2001 ) suggest that a better understanding of melanocyte responses to wounding may suggest ways to prevent post-healing pigmentary disturbances and avoid the necessity for further surgical intervention.

Pressure ulcers

A pressure ulcer has been defined as ‘an area of localised damage to the skin and underlying tissue caused by pressure, shear, friction and/or a combination of these'(EPUAP 1999). They frequently occur over bony prominences (Barton and Barton 1981).

Pressure ulcer aetiology is complex and the costs in terms of patients’ quality of life and NHS resources are significant (Gebhardt and Bliss 1994). Pressure ulcers are a major financial burden to health services as they are common and the cost of prevention and treatment is high. Estimates of the cost of pressure ulcers in the United Kingdom (UK) range from annual costs of 300 million in 1988 (with no supportive data provided) (Waterlow 1988), approximately 60 million in 1991 (Department of Health (DH) 1991), 288 million (1991-1992) (Hollingsworth et al 1997) to 420 million (Centre for Reviews and Dissemination 1995). Other countries also have no definitive costs and there are similar variations in estimates. Annual estimates of costs in the US ranged from $836 million in 1992 (Tomaselli and Granick 2000), to more recent estimates of $1.3 billion (Dealey 2004) and $2.8 billion (Tomaselli and Granick 2000). It would appear that there are no data available that clearly define the costs of pressure ulceration.

The aetiology of pressure ulcer formation is still not fully understood (Bliss 1998) and many areas of assessment and practice remain ineffective (Gebhardt and Bliss 1994) and controversial, including the identification and assessment of grade 1 pressure ulcers.

However, it is now generally accepted that the aetiology of pressure ulcers is a result of two coexisting concurrent processes, pressure and shear, which ultimately cause tissue anoxia (Neumark 1981, Scales 1982, Alterescu and Alterescu 1988, Scales 1990). However, pressure and shear do not account for the whole pathogenesis of pressure ulcers (Barton and Barton 1981, Barton 1983, Bennett and Lee 1988, Bridel 1993, Leigh and Bennett 1994, Bliss and Simini 1999).

The tissues involved in pressure ulcer development are the skin, subcutaneous fat, deep fascia, muscle and bone (Nixon 2001 ). Skin in particular plays an important role (Krouskop 1983, Woolf 1998). The prevalence and incidence of pressure ulcers are highest in older patients (Barbenel et al 1977, Versluysen 1986, Meehan 1990, Clark and Cullum 1992, Meehan 1994, O’Dea 1995, Hagisawa and Barbenel 1999).

If non-blanching erythema has developed, then irreversible damage has been sustained and this will progress to deeper skin layers if pressure is not relieved (James 1998). In American prevalence surveys, dark-skinned African-American patients had the most severe grade 4 pressure ulcers (Meehan 1990, 1994, Meehan et al 1999). This was probably because early non-blanching erythema was not detected and deep tissue injury occurred before action was taken (Bethell 2002). However, difficulties in identifying a stage 1 pressure ulcer or nonblanching erythema in patients with darkly pigmented skin led to the setting up of a special task force in the US to try to address the problem.

A definition of a stage 1 pressure ulcer, with emphasis on redness, was not helpful in assessing patients with darkly pigmented skin (Bennett 1995). It was acknowledged that localised skin colour changes can occur at the site of pressure; these colours differ from the patient’s usual skin colour. The area of skin over a point damaged by pressure may appear darker than the surrounding skin and may feel warmer to the touch, taut, shiny and/or indurated. The patient may complain of discomfort or pain in these areas.

A more specific definition has been approved by the NPUAP (Henderson et al 1997), which incorporates skin temperature, pigmented skin, and purple hues (Box 1). The EPUAP ( 1999) has also acknowledged the problem and offers similar guidance (Box 2), while NICE (2001) emphasises the importance of discoloration (Box 3).

Purple ulcers

The NICE (2001) guidelines only discuss the connection between purplish/bluish areas and pressure damage in relation to people with darkly pigmented skin. The aetiology is the same for all skin types, regardless of pigmentation (Bethell 2003b).

Further controversy arises over ‘purple’ ulcers which are often classified as stage 1 (Torrance 1983, Lyder 1991, Dailey 1992, Witkowski 1993) or even ignored. However, Dailey (1992) described the increasing number of patients admitted with ‘purple’ ulcers as purple-red, ecchymotic – an effusion of blood under the skin causing discoloration – pale ecchymotic, or bruised. The skin may be intact or the epidermis ‘brushed’ off, exposing a discoloured area. These can rarely be reversed. Biopsy specimens of the purple lesions demonstrate haemorrhage and early gangrenous changes (Witkowski 1993).

Purple ulcers appear to be treated less seriously than they should be, especially in patients with darkly pigmented skin where they are clinically difficult to identify (Dailey 1992, Witkowski 1993). Both authors suggest that the main problem is the lack of recognition of the serious nature of these ulcers. However, it is vital that practitioners are aware that the purple patch is the end stage of non-blanching erythema and signifies a full-thickness skin loss, and take appropriate action.

Blanch test

To distinguish between blanching and non-blanching erythema an assessor has to press a finger on the skin. However, while the finger is on the skin there is no means of telling what is occurring immediately beneath the finger. The study of stage 1 pressure ulcers needs reliable measurements (Halfens et al 2001). A simple, more accurate widely accepted means of detecting non-blanching erythema is to use clear glass or a plastic disc to assess whether discoloration blanches or not (Halfens et al 2001).

When gentle pressure is exerted on the skin, blood is temporarily forced out of the area, causing skin to appear white instead of pink. In healthy tissue colour returns swiftly as blood refills the dermal capillaries. This is the basis of the blanch test, which differentiates healthy skin from damaged skin that is non-blanching erythema. In patients with darkly pigmented skin the presence of melanin will ensure that the practitioner or carer carrying out the test will be unable to see the evacuation of blood, followed by the refill; only the melanin will be visible (Matas et al 2001).

Some studies have attempted to distinguish between blanching and non-blanching erythema. Halfens et al (2001) instructed nurses to use a convex glass. Wee et al (2004) used a thumb and a transparent disc. The results from both studies demonstrated that more non- blanching erythema was identified when these tools were used.

Pulse oximetry

Non-invasive pulse oximetry is a popular method of assessing and determining oxygenation status. Good oxygenation is important for wound healing. Adler et al (1998) identified that pulse oximetry may not be as accurate and work as reliably in patients with darkly pigmented skin, compared to patients with less darkly pigmented skin. The effect of skin pigmentation is controversial (Adler et al 1998). However, Adler et al’s (1998) observational study of 274 patients led researchers to conclude that skin pigmentation does not bias or affect the precision of pulse oximetry.

Pressure ulcer risk prediction scores

The Waterlow scale (1988) is the most widely used pressure ulcer assessment tool in the UK while in the US it is the Braden scale (Braden and Bergstrom 1987). Although there is no evidence to question the use of the Braden and Waterlow scales in patients with darkly pigmented skin, there is no definitive evidence that either scale is effective in this population. Lyder et al (1998) carried out a pilot study to examine the validity of the Braden scale in black and Latino/Hispanic elders. Although the study sample was small, statistical analysis revealed that the Braden score significantly under-predicted those participants at risk of pressure ulcers.

BOX 1

National Pressure Ulcer Advisory Panel (NPUAP) definition of grade 1 pressure ulcers

BOX 2

European Pressure Ulcer Advisory Panel (EPUAP) definition of grade 1 pressure ulcers

Lyder et al ( 1998 ) state that clinicians should examine pressure ulcer prediction tools and those variables that place older people at risk in non-white populations, for example, diet. They noted that the diets of black and Latino/Hispanic people differ from the diets of white people. Dietary differences may affect hospitalised patients who are accustomed to traditional foods. This important factor may alter risk scores if patients do not eat. These findings can also be extrapolated to certain areas in the UK, therefore nutritional assessment of patients is vital, particularly in those who have wounds.

BOX 3

National Institute for Clinical Excellence guidance on pressure ulcer development

Conclusion

The NICE (2001) guidelines state that risk assessment should be carried out by personnel who have undergone appropriate training to recognise the risk factors that contribute to the development of pressure ulcers. This applies to any wound assessment. However, few healthcare professionals receive enough formal training and clinical support in this complex area of care (Scanlon and St\ubbs 2004).

The literature reveals that there is more variability in research that attempts to classify the aetiology of grade 1 pressure ulcers than any other grade (Lyder 1991, Hitch 1995). If healthcare professionals and carers aim to prevent a stage 1 pressure ulcer progressing to a more serious potentially life-threatening stage, they must be able to identify it correctly (Lyder 1991). However, it is particularly difficult to recognise a pressure ulcer in its early stage and to ascertain the extent of the damage in patients with darkly pigmented skin (Bennett 1995, Russell and Reynolds 2001).

It is vital that nurses and carers receive appropriate information and training. Educationalists must be clear in their teaching and assess nurses on theory and clinical competence. It is also important that patients are given explanations as to why their skin and bony areas will be palpated and touched to carry out a detailed assessment. Translators may be required.

A means of examining patients’ skin to appropriately diagnose and prevent wounds is required to assist practitioners. A variety of devices are being tested and evaluated and may be suitable to detect alterations in blood flow and other changes specific to ischaemia and reperfusion injury associated with chronic wounds (Salcido 2002). This will aid diagnosis regardless of skin colour, but more so in patients with darkly pigmented skin.

Lyder et al (1998) highlighted that researchers have developed systematic assessment tools and identified pressure ulcer predictive variables without considering ethnic minority groups. The specific risk to patients with darkly pigmented skin should no longer be ignored. Pressure ulcer risk assessment tools that are validated for patients with darkly pigmented skin may be required. Researchers should include significant numbers of ethnic minorities in their investigations of pressure ulcer risk and investigate risk factors specific to these groups (Lyder 1996).

The EPUAP carried out a pressure ulcer prevalence survey, without taking into account patients with darkly pigmented skin (Clark et al 2002). Perhaps the next study could include this patient group as this would help to ascertain the extent of the problem, establish a baseline and enable data to be compared to the US.

Practitioners in the UK and Europe can learn from the guidance cited by American colleagues (Box 1). European practitioners, the EPUAP, Tissue Viability Nurses Association and NICE should promote this guidance in relation to grade 1 pressure ulceration. Salcido (2002) emphasises that patients should not be undiagnosed because of the colour of their skin. Subsequent research in education, wound healing and pressure ulcers should include patients with darkly pigmented skin

Bethell E (2005) Wound care for patients with darkly pigmented skin. Nursing Standard. 20, 4, 41-49. Date of acceptance: June 6 2005.

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Author

Elaine Bethell is tissue viability clinical nurse specialist, Sandwell and West Birmingham Hospitals NHS Trust, City Hospital, Birmingham. Email: [email protected]

Copyright RCN Publishing Company Ltd. Oct 5-Oct 11, 2005

Zambia starts herbal AIDS drug trials

By Shapi Shacinda

LUSAKA (Reuters) – Zambia has launched clinical trials of
herbal medicines for AIDS, and early signs are hopeful they
could help boost the body’s defenses, a government health
official said on Wednesday.

Dr Patrick Chikusu, principal investigator of clinical
trials of traditional herbal remedies, said three herbal drugs
had been selected for the trials, including a remedy mixed by
former Works and Supply Minister Ludwig Sondashi, a lawyer.

“We have started clinical trials for three products on
human beings. The process has undergone extensive research by
our team and we have met World Health Organization (WHO)
specifications,” Chikusu told a news conference.

“The drugs show they are able to reduce the viral load and
increase CD4 cells, which defend the body, and that is why we
have proceeded with further trials. We have been using WHO 2003
guidelines on herbal remedies,” Chikusu said. “They are also
safe,” he added.

CD4 cells are the front line of the body’s immune system.

One in five Zambians is infected with HIV or is living with
AIDS. The country has 10 million people.

Chikusu, a medical doctor, said 14 natural remedies were
initially submitted for preliminary tests, but only three had
made it to the final stage of clinical trials.

Health Minister Sylvia Masebo said the three drugs had been
checked thoroughly to ensure they were not toxic.

“It is a momentous occasion for Zambia which establishes a
partnership between conventional medicine and traditional
medicine,” Masebo told reporters at the same news conference.

Chikusu said 25 patients had been placed on the three
herbal remedies on a three-month trial basis.

He identified the remedies as the Sondashi Formulation
invented by the former minister, the Mailacin Formulation,
which was developed by a school teacher, and the Mayeyanin
Formulation.

Doctors say that despite some price rebates to poor
countries and limited government assistance, Western-made
life-prolonging antiretroviral drugs cost as much as $500 per
monthly dose in Zambia, well beyond the reach of many poor
people with HIV.

Like most countries across southern Africa, Zambia has been
grappling with ways to reduce HIV infections. The country’s
treasury says AIDS is killing qualified professionals faster
than it is able to train replacements.

Genentech says Tarceva doesn’t aid Avastin effect

CHICAGO (Reuters) – Genentech Inc. said on Tuesday early
results from a mid-stage trial show that combining lung cancer
drug Tarceva with Avastin works no better than Avastin alone in
patients with advanced kidney cancer, sending shares of Tarceva
partner OSI Pharmaceuticals Inc. down 7 percent.

As a result, the world’s No. 2 biotechnology company said
it will not pursue further studies of the Avastin/Tarceva
combination in kidney cancer but will continue to analyze the
results of the study.

The companies continue to enroll patients in a Phase 3
trial designed to test the combination of the two drugs in lung
cancer patients, Genentech spokeswoman Colleen Wilson said.

Genentech had hoped that Avastin, which works by cutting
off blood supply to tumors, when combined with Tarceva would
add to the progression-free survival of patients and improved
response rate of Avastin alone.

Preliminary analysis of data from the 104-patient study
found that receiving Avastin plus a placebo resulted in
progression-free survival and response rates similar to those
achieved with the drug combination, Genentech said.

“We consider today’s announcement to be the death of the
prospects for widespread use of Avastin plus Tarceva in renal
cell carcinoma,” Rodman & Renshaw analyst Michael King said in
a report.

He had previously expected Tarceva sales for the
combination therapy to reach $9.1 million in 2010.

Genentech said it was encouraged by the duration of
progression-free survival seen in patients treated with Avastin
in this and previous studies in kidney cancer.

Avastin is currently approved only to treat colon cancer.
But the company has reported encouraging results against
several other tumor types and oncologists are already using
Avastin to treat some forms of lung and breast cancer on an
off-label basis.

OSI’s fortunes are far more dependent on Tarceva’s
performance than is Genentech.

Tarceva sales growth has been disappointing, but OSI
earlier this month expressed confidence in the drug’s long-term
prospects for its flagship drug.

The company is awaiting a decision by U.S. regulators on
its application to sell Tarceva to treat pancreatic cancer.

Lazard Capital Markets on Tuesday cut its price target for
OSI shares to $40 from $45, but maintained its “buy” rating on
the stock.

OSI shares closed down $2.04, or 7.9 percent, at $23.65 on
Nasdaq, while Genentech shares were up 63 cents at $84.83 on
the New York Stock Exchange.

(Additional reporting by Bill Berkrot in New York and Deena
Beasley in Los Angeles)