Unpasteurized Cheeses and Pregnancy are a Dangerous Combination

Feta, brie, goat's milk cheese and Mexican-style cheeses such as queso fresco are common ingredients in many gourmet dishes and traditional Hispanic cuisine.

But the cheeses in their unpasteurized, or raw, form are a delicacy that could be dangerous to a pregnant woman and her unborn baby, says Dr. Kevin Magee, assistant professor of obstetrics and gynecology at UT Southwestern Medical Center at Dallas.

Unpasteurized cheese and other raw dairy products and meats could be contaminated with listeria, a bacteria that can cause serious infections and complications during pregnancy.

"Don't think that just because you use the cheese at home that it's safer. It's not," Dr. Magee says. "We recommend that our patients wash all raw vegetables, thoroughly cook all meat products and avoid any unpasteurized cheese or milk products.

"Finally, if you plan to eat leftovers, thoroughly heat them."
Media Contact: Staishy Bostick Siem

http://www8.utsouthwestern.edu/utsw/cda/dept37377/files/69377.html

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Superbug MRSA deaths up 1400% in a decade

The number of people in the UK who have died as a result of being infected with the superbug MRSA (methicillin-resistant Staphylococcus) has risen steeply over the last ten years, according to official figures.

In 1993 51 people died from MRSA. Two years ago the figure stood at 800.

If we look at MRSA cases in total (not just deaths) they have risen 2300% from 210 in 1993 to 5,309 in 2002.

According to experts two things are happening here. There are more cases of MRSA, but we are also getting better at spotting it.

The costs to the NHS (UK) of hospital-acquired infections is estimated to be around �1 billion a year. This figure includes all hospital acquired infections, of which MRSA is one.

The UK government is starting to do something about it. In December it announced a crackdown on hospital hygiene.

Each hospital must have a Director of Infection. This person's job is to explain to people the importance of handwashing and general hygiene in hospitals. MRSA's main route of transmission is through unwashed hands.

These figures come from a study carried out by the UK Office of National Statistics and Health Protection Agency.

They examines tens of thousand of death certificates from the 1993-2002 period. They looked out for any mention of Staphylococcus aureus. Then they selected those that mentioned MRSA as the direct or contributing cause of death. MRSA is the drug-resistant from of the infection.

Dr Georgia Duckworth, an expert at the Health Protection Agency on this said 'It is difficult to establish whether MRSA is the underlying cause of a patient's death or just a contributory factor because the majority of infections are in people who are already very sick, and we don't know if they would have died as a result of their underlying illness whether or not they had MRSA. This research however does show that MRSA is making an increasing contribution to illness and mortality.'

Dr. Duckworth also said 'By following good infection control procedures, the spread of MRSA and other infections in hospital can be limited and controlled. However, although many of these infections can be prevented, they cannot be totally eradicated as they are the price we pay for advances in medical treatments, which often allow patients who are severely sick and vulnerable to infection, to survive.'

Many opposition MPs (Members of Parliament) are saying that these high figures could be partly due to chronic staff shortages in the UK National Health Service.

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Orthorexia nervosa - Obsessed with Eating to improve your Health

A new type of eating disorder is emerging where people are becoming obsessed with eating to improve their health. According to the Swiss Food Association, this new wave of nutritional obsession, known as 'Orthorexia' or 'Orthorexia nervosa', from the Greek "orthos" meaning right and correct, and "orexis" meaning appetite, is reaching worrying proportions.

In a quest to cure themselves of a specific disorder, or simply just taking healthy eating to extremes, orthorexics develop their own increasingly specific food rules. Working out how to stick to their self-imposed dietary regimen takes up more and more of their time and they are compelled to plan meals several days ahead. They tend to take a 'survival kit' of their own food with them when they go out, as they cannot eat readily available foods for fear of fat, chemicals or whatever their particular phobia might be.

Sticking to their regimen takes strong willpower and they feel self-righteous and superior to people who do not have such self-control. "Someone whose days are filled with eating tofu and quinoa biscuits can feel as saintly as if they had devoted their whole life to helping the homeless" states Dr. Steve Bratman, the man who initially described orthorexia back in 1997.

By contrast, if the orthorexic breaks their health-food vows and succumbs to a craving for a 'prohibited' food, they feel guilty and defiled. This drives them to punish themselves with ever stricter dietary rules or abstinence. This behaviour is similar to those who suffer from anorexia or bulimia nervosa, except that anorexics and bulimics are concerned with the quantity of food consumed whereas orthorexics are concerned with the quality.

In Europe we are now bombarded with information about what is 'good' and what is 'bad' for us all the time. Food scares and the organic movement have added to the complexity of decisions people need to make about the food they eat. Dr. Bettina Isenschmid, consultant for food disorders at L'H�pital de l'Isle in Berne, believes that this focus on good and bad foods is problematic and fuels an increasingly neurotic relationship with food in modern western society. Health is now an important consideration for many Europeans when menu-planning . How do we get the right balance between eating healthily and healthy eating obsession?

As with most aspects of diet, moderation is the key. Changes in food choices should be made gradually and in a way that fits in with a person's tastes and lifestyle. Eating more healthily should have a positive effect on health without reducing the enjoyment of life or affecting relationships with others. To check if someone has healthy eating in perspective, or is becoming obsessed, try the 'Bratman Test for orthorexia'.

further information:

The French Institute for Health Education: http://www.ineps.sante.fr
The Swiss Food Association: http://www.sve.org
The Health Food Junkie by Dr. Steve Bratman extracts: http://www.orthorexia.com

The Bratman Test for Orthorexia

-- Do you spend more than 3 hours a day thinking about your diet?

-- Do you plan your meals several days ahead?

-- Is the nutritional value of your meal more important than the pleasure of eating it?

-- Has the quality of your life decreased as the quality of your diet has increased?

-- Have you become stricter with yourself lately?

-- Does your self-esteem get a boost from eating healthily?

-- Have you given up foods you used to enjoy in order to eat the 'right' foods

-- Does your diet make it difficult for you to eat out, distancing you from family and friends?

-- Do you feel guilty when you stray from your diet?

-- Do you feel at peace with yourself and in total control when you eat healthily?

-- Yes to 4 or 5 of the above questions means it is time to relax more about food.

-- Yes to all of them means a full-blown obsession with eating healthy food.

http://www.eufic.org/gb/food/pag/food42/food421.htm

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Once daily Solifenacin Succinate significantly reduced urgency episodes for Patients with Overactive Bladder

Solifenacin succinate appears to be the first antimuscarinic agent to show statistically significant reductions in episodes of urgency across multiple trials

Solifenacin succinate, a once-daily oral antimuscarinic agent in development for the treatment of overactive bladder (OAB), significantly reduced urgency episodes in a pooled analysis of four pivotal trials involving more than 2800 patients, according to data presented today at the annual meeting of the American Urogynecologic Society (AUGS). OAB is a condition that affects approximately 17 million men and women in the United States.

According to the definition of OAB by the International Continence Society, the defining symptom of OAB is urgency, or the sudden, compelling desire to urinate that is difficult to defer. From this data, solifenacin appears to be the first antimuscarinic agent

to show statistically significant reductions in episodes of urgency across multiple trials. "The constant urgent need to urinate can have a debilitating effect on patients," said Vincent Lucente, MD, Chief Medical Officer at the Institute for Female Pelvic Medicine & Reconstructive Surgery. "It can affect the emotional and practical aspects of everyday life - such as being able to sit through an important meeting at work or getting a good night's sleep."

The study results showed patients taking solifenacin 5 mg once-daily experienced 2.9 fewer urgency episodes per 24 hours and patients taking solifenacin 10 mg once-daily experienced 3.4 fewer episodes per 24 hours, compared with those taking placebo who experienced 2.0 fewer episodes per 24 hours (P<0.001 for both doses). Patients reported a mean of approximately six urgency episodes per 24 hours at the time they entered the study.3

"Urgency is one of the defining symptoms of OAB," said Steven Swift, MD, Associate Professor of Benign Gynecology at the Medical University of South Carolina in Charleston, SC. "That's why reducing the number of daily 'urgency episodes' is an important therapeutic goal for both healthcare professionals and patients."

About the studies 3,4

The four pivotal, randomized, double-blind, placebo-controlled, 12-week studies, involving more than 2800 patients, had similar protocols, which permitted pooling of the results for the analysis. Patients evaluable for the efficacy analysis included 1124 treated with placebo, 548 treated with solifenacin 5 mg once-daily, and 1151 treated with solifenacin 10 mg once-daily.

Results included the following:

-- At the end of the study, 62 percent of patients receiving the once-daily dose of solifenacin 5 mg and 66 percent of patients receiving the once-daily dose of 10 mg reported that the number of urgency episodes was reduced by at least 50 percent, compared to only 44 percent of patients receiving placebo.

-- Median percent reductions in urgency episodes from baseline were 66 percent for 5 mg once-daily and 70 percent for 10 mg once-daily, compared with 40 percent for placebo (P<0.001 for both dosage groups vs. placebo). -- Twenty-nine percent of patients receiving solifenacin 5 mg once-daily and 26 percent of patients receiving solifenacin 10 mg once-daily reported no symptomatic urgency at the study endpoint, compared to 16 percent of patients receiving placebo (P<0.001 for both dosage groups vs. placebo).

A subset analysis revealed that solifenacin was effective in reducing urgency episodes in both women and men.

Solifenacin was well-tolerated in placebo-controlled trials; side effects were predominantly mild or moderate in severity and included dry mouth, constipation and blurred vision. Approximately 11 percent of patients taking solifenacin 5 mg once-daily experienced dry mouth, compared with 28 percent of patients taking solifenacin 10 mg once-daily and 4.2 percent of patients taking placebo. Only 2.8 percent of the patients taking solifenacin 5 mg once-daily and 6.8 percent of patients taking solifenacin 10 mg once-daily discontinued treatment due to an adverse event, compared to 4.4 percent of patients taking placebo.

About Overactive Bladder

Overactive bladder (OAB) is a common bladder control problem affecting more than 17 million Americans and between 50 and 100 million people worldwide. In the past, most studies underestimated the prevalence of OAB because they focused on only those patients with incontinence, and not the more common symptoms of frequency and urgency. As a result, recent studies have suggested that the prevalence of OAB may actually be higher.1

Frequently, sufferers do not seek medical care because they believe - inaccurately - that their symptoms are part of the normal aging process. Patients often are too embarrassed or are reluctant to talk with their physician about bladder control problems. Indeed, 40 percent of affected patients do not seek medical attention, and nearly 75 percent remain untreated.5

About Solifenacin Succinate

Solifenacin succinate is a once-daily oral muscarinic antagonist in development for the treatment of overactive bladder that acts to block the receptors in the smooth muscle of the bladder. The compound was discovered and developed by Yamanouchi Pharmaceuticals and its New Drug Application (NDA) was submitted to the U.S. Food and Drug Administration by Yamanouchi Pharma America in December of 2002. In August of 2003, Yamanouchi and GlaxoSmithKline signed an agreement for the co-promotion of solifenacin in the United States, and both are collaborating to help ensure an expeditious and efficient launch of solifenacin in the US market.

About Yamanouchi Pharmaceutical Co., Ltd.

Yamanouchi Pharmaceutical Co., Ltd., established in 1923 and headquartered in Tokyo, Japan, is a leading pharmaceutical company in Japan. With its subsidiaries worldwide, Yamanouchi is expanding its business base to Europe, the United States and Asia and employs approximately 9,300 people worldwide. The company has discovered and developed many medicines now marketed in the United States through successful licensing agreements. For detailed company information, visit http://www.yamanouchi.com.

About GlaxoSmithKline

GlaxoSmithKline, one of the world's leading research-based pharmaceutical and healthcare companies, is committed to improving the quality of human life by enabling people to do more, feel better and live longer. For more information, please visit the company's Web site at http://www.gsk.com

i Nitti VW. Clinical impact of overactive bladder. Reviews in Urology. 2002;4(4):S2-S6.

ii Abrams P, Cardozo L, Fall M, et al. The standardisation in terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourology & Urodynamics. 2002;21(2):167-78.

iii Lucente V, Swift S, for YM-905 Study Group. Urgency episodes were significantly reduced with solifenacin treatment for overactive bladder. Abstract presented at: AUGS/SGS Joint Scientific Meeting; July 29-31, 2004; San Diego, Ca.

4 Lucente V, Swift S, for YM-905 Study Group. Urgency episodes were statistically significantly reduced with solifenacin in patients with overactive bladder. Poster presented at: AUGS/SGS Joint Scientific Meeting; July 29-31, 2004; San Diego, Ca.

5 Milsom I, Abrams P, Cardozo L, Roberts RG, Thuroff J, Wein AJ. How widespread are the symptoms of an overactive bladder and how are they managed? a population-based prevalence study. BJU International. 2001;87:760-766.

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New Drug for Neuropathic Pain, Cymbalta (duloxetine)

People with diabetes who experience the pain associated with nerve damage (diabetic peripheral neuropathy) have a new treatment option--the first FDA-approved drug for managing the burning, tingling, and numbing sensations in the feet, legs, or hands that mark this condition.

The drug, Cymbalta (duloxetine), was recently approved for treating the condition, the most common complication of diabetes.

In clinical trials, people treated with Cymbalta reported less pain compared to those given an inactive substance (placebo). Fifty-eight percent of people treated with Cymbalta reported at least a 30 percent sustained reduction of pain. In comparison, 34 percent of people treated with a placebo reported sustained pain reduction. The most commonly reported side effects were nausea, dry mouth, constipation, and diarrhea. In some cases, patients experienced dizziness and hot flashes.

Cymbalta is manufactured by Eli Lilly and Company of Indianapolis.
http://www.diabetesnews.com/

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Hardening of the Arteries in the Leg Is a Red Flag for Vascular Disease

Peripheral arterial disease (PAD), hardening of the arteries in the leg, is a marker for premature cardiovascular events and vascular-related death. The November issue of the Journal of Vascular and Interventional Radiology includes a comprehensive review of this disease that affects more than 10 million Americans, as well as a comprehensive treatment plan for all types of PAD patients.

PAD develops most commonly as a result of atherosclerosis, or "hardening of the arteries," which occurs when cholesterol and scar tissue build up, forming a substance called plaque inside the arteries that narrows and clogs the arteries. Because atherosclerosis is a systemic disease, people with PAD are likely to have blocked arteries in other areas of the body. Thus, people with PAD are at increased risk for heart disease, aortic aneurysms and stroke. PAD is also a marker for diabetes, hypertension and other conditions.

Efforts on a national level to improve the awareness of PAD among patients and caregivers alike are critical to prevent premature death and impaired quality of life among this expanding group of patients.

As baby boomers continue to age, the number of those affected by PAD will continue to increase. Research shows that the prevalence of PAD increases 10-fold from men aged 30-44 to men aged 65-74 and almost 20-fold in women of the same ages.

As patients age, many of them dismiss one of the most common symptoms of PAD, known as claudication, as part of the "normal" aches and pains of aging. Intermittent claudication is leg pain that occurs when walking or exercising and disappears when the person stops the activity. Other symptoms of PAD include numbness and tingling in the lower legs and feet, coldness in the lower legs and feet, and ulcers or sores on the legs or feet that don't heal.

With more than 50 percent of PAD patients asymptomatic or with atypical symptoms, screening is essential for diagnosis. The ankle brachial index (ABI) test is a painless test that compares the blood pressure in the legs to the blood pressure in the arms to determine how well the blood is flowing and whether further tests are needed.

Once PAD is diagnosed, the goals of therapy for patients with PAD are to prevent systemic atherosclerotic disease progression and clinical cardiovascular events, prevent limb loss, and improve functional status of patients with intermittent claudication (pain when walking that stops during rest).

Management of PAD includes:

1. Smoking cessation

2. Physical activity

3. Dietary modification

4. Weight maintenance or reduction with target body mass index and waist circumference

5. Blood pressure control

6. Modification of elevated total and LDL-cholesterol levels

7. Antiplatelet therapy

8. ACE inhibitor therapy

9. Glycemic control in patients with diabetes mellitus

Interventional radiologists are doctors who specialize in minimally invasive, targeted treatments that have less risk, less pain and less recovery time compared to open surgery. They use their expertise in interpreting X-rays, ultrasound, MRI and other diagnostic imaging studies to understand, visualize and diagnose the full scope of the disease's pathology and to map out the procedure tailored to the individual patient. Then during the procedure, they image as they go to guide tiny instruments, such as catheters, through blood vessels or skin, to treat diseases at the site of the illness nonsurgically. IRs pioneered angioplasty and stenting, which was first performed to treat peripheral arterial disease to prevent amputation.

Interventional radiology is a recognized medical specialty by the American Board of Medical Specialties. Interventional radiologists are board-certified in diagnostic radiology and fellowship-trained in vascular and interventional radiology. The American Board of Radiology certifies their specialized training.

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European regulators extend missed pill window for Cerazette, Contraceptive without Estrogen

The 'missed pill window' for Cerazette�, the estrogen-free contraceptive pill, has been extended from 3 to 12 hours, following an agreement reached by MRFG, the responsible European regulatory body and Organon.(1)

This means that for the first time women can choose an oral contraceptive that is free of estrogen and its associated side effects, but with comparable reliability and margin of error as the combined pill.(2) Cerazette is the first and only estrogen-free pill that offers consistent ovulation inhibition.

Current prescribing information for "progestogen-only" pills rules that women should take their pill within a three-hour window each day, leaving little room for error. This reflects the fact that such products do not consistently prevent ovulation. Now, based on evidence of Cerazette's consistent inhibition of ovulation, its window will be extended to 12 hours. This will further widen the appeal of this estrogen-free pill.(3)

"A significant number of women - who cannot or do not want to take estrogen - stand to benefit from an oral contraceptive that does not contain estrogen. However, the appeal of traditional progestogen-only pills has always been limited by their lower reliability and more stringent pill-taking regimen compared to the combined pill. Cerazette has overturned that," said Dr Ulrich Karck, director of Stuttgart's Women's Hospital in Germany. "Cerazette has already proved tremendously popular since its introduction in Germany. The extension of its missed pill window will no doubt increase its appeal to an even greater extent."(4)

New study findings confirm prevention of ovulation

The new evidence was presented today at the 8th Congress of the European Society of Contraception. Dr Tjeerd Korver from the clinical development group of Organon presented study results showing that Cerazette consistently inhibits ovulation even when tablets are taken 12 hours late. More than 100 women took part in the study.

"The study shows that Cerazette inhibits ovulation to the extent known from the conventional combined pill," says Dr Korver. "It means women can take an estrogen-free pill just as conveniently as a combined pill and with the same confidence."

Convenience and reliability without estrogen

Estrogen, although traditionally important for preventing ovulation in the pill, is also associated with several unwelcome side effects. Headache, nausea and breast tenderness have long been associated with the estrogen content of the pill. And there are many women who cannot - or choose not to - take estrogens.

However, Cerazette's benefits do not just lie in its estrogen-free composition. With its new wider window of confidence for missed pills, Cerazette's margin for user error will be extended.

Cerazette may initially cause irregular bleeding. Some women may also have amenorrhea. However, after a few months most women will have less frequent bleeding episodes.


MRFG's approval underlines Cerazette's consistent effect on ovulation, and will increase user confidence in this estrogen-free product. This, alongside Cerazette's continuous 28-day regimen, results in an easy-to-take pill that is free of estrogen-related side effects but without any compromise of high contraceptive efficacy.(5)

About Organon

Organon - headquartered in Roseland, NJ, USA - creates and markets prescription medicines that improve the health and quality of human life. Through a combination of independent growth and business partnerships, Organon strives to become or remain one of the leading pharmaceutical companies in each of its core therapeutic fields: reproductive medicine, psychiatry and anesthesia.

Organon products are sold in over 100 countries, of which more than 60 have an Organon subsidiary. Organon is the human health care business unit of Akzo Nobel.

1. The change to the official European prescribing information for Cerazette was agreed by the Mutual Recognition Facilitation Group (MRFG) on 27th May 2004. The MRFG was established by the Member states in March 1995 and held its first meeting in June of that year. Next step is to implement the new prescribing information by national regulatory authorities before being applicable in individual countries.

2. Traditional contraceptive pills without estrogen are known as "progestogen-only" pills (POPs), or "mini pills". The progestogen causes mucus in the cervix to thicken, which thereby prevents the penetration of sperm into the uterus and the tubes. This is a primary mode of action for conventional POP's. This effect on cervical mucus has been found to last no more than 27 hours - hence the short margin for error (3 hours) traditionally applied to POPs. However, Cerazette has a different mechanism of action from conventional POPs. Because Cerazette works by consistently preventing ovulation (as well thickening cervical mucus), studies have shown that its contraceptive efficacy is maintained for up to 36 hours after taking a tablet - hence the extension of the missed pill window from 3 to 12 hours. This is similar to that applied to combined pills (which contain both estrogen and progestogen).

3. Estrogen, although traditionally important for preventing ovulation in the pill, is also associated with several unwelcome side effects. Headache, nausea and breast tenderness have long been associated with the estrogen content of the pill. And there are many women who cannot - or choose not to - take estrogens.

4. Karck U. XVII World Congress of Gynecology and Obstetrics, Santiago,Chile, 2003.

5. Each tablet of Cerazette contains 75 micrograms of the progestogen hormone desogestrel. Tablets are taken each day for a cycle of 28 days. A recent study to assess the efficacy of Cerazette found pregnancy rates were much lower than with a conventional POP (a Cerazette Pearl Index of 0.4 versus a POP Pearl Index of 1.6). (Rice CF, Killick SR, Dieben T, Coelingh Bennink H. A comparison of the inhibition of ovulation achieved by desogestrel 75 mcg and levonorgestrel 30 mcg daily. Hum Reprod 1999; 14: 982-5).

The pregnancy rates found with Cerazette were in the range associated with traditional combined pills. The study reported by Dr Korver at the ESC congress showed that ovulation was prevented in 99% of cases, even when tablets were taken 12 hours late. Thus, accidental delays in tablet taking of up to 12 hours do not jeopardize the ovulation inhibition and contraceptive efficacy of Cerazette.

N.V. Organon (Communications)
Visiting address:
Molenstraat 110
5342 CC Oss
The Netherlands
Mailing address:
P.O. Box 20
5340 BH Oss
The Netherlands
Phone
+31.412.66.54.40
Fax:
+31.412.66.25.68
Email address:
monique.mols@organon.com

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Becoming a nurse or midwife in the UK

INTRODUCTION - "THERE HAS NEVER A MORE EXCITING TIME"

There has never a more exciting time to join the nursing or midwifery profession. The number and variety of roles is huge. As a nurse it is possible to work in, among others, hospitals, GP surgeries, clinics, nursing and residential homes, occupational health services, voluntary organisations that run hospices or residential care and the pharmaceutical industry. Nurses also work in the prison service, university education, on leisure cruise ships or for the armed forces.

Nurses focus on the needs of the individual, rather than specific illnesses or conditions. They help individuals and their families to live more comfortable lives by providing care, advice and counselling.

Midwives are often the key health professional supporting, guiding and caring for the mother, baby and family through the months of pregnancy, during the birth itself and afterwards in the postnatal period.

NURSE AND MIDWIFERY EDUCATION

It is possible to take either a diploma or degree course to qualify as a nurse. Education is provided by universities, with placements in local hospital and community settings. The course is 50% theory and 50% practical. The first year is a Common Foundation Programme, which will introduce you to the basic principles of nursing. You will then specialise in either adult, children's, mental health or learning disability nursing. Full time diploma courses last three years. Degree courses last three or four years.

Midwifery education is also at diploma or degree level. You will learn the theory and practical skills required to care for pregnant women, delivering babies, educating and supporting parents. The social , political and cultural issues affecting maternity care are also covered.

ADULT NURSING

The number of opportunities for those qualifying in the adult branch of nursing is huge. It is possible to work in hospitals or the community - in peoples homes, attached to a health centre or in nursing homes. You will care for, support and educate people of all ages. Once qualified, many nurses take extra courses to specialise in areas such as cancer care, women's health, accident and emergency, critical care, practice nursing, health visiting or school nursing.

CHILDREN'S NURSING

Those qualified in the children's branch of nursing work with 0 to 18 year olds in a variety of settings, from specialist baby care units to adolescent services. Children react to illness in a very different way to adults, which is why they need to be cared for and supported by specially trained nurses who understand their particular needs. Children's nurses also support, advise and educate parents and other close relatives. Once qualified, it is possible to specialise in hospital and community settings in areas such as burns and plastics, intensive care, child protection and cancer care.


LEARNING DISABILITY NURSING

About two to three percent of the population has a learning disability. Nurses who qualify in this branch of nursing help those with learning disabilities to live independent and fulfilling lives. This may involve working with people in supported accommodation - typically three to four people with learning disabilities live together in flats or houses, with 24 hour support. Some nurses work with individuals who require more intensive support - for instance, in hospitals or in specialist secure units for offenders with learning disabilities. Others specialise in areas such as epilepsy management or working with people with sensory impairment.

MENTAL HEALTH NURSING

Mental health nurses work with GPs, psychiatrists, social workers and others to co-ordinate the care of people suffering from mental illness. The vast majority of people with mental health problems live in the community. Nurses plan and deliver care for people living in their own home, in small residential units or specialist hospital services. Some are based in health centres. It is possible to develop expertise in areas such as rehabilitation, child and adolescent mental health, substance misuse and working with offenders.

MIDWIFERY

Many midwives carry their own caseload of women and work in the community. others are based in hospital. There are opportunities to specialise in public health, women's health and to run specialist services, such as teenage pregnancy clinics.

FUNDING

Those who undertake an NHS funded degree course receive a means tested bursary. Your tuition fees are paid, but the grant allowance you receive will depend on your income or that of your partner/parents.

Those who undertake an NHS funded diploma course receive a non means tested bursary, which currently stands at �5,432 (�6,382 in London). Depending on your circumstances you may be elligible for extra allowances - for example, if you have children.

Further information is available from the following organisations:

The NHS Student Grants Unit
Rm 212c Government Buildings
Norcross
Blackpool
FY5 3TA

Tel: 01253 655 655 (Diploma Enquiries)
Tel: 01253 333 314 (Degree Enquiries)
Fax: 01253 333256

in Scotland,
The Students Awards Agency for Scotland
3 Redheughs Rigg
South Gyle
Edinburgh
EH12 9HH
Tel: 0131 4768212

in Wales,
NHS Wales Student Award Unit
2nd Floor
Golate House
101 St Mary Street
Cardiff
CF10 1DX

Tel : 029 2026 1495
Fax: 029 2026 1499.

in Northern Ireland,
The Department of Higher and Further Education Training and Employment
Student Support Branch
4th Floor Adelaide House
39-49 Adelaide Street
Belfast
BT2 8FD

Tel: 028 9025 7777

ENTRY REQUIREMENTS

Personal qualities

If you enjoy working with people and would like to make a difference to their lives nursing has a lot to offer you. You need to be non-judgmental and a good communicator, with the ability to listen, empathise and provide support. Nursing attracts all kinds of personalities from all sorts of backgrounds. Whether you're an extravert or introvert you'll find an area of nursing that helps you to fulfil your potential.

Age

By law you must be aged 17 and a half (17 in Scotland) at the start of the course.

Health

You have to complete a health questionnaire when you apply for nurse or midwifery training and will be asked to identify any special needs related to a disability. Your acceptance on a course will be subject to satisfactory health clearance. If you have a disability, you may find it useful to contact SKILL (The National Bureau for Students with Disabilities), on telephone number 0800 328 5050, or visit their website at www.skill.org.uk

Past convictions

If you have any past convictions, you will need to declare this on the application form. The university will also ask you to sign a form allowing them to check whether you have a police record. You will not automatically be barred from entering the nursing or midwifery profession if you have a criminal conviction or caution. The university will take into account the circumstances surrounding the case and should treat any information in the strictest of confidence.

QUALIFICATIONS

The minimum entry requirements are given below, but note that many universities will require you to hold more than the minimum, including A' levels:
(In UK A levels = Senior High School Certificate. GCSE = Junior High School Certificate)

-- 5GCSE/GCE O levels, grade C or above (including English and a Science/Maths subject for entry to Midwifery); or
-- 5 CSEs Grade 1; or
-- 5 SCEs grade 1 (Scotland); or
-- 5 SCE ordinary, grades A-C (Scotland); or
-- GNVQ Intermediate level plus one GCSE/GCE O level, grades A-C; or
-- GNVQ Advanced Level or NVQ level 3; or
-- SVQ level 3; GSVQ level 3 (Scotland); or
-- SVQ level 2 (Scotland) if the programme began after Sepetember 2000
-- A Kitemarked Access to Higher Education course; or
-- EDEXEL Foundation (BTEC) National or Higher National Diploma; or
-- Passes in the Northern Ireland Grammar School Senior Certificate of Education;
-- A qualification awarded by the NNEB dating from 1985, including the Diploma in Post-Qualifying Studies

Further details are available from NHS Careers (England) or the organisations in Scotland, Northern Ireland and Wales listed (see Application Process below).

NURSING CADETS

If you do not hold any of the above qualifications you can apply for a new initiative called the nursing cadet scheme. Run by various NHS trusts in England, this scheme enables you to undertake an initial training programme, successful completion of which gives you an NVQ level three or Access to nursing qualification. You are then seconded to a nearby university to take a nursing diploma course, leading to registration as a nurse. Further details are available from NHS Careers (see below).

APPLICATION PROCESS

There is a central application process for both degree and diploma programmes.

For degree programmes you will need to apply to:

The University and Colleges Admissions Service (UCAS)
Barn Lane
Cheltenham
Gloucestershire
GL52 3LZ
Tel: 01242 227788 - for application package only
01242 222444 - general enquiries
Fax: 01242 544961

For diploma programmes you will need to apply to:

The Nursing and Midwifery Admissions Service (NMAS)
Rosehill
New Barn Lane
Cheltenham
Gloucestershire
GL52 3LZ
Tel: 01242 223707 - application package only
01242 544949 - general enquiries
Fax:: 01242 544962

Further information on all of the above is available from the following organisations

NHS Careers
PO Box 376
Bristol
BS99 322
Telephone: 0845 60 60 655
Email: advice@nhscareers.nhs.uk
Web site: www.nhscareers.nhs.uk

NHS Education for Scotland
66 Rose Street
Edinburgh
EH2 2NN
Telephone: 0131 220 8666
Email: careers@nes.scot.nhs.uk
Web site: www.nbs.org.uk

Health Professions Wales
2nd Floor
Golate House
101 St Mary Street
Cardiff
CF10 1DX
Telephone: 02920 261400
Fax: 02920 261499
e-mail: info@hpw.org.uk
Web site: www.hpw.org.uk

Queen's University Belfast
University Road
Belfast
BT7 1NN
Telephone: 028 9024 5133
Fax: 028 9024 7895
Web site: www.qub.ac.uk

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Beating Persistent Tiredness

At any given time, 1 in 10 people are suffering from persistent tiredness, with women more likely to be affected than men. Severe tiredness is a common reason for people visiting their GP.

With our stressful, busy lives, most people experience tiredness sometimes. Following some rest and relaxation and a good night's sleep, tiredness generally disappears, leaving us refreshed and ready to face our usual activities. For some people, however, tiredness becomes a chronic problem which severely affects their quality of life and their day-to-day functioning.

Causes of tiredness

There are many possible reasons for chronic tiredness. Usually, tiredness is due to a combination of causes. Tiredness can have physical triggers, such as a recent illness, pregnancy or breastfeeding. It can also be triggered by stressful situations, for example a recent bereavement, moving house, family or work problems.

As well as well-defined triggers, there are many factors that can increase your tiredness, or stop you from regaining your energy when you are tired and run down.

Physical causes

Being tired can lead you to avoid physical activity. However, as you become more unfit, you will be even more tired when you try to do something. When you are chronically tired, this can become a vicious circle.

Being too fat or too thin can cause tiredness. If you are overweight, your body has to work harder than normal to do everyday activities. If you are very underweight, you have less muscle strength and may tire more quickly.

Many types of illness can leave you feeling very tired, especially anaemia, an underactive thyroid and heart failure.

Sleep problems such as insomnia and sleep apnoea (abnormal breathing while asleep) can also stop you getting a good night's sleep, while pregnancy is another common reason for severe tiredness.

Emotional causes

Stress and worry are tiring emotions. Facing a stressful situation can be draining, especially when you cannot see a solution to your problems. Feeling that you have no control over a situation may lead to frustration, irritability and tiredness.

Mental health problems such as depression or anxiety can make you feel more tired and can prevent you from sleeping properly.

Lifestyle causes

People with unusual or disturbed sleep patterns such as shift workers, nurses, doctors and nursing mothers can find it difficult to get refreshing sleep.

Looking after small children is a particularly draining activity, especially if children do not sleep through the night.

Sleeping in the day can prevent you from sleeping at night. Drinking too many caffeinated or alcoholic drinks can also make it difficult to get a good night's sleep, especially if you drink them close to bedtime. Continues......BUPA

What is Tiredness?

For more information on what tiredness is and how to beat it, please see:
What is Tiredness or Fatigue? How Can I Beat Tiredness? Why am I Tired?

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New Treatment for Bladder Infections and UTIs

York-based company Sweet Cures is achieving astonishing success with their own health product, Waterfall D-Mannose, a cure and preventative treatment for bladder infections and UTIs.

A specialist market, you might think, but up to 50% of women worldwide have some type of urinary tract infection in their lifetime, and up to 10% of women have recurring infections that are resistant to even broad-spectrum antibiotics.

That's where Waterfall D-Mannose comes in. With increasingly resistant E.Coli strains appearing, and increased public awareness of the dangers of taking antibiotics - some of which are so toxic to the body that they can occasionally kill on the first dose, people are looking for alternative ways to deal with their infections.

John Bremner and Anna Sawkins discovered that D-Mannose - a monosaccaride isomer of glucose, effectively attaches itself to the mannose receptors that Escherichia coli - the cause of around 90% of bladder infections - uses to hook itself to human tissue. The E.coli is then flushed out of the system during normal urination.

The treatment was tested on over 300 women, with only one failure where E.coli was involved. This contrasts with an average failure rate of 35% for antibiotics treating the same infection.

As the properties of Waterfall D-Mannose have become known, (it works agains antibiotic resistant strains of E.coli) Sweet Cures has exported the isomer all over the world, even sending the product to customers as far afield as Australia.

So far, although Sweet Cures does have one Harley Street specialist who recommends their product, not many doctors have come on board. Naturally, they would like to attract more.

'It's a cause we are very interested in,' said Anna Sawkins, 'Doctors recommend and prescribe standard allopathic treatments for UTIs, but in the long term these can do more harm than good.

Fluoroquinolene-based antibiotics can have particularly devastating side effects such as fluorodosis/fluorosis - basically fluorine poisoning. And the effects are cumulative. We'd just like doctors to consider the alternatives.'

Meanwhile, patients all over the world are taking their treatment out of the hand of doctors and successfully treating themselves with Waterfall D-Mannose.

John Bremner agrees with Anna's sentiments, and goes further, 'The pharmaceutical industry has a vested interest in cures that don't work long-term.

After all, if they cured the problem, they would lose sales. And if antibiotics have bad side effects, what do people do? Go to the doctor for more drugs to treat those side effects.'

It's clear why he is not making many friends amongst the medical profession. But it's also clear that he is making a point that needs to be made.

For more information contact John Bremner or Anna Sawkins, Sweet Cures, 101 Foxwood lane, York, YO24 3LQ. Tel: 01904-340916.
Website: www.bladder--infection.com
email: john@bladder--infection.com or anna@bladder--infection.com

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Products containing bitter orange or synephrine: suspected cardiovascular adverse reactions

Products containing bitter orange (Citrus aurantium) or synephrine are used for their claims of promoting weight loss. However, these products are not authorized by Health Canada for this indication. Synephrine, the main active compound in bitter orange, is claimed to increase metabolism and promote thermogenesis.1 Although their effectiveness remains unclear,1 many products containing bitter orange are being promoted as "Ephedra/ephedrine free," since the use of Ephedra has been restricted in Canada2 and prohibited in dietary supplements in the United States3 owing to adverse cardiovascular and cerebrovascular reactions.

Synephrine, a sympathetic a-adrenergic agonist, is structurally related to ephedrine; thus bitter orange extract may be associated with a spectrum of adverse reactions (ARs) similar to those associated with the use of Ephedra/ephedrine.4 In animals, synephrine use has been associated with dose-related cardiotoxicity, specifically ventricular arrhythmias.5 A case of myocardial infarction in a patient with no history of heart disease has been reported in association with synephrine-containing products.6 Health Canada issued an advisory on a natural health product containing synephrine and other stimulants, cautioning that synephrine may have cardiovascular effects similar to those of ephedrine.4 Synephrine's cardiovascular effects may be increased when combined with other stimulants such as caffeine.7 Previously, Health Canada warned consumers about using Ephedra products containing caffeine, for the same reasons,2 and other reviews have reiterated this safety concern.8

From Jan. 1, 1998, to Feb. 28, 2004, Health Canada received 16 reports in which products containing bitter orange or synephrine were suspected of being associated with cardiovascular ARs, including tachycardia, cardiac arrest, ventricular fibrillation, transient collapse and blackout. All cases were considered serious. One involved a suspect product containing bitter orange but no caffeine or Ephedra/ephedrine. In 7 cases the suspect product also contained caffeine, and in 8 cases the suspect product also contained both Ephedra/ephedrine and caffeine. Two of the 16 patients died, both of whom had taken products containing Ephedra/ephedrine and caffeine in addition to bitter orange. Evaluation of these reports is challenging because of many factors such as the lack of information on the ingested dose of synephrine, the contributory effects of other (multiple) ingredients such as Ephedra and caffeine, and the ambiguity of the reported information.

Consumers need to be aware of the potential serious ARs when using these products containing bitter orange or synephrine and may wish to consult their health care providers with regard to their use. Health care professionals are encouraged to ask their patients to list the natural health products they are taking and report to Health Canada any suspected ARs related to the use of such products, including those claiming to promote weight loss.

Scott Jordan, PhD, Mano Murty, MD, CCFP, FCFP, and Karen Pilon, RN, Health Canada

References

1 Blumenthal M, senior editor. Herbal medicine - expanded Commision E monographs. 1st ed. Austin (TX): American Botanical Council; 2000. p. 287-9.

2 Health Canada reminds Canadians of the dangers of Ephedra/ephedrine products. Ottawa: Health Canada; 2003 June 9. Available: http://www.hc-sc.gc.ca/english/protection/warnings/2003/2003_43.htm (accessed 2004 July 5).

3 FDA announces rule prohibiting sale of dietary supplements containing ephedrine alkaloids effective April 12 [FDA statement]. Rockville (MD): US Food and Drug Adminstration; 2004 Apr 12. Available: http://www.fda.gov/bbs/topics/NEWS/2004/NEW01050.html (accessed 2004 June 28).

4 Health Canada warns Canadians not to use "Thermonex." Ottawa: Health Canada; 2004 May 28. Available: http://www.hc-sc.gc.ca/english/protection/warnings/2004/2004_30.htm (accessed 2004 July 5). 5 Calapai G, Firenzuoli F, Saitta A, Squadrito F, Arlotta MR, Canstantino G, Inferrera G. Antiobesity and cardiovascular toxic effects of Citrus aurantium extracts in the rat: a preliminary report. Fitoterapia 1999;70:586-92.

6 Nykamp DL, Fackih MN, Compton AL. Possible association of acute lateral-wall myocardial infarction and bitter orange supplement. Ann Pharmacother 2004;38(5):812-6.

7 Bucci L, Shugarman AE, Feliciano J, Wright J. Acute metabolic responses to synephrine-caffeine compared to ephedrine-caffeine. Presented at the Conference on the Science and Policy of Performance-Enhancing Products. NIH Office of Dietary Supplements; Bethesda, Md; Jan. 8-9, 2002. Available: http://ods.od.nih.gov/news/conferences/BucciPEPCRN _Ephedra_Presentation_Jan02.pdf (accessed 2004 June 27).

8 Bitter orange. Natural Medicines Comprehensive Database. Available: http://www.NaturalDatabase.com (accessed 2004 June 27). Jellin JM, Gregory PJ, Batz F, Hitchens K, et al. Pharmacist's letter/prescriber's letter. Natural Medicines Comprehensive Database. 6th ed. Stockton (CA): Therapeutic Research Faculty; 2004. p. 146-8.

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Ankle Replacement Surgery for Patients with Severe Ankle Arthritis

Encouraging trends in the long term success of total ankle replacement were reported in a study presented at the American Orthopaedic Foot and Ankle Society's (AOFAS) annual summer meeting today.

This study, conducted by Charles Saltzman MD, a Professor of Orthopaedic Surgery and Engineering from the University of Iowa, found total ankle replacement to be an option for patients with severe arthritis. Similar to hip and knee replacement surgeries, total ankle replacement involves removing the arthritic ankle joint and replacing it with an implant.

Total ankle replacement was developed in the 1970's but initially was plagued with high long term failure rates. The older prosthetics implants loosened or malfunctioned and frequently needed to be removed. Newer implants were developed in the late 1990's that have made the surgery a more viable option.

In the study, Dr. Saltzman reported long term results with the use of the new Agility Total Ankle ( Depuy, Inc) implant developed by Dr. Frank Alvine. The Agility ankle consists of a bearing joint made of a highly mobile and refined polyethylene plastic and mimics the motion of a real ankle. The polyethylene meets with a polished metal surface acting as a hinge giving the patient a range of motion of 20 degrees. Dr. Alvine's invention is currently the only FDA approved total ankle implant in use in the United States.

Prior to total ankle replacement surgery, the only surgical option for patients with disabling arthritis was fusion. This procedure involves fusing the bones together completely restricting ankle motion.

To measure the success of total ankle replacement surgery Dr. Saltzman initially studied the patients of Dr. Alvine four and a half years after they received their ankle implants. His new study re-examines those patients nine years after their surgery.

"The results of total ankle replacement are encouraging," said Dr. Saltzman. "The new failure rate is 11% an improvement from previous reports in the past. This suggests that the newer designs are having good mid-term outcomes." He warns that a failure rate of 11% still exceeds those of total knee and hip replacement. Although the procedure still needs improvement the implant is arguably better than joint fusion for selected patients according to Dr. Saltzman.

Future improvements will depend upon further training of doctors on how to use and properly implant the prosthetic device. The surgery should be done by surgeons with a background in total knee and total hip replacement who possess an extensive understanding of the foot and ankle.

Success also depends on the proper selection of patients. In Dr Saltzman's study, the average age of the patients at the time of surgery studied by Dr. Saltzman was 63. To receive a total ankle replacement, a patient must have debilitating, end-stage arthritis.. End-stage arthritis can be intermittently extremely painful and leaves patients incapacitated.

They find it difficult to stand and have a hard time maintaining employment. Furthermore, some ankle arthritic conditions are so severe that patients are unable to continue walking, even with the aid of a brace or cane. Most have been treated with anti-inflammatory medicine for many years without substantial relief. For these patients, surgery becomes the only option.

The short term complications associated with total ankle surgery are rare, but can be devastating. A deep infection can lead to removal of the implant and an extensive reconstructive surgery of the foot and ankle.

Long term problems include implants loosening and plastic irritation to the bone liner from deformation or wear. Sometimes the bone crumbles underneath the metal implant in a process known as subsidence.

This type of situation will require revision surgery to strengthen the bone and reattach the implant. If the plastic liner frays, the small particles released can induce damage to the surrounding bone, accelerating the process of subsidence. This type of situation will require revision surgery to strengthen the bone and reattach or replace the implant.

Dr. Saltzman cautions that the implant is made of mechanical parts. "All mechanical parts wear out, so patients with long term use will sometimes require maintenance," he said. Ideal candidates are elderly, inactive people with end stage arthritis simply because they are low demand and usually realistic about the capabilities of their implant.

"Patients need to be realistic about the limitations and expectations with use of an ankle replacement," Dr. Saltzman says, "but it is a viable option to treat people with debilitating end-stage ankle arthritis."

The AOFAS is the leading professional organization for orthopaedic surgeons specializing in disorders of the foot and ankle. Orthopaedic surgeons are medical doctors with extensive training in the diagnosis and treatment of the musculoskeletal system that includes bones, joints, ligaments, tendons, muscles, and nerves.

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Dental Appliances Effective in Treating Obstructive Sleep Apnea

New data presented today at the Annual Meeting of the American Academy of Otolaryngology confirm that specialized oral appliances are a viable option to counter the devastating effects of obstructive sleep apnea (OSA) and new FDA-approved technologies for home-based sleep studies are a valuable tool to diagnose and assess the effectiveness of the therapy.

Obstructive sleep apnea syndrome (OSAS) is a disorder characterized by repeated episodes of reductions or cessation in breathing during sleep. Millions of Americans, both men and women, have this medical problem, which is associated with clinical complications such as daytime sleepiness, high blood pressure (hypertension), heart disease, increased risk for stroke, and an increased risk for early death.

The gold-standard method to diagnose and quantify OSA is considered the overnight sleep polysomnography (PSG). With this system, patients spend the night in a sleep lab while hooked to a variety of electrodes, which measure various channels (such as EEG, EOG, EMG, ECK, Flow, Respiratory Effort, Oximetry). The severity of the disorder is expressed as the respiratory disturbance index (RDI), which is the number of sleep disordered breathing events per hour of sleep.

The expense and patient inconvenience of the PSG has lead to the development of a variety of ambulatory sleep study systems performed in the home. These include simple devices such as ambulatory pulse-oximetry, more complex devices that monitor several channels, and even full ambulatory PSG. Recently, the novel Watch-PAT100 ambulatory system, an FDA approved device, has been introduced to diagnose and quantify sleep apnea in the comfort of the patient's home. The WATCH-PAT100 has been shown to be accurate in diagnosing OSA, and at the same time to be an easy-to-use device; enabling physicians to manage sleep apnea at their own practices.

The most effective treatment for OSA is continuous positive airway pressure delivered via a nasal mask (nCPAP), but it has a very low compliance rate. Weight reduction can greatly alleviate the OSA severity, but it is frequently difficult to achieve or maintain. Surgical procedures benefit some patients but their long-term effectiveness is questionable. Recently, another therapeutic approach has been introduced: the anterior mandibular positioning (AMP) dental device is designed to increase airway caliber and decrease airway resistance by moving the mandible forward during sleep. Previous studies have reported beneficial effects of oral appliances in OSA on mild to moderate cases.

"OSA is significantly under-diagnosed and its consequences are a burden on the healthcare system," noted Professor Giora Pillar. "The PAT is a sensitive indicator of sympathetic activity induced by acute periods of airflow obstruction, such as associated with OSA and the Watch-PAT 100 fills an important void in creating a simple, cost-effective approach to the diagnosis of OSA."


A research team set out to examine whether two different oral appliances were beneficial for various severities of OSA, and whether response can be easily monitored in the dental clinic by the ambulatory Watch-PAT100 sleep diagnosis device. The authors of "Efficacy Assessment of Obstructive Sleep Apnea Treatment: Watch-PAT100 Follow-Up of Patients Treated with Two Oral Appliances," are Giora Pillar, Sleep laboratory, Rambam Medical Center and Technion - Israel Institute of Technology, Haifa, Israel; Steven Merahn, MD with the Academy of Clinical Sleep Disorders Dentistry , USA; and Edward P. Spiegel, DDS, of Erie, PA. Their findings are being presented at the American Academy of Otolaryngology-Head and Neck Surgery Foundation Annual Meeting & OTO EXPO, being held September 19-22, 2004, at the Jacob Javits Convention Center, New York City, NY.

Methodology: Twenty patients (four females, 16 males) with a diagnosis of OSA (six with a severe condition) were studied. Patients were overweight (mean BMI 31.7 � 5.7 Kg/m2), had wide necks (mean neck circumference 17.1 � 0.9''), and reported daytime sleepiness (somnolence). They were randomized to use either the EMA2 or the Silencer oral appliance. Both oral appliances are laboratory fabricated and allow three major functions: vertical and anterior positioning, and free lateral movement.

All underwent a pre- and post treatment ambulatory sleep study, using the Watch-PAT100 device. This device detects peripheral arterial tone, sleep state, oxygen saturation, pulse rate and autonomic activation, and has been shown to be accurate at quantifying sleep disordered breathing. The follow-up treatment efficacy study was performed at least three weeks after commencing treatment. Vertical and anterior positioning of the oral appliance was determinate using imaging airway assessment.

Results: Ten patients have been using the EMA2 and ten patients the Silencer device on a nightly basis (reportedly). Age, BMI, neck circumference and pre-treatment OSA severity were similar between the groups. Out of 40 home studies, two were repeated due to technical problems.

On treatment, mean RDI with the EMA2 decreased from 36�17/h to 11�12/h and minimal oxygen saturation increased from 82�6 to 88�4 percent. In 80 percent of the patients, treatment was considered successful (defined as reduction of RDI by at least 50 percent or to less than 10/h). With the Silencer, RDI decreased from 30�20/h to 13�13/h and minimal oxygen saturation increased from 81�12 to 88�4 percent. In 80 percent of the patients, treatment was considered successful. For both appliances, the unsuccessful treatment was in relatively severe patients.

Conclusions: Despite the lack of long-term data, the researchers believe their findings confirm previous reports that oral appliances are beneficial for OSA. While several previous studies concluded that oral appliances should be reserved only for the mild and moderate OSA cases, their results suggest that this treatment may be adequate for severe cases as well (especially for patients non-tolerant to CPAP). In addition, the study offers evidence that the ambulatory monitoring system WATCH-PAT100 is an easy and convenient way to monitor these patients and follow-up on them during treatment.

Note: The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) represents the nation's 11,000 otolaryngologist-head and neck surgeons. These specialists diagnose and treat disorders of the ear, nose, and throat and related structures of the head and neck. Learn more about the specialty and otolaryngic disorders at the AAO-HNS Internet web site, http://www.entnet.org

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Girl takes Children's Motrin, goes blind and sues Johnson & Johnson

Sabrina Brierton Johnson, age-7, filed suit today against Johnson & Johnson in Los Angeles Superior Court/Compton Division claiming that an allergic reaction to taking Children's Motrin (Stevens-Johnson Syndrome) caused her to become blind and photosensitive. Her complaint for damages alleges strict product liability, negligence, breach of express and implied warranties, and deceit by concealment. McNeil Consumer & Specialty Pharmaceuticals (a division of McNeil-PPC, Inc.); McKesson Corporation [NYSE: MCK]; SAV-ON Drug Stores, Inc. (a wholly owned subsidiary of Albertsons, Inc. [NYSE: ABS]); Cardinal Health, Inc. [NYSE: CAH]; and Ralphs Grocery Company (a wholly owned subsidiary of The Kroger Company [NYSE: KR]) are also named as defendants. Sabrina's parents, Kenneth and Joan Brierton Johnson, are acting as her guardian ad litem. She is represented by Browne Greene and Geoffrey S. Wells with the Santa Monica, CA. law firm of Greene, Broillet, Panish & Wheeler, LLP. Sabrina Brierton Johnson vs. Johnson & Johnson, et. al., Case Number TC 018540.

Miss Johnson alleges that Johnson & Johnson and the other Defendants' failure to warn the public or educate the medical community about the possible risk of Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis (TENS) or any other serious skin reactions associated with using Children's Motrin makes it an unsafe product and dangerous to sell to consumers.

Since the late 1980's, the Plaintiff contends that the Defendants knew about the connection between Children's Motrin and these severe, potentially fatal reactions. Miss Johnson also alleges that the Defendants knew from their own clinical trials of Children's Motrin that it caused cases of Stevens-Johnson Syndrome/TENS and that Defendants had warned about Stevens-Johnson Syndrome/TENS in their drug package insert for the prescription form of the drug before Children's Motrin began being distributed and sold over-the-counter (OTC) to the public.

Miss Johnson alleges that Defendants were put on notice of the high risk to consumers and users of Children's Motrin after the completion of a major clinical trial known as the Boston Fever Study, which was the basis of the FDA's approval of the OTC sale of the drug. She contends that the Defendants knew that there were cases of Stevens-Johnson Syndrome and TENS in the clinical trials, but did not report them and misrepresented the true incidence of serious mucocutaneous reactions associated with the drug during the Boston Fever Study.

On September 8, 2003, Topanga, CA. resident Sabrina Brierton Johnson, then age-6, came home from school complaining of a fever. Her parents gave her Children's Motrin in accordance with the materials and instructions included with the drug that afternoon and again that evening.

On the morning of September 9, 2003, Sabrina still did not feel well and was taken to see her doctor. After being examined by her pediatrician, she was hospitalized and isolated in the Pediatric Intensive Care Unit at Cedars-Sinai Medical Center in Los Angeles, CA. with a high fever, a redness of the sclera (commonly known as the white of the eye), a sore throat and a rash covering her back, trunk and other parts of her body. On September 10, 2003, Sabrina's eyes could only be forcibly opened by an ophthalmologist, causing her unbearable, excruciating pain.


By November 2003, Sabrina Brierton Johnson was completely blind. It was later discovered that she suffered a severe, adverse skin reaction known as Stevens-Johnson Syndrome as a result of ingesting Children's Motrin. Sabrina continues to have ongoing medical problems as a consequence, including photosensitivity. She is unable to independently open her eyes and has had nearly 20 eye surgeries in a continued effort to restore her vision.

"In the name of children everywhere, our family wants Children's Motrin taken off the market until it carries a warning label about the risk of Stevens-Johnson Syndrome and describes its symptoms," said Joan Brierton Johnson. "Had there been appropriate warnings on the Children's Motrin that we gave Sabrina, we would have known what to look for and would have known to stop giving her the drug and call a doctor. Johnson & Johnson and the other Defendants never gave us that opportunity, and our precious little girl now lives literally and figuratively in the dark."

"Johnson & Johnson made a reckless, callous decision when it decided not to tell the public that Stevens-Johnson Syndrome is one of the adverse side-effects of taking Children's Motrin," said Kenneth Johnson. "The pharmaceutical industry owes a duty to consumers to warn them of any and all potential risks in taking their drugs, whether they are prescription or over the counter. Not a day goes by that Joan and I don't say to ourselves, 'if we had only known, if we had only known'. We hope that this lawsuit will put an end to their indifference."

"This lawsuit is the only warning label that the public is going to get until Johnson & Johnson re-labels Children's Motrin," stated Browne Greene, "so that it carries a warning about the dangers of Stevens-Johnson Syndrome. We hope that families around the world will take heed and toss out any Children's Motrin that's in their medicine cabinets and demand that stores pull it off their shelves. The alleged benefits of Children's Motrin do not outweigh exposing any child to Stevens-Johnson Syndrome and its dire consequences. Better safe than sorry."

"The fact that even one child might react adversely to Children's Motrin is enough reason to require the makers of Children's Motrin's to provide full disclosure to consumers and their doctors about the risks of Stevens-Johnson Syndrome," said Geoffrey S. Wells. "Just ask Sabrina Johnson and her parents. We intend to marshal all of our resources to make sure that she has her day in court."

Editor's Note # 1

Stevens-Johnson Syndrome is a potentially devastating allergic reaction to ibuprofen that can result in serious gastrointestinal problems, blindness or death. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) and is sold over-the-counter under such brand names as: Children's Motrin, Motrin, Advil, Genpril, Haltran, Medipren, Midol 200, Nuprin and PediaProfen.

Editor's Note #2

Plaintiff Sabrina Brierton Johnson is represented by Browne Greene and Geoffrey S. Wells with the Santa Monica, CA. law firm of Greene, Broillet, Panish & Wheeler, LLP (www.gbpwlaw.com); Tel: 310 576.1200.

Defendant Johnson & Johnson is based in New Brunswick, NJ and Roger S. Fine is its General Counsel; Tel: 732.524.0400.

Defendant McNeil Consumer & Specialty Pharmaceuticals (a division of McNeil-PPC, Inc., which is a subsidiary corporation of Johnson & Johnson) is based in Fort Washington, PA and Michael B. McCulley is its Assistant General Counsel; Tel: 215.273.7000.

Defendant McKesson Corporation is based in San Francisco, CA. and Ivan D. Meyerson is its General Counsel; Tel: 415.983-8300.

Defendant SAV-ON Drug Stores, Inc. is based in Boise, ID and John Sims is Executive VP and General Counsel of its parent corporation, Albertsons, Inc.; Tel: 208.395.6200.

Defendant Cardinal Health, Inc. is based in Dublin, OH and Steven Alan Bennett is its General Counsel; Tel: 614.757.5000.

Defendant Ralphs Grocery Company (a subsidiary of The Kroger Company) is based in Compton, CA and Matthew C. Kane is its Senior Attorney; Tel: 310.884.9000.

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The New 'Instant' Recovery Face Lift

Prominent Long Island plastic surgeon Dr. Zachary Gerut develops revolutionary new surgical procedure - Until now, patients desiring a younger look have had to choose between having a mini procedure or thread lift that offered only a small improvement and short term result -or, a substantial face lift procedure that required a one, two or even a three week recovery.

The Gerut Lift is a full face lift procedure, known to have a reliable record of providing excellent facial rejuvenation and lasting many years. Dr. Gerut has combined many innovations and techniques including a very striking departure from the usual: the facelift is done with the patient totally awake yet totally comfortable. Dr. Gerut states "Anesthetic drugs cause major physiologic changes and without them, the recovery is significantly and even amazingly faster- so much less swelling and bruising that patients look exceptionally well healed in as quickly as one, two or three days."

In developing his new procedure Dr. Gerut borrowed techniques from other cosmetic procedures, but never with facelifts until now. Dr. Gerut uses Novocain to numb the face with several totally painless injections using a tiny, imperceptible needle and a special apparatus that spreads the Novocain slowly to avoid even the slightest discomfort. Distributing the Novocain throughout the face can take approximately 1/2 hour or more. For those patients who are squeamish about the thought of needles, Dr. Gerut can administer Valium orally or small amounts of local I.V. sedation to keep them comfortable.

How can Dr. Gerut be sure that a patient is numb? Dr. Gerut explains that the entire face is full of the diluted lidocaine, saline and adrenaline (which is commonly used in tumescent liposuction), which turns the tissues completely white so that he can see the affect the adrenaline is having on the numbing process.

What about the patient 'fear factor' in terms of being completely awake during surgery? As Dr. Gerut explains, "the patient is lying back and listening to soft music if they wish." If the patient feels he or she wants to take a break, Dr. Gerut can pause during the surgical procedure. The patient can speak with Dr. Gerut but if he needs them to remain especially still or silent, he will let them know. As Dr. Gerut points out, "even when a patient is sedated by traditional means, they can still make involuntary movements such as scratching or hand movements so there is no more risk in terms of patient movement using this Novocain method. If a patient feels the need to scratch or shift positions they simply let Dr. Gerut know so that that he can pause."

In addition to eliminating the potentially life threatening danger of being put under anesthesia, there is no post operative nausea, grogginess, or anesthesia 'hangover.' The Novocain wears off an hour or two after the surgery is over and patients do not feel pain. There is perhaps some tightness, which is quite normal. Dr. Gerut uses a very long acting Novocain called Marcain that lasts up to six hours.

Because tumescent liposuction is so successful in minimizing bruising and swelling, Dr. Gerut has been tumescing the face for many years, and is adept in his surgical technique to accommodate for the facial changes that occur when the patient's face is full of saline and Novocain. At this point, Dr. Gerut has successfully performed over 25 facelift procedures using this anesthesia-free method. He has had no complications and only positive aesthetic outcomes.

Just as surgeons have readily accepted the tumescent technique for liposuction, Dr. Gerut feels that once this facelift technique has been taught to other plastic surgeons that it will be widely embraced. Although Dr. Gerut is not suggesting that the use of anesthesia is a uniformly dangerous method of performing plastic surgery, the fact remains that its use does pose potential risks even in healthy patients.

For those patients wishing to minimize that risk and recover much faster post operatively, this is perhaps the most exciting news to emerge from cosmetic surgery in a long time.

*** Dr. Gerut will be submitting a paper on this technique to The American Society for Aesthetic Plastic Surgery.

Dr. Gerut is a diplomate of The American Board of Plastic Surgery, a member of the American Society of Plastic Surgeons and a member of the American Society for Aesthetic Plastic Surgery.

****An understanding of tumescent liposuction helps to better comprehend the principles of Dr. Gerut's no-anesthesia technique

One of the most significant improvements in liposuction in recent years has been the use of tumescent anesthesia, introduced by dermatologist Dr. Jeffrey Klein a few years ago. Tumescent liposuction (Tumescent Technique) refers to the performance of liposuction using large volumes of a dilute solution of lidocaine, a local anesthetic, in combination with the drug epinephrine that temporarily shrinks capillaries. This is comfortably performed with minimal or no sedation required. The Tumescent Technique minimizes post-operative swelling, bruising and discomfort.

With the Tumescent Technique there is no post-surgical nausea, nor the unpleasant feeling of "hang-over" usually associated with general anesthesia. The Tumescent Technique dramatically reduces both the bleeding during surgery, and the post-operative bruising and swelling as compared to liposuction done purely by general anesthesia. Minimal bleeding reduces post-operative recovery time. Most patients can return to work within three to four days after surgery.

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New Drug Shows Promise in Helping Obese Patients Lose Weight

After two years on a drug that affects the pleasure center of the brain, obese patients had reason to feel good: Their bellies shrank, their cholesterol improved and their insulin levels moved toward normal, according to research presented Tuesday in New Orleans.

In the trial, more than 3,000 patients lost an average of 19 pounds, including an important reduction of 3.1 inches on their waistlines, compared with a 5-pound weight loss in the placebo group. Central fat is the kind that is most associated with heart disease risk.

Results of the latest trial of the drug rimonabant, which works on certain receptors in brain cells, were presented at the American Heart Association's Scientific Sessions. A Milwaukee hospital will be conducting a new clinical trial of the drug beginning next month.

"It could be an exciting new player in obesity," said Robert Eckel, a physician and professor of physiology at the University of Colorado Health Sciences Center who was not associated with the study.

In addition to taking the drug or a placebo, patients in the clinical trial were instructed to cut food intake by 600 calories a day.

Along with the weight loss, their HDL cholesterol (the good kind) went up 24.5 percent, compared with a 13.8 percent increase in the placebo group, and triglycerides, an unhealthy type of fat in the blood, went down 9.9 percent, compared with 1.6 percent in the placebo group.

The patients also experienced a significant improvement in their ability to use insulin, which is important in preventing type 2 diabetes.

"This seems to be an encouraging drug for weight loss, in particular central fat," said lead author F. Xavier Pi-Sunyer, chief of the division of endocrinology at St. Luke's-Roosevelt Hospital at Columbia University.

The study, which is the third and largest trial of the drug, was sponsored by the drug's maker, Sanofi-Aventis. The company calls the drug Acomplia.

The drug appears to have a low level of side effects with no significant EKG or heart rate changes. It did have slightly higher rates of depression, anxiety and irritability than the placebo, Pi-Sunyer said.

About 13 percent of patients stopped taking the drug because of side effects, compared with about 7 percent in the placebo group.

Doctors not associated with the trial said they were encouraged that a new diet drug soon should be available in the battle against obesity, but they raised several concerns.

"What worries me is this may be an excuse to not go out and do what you are supposed to be doing in terms of lifestyle," said George Bakris, vice chairman of the department of preventive medicine at Rush University Medical Center in Chicago.

He also said he was concerned about the potential for the drug to cause depression.

"When you start interfering with that part of the brain, things can happen," Bakris said.

Others said that while the drug should be helpful, it is not the answer to the obesity epidemic.

"It is such a huge problem," said Robert Bonow, a professor of cardiology at the Northwestern University Feinberg School of Medicine. "Whether a single drug can be a cure-all is not clear."

Rimonabant is the first in a new class of drugs that target certain receptors on the surface of brain cells that are part of the endocannabinoid system, which helps regulate food intake and energy expenditure. In particular, the drug blocks the cannabinoid type 1 receptor, which is the same receptor that is active when people smoke marijuana and get hungry. The receptors also are found on the surface of fat cells.

People who overeat are believed to have an overactive cannabinoid system. The same system is active in cocaine use and smoking. Preliminary research suggests that rimonabant may help people quit smoking as well.

"It's that weird spot in the brain that makes you want to do bad things," said Dana Kappel, senior research coordinator and registered nurse with Cardiovascular Associates at St. Luke's Medical Center in Milwaukee.

The hospital plans to enroll about 10 people in a new study of the drug in December, she said. Researchers will be looking for people who are overweight, diabetic or who are smokers, and who have blockages in their coronary arteries. Once that is established, patients will be put on the drug for 18 months, and a repeat catheterization will be done to gauge whether the blockages have diminished.

Sanofi-Aventis plans to seek Food and Drug Administration approval for rimonabant in the second quarter of 2005, said Douglas Greene, a physician and vice president of corporate and medical affairs.

Greene acknowledged that other drug companies are developing their own compounds that work on the same brain receptors, but Sanofi-Aventis is the first to do clinical trials.

He said he did not know how much Acomplia would cost, but because obesity is now considered a health condition, insurance should pay for it.

"I think there is a strong rationale for this to be covered," Greene said. "It is like a statin (a cholesterol-lowering drug like Lipitor)."

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Alcohol's effect on People's Health, Behaviour and Safety

As inroads are finally being made into smoking rates, so attention is swinging towards the effect that alcohol has on people's health, behaviour and safety. And the picture is not a pretty one. According to the government's alcohol harm reduction strategy for England, published in March, excess alcohol costs England alone �20bn a year, with alcohol-related injuries and illness costing the health service �2bn annually.

Alcohol is a feature in 50 per cent of all reported crimes and a third of all domestic violence incidents. It is implicated in 22,000 premature deaths each year, 1,000 suicides and 17 million lost working days.

There are two main types of drinking that are a cause for concern - binge drinking and chronic drinking. Binge drinkers tend to be under 25, while chronic drinkers tend to be 30 or over. These two groups are the main targets of the alcohol strategy, which aims to tackle alcohol-related disorder and health problems and to provide better information for people about alcohol misuse while clamping down on the irresponsible promotion of drinking.

The strategy highlights binge drinkers as being more likely to be men, although women's drinking has been rising fast over the last 10 years. A new study carried out in the US found that binge drinking might cause the type of brain damage usually associated with people undergoing treatment for alcoholism.

The research, undertaken at Vanderbilt University in Tennessee and the University of California in San Francisco, found that people who drank more than 100 alcohol units a month suffered from brain damage which led to memory loss, impaired mental function and lowered intelligence.

Crime and disorder are obvious consequences of excess alcohol consumption that also have a heavy impact on health services. Binge drinkers are most at risk of accidents and alcohol poisoning, risk being a victim of violence or sexual assault, and are more likely to commit violence.

Up to 70 per cent of all admissions to accident and emergency are likely to be alcohol-related. Johnathan Shepherd, professor of oral and maxillo-facial surgery at University Hospital, Cardiff, has spent 15 years researching public health and criminology. It was the high incidence of alcohol-related injuries that were being treated in hospital that first sparked his concern.

'About one-in-ten assault victims treated in the NHS is hit with a glass,' he says. 'They are as common as knife wounds, and glass bottles are everywhere - they litter the street late at night and they are the objects to hand. In terms of a threat to life, it's never as bad as a knife, but the face is the target and people end up scarred for life. We have been calling for a shift from glass bottles to plastic bottles. It's an easily understood and achievable objective in urban centre licensed premises. A few years ago there was a shift to toughen glasses and now we are calling for plastic bottles.'

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Telmisartan (Micardis/Pritor) protects against Progression of Diabetic Nephropathy

The angiotensin receptor blocker (ARB) telmisartanb (Micardis™/Pritor™) slows the progression of nephropathy in hypertensive patients with type 2 diabetes, according to pivotal study results published today in the New England Journal of Medicine.1 Telmisartan is the first ARB to demonstrate stabilization of glomerular filtration rate (GFR)c decline over 5 years, indicating long-term renoprotection in diabetic patients.

The five year DETAILTM (Diabetics Exposed to Telmisartan And enalaprIL) study randomised 250 patients with type 2 diabetes, hypertension and early stage nephropathy to once daily telmisartan 80mg or the ACE-inhibitor enalapril 20mg. The primary endpoint of the study was the change from baseline in glomerular filtration rate (GFR) - widely accepted as the best measure of overall kidney function in health and disease2 - after five years. The decline in GFR was similar with telmisartan and enalapril.1 The study demonstrated that telmisartan was as effective as enalapril in protecting against the progression of diabetic nephropathy.

DETAIL study published in The New England Journal of Medicine

"DETAIL is highly clinically relevant. We believe it is the only long-term, hard end-point comparison of an ARB and an ACE-inhibitor in early nephropathy. The results provide long-term data which support the renoprotective benefits of the ARB class suggested by previous studies. This study confirms that telmisartan is a valid choice for first-line treatment of hypertensive patients with diabetic nephropathy. The fact that telmisartan is equally effective as enalapril is particularly encouraging in view of the superior tolerability profile of ARBs compared with ACE-inhibitors." commented lead investigator Professor Anthony Barnett, Consultant Physician, Clinical Director of Diabetes and Endocrinology, Birmingham Heartlands and Solihull Hospitals and Professor of Medicine, University of Birmingham, United Kingdom.

Despite all DETAIL patients having type 2 diabetes, hypertension and nephropathy, cardiovascular mortality was only 5% in both groups over five years - much lower than would be expected in this high-risk group, half of whom had a history of cardiovascular disease at baseline.1 Blood pressure was lowered in both groups to a comparable degree over the course of the trial.1

The study inclusion criteria required all patients to be tolerant of ACE-inhibitors. There were therefore no major differences in adverse events between the two drugs.1 However, ACE-inhibitors can be poorly tolerated, with cough a common side effect that can impact on patient compliance.3 It is therefore worthy to note, that in two comparative studies of telmisartan and enalapril in patients who were not pre-selected for ACE-intolerance, telmisartan was better tolerated.4,5


Professor Eberhard Ritz, Vice President of the International Society of Nephrology, at the Ruperto Carola University of Heidelberg, Germany, commented, "DETAIL is a much needed study that adds weight to the body of evidence for ARBs, and in particular, telmisartan. The DETAIL study undoubtedly represents a breakthrough in our understanding of the management of diabetic nephropathy. DETAIL shows that treatment in the earliest stages of diabetic nephropathy yield results which are far better than what have been achieved previously with ARBs in advanced diabetic nephropathy (IDNT,RENAAL). After 5 years the loss of renal function (GFR) was comparable to what is expected with advancing age. This is most encouraging and implies that loss of renal function has been halted."

Current US and European hypertension guidelines advocate first line use of ARBs and ACE inhibitors for hypertensive patients with type 2 diabetic nephropathy.6,7 Various studies have shown that effective blockade of the renin-angiotensin-aldosterone system (RAAS) can reduce renal damage by mechanisms beyond those of blood pressure control alone. For ACE-inhibitors, the evidence for renoprotection independent of blood pressure control derives mainly from observations in patients with type 1 diabetes.2 In type 2 diabetes, trial evidence for renoprotection is now stronger with ARBs which have proved to be more effective than other classes of antihypertensives in slowing the progression of kidney disease in patients with microalbuminuria or proteinuria.8-11

A number of studies of telmisartan (Micardis�/Pritor�) in microalbuminuria and proteinuria have already delivered encouraging results.12-17 DETAIL is the first of five major trials investigating the renoprotective benefits of telmisartan which form part of the ongoing PROTECTIONTM (Programme of Research tO show Telmisartan End-organ proteCTION) study programme.18 PROTECTION involves more than 6,500 patients from 32 countries worldwide.

Notes to Editor

a) The DETAIL study is an independent, investigator-led study supported by a grant from Boehringer Ingelheim.

b) Telmisartan (Micardis™/ Pritor™) was discovered and developed by Boehringer Ingelheim, Germany. Boehringer Ingelheim markets telmisartan under the trademark Micardis™ in 84 countries around the world, including the USA, Japan and major European countries. In Canada and Australia GlaxoSmithKline (GSK) and Boehringer Ingelheim co-promote telmisartan under the Micardis™ trademark. GSK currently promotes telmisartan as Pritor™ under a co-marketing agreement with Boehringer Ingelheim in 30 countries excluding the USA.

Telmisartan was licensed to GSK from Boehringer Ingelheim in March 1998. The European, centralised marketing authorisation for telmisartan 40 mg & 80 mg tablets was granted to Boehringer Ingelheim on 11th December 1998.

Furthermore, Boehringer Ingelheim markets telmisartan in cooperation with Bayer AG in some European countries, Yamanouchi in Japan and Abbott Laboratories in the USA.

c) Although GFR declines naturally with age, in individuals with diabetes, GFR declines at a faster rate indicating the progression of kidney disease. The objective of prescribing an ARB or an ACE inhibitor is to reduce the progression of kidney disease, demonstrated by a reduction in the speed at which GFR declines.

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Why some people never feel cold while others never get warm

Scientists have found a reason why some people never seem to get warm while others never seem to feel the cold: some nerve cell receptors deep in the body are stimulated by signals other than temperature.

These cells never come in contact with environmental signals like those near the skin but are studded with receptors that appear to get sensory input from hormones, proteins and other biochemical compounds within the body.

The findings, published last month in the Journal of Neuroscience by researchers at the University of Florida, advance the understanding of why menopause, depression and fevers sometimes cause chills along with feeling overheated.

'What we are working to understand is the physiological and pathological roles of these receptors and why some people may feel cold or pain despite external stimuli,' said neuroscientist Jianguo Gu, a researcher in the university's College of Dentistry and the McKnight Brain Center.

'That could explain why it is that you and I can sit in the same space and you will feel comfortable and I may feel cold, yet the environmental stimuli are the same.'

Other scientists have only recently identified hot and cold nerve cell receptors in the peripheral nervous system located just beneath the skin. This is the system that tells the brain to pull the hand back from the flame or to bundle up when it's cold outside.

But what Gu and his colleagues found is that there are receptors so deep in the body that they literally chill to the backbone. 'In addition to under the skin on the peripheral side of the nervous system, there are also cold receptors on the central side of the peripheral nervous system within the spinal cord,' he said.

The researchers studied the effects cool temperatures and menthol, a chemical derivative of peppermint associated with cooling effects, had on a specific sensory molecule found on the tips of peripheral nerves.

They placed central and peripheral nerve cells taken from rats together in lab dishes to mimic the cells' relationship to each other inside the body. Then they exposed the cells to cold and menthol.

'When they are together, just as in the body, these neurons make a connection called a synapse that transmits cold sensory information from the peripheral to the central nervous system neuron when stimulated by cold temperature and menthol,' Gu said.

'What makes this exciting is that the central terminal - or ending - of a peripheral nerve actually expresses the cold and menthol receptors.'

This response of the receptor is important because, inside an animal, those nerve cells are never exposed to environmental temperatures, and the researchers suggest that means they respond instead to biochemical substances inside the body.

'The finding that the cold receptor is present in a functional form at nerve terminals within the spinal cord is potentially quite exciting,' said Dr. Michael Caterina, a researcher at Johns Hopkins University School of Medicine who was the first to find hot receptors in the peripheral nervous system sensitive to heat and capsaicin, the chemical that makes hot peppers hot.

Doctors now use creams containing the substance to treat some arthritic conditions and neuralgic pain that comes from oversensitive nerve endings near the skin.

Caterina said it's unclear whether the cold receptors near the spinal cord are actually functional, or just an evolutionary leftover. But even if they serve no regular function, drugs that target the receptor might still be useful to alter spinal processing of sensory information in people suffering spinal injuries or other disorders, he suggested.

More research will be needed to understand how the mechanisms for activating the receptor work inside the body, Gu said. 'Right now, we really just don't know how this receptor might function in the central nervous system, but we see all these possibilities.'

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Stress affects hormones which affect immune system which alters Mental and Physical Disease

A panel of experts speaking at Experimental Biology 2004 reports on new understandings of the mechanisms and pathways through which the body's hormonal response to stress alters immune system function and influences susceptibility, onset and exacerbation of mental and physical diseases, including atherosclerotic heart disease, depression, infectious diseases, and autoimmune diseases such as multiple sclerosis.

Thanks to a growing understanding of this process, scientists and clinicians increasingly are identifying individuals' risk factors and are teaching people - from high level executives to young children - simple coping behaviors that can successfully buffer the effect of stress on immune function and health.

The panel on "Alteration of Health by the Hormonal Response to Stress" is made up of members of the PsychoNeuroImmunology Research Society. Chaired by Dr. Bruce S. Rabin, University of Pittsburgh, the symposium is part of the scientific sessions of The American Association of Immunologists, one of the six sponsoring societies of Experimental Biology 2004.

How does stress create damage? Dr. William B. Malarkey, Ohio State University, describes how the perception of stress activates the interface between the endocrine (or hormonal) system and the immune system, initiating a cascade of physiological events. If the perception of stress is short-term, these hormonal changes fade away.

But if the stressful sensory input persists, the resulting dysregulation of the immune system initiates an inflammatory state that, if not stabilized, leads to symptoms and then established disease processes.

Many of these stress-induced inflammatory immune responses are precursors to the chronic diseases of aging, says Dr. Malarkey.

As the immune system modifies in response to hormones produced by stress as perceived by the brain, it produces soluble factors that affect the brain itself. Dr. Andrew H. Miller, Emory University, describes data indicating how this two-way interaction between the brain and immune system has a significant impact on causing and maintaining clinical depression.

Further stressors make things worse. Scientists increasingly recognize that stress in childhood or early life can create a hypervigilancy and hyperresponse to stressors later in life.

This intense response to stress is associated with an increased vulnerability to develop clinically significant depression during chronic immune stimulation, such as occurs during immunotherapy for cancer.

The immune system also plays an important role in the onset and progression of artherosclerotic coronary artery disease, including heart attacks.

By now, most scientists and clinicians - and many lay people - understand that psychological factors can act as risk factors for coronary diseases. Dr. Willem J. Kop, USUHS, explains three types of psychological risk factors and the psychoneuroimmunolgical pathways involved in the progression of coronary disease.

In brief, chronic psychological risk factors, such as hostility and low-socioeconomic status, play important roles at early disease stages. In the transition from stable to unstable atherosclerotic plaques, episodic factors like depression and exhaustion become more important. And finally, acute psychological triggers - mental stress and anger, for example - can promote myocardial ischemia and plaque rupture.

Thus, he says, "the specific hormonal and immunological pathways by which psychological factors promote heart disease change with increasing stages of coronary atherosclerosis."

Dr. Bruce Rabin describes behaviors that help ameliorate hormonal response to stress and how these can be taught or learned on one's own.

At the University of Pittsburgh Medical Center's Healthy Lifestyle Program, which he directs, stress coping behaviors are taught to groups of all ages, from all socioeconomic and educational levels, and to people with autoimmune disease, cancer survivors, and the children of parents who have or have survived cancer.

Techniques include deep breathing, guided imagery using CDs or scripts, and expressive writing (15 minutes writing about a stressor, then discarding the writing without reading it).

Dr. Rabin says that across all groups, people who utilize stress coping behaviors report improvement in the problems they face and in many aspects of their lives, including less depression, improved sleep patterns, enhanced social interactions, and improved ability to be more compliant with diets and good nutrition.

In addition to describing these and other advances in the biopsychosocial approach to health and disease -- the usual exchange of new scientific information that characterizes the interdisciplinary Experimental Biology meetings, Dr. Rabin says he and other panel members believe it is important information personally for those scientists (and journalists) at the meeting whose own lives produce stress-related risks.

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