In recent decades, men have been bombarded with images in society that depict the “ideal” male: strong, muscular, lean, with perfect features. What many adolescents do not realize is that most of the male bodies that they idealize can be acquired only with the use of anabolic steroids. Thus, many adolescent boys find themselves pursuing a body type that is impossible to obtain. By the time these boys reach adulthood, many have developed an eating disorder, such as bulimia, or an image disorder, such as muscle dysmorphia. In this article, the authors describe body image disorders in adolescent males and offer intervention strategies for school counselors.

Seth, a 17-year-old wrestler, is worried about his upcoming weigh- in for a match. Although he has taken various over-the-counter products to help him gain muscle mass, and has lifted weights 6 days a week for the past 4 months, he is now worried about weighing too much to qualify today. After spending the night sleeping in garbage bags to help him “sweat off” any excess weight he can, Seth, clad in two layers of sweatpants and three layers of sweatshirts, is running full-speed on a treadmill one hour before his weigh-in. After the match, Seth will go out eating and drinking with his friends, and the next day the cycle will start again.

Brian, a high school freshman, dreads going to gym class each day. At 6’2″ and 130 pounds, Brian feels that his muscle development is well below other boys his age. Spending each night feeling his arms and counting his ribs in front of the mirror, Brian refuses to go to the gym, too afraid that others will make fun of him, and instead overeats constantly in an attempt to gain weight. Today in physical education, the all-male class is playing “shirts and skins” basketball. Knowing that he will be on the “skins” team, Brian is trying to think of a way to get out of class.

A UNIVERSAL PROBLEM

For years, the public has been aware of eating disorders in women, especially the conditions of . anorexia nervosa and bulimia. Wc have learned that one’s body image is a complex configuration of the physiological, psychological, and sociological self, and that a woman’s eating disorder affects all of these areas until it eventually consumes her life (Parks & Read, 1997). Research results show that body concerns, usually the belief that one is too fat, are much more prevalent in women than in men (Cohn & Adler, 1992; Davis, Dionnc, & Lazarus, 1996; Hoyt & Kogan, 2001 ). Thus, counselors have developed a sensitivity to women with body image disorders, but they largely have neglected men.

The recent public exposure of female body image and eating disorders has led women to confront society’s demanding and often impossible ideas of beauty and perfection. As a result, women are being empowered to speak openly about such issues. However, men, who also receive their cues about societal expectations communicated through the media, often believe it is taboo to talk about their feelings. They are painfully aware of the cultural proscription regarding insecurity about their looks (Pope, Phillips, & Olivardia, 2000). Regardless of this silence, contemporary researchers on body image and ideals are reporting a growing trend toward male body obsession (Pope et al., 2000). The purpose of this article is to raise the issue of adolescent male body image concerns and, by way of case illustrations, to provide strategies for school counselors to address these issues.

THE IMPOSSIBLE DREAM

The current understanding of the etiology of body image disorders in boys and men is incomplete, restricted by limited research (Philpott & Shcppard, 1998). We do know that the preference in society is toward mesomorphic (muscular) males, and there is an aversion toward endomorphic (fat) and ectomorphic (thin) males (Weinke, 1998). Therefore, many boys and men who fall into the endomorphic or eetomorphic eategory recognize that they do not fit the ideal and thus strive to obtain the more mesomorphic body that they see in television and movies, in magazines, and on romance novel covers. Additionally, and perhaps more harmful, are the mesomorphic males who strive to become even more muscular, looking at a body type that, for most, is impossible to attain without the use of anabolic steroids (Pope et al., 2000). These men are doomed either to spending their lives chasing an impossible dream or to taking supplements and drugs that have very negative effects on overall health. Hoyt and Kogan (2001) discovered that, on average, men tend to emphasize physical attractiveness in relationships more than women do, which might imply that, even though a woman may accept her partner for how he looks, the man may continue to be dissatisfied with himself.

THE INFLUENCE OF THE MEDIA

In spite of the “impossible dream” and the harm that can come from pursuing a Mark Wahlberg- or Fabio-type physique, men continue to hold up those figures as the ideal for what makes a man. Grogan and Richards (2002) found that the adult ideals for the male body include “perfect pecs,””defined stomach muscles,” and being “healthy and fit,””toned,” and “athletic.” It is no surprise that the ideal man has been reduced only to a physical image. For example, the Charles Atlas ads that ran in the 1940s revealed a 97- pound weakling who had sand lacked in his face on the beach by muscular “real men” until he finally built up his own body. The message was that to be a “man,” one had to have a powerful presence in the world, a masculinity represented by muscles, conveying power and control (Weinke, 1998).

Current magazine advertising has become equally damaging in promoting this male image. Kolbe and Albanese (1996) conducted a study to evaluate portrayals of men when appearing alone in magazine ads. Examining samples from six different maleaudience magazines, the researchers found that the majority of the men in the advertisements represented the male icon as strong and muscular. Several of the sampled magazines, such as Rolling Stone and Sports Illustrated, appeal to a large adolescent male population, which means boys are being bombarded with these images at the very age when they are deciding for themselves what kind of man they should be.

The rise of the male ideal as a sex symbol also has become prevalent in magazine photographs. For example, in 1958, Cosmopolitan magazine had only 6% of its male models undressed in some way (compared to 17% of female models), but in 1998 it had 32% of its male models undressed (compared to 27% of female models). Many of these photographs were used to sell products that had nothing to do at all with the human body (Pope et al., 2000). Pope et al. also found that the Playgirl centerfold has shed an average of 12 pounds of fat and gained an average of 27 pounds of muscle in the past 25 years. With the increasing emphasis in the media of a lean yet muscular male body as the ideal, it is no wonder that so many boys and men are becoming dissatisfied with their own bodies and are paying incredible costs to achieve the “perfect” body.

Finally, even toys have changed over the years to promote an ideal male physique. Pope, Olivardia, Gruber, and Borowiecki (1999) noted that the increase in muscularity of American action-figure toys over the past 30 years exhibits a greater level of muscularity than even the top bodybuilders! For example, one can consider the evolution of the G.I. Joe figure. In 1964, G.I. Joe was 5’10” tall, had a 32″ waist, a 44″ chest, and 12″ biceps, which was a figure reasonably attainable by most fit men. By 1974, G.I. Joe had developed quite defined abdominal muscles, sporting the now-popular “six-pack” look, and by 1991, G.I. Joe had slimmed down to a 29″ waist and increased to a 16″ bicep (Pope et al., 2000). With young boys exposed to a G.I. Joe who looks like that, it is no wonder that they are becoming worried about their own bodies at younger ages. What these boys and men do not know is that most of these figures are not the result of healthy eating and working out, but rather the result of anabolic steroid use, dehydration, and other unhealthy habits.

ADOLESCENT MALES AND BODY IMAGE ISSUES

Regardless of the limited research on the topic of male body image disorders, Sondhaus, Kurtz, and Strube (2001) found a positive correlation between body attitudes and self-concept, and these attitudes were prevalent as early as adolescence, the pivotal period when boys are strengthening their self-concepts and searching for identity. In interviews with adolescent males, Grogan and Richards (2002) learned that boys viewed the ideal man as having “muscular legs” and a “good tan,” who usually is a “bodybuilder” or a “boxer,” and whose muscles are contained in the “arms,” the “chest,” and the “back, biceps, and triceps.” Thus, boys learn early on that their identities are closely tied with the physical characteristics that they see in bodybuilders and athletes. These high standards cause many young men to become dissatisfied with their own appearance in pursuit of this ideal.

Muscle Dysmorphia

When people think of eating disorders, many tend to consider anorexia nervosa and bulimia to be the two main labels under which all people fall. The popular conception is that eating disorders result from \people thinking that they are “too big” or “too fat.” However, a third disorder, which is becoming more and more prevalent among adolescent and young adult males, is muscle dysmorphia. Muscle dysmorphia (colloquially known as “bigorexia nervosa” or “reverse anorexia”) occurs when one has an excessive preoccupation with body size and muscularity, even if he already has a toned and muscular body (Pope et al., 2000). Consider the earlier case of Seth the wrestler, who probably spent hundreds of dollars on supplements and hundreds of hours at the gym to make himself bigger, when he very likely already had a healthy and desirable physique. Remember also the case of Brian, who became consumed with thoughts of inadequacy about his body but felt powerless to make healthy changes. Instead, he relied on overeating to gain what he saw as the ideal male physique, probably continuing to foster an unhealthy self-concept that will follow him into adulthood. What is even more distressing is that these boys will suffer in silence (Keel, Klump, Leon, & Fulkerson, 1998), adhering to what William Pollack (1998) called the “Boy Code of Silence,” rather than seeking out help from the caring adults in their lives.

Peer Pressure

Peer pressure is also a problem for adolescent boys. As more boys become attuned to the male ideal presented to them in society, they also become more adept at identifying the shortcomings in themselves and, when that process becomes too painful, they begin to point out the physical shortcomings in others. On the flip side, boys who themselves do not fit into the concept of the ideal male image feel a silent peer pressure that they begin to enforce on themselves. In a series of interviews with 16-year-old boys, Grogan and Richards (2002) spoke with a boy named Tom, who said, “If you’ve got friends who are, like, quite big in build, you want to be the same as them. Although you might not be able to do anything about it, it’s on your conscience all the time. You want to be that sort of size” (p. 229). Tom represents the voices of so many other teenage boys who see the men with bulging biceps and rippling abdominal muscles and ask themselves, “What’s wrong with me?”

Health Problems

Many people-including parents, teachers, counselors, and coaches who observe boys obsessing over their bodies-perceive that these boys are just trying to be healthy. However, overall health barely fits into the picture for boys who are developing body image disorders. Their reasons for wanting to look good are mostly cosmetic rather than health related (Grogan & Richards, 2002). Adults need to make themselves aware that the eating and body disorders that boys face are very similar in etiology to those that girls face. Eliot and Baker (2001) questioned and reviewed the charts of 40 adolescent males in the Eating Disordered Clinic in Boston and discovered that the courses and outcomes of the disorders were quite similar to those of females. Keel et al. (1998) reported that, like their female counterparts, males have disordered eating and dietary habits that many times occur in the absence of significant weight problems, and that disordered eating in males, like in females, appears to be more psychological than physical. Finally, Keel et al. reported that eating-disordered boys experience great body dissatisfaction, depression, and perfectionism, as do eating-disordered females.

Language Bias

Anderson, Cohn, and Holbrook (2000) also pointed out that the descriptive words society uses to describe human body shapes are prejudiced against boys. For example, when describing a thin woman, people tend to use words like “svelte,””slim,” and “willowy”; in describing a thin man, however, people tend to use words with a much more negative connotation, such as “pencil-neck,””stick,” and “twerp.” Based on the semantics, being a big man is preferable to being thin, because big men are referred to in less negative terms, such as “big daddy,””monster,” and “hulk.” Indeed, empirical studies suggest that being thin is hardly the ideal (Dittmar et al., 2000). LeDoux (1993) reported that 10.1% of the adolescent boys surveyed thought themselves to be too thin, compared with 4.2% of the surveyed girls. Also, in a survey of 44 adolescent male football players and 30 adolescent male cross-country runners, Parks and Read (1997) found that 80% of the football players desired an increase in their weight, and 43% of the cross-country runners desired an increase in their weight. Boys, then, hear body types described in a pejorative way every day, and it does not take them long to figure out which type is the one to which they should aspire.

Coping Strategies

Adolescents construct their own methods for coping with body image disturbances. In his interviews with 20 college males, Weinke (1998) discovered three coping strategies that males used when faced with the ideal male image. The most harmful coping strategy, and, sadly, the most common, was the reliance on the popular muscular images for how a man should look. These young men saw the ideal male as realistic and either spent their time trying to achieve that image or berated themselves for not fitting it. A second coping strategy was the reformulation of the male body ideal; that is, boys modified the ideal and addressed it on their own terms. Although these young men may not have been totally consumed with thoughts of their own physical inadequacies, they still constructed the image to fit in their own schema and may have attempted to change themselves to fit this new image. The final coping strategy was the rejection of the ideal male image, which may have resulted in one’s accepting himself for whom he currently was. Not surprisingly, this strategy was the most rare. When looking at these three strategies, one can see two common themes emerge. One is that males tend to view the image of the ideal man based on the images found throughout society. Even if they eventually reject the image, they still see the image as the ideal to some degree. The second theme, and perhaps even more damaging, is that these males tend to cope alone with their conflicts with the ideal male body image, without support.

STRATEGIES FOR SCHOOL COUNSELORS

School counselors are in a unique position to help adolescent boys address issues of body image that may be eroding their self- esteem and jeopardizing their physical and emotional health. Because of their presence in secondary schools, counselors may be pivotal people in increasing awareness among their peers of adolescent male body issues. In addition, they have access to parents and to individual boys who may be struggling with these issues. Several strategies for school counselors are described below.

Providing Individual Counseling

The first major hurdle to offering individual counseling to boys with body image disorders is the societal stigma for males seeking psychological assistance. Moreover, among males there is a greater taboo against revealing a body image problem because these problems largely have been associated with girls and women. Also, a boy might be feeling a sense of isolation, believing that he is “the only one” who feels this way about his body. Becoming an approachable, trustworthy adult in a male adolescent world is the first step toward providing individual counseling for boys with body image disorders.

Let’s return to the case of Brian. Imagine that Brian were to be caught for skipping class (A-activating event), and his response would be to “come unglued” and yell at the principal who asked him why he skipped class (C-emotional and behavioral response). The principal might then refer Brian to the school counselor. The counselor, through his or her listening skills and ability to draw Brian out, might discover Brian’s negative feelings about his body. The counselor’s realization that Brian’s outburst had little to do with the principal’s questions and more to do with Brian’s unwillingness to admit his own insecurities about his body (B- belief) would be a significant aspect of applying CBT to this case. The counselor would then challenge Brian’s beliefs about himself (D- disputing intervention) by asking Brian what proof he had that his body was terribly inadequate or by showing Brian images of the various body shapes that real men truly have. If the counselor can begin to change Brian’s thinking about the way he looks, Brian might experience a new effect (E) and then a new feeling (F) about himself.

Of course, this example is a simplified version of what might happen, as it is very likely that a counselor would have to work with Brian for some time to get him to change his ideas about himself. However, such an approach would help Brian begin to get past the filtering (ignoring all the positive aspects about himself while choosing to focus on the negative) and polarized thinking he is doing, making it possible to create a change (Pope et al., 2000).

Providing Group Counseling

Group counseling in the schools also can be an effective way to change adolescent boys’ opinions about their own bodies. Akos and Levitt (2002) suggest that the peer groups of middle- and high- school students can have strong positive effects on adolescents’ self-concepts, including body image. Because many boys with body image disorders suffer in silence, learning that other boys in their peer group suffer from the same insecurities and receiving support from those peers can be quite beneficial to adolescent boys working within a single-gender support group.

An effective counselor facilitator is key to the efficacy of these groups. Rhyne-Winkler and Hubbard (1994) give several recommendations for counselors to make these groups a success, such as using materials that build self-esteem and maintaining current information on eating and body image disorders. For many adolescent boys, however, just knowing that an adult is aware of and cares about wh\at they are going through can be the beginning of rebuilding a positive self-image.

Working with Parents

Arguably the most influential adults in a boy’s life arc his parents, who are likely to be the most accessible instruments for change in a boy’s ideas about himself. School counselors can be important bridges between parents and their adolescents. Counselors can offer informational groups and support groups for the purpose of raising awareness among parents of the seriousness of body image problems for adolescent males. Pope et al. (2000) outlined the following simple interventions that parents can do when they suspect that their son might be suffering from a body image disorder. Counselors can assist parents with these interventions individually or in support groups.

First, counselors can alert parents to the value of listening to their sons. Many times personal insecurities emerge when least expected, such as when a parent and a son are doing an activity together. It is when the boy is active that he might feel most comfortable about opening up. Second, parents can be intentional about talking to their sons about the prevailing and unrealistic male body ideals in society. They can let their sons know that having muscles is not the only way to be a real man. Third, counselors can caution parents to express their concerns to their sons without blaming. It is important for parents to let boys know that they care about their well-being but arc not judging them from their mistakes. Fourth, counselors can remind parents to refrain from criticizing their sons’ appearance. Counselors can help parents to see that although they want their sons to be healthy, putting undue pressure on them to conform to a certain body type can cause more harm than good. Fifth, although most parents want to offer their sons reassurance, it must be done wisely. Counselors can help parents remember not to dismiss their sons’ concern about their bodies by saying, “Oh, I think you look great!” Such a response might keep the boy from opening up again, thinking that his parents just do not understand what he is experiencing. Finally, counselors can assist parents in helping their sons look for other sources of self-esteem. If a boy’s only source of self-esteem is his body, parents need to point out other strengths that he has and encourage him to use those strengths in positive ways.

Overall, parental support and encouragement not to conform to societal images of the perfect man can do a lot to help a boy who might have a mild body image disorder. Having parents acting as the role models also speaks volumes to adolescent boys.

Consulting with Teachers and Coaches

Next to parents, teachers and coaches exert significant influence on adolescents. Often, however, they themselves may ascribe to some of the media-driven notions of what constitutes the “ideal” male physique. These adults have the potential to reinforce the cultural norm or to become open opponents of it. School counselors, by virtue of their role as both staff members and student advocates, have a special opportunity to influence the thinking and behavior of their colleagues. By conducting in-service and even pre-service training for teachers and coaches, school counselors can increase awareness of the growing body image disorders among adolescent males. Such training requires helping colleagues confront and address the ways in which they have accepted the prevailing views of masculinity as muscularity. Exposing the tactics of the media through a review of television commercials and magazine advertisements will help teachers and other school personnel understand the unrealistic goals they may set for themselves and, concomitantly, the adolescent boys they mentor. Engaging the support of school administrators and other officials will lend credibility to such training programs.

Organizing Consciousness-Raising Campaigns

Once there is grassroots acknowledgment of the body image disorder problem among adolescent males, and when teachers, coaches, and other school personnel commit themselves to providing alternative, healthy perspectives on body image, school counselors can spearhead a consciousness-raising campaign in the entire school. Such a program would involve seeking volunteers from the community as well as colleagues to hold forums, to host informal focus groups, and potentially to infuse alternative ideas into the curriculum in health and physical education classes. Inviting local celebrities, athletes, and medical personnel to speak in school-wide assemblies to counter the existing cultural messages about the ideal body could be effective. Such a program could be the vehicle to break the silence about adolescent boys’ body image problems. It could be a turning point for changing young people’s unrealistic goals and attitudes about attaining the “ideal” in physical appearance.

Making Outside Referrals

Sometimes a boy’s body image disorder can be severe enough that he needs to seek more intensive professional help. Family therapy is an important treatment option, given the known reciprocal impact of a family on disease and recovery (Andeson et al., 2000).

In addition, antidepressants prescribed by psychiatrists have been shown to be an effective treatment for bulimia nervosa. They can treat the symptoms of bulimia even if the patient is not depressed (Pope et al., 2000). Especially in the more extreme cases of body image disorders, a medical evaluation by a physician would be essential in the boy’s healing process.

CONCLUSION

Boys in America are in a crisis over their bodies. Although it might be firmly entrenched in many minds that masculinity and muscularity go hand in hand, much can be done to put an end to that perspective. School counselors can be important catalysts for parents, educators, coaches, and other adults to become aware of the damaging effects that society’s conception of the ideal male body image are having on adolescent boys. School counselors can provide work with individual boys on body image issues when time and circumstances permit this approach. They can provide information and support to parents as they work intentionally with their sons to combat the prevailing notions of masculinity in the culture. School counselors can function as consultants to teachers and coaches who may unwittingly participate in perpetuating the harmful and skewed beliefs about what it means to be “perfect man.” School counselors can organize consciousness-raising campaigns in their schools to increase awareness of the problem and to minimize the stigma of boys seeking help. In cases of severe body image disorders, school counselors can make outside referrals to appropriate mental health providers. Moreover, school counselors can work to educate boys on what it truly means to be a man. Counselors can assist other adults in an adolescent boy’s world to model the notion that being a man is about love, responsibility, tenderness, work, dependability, kindness, and respect, all of which can be attained regardless of one’s body shape. The sooner we can emphasize those important inner qualities over the outer appearance, the sooner we will see adolescent boys become happy, healthy, real men.

In spite of the “impossible dream” and the harm that can come from pursuing a Mark Wahlberg- or Fabiotype physique, men continue to hold up those figures as the ideal for what makes a man.

Boys learn early on that their identities are closely tied with the physical characteristics that they see in bodybuilders and athletes.

Adults need to make themselves aware that the eating and body disorders that boys face are very similar in etiology to those that girls face.

Counselors can offer informational groups and support groups for the purpose of raising awareness among parents of the seriousness of body image problems for adolescent males.

References

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Davis, C., Dionne, M., & Lazarus, L. (1996). Gender-role orientation and body image in women and men:The moderating influence of neuroticism. Sex Roles, 34(7/8), 493-507.

Dittmar, H., Lloyd, B., Dugan, S., Halliwell, E., Jacobs, N., & Cramer, H. (2000). English adolescents’ images of ideal bodies. Sex Roles, 42(9/10), 887-915.

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Ellis, A. (1999). How to make yourself happy and remarkably less disturbable. San Luis Obispo, CA: Impact.

Grogan, S., & Richards, H. (2002). Body image: Focus groups with boys and men. Men and Masculinities, 4(3), 219-232.

Hoyt, W. D., & Kogan, L. R. (2001). Satisfaction with body image and peer relationships. Sex Roles, 45(3/4), 199-215.

Keel, P. K., Klump, K. L., Leon, G. R., & Fulkerson, J. A. (1998). Disordered eating in adolescent males from a school-based sample. The International Journal of Eating Disorders, 23(2), 125- 132.

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Eric J. Stout is a teacher, and Dr. Marsha Wiggins Frame is an associate professor. They are with the University of Colorado at Denver. E-mail: [email protected]

Copyright American Counseling Association Dec 2004

ABSTRACT.

The author investigated A. Antonovsky’s (1979) concept of the sense of coherence (SOC) in relation to social support, coping styles, and the stress experiences of college students. A multivariate model was used to assess the relationships between the psychosocial resources, perceived stress, and the effect of different coping styles among 261 undergraduate students in three Israeli institutions of higher education. Results of a multivariate analysis of variance revealed that younger students used more emotional strategies and perceived having greater social support from friends than did older students. Students who did not work reported experiencing higher levels of stress associated with daily life and work-related issues. Women used more emotional and avoidance coping strategies. The findings of the regression analysis demonstrated that task-oriented and emotional coping modes, work stress, and family support explained 30% of the variance of SOC. These results increase our understanding of the salutogenic model of students within university settings and suggest focusing on the students and their interaction with the environment, using the concepts of stress, coping, and social support as inseparable characteristics of systems models.

Key words: coping, salutogenic model, stress, support, university students

THE SALUTOGENIC MODEL, developed by Aaron Antonovsky (1979, 1987), focused on exploring the origin of health rather than explaining the causes of disease. The salutogenic approach is an alternative perspective to the traditional pathogenic model; it is an approach that looks for the health-promoting factors within individuals and societies. In contrast to the pathological orientation (the health vs. disease dichotomy), in Antonovsky’s model, health is viewed as a continuum from health (ease) to disease (dis-ease). The author suggested that the individual’s cognition of and mode of response to the environment and to stress may be important in promoting good health (Antonovsky, 1998).

The salutogenic model highlights the strengths of individuals and their capacity for successful adjustment and tries to explain why certain people seem to preserve health and well-being and successfully cope with tension and the exposure to life’s stresses and difficulties. If stress is handled well, its outcome can be positive or neutral, and the individual moves toward the health- ease end of the continuum, whereas if stress is poorly handled, the person moves toward the dis-ease end of the continuum.

Antonovsky (1979) developed the concept of sense of coherence (SOC) as central to his salutogenic model, which is a global orientation that expresses a general view of individuals regarding their internal and external environment. Social, historical, and cultural context and life experiences are the foundations of an individual’s degree of SOC. Within the SOC, Antonovsky (1987, p. 19) identified three main resources that may help facilitate individuals’ positive adjustment, how they deal with challenges, and how they cope with difficulties: These resources are revealed by the extent to which one has a pervasive, enduring though dynamic, feeling of confidence that (a) the stimuli derived from one’s internal and external environments are comprehensible, structured, predictable, and explicable; (b) the sources are manageable and available; and (c) demands are meaningful, challenging, and worthy of investment and engagement.

In other words, to optimize the chances of successfully coping with stress, individuals must feel that they understand the task, have the needed resources at their disposal, and view the task as a challenge. Individuals who perceive their world as comprehensible and a situation as meaningful are able to select strategies to cope with stress; they view a situation as manageable, and they feel capable of controlling it. These constructs lead to an individual’s SOC (Antonovsky, 1987). Individuals with a strong SOC, although conscious of difficulties or frustrations, do not ignore them, are more confident that basic difficulties will be resolved or can be dealt with, and have confidence that they will be able to cope with the inherent pressures of daily life (Antonovsky, 1979).

In previous studies, SOC has been related to coping, locus of control, problem solving, and self-esteem (Jahnsen, Villien, Straghelle, & Holm, 2002), and to emotional, social, and behavioral variables (Kaiser, Sattler, Bellack, & Dersin, 1996; Langius, Bjoervell, & Antonovsky, 1992). Soderfeldt (2000) found that SOC was negatively correlated with job pressure and positively related to social support. Soderfeldt suggested that individuals with lower SOC scores were more anxious. In addition, SOC has been suggested as defining an overall ability to cope with life stress (Nilsson, Holmgren, Stegmayr, & Wesrman, 2003). A survey of undergraduate students showed that SOC was negatively associated with psychological distress and anxiety, and a significant positive relation was found between SOC, work relations, and competence (Harri, 1998).

College and university attendance is regarded as a positive event that provides great opportunities for individual development and represents a critical developmental period for older adolescents and young adults, in which students enter a new social environment where they must adjust to new social norms and establish new relationships (Tao, Dong, Pratt, Hunsberger, & Pancer, 2000). Yet, this experience is also accompanied by multiple and significant changes, stress, and challenges in academic, social, and emotional areas. These developmental challenges can be acutely stressful (Cutrona, 1982). In the present study, I examined the concept of SOC in the college setting and investigated the relationship between SOC, social support, coping style, and the stress experiences of college students.

Support Resources

Antonovsky (1987) proposed “generalized resistance resources” such as money, faith, and social support, that help individuals perceive the world as an organized and structured reality. Social support can make life more manageable and understandable and can assist the individual in making decisions. A number of studies have noted that measures of social help and support seem to be related to SOC, and a strong SOC increases the chance that a person will discover support resources that will help in handling stress. Relationships with parents are often overlooked as a variable that can influence or predict a student’s academic and personal adjustment to college (Kenny & Perez, 1996; Lopez, 1991; Winter & Sugar, 2000; Winter & Yaffe, 2000). A secure relationship with parents facilitates adjustment and is negatively associated with psychological symptoms of distress at the time of entering college. Family support has been strongly related to adjustment and social relationships (Gurung, 1992) and even in academic areas when students have reported that they got help from family and friends (Heiman & Precel, 2003).

Coping Style

Social support is viewed as an important resource for encouraging adaptive coping strategies (Lazarus & Folkman, 1984). Differences in the conceptualization of coping have led to a number of ways of classifying coping strategies. Lazarus and Folkman offered a widely used definition of coping-constantly changing cognitive and behavioral efforts to manage specific external or internal demands. They developed three main theoretical assumptions regarding coping strategies (task-oriented, emotion-oriented, and avoidance). The task-oriented coping style stresses an active reaction strategy and focuses on efforts directed at modifying or managing a situation. In emotion-oriented coping, efforts are directed at altering emotional responses to stress. The third strategy, avoidance, includes strategies such as avoiding the situation, denying its existence, losing hope, or making indirect efforts to adjust to a situation by distancing oneself from it or evading the problem (Lazarus & Folkman; Roth & Cohen, 1986).

The first two strategies involve pro-active efforts to alter the situation, whereas avoidance strategy is characterized by the absence of attempts to alter the situation and represents withdrawal behavior. Pro-active coping strategies have been related to better adjustment (Causey & Dubow, 1993; Compas, Malcarne, & Fondacaro, 1988), whereas avoidance has been related to poorer adjustment (Billings & Moos, 1981). Endler and Parker (1990) suggested that in the long run, task-oriented coping is the most efficacious strategy. Hollahan and Moos (1987) found that individuals with greater family support were more likely to rely on approach coping and less likely to use avoidance coping styles.

Stressors

College students perceive academic life as stressful and demanding (Hammer, Grigsby, & Woods, 1998; Wan, 1992) and report experiencing emotional reactions to this stress, especially as a result of external pressures and self-imposed expectations (Misra & McKean, 2000). SOC has been shown to be an important factor in coping with stress. Antonovsky (1998) believed that for adults, the work environment was the most important setting in determining an individual’s \SOC. Thus, work can strengthen SOC when expectations are known and consistent; the worker feels that he or she has the resources to competently complete job tasks and believes that there is a shared sense of responsibility.

Age differences regarding support sources, stress, and coping have yielded inconsistent results. Hamarat, Thompson, Zabrucky, Steele, & Matheny (2001) indicated that stress decreases with age at the same time that social support increases with age. As a variable, gender can affect the way in which individuals manifest stress outcomes. Results of various studies indicated the presence of gender differences, with women generally reporting a higher level of stress (Brimblecombe & Ormston, 1996; De-Anda, Bradley, & Collada, 1997; Zeidner, Klingman, & Itskowitz, 1993) and greater social support (Reevy & Maslach, 2001) than do men. Lee, Keough, and Sexton (2002), who examined the effects of social appraisal of the campus climate and perceived stress of college women and men, found that social connectedness was more negatively related to perceived stress for men than for women.

The salutogenic orientation, as suggested by Antonovsky, is offered as a basis of a person’s perception of his or her world and viewed as a concept of health promotion. In his model, Antonovsky (1987) sought to explain successful coping with stress by SOC and to relate SOC to emotional, social, and behavioral measures. Accordingly, a person with a strong SOC is less likely to perceive a situation as stressful than a person with a weak SOC.

Although SOC has been studied extensively in groups experiencing a variety of stress, it has not often been examined in students. College students could be guided in ways to strengthen SOC, thereby increasing their chances of success. Thus, there is a need to explore the relationship of SOC to academic coping strategies with populations that are experiencing stress related to academic tasks or work load. Consequently, to investigate students’ support resources and strategies for coping with academic tasks, I formulated the following research questions:

1. Do students’ background characteristics (gender, age, family status, and work) differentiate among the self-reported measures?

2. How is SOC related to students’ reports on coping strategies, various stresses, and different sources of social support?

3. To what extent do the different measures (coping, support, and stress) predict SOC in adult students?

I expected students with a strong SOC to be more task-oriented, to perceive having a higher level of support, and to experience lower stress than students with a weak SOC.

Method

Participants

The participants were 261 undergraduate students (115 men and 146 women) ranging in age from 20 to 55 years (mean age was 28.7, SD = 7.06), studying social sciences (education, management, economics, psychology, and sociology) in three institutions of higher education in the central part of Israel: 51 students were from a traditional campus university, 104 were from a distance-learning university, and 106 were from an academic college of management. Table 1 contains the biographical information of the students. I performed a chi- square analysis to determine whether there were differences among the three institutions of higher education according to the background variables of gender, age, family status, and work. No significant differences were found for these variables. Therefore, I treated the participants as one group, regardless of the educational institution they were attending. Because of the wide age spread (from 20 to 55), I divided the students into two groups by median: younger students (aged 20 to 27; n = 126) and older students (aged 28 and older; n = 135). Within the younger group, most of the students were not married, or if married, they had no children (96.3%), whereas most of the students in the older group were married and had children (82.6%).

TABLE 1. Biographical Information of the Students (N = 261)

Measures

Four instruments were used in this study. A biographical survey was used to collect information on age, gender, marital status, institution, and work status.

The Sense of Coherence Scale (SOC; Antonovsky, 1987) was used to assess the students’ SOC in their world, expressing thoughts, feelings, and expected behavior regarding their lives. The scale consists of 13 items on a 7-point Likert scale ranging from always (1) to never (7), in which a higher score expresses a higher SOC. For example, to express a sense of comprehensibility: “When you talk to people, do you have the feeling that they don’t understand you?” To express the sense of manageability: “When you have a difficult problem, the choice of a solution is . . .” (responses ranged from “always confusing and hard to find” to “always completely clear”). And to express meaningfulness: “You anticipate that your personal life in the future will be . . .” (responses ranged from “totally without meaning” to “full of meaning and purpose”).

Internal consistency reliability coefficients (Cronbach alphas) have been reported to be between .86 and .95 (Antonovsky, 1993). In the present study, an internal consistency estimate of .72 was found. Criterion validity was examined by Antonovsky by presenting significant correlational data between SOC and measures in four domains: (a) global orientation to oneself and one’s environment; (b) stress; (c) health, illness, and well-being; and (d) attitudes and behavior.

The Coping Inventory for Stressful Situations (CISS; Endler & Parker, 1999) consists of 41 items arranged on a 5-point Likert- type scale from not suitable at all (1) to very suitable (5). Three subscales describe the individual’s coping strategy: (a) Task Orientation (16 items); (b) Emotional Orientation (14 items); and (c) Avoidance (11 items). Higher scores on each scale indicate frequent use of the strategy. For this sample, test-retest correlation coefficients over a 9-month period averaged .89 for task orientation, .87 for emotional orientation, and .83 for avoidance.

The Multidimensional Scale of Perceived Social Support (MSPSS; Zimet, Dahlem, Zimet, & Farley, 1988) consists of 12 items arranged on a 7-point Likert-type scale from not suitable at all (1) to very suitable (7). Three subscales describe the individual’s social support from (a) Family (4 items), (b) Friends (4 items), and (c) a Significant Other (4 items). Scores on each of these scales range from 1 to 28; a higher score expresses higher social support. Cronbach’s alpha for the entire scale for this sample was .92; for family, .91; friends, .89; and significant other, .90. Concurrent validity was suggested by significant correlations of .43 between family and friends’ support, .62 between family and significant other, and .55 between friends’ and significant other’s support.

Three questions were posed regarding a feeling of stress in daily life and academic stress: (a) “How much stress do you feel due to academic studies?” (b) “How much stress do you feel due to your work?” (c) “How much stress do you feel in your daily life?” Students answered on a 4-point Likert-type scale ranging from feel great stress (4) to feel no stress (1). Higher scores are indicative of greater stress. Test-retest correlation coefficients (over a 9- month period) were found to be .45 between academic stress and daily stress and .46 between work stress and daily stress.

Procedure

Students were randomly selected from regular classes and participated in the study voluntarily. The author introduced herself to the students, presenting herself as interested in students’ perceptions of academic studies and how they coped with them and guaranteeing anonymity. Participants provided biographical information and completed the self-report questionnaires on coping strategies, social support, stress, and SOC.

Results

I performed a multivariate analysis of variance with student backgrounds (gender, age group, family status, and work status) as the independent variables and the total scores of each of the dependent variables: (a) coping strategies, (b) support sources, (c) stress perception, and (d) SOC. For this analysis, the effect sizes were calculated by using eta-squared. The results revealed significant main effect for gender, F(1, 260) = 4.29, p

Regarding age (older or younger), findings showed that the older group reported more task-oriented coping and reported higher perceived SOC, whereas the younger students reported more emotional coping and greater support from friends and from significant others. Regarding gender, the univariate analyses showed that the women reported more emotional and avoidance coping strategies, higher academic stress, and lower perceived SOC than did the men (see Table 2).

TABLE 2. Means, Standard Deviations, and F Scores for Coping Strategies, Support Sources, Stress, and Sense of Coherence (SOC) Variables by Age Group and Gender (N= 261)

In addition, the follow-up tests regarding work status (worked or did not work) revealed that the nonworking students demonstrated more emotional coping strategies than the working group and that the students who worked reported having higher stress concerning work issues and daily life issues than those who did not work. There were no significant findings for the independent variable of family status. Means, standard deviations, and F values of the univariate analysis regarding age groups, gender, and work status are presented in Tables 2 and 3.

To examine the relations between the different aspects of students’ self-repo\rts and SOC, I performed Pearson correlations. Results indicated that (a) for coping strategies, SOC was correlated positively with task-oriented strategies and negatively with emotional strategies and with avoidance; (b) for sources of social support, SOC was correlated significantly only with family support; and (c) stress measures (academic stress, work stress, and daily life stress) were negatively correlated with SOC. In other words, students with a higher SOC used more task-oriented strategies and fewer emotional or avoidance coping; they perceived their family support as stronger and felt less stress in their academic lives, in working situations, and in daily life (see Table 4).

TABLE 3. Means, Standard Deviations, and F Scores for Coping Strategies, Support Sources, Stress, and Sense of Coherence (SOC) by Work Status

TABLE 4. Correlations Between Pearson Correlation for Sense of Coherence (SOC) and Coping Strategies, Support Sources, and Stress Variables

I computed multiple regressions to examine the effects of coping strategies, stress, and support sources on students’ SOC. I included the control variables of gender, age, working or not working, and family status. The independent variables of coping, stress, and support were entered as a block, and the control variables were added to the equation in a second step in block form. The regression analyses are presented in Table 5. Coping, stress, and support explained 30% (p

Discussion

In the current study, I attempted to characterize the concept of SOC in college students and its relation to social and emotional variables. The study was based on Antonovsky’s (1998) salutogenic theory, which proposed that when individuals with a strong SOC face stress, they are motivated to adjust to the situation, find the challenge to be comprehensible, and believe that support sources will help them to adjust to and manage the situation. Although a stronger SOC helps individuals to use the most suitable social resources to confront stress, they can also learn from past failures.

The results support the first assumption that individual resources, such as coping strategies, perceived support sources, stress, and SOC differ according to students’ background characteristics. The findings also revealed significant differences regarding proactive coping strategies (task oriented and emotion oriented), in which older students were more task oriented and younger students used more emotional coping strategies. Women reported more emotional and avoidance coping strategies than men did, and unemployed students used more emotional coping strategies than did employed students.

TABLE 5. Regression Analyses of Coping, Support Sources, and Stress on Sense of Coherence

As Roth and Cohen (1986) noted, proactive coping comprises various cognitive, behavioral, and emotional activities that are oriented to reduce stress, whereas the avoidance style reflects activities oriented away from the stress. The approach or avoidance model of coping may provide a useful conceptual framework for students in higher education by indicating that men and women and younger students and older students choose different coping strategies to reduce stress. In keeping with Endler and Parker’s (1990) division of coping strategies, we can assume that in the long run, students using proactive coping strategies (behavioral and emotional) will be better adjusted than students who use negative or avoidance strategies. Longitudinal studies are needed to examine students’ future adjustment.

Consistent with previous studies regarding the contribution of social support to SOC perception, in which social support can make life more manageable and understandable and can assist in making decisions (Antonovsky, 1998; Lusting, Rosenthal, Strauser, & Haynes, 2000), the present study results revealed that students with strong sources of support demonstrated overall positive SOC. Younger students perceived stronger support from friends and others than did the older students. As most of the younger students were not married, we can assume that the support needed came from friends rather than spouses.

Results also revealed the presence of greater academic stress reported by women, which can be explained in terms of gender differences as found in previous studies on stress (Brimblecombe & Ormston, 1996; De-Anda et al., 1997). In addition, employed students expressed a higher rate of work stress and daily life stress than did the unemployed students.

Previous studies examining the SOC within various populations obtained varied results regarding age and gender. For example, in previous examinations of adults (Drory & Florian, 1998), no significant differences were found for age or gender. Within a Swedish adult population (Nilsson et al., 2003), the SOC score showed that women seemed to be more affected by social changes than did men, which influenced their SOC, and in another study of patients with HIV, women’s scores indicated significantly less positive well-being, weaker SOC, and lower social support than men’s scores (Cederfjall, Langius-Eklof, Lindman, & Wredling, 2001).

In the present sample, we found that the older group of students reported a higher SOC than did the younger group, and men reported a higher SOC than did women. One interpretation of this finding may be that, as women are more sensitive to social or environmental changes (Nilsson et al., 2003), they reported a weaker SOC. Another suggestion is based on a previous study by Harri (1998), who found that SOC was negatively related to stress. That finding could explain the gender differences found here, in which women reported higher academic stress and lower SOC. Because no previous studies have examined university students, it would be worthwhile to consider a further examination of these measures among students.

As we expected, coping strategies and stress measures, as well as family support, were significantly correlated with SOC. These results reaffirm Antonovsky’s (1998) claim that intensified perceived stress, as described by the participant, is negatively correlated with a strong SOC. The correlation between SOC and coping has been described in previous research (Sadan, Bareli, & Rubin, 1998), pinpointing the positive relation between SOC and active coping and confirming the contribution of active coping to stressful aspects of daily life. The self-report on coping measures used in this study appears to be a promising tool for assessing how students cope with daily stress.

The results of the regression analysis show the contribution of the dependent variables (such as coping strategies, family support, and work stress) to SOC, whereas the background measures of age and gender did not contribute to perceived SOC. The findings indicated that higher SOC can be predicted by more task-oriented strategies and fewer emotional coping strategies, family support, and reduced work stress. Conversely, a person with a higher perceived SOC tends to cope actively with a situation, with the help of higher sources of familial support and lower stress perception. On the basis of these results, we can assume that having social support, effective coping strategies, and perceptions of lower stress may enhance one’s SOC. We can also assume that the impact of environmental variables such as stress, social support, and coping strategies has a stronger effect on students’ SOC than does age or gender. Although Antonovsky (1998) argued that it is important to take into consideration jobs and specific places of employment as contributors to strengthened SOC, in the current study, there was not enough variance between students who worked and those who did not; thus, the work status did not significantly contribute to the regression for SOC.

Conclusions based on the results of this study are limited by the following considerations: First, the sample may not be representative of the university population. As the participants were students of the social sciences only, the nature of the data suggests that the interpretation of the results should be limited to the sample examined at the time of the study. Additional research is needed to examine the construct of SOC among students with different course specialties. A larger sample with cross-sectional data should be considered. Second, causal conclusions concerning the relationship between SOC and the different measures should be considered with caution. Although Antonovsky (1987) theorized that there is a causal relationship between SOC and positive adjustment, the current findings should be interpreted with prudence. Finally, our data were entirely self-reported: Both social and emotional variables were measured with single questionnaires. Future studies should use additional measures, including work and family measures.

The results of this study underline the importance of designing a longitudinal study to investigate the relationship between stress and SOC among students. This would provide insight into how SOC may change over time after the onset of stress. Although Antonovsky (1987) theorized that SOC is a stable trait, he also stated that significant life events or emotional changes may affect an individual’s SOC. Thus, a longitudinal study could provide a rich source of information specific to coping with stress. Further research should also differentiate between students’ modes of coping with an academic load under stressful conditions and investigate how students’ needs are met through resources and support systems and how they interact with the complex demands of institutions of higher education.

The social significance of the salutogenic model can serve as a guide to providing interventions direct\ed toward stress reduction, strengthening social support, and enhancing various coping strategies. Within universities, it would be helpful to develop coping strategies suited to students’ personal characteristics (e.g., age, gender, work status, perception of stress) that could contribute to their competencies and particularly affect their future success.

REFERENCES

Antonovsky, A. (1979). Health, stress and coping. San Francisco: Jossey-Bass.

Antonovsky, A. (1987). Unraveling the mystery of health. San Francisco: Jossey-Bass.

Antonovsky, A. (1993). The structure and properties of the Sense of Coherence Scale. Social Science and Medicine, 36, 725-733.

Antonovsky, A. (1998). The salutogenic model as a theory to guide health promotion. Megamot, 39, 170-181. (in Hebrew)

Billings, A. G., & Moos, R. H. (1981). The role of coping responses and social adjustment in attenuating the stress of life events. Journal of Behavioral Medicine, 4, 139-157.

Brimblecombe, N., & Ormston, M. (1996). Gender differences in teacher response to school inspection. Educational Studies, 22, 27- 42.

Causey, D., & Dubow, E. F. (1993). Development of a self-report coping measure for elementary school children. Journal of Clinical Child Psychology, 21, 47-59.

Cederfjall, C., Langius-Eklof, A., Lindman, K., & Wredling, R. (2001). Gender differences in perceived health related quality of life among patients with HIV infection. AIDS Patient Care, 15, 31- 39.

Compas, B. E., Malcarne, V. L., & Fondacaro, K. M. (1988). Coping with stressful events in older children and young adolescents. Journal of Consulting and Clinical Psychology, 56, 405-411.

Cutrona, C. E. (1982). Transition to college: Loneliness and the process of social adjustment. In L. A. Peplau & D. Perlman (Eds.), Loneliness: A sourcebook of current theory, research, and therapy (pp. 291-309). New York: Wiley.

De-Anda, D., Bradley, M., & Collada, C. (1997). A study of stress, stressors, and coping strategies among middle school adolescents. Social Work in Education, 19, 87-98.

Drory, Y, & Florian, V. (1998). Sense of coherence and mental health profile in first myocardial infarction patients. Megamot, 1- 2, 116-127. (in Hebrew)

Endler, N. S., & Parker, J. D. A. (1990). Multidimensional assessment of coping. A critical evaluation. Journal of Personality and Social Psychology, 58, 844-854.

Endler, N. S., & Parker, J. D. A. (1999). Coping Inventory for Stressful Situations (CISS): Manual (2nd ed.). Toronto, Ontario, Canada: Multi-Health Systems.

Gurung, R. A. (1992, August). Family environments, specific relationships, and general perceptions of adjustment. Paper presented at the 100th Annual Meeting of the American Psychological Association, Washington, DC.

Hamarat, E., Thompson, D., Zabrucky, K., Steele, D., & Matheny, K. (2001). Perceived stress and coping resource availability as predictors of life satisfaction in young, middle-aged, and older adults. Experimental Aging Research, 27, 181-196.

Hammer, B. L., Grigsby, D. T., & Woods, S. (1998). The conflict demand of work, family, and school among students at an urban university. The Journal of Psychology, 132, 220-226.

Harri, M. (1998). The sense of coherence among nurse educators in Finland. Nurse Education Today, 18, 202-212.

Heiman, T., & Precel, K. (2003). Students with learning disabilities in higher education: Academic strategies profile. Journal of Learning Disabilities, 36, 248-258.

Hollahan, C., & Moos, W. H. (1987). Personal and contextual determinants of coping strategies. Journal of Personality and Social Psychology, 52, 946-955.

Jahnsen, R., Villien, L., Straghelle, J. K., & Holm, I. (2002). Coping potential and disability sense of coherence in adults with cerebral palsy. Disability and Rehabilitation, 24, 511-518.

Kaiser, C. F., Sattler, D. N., Bellack, D. R., & Dersin, J. A. (1996). Conservation of resources approach to a natural disaster: Sense of coherence and psychological distress. Journal of Social Behavior and Personality, 11, 459-476.

Kenny, M. E., & Perez, V. (1996). Attachment and psychological well-being among racially and ethnically diverse first year college students. Journal of College Student Development, 37, 527-535.

Langius, A., Bjoervell, H., & Antonovsky, A. (1992). The sense of coherence concept and its relation to personality traits in Swedish samples. Scandinavian Journal of Caring Sciences, 6, 165-171.

Lazarus, R. L., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer.

Lee, R. M., Keough, K. A., & Sexton, J. D. (2002). Social connectedness, social appraisal, and perceived stress in college women and men. Journal of Counseling & Development, 80, 355-361.

Lopez, F. G. (1991). Patterns of family conflict and their relation to college students’ adjustment. Journal of Counseling and Development, 69, 257-260.

Lusting, D., Rosenthal, D., Strauser, D., & Haynes, K. (2000). The relationship between sense of coherence and adjustment of persons with disabilities. Rehabilitation Counseling Bulletin, 43, 134-141.

Misra, R., & McKean, M. (2000). College students’ academic stress and its relation to their anxiety, time management, and leisure satisfaction. American Journal of Health Studies, 16, 41-51.

Nilsson, B., Holmgren, L., Stegmayr, B., & Wesrman, G. (2003). Sense of coherence-stability over time and relation to health, disease, and psychological changes in general population: A longitudinal study. Scandinavian Journal of Public Health, 31, 297- 305.

Reevy, G. M., & Maslach, C. (2001). Use of social support: Gender and personality differences. Sex Roles, 44, 437-459.

Roth, S., & Cohen, L. J. (1986). Approach, avoidance, and coping with stress. American Psychology, 41, 813-819.

Sadan, K., Bareli, C., & Rubin, N. (1998). Chronic disease and family functioning: The case of juvenile diabetes. Megamot, 1-2, 97- 115. (in Hebrew)

Soderfeldt, M. (2000). The impact of sense of coherence and high- demand/low-control job environment on self-reported health, burnout and psychophysiological stress indicators. Work & Stress, 14, 1-15.

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Winter, M. G., & Yaffe, M. (2000). First-year students’ adjustment to university life as a functioning of relationships with parents. Journal of Adolescent Research, 15, 9-37.

Zeidner, M., Klingman, A., & Itskowitz, R. (1993). Children’s affective reactions and coping under threat of missile attack: A senniprojective assessment procedure. Journal of Personality Assessment, 60, 435-458.

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Original manuscript received April 25, 2003

Final revision accepted March 3, 2004

TALI HEIMAN

Department of Education and Psychology

The Open University of Israel

Address correspondence to Tali Heiman, Department of Education and Psychology, The Open University, The Dorothy de Rothschild Campus, 108 Ravutski Street, Raanana, 43107, Israel; [email protected] (e-mail).

Copyright HELDREF PUBLICATIONS Nov 2004

Abstract

Gingival diseases are the most widely held diseases in America. In some patients, periodontal disease appears in a generalized form, but more often it appears in localized areas. Furthermore, after treatment with scaling and root planing (SRP) in generalized cases, the disease is often reduced to a few local areas in the patient’s mouth. Since periodontitis is a bacterial infection with known pathogenic microorganisms, the local delivery of antimicrobials has been considered to be a possible solution for treating and controlling localized forms of periodontal disease.

Three current local chemotherapeutic agents are reviewed in this paper: doxycycline gel, chlorhexidine chip and minocycline microspheres. With the advancement of local drug delivery systems, clinicians and their patients have new alternatives for treatment of periodontal disease.

Introduction

Since the early experimental gingivitis studies in the 1960s, the consensus of clinical research supports the concept that the initiation and progression of periodontal dis ease is due to bacterial plaque and its metabolic by-products.1-3 Epidemiological studies have also demonstrated that periodontal disease is a site specific process, rather than the previous model of a generalized destruction of the periodontium.4,5 With a site specific model of destruction, treatment can then be concentrated in those sites demonstrating breakdown rather than attempting to treat the whole dentition.

A bacterial etiology for periodontal dis ease provides an opportunity for an antimicrobial approach to treatment. Systemic therapy has demonstrated success in periodontal diseases such as aggressive periodontitis (specifically the former juvenile and refractory periodontitis), where precise bacterial species have been identified.6,7 However, for generalized chronic (formerly adult) periodontitis, systemic antibiotic therapy has demonstrated little clinical efficacy.8,9 Additionally, in contrast to local chemotherapeutics, systemic antibiotic usage presents the risk of producing antibiotic resistant bacterial strains.3

Several local delivery antimicrobial systems have demonstrated clinical efficacy. Tetracycline, doxycycline, minocycline and metronidazole have all been formulated in a local delivery system.3,0-15 Along with the above traditional antibiotics, the topical antimicrobial, chlorhexidine, has been formulated for local delivery at subgingival sites as well.16-18

Scaling and Root Planing

Periodontitis is usually treated with scaling and root planing (SRP) as an initial therapy to remove subgingival plaque and calculus.19-21 SRP generally reduces probing depths (PD), increases gain in clinical attachment levels (CAL) and can decrease disease progression.20-23 Sites initially 4 to 6 mm have averaged 1.29 mm reduction with 0.55 mm of attachment gain, while sites 7 mm or greater demonstrate an average of 2.16 mm reduction with 1.29 mm attachment gain.20

Unfortunately the effectiveness of removing subgin-gival deposits decreases with increasing probing depths.24,25 It has been demonstrated that when probing depths exceed 5 mm, complete root debridement occurs only 32% of the time.24 Although mechanical therapy is effective for the majority of periodontal patients, it rarely results in complete removal of periodontal pathogens.19-25 Local chemotherapeutics have been developed to augment traditional SRP.

Three agents currently used in clinical practices are reviewed in this paper: doxycycline gel, chlorhexidine chip and minocycline microspheres. With the advancement of local drug delivery systems, dentists and hygienists have new alternatives for treatment of periodontal disease. Local chemotherapeutic agents offer an additional mode of therapy and should be used on a case-to-case basis, not necessarily as an initial treatment.

Doxycycline Gel (Atridox(TM))

Atridox(TM) -CollaGenex Pharmaceutical, Inc. Newton, PA 18940 (1- 888-339-5678)

Atridox(TM) is a biodegradable gel containing 10% by weight doxycycline.26 The medicament is supplied in two syringes that must be mixed together chairside for 25 repetitions (approximately 30 seconds) (Figure 1). The mixed solution is placed into one syringe where it is placed to the depth of the pocket. The solution is expressed until it overfills the pocket and begins to set (Figure 2). Upon contact with the moist environment, the liquid rapidly solidifies. The residual polymer can then be packed into the pocket using the underside of a curette. Treatment areas should not be brushed or flossed for one week.

Garrett et al. published a study in 1999 that evaluated the effectiveness of Atridox in 822 moderate to severe periodontitis patients.27 They compared doxycycline polymer (8.5%) to placebo control, oral hygiene, and SRP in two multicenter sites. After nine months the authors concluded that Atridox alone produced the largest decrease in probing depth at 1.2 mm, as compared with the oral hygiene group (0.6 mm), the placebo group (0.8 mm) and the SRP group (1.1 mm). Mean increase in CAL for the Atridox group was 0.8 mm, superior to the oral hygiene group (0.4 mm), the placebo group (0.4 mm) and the SRP group (0.7 mm).27

Figure 1 (above): Atridox syringe mixed chairside.

Figure 2 (left): Atridox application.

Figure 3 (above right): PerioChip in foil pouch.

Figure 4 (right): PerioChip application.

Chlorhexidine Chip (PerioChip)

PerioChip – Dexcel Pharm, Edison, NJ 08837 (1-866-737-4624)

Chlorhexidine (CHX) was introduced in the 1970s as a topical antimicrobial.28 Since then it has developed into a powerful antiseptic capable of reducing plaque by 25 to 40% when used as a rinse or irrigation, respectively.29 CHX has a specific mechanism of action against bacteria.29 The positively charged, long chain molecule attaches to the negatively charged cell wall of the bacteria, disrupting the cell wall membrane. The cell wall ruptures with loss of the cytoplasm, resulting in cell death.29

The CHX chip is a 4 x 5 mm biodegradable film of hydrolyzed gelatin containing 2.5mg of chlorhexidine gluconate30 (Figure 3). The chip is easily placed into periodontal pockets greater than 5 mm and requires no retentive system (Figure 4). The body resorbs the chip in eight to ten days.

The main adverse effects of CHX rinse are staining of the teeth, calculus formation, and altered taste sensation. However, few anaphylactic and allergic reactions have occurred in patients mainly of Japanese descent.31 When CHX is employed in a chip, minimal side effects are induced. Most notable is a tendency for patients to complain of toothache or tooth sensitivity.28 The CHX chip does not visibly stain the teeth.28

Figure 1 (above): Atridox syringe mixed chairside.

Figure 2 (left): Atridox application.

Figure 3 (above right): PerioChip in foil pouch.

Figure 4 (right): PerioChip application.

Chlorhexidine is delivered from the chip into the gingival sulcus at a concentration above 125 g/ml for at least seven days.32 At this concentration, the mean percentage of subgingival bacteria inhibited in vitro was 99%.33

Studies have shown that the CHX chip can significantly improve gingival health when used as an adjunct to SRP.33,34 Jeffcoat et al. reported on a total of 447 patients.34 At nine months, the CHX chip treatment group had significant reductions in PD with respect to the two control groups (CHX + SRP, 0.95 mm; SRP, 0.65 mm; Placebo chip + SRP, 0.69 mm). The CHX chip treatment group also showed significant reductions in CAL with respect to the two control groups (CHX + SRP, 0.75 mm; SRP, 0.58 mm; Placebo chip + SRP, 0.55 mm). Furthermore, 19% of patients in the CHX chip group experienced a significant PD reduction from baseline of 2 mm or more at nine months as compared to the SRP group (8%).34

A later study evaluated the effect of CHX on alveolar bone height after nine months.35 Radiographs of 45 patients were taken via quantitative digital subtraction radiography. Interestingly, 25% of sites treated with SRP and the CHX chip experienced bone gain. Conversely, 15% of the subjects treated with SRP alone continued to lose bone in one or more sites over the period of the study.35

Studies on the CHX chip demonstrate that it is a safe and effective adjunctive chemotherapy for the treatment of periodontal disease. Adverse effects to CHX chip placement have been minimal.

Minocycline Microspheres (Arestin(TM))

Arestin(TM) OraPharma, Inc, Warrminster, PA 18974 (1-215-956- 2200)

Arestin(TM) is a microencapsulated minocycline hydrochloride in a bioabsorbable polymer (Figure 5) resulting in microspheres that are injected (Figure 6) in a powdered form into periodontal pockets.19 Arestin administration results in local antibiotic concentrations of 340 g/ml for up to 14 days.19

In a study of 748 patients, Williams et al. reported that Arestin plus SRP resulted in mean probing depth reductions of 1.32 mm for SRP plus Arestin compared to 1.08 mm with SRP alone.19 Additionally, the mean percentages of sites with greater than or equal to 2 mm of probing depth reduction was 40.52% for the SRP + Arestin group vs. 32.87% for the SRP alone group.19 Due to the limits of clinical accuracy with a periodontal probe, it is important to note that the “2 mm threshold” is the gold standard clinicians use to monitor dis ease progression. Therefore, any adjunct that can increase the percentage of sites respondin\g with a 2 mm probing reduction is significant.

Clinical trials demonstrate that Arestin is easy to place, is safe and efficacious. Adverse effects are minimal.

Discussion

With the advancement of local drug delivery systems, clinicians and their patients have new alternatives for treatment of periodontal disease. Local chemotherapeutic agents offer an additional mode of therapy and should be used on a case-to-case basis, not necessarily as an initial treatment. No other treatment has proven as beneficial as oral hygiene instructions and conventional scaling and root planing. For the majority of patients, periodontal sites will respond adequately to scaling and root planing and require no additional therapy. The use of local drug delivery systems in those situations would be considerable over treatment. Therefore, after thorough scaling and root planing local antimicrobial therapy should be used after a thorough re- evaluation, and only if a possibility to reduce the need for periodontal surgery exists.

Figure 5: Arestin syringe.

Figure 6. Arestin application.

Conclusion

Three local chemotherapeutic agents have been reviewed: Atridox(TM), a doxycycline gel, PerioChip, a chlorhexidine chip and Arestin(TM), a minocycline microspheres. All three are proven adjuncts that can improve the clinical response to traditional scaling and root planing.

References

1. Loe H, Theilade E, Jensen SB. Experimental gingivitis in man. J Periodontol 1965; 36:177-181.

2. Theilade E, Wright WH, Jensen SB, Loe H. Experimental gingivitis in man. II. A longitudinal clinical and bacteriological investigation. J Periodont Res 1966; 1:1-4.

3. Ciancio SG. Site specific delivery of antimicrobial agents for periodontal disease. General Dentistry 1999; 47(2): 172-181.

4. Haffajee AD, Socransky SS. Attachment level changes in destructive periodontal diseases. J Clin Periodontol 1986; 13(5): 461-475.

5. Socransky SS, Haffajee AD, Goodson JM, Lindhe J. New concepts of destructive periodontal disease. J Clin Periodontol 1984; 11(1): 21-32.

6. Slots J, Rosling BG. Suppression of the periodontopathic microflora in localized juvenile periodontitis. J Clin Periodontol 1983; 10:565-486.

7. van Winkelhoff AJ, Tijof CJ, de Graff J. Microbiological and clinical results of metronidazome plus amoxicillin therapy in Actinobacillus actinomycetemcomitans associated periodontitis. J Periodontol 1992; 63:52-57.

8. Listgarten MA, Lindhe J, Hellden L. Effect of tetracycline and/ or scaling on human periodontal disease. Clinical, microbiological, and histopathological observations. J Clin Periodontol 1978; 5:246- 271.

9. Scopp IW, Froum SJ, Sullivan M, Kazandijan G, Wank D, Fine, A. Tetracycline: A clinical study in human gingival tissue in patients with chronic periodontal disease. J Periodontol 1980; 51:328-330.

10. Tonetti M, Cugini AM, Goodson JM. Zero order delivery with periodontal placement of tetracycline loaded ethylene vinyl acetate fibers. J Periodontol Res 1990; 25:243-247.

11. Goodson JM, Cugini MA, Kent RL, et al. Multicenter evaluation of adjunctive tetracycline fiber therapy used in conjunction with scaling and root planing in maintenance patients: Clinical results. J Periodontol 1994; 65:685-691.

12. Polson AM, Southard GL, Dunn RL, et al. Periodontal pocket treatment in beagle dogs using subgingival Doxycyline from a biodegradable system. I. Initial clinical responses. J Periodontol 1996; 67: 1176-1184.

13. Larsen T. Occurance of doxycycline-resistant bacteria in the oral cavity after administration of doxycycline in patients with periodontal disease. Scand J Infect Dis 1991; 23:89-95.

14. Van Steenberghe D, Bercy P, Kohl J. Subgingival minocycline hydrochloride ointment in moderate to severe chronic adult periodontitis: A randomized, double-blind, vehicle-controlled, multicenter study. J Periodontol 1993; 64:637-644.

15. Ainamo J, Lie T, Ellingsen BH, Hansen BF, Johansson LA, Karring T, et al. Clinical responses to subgingival application of a metronidazole 25 percent gel compared to the effect of subgingival scaling in adult periodontitis. J Clinic Periodontol 1992; 19:723- 729.

16. Stabholz A, Soskoline W, Freidman M, et al. The use of sustained release delivery of chlorhexidine for the maintenance of periodontal pockets: A two-year clinical trial. J Periodontol 1991; 62:429-433.

17. Stabholz A, Sela M, Freidman M, et al. Clinical and microbiological effects of sustained release chlorhexidine in periodontal pockets. J Clin Periodontol. 1986; 13:783-788.

18. Palcanis K, Weatherford T, Reese M, et al. Biodegradable chlorhexidine gelatin chip for the treatment of adult periodontitis: Effect on alveolar bone. J Dent Res 1997; 76 (Special issue): 152 Abst 167.

19. Williams RC, Paquette DW, Offenbacher S, et al. Treatment of periodontitis by local administration of minocycline microspheres: A controlled trial. J Periodontol 2001; 72:1535-1544.

20. Cobb CM. Nonsurgical pocket therapy: Mechanical. Ann Periodontol 1996; 11443-490.

21. Haffajee AD, Cugini MA, Dibart S, et al. The effect of SRP on the clinical and microbiological parameters of periodontal diseases. J. Clin Periodontol. 1997; 24: 324-334.

22. Greenstein G. Nonsurgical periodontal therapy in 2000: A literature review. JADA 2000; 131:1580-1592.

23. Greenstein G. Periodontal response to mechanical nonsurgical therapy: A review. J Periodontal 1992; 63:(2): 118-130.

24. Caffesse RG, Sweeney PL, Smith BA. Scaling and root planing with and without periodontal flap surgery. J Clin Periodontol 1986; 13:205-210.

25. Rabbani GM, Ash MM Jr, Caffesse RG. The effectiveness of scaling and root planing in calculus removal. J Periodontol 1981; 52(3): 119-123.

26. Johnson LR, Stoller NH. Rationale for the use of Atridox therapy for managing periodontal patients. Compendium 1999; (20) 19- 25.

27. Garrett S, Johnson L, Drisko CH, et al. Two multicenter studies evaluating locally delivered doxycycline hyclate, placebo control, oral hygiene, and scaling and root planing in the treatment of periodontitis. J Periodontol 1999; 70(5): 490-503.

28. Ciancio SG. Local delivery of chlorhexidine. Compendium 1999; 20:427-433

29. Fleming TF, Newman MG, Doherty FM, Grossman E, Meckel AH, Bakdash B. Supragingival irrigation with 0.06% chlorhexidine in naturally occurring gingivitis. I. 6-month clinical observations. J Periodontol 1990; 51:112-117.

30. Killoy WJ. Assessing the effectiveness of locally delivered chlorhexidine in the treatment of periodontitis. JADA 1999; 130:567- 570.

31.Okano M, Nomuar M, Hata S, et al. Anaphylactic symptoms due to chlorhexidine gluconate. Arch Dermatol 1989; 125:50-52

32. Soskolne WA, Heasman PA, Stabholz A, et al. Sustained local delivery of chlorhexidine in the treatment of periodontitis: a multicenter study. J Periodontol 1997; 68:32-38.

33. Stanley A, Wilson M, Newman HN. The in vitro effects of chlorhexidine on subgingival plaque bacteria. J Clin Periodontol 1989; 16:259-264.

34. Jeffcoat MK, Bray KS, Cianco SG, et al. Adjunctive use of a subgingival controlled-release chlorhexidine chip reduces probing depth and improves attachment level compared with scaling and root planing alone. J Periodontol 1998; 69:989-997.

35. Jeffcoat MK, Palcanis KG, Weatherford TW, Reese M, Geurs NC, Flashner M. Use of a biodegradable chlorhexidine chip in the treatment of adult periodontitis: clinical and radiographic findings. J Periodontol 2000; 71:256-262.

By COL Lawrence G. Breault, DMD, MS and SGM Stephen E. Spadaro

COL Lawrence G. Breault, DMD, MS, is the Chief of Periodontics and Periodontal Mentor for the Advanced General Dentistry Program – one Year, U.S. Army Dental Activity, Fort Benning, GA.

SGM Stephen E. Spadaro is the Senior Noncommissioned Officer for the U.S. Army Dental Command (DENCOM), Fort Sam Houston, TX, and the 13th District Trustee for the ADAA.

Copyright American Dental Assistants Association Nov/Dec 2004

Fritz de Quervain was the first surgeon to describe and treat chronic stenosing tendovaginitis at the radial styloid process. The current management of this condition differs little from his initial description and as a result the condition now bears his name. He and his mentor, Nobel Prize winner Theodor Kocher, advanced the understanding and treatment of thyroid disease, especially subacute nonsuppurative thyroiditis, another condition to which his name is attached. He was a pioneer of surgical technology and author of books and articles read worldwide and is largely responsible for the introduction of iodized table salt. (J Hand Surg 2004;29A:11 64-11 70. Copyright 2004 by the American Society for Surgery of the Hand.)

Key words: Fritz de Quervain, stenosing tendovaginitis, hand surgery.

de Quervain’s stenosing tendovaginitis is a condition that is well known to all hand surgeons but most may not he familiar with the important Swiss surgical figure himself, whose academic accomplishments influenced many generations of surgeons. Fritz de Quervain was a prominent ligure in his time. He was Nobel Prize- winning Theodor Kocher’s first assistant of surgery and he later succeeded Kocher as Chief of the University Surgery Clinic in Bern, Switzerland.

The only publication by de Quervain available in English is a translation of his original ( 1895) work on stenosing tendovaginitis entitled On a Form of Chronic Tendovaginitis1 and there is very little historical information regarding the Swiss surgeon. Consequently we translated several German and French publications2- 6 that detail the life of this innovative surgeon. We also obtained documents from his grandson-in-law, Dr. Ulrich Trhler, Professor of Medical History at the University of Freiburg, to gain a more personal, original perspective on Dr. de Quervain.

The Early Years (1868-1887)

On May 4, 1868 Johann Friedrich de Quervain (who would later call himself Fritz) was born in the Swiss town of Sion in the Valais Canton to Johann Friedrich de Quervain, a pastor, and his wife Anna, daughter of Charles F. Girard, professor of French literature at the University of Basel.^ He was of Huguenot descent, related distantly to a Protestant lord, Jean de Juzd, who owned a piece of land called Kervain in England. In 1683, fearing persecution for his Protestant beliefs de Juzd liquidated his assets and relocated to Switzerland where his descendents, the de Quervains, became part of the bourgeoisie/

The de Quervain family was very large: Fritz had 4 brothers and 5 sisters, many of whom became notable in their own right. For example, his brother Alfred was a professor at the University of Zurich and vice-director of the Central Institute of Meteorology and led 2 expeditions into Greenland. His brother Theophil was a minister and a writer who wrote biographies of famous personalities such as James Garfield, Abraham Lincoln, and General Alfred Girard (his uncle, who immigrated to the United States and became ultimately chief of the military health service). It is to this large family structure that Fritz de Quervain’s traits of consideration, compassion, and unselfishness are generally attributed.2

de Quervain attended the Lerber School in Bern and in the spring of 1887 he passed an entrance examination to begin his medical studies at the University of Bern. According to his brother Theophil he could have been a competent professor of old and new languages or an engineer.2 His decision to go into medicine was influenced by a family history of pursuing medical careers. His maternal great- grandfather had been a doctor,2 as had his mother’s brotherGeneral Alfred Girard-to whom he was very attached.3

Medical School and Residency (1888-1894)

de Quervain matriculated at the University of Bern in 1888 and over the course of his time there he learned from many esteemed faculty members including Theodor Kocher who in 1909 received the Nobel Prize in Physiology of Medicine “. . . in recognition for his work concerning the physiology, pathology, and surgery of the thyroid gland.”7 Other notable members of the faculty were Theodor Langhans, an eminent pathologist for whom the Langhans cell is named, and Hermann Sahli, an internist who contributed to the diagnostic methods of many fields of internal medicine, especially hematology. The time de Quervain spent with these professors undoubtedly had a profound impact on him and influenced his research endeavors throughout the course of his career. According to some of his professors at the medical school de Quervain possessed “clear intellect, tremendous capacity for work, [and] extraordinary memory.”2

de Quervain completed medical school and in the spring of 1892 he passed the state licensing examination. He then immediately started work as third assistant to Dr. Kocher at the surgical hospital at Bern. After only 18 months he became first assistant, or chief, of the surgical clinic.2 His ties to Bern would remain strong and for the remainder of his days he would remain in close correspondence with his mentors from the University, especially Theodor Kocher.

de Quervain in La Chaux-de-Fonds (1894-1910)

In November 1894, pushed by a need for independent activity, de Quervain decided to leave the University of Bern and settle in La Chaux-de-Fonds, a watch-making district in the Neuchtel Mountains. This district of 30,000 people provided him with an abundance of patients with varied illnesses and conditions that broadened his knowledge of medicine and provided the basis for his publications. In his 15 years in La Chaux-de-Fonds he wrote a number of books and articles such as his first publication describing chronic tendovaginitis8 and his book on surgical diagnosis entitled Clinical Surgical Diagnosis for Students and Practitioners.9 These publications paved the way for his subsequent academic positions.3

From 1894 to 1897 de Quervain worked both in the hospital of La Chaux-de-Fonds, which was too small and outdated to provide adequately for its patients, and in his own private clinic. In 1897 he decided to enter into a group practice with Dr. Bourquin, an internist, and Dr. Theodore de Spuir, an ophthalmologist.3 Both of these physicians shared de Quervain’s attraction to new and innovative technologies and his affinity for clinical research. Also in 1897 de Quervain was named Chief of the Surgical Service, which allowed him to oversee construction of a modern 70-bed hospital at La Chaux-de-Fonds. With the pathophysiologic approach to surgery he learned from Kocher, de Quervain transitioned his hospital “from the era of pragmatic medicine to scientific medicine.”6

There existed another hospital in the region of La Chaux-de- Fonds, the hospital of Locle, which in 1900 named de Quervain to the newly created post of surgical consultant. Thus his expansive practice included 2 hospitals and his own private clinic and this gave him a huge pool of patients from which to draw experience.3 de Quervain later remarked that during this time period, “The total number of my clinically handled patients amounted to 600 per year, and the number of operations 500 per year.”2

de Quervain’s Disease (Stenosing Tendosynovitis at the Radial Styloid Process)

During his time at La Chaux-de-Fonds de Quervain recognized an affliction that had not received much prior attention. On December 18, 1894 he saw a 35-year-old woman, Mrs. D, who suddenly became afflicted of “a severe pain in the region of the thumb extensor.”‘ de Quervain excluded tuberculosis as a diagnosis “with moderate certainty” because of the “acute inceptions” and “quick reductions of acute symptoms” and “because no palpable visible changes had developed despite an 8-month duration of pain.”1

de Quervain then remembered a prior similar case that he had observed while working under Dr. Kocher as first assistant of clinical surgery in Bern. That patient, Mrs. L. had noticed that “motion of her right thumb had gradually become painful.” He also remarked, “She showed no evidence in her whole body of syphilis, tuberculosis, or gout.” He noticed no physical abnormalities except a slight “thickening of the tendon-sheath compartment at the distal radial end of the muscle extensor pollicis |brevis] and abductor longus.” Based on de Quervain’s description of his treatment of the patient” it does not appear that he attempted to treat the condition nonsurgically. Rather, in that patient he opened the compartment of those tendons and placed them in the subcutaneous tissue. One year after the surgery he noted that the patient remained fully healed and that the surgery had caused her no discomfort.1

de Quervain then performed the same surgery on Mrs. D on January 8, 1895 and noted that it had the same salutary effect as in the first case and remained so at the 5-month follow-up examination. He saw an additional patient with the same affliction and received case reports of another 2 patients. He communicated his findings to Dr. Kocher and in response Kocher commented he had seen β or 4 similar cases, which he had treated with partial excision of the tendon sheath and had attributed to “a passive type of work hypertrophy.” In the same letter Kocher referred to the condition as “fibrous, stenosed tendovaginitis.” It was de Quervain’s name, however, that became attached to the eponym.1

de Q\uervain then published his findings-both of the 3 cases he had seen and the 2 cases to which Dr. Sandos, his partner, had granted him publication rights-in an article in 1895 entitled “Ueber eine Form von chronischer Tenovaginitis”8 (“On a Form of Chronic Tendovaginitis”). In this article he detailed both his observations and the surgical technique with which to correct this pain syndrome and made a note of differentiating it from the previously described “trigger finger.” In May 1912 he followed up on his findings with another article detailing 8 additional cases with further comments on the etiology and pathogenesis of the condition.10

Figure 1. The Eichhoff test: the thumb is gripped in the fist and the wrist is placed in ulnar deviation, which causes pain at the radial styloid process in a positive test result.

An American surgeon at the Hospital for Joint Diseases in New York City, Harry Finkelstein, read de Quervain’s descriptions of stenosing tendosynovitis and began reviewing the literature of other physicians who had added their own observations of the condition. He then published a paper of his own in 1930 summarizing these previous publications and adding 24 cases of his own, noting that in the United States the condition was often misdiagnosed as “rheumatism, neuritis, periostitis,.. . and even tuberculous osteitis.”” Interestingly, he quoted the surgeon Eichhoff’- who described initially a test for de Quervain’s disease by saying, “A simple experiment will verify this assumption. If one places the thumb within the hand and holds it tightly with the other fingers, and then bends the hand severely in ulnar abduction, an intense pain is experienced on the styloid process of the radius, exactly at the place where the tendon sheath takes its course. The pain disappears the moment the thumb is again extended, even if the ulnar abduction is maintained”11 (Fig. 1).

This test, which for many years was considered diagnostic of dc Quervain’s disease, is now referred to generally as the Finkelstein test although in fact it was Eichhoff who had described it in 1927. This test is not actually the test that Finkelstein described and in recent years this test described initially by Eichhoff has been criticized for giving false-positive results.13

The test Finkelstein described differed from Eichhoff s test in that it did not involve gripping the thumb within the fist. Rather, the test Finkelstein described is as follows: “On grasping the patient’s thumb and quickly abducting the hand ulnarward, the pain over the styloid tip is excruciating”11 (Fig. 2).

Figure 2. Finkelstein’s test: the patient’s thumb is grasped and the wrist is placed in ulnar deviation, causing pain at the radial styloid process.

In 2003 Brunelli published an article4 stating that he had devised a new test for de Quervain’s disease that was more accurate than Finkelstein’s test. The test Brunelli categorized as Finkelstein’s test is the true test that Finkelstein described, not the test described by Eichhoff. Brunelli states that in Finkelstein’s test the tendons of the abductor pollicis longus and extensor pollicis brevis are “moved away from the pulley”4 and that this technique may stretch the radial collateral ligament, the scaphotrapezial ligament, or the thumb carpometacarpal ligament, which could result in false-positive findings. Brunelli’s test is administered by maintaining the wrist in radial deviation and forcibly abducting the thumb (Fig. 3). Brunelli further states that he has been using this test for 30 years and has found it to be quite accurate.4

A Pioneer in La Chaux-de-Fonds

de Quervain pioneered a number of technologies during his stay in La Chaux-de-Fonds including endoscopy, radiology, and sterilization techniques; he also had a hand in the creation of the modern surgical table, de Quervain met with considerable resistance from the hospital when requisitioning new equipment; many times he had to procure the necessary materials at his own expense. This resistance quickly melted away as everyone realized the value of these new and innovative surgical techniques.3

The antimicrobial principles that he learned at Bern stayed with him and he applied them to his practice at La Chaux-de-Fonds. He had all of the instruments sterilized along with the drapes and dressing materials. With the help of a Bernese artisan, Maurice Schaerer, he created autoclaves that would create pressures of 2 atmospheres, a large improvement over the then-standard 0.5-atmosphere variants. These advanced autoclaves were accepted instantaneously and were produced industrially.3

de Quervain, again with the help of Schaerer, constructed a new kind of surgical table. This new surgical table included features such as adjustability to patients’ varying body types and sizes, a concave headrest, and the ability to elevate the surgical field. He first displayed this new surgical table in 1905 at the International Congress of Surgeons at Brussels. He then published 2 articles in 1906 and 1909 detailing the construction of this table.5 This endeavor was well received by the surgical community and within a few years 600 of the new Quervain-Schaerer tables had been sold worldwide.3

In 1898 de Quervain acquired the necessary parts from Germany and constructed an x-ray machine in his clinic. This was a remarkable event because the discovery of x-rays by Rntgen had just occurred in 1895 and the machines existed only in a few places in Switzerland in 1898.3 Of this device de Quervain remarked, “Each visitor wanted to see . . . out of curiosity . . . the hand skeleton and the transparent purse [with coins in it].”2 de Quervain was convinced of the utility of this new technology and contributed to the progress of radiologie technique, especially with respect to its application to gastrointestinal pathology.3

An Author of International Renown

de Quervain authored a number of works while residing in the Neuchtel mountains and these works were largely responsible for bringing him worldwide renown.2 With Kocher he coedited Die Encyklopdie der gesamten Chirurgie14 (The Encyclopedia of Entire Surgery), which initially appeared only in German from 1901 to 1903. This encyclopedia of surgery contained contributions from over 100 eminent specialists drawn mostly from the German-speaking world.3

Figure 3. Brunelli’s test: the wrist is maintained in radial deviation and the thumb is abducted, causing “a painful attrition of the tendons against the pulley.”4

Being enamored with both the utility of surgery and recognizing the crucial nature of proper diagnosis, as well as combining the pathophysiologic approach he learned at Bern with the art of medical intuition he learned at La Chaux-de-Fonds,6 de Quervain spent 4 years organizing both his acquired knowledge and real life experiences into a comprehensive work entitled Spezielle chirurgische Diagnostik fr Studierende und Arzte9 (Clinical Surgical Diagnosis for Student and Practitioners), which appeared in 1907. This book was acclaimed highly and became the book of reference for many surgeons. It had 5 subsequent editions and was translated into English, French, Spanish, Italian, and Russian.3 Professor Jacques Louis Reverdin of Geneva, who many times was critical of the University of Bern, wrote “[the book] . . . is a real life book, reflecting a rich personal experience happily placed in valor. This volume will be a precious guide for the practitioner, and a life saver for patients.”3 This work, perhaps more than any other singular work of de Quervain’s, brought him worldwide fame within the medical community in a relatively short period.

In 1908 de Quervain wrote a chapter on surgery of the head and neck with a large emphasis on thyroid diseases for Wullstein and Wilms’s publication, Lehrbuch der Chirurgie15 (Textbook of Surgery).

de Quervain’s Thyroiditis

In addition to his busy practice and his exploration of new technologies, de Quervain retained his interest in clinical research. He remained especially interested in the thyroid, an organ with which his mentor, Kocher, spent a great deal of time, de Quervain’s doctorate thesis, written in 1893, was entitled ber die Vernderung des Centralnervensystems bei experimeteller Kachaxia thyreopriva der Thiere16 (On the Change of the Central Nervous System by Experimental Hypothyroid Cachexia) and was the result of research on cachexia in animals caused by hypothyroidism. His work with the thyroid continued and on April 5, 1902 he presented to the Congress of the German Society for Surgery his work on a thenunknown form of thyroid inflammation, “Ueber acute, nicht eiterige Thyreoiditis”17 (“Subacute Nonsuppurative Thyroiditis”). In 1904 he published a complete work on this subject18 and this condition would later be known as de Quervain’s thyroiditis.3 As a result of his work on the thyroid de Quervain was largely responsible for the introduction of iodized table salt.19

Stepping Stones

Finally, while in La Chaux-de-Fonds de Quervain obtained 2 positions on the medical faculty at Bern that were awarded to him in an interesting way. In 1901 he requested that he be admitted to the faculty of medicine at Bern as a private practitioner, stating that it would help him to remain in contact with the academic world and stimulate him to create progress in surgery.3 The faculty hesitated initially because it was not customary to award such a position to a physician who was so geographically remote from the university. Thanks to the urging of Dr. Kocher, however, they eventually acquiesced and Dr. de Quervain was accepted to the faculty of medicine at Bern as a private surgeon.3

In 1906, “urged by Kocher,”2 he sought to become a Titular Professor at Bern and wrote to the state council of Bern regarding this matter. Again the faculty was initially hesitant to provide a professorship to a distant practitioner but de Quervain’s reputation for relentless promo\tion of modern surgery, the already proven value of his scientific work, and the urging of the highly respected Dr. Kocher persuaded them to grant him this title in 1907. This professorship at Bern would provide a means to later academic positions.3

In 1910 the University of Basel offered de Quervain the position of Chair of Surgery and he accepted, although he was reluctant to leave La Chauxde-Fonds. In a letter to his friend Paul Pettavel, a pastor in La Chaux-dc-Fonds, de Quervain wrote, “I also leave excellent friends-pastors, doctors, watchmakers, etc.-at an age where solid friendships are not made so easily any more. I leave in La Chauxde-Fonds a piece of myself.”3

Evidently the medical community at La Chaux-deFonds held de Quervain in similar esteem because on September 24, 1910 they held a banquet for de Quervain at the hotel of Paris and gave him a gold stopwatch as a gift in remembrance.3

de Quervain at Basel and Bern (1910-1940)

Dr. de Quervain lectured and practiced very happily in Basel, so much so that he rejected an offer from the new surgical hospital in Geneva in 1916. Said one resident of Basel, “. . . our admired surgeon, Professor de Quervain, who received a call to Geneva and whose departure in high measure would be regretted. For public relief, you should hear that the scholar did not find missing anything in our instructional department that would cause him to move from our town.”2

In his time at Basel de Quervain ensured the creation of a new surgical theater and lecture building for the surgical hospital and the construction began in 1917.3

Perhaps de Quervain would have finished out his career at Basel but on July 27, 1917 an unexpected event changed the course of his life drastically: his beloved mentor, Theodor Kocher, died suddenly. Rather than open the position to application, as was customary, the faculty of Bern voted unanimously to offer it to de Quervain, a stark contrast from their earlier reservations when he applied to become a private practitioner and then again when he applied to be a professor. Along with this offer they also promised him the construction of a brand new, stateof-the-art surgery clinic.3

de Quervain struggled with this decision because he enjoyed great respect in Basel and as a result his “suggestions gained a foothold very rapidly.”2 He had resolved, especially after rejecting the position in Geneva, to stay at Basel indefinitely. Said de Quervain, “When I declined Geneva last year, I had foreseen to stay in Basel indefinitely since I would not have applied to this job in Bern if it has been announced as usual.”2

He was ultimately swayed, however, by the unanimous vote of confidence by the faculty at Bern and his deep attachment to the university at which he had begun his medical studies. He felt also that at Bern he could work more efficiently on resolving certain “social” issues, such as tuberculosis.2

Thus it came to be that in 1918 de Quervain became the head of the University Clinic of Surgery at Bern, succeeding his life-long mentor, Theodor Kocher. For the next 2 decades, until October of 1938, he ran the University Clinic of Surgery, where he helped to train and shape the next generations of Swiss physicians who would go on to work all around the country and the world. It was not only from Switzerland that physicians came to study at Bern, however; the hospital received visitors from all over the globe. For example, one of de Quervain’s former Japanese pupils wrote to him “[we] have a meeting every three months, where we speak of you often … we call our small community the Swiss Doctor Company!”2

On May 4, 1938 de Quervain reached 70 years of age. In honor of this the Swiss Medical Weekly dedicated to him a commemorative publication, which contained contributions of many prominent European surgeons.2

de Quervain retired from the University of Bern in October 1938 although he remained active, still performing some surgeries and conducting some research.2 On January 24, 1940, 3 days after performing his last surgery, Fritz de Quervain died suddenly of complications from a thrombosis of a portal vein.3

Awards, Accomplishments, and Involvement in the International Community

Throughout his life de Quervain was the recipient of a number of distinctions and awards and he held numerous positions in various medical societies. Furthermore he was very active in the international medical community, visiting many of his colleagues abroad and attending many international conferences. In 1899 he received the Haller Medal from the University of Bern. The Haller Medal, named after the famous humanist Albert de Haller, was awarded to a young doctor who distinguished himself by conduct, application, and talent.3

He was secretary of the Medical Society of Neuchtel in 1896 and then became president in 1898. He attended the first International Congress of Surgeons in 1905 where he spoke on the treatment of tuberculosis and his new surgical table. He also attended the second and third International Congress of Surgeons in 1908 and 1911 where he spoke on breast cancer, spinal cord trauma, and x-ray diagnosis of the gastrointestinal tract. He attended the founder’s meeting and all of the congresses of the Swiss Society for Surgery save one and was president of the Swiss Society for Surgery from 1919 to 1920.2

In 1963 a bust of de Quervain was placed in the Hall of Fame of the International College of Surgeons in Chicago. Upon placement of the bust the secretary of the International College of Surgeons said to de Quervain’s daughters, “This bust will be an addition of great value, since there is not a single surgeon who has not heard about your illustrious father or read his work.”2

Fritz de Quervain was a master surgeon, often regarded as one of the last great surgical giants. His keen observation and treatment of stenosing tendovaginitis of the thumb dorsal compartment remains an important contribution to the field of hand surgery that has withstood the test of time. He pioneered a number of technologies including endoscopy, radiology, and sterilization techniques and developed the modern surgical table. He was one of the first to recognize the power of epidemiologic studies and strove endlessly to bridge the widening gap between scientists in opposing countries during and after the First World War. Truly, Dr. Fritz de Quervain was a remarkable man who did remarkable things in a remarkable time. Perhaps the Austrian surgeon Anton von Eiseisberg said it best in 1907 when he wrote to de Quervain, “You are an amazingly industrious man.”2

We would like to thank Dr. Ulrich Trhler, Professor of Medical History at the University of Freiburg, for his help. Without his extensive work on Dr. Fritz de Quervain, especially his work Der Schweizer Chirurg J.F. de Quervain (1868-1940). this article would have been largely impossible.

References

1. de Quervain F. On a form of chronic tendovaginilis [translated by Illgen R, Shortkroff S]. Am J Orthop 1997:26:641644.

2. Trhler U. Der Schwei/er Chirurg J.F. de Quervain (18681940): Wegbereiter neuer internationaler Be/Jehungen in der Wissenschaft der Zwischenkriegszeit. Aarau: Sauerlnder, 1973:5-63.

3. Terrier G. Le docteur Frit/, de Quervain la Chaux-de-Fonds (1894-1910). Rev Med Suisse Romande 1998;! 18:193-201.

4. Brunelli G. Finkelstein’s versus Brunclli’s test in Dc Quervain tenosynovitis. Chir Main 2003;22:43-45.

5. Grundmann R. Zur Operationstischfrage (anlsslich des 126. Geburtstags vol F. de Quervain). (The operating room table (on the 126th birthday of F. de Quervain).]. Zentrallbl Chir 1994;119;449- 450.

6. Trhler U. Quelques mdecins suisses et leur apport la chirurgie de la main. (Swiss physicians and their contribution to surgery of the hand.]. Helvetica chirurgica acta 1977;44:569-576.

7. Mrner KAH. Presentation speech: the Nobel Pri/,e in physiology or medicine in 1909. Nobel e-Museum. 1995. The Nobel Organization. Available at: http://www.nobel.se/ medicine/laureates/1909/ press.html. Accessed March 30, 2004.

8. de Quervain F. Ueber eine Form von chronischer Tendovaginitis. Korrespondenzblatt fr Schweizer Arzte 1895;25: 389-394.

9. de Quervain F. Spezielle chirurgische Diagnostik fr Studierende und Arzte. Vogel: Leipzig, 1907.

10. De Quervain F. Veber das Wesen und die Behandlung der stenosierenden Tendovaginitis am Processus styloideus radii. Munchen Med Wochenschr 1912; 59:5-6.

11. Finkelstein H. Stenosing tendovaginitis at the radial styloid process. J Bone Joint Surg 1930; 12:509-540.

12. Eichhoff E. Zur Pathogenese der Tendovaginitis stenosans. Bruns’ Beitrage Zur Klinischen Chirurgie 1927;139:746-755.

13. Elliot BG. Finkelstein’s test: a descriptive error that can produce a false positive. J Hand Surg 1992;17B:481-482.

14. Kocher T, de Quervain F. Die Encyklopdie der gesamten Chirurgie. Vogel: Leipzig, 1903.

15. Wullstein L, Wilms M. Lehrbuch der Chirurgie. Jena, Germany: Fischer, 1908:360-449.

16. de Quervain F. ber die Vernderung des Centralnervensystems bei experimenteller Kachexia thyreopriva der Thiere. MD thesis. Bern: University of Bern, 1893.

17. de Quervain F. Ueber acute, nicht eiterige Thyreoiditis. Archiv fr klinische Chirurgie 1902;67:706-714.

18. de Quervain F. Die akute, nicht eitrige Thyreoiditis und die Beteiligung der Schilddrse an akuten Intoxikationen und Infektionen berhaupt. Jena, Germany: Fischer, 1904, 1-23.

19. Rang M. De Quervain’s stenosing tenovaginitis: Fritz de Quervain (1868-1940) [reprinted]. Orthopedic Nursing 1982;1:24-25.

Naveen K. Ahuja, BS, Kevin C. Chung, MDx Ann Arbor, Ml

From the University of Michigan Medical School and section of Plastic Surgery, Department of Surgery, the University of Michigan Health System, Ann Arbor. Ml.

Received for publication April 14. 2004; accepted in revised form May 19. 2004.

No benefits in any form have been received or will be received from a commercial party related directly or indirec\tly to the subject of this article.

Reprint requests: Kevin C. Chung, MD. MS. section of Plastic Surgery. The University of Michigan Health System. 15(X) E Medical Center Dr. 2130 Taubman Center. Ann Arbor. Ml 48109-0340.

Copyright 2004 by the American Society for Surgery of the Hand

03630 -5023/04/29A060 -0029$30.00/0

doi:10.1016/j,jhsa.2004.05.019

Copyright Churchill Livingstone Inc., Medical Publishers Nov 2004

The purpose of this paper is to discuss the role and efficacy of dextran in vascular procedures using evidence-based data from the review of surgical literature. A MEDLINE search using “dextran,””vascular surgery,” and “antiplatelet therapy” as keywords was performed for English-language articles. Further references were obtained through cross-referencing the bibliography cited in each work. Dextran is commonly used in carotid endarterectomy (CEA) patients where the embolic rate is reduced by 46%, resulting in fewer procedure-related strokes. As a prophylactic agent against thrombosis, multiple randomized studies have reported its benefit over other antithrombotic medications. Dextran is also particularly useful in “difficult” infragenicular lower extremity bypasses where artificial grafts (such as polytetrafluoroethylene [PTFE] or umbilical vein) are used in the setting of poor outflow vessels, or those with composite grafts and small-caliber venous conduits. Distal bypasses with adjunctive procedures (eg, arteriovenous fistula or anastomotic cuffs) also have a better outcome with the addition of dextran. Dextran has numerous important implications in vascular surgery, in particular with CEA patients or “difficult” infragenicular bypasses. Its effectiveness with endovascular stents remains unknown.

Introduction

Dextran is a macromolecule crystalline polymer with numerous functions. Inhibition of platelet aggregation and adhesiveness, with prolongation of bleeding time, is its most important feature. Over the past 60 years, dextran has been widely used in vascular surgical procedures as well as other subspecialties such as plastics, orthopedics, and trauma. In this paper, we review the properties of this molecule and its role in specific procedures and conditions that may be optimized with the addition of dextran. A MEDLINE search using “dextran,””vascular surgery,” and “antiplatelet therapy” as keywords was performed for English-language articles. Further references were obtained through cross-referencing the bibliography cited in each work.

Structure

Dextran sulfate is a biopolymer macromolecule composed of repeating glucose subunits (Figure 1). The white crystalline form of dextran is solid and odorless with moderate solubility. It is synthesized by the action of the bacterium Leuconostoc mesenteroides on sucrose. It is a polysaccharide and so it is composed of polymers with variable molecular weights. There are 2 commercially available preparations-dextran-40 (molecular weight [MW] ranging between 10,000 and 75,000) and dextran-70 (MW ranging between 20,000 and 115,000). This difference in MW leads to a difference in the renal clearance of the 2 molecules. Renal clearance of dextran is inversely proportional to its MW. Dextran-40 contains molecules of varying sizes that are cleared at various time points. For example, molecules with MWs ranging from 18,000 to 23,000, 28,000-36,000, 44,000-55,000, and 55,000-69,000 have a halflife of 20 minutes, 30 minutes, 7.5 hours, and 12 hours, respectively. In contrast, 50% of dextran70 will be recovered in the urine within 48 hours. Molecules with weight > 50,000 daltons are first catabolized by dextranases located in liver, spleen, lung, and kidney before being eliminated.

Figure 1. Chemical structure of dextrans.

Table I. Function of dextran.

Mechanism of Action

Dextran acts via various mechanisms (Table I). It has effects on primary and secondary hemostasis. It also has antiplatelet activity, interferes with fibrin polymerization, inhibits erythrocyte aggregation, decreases blood viscosity, and is an osmotic agent.

In 1994, Erdtmann et al1 showed that Dextran-40-coated cellulose decreased platelet adhesion to 80% and dextran sulfate-coated cellulose with an MW of 500,000 decreased platelet adhesion to 30% when compared to subendothelial matrix. It has been reported that lowmolecular-weight dextran sulfate dose dependently decreased ristocetin-induced platelet aggregation.2 However, the exact mechanism could not be elucidated, but it was postulated that either direct binding of dextran to platelet or binding of dextran to von Willebrand factor or decreasing factor VIII levels may be the possible mechanism of action.

Early experiments showed that dextran, regardless of MW (10,000- 776,000) interfered with the formation of fibrin clot, when purified fibrinogen was clotted with thrombin.3 Dextran was shown to modify all 3 phases of clot formation-diminishing the induction phase and the second phase while accelerating the equilibration phase. It was speculated that this alteration of clot morphology would lead to changes in biophysical properties of the clot, such as clot porosity and mechanical strength. This was later confirmed when it was shown that dextran modified fibrin polymerization, resulting in thicker fibers.4 The resulting fibers had different biochemical properties. The addition of dextran to normal plasma or plasma from patients with Dusart syndrome (a form of congenital dysfibrinogenemia) shortened the clot lysis time when recombinant tissue-type plasminogen activator (rt-PA) was added to the plasma.5

Dextran molecules have been shown to interact with erythrocytes and change the velocity of rouleaux formation, subsequently increasing the propensity to form clot. At low concentration, the velocity of rouleaux formation increases. Interestingly, beyond a critical concentration, the velocity of rouleaux formation decreases. The exact mechanism for the change in the velocity of rouleaux formation is unclear, but conformational change in the dextran macromolecule has been implicated. The critical concentration for dextran70 was calculated to be 3 g/dL.6

Owing to its large MW, dextran exerts an osmotic force similar to other intravascular proteins such as albumin and globulin. This leads to a decrease in the permeability of blood vessels. With use of a modified Landis microocclusion technique, the addition of dextran-70 to both hypertonic and isotonic saline decreased single microvessel (20-30 m in diameter) permeability.7

Complications

Several notable side effects of dextran have been described in literature. These are summarized in Table II.

Hemorrhage

As described above, dextran has various effects on primary and secondary hemostasis. As a result, hemorrhage can occur secondary to the use of dextran. Epidural hematoma at the injection site was described recently in a patient undergoing a peripheral vascular bypass.8 A retrospective review showed that 26/32 patients treated with 400 mL of dextran-70 developed bleeding from skin and had prolonged coagulation times, and 12/32 developed thrombocytopenia.9 A study of uncontrolled hemorrhage in dogs showed that infusion of dextran resulted in an increased cumulative blood loss.10

Table II. Complications with dextran use.

Pulmonary Edema

The cause of dextran-mediated pulmonary edema is controversial. Several studies have cited the osmotic effects of dextran as a cause for plasma volume expansion leading to cardiogenic pulmonary edema. Elderly patients with cardiac failure are at high risk of developing dextran-induced pulmonary edema. This risk is reduced when the volume of dextran infused is limited to less than 10% of the patient’s blood volume daily. Major complications, such as volume overload and hemorrhage, are more frequent with dextran-70 than with dextran-40.11

The “dextran syndrome” is characterized by acute hypotension, hypoxia, coagulopathy, and anemia. Its mechanism remains unknown. A case report describes this syndrome in a healthy 26-year-old woman who underwent hysteroscopy for intrauterine adhesions. Her uterus was instilled with 300 cc of 32% dextran-70 in an equal volume of normal saline for better visualization. Postoperatively she developed noncardiogenic pulmonary edema with low filling pressures. The authors speculated that the mechanism for the pulmonary edema was related to pulmonary microvascular damage leading to flooding of alveoli with proteins, as has been show in canines.12

Renal Failure

Currently 60 cases of dextran-induced acute renal failure have been reported in the literature. However, a review study reported that 4.7% (10/211) of patients with acute ischemie stroke developed acute renal failure when they were treated with dextran-40 (50-100 g/ day) for 3-6 days.13 The incidence of renal failure increased dramatically among patients who had a glomerular flow rate of less than 30 cc/minute. The mechanism by which dextran induces renal failure is unclear. Some have implicated the direct toxic effect of dextran on kidneys as the cause for renal failure. Some groups have reported that dextran induced extensive swelling and vacuolization of the proximal tubules.14 Others have found that administration of dextran can cause acute interstitial nephritis. Siegel15 implicated the precipitation of dextran in the renal tubules leading to plug formation and subsequent renal failure. Damage of tubular cells, leading to leakage, of dextran into the renal parenchyma and resulting in osmotic nephrosis, has also been postulated as a potential mechanism for acute renal failure. Dextran is not removed by hemodialysis, and hence, plasmapheresis is the current established treatment of choice for dextran-induced renal failure.

Allergic and Anaphylactic Reactions

Allergic reactions (1%) and anaphylactic shock dire\ctly related to dextran infusion have been reported (

Table III. Role of dextran in vascular surgery.

The incidence of anaphylactoid reactions can be decreased by premedicating the patients with a monovalent hapten dextran- Promiten (20 mL dextran 1, 15%, Mw 1,000 dalton). This is usually given before dextran infusion, and it binds the antigen sites on the dextran-binding antibodies. Binding of these antibodies with the monovalent dextran will prevent the binding of the antibodies to larger dextran molecules that are polyvalent and will prevent the formation of large immune complexes. In 1 Swedish study, patients who received dextran-70 or 40 and had prophylactic intravenous injection of 20 mL dextran 1 hour before the infusion experienced a significantly lower (p = 0.01) dextran-induced anaphylactic reaction.17 However, other authors have demonstrated that only 40% of iron dextran-related anaphylactic-like reactions occur in response to the initial test dose.18 Therefore, subsequent doses of iron dextran may still pose a risk.

Hemodilution

The dextran-related hemodilutional phenomenon19 was described when dextran-40 was given after coronary stent placement. The hematocrit decrease often returns to near-baseline levels within 48 hours of stopping dextran.

Contraindications

Contraindications to the use of dextran include those patients with severe biventricular failure, pulmonary edema, or severe congestive heart failure. These patients are prone to worsening of their cardiac failure when given dextran because of its high osmotic properties. Prior anaphylaxis to dextran and severe bleeding diathesis with platelet dysfunction or hemostatic defects are other contraindications. It should also be used cautiously in people with renal disease. Patients with renal insufficiency may not be able to handle the osmotic load and subsequent volume expansion caused by dextran. In addition, the administration of dextran may induce electrolyte abnormalities, particularly hyperkalemia, in this patient population. Adequate hydration with crystalloids is needed in this population to prevent acute renal failure.

Role in Vascular Surgery

Volume Expansion

Dextran was used as blood-plasma volume expanders in the early 1940s, and over the past 60 years, its antithrombotic properties have been better defined. It is both osmotically active and too large to pass through the uninjured vessel. These characteristics, combined with its high oncotic properties, make this agent an ideal plasma expander, and it has been previously used in hypovolemic shock (Table III). However, the data regarding the use of 6% dextran- 70 in combination with 7.5% NaCl (HSD) are conflicting. HSD is a hypertonic-hyperosmotic solution that has been used as a plasma expander in the treatment of hemorrhagic hypotension. In animal models of controlled hemorrhage there is enough evidence to prove the superiority of HSD compared to crystalloids in equal volumes.20 However, its benefits in human studies have not been clearly demonstrated. Recently, a randomized, double-blinded study demonstrated improved survival in patients with penetrating trauma to the torso who received initial fluid resuscitation with HSD as compared to normal saline.21 In contrast to controlled hemorrhage, in animal models of uncontrolled hemorrhage HSD has been shown to increase and or accelerate mortality. Its role in uncontrolled hemorrhage remains controversial.10

Antithrombotic

Dextran has been used prophylactically to prevent venous and arterial thrombosis. Several randomized clinical trials have demonstrated reductions in deep venous thrombosis (DVTs) (15.6% with dextran versus 24.2% in controls), and pulmonary emboli (PE) (1.2% with dextran versus 2.8% in controls).22 Dextran has provided effective DVT prophylaxis in patients undergoing hip surgery.23 In an international multicenter prospective study of general surgical, urological, gynecological, and orthopedic patients undergoing elective operations lasting at least 30 minutes, prophylaxis with dextran-70 (given as 3 500-mL doses with the first dose given during surgery) was compared with low-dose subcutaneous heparin (5,000 units given every 8 hours, starting 2 hours before surgery and continuing for 6 days or until full mobility). There was no difference in the incidence of fatal pulmonary embolism in the 2 groups.24 An equal number of bleeding complications occurred with both regimens, and serious allergic reactions occurred in 1.1% of patients with dextran.24

Dextran has been widely used as an alternative to heparin anticoagulation and antiplatelet agents. Its ability to inhibit factor VIII activity, lyse clot, and inhibit platelet aggregation in response to collagen made this an ideal agent in combating the postoperative hypercoagulable state.25-27 Data in rabbits from Matthiasson et al28 suggest that there might be a potential additive effect of using heparin and dextran without increasing the risk of bleeding complications. However, there are not sufficient data from clinical trials on the additive effect of using a combination of dextran and other anticoagulants. Clinical trials on the use of this combination therapy are needed.

Antiplatelet and Antifibrin (Graft Patency)

Dextran-40, also known as low-molecular-weight dextran (LMD), has been shown to reduce the platelet deposition onto prosthetic materials.29 It does not improve the early patency of autogenous infrainguinal bypass grafts.30 However, there may be subsets of patients who might benefit from dextran administration, in particular, those with veins of poor quality, those with poor outflow, and those undergoing prosthetic bypass grafting. Dextran- 40 is beneficial in any scenario in which the risk of early thrombosis is high, but its routine use as an adjunct to lower extremity revascularization performed with autologous vein is not recommended.30

Randomized animal studies have documented the efficacy of dextran in decreasing both platelet and fibrin deposition in arterial grafts.31 Intravenous dextran-40 continues to be used in microsurgical anastomosis. Dextran-70 in an ordinary dose exerts such a profound antithrombotic effect in small traumatized arteries that the addition of a high dose of low-molecular-weight heparin (LMWH) would not be beneficial.32 Dextran, however, significantly prolongs bleeding times and improves early patency rate in both arterial and venous reconstructions. It does not improve the patency beyond 1 week, and it has little effect on long-term patency.33 It has been demonstrated that dextran mixed with hypertonic normal saline solution has a significant flow-promoting action in several vascular beds and potential beneficial effects on the patency of small-diameter polytetrafluoroethylene (PTFE) grafts.34

Dextran has also been investigated as an intravenous infusion given perioperatively and for 3 days after peripheral bypass surgery. Graft patencies at 3 days and 1 week have been shown to be improved by dextran-40 in comparison to an untreated control group or in addition to standard perioperative treatment with heparin.25,34 These benefits were evident only in grafts to the tibial or peroneal vessels and were not seen in autogenous vein grafts.35 This study randomized 200 patients, and with initial 1- month follow-up, there was a 6.9% occlusion rate in the dextran group compared to 20.5% in the group that did not receive dextran. However, long-term follow-up on the same patient population confirmed no beneficial long-term patency with dextran.36 A more recent single-center study in reversed vein grafts found that there was no benefit at 30 days in terms of graft patency or in the number of patients alive with a patent bypass with dextran therapy.29 A nonrandomized comparison of dextran with the combination of dextran and warfarin suggested that the combination gave better results on clinical endpoints.37 This has also been shown in case reports.38

Infusions of dextran-40 have been shown to significantly reduce the early postoperative thrombosis in difficult distal bypasses. Rutherford and associates,25 in a multicenter, randomized trial, showed significantly improved 1-week patency rates after 156 difficult distal bypasses (6.8% vs 20.5%). In a subsequent analysis including additional cases (n = 195), a statistically significant advantage was also demonstrated after 1 month.25 Significantly greater benefit was demonstrated in the dextran group for 2 subsets of patients. The first group of patients underwent peroneal and tibial bypasses (0% vs 31.1%). The second group of patients were those who were undergoing femorodistal bypasses in which grafts other than saphenous vein grafts were used (10% vs 36.4%), such as umbilical vein or PTFE.

Shoenfel\d et al28 have demonstrated, in an ex vivo baboon shunt preparation in which its flow and dilutional effects were controlled, that dextran-40 infusions significantly reduced the rate of platelet deposition in both PTFE and Dacron grafts. This effect occurred at an infusion rate equivalent to 25 mL/kg. The regimen effective in the clinical trial employed an alternative infusion rate of 100 mL/hr (1 unit) and postoperative infusion rates of 75 mL/ hr (1 unit per day). This 4-day, 5-bottle regimen was designed to increase flow as well as to decrease thrombogenicity. The latter effect is probably more important and is multifactorial in clinical settings. Low-molecular-weight dextran coats both platelets and vascular endothelial cells, increases their electronegativity,40 and produces a decrease in factor VIII-related antigen out of proportion to what would be expected by dilutional effects alone.26,39 Also, dextran acts as a plasminogen activator and inhibits alpha-2- antiplasmin, thereby accelerating plasma clot lysis.41 Lower infusion rates of 25 mL/hr rather than larger doses are recommended in those with acute renal dysfunction and congestive heart failure. Similar lower dosage is appropriate if other means of increasing flow have been employed such as distal arteriovenous fistula or sympathetic blockade.

Antiembolic

Carotid endarterectomy (CEA) is complicated by thrombosis in approximately 3% of cases, and commonly presents in the first 6 hours postoperatively.42 The majority of perioperative strokes are secondary to thromboembolic complications occurring during carotid dissection or in the immediate postoperative period. Numerous methods have been used in an attempt to decrease the incidence of thromboembolic complications associated with CEA. These include the administration of perioperative aspirin and the intraoperative use of unfractionated heparin. In addition, some investigators have advocated the use of dextran-40 postoperatively to decrease the stroke rate.43,46

In 1 Australian study, dextran was shown to reduce the embolie signals after carotid endarterectomy42; 150 patients undergoing CEA were randomized to dextran-40 and placebo. Transcranial Doppler monitoring of the ipsilateral middle cerebral artery was performed in all the patients. The overall embolic signal counts were 46% less for the dextran group after 0-1 hour postoperatively (p = 0.052) and also 64% less again in the dextran group after 2-3 hours postoperatively (p = 0.040). Concluding results indicate that dextran reduces embolic signals within 3 hours of CEA.

Hayes et al44 conducted a prospective study on 600 consecutive CEAs using transcranial Doppler-directed dextran-40 therapy. Patients were monitored with transcranial Doppler for 6 hours postoperatively following CEA. Patients who showed evidence of postoperative thromboembolism by transcranial Doppler were started on dextran-40 at 20 mL/hr. There were no complications associated with the use of dextran in this study. The authors concluded that the use of transcranial Doppler-directed dextran-40 therapy can significantly reduce the stroke rate associated with CEA in centers performing more than 50 CEAs per year.44

Naylor et al45 performed a prospective study on 500 consecutive patients undergoing CEA. Transcranial Doppler monitoring was started after the induction of anesthesia and continued for 3 hours postoperatively. Dextran-40 was started in any patient who showed evidence of thromboembolism by transcranial Doppler. Twenty-two of 500 patients (4.4%) required dextran therapy. Dextran therapy decreased the median embolus count within the first 3 hours. The postoperative stroke rate was decreased by 60% (from 4% to 0.2%) in this study.

Lennard et al46 did a prospective study in 166 patients undergoing CEA and found that monitoring patients with transcranial Doppler-directed dextran therapy for 3 hours postoperatively was as effective as 6-hour monitoring in the prevention of postoperative carotid thrombosis. Patients who had more than 25 emboli detected in any 10-minute period or had emboli that distorted the arterial waveform were started on dextran-40. Nine of 166 patients (5.4%) required dextran therapy. Dextran therapy significantly reduced the number of emboli detected by transcranial Doppler. Emboli stopped in all patients on dextran therapy. Of the 166 patients in this study, 97% required monitoring for 3 hours, 2% for 4 hours, and 1% for more than 4 hours.

Stroke is a major cause of morbidity and mortality following CEA. Thromboembolism accounts for a significant percentage of perioperative neurologic complications from CEA. Platelet activation, adhesion, and aggregation are triggered by the surface of the endarteriomized carotid wall following CEA, leading to embolism and carotid occlusion. Dextran, owing to its antiplatelet properties, is useful in reducing the perioperative stroke rate in patients undergoing CEA.

Conclusion

Based on the current data available, we recommend that patients undergoing CEA be placed on dextran-40 at 20 cc/hr and that the infusion be started after a Promit test-dose. The infusion should continue for overnight hospital stay, and be stopped if signs of congestive heart failure or bleeding occur.

If cryopreserved, umbilical veins or PTFE grafts are used for lower extremity bypasses, in particular, those infragenicular groups, dextran40 should be used postoperatively in conjunction with systemic and oral anticoagulation. We also recommend its use in difficult bypasses: poor outflow, composite grafts, or small- caliber vein grafts, and in adjunctive procedures such as arteriovenous fistula or distal vein cuffs. In certain patients with a history of HIT (heparin-induced thrombocytopenia), dextran has been effectively used. Further prospective, randomized studies are essential to better study the effects and potential uses of dextran in vascular surgery.

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25. Rutherford RB, Jones DN, Bergentz S-E, et al: The efficacy of dextran-40 in preventing early postoperative thrombosis following difficult lower extremity bypass. J Vase Surg 1:765-773, 1984.

26. Aberg M, Hedner V, Bergentz SE: Effect of dextran on factor VIII and platelet function. Ann Surg 189: 243-247, 1979.

27. Aberg M, Bergentz SE, Hedner V: The effect of dextran on the lysability of ex vivo thrombi. Ann Surg 181:342-345, 1975.

28. Matthiasson SE, Lindblad B, Matzch T, et al: Study of the interaction of dextran and enoxaparin on heamostasis in humans. Thromb Haemost 72:722-727, 1994.

29. Shoenfeld NA, Eldrup-Jorgensen J, Connolly R, et al: The effect of low molecular weight dextran on platelet deposition onto prosthetic materials. J Vase Surg 5:76-82, 1987.

30. Katz SG, Kohl RD: Does dextran 40 improve the early patency of autogenous infrainguinal bypass grafts? J Vase Surg 28:23-26, 1998.

31. Rothkopf DM, Chu B, Bern S, et al: The effect of dextran on microvascular thrombosis in an experimental rabbit model. Plast Reconstr Surg 92:511-515, 1993.

32. Zhang B, Wieslander JB: Dextran’s antithrombotic properties in small arteries are not altered by lowmolecular-weight heparin or the fibrinolytic inhibitor tranexamic acid: An experimental study. Microsurgery 14:289-295, 1993.

33. Salemark L, Knudsen F, Dougan P: The effect of dextran 40 on patency following severe trauma in small arteries and veins. Br J Plast Surg 48:121-126, 1995.

34. Frost-Arner L, Bergqvist D: Effects of hypertonic saline- dextran solution on regional blood flow and thrombogenicity in PTFE grafts in the vena cava of the rabbit. Eur J Vase Endovasc Surg 19:12-20, 2000.

35. Waibel P: Antikoagulation in der Gefsschirurgie. Vasa 5:107,110, 1976.

36. Rutherford RB, Jones DN, Bergentz S-E, et al: Factors affecting the patency of infrainguinal bypass. J Vase Surg 1988;8:236-246.

37. Kluge TH, R0 JS, Fretheim B, et al: Thrombosis prophylaxis with dextran and warfarin in vascular operations. Surg Gynecol Obstet 135:941-944, 1972.

38. Ferraboli R, Malheiro PS, Abdulkader RCRM, et al: Anuric case Report: Vos et al: Dextran-Induced Acute Renal Failure acute renal failure caused by dextran 40 administration. Ren Fail 19:303-306, 1997.

39. Ross S, Ebert R: Microelectrophoresis of blood platelets and the effect of dextran. J Clin Invest 38:135-139, 1955.

40. Sawyer RB, Moncrief JA: Dextran specificity in thrombus inhibition. Arch Surg 90:562-566, 1965.

41. Carlin G, Saldeen T: On the interaction between dextran and the primary fibrinolysis inhibitor alpha-2-antiplasmin. Thromb Res 19:103-110, 1980.

42. Guant MR, London NJM, Smith J, et al: Early diagnosis of postoperative carotid occlusion using transcranial Doppler ultrasound. J Vase Surg 20:1004-1005, 1994.

43. Levi CR, Stork JL, Chambers BR, et al: Dextran reduces embolie signals after carotid endarterectomy. Ann Neurol 50:544- 547, 2001.

44. Hayes PD, Lloyd AJ, Lennard N, et al: Transcranial Doppler- directed Dextran-40 therapy is a cost-effective method of preventing carotid thrombosis after carotid endarterectomy. Eur J Vase Endovasc Surg 19:56-61, 2000.

45. Naylor AR, Hayes PD, Allroggen H, et al: Reducing the risk of carotid surgery: A 7-year audit of the role of monitoring and quality control assessment. J Vase Surg 32:750-759, 2000.

46. Lennard N, Smith JL, Hayes P, et al: Transcranial Doppler- directed dextran therapy in the prevention of carotid thrombosis: Three-hour monitoring is as effective as six hours. Eur J Vase Endovasc Surg 17:301-305, 1999.

Farshad Abir, MD, Siamak Barkhordarian, MD, and Bauer E. Sumpio, MD, PhD, New Haven, CT

Vasc Endovasc Surg 38:483-491, 2004

From the Yale University School of Medicine, section of Vascular Surgery, New Haven, CT

Correspondence: Bauer E. Sumpio, MD, PhD, Yale University School of Medicine, section of Vascular Surgery, 333 Cedar St., FMB 137, New Haven, CT 06520-8062

E-mail: [email protected]

2004 Westminster Publications, Inc, 708 Glen Cove Avenue, Glen Head, NY 11545, USA

Copyright Westminster Publications, Inc. Nov/Dec 2004

The clinical significance of lower extremity deep vein thrombus (DVT) propagation in the setting of anticoagulation therapy remains unclear. The purpose of this study is to compare results of thrombus outcome found with repeat duplex ultrasonography to the incidence of pulmonary embolism and mortality. During a recent 18-month period, 457 patients were diagnosed with lower extremity DVT with duplex ultrasonography and their data were retrospectively analyzed. Repeat examinations were available for review in 118 patients (51 men, 67 women). Results of repeat duplex exams were divided into 4 groups: resolved, improved, unchanged, or extended proximally. All patients received heparin and warfarin therapy. Ventilation-perfusion (V/Q) scans were obtained only for signs and symptoms of pulmonary embolism (n = 30). Mortality, the prevalence of high-probability V/ Q scans, frequency of intracaval filter insertion, gender, mean age, mean prothrombin time (PT), mean partial thromboplastin time (PTT), mean number of repeat ultrasounds per patient, and mean time over which the repeat ultrasounds took place were compared among the 4 groups. Patients who had proximal extension of DVT (19%) on repeat duplex ultrasound had an increased prevalence of pulmonary embolism (p

Introduction

Several studies have prospectively assessed deep vein thrombosis (DVT) in regard to thrombus resolution and propagation using repeat duplex ultrasound1-7 However, little is known about the clinical significance of proximal DVT extension documented by repeat duplex exam in the setting of adequate anticoagulation. Furthermore, routine monitoring of DVT can be justified in this era of cost- containment medicine only if therapy is changed as a result of such testing. The purposes of this study are to retrospectively review our experience with repeat duplex imaging of lower extremity DVT and compare results of thrombus outcome to level of anticoagulation, incidence of pulmonary embolism, and mortality.

Patients and Methods

During an 18-month period, 457 patients were diagnosed with lower extremity DVT with venous duplex ultrasonography at the Maimonides Medical Center Vascular Laboratory. Repeat duplex exams were available for review in 118 (26%) patients. There were 67 women and 51 men ranging in age from 23 to 91 years (mean 62 17 years). All patients were referred for evaluation by either the surgical or medical service. Total follow-up time with ultrasound and the length of time each patient spent in the study were calculated.

Duplex imaging studies were performed with an Acuson 128, or a Toshiba SSH-140A, or a Quantum 2000 scanner using a 5 MHz probe. Deep vein segments evaluated for thrombosis included the external iliac vein when possible, the common femoral vein, the superficial and deep femoral veins, the popliteal vein, and the calf veins. All veins were examined in the transverse and longitudinal views. All exams were performed by vascular technologists, recorded on videotape, and interpreted by one attending vascular surgeon.

Criteria for diagnosis of DVT included absence or diminished color Doppler signals with respiration or augmentation maneuvers, echogenie signals within the vein lumen either partially or completely occluding the vessel, inability to compress the vein by pressure on the transducer, and dilated veins where thrombus was suspected. Once the diagnosis of DVT was made, all vein segments involved were recorded.

Patients were stratified into 4 groups (extended, unchanged, improved, or resolved) based on the results of the repeat duplex ultrasound as compared to the original exam. Thrombus extension was defined as propagation to the next proximal vein segment. Clots that propagated only distally were not included in this group. Thrombus was determined to be unchanged if the clot remained in the same vein segment without evidence of recanalization or only propagated distally. Improvement of thrombus was recorded if there was evidence of recanalization or regression in the overall size or number of vein segments involved. A thrombus was determined to be resolved if intraluminal echogenic signals disappeared, the vein was fully compressible with pressure on the transducer, and color Doppler signals returned with augmentation maneuvers and respiration.

All patients diagnosed with acute DVT were begun on an intravenous heparin regimen and subsequently placed on a warfarin regimen after 24 hours of heparin therapy. Routine prothrombin time (PT) and partial thromboplastin time (PTT) were obtained and heparin was discontinued once the PT was 1.5 to 2.0 control levels. (International normalized ratio values were not yet the standard when these data were collected.) The interval for oral anticoagulation ranged from 3 months to the entire length of the study. Average PT and PTT were calculated from hospital laboratory records for each patient when available.

Ventilation-perfusion (V/Q) scans and chest roentgenograms were obtained only when patients presented with signs and symptoms of pulmonary embolism (PE). Briefly, with the patient in the supine position, ventilation scans were performed with inhaled aerosolized diephilene triamine pentatate acid (DTPA) and perfusion scans were obtained by intravenous injection of technetium Tc 99m macroaggregated albumin. Pulmonary ventilation and perfusion images were then created with wide-field scintillation cameras collecting a determined number of counts. Scans were interpreted to be high- probability if there were large segmentai perfusion defects without corresponding ventilation or roentgenographic abnormalities. Low- probability scans demonstrated perfusion defects with matching ventilation or roentgenographic abnormalities. Normal V/Q scans had no perfusion defects present. Intermediate scans did not meet criteria for normal, low, or high probability of PE.8 Only high- probability V/Q scans were determined to depict pulmonary emboli.

The number of Greenfield filter devices inserted was obtained from the vascular surgery operative database. Indications for insertion of an intracaval filter device were PE despite adequate anticoagulation or a contraindication to anticoagulation therapy. All procedures were done percutaneously under fluoroscopic guidance. There were no postoperative hematomas and all filters were placed in the infrarenal position.

Mortality data were obtained from the New York City Department of Vital Records. Mortality could be documented only if the death occurred in 1 of the boroughs of the city of New York.

One hundred and five patients were then randomly selected from the 341 patients who had a single duplex ultrasound exam demonstrating lower extremity DVT during the same study period. Results for average age, PT, PTT, gender, prevalence of high- probability V/Q scans, and Greenfield filter insertion were compared with those for patients who underwent repeat scanning to determine if there was evidence of a selection bias for these parameters among either group.

Data were analyzed with aid of SPSS entry program. Mortality was compared with Cox’s proportional hazard model adjusting for age, gender, and length of time spent in the study. The Cochran-Armithee trend test was used to examine the relationship between thrombus outcome and prevalence of high-probability V/Q scan. Exact contingency analysis was used to compare the prevalence of Greenfield filter insertion among the 4 groups. Analysis of variance (ANOVA) was used to compare mean age, mean PT, mean PTT, mean number of repeat ultrasounds per patient, and mean time over which the repeat ultrasounds took place.

Results

A total of 342 duplex ultrasounds were performed for lower extremity DVT on 118 patients over an 18 month period. The mean number of exams per patient was 2.9 1.3 (range 2-8). The average length of time to the first follow-up exam was 1.25 months, and the average total follow-up time with ultrasound was 4.3 months. The average total length of time spent in the study, which was calculated from the date of original diagnosis to date of death or the concluding date of the study, was 10.6 5.6 months. Average PT was 18.5 2.4 while average PTT was 49.6 18.3. In total, 30 V/Q scans were obtained: 2 were normal, 18 were low probability, 1 was intermediate probability, and 9 were high probability. Fourteen Greenfield filters were inserted and 14 deaths were recorded. There were no fatal pulmonary emboli.

Twenty-three patients (19%) had thrombus extend proximally, 45 patients (38%) had thrombus remain unchanged, 23 patients (19%) had thrombus improve, and 27 (23%) patients had complete resolution of thrombus. There was no association between the most proximal original vein segment involved and thrombus outcome (Table I). The average length of time todemonstrate proximal extension of DVT was 28 days. There was no statistical difference in the length of time to demonstrate proximal extension between patients with or without high probability V/Q scans.

Men and women were equally represented in all 4 groups. The extended, unchanged, and improved groups all had similar ages, whereas patients whose DVT resolved were younger (p

Patients whose DVT extended proximally had a significantly increased prevalence of highprobability V/Q scans (p

Results for 105 patients with no duplex ultrasound follow-up for lower extremity DVT are detailed in Table VI. These patients were found to be older than those patients with follow-up ultrasound exams (p

Discussion

Duplex ultrasound was accurately able to identify lower extremity DVT and the particular vein segments involved with thrombus in all patients. Nineteen percent of patients who had repeat duplex exams had thrombus extend proximally while 38% of DVTs remained unchanged and 19% of patients had improvement of the DVT. Only 23% of patients had complete resolution of thrombus over the course of the study. Average anticoagulation parameters were all therapeutic although the range included some values that were above and below 1.5 to 2.0 control values. These findings are similar to other studies that have prospectively assessed DVT outcome with serial duplex scanning and demonstrated a 30%,1 19%,2 38%4 and a 20%5 incidence of propagation despite standard anticoagulation measures. No particular vein segment that was originally involved with thrombus had an increased likelihood of propagation and the average length of time to thrombus extension was 28 days, indicating this process tends to occur early.

Table I. Thrombus outcome and original vein segment involved.

Table II. Demographics and thrombus outcome.

Table III. Thrombus outcome and distribution of V/Q scans.

Table IV. Thrombus outcome and anticoagulation parameters.

Table V. Thrombus outcome compared to mortality and Greenfield filter insertion.

Table VI. Ultrasound follow-up verses no ultrasound follow-up.

This would seem to imply that some patients with lower extremity DVT can have extension of their thrombi despite anticoagulation measures. It seems likely that the effectiveness of anticoagulation on thrombus varies, and factors that determine efficacy of anticoagulant therapy are not completely understood. However, the incidence of recurrent venous thromboembolism is 15 times greater in patients who are inadequately anticoagulated for 24 hours or more during therapy when compared to patients who are continuously anticoagulated.9 When therapeutic, heparin prevents extension of thrombi, accelerates clot organization and lysis,10,11 and decreases the incidence of thromboembolism.12 Yet venographically proven DVTs have a 32% incidence of propagation on repeat contrast study in the setting of adequate anticoagulation.13 Our data and the aforementioned prospective studies substantiate this same finding with serial duplex scanning.

This raises the question of what is the clinical implication of proximal extension of DVT in regard to thromboembolism? The overall incidence of high-probability V/Q scans in our patients with lower extremity DVT assessed by repeat duplex exam was 7.8%. Patients who had DVT extend proximally had a significantly higher prevalence of high-probability V/Q scans (13%) as compared to those patients with thrombi that remained unchanged, improved, or resolved (11%, 0%, and 3.7%, respectively). Furthermore, the difference in pulmonary embolism among these 4 groups could not be attributed to any difference in the number of Greenfield filters inserted or the level of anticoagulation. It may be that thrombi that propagate are less stable and more likely to fragment and cause pulmonary emboli.

The prevalence of pulmonary embolism was determined by the number of high-probability V/Q scans. Some controversy exists over the ability of V/Q scans to accurately diagnose pulmonary emboli. The Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED)8 assessed the sensitivity and specificity of V/Q scans by comparing 755 pulmonary angiograms to 931 V/Q scans in patients suspected of suffering from PE. Eighty-eight percent of patients with high- probability V/Q scans had angiographically proven PE, whereas 33% of patients with intermediate-probability scans and 12% of patients with low-probability V/Q scans had PE confirmed by angiography. Although including only high-probability V/Q scans as a positive outcome sacrifices some sensitivity, it gives the greatest positive predictive value. Furthermore, including intermediate-probability or even low-probability V/Q scans to increase sensitivity of outcome would markedly reduce specificity.

Given these data, the therapy for patients who propagate lower extremity DVT has not been established. Thrombolytic therapy is one alternative, but venous rethrombosis following treatment of DVT with streptokinase has been reported as high as 60%.14 An analysis of published estimates of the probabilities of various adverse outcomes associated with treatment of DVT with heparin verses heparin plus thrombolytic therapy found that patients treated with heparin alone would have a slightly increased life expectancy.15 This brings into question the use of thrombolytic therapy for proximal extension of DVT’. A second alternative would be insertion of a Greenfield filter. Risks and benefits of surgery must be weighed against a 13% prevalence of PE in patients with propagating DVT. In 1 series examining extended indications for placement of an inferior vena cava filter,16 no deaths were related to filter insertion. A 4.5% wound complication rate was found, and there was a 4.5% incidence of pulmonary emboli following filter insertion, which is similar to the 5% incidence commonly reported by others.17 Additionally, 98% caval patency has been found after filter insertion in longterm follow- up.17 A patient with marginal pulmonary function who cannot sacrifice any pulmonary reserve may be the ideal candidate for insertion of an intracaval filter device when DVT has been found to extend proximally.

Since this is a retrospective study, a certain selection bias might exist for patients who undergo repeat duplex ultrasound for lower extremity DVT as compared to those patients who have only a single exam for the same problem. Perhaps patients with persistently swollen extremities with more pain and/or tenderness prompt physicians to obtain repeated duplex exams to assess the thrombus. Furthermore, persistently symptomatic DVT may be associated with more thromboembolic complications. Conversely, patients with multiple duplex exams for DVT may be more “health conscious” and wish to have repeated exams to follow the outcome of their thrombus. In order to account for such a selection bias, we randomly selected 105 patients from the same study period who had a single duplex exam demonstrating lower extremity DVT and compared them to patients with multiple duplex exams for DVT. Although patients without followup were older, there was no difference in anticoagulation parameters, prevalence of intracaval filter insertion, or high-probability V/Q scans. These findings tend to diminish selection bias favoring either poor or improved outcome associated with repeat duplex exams for lower extremity DVT, further substantiating our findings.

In conclusion, repeat duplex ultrasound identifies proximal extension of lower extremity DVT, which may be associated with an increased prevalence of high-probability V/Q scans. To detect this propagation, we have suggested repeat duplex ultrasonography 1 week and 1 month after the initial diagnosis.1821 Those patients with extension of thrombus despite anticoagulation may benefit from insertion of an intracaval filter device. Prospective, multicenter trials are required to obtain necessary numbers to further substantiate these findings.

REFERENCES

1. Meissner MH, Caps MT, Bergelin RO, et al: Propagation, rethrombosis and new thrombus formation after acute deep venous thrombosis. J Vase Surg 22:558-567, 1995.

2. Killewich LA, Bedford GR, Beach KW, et al: Spontaneous lysis of deep venous thrombi: Rate and outcome. J Vase Surg 9:89-97, 1989.

3. Murphy TP, Cronan JJ: Evolution of deep venous thrombosis: A prospective evaluation with ultrasound. Radiology 177:543-548, 1990.

4. Krupski WC, Bass A, Dilley RB, et al: Propagation of deep venous thrombosis identified by duplex ultrasonography. J Vase Surg 12:467-475, 1990.

5. Ramhorst B, Bemmelen PS, Hoeneveld H, et al: Thrombus regression of spontaneous thrombolysis with duplex scanning. Circulation 86:414-419, 1992.

6. Johnson BF, Manzo RA, Bergelin RO, et al: Relationship between changes in the deep venous system and the development of the postthrombotic syndrome after an acute episode of lower limb deep vein thrombosis: A one- to six-year follow-up. J Vase Surg 21: 307- 313, 1995.

7. Markel A, Manzo RA, Bergelin RO, et al: Valvular reflux after deep vein thrombosis: Incidence and time of occurrence. J Vase Surg 15:377-384, 1992.

8. Results of the Prospective Investigation of Pulmonary Embolism Diagnosis(PIOPED). Value of the ventilation/perfusion scan in acute pulmonary embolism. JAMA 263:2753-2759, 1990.

9. Salzman EW, Deykin D, Shapiro RM, et al: Management of heparin therapy: Controlled prospective trial. N Engl J Med 292:1046-1050, 1975.

10. Bauer G: Clinical experiences of a surgeon in the use of heparin. Am J Cardiol 14:29-35, 1964.

11. Carey LC, Williams RD: Comparative effects of dicoumarol, tromexan, and heparin on thrombus propagation. Ann Surg 152:919- 922, 1960.

12. Coon WW, Willis PW III: Thromboembolic complications during anticoagulant therapy. Arch Surg 105:209-212, 1972.

13. Holm HA, Finnanger B, Hartmann A, et al: Heparin treatment of deep venous thrombosis in 280 patients: Symptoms related to dosage. Acta Med Scand 215: 47-53, 1984.

14. Dhall D, Dawson AA, Mavor GE: Problems of resistant thrombolysis and early recurrent thrombosis in streptokinase therapy. Surg Gynecol Obstet 146:15-20, 1978.

15. O’Meara JJ, McNutt RA, Evans AT, et al: A decision analysis of streptokinase plus heparin as compared with heparin alone for deep-vein thrombosis. N Engl J Med 330:1864-1890, 1994.

16. Rohrer MJ, Scheider MG, Wheeler B, et al: Extended indications for placement of an inferior vena cava filter. J Vase Surg 10:44-50, 1989.

17. Greenfield LJ: Current indications for and results of Greenfield filter placement. J Vase Surg 1:502-504, 1984.

18. Berry RE, George JE, Shaver WA: Free-floating deep venous thrombosis. A retrospective analysis. Ann Surg 211:719-712, 1990.

19. Lively SA, Devitt DT, Elder T, et al: Early Repetitive duplex after diagnosis of deep venous thrombosis. J Vase Tech 26:278-280, 2002.

20. Passman MA, Moneta GL, Taylor LM Jr, et al: Pulmonary embolism is associated with the combination of isolated calf vein thrombosis and respiratory symptoms. J Vase Surg 25:39-45, 1997.

21. Wolf B, Nichols DM, Duncan JL: Safety of a single duplex scan to exclude deep venous thrombosis. Br J Surg 87:1525-1528, 2000.

Enrico Ascher, MD, Patrick S. DePippo, MD, A. Hingorani, MD, W. Yorkovich, RPA and S. Salles-Cunha, PhD, Brooklyn, NY

Vase Endovasc Surg 38:525-531, 2004

From the Division of Vascular Surgery, Department of Surgery, Maimonides Medical Center, Brooklyn, NY

Correspondence: Enrico Ascher, MD, Director, Division of Vascular Surgery, Maimonides Medical Center, 4802 Tenth Avenue, Brooklyn, NY 11219

E-mail: [email protected]

2004 Westminster Publications, Inc, 708 Glen Cove Avenue, Glen Head, NY 11545, USA

Copyright Westminster Publications, Inc. Nov/Dec 2004

Women have been shown to have a lower incidence of vascular disease when compared to men. However, the incidence of vascular disease increases as women progress through menopause and reaches an incidence similar to that of men later in life. Women with peripheral vascular disease often have a delay in diagnosis, a higher incidence of asymptomatic disease, and poorer outcome after interventions. The differences in outcome have been attributed to a number of factors such as anatomic and hormonal differences. It is thought that estrogen deficiency is at least partially responsible for the increased risk of developing vascular disease after menopause, and thus hormone replacement therapy has been considered as a method to prevent progression of vascular disease. Conclusions drawn from a number of recent studies have resulted in a divergent view of hormone replacement therapy (HRT). This article explores the risk of peripheral vascular disease in women and the current state of research on hormone replacement therapy. The aims of this review are to present current perspectives on gender differences in the pathogenesis and outcomes of peripheral arterial disease (PAD). The effect of estrogen on atherogenesis, the role it plays in modulating the vascular endothelium, and the current evidence of the effects of HRT on vascular pathology is discussed. The most recent HRT clinical trials and present evidence for the benefits and risks of postmenopausal hormone replacement therapy are summarized. The effect of these issues on treatment practices is explained and suggestions are made for future directions of HRT and PAD research.

Introduction

Peripheral arterial disease (PAD) affects millions of patients and is a significant cause of morbidity and mortality. Significant vasculopathies include atherosclerotic occlusive disease, carotid artery occlusive disease, and abdominal aortic aneurysm. These diseases increase in prevalence with age and are associated with the presence of vascular risk factors such as cigarette smoking, hypertension, diabetes mellitus, and menopause. Although the prevalence of PAD is lower in women than in men,1 up to 25% of women aged 55 to 74 years may be affected with PAD, which can lead to significant morbidity such as loss of limb, stroke, or cardiovascular death.2 Research has shown that women may be afflicted with more asymptomatic disease and that those with vascular disease have a 2- to 4-fold increase in cardiovascular morbidity and mortality. Furthermore, outcomes after vascular operations, including patency rates and myocardial infarction, appear to be worse for women than those for men.36

Over the past 2 decades, there has been a growing awareness of the gender differences in vascular disease. It has been postulated that delays in diagnosis, anatomic differences, and clinicians’ underestimation of the magnitude of disease in women may contribute to differential prevalence rates and differences in outcomes. Although anatomic variations are not modifiable by the clinician, there are certain areas for early intervention to help improve vascular outcomes in women. Practical solutions include offering patients opportunities for education, counseling for preventive risk factor management, risk factor modification, and aggressive medical treatment.

Medical treatment generally consists of lipidlowering agents, platelet inhibitors, and hormone replacement therapy (HRT). The benefits of the first 2 drug classes have been well documented; however, the use of hormone therapy for cardiovascular risk reduction in postmenopausal women has been more controversial with several recent large-scale clinical trials reporting conflicting results.7 The findings, although far from conclusive, have cast doubt on the benefits of this therapy for cardiovascular health, and many questions remain unanswered.

One of the difficulties in assessing the literature on vascular disease and its treatment in postmenopausal women is that dramatic changes in clinical practice and disease knowledge have occurred over time. We have limited our review to randomized clinical trials and observational studies published within the past 15 years (1990- 2004), and to systematic reviews of literature published before this time. The aims of this review are to present current perspectives on gender differences in the pathogenesis and outcomes of peripheral arterial disease. We then discuss the effect of estrogen on atherogenesis, the role it plays in modulating the vascular endothelium, and the current evidence of the effects of HRT on vascular pathology. The most recent HRT clinical trials and present evidence for the benefits and risks of postmenopausal hormone replacement therapy are summarized. Finally, we discuss how these issues affect treatment practices and suggest future directions of HRT and PAD research.

Peripheral Arterial Disease in Postmenopausal Women

The major known risk factors for the development of atherosclerosis are hyperlipidemia, smoking, hypertension, diabetes mellitus, obesity, and homocysteinemia. Atherosclerotic occlusive disease is a significant cause of morbidity and mortality in postmenopausal women. The onset of peripheral arterial disease in women usually occurs 10-20 years later in women than in men.8 Menopause, whether surgically induced or naturally occurring, is associated with an increased risk of arterial disease.

A number of studies have addressed gender differences in surgical outcomes for carotid artery disease, PAD, and aortic aneurysmal disease. The majority of these studies indicate that women have poorer outcomes following vascular operations compared to their male counterparts.4’8-11 Even though there is no clear explanation for these findings, a number of theories exist. These include gender- related structural differences, lack of physician awareness of the disease process, or a lower degree of suspicion in treating vascular disease in women. The question then arises about which strategies, both medical and surgical, can be employed by physicians to improve outcomes in female patients afflicted by arterial disease.

Carotid Artery Disease

Carotid artery disease is approximately 1.5 times more prevalent in men than women. However, in some studies (Table I) women appear to have worse outcomes compared to men. In a retrospective study, Sarac and colleagues12 reviewed 3,422 carotid endarterectomies performed at their institution. Their data demonstrated that women had a higher postoperative mortality rate and female gender was an independent predictor of postoperative stroke or transient ischemie attack. Similarly, a study by Lane et al9 (n = 361) indicated that men and women had similar stroke rates at 5 years but also found that women using HRT showed a trend toward increased stroke rate at 30 days. Furthermore, Ballotta et al13 reported confirmatory data showing that women have increased late occlusive events after carotid surgery. Although several other studies conclude that women have a similar risk of stroke following carotid revascularization, it is generally concluded that women with carotid artery disease have inferior outcomes when compared to male cohorts.

Table I. Studies comparing outcomes of carotid artery surgery in women versus men.

Peripheral Arterial Disease

Lower extremity peripheral arterial disease exists in 16-19% of the elderly population and is associated with an increased risk of cerebrovascular and cardiovascular events.8 Intermittent claudication is the most common presenting symptom for patients with PAD, but alone it is an insufficient diagnostic indicator for PAD. In a study of the detection of PAD, only 6.7% of female participants were found to have claudication.14 However, ankle brachial indexes (ABI) revealed that more than 35% of female participants had significant PAD, albeit no specific symptomatology existed. Additionally, women with intermittent claudication have been found to have a lower probability of successful conservative therapy, thereby necessitating surgical intervention.15 The University of Maryland reported that more than 50% of the women who present with claudication have limbthreatening ischemia.16 Many of these patients proceed directly to amputation without any opportunity for operation. Unfortunately, previous studies have shown that even women who are presented with the opportunity for intervention have far less successful outcomes than men after peripheral vascular reconstruction.4,10

A number of studies have examined gender differences in outcomes following lower extremity vascular bypass grafting. Multivariate analysis by Magnant et al10 revealed that the patency rates in women were significantly lower than in men at 3-year follow-up. Additional analysis has demonstrated that female gender is a significant independent predictor of graft occlusion.4 Overall, data from studies of various vascular operations for women with PAD show that women have a higher rate of occlusion and that gender is an independent factor in inferior outcomes of lower extremity revascularization procedures.

Abdominal Aortic Aneurysms

Women typically present with abdominal aortic aneurysms (AAA) at an older age and are less likely to receive elective or emergent operation for an AAA. Furthermore, women who do receive an operation have a 40-45% greater risk of dyin\g when compared to their male counterparts.11 Although it is not clear why women have worse outcomes, it is important that clinicians recognize this when discussing morbidity and mortality with their female patients.

Estrogen and Atherosclerosis

Women today spend nearly 30% of their life in menopause, and the number of menopausal women continues to increase as the population ages.5 Endogenous estrogen production diminishes with menopause. This decrease in a woman’s estrogen levels may have multiple detrimental effects on vasculature, overall lipid profile, and both the fibrinolytic and coagulation systems. The long-term effects of these physiologic changes may lead to accelerated atherosclerosis and an increase in clinically apparent cardiovascular, cerebrovascular, and PAD.

Estrogen plays numerous roles in the regulation of vascular endothelium, proliferation, and the inflammatory response. There are several different forms of estrogen; however, the main source of endogenous circulating estrogen is 17-β estradiol. Estrogen is a hormone that complexes with an intracellular receptor via passive diffusion through the cell membrane. There are 2 forms of the estrogen receptor: alpha and beta. Vascular cells and endothelial cells express both the α and β form of the estrogen receptor.17,18 The binding of estradiol to the receptor initiates the formation of a ligand-receptor complex, which then travels to the cell nucleus targeting specific regions of the genome, causing transcriptional activation of various target genes. Currently, estrogen is believed to activate more than 12 different target genes, which are associated with vascular physiology. The actions of estrogen on vascular endothelium and physiology are summarized in Table II. In this section, we discuss estrogen’s differing mechanisms of action and the role it plays in atherogenesis.

Table II. Summary of vascular effects of estrogen.

Cytokines

Estrogen has been found to play a large role in cytokine- mediated inflammation.19 Monocytes express surface estrogen receptors, implicating a role for estrogen binding and modulation of cytokine release in monocyte function. Furthermore, monocytes play an integral role in atherosclerosis development owing to migration into the vascular wall and release of proinflammatory cytokines. Interleukin-1 (IL-I), tumor necrosis factor-α (TNF-α), and interleukin-6 (IL-6) are believed to play an important role as mediators of the vascular inflammatory response. Initial studies on the relationship between cytokine levels and estrogen were observed in women who had undergone hysterectomy and oophorectomy. These patients showed higher levels of IL-I and TNF-a secretion in comparison to patients receiving HRT.20 Furthermore, clinical studies on cytokine levels have shown decreased IL-6 expression in women receiving HRT compared to a placebo group.21 For example, Anwar et al22 recently reported that TNF-α contributed significantly to down-regulation of growth factors that were important to smooth muscle cell function and integrity. In addition, TNF-α and IL-I initiate a complex cascade of leukocyte migration, adhesion molecule expression, platelet activation, and thrombogenesis.23 Conversely, a small subset of patients from the Women’s Health Initiative study were evaluated for the role of IL- 6, HRT, and chronic heart disease (CHD).24 This particular study identified no association between IL-6 and HRT; however, elevated IL- 6 levels were associated with a 2-fold increased occurrence of coronary heart disease (CHD) events.

HRT Effect on Lipid Profile

Estrogen has long been associated with elevated levels of high- density lipoprotein (HDL) and decreased levels of low-density lipoprotein (LDL). In a small patient cohort, Walsh et al25 identified the benefit of estrogen on cholesterol. These investigators found that oral estrogen increased HDL and decreased LDL, but transdermal estrogen did not have a similar benefit. Other groups have reached comparable conclusions concerning the benefit of HRT and lipid profiles.26 Moreover, estrogen is also believed to play a role in preventing LDL oxidation, which is implicated in atherosclerotic plaque development. Koivu et al27 demonstrated that the severity of atherosclerotic plaque deposition and the number of plaques were decreased in 101 postmenopausal women who used HRT. Furthermore, these authors concluded that there was a direct association between HRT and a decrease in LDL oxidation, which resulted in reduced plaque severity. In addition, the use of HRT has also been associated with changes in triglyceride (TG) levels. A recent study of 300 oophorectomized women demonstrated that TG levels increased overall in the group randomized to treatment with conjugated equine estrogen. However, in patients presenting with initially high TG levels, HRT actually decreased the levels.28 Conversely, other studies have demonstrated no difference in TG levels with HRT use.29 Clinical trials have shown that HRT can affect the serum concentrations of cholesterol in patients with preexisting cardiovascular disease. However, the benefits of HRT therapy have not been shown to alter the outcomes of cardiovascular disease. Herrington and coinvestigators30 conducted a study of 309 women with coronary artery disease and HRT. The HRT group had a significant decrease in the LDL levels and a corresponding increase in the HDL levels. However, the alterations of the cholesterol levels were not associated with progression or regression of coronary atherosclerosis.

HRT Effects on Coagulation

Embolie events are a major concern in cardiac or vascular disease. The role of estrogen in coagulation has long been a point of debate owing to divergent data. Initially, it was hypothesized that the use of estrogen following menopause correlated with increased factor VII and factor VIII levels.31 However, more recent data suggest that estrogen is involved with components of both the coagulation pathway and the fibrinolytic pathway. In their study, Post et al32 recognized that women using oral HRT therapy had an increase in fibrinolytic variables and a decrease in procoagulant variables. In addition, data exist to show that HRT causes increased resistance to activated protein G.33,34 This may partly explain the procoagulant effects of HRT.

There has been intense scrutiny on HRT and its effects on blood coagulation within the past few years after the HERS trial demonstrated an increased risk of venous thromboembolism with HRT treatment.35 In accordance, the Women’s Health Initiative (WHI) trial36 also demonstrated a twofold increased risk of venous thromboembolism in the HRT group versus placebo group. Additionally, another study also concluded that women with a known procoagulant or hypercoagulable state should not use HRT. Female patients in this trial who had factor V Leiden mutation had a 15-fold increased risk of thrombolic events with HRT therapy.37

HRT: Benefits and Risks

The term HRT is most commonly used to describe hormone therapy consisting of conjugated equine estrogen and medroxyprogesterone acetate. Currently, HRT is used by millions of postmenopausal women. The major benefits include relief of vasomotor symptoms, sexual dysfunction, and fatigue, and a decrease in fracture risk. There was also the belief that HRT would have cardioprotective benefits. Preliminary investigations of the cardioprotective effects of estrogen were encouraged by the observation that as women passed menopause and reached postmenopausal status, the incidence of CHD approached that of men. This was hypothesized to be due to decreased circulating levels of estrogen.38 Much of the initial excitement over the cardioprotective benefits of HRT was motivated by studies demonstrating the beneficial results of hormone replacement therapy following the onset of menopause.39 These findings supported animal and basic research demonstrating protective effects of HRT on acute coronary outcomes40 as well as the beneficial effects of estrogen on lipid profiles.

Observational studies have suggested that HRT might prevent cardiovascular disease. For example, as part of a 10-year follow- up, the Nurses Health Study (n = 48,470) found a 44% relative risk reduction in the incidence and mortality of major coronary disease in individuals taking HRT.41 This reduction in incidence and mortality from coronary artery disease (CAD) was greatest in women with multiple risk factors for cardiovascular disease. These women were found to have a 50% reduction in all-cause mortality with hormone replacement therapy compared to an 11% reduction in risk in women without risk factors for CAD. In another study, Grodstein et al39 also concluded that women who use HRT for many years have a decreased risk of CHD. A systematic review of 25 published studies concluded that HRT confers cardioprotective benefits to women using unopposed estrogen (relative risk of 0.7O).42 In a subset of 7 studies from this meta-analysis, estrogen plus a progestin offered a risk estimate of 0.66.

However, observational studies may have been confounded by selection bias. Hemminki and McPherson43 reviewed 22 randomized trials of short-term estrogen therapy in which cardiovascular events were listed only as reasons for dropping out of a study or as an adverse event. These women were not included in any study’s final analysis, all of which demonstrated positive effects of estrogen therapy.42,43 Contradictory results have also been observed in peripheral artery disease and HRT treatment.44

Unlike previously published observational studies, recent randomized controlled trials do not show benefits in terms of secondary prevention of cardiovascular disease. In fact, there may be an increase in risk of cardiac and vascular events, especially during the first year of treatment. For example, the most recent statements from the Women’s Health Init\iative (WHI) and the Heart and Estrogen/Progestin Study (HERS), both large-scale, multicenter trials, report a failure to identify any benefit associated with the use of HRT for secondary prevention of cardiac events in postmenopausal women.36,45 The WHI (n = 16,608) was a randomized, placebo-controlled, double-blind trial designed to identify the potential risks and benefits of HRT. Results from the WHI, which were published in 2004, indicated a significant increase in the risk of adverse clinical vascular events in women receiving HRT compared to placebo.46 Part of the clinical trial was stopped early after results showed that estrogen-progestin combination resulted in increased risks of developing invasive breast cancer, heart disease, stroke, and thrombotic events.

Table III. Studies comparing HRT and effect on vascular disease.

In the HERS study35 (n = 2,763) women were randomized to receive HRT (estrogen plus continuous medroxyprogesterone acetate) or placebo. No reductions in adverse cardiovascular events were observed after a mean follow-up of 4 years. Furthermore, the risk was actually slightly increased during the first year of treatment, and thus, the conclusion was made that there was no benefit of HRT on vascular outcomes. At the 6.8-year follow-up point, the study was halted early owing to an unacceptable increase in the number of adverse clinical events for venous thromboembolism, stroke, coronary heart disease, and breast cancer. The HRT group had a 29% increased risk of coronary artery disease and a 21% increase in venous thromboembolism.35 Other studies have found that hormone therapy is not consistently associated with a reduced or increased risk of stroke.47

The question remains whether estrogen may play a differing role in the periphery. Currently, a significant number of clinical trials have assessed effects of HRT on PAD (Table III). One of the first large studies, published in 2000 as part of the Postmenopausal Hormone Replacement Against Arteriosclerosis Trial, looked at the progression of carotid artery disease and HRT. After 2 years, the investigators found there was no difference in the carotid artery intimai thickness between the treatment and control group.48 The second study focused on femoral artery disease and also came to the conclusion that HRT has no benefit on PAD.49 In the Estrogen Replacement and Atherosclerosis (ERA) study (n = 309), both unopposed and opposed HRT did not influence the angiographie progression of coronary atherosclerosis.30 Lastly, in a subset of patients from the HERS trial, Byington et al50 also showed that HRT treatment did not decrease the overall intimai medial thickness of carotid artery disease in comparison to the control group. Similar results have been shown by others: that of no association between the use of HRT and carotid disease regression in postmenopausal women.51’52

All the previously mentioned studies were conducted with estrogen and progesterone HRT. Differing results have been observed with unopposed estrogen therapy. For example, Hodis and colleagues53 conducted a 2-year trial using unopposed estrogen therapy in young postmenopausal women and reported decreased progression of atherosclerotic disease in the carotid arteries. In addition, use of transdermal estrogen has shown a benefit in progression of carotid artery atherosclerosis.54 Finally, study length may also play a role in the conflicting results from these studies. The Rotterdam group demonstrated a 52% reduction in PAD in postmenopausal users of HRT. However, patients who used HRT for less than 1 year did not have any significant reduction in atherosclerotic progression.44

Conclusion

Women appear to have inferior outcomes following major vascular surgery even though there is an overall lower incidence of vascular disease in women compared to men. Despite evidence suggesting cardioprotective effects, estrogen or hormone replacement therapy cannot be recommended for all postmenopausal women. Studies and the media continue to provide conflicting and confusing information. Widely publicized conflicting results have altered both clinical and public opinions of the risks and benefits of HRT for cardiovascular protection. The studies presented in this review indicate potentially no benefit of combined estrogen-progesterone HRT for primary or secondary prevention of vascular disease. Furthermore, HRT may be associated with adverse clinical events and outcomes in certain women. Combination HRT (estrogen-progesterone) reduces the beneficial effect of estrogens on coronary arteries, increases the progression of coronary artery atherosclerosis, increases the thrombotic potential of atherosclerotic plaques, and may significantly lower high-density lipoproteins, thereby decreasing the cardioprotective benefit of estrogen therapy. However, unopposed estrogen may provide some degree of vascular protection. Preliminary findings from clinical trials suggest that estrogen-only HRT may be a beneficial treatment. This information merits additional research to assess the impact of estrogen alone on PAD.

As life expectancy increases, women can expect to live a considerable portion of their lives after menopause. When considering treatment options for preventing vascular disease, it is important to address not only benefit-versus-risk ratios but also how this treatment will affect the patient globally. Quality of life issues go beyond statistics and study findings. The quality of many women’s lives has been dramatically improved through the use of HRT. Without HRT, many women feel miserable, exhausted, and unable to cope with the symptoms of menopause. Yet, there are important vascular risks to consider in considering the use of HRT. Currently the use of HRT should be planned on a patient-by-patient basis and should be contraindicated in patients with hypercoagulability disorders. Future studies should assess the impact of estrogen alone on peripheral vascular disease and on whether the duration of HRT treatment plays a role in halting the progression of atherosclerosis.

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50. Byington RP, Furberg CD, Herrington DM, et al: Heart and Estrogen/Progestin Replacement Study Research Group. Effect of estrogen plus progestin on progression of carotid atherosclerosis in postmenopausal women with heart disease: HERS B-mode substudy. Arterioscler Thromb Vase Biol 22:1692-1697, 2002.

51. Nabulsi AA, Folsom AR, White A, et al: Association of hormone- replacement therapy with various cardiovascular risk factors in postmenopausal women. The Atherosclerosis Risk in Communities Study Investigators. N Engl J Med 328:1069-1075, 1993.

52. Angerer P, Stork S, Kothny W, et al: Effect of postmenopausal hormone replacement on atherosclerosis in femoral arteries. Maturitas 41:51-60, 2002.

53. Hodis HN, Mack WJ, Lobo RA, et al, and the Estrogen in the Prevention of Atherosclerosis Trial Research Group: Estrogen in the prevention of atherosclerosis. A randomized, double-blind, placebo- controlled trial. Ann Intern Med 135:939-953, 2001.

54. Le Gal G, Gourlet V, Hogrel P, et al: Hormone replacement therapy use is associated with a lower occurrence of carotid atherosclerotic plaques but not with intima-media thickness progression among postmenopausal women. The vascular aging (EVA) study. Atherosclerosis 166:163-170, 2003.

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Liz Nguyen, MD, Debra R. Lues, BA, Peter H. Lin, MD, and Ruth L. Bush, MD, Houston, TX

Vase Endovasc Surg 38:547-556, 2004

From the Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston; and The Methodist Hospital, Houston, TX

Correspondence: Ruth L. Bush, MD, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston VAMC – 2002 Holcombe Blvd (112), Houston, TX 77030

E-mail: [email protected]

2004 Westminster Publications, Inc, 708 Glen Cove Avenue, Glen Head, NY 11545, USA

Copyright Westminster Publications, Inc. Nov/Dec 2004

A NEW device that destroys tissue with sound waves has been successfully used to treat women with uterine fibroids.

The technology offers women an alternative to other treatments, including hysterectomy. British doctors, who have so far used the treatment on 100 women with fibroids, say it has huge potential for many of the one in four women who suffer with the condition.

Uterine fibroids are benign tumours that grow from the muscle beneath the lining of the womb. They usually go away after menopause.

The causes are not known and symptoms can vary. Up to half of all women with fibroids have heavy periods, and fibroids can also affect the shape of the uterus, making it more difficult to conceive. They can cause miscarriages and painful menstruation.

It is estimated that one in four women suffer with uterine fibroids, but that as many as 77 per cent of women may have the condition but be unaware because of the lack of obvious symptoms.

Treatments include hormone therapy, surgery to remove the growths, and hysterectomy. It is estimated that more than a quarter of women with problems may eventually require a hysterectomy – the most common procedure for treatment of the disease.

Each year around 45,000 women in the UK have a hysterectomy, requiring a recovery time of six to eight weeks. For a woman of reproductive age, it means that she will no longer be able to have children.

The new treatment on trial at St Mary’s Hospital, Paddington, offers a painless alternative and is carried out as an outpatient procedure. St Mary’s is the only centre in the UK taking part in an international trial.

The technology harnesses two systems: a magnetic resonance imaging or MRI machine to map the position of the fibroids and monitor temperatures in the womb, and a focused ultrasound beam that heats and destroys the fibroid tissue.

It is the first time these two systems have been combined, and the first time an MRI has been used to monitor tissue temperature.

The patient lies inside a scanner which provides three- dimensional images of the fibroid and surrounding tissue. These images are then used to target ultrasound waves at the fibroid. These raise the temperature in the fibroid, cutting off the blood supply and killing the tissue.

The scanner also carries out thermal imaging so that the whole procedure can be carefully monitored.

Research shows that the treatment is highly effective. In one study, the device was shown to reduce uterine fibroid problems for 71 per cent of women.

Researchers say that the technology has potential in other areas, too.

‘The ability to destroy a tumour from inside the body in a completely noninvasive manner represents a major advance in surgical procedure and strong promise for the treatment of a variety of tumours,’ said Professor Wladyslaw Gedroyc.

Sally Monck, 45, was one of the first to have the treatment. She had been suffering from heavy periods and severe period pain. ‘My doctor arranged an MRI scan, which showed that the fibroid was quite large – about 10 centimetres,’ she said.

‘I had to have hormone therapy, which involved implants for three months, because they wanted to shrink the fibroid.

‘I then had another scan, and they felt that it was small enough to have the ultrasound treatment. I felt fine almost straight way. There was no pain or any other symptoms.

‘A hysterectomy would have meant invasive surgery, and also have prevented me for driving for several weeks – which, with two boys to ferry around everywhere, would have been a problem.

‘I have since had another scan and everything is fine. It was an incredible experience.’

Dr. Ann Kay Lagarbo’s view of the world changed the night the Covington pediatrician found that faith could be more powerful than the medicine she practices.

Her grand-niece, 6-year-old Caroline Crouch, had just spent the past two days in Children’s Hospital in New Orleans having seizures caused by encephalitis.

Logarbo’s medical training – and that of the physicians attending to Caroline – told her that the little girl was probably brain- damaged, unable to breathe for herself, and she would soon die.

Logarbo said she knew medicine had done all it could do, and Caroline’s fate was in the hands of a Higher Power.

More and more, medicine acknowledges that faith and spirituality can be powerful tools in healing the sick. What happened to Caroline and Logarbo illustrates the question of what role, if any, does faith play in health and healing: Did the power of prayer pull Caroline from the brink of death in August three years ago? Or, was she just another example of the human body’s potential to recover from serious illnesses?

Deeply religious, Crouch’s extended family began to pray for Caroline. Logarbo’s mother-in-law, Ouida Logarbo from Baton Rouge, suggested prayers to Father Francis Xavier Seelos.

Logarbo had never heard of the Bavarian Roman Catholic priest who died of yellow fever in New Orleans in 1867. But others had heard of healings attributed to Seelos’ intercession, and the Vatican declared him blessed in 2000, one step away from sainthood.

The Seelos Center at St. Mary of the Assumption Catholic Church in downtown New Orleans has volunteers who offer prayers on behalf of the sick.

Catholics believe that special people, such as saints and the blessed, can act as intermediaries between people and God and make prayers stronger, said the Rev. Byron Miller, who is working to get Seelos declared a saint.

Logarbo said she believes Caroline’s recovery is a miracle – and it could be the one that elevates Seelos to sainthood.

“Caroline was going to be left … in a vegetative state” or completely bed ridden, Logarbo said. “I am supposed to preserve life at all costs,” she said, but said she began to feel that God should just take the child. The best prognosis she could see was dim: breathing apparatuses and feeding tubes for the rest of Caroline’s life.

“Caroline’s mother was just certain that God was going to step in,” Logarbo said.

On Monday afternoon, Logarbo tracked down the Seelos Center. All of their blessers were busy until the next day, but they began praying immediately.

Months later, when Logarbo looked at Caroline’s medical records, she could see what doctors couldn’t – Caroline’s vital signs began to improve in the same hour.

That night, “we were prepared for the worst” and about 1:30 a.m., Logarbo had the experience that she says changed her life.

“I receded to a corner and I told God, ‘I can’t do this any more. I cannot go on like this. It is not that I don’t believe You can save this child. Honest to God, there was no one who could save the child. The only way she is going to survive, the only way she is going to be given back to us, is God’s intervention.'”

Suddenly, Logarbo felt an “excruciating” pain in her chest and shortness of breath – and she thought it was ironic she could have a heart attack inside a children’s hospital. When she sat up, the shortness of breath disappeared. “There was this deep, deep, deep sensation in my chest. I didn’t hear anyone but what I felt was: Get up now and go see.”

“I felt this pull,” she said, and she left her sleeping family in the waiting room.

In the ICU, Caroline “had multiple tubes coming out of every orifice.” Logarbo leaned down to her face and said, “Caroline, I don’t know why I am here except God told me to come talk to you.”

“Your mom has been telling you to follow the angels, they are going to bring you back to us.”

She asked Caroline to help her show her mother there was hope.

Logarbo asked her to blink her eyes if Caroline could hear. After about a minute of asking, Logarbo said her great-niece faintly blinked.

“Her eyelashes fluttered. I wasn’t even sure I saw what I saw.” A respiratory therapist standing next to the little girl asked Logarbo to ask again.

“With the greatest difficultly, she fluttered her eyes and opened them just a little so slightly, so I could see her corneas. Being the ‘Doubting Thomas’ I am, I asked her to do it one more time.

“She moved her head about an inch, opened her eyes and closed them. At that point, everyone in the ICU started crying. We knew, at least at that point, the child could hear me.”

Logarbo ran to the waiting room with the news. Caroline’s mother, Mary Ann Crouch, “had the calmest look on her face. She said, ‘I told you, I told you.'” That was about 2 a.m.

About 9 a.m. the people from The Seelos Center came by to bless Caroline with a cross.

“She opened her eyes, followed the cross – from her head to her feet and from her left shoulder to her right shoulder.” Within a few minutes, a doctor conducted a neurological exam and “she started responding to commands. Move her leg. Move her arm,” Logarbo said.

By 5 p.m., the neurologists decided Caroline would live, but would probably require a year in the hospital, learning to walk and talk again.”

“On the Feast of the Assumption, which was eight days later, Caroline was discharged, walking and talking,” Logarbo said.

A week after being discharged, she was back in school. Today she is an honor roll student, learning to play piano and in every way healthy.

“Medically, there was no explanation for the recovery of Caroline,” Logarbo said.

Eric Ford of the Tulane Medical School in New Orleans is studying the link between faith and healing.

“Many studies have found a very strong, positive correlation between both spiritual and religious activities and health status. People who go to church more often tend to be healthier on average,” Ford said.

As the Baby Boom begins to enter the final phases of life -aging – there is more interest in such issues, Ford said. Research shows that as society ages, people become more spiritually attuned.

At the same time, those who practice medicine are asking more questions about the role of spirituality in healing and health. That’s because as more studies are done, more conclude, or at least point to, the idea that spirituality and religiosity (which is more measurable), have a role to play in health and healing, Ford said.

Even the National Institutes of Health shows a vigorous interest in the topic, with its alternative medicine branch funding more and more studies, Ford said.

For 2005, the National Center for Complimentary and Alternative Medicine has been increasing its funding for studies linking medicine and religion and faith from $1.4 million in fiscal year 1999 to $3.2 million for the 2003-2004 fiscal year.

“The problem is explaining why there seems to be a link – since the spiritual is difficult to measure,” Ford said.

There are “confounding” factors, such as those who go to church often lead a healthier lifestyle, may be more affluent, and seek health care more often, and other social and demographic factors that need to be controlled to make the observations better fit the rigors of scientific study, Ford said.

A Johns Hopkins study reported last year that there has been a resurgence of clinical and behavioral studies that have begun to clarify how spirituality and religion can contribute to the coping processes used in experiences of illness.

The study said patients wanted physicians to consider their spiritual needs in the course of treatment. The Rev. Don Owens, the chaplain for Tulane University Medical School, said some hospitals are taking patients’ spiritual history as well as their medical history.

Dr. Harold G. Koenig at Duke University’s Center of Spirituality, Theology and Health, said there is a growing science base showing a connection between religion and spirituality in both mental health and physical health as well as better disease outcomes. “There is a whole lot of smoke here,” he said.

“We are really on the beginning edge of medicine addressing these issues.”

“Religious people have lower blood pressure, better immune function and greater longevity,” he said.

“Lots of studies are beginning to show that people who have better immune functions do better with different health outcomes,” he said. Lowered immune systems can affect everything “from catching cold … to the spread of cancer.”

Andrew Skolnick, executive director of the Commission for Scientific Medicine and Mental Health (a part of the Center for Inquiry), said many such studies that show prayers to “evoke supernatural powers” often fall under what he calls “voodoo science” where methodology is poorly controlled.

“In some cases, they are misleading, deceptive and possibly fraudulent,” he said.

However, there has been a resurgence of studies that look at people who seek faith-based support and “and there is good solid evidence that people who have good social, psychological, spiritual support do better” in health outcomes, especially in those with terminal diseases having a better quality of life, said Skolnick, who was associate news editor for the Journal of the American Medical Association’s Medical News in Perspective.

The reason for the cause and effect is still difficult to pin down.

Often medication takes times to get the right levels, so Caroline’s recovery “may be more of a coincidence.” An individual case such as Caroline’s “you can’t conclude much from that … one way or the other because there is no way to demonstrate what was the cause of her improvement,” Skolnick said.

In many cases, people who are prayed for still die, he said.

Rabbi Barry Weinstein of Congregation B’nai Israel said “in Jewish life we are encouraged … to properly take care of ourselves … your body is God’s creation, the vessel of the soul.”

“I would advise you – and myself as a survivor of prostate cancer – to do the following: attend the synagogue or worship, meet with your rabbi or priest for support in the spiritual struggle to recover from illnesses” and to pray for the doctors, science and medicine who are helping a person.

As a cancer patient, Weinstein was told to keep a positive mental attitude, and he used his faith and religion to do so.

“Bishop (Alfred) Hughes came to my home when I learned I had prostate cancer and prayed with me” along with the Rev. Jeff Bayhi, of the Catholic Diocese of Baton Rouge, and the Rev. Chris Andrews, pastor of First United Methodist Church, all of whom Weinstein counts as friends.

“It was very helpful and very spiritual for my family.”

“To know there are people out there who care for us is a tremendous lift,” Weinstein said of having even strangers pray.

Faith in the possibility of being healed is also illustrated in Baton Rouge on the last Sunday of each month when people attend a healing Mass held after the noon Mass at St. Joseph Cathedral. The Father Seelos Mass is held for people who would like to be blessed with a relic holding a fragment of Seelos’ bones.

Marie Schroeder stayed after Sunday Mass in September to be anointed.

“I feel like I needed this anointment, she said.”

Schroeder suffers from fibromyelitis syndrome and has a degenerative disk in her back.

“This has given me the strength to deal with the pain and offer it as a prayer to God. If he so wishes, he might” stop the pain, she said.

Lena Baptiste limped away from the Rev. Gerard Young’s anointment. “I thought it might help me,” she said. “They say faith heals. I don’t think it is the (healing) service itself, but the faith you have in God.”

Preston Edwards, publisher of Black Collegiate Magazine and two Web sites, said he is certain Father Seelos cured him of cancer.

Four years ago, Edwards had a lymph gland removed and 10 days later received the shocking news – he had cancer of unknown origin. A cancer somewhere else had traveled to the lymph gland.

“I was told that I had a 40 percent chance of living for one year and a 10 percent chance of living two years – with treatment.”

Before he left to take a test to identify where the cancer was in his body, one of his employees slipped him a card. Inside was a Seelos relic, a small piece of cloth that had been used to bind Seelos’ bones when he was exhumed, and a Seelos prayer card.

While undergoing the scan, Edwards rubbed the cloth on his surgical scar and repeated the prayer, asking Seelos’ help.

“I just about had it remembered,” he said of the number of times he repeated the prayer during the 30-minute procedure.

A few days later, his doctor told him the PET scan did not detect cancer anywhere in his body. Edwards said he still goes to his doctor every quarter to get checked because his physician is convinced that Edwards had cancer, and he wants to keep a close eye on his patient.

Edwards said he recently told a dermatologist who looked for his lymph gland scar and couldn’t find it. “She said, ‘Who is your surgeon?’ I said, ‘God is.'”

Edwards is a volunteer for The Seelos Center. He carries a small relic wherever he goes – until he gets a chance to tell his story and pass on the relic.

Meanwhile, Caroline recently underwent testing requested by the Vatican in its determination of whether the healing was a miracle. If it is, Seelos will be on his way to becoming Saint Seelos.

More information

Check out www.2theadvocate.com for more about “Faith and Healing”:

Advocate photos in narrated photo galleries.

Caroline Crouch playing the piano.

Message boards discussing “Faith and Healing.”

Advocate reporter Mike Dunne’s report prepared for WBRZ-Channel 2.

Links to the National Institutes of Health, Duke University and more.

The “Faith and Healing” stories in today’s Advocate are a joint project of the newspaper, WBRZ-TV and www.2theadvocate.com WBRZ will air a segment on this topic at 10 p.m. Sunday. The Web site has additional information. Click on the “Faith and Healing” button.

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Culture of Patriarchy in Law: Violence from Antiquity to Modernity Orit Kamir, Every Breath You Take: Stalking Narratives and the Law. Ann Arbor: University of Michigan Press, 2001. 245 pages. $55.

Stalking is a social behavior of repeatedly watching and imposing surveillance on the victim (usually a woman) in ways that intimidate her autonomy. On April 3, 2001, a jury in Miami, Florida, had found a 46-year-old man guilty of stalking the tennis superstar Martina Hingis. He sent her flowers, faxes, and letters, and then traveled to her home in Zurich to tell her how much he was emotionally attached to her, after he had seen Hingis on television. Her friends repeatedly told him that Hingis would not like to meet him, but the stalker had insisted and followed her all around the world where she played tennis. Hingis claimed in court that she was fearful of being stalked by a “crazy” fan.’ Other heroes of cultures, such as film and music stars, have experienced similar events that are constitutive parts of cultures that frantically consume sex and pornography (Friedman 1990).

Male stalking of women is a common practice. In countries including Australia, Belgium, Canada, Denmark, Ireland, Israel, Japan, Netherlands, Norway, the United States, and the United Kingdom, male stalking has become a prevalent phenomenon that has attracted the attention of feminist nongovernmental organizations (NGOs) and activated antistalking legislation (Malsch 2000; Mullen, Pathe, & Purcell 2000). Figures reported by U.S. federal and NGO sources about stalking are staggering: 8% among women and 2% among men in the United States have been stalked in their lifetime. Most of them (77 and 64%, respectively) knew their stalker and had had a relationship with them. In 1999, for example, more than 1 million American women were stalked. In 2003, Congress reported about 1,006,970 women and 370,990 men who were stalked annually in the United States. Worse, 76% of femicides committed by intimate partners, and 85% of attempted femicides by intimate partners, involved at least one incident of stalking within one year of the (attempted) murder.2

Orit Kamir’s book on stalking narratives and the law is well integrated into law and society scholarship. Though it is primarily stimulated by contemporary U.S. experience, the book expounds the historical sources of stalking as a transnational and transhistorical problem. It profoundly analyzes stalking as male violence embedded in patriarchy: “[j]udging by the statistical data that has just begun to accumulate, stalking seems to serve as a pattern of abuse, perpetrated by men on women they know. Its consequences seem to be significant. It may, therefore, justify legal intervention, including new legislation and enforcement policies” (2001:11).

Unexpectedly, the book begins with examination of the archetypal female stalker, Lilit, a goddess in antiquity, to explicate how the transhistorical subordination of women to men has led to the characterization of independent and assertive women as stalkers. Then it dwells on female stalkers throughout the medieval ages until modernity. Only in subsequent chapters does Kamir explore the phenomenon of male stalkers and its most violent aspect of serial killings. As I explore below, she conceptualizes both types of stalkers as major phenomena of patriarchy. The last two chapters deal with legal moral panic, namely public hysteria, and culture as perceived through stalking mythologies. Kamir employs narration analysis of intergenerational mythologies and demonstrates how they have constructed patriarchal culture and law. It accords with critical feminist studies that understand patriarchy, and male violence, as a fundamental structuring logic in Western thought and practices. Below, I review these topics in a focused theoretical context that I offer.

Rooted Violence and Narrow Public Policy of Legal Responses

The book conceives stalking as neither an exclusively modern phenomenon nor a deviant behavior, but as a transhistorical embedded violent behavior. Nearly all stalkers are ordinary men, constructed in and reproduced through patriarchy, who use stalking to control women (2001:210).

From tribalism to modernity, despite egalitarian illusions and some achievements in modernity, women have largely been subordinated to male control and violence, as indicated in economic inequality, political underrepresentation, cultural marginalization, and sexual violence (Abu-Lughod 1995; Barzilai 2003; Butler 1990; Cuomo 1998; Ferguson 1995; Fraser 1997; Freedman 1995; Greenberg, Minow, & Roberts 1998; Shachar 2001; Young 1990; Ranyard West 1998). Male violence against women, with its multifarious appearances, has internationally transcended specific religions and local traditions (Amnesty International 2001; Shalhoub-Kevorkian 2002).3 Even in Western societies, which articulate liberal egalitarianism, male violence against women is widespread.4

Stalking as a type of violence should be theorized as part of multidimensional power relations in patriarchy.5 A man who holds the power of control holds the violent means to impose his desires on a woman.6 She will not do what he wants, against her better interests, unless he violently controls her behavior. His violent control does not need to be physical. Due to biology, most men are physically stronger than most women (Gat 2000). Yet he controls her not necessarily because he is physically stronger; rather, he enjoys the patriarchal society that makes her dependent on him (Panichas 2001). He can control her violently through means such as forced domestication and economic dependence (Fraser 1997; MacKinnon 1993; Minow 1993; Polan 1993; Rifkin 1993; Shachar 2001; Robin West 1993; Young 1990). Violence is not only to beat and harass, even to kill; violence is the power to discipline the victim through, inter alia, cultural and economic means.7 The ability of X1 to force X2 to behave in contradiction to the essential interests of X2 is contingent on X2’s vulnerability to X1’s intimidation. In a gender- stratified setting, the intimidation inflicted by X1 upon X2 is further empowered since X1 is significantly supported by a patriarchal culture.

Despite some success of feminism inside and outside the courtroom, basic practices of male-dominated societies against women- marginalization, domestication, discrimination, subjugation, displacement, underrepresentation, sexual exploitation, and violence- have not significantly been altered even when globalization has generated expectations of liberal egalitarianism (Calavita 2001; Merry 2001).

However, the common legalistic approach to stalking has not comprehended it as a prevalent, violent intimidation. Following public panics due to serial killings, and subsequent reactions of anti-stalking legislation, legal scholars, psychologists, and psychiatrists have erroneously perceived stalkers as deviants, either erotomaniacs or obsessives, instead of recognizing stalking as violence rooted in patriarchy (Kamir 2001:198-202).

Toward the end of the 1970s, the press in the United States, heavily influenced by Taxi Driver (1976) and similar films, depicted male stalkers as serial killers. Most serial killers were men obsessed with sexual fantasies and pornographic material, and they stalked their female victims before killing them. Around that time, Kamir keenly shows, the term stalking, previously popular in the United States from the male sports of hunting and boxing, became a social category that labeled men who intruded and fatally attacked women. Referring to the immediate etiology of the category of stalking, Kamir notes:

Thus, through the media and professional literature, Travis Bickle, Son of Sam, and Ted Bundy were defined as stalkers and serial killers. Their stalking was established as an essential element of their serial killing, and their serial killing was portrayed as the ultimate expression of their stalking. They became a social category, a type of people who shared a scientific profile. Closely associated with the traditional imagery of the male stalker, the serial-killing stalker became a mediating social category: at a time of deep social anxiety, it associated a small, defined group of people with the archetypal male stalker. (2001:153)

The case of Robert Bardo exemplifies the insufficiencies in legalistic categorizations of stalking. The murder of California actress Rebecca Schaeffer by her male stalker, Bardo, led to the first anti-stalking legislation in the United States (California Penal Code 1990). Stalking was simply defined as the violence of deviant, mentally disturbed men. Its historical cultural context- profoundly analyzed by Kamir-was absent in that legislation. In reacting to the public hysteria, the California legislature defined stalking in a very narrow way. Only a malicious intent and a repeated behavior that placed the victim under a reasonable fear for life or of great bodily injury were defined as unlawful stalking. Correspondingly, Kamir argues, most anti-stalking legislation in the United States reflected the public panic concerning serial killers, while much more frequent and non-murderous incidents of male stalking were neglected in state law. Anti-stalking legislation was affect\ed by public panic and hysteria, and did not respond to the sources of women’s subjugation to violence. In that sense, state law signals the structuring logic of patriarchy that transcends and undermines attempts at in-depth sociolegal change. Reforming a society requires knowing more about the place of mythologies in our normative and practical world.

Mythologies of Stalking as Culture Based in Law: Transmissions and Conjunctions

Kamir’s major contributions are embedded in her analysis of the transhistorical and intergenerational mythologies of stalking. The focus on mythological genealogy explores how stalking was dehistoricized and displaced from its context in contemporary state law that upholds patriarchal power relations. While state law has presumed that stalkers should be punished as individuals who have deviated from egalitarian behavioral norms, Kamir intends to deconstruct these legal categories of stalking and to look into the sociopolitical origins and contexts of male intimidation. She follows feminist theorists such as MacKinnon and Dworkin (1997) who have aimed to challenge state law, and its ideology, through its deconstruction as patriarchal.

Since culture and the sociopolitical forces that shape it are based in law, and not only interact with law (Umphrey 1999), Kamir is correct to trace the cultural genealogy of stalking through mythologies. Since mythologies are broad cultures embedded in the public consciousness, they enable us to better comprehend how legal ideologies, as the normative motives of state law, are constituted. Scholarship of culture in law is characterized by diverse methodologies: public opinion polls (Gibson & Caldeira 1995; Gibson & Gouws 1997), neo-institutional perspectives on courts and norms (Epstein & Knight 1998; Gillman 1997), daily stories explored through interviews (Ewick & Silbey 1998), and narration analysis (Brigham 1998; Merry 2001; Umphrey 1999; Yngvesson 1997). Public opinion polls may detect current collective trends of articulated attitudes and beliefs, which may indicate some veiled social proclivities. They lack historical etiological depth, however, and do not necessarily explicate daily practices. Interviews with ordinary people may expound more intricate stories about law and culture and allow more insights into daily practices. That methodology is highly dependent on the questionnaire and its structure, whilst the mode of interactions between the respondent and the interviewer is crucial. Even so, interviews with common people who are asked about law in their daily life are illuminative, but they lack historical depth and only partially reflect practices.

Kamir uses narration analysis and investigates popular mythologies through poems, books, plays, songs, religious texts, and films. Films have had a special effect: Since they are available via television, video, DVD, and the Internet, they can greatly influence the collective consciousness.8 As Austin Sarat, in his seminal Law & Society Association Presidential Address, pointed out, no in-depth study of law and society is possible without an explication of films’ influence on constructing legal cultures (Sarat 2000). Since films are broadly watched, easily accessible, and powerfully visualize daily practices, their effect on collective consciousness and behavior may be especially crucial (N. Rosenberg 2001; Rosenfield 1993; Stoneman 2000).

The book exceeds the possible differences between various types of texts in order to construct a solid theme about mythologies in law.9 Such a methodology has two major advantages. First, the book goes deeper than explaining public mood and rhetoric and explicates how culture has been practiced. Further, it discusses intergenerational transmissions and historical transformations of mythologies. Second, it explains the legalistic effects of public hysteria that erupts in reaction to daily events and equally explicates which cultural materials have constructed a legal ideology that has separated stalking from its patriarchal context. Myths, referring to assertive women as stalkers and to male stalkers as deviants, may not only derive from legal ideologies, but once practiced they may constitute legal ideologies.

Compared with studies that rely on personal interviews (Kostiner 2003), narration analysis may overshadow the possibilities of causal constitutive relationships between mythologies and practices. Since the book aims to cover stalking stories along five millennia, the ability to unveil causal constitutive relationships between meta- stories and practices is even more problematic. Yet Kamir’s analysis of folk mythologies is sensitive to historical developments of myths that are embedded in legal categories. A similar methodology has been used to study criminal procedures and the constitutive influences of narratives of criminal responsibility (Umphrey 1999). That methodology enables us to see that each mythology is a certain layer in an open-ended, potentially circular historical process. Each mythology points to identities that may constitute practices of stalking.

Hence, the book provides unexpected insights culled from the ingredients of mythologies: emotions, fears, obsessions, sexual fantasies, hidden behavioral modes, forbidden dreams, faith, beliefs, and informal interests. Such a methodology unveils the patriarchal power relations that stalking signals, and it illuminates the inadequacies of contemporary conceptualizations of male stalking. It demonstrates that certain facets of violence are deeply embedded in our intergenerational cultural psyches in an archetypal way.

Mythologies about Women and Men as Stalkers

Through systematically illuminating mythological texts, we may explore insights related to women as stalkers and men as their presumed stalked subjects. If the context in which Kamir’s book should be comprehended is patriarchy, how can we explain violent women? The story of Lilit, a Sumerian goddess canonized in Western culture, is Kamir’s allegory to the popular framing of female stalking.

Lilit is a mythological evolvement of Inanna, the goddess of law and social life in Sumer, in about 3,000 B.C. With the consolidation of patriarchy in Sumer, Eve, the image of the domesticated woman, and Lilit, the female stalker, had replaced Inanna’s image in Sumerian mythology. At that historical point, with the disempowerment of women in control, violence was related to the undomesticated woman, who aims to be in power. Already in the middle of the first millennium B.C., the symbols that were associated with Lilit had become associated with female witchcraft. These symbols were later transmitted to the Hebrew-Jewish and Christian canonical texts. Thus, the mythology of the female stalker, which was originated in early Sumer, became an integral part of culture in law.

Modern law, as Fitzpatrick has claimed, following Marxist, neo-, and post-Marxist traditions, contains mythical symbols (Fitzpatrick 1992). Kamir moves one significant feminist step further in explicitly and critically exploring how mythologies have constituted a male legal ideology that has empowered and generated gender-based structures. It is a significant contribution to the literature, since law is not only a mythology by itself (Fitzpatrick 1992; Scheingold 1974). Rather, it has been constituted by antique mythologies that constructed patriarchy. Women who have desired to challenge patriarchy were perceived as stalkers, as witches, and as prostitutes (Kamir 2001:42).

The more insecure men feel, the more they fabricate the image of progressive women as stalkers. Thus, the witch-hunts in Europe between the fourteenth and seventeenth centuries were violent practices that reflected the image of stalking in law. Notably, the Catholic Church prosecuted women who were outside its disciplinary power in order to reconsolidate its powerful position vis–vis the younger Protestant Church. Using the legal category of diabolism, tens of thousands of women were convicted in courts, after they were tortured during interrogation (Kamir 2001:62).

The genealogy of stalking includes the story of modernity. The book continues the themes of Foucault (1980) and MacKinnon (1987, 1989, 1993) on the centrality of sexuality in modernity and its regulation for preserving patriarchy. The nation-state has contributed to the engendering of stalking mythologies in order to regulate feminine sexuality, especially when women might have endangered the patriarchal social order. Kamir masterfully explicates how in the eighteenth and nineteenth centuries, when feminine sexuality became more prevalent and was still veiled through conservative arrangements of marriage, prostitutes became targets of legal prosecution by state authorities, blamed as spreading dangerous diseases such as syphilis, since like Lilit and the witch, “the prostitute enabled the female stalking story to be burst out into a series of moral panics” (2001:64).10

Liberalism and liberal feminism in the twentieth century, which could have reduced the scope of stalking due to constitutional protections of individual autonomy and privacy, incited the opposite public reaction. This reaction was articulated in films, as films are spheres of legal imagination;11 they construct the boundaries of our imagined reality by showing and framing-through the moving images-what is “happening” and what may “happen” (Black 1999; Denvir 2000; Sarat 2000:9).

Fatal Attraction (1987) demonstrates a narrative of female stalking. Alex is a single, professional woman who seduces a married man, Dan, when his wife and daughter are away for the weekend. When Dan refuses to continue their relationship, Alex insists, and she imposes herself by appearing constantly in his office, by his car, and even in his home, but fails to attract him again. Then she attempts a suicide, and finally tries to kill Dan’s wife, and finds her death. Kamir arg\ues, “[as a] sexually initiating woman, she is portrayed as a contemporary Lilit who refuses to go away, a witch and a female erotomanic serial killer” (2001:171). Fatal Attraction articulated female stalking amidst liberalism, when feminism propelled feminine dignity, imposed pressures on policy makers to frame more egalitarian public policies, and demanded public attention to male stalkers. In reaction, independent and strong women, social constructs of liberal feminism, have been conceived as stalkers. In the imagination of Fatal Attraction, the social guilt has completely been transformed from the male to the female stalker.

Less convincingly, Kamir argues the same about The Eyes of Laura Mars (1978), which depicts an assertive, celebrated photographer and liberal woman, Laura Mars. A mysterious serial killer is murdering her lesbian models. He happens to be the police officer who investigates the murders, and with whom Laura Mars has a passionate affair. She experiences uncontrolled visions of the murders before they take place since her sight is being taken over by the murderer, her lover, and she can only see what he sees when he stalks his next victim. Furthermore, her murdered models are found dead in the same positions that are identical to the sexual and violent positions that she has staged and photographed prior to the murders.

Kamir analyzes how Mars is depicted as a female stalker:

Although she does not perform the actual killings, she participates in the stalking phase of the murders through her psychic visions. . . . More significantly, the uncanny similarity between the models’ positions in death and in their photographs underlines Mars’s moral responsibility in the bloodshed. It is explained, in the film fictional world, by the telepathic, premonitionary connection between Mars and the murderer. The telepathy symbolizes the inherent connection between Mars’s violent sexual fantasies and their dangerous execution in reality. (2001:167- 8)

It may be argued, however, that in this film the man is exhibited as the stalker, while the woman is framed as the victim. Unlike Alex, Laura is compelled to be part of the murders and can be depicted as a victimized personality manipulated by a male stalker.

When men stalk women, they repeatedly watch them, supervise them, intrude upon their life, and strive to subordinate them to their own will. As studies cited in the book exhibit, the male stalker expects that the stalked woman will behave according to his expectations (Kamir 2001:210). Under patriarchy, she is expected to behave according to his own interests, due to his control of her safety. This is how X1 (the male stalker) has power over X2 (the stalked woman).

That intimidation of one’s personality cannot lead to symbiotic relations, but to the subordination of women to men. While rape and other types of physical violence are intrusions into the female body, stalking is an intrusion into her spirit, and the demand that she would surrender her autonomy (to him). In allegories such as Satan, Dracula, Frankenstein, Faust, and the Vampire, the male stalker has been portrayed as an abusive intruder, as a vampirish trespasser (2001:89-98, 102-3). In a culture of patriarchy, however, that abusive behavior has been celebrated as a desirable and canonized behavior:

Tales written by male writers portrayed stalking as thrilling woman-hunting, inviting readers to participate and take delight in the predator’s excitement. Such literary treatment of stalking was voyeuristic and often pornographic. It conformed with dominant patriarchal perceptions, establishing vampirism and stalking as sensational mass entertainment. (2001:98)

Furthermore, the male stalker is often framed as somebody innocent who punishes a female stalker, namely a prostitute or his wife who has an affair.

The film Taxi Driver (1976) demonstrates how the Vietnam trauma had incited stories of male stalking as an extreme and isolated category of serial killing. Vietnam veterans were perceived as potential male stalkers, even murderers, who try to compensate for their feelings of weakness and castration. In Taxi Driver the stalker, a shy and lonely Marine veteran working as a New York taxi driver is a serial killer. The film portrays a sleepless driver who aspires to clean the city of its corruption, tries to save an underage prostitute from her pimp, and ends up committing murder. Based on the genealogical explication of transhistorical mythologies, Kamir’s book criticizes that narrow category of male stalking as serial killing and argues that such narrow categories of stalking have “normalized” nonmurderous male stalkers who have rejoiced in the subordination of women (2001:141-4).

Problems with the Mythological Approach

Kamir’s attempt to conjoin the deconstruction of intergenerational and transhistorical mythologies with current prescriptions for legislation is problematical. On the one hand, she powerfully exhibits that legal categories are epiphenomena of a cultural context (see similarly Cover 1992; Olsen 1990). On the other hand, she aspires after legal categories as the remedy for stalking. I will first explore her attempt to offer better legalistic regulations of stalking and then explain the problem with her important project and the antinomy embedded in it.

The call for legal regulation of male stalking through a broader category of unlawful stalking is similar to ambitions in other critical legal feminist writings that aspire to exclude violent sex through formally regulating and excluding pornography (MacKinnon & Dworkin 1997). Kamir’s book submits a genuine feminist criticism of the “reasonable person test,” required in most anti-stalking legislation,12 following critical scholars who have deconstructed legalistic tests that veiled sociopolitical interests and ideology (Garth & Sterling 1998; Horwitz 1990; Kairys 1990; Mautner 1994; Shamir 1994). It is forcefully argued that the reasonable woman test in anti-stalking legislation internalizes injustice, since it asks whether other women would have felt what the alleged stalked woman claims to feel as a result of the alleged stalking.

To obligate a victim to feel what others “should” feel as “reasonable” women is in practice to substantiate the hegemonic values of patriarchy. As Kamir argues, the alleged victim has to prove in court her reasonable suffering, namely that she is not merely hysteric and fragile, as women are often suspected to be in a patriarchy. Furthermore, I argue, because the injured feelings of the stalked woman are subjective and cannot be standardized, the distortion caused by the reasonableness test is even greater than in many other legal categories of unlawfulness that refer to concrete tangible damage caused by violence. Requiring reasonableness of feelings is an attempt to objectify stalking and therefore to transcend its social facets from the context of patriarchal violence. Since stalking is mainly a male violence against women,13 men are unable to judge what a stalked woman feels. Furthermore, I argue, the reasonableness test ignores the heterogeneity of women and their diverse multicultural reactions to male stalking. How can a white man know what a black woman felt while a white man had stalked her?

Current legislation would enable legal authorities to convict only about 6% of alleged stalkers (Kamir 2001:206), while a 2001 report on stalking, submitted to Congress by the U.S. Attorney General, reveals that only 1% of stalking instances are brought to court in criminal procedures (Ashcroft 2001). Kamir’s book advises that anti-stalking legislation should define stalking broadly, and not require women to prove the damages that were allegedly caused by their stalkers.

Problematically, Kamir does not follow her own fascinating account of mythologies that should cast severe doubts on the efficacy of any legal reform. She turns rather drastically from a criticism of male-state-constituted culture to advocacy of male- state public policy, and seems to believe in the willingness and ability of state law to reform practices, at least as a first significant step in a more compound journey of social reforms. Will the abolishment of the reasonable woman test reform reality? Formal state law codes a certain behavior as unlawful and frames a space in which criminal prosecution and the courts may punish (Sarat & Kearns 1993, 1998). But as comprehensive as the categorization of unlawful stalking may be, violence against women and stalking are graver social problems and not merely legalistic issues.14 The inherent tension in trying to conjoin research of transhistorical mythologies with an attempt to shape a contemporary legal policy is prominent because legal formalities deal only with manifestations and not with the sociopolitical and cultural sources of male violence against women. The section below explicates possible directions for women’s redemption.

Can Legislation Quell Stalking?

In order to seriously confine the scope of male stalking, a broader legislation such as Kamir offers will not suffice. Instead, the prime strategy of feminists should be the deconstruction of the culture of patriarchy, even if that deconstruction is incrementally implemented. My advocacy of the author’s criticism of the reasonable person test notwithstanding, the book expects too much from state law. Social forces, such as feminist NGOs, should carry the criticism and deconstruct patriarchy through placing nonnormative and normative mythologies, while state law cannot render such a social change by itself. Since patriarchy is grounded in state law itself-in its formalities, legal ideology, and practices (MacKinnon 1989; Olsen 1990; Polan 1993), legislation and court rulings are constitutive constructs of patriarchy itself, despite the contingencies and dynamics of hermeneutics. As the empirical findings point out above, it is significantly doubtf\ul whether anti- stalking legislation, as capacious as it may be, spurs fundamental sociopolitical changes. The formal legal text may form a basis of incremental legal change, but much more is required for inciting reforms in practices (G. Rosenberg 1991).

Anti-stalking legislation may benefit from knowing about the place of mythologies in culture and law, and it may touch upon some mythological thinking as nonnormative. Yet the origin of stalking is the subjugation of women, so feminism should endow its foremost efforts elsewhere, and not in formal law that may be futile without the liberation of women from the primary elements that constitute their subjugation (Brown 1995; Hartsock 1983; Nussbaum 1999). In order to significantly transform the status quo of patriarchy, above some legalistic moves of legislation and litigation, feminists have to practically expel the culture of patriarchy from law.

Such a claim has concrete consequences. State law should not be the main field of endeavors to expel patriarchy. Women have to acquire a strong collective feminist consciousness (Weiss & Friedman 1995), which is a precondition to the liberation of oppressed, nonruling communities (Barzilai 2003). Empirical studies show that grassroots efforts to build feminist consciousness are not futile and do have a record of success (Barzilai 2003; Weiss & Friedman 1995). One need not exclude using legal reforms as part of the process. State law may assist in mobilizing feminist purposes of constructing a feminist collective consciousness. Its assistance, however, may be confined within the basic patriarchal configurations in cultures and institutions (McCann 1994).

Legal reforms through state law should be a sociopolitical tactic and not a strategy in and of themselves. While the book invites a criticism of the strategy of legal reforms, its emphasis on legislation contradicts its cultural message. Feminists should begin with a concept of a feminist collective consciousness in order to challenge patriarchal myths outside and inside the law. Legal reforms by themselves are only secondary in constructing such a consciousness, since usually they would not transcend the prevailing legal ideology of the state and its prevailing patriarchal myths (Olsen 1990).

The book’s findings should enable women to overcome the myths that feminine independence is evil and that assertive, educated, and liberal women are stalkers. Deconstructing culture through exposing mythologies, as Kamir does, should become part of education, in order to empower women to fight male stalking and acquire economic and social independence. When that politics prevails, while patriarchy has significantly been deconstructed, anti-stalking legislation will be effective, and yet prominently less relevant. Anti-stalking legislation that considers mythologies, as Kamir prescribes, is part of a more egalitarian society. Yet it is ineffective without the other social forces of women’s liberation coming to the fore, theorizing and practicing alternatives to settings of patriarchy and violence. Grass roots activities among women through unveiling and deconstructing mythologies may assist in reaching a communal feminist consciousness and economic independence. Every Breath You Take is an important base of such a feminist theory, since it genuinely explores how intensely violence, and particularly male violence, is embedded in our cultural psyches.

Conclusion

Exploring the place of mythologies in law is an important endeavor to redeem law from its formalistic and positivistic stigmatizations and to deconstruct it in order to reform society. A narration analysis of transhistorical mythologies, through varied primary texts, is pathbreaking in studying popular legal cultures, since the temptation to be a stalker and the fear of being stalked are substantially framed and reproduced through such spaces as films (and lately the Internet) and through more traditional types of texts from antiquity to modernity (U.S. Attorney General 1999).

The book neither neglects the law nor neglects society. Its research advances scholarly endeavors in law and society because it enables us to better comprehend how popular beliefs and folk practices have constructed and shaped legislation, court rulings, law, and hermeneutics. The book provides us with a transhistorical model of law and culture against which scholars may evaluate the merits and deficiencies of contemporary law. That transhistorical model shows that due to power struggles; the intimacies between law, male violence, and popular culture; and the role of courts in regulation of sexuality existed even several millennia before the creation of the nation-state. One who reads Kamir’s book can not but be impressed that instead of being either state critics or state protagonists, or both, we should be interested in the various historical configurations of power and violence against women.

Rather than suggesting abstractions detached from a concrete local knowledge, the book constructs a very detailed and compound picture of stalking from interdisciplinary perspectives without losing the conceptual aspects of feminist legal criticism. Conceiving it as an important book about violence in patriarchy, as I argue, offers a critical conceptual prism to evaluate its high quality and its potential to invite additional studies about mythologies and law. Understanding mythologies in law from antiquity to modernity, as Kamir does, is a very impressive, meaningful effort that should be prominent in both feminist theories and law and society studies, since with Every Breath You Take, someone is watching you.

1 BBC News, April 4, 2001.

2 These data are collected by the National Center for Victims of Crime, http:// www.ncvc.org. For similar data updated to 2003, see the July 8, 2003, congressional report preceding the resolution to establish a National Awareness Stalking Month in the United States, http://www.ncvc.org./policy/Stalking%20Resolution.htm.

3 For updated information on male violence against women around the world, see http://www.qweb.kvinnoforum.se/violence/papers.html.

4 The U.S. Attorney General has devoted attention in reports on domestic violence against women as a symbolic reaction to the harsh realities of the female predicament.

5 For a somewhat similar argument as a basis of jurisprudence, see Minow and Shanley (1997).

6 The political control of men over political power foci in Western societies is enormous. Violence against women is partly due to their political weakness. For comparative figures, see Siaroff (2000).

7 For concepts of power, see Lukes (1986); For a claim that violence, also as intimidation, is embedded in law, although not necessarily in its gender-based context, see Derrida (1992).

8 Kamir reflects on the Internet as a possible major source of stalking in the twenty-first century but does not develop her argument (2001:139). The Internet may further enable men to stalk women while the stalkers are in their private rooms, or workplaces, in a relatively free and isolated environment. Reports from different countries testify that stalking has increased due to the Internet (Bocij 2003). Especially in cyberspace, the ability of stalkers to reconcile family values, such as loyalty and monogamy, with stalking other women is greater than ever before, because cyberspace diversifies personal capabilities to simultaneously enjoying different sexual practices and fantasies.

9 Critical thinkers such as Marcuse (1968) and Gramsci (1971) have alluded to how the mass media, which is motivated and controlled by and through the materialistic capitalistic process, constructs distorted social needs such as the mass consumption of sex, and hampers sociopolitical attempts to deconstruct them. The absence of that criticism has missed a critical context that alludes to the interests and ability of the film industry to maintain a patriarchal society. The generation of images of stalking is not only a reflection of prevailing myths (Kamir 2001:112-39), but also a result of the profit-oriented film industry.

10 The argument concerning state regulation of sexuality in times of public panic (Kamir 2001:175-203) transcends female stalking and illuminates other types of gender-based violence. Thus, the same apparatus was utilized through the heterosexual ideology against homosexuals in the twentieth century, as they were blamed for spreading AIDS (Richards 1999).

11 For a list of films with legal themes, see http:// www.law.gwu.edu/apply/read.asp#FILMS.

12 Only in a few instances, in Belgium, Denmark, Ireland, and Norway, is there no requirement of the reasonable person test (Maisch 2000). According to the 1990 California law, the defendant is guilty of stalking if he or she makes a credible threat with the intent to place a person in reasonable fear of death or great bodily injury. A person can be accused of stalking if she or he willfully, maliciously, and repeatedly follows or harasses another person. Harassment is defined in the law as a course of conduct that would cause a reasonable person to suffer substantial emotional distress.

13 For various data sets, see http://www.ncvc.org/special/ stalking.htm.

14 It is outside the scope of this article to debate legalistic calculus. A broad legal category of unlawful stalking may be ineffective in its enforcement or struck down as too vague.

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Statute Cited

California Penal Code 646.9. Stalking. 1990, amended 2002.

Web Sites Accessed

http://www.qweb.kvinnoforum.se/violence/papers.html

http://www.ncvc.org

http://www.cybercrime.gov/cyberstalking.htm

http://www.law.gwu.edu/apply/read.asp#FILMS

I am very much grateful to Martha Merrill Umphrey for her excellent remarks and suggestions. The responsibility is mine. Please address correspondence to Gad Barzilai, Jackson School of International Studies and the Comparative Law and Society Studies Center, University of Washington, Seattle, WA; e-mail: [email protected]; Web site: www.tau.ac.il/~gbarzil.

Copyright Blackwell Publishers Dec 2004

Editor’s Note: The author of the following Clinical Observation was one of a dozen Associates of the American College of Physicians selected to present a clinical vignette at the 2003 Annual Session in Philadelphia. We are proud to present this case report through a special arrangement with the Council of Associates of the College.

TO THE EDITOR: Background: Thiamine deficiency is prevalent among nutritionally deficient persons and typically manifests as Wernicke encephalopathy or beriberi (1). In the published literature, a primary syndrome consisting of gastrointestinal symptoms and signs has not been previously attributed to thiamine deficiency. The following report illustrates 2 cases of gastrointestinal symptoms and lactic acidosis that were probably related to thiamine deficiency.

Objective: To describe 2 patients with a gastrointestinal syndrome associated with thiamine deficiency.

Case Report: Patient 1 was a 57-year-old alcoholic man who presented with nausea, vomiting, and abdominal pain. He was in significant distress and had a lactate level of 27 mmol/L, a pH of 6.82, and a central venous oximetry level of 95%. On the basis of the severity of pain and elevated lactate level, the patient underwent exploratory laparotomy. Surgical findings were negative. After surgery, the patient improved rapidly; the only identifiable therapeutic intervention he received was intravenous thiamine. All cultures remained negative, and no competing diagnosis was found. Several months later, the patient presented again with similar symptoms and an elevated lactate level (11.9 mmol/L). After reviewing the medical record, the treating physician administered thiamine and the patient rapidly improved.

Patient 2 was a 55-year-old alcoholic woman who presented with a decreased level of consciousness and abdominal pain. She had a lactate level of 19.9 mmol/L, a pH of 7.06, and a central venous oximetry level of 93%. A computed tomography (CT) scan of the abdomen was ordered and thiamine was administered. Upon admission to the intensive care unit, the patient was alert and had no abdominal pain. The lactate level had decreased to 1.9 mmol/L, and the pH was normal. The CT scan was canceled and the patient was discharged without a competing diagnosis.

Discussion: In the 1940s, several separate experiments induced thiamine deficiency in humans; almost all participants reported nausea, vomiting, and abdominal pain (2). These early observations were not translated into a clinical syndrome and have essentially been forgotten.

A case series documented the occurrence of “fulminant beriberi” in intensive care unit patients who were deprived of thiamine during administration of total patenteral nutrition (3). Eleven patients in that series had undergone laparotomy for abdominal pain; surgical findings were negative. All patients given intravenous thiamine recovered. The current report of 2 cases is the first to recognize a primary gastrointestinal syndrome secondary to thiamine deficiency. Both patients were critically ill and recovered rapidly after receiving thiamine as the only therapeutic intervention. In patient 1, the abdominal pain was severe enough to warrant an operation. Both patients also displayed severe venous hyperoxia (central venous oximetry ≥ 93%), which indicates a mitochondrial defect in oxygen utilization consistent with thiamine deficiency. The rapid recovery from such profound venous hyperoxia and lactic acidosis (in the absence of other treated causes) can be explained only by thiamine repletion. The repeated presentation (patient 1) and rapid response to thiamine validate this hypothesis.

Thiamine deficiency may lead to a gastrointestinal syndrome of nausea, vomiting, abdominal pain, and lactic acidosis. Further delineation of this potential syndrome is of paramount importancefailure to recognize and treat it may lead to unnecessary morbidity and death. Thiamine administration should be considered for all inadequately nourished patients who present with gastrointestinal symptoms and lactic acidosis.

References

1. Reuler JB, Girard DE, Cooney TG. Current concepts. Wernicke’s encephalopathy. N Engl J Med. 1985312:1035-9. [PMID: 3885034]

2. Williams R. Observations on induced thiamine deficiency in man. Arch Intern Med. 1940;66:785-99.

3. Kitamura K, Yamaguchi T, Tanaka H, Hashimoto S, Yang M, Takahashi T. TPNinduced fulminant beriberi: a report on our experience and a review of the literature. Surg Today. 1996;26:769- 76. [PMID: 8897674]

Michael Donnino, MD

Henry Ford Hospital

Detroit, MI 48202

Copyright American College of Physicians Dec 7, 2004

Could it be that “absence makes the heart grow fonder” is just one of those romantic myths generated from wishful thinking?

IN some circumstances, time apart may well allow an opportunity to reflect on your loved one’s most endearing qualities and forget about the irritating ones. It seems logical that respite from washing smelly socks and underwear could help to resurrect flagging sexual desire.

Perhaps if some form of communication is possible — quite likely these days with so many high-tech options — then an enforced separation can be turned into an opportunity for endearing courtship or a tantalising email affair.

After all, given that people who’ve never met each other can have steamy internet sex, couldn’t a couple who’ve been married for 10 years achieve the same or even better?

The big difference in times of separation for couples already in a relationship is, of course, that you already know each other.

That means the mystery and fantasy parts are less likely to be present but, on the other hand, you have the reality of your partner’s voice and touch to enhance your internet or telephone words. This expression of loving feelings can build on the good memories you already have.

The reality for many couples, however, is that extended time apart is a huge challenge for at least one of the partners, and therefore for the relationship.

Handled well, it can enhance the relationship, as does the successful working through of any of the other hard times life may bring your way.

Being able to do that requires certain skills and understanding that many people will not necessarily possess.

This is one of the common situations that can lead couples to engage professional help.

Time apart for most couples occurs because of work. Sometimes there’s an element of choice in that, sometimes not. It can be one extended period of time — as when defence force personnel serve overseas for six months or more at a time — or it may be the brief trips away of someone whose job requires frequent travel. There may be a long period leading up to the absence or there may be little warning.

Whatever the circumstances, one of the first factors in helping a couple handle the impact of being separated is to discuss the situation.

Doing this creates an obligation on each partner’s behalf. The one who is to leave has to raise the topic as early as possible, discuss it as fully and openly as they can, provide all the information they have and take responsibility to find out anything else that is relevant.

The traveller must also ask their partner how they feel about the time apart, and be willing to listen carefully and with empathy to the response. Sharing their own feelings honestly in return is also important.

Of course, it may not be easy for the about-to-be-abandoned-one to hear their partner’s excitement over this travel opportunity. Equally, being left to look after the children and the home all by yourself, or simply being left behind, may make it difficult to sympathise with moans about the tedium of travel.

This is the obligation of the one left behind. Be open to making this discussion as profitable as possible. Hysterical arguments are only going to make it less likely that you get well informed and have the opportunity to address your feelings.

Both people need to bring all of their generosity and empathy into the discussion for the sake of the relationship. You don’t need to like the separation, but you do need to accept it. It’s very normal to have feelings of abandonment and rejection at the prospect of a partner leaving, however temporarily.

If you can’t work through these issues effectively, it’s important to consider what this might mean. Perhaps this time apart is triggering memories and feelings of an earlier rejection or loneliness that needs to be dealt with.

Perhaps the feelings are an indication of dependence and this temporary separation will be a good time to discover in yourself the ability to cope on your own. Often we are drawn to someone who possesses characteristics we see as missing from ourselves. This may be the opportunity to develop a particular strength in yourself, to become more whole.

When the talking about parting is done and shared understandings are reached, then it is time to say goodbye.

Do that with all your heart and soul, in whatever ways feel right to you both. That may result in a long hug and some tears, or may give rise to passionate, memorable sex.

Perhaps you will want to farewell each other in different ways, meaning the only possible parting is some wry humour about the difficulties of loving a unique individual rather than a mirror image of yourself. Maybe you’ll compromise and get to have both the hug and the sex.

And no matter how much you long to be reunited, be aware that your fantasies and discussions about how that will turn out won’t necessarily be realised. For many people there’s a rocky process of gradually letting the other in, of catching up, of readjusting to each other’s company and habits, of forgiving the abandonment.

If that process isn’t going well, don’t feel like you have to struggle on your own, there are skilled professionals who know how to help you deal with these matters.

* Robyn Salisbury is a clinical psychologist and director of Sex Therapy New Zealand, a referral network. To seek professional help with any sexual relationship problem contact (06) 354-2449 or www.sextherapy.co.nz

Summary: A national opportunistic chlamydia screening programme, mainly targeting young sexually active women, is gradually being introduced across the UK and in future will predominantly occur in primary care sites. The relative efficacy of recommended antibiotic treatments for chlamydia has been poorly studied and especially that of single dose azithromycin. In Portsmouth, 1536 patients treated for chlamydia, with four different antibiotic regimens, during the Department of Health pilot study, were asked to return for test of cure. No difference in treatment outcome was found using doxycycline, oxytetracycline, erythromycin or azithromycin. Directly observed therapy with azithromycin may be especially helpful in treating young chlamydia-positive patients.

Keywords: Chlamydia trachomatis, treatment, antibiotics

Introduction

The most active drugs against Chlamydia trachomatis infection, in tissue culture assays, are tetracyclines followed by macrolides, sulphonamides, some quinolones and clindamycin1. In the UK the Association for Genitourinary Medicine (AGUM) and the Medical Society for the Study of Venereal Diseases (MSSVD) have produced clinical effectiveness guidelines for the management of C. tmchomatis genital tract infection2. For uncomplicated infection they recommend the use of either doxycycline or azithromycin. Erythromycin, Deteclo (tetracycline), ofloxacin or tetracycline are mentioned as alternative regimens. In clinical practice resistance to these antibiotics appears to be rare3 and such treatment is safe, cheap and effective4 so that routine test of cure (TOC) is no longer considered necessary. However, randomized controlled studies of chlamydia treatment are few, mostly with small numbers of participants, short follow-up and incomplete details of partner notification4. In 1999 the Department of Health (DH) England set up pilot sites, in Portsmouth and the Wirral, to assess the feasibility, effectiveness and acceptability of opportunistic testing for genital tract C, tmchomatis infection in women aged 16 to 24 years over a period of 12 months. The main findings from this study have now been published5-7. As part of the screening pilot over 1500 participants found to be chlamydia-positive in Portsmouth were treated with either doxycycline, azithromycin, erythromycin or oxytetracyline and all were offered partner notification and TOC. The aim of this study was to compare the cure rates for each of these antibiotics.

Participants and methods

In the DH pilot study all women aged 16-24 years, who had ever been sexually active, were offered opportunistic chlamydia screening when they attended for any reason at a variety of healthcare sites. The majority of 60% were screened in general practice (GP), 20% in family planning (FP) and 5% in genitourinary medicine (GUM) with the remainder attending antenatal, gynaecology, colposcopy, infertility or young people’s clinics. Men in the same age group were offered testing if they attended GUM or young people’s clinics. Men and women under the age of 16 years who attended for a sexual health matter could also participate if deemed Fraser competent. Full details of the study methodology have been published elsewhere8.

First-pass urine samples were tested using a nucleic acid amplification method – the ligase chain reaction (Abbott Laboratories, Maidenhead, UK). Patients found to be chlamydia- positive were contacted by the research nurse and advised to attend GUM for treatment, partner notification and full sexual health screening9. Those unable to attend GUM were treated by the research nurse, usually in a FP clinic, or by their general practitioner. Doxycycline, 100 mg twice daily for seven days, was the standard first line treatment given. Azithromycin as a single l g oral dose, taken under direct observation, was given when compliance with a longer regimen was doubtful. Erythromycin, 500 mg twice daily for 10 days, was prescribed for pregnant women and those known to be allergic to tetracyclines. Although not included in the study protocol some patients, mostly those offered screening while attending GUM, were treated with oxytetracyline 500mg twice daily for 10 days for a suspected infection prior to chlamydia results becoming available. This was the routine therapy for chlamydia infection in use in the GUM department at the time.

All patients treated for chlamydia were asked to return for a TOC, using the same methodology, after 2-4 weeks.

Results

In Portsmouth, 1203 patients diagnosed with chlamydia predominantly in a community setting (GP or FP clinics) were known to have received antibiotic treatment. A further 333 initially diagnosed in GUM were also treated. Details of the medication prescribed, whether patients returned for a TOC and TOC results are shown in Table 1. Overall, of the 1203 community-diagnosed patients 40 (3.3%) were still chlamydia-positive on TOC compared with 1 (0.3%) of the 333 GUM-diagnosed patients.

Table 1. Details of antibiotic therapy in patients diagnosed Chlamydia trachomatis-positive in community and CUM settings

Table 2. Community and genitourinary medicine treated patients analysed together

Table 2 shows cure rates, as indicated by a chlamydia-negative TOC, obtained with each of the four antibiotic regimens when community and GUM patient results were analysed together. Of those who attended for TOC no difference in positivity rate was found (P = 0.4333). Partner notification details for those patients with a chlamydia-positive TOC are included.

Discussion

In this study no difference in efficacy, as determined by the number of patients with a chlamydiapositive TOC, was found between doxycycline, azithromycin, erythromycin or oxytetracycline

With the availability of effective antibiotic treatments, as well as staffing and cost pressures, TOC for chlamydia is no longer recommended. Not unexpectedly, of the 1536 treated patients described in this paper 300 (19.5%) failed to attend for TOC with little difference across the treatment arms. The number of patients with chlamydiapositive TOC was small in all groups and the majority of their partners are known to have been seen and treated. All patients with a chlamydiapositive TOC reported only one partner in the previous three months with the exception of five patients who reported two. Partner notification was considered unsuccessfully completed unless all traceable partners named by the patient were known to have been seen. Inevitably the accuracy of contacts’ details cannot be guaranteed but the treatment results obtained in this study may reflect a true failure rate of the antibiotics used.

Patients diagnosed with chlamydia in the community had a TOC chlamydia-positivity rate of 3.3% compared with 0.3% in those initially diagnosed in GUM. This marked difference may be accounted for by the fact that those attending GUM had chosen to present for a sexual health screen possibly suspecting that they may have been at risk of acquiring a sexually transmitted infection. Those tested in the community were offered screening while attending for any health reason. In GUM, patients found to have evidence of infection on examination or microscopy, even if asymptomatic, were treated and contact tracing initiated ahead of a positive chlamydia result being obtained. Often a partner would accompany a patient to the clinic and if necessary would be offered a check at the same time. It is likely that in these circumstances motivation to complete medication and to ensure treatment of partners would be higher than in those offered opportunistic screening elsewhere who might wait several weeks before receiving their results and obtaining treatment.

In conclusion, the main finding of this study was that, in a large opportunistic screening programme for chlamydia in young people attending predominantly primary care settings, there was no difference in treatment outcome using doxycycline, azithromycin, erythromycin or oxytetracycline in those found to be chlamydia- positive.

Acknowledgements: The authors wish to thank all doctors, nurses and receptionists in the Portsmouth GUM department who worked with them on the pilot study. The Chlamydia Pilot Study was funded by the DH (England).

References

1 Stamm WE. Chlamydia trachomatis infections of the adult. In: Holmes KK, Sparling PF, Mrdh PA, et al., eds. Sexually transmitted diseases, 3rd edn. New York: McGraw-Hill, 1999

2 UK Clinical Effectiveness Guidelines, [www.agum.org.uk]

3 Somani J, Bhullar VB, Workowski KA, et al. Multiple drug- resistant Chlamydia trachomatis associated with clinical treatment failure. J Infect Dis 2000;181:1421-7

4 Drug treatment of genital chlamydia infection. Drug Ther Bull 2001;39:27-30

5 Pimenta JM, Catchpole M, Rogers PA, et al. Opportunistic screening for genital chlamydial infection. 1: Acceptability of urine testing in primary and secondary healthcare settings. Sex Transm Infect 2003;79:16-21

6 Pimenta JM, Catchpole M, Rogers PA, et al. Opportunistic screening for genital chlamydial infection. 2: Prevalence among healthcare attenders, outcome, and evaluation of positive cases. Sex Transm Infect 2003;79:22-7

7 Underhill G, Hewitt G, McLean L, et al. Who has chlamydia? The prevalence of genital tract Chlamydia trachomatis within Portsmouth and South East Hampshire, UK. J Fam Plann 2003;29:17-21

8 Catchpole M, Gr\ay M, Hopwood J, et al. Chlamydia trachomatis screening pilot: Project initiation document. London: Department of Health, 2000

9 Harindra V, Tobin JM, Underhill G. Opportunistic chlamydia screening; should positive patients be screened for co-infections? M J STD AIDS 2002;13:821-5

(Accepted 5 August 2003)

J M Tobin FRCOG MFFP1, V Harindra FRCP1 and R Mani MRCP2

1 Department CU Medicine, St Mary’s Hospital, Portsmouth PO3 6AD; 2 Department CU Medicine, Royal South Hants Hospital, Southampton, UK

Correspondence to: Dr J M Tobin

E-mail: [email protected]

Copyright Royal Society of Medicine Press Ltd. Nov 2004

The author discusses issues confronted by aging women, particularly those related to ageism and body image, emphasizing society’s role in influencing women’s perceptions of their bodies. Although body image issues cause anxiety throughout most women’s lives, women entering middle age become more conscious of this concern. Problems related to a woman’s realization that she no longer conforms to society’s standards of youth and beauty include low self-esteem, depression, and anxiety.

The issues related to aging are becoming more evident in Western culture as the baby boomers reach middle age and beyond. According to Armbrust (2001), “by 2014, for the first time in the world, there will be more older people than younger” (p. 4). Although both genders experience the effects of aging and there are an increasing number of men with body dissatisfaction (Pope, Phillips, & Olivardia, 2000), the standards of our culture seem to create more problems for women as they move through their middle and later years. The emphasis on youth and beauty is overwhelmingly apparent in advertising, television, movies, and print media. Women are constantly bombarded with visual images of young women and ads promising youthful looks forever. This immersion in a culture in which youth is worshipped can cause serious problems for women as they age, ranging from low self-esteem to depression and anxiety. Women seem to be more vulnerable than men to the pressure from society to conform to its expectations and, as a result, face more questions about self-worth as they enter the middle years of their lives. The purpose of this article is to explore (a) ageism as it relates to men and women; (b) the double standard of body image in our culture; (c) the role played by the media in setting standards for beauty; (d) the impact that the emphasis on physical appearance has on aging women, especially in terms of self-concept; and (e) the implications of these issues for counseling.

AGEISM AS IT RELATES TO MEN AND WOMEN

Ageism was coined in 1969 by Robert Butler, the first director of the National Institute of Aging, and he defined it as discrimination against people because they are old. Today, the term is more broadly defined as “any prejudice or discrimination against or in favor of an age group” (Palmore, as cited in Robinson, 1994, “What is Ageism'” section, 1). According to Woolf (1998), some of the contributing factors to ageism are fear of death, emphasis on the youth culture in American society, and emphasis on productivity in American culture. Ageism seems to be much more prevalent in “Westernized” cultures (Pocuca, 2002), and although ageism affects both genders, women tend to be more negatively influenced by the prejudice against older adults than are men.

According to Sontag (1979), “society is much more permissive about aging in men, as it is more tolerant of sexual infidelities of husbands” ( 5). Also, most positive traits associated with masculinity actually increase with age (e.g., competence, autonomy, self-control, and power), whereas feminine characteristics such as sweetness, passivity, noncompetitiveness, and gentleness usually remain stable as women age. Because women’s wisdom is considered to be “age-old, intuitive knowledge about the emotions” (Sontag, 1979, 1 5), aging adds nothing to “feminine” knowledge. Men, on the other hand, valued for their rational, intellectual minds, actually benefit from aging because experience tends to increase this type of knowledge. Also, because the business of men in our culture is about being and doing, rather than appearing, the standards for appearance weigh less heavily on men than on women (Sontag, 1979). Women are set up to fail in a system that defines success for men in terms of productivity and accomplishment and designates beauty and sexiness as the measure of success for women. Women cannot maintain their youthful looks as they age-despite creams, cosmetics, and surgeries- and thus they often feel pressured to defend themselves against aging at all costs.

UNATTAINABLE BEAUTY

Currently, the ideal female body, exemplified by models, actresses, and Miss America contestants, represents the thinnest 5% of women (Wolszon, 1998). Thus, 95% of women do not measure up to the standards of physical attractiveness they see on a daily basis. According to Kilhourne (as cited in Wolszon, 1998), “survey data indicate that three fourths of normal-weight women in the United States feel fat, more than half of adult women are on a diet, and one study showed that nearly 80% of fourth grade girls are watching their weight” (p. 542). The concern over physical appearance has led some social critics to observe “that women act as if they believe the shape of their lives depends on the shape of their bodies” (Seid, as cited in Wolszon, 1998, p. 542). This concern increases with age, as women realize that they are being betrayed by their bodies in a culture dedicated to youth (Mackin, 1995).

Whereas signs of aging in men make them look “distinguished,” these same signs (wrinkles, graying hair, weathered skin) are interpreted as negative characteristics for women (Grogan, 1999). In a survey of persons 55 years and older, men were defined as “older” between the ages of 60 and 64 years versus 55 and 59 years for women (Sherman, 1997). Women are expected to maintain thin bodies, unwrinkled and unblemished faces, and all other physical traits associated with youth, perhaps because “most women’s bodies are inherently more childlike than men’s-smaller, smoother, weaker” (Freedman, 1986, p. 193). This disparity between the standards of physical attractiveness for men and women as they age is discussed by Sontag (as cited in Freedman, 1986) in the following passage:

Only one standard of female beauty is sanctioned: the girl. The great advantage men have is that our culture allows two standards of male beauty: the boy and the man. . . . Men are able to accept themselves under another standard of good looks-heavier, rougher, more thickly built. A man does not grieve when he loses the smooth, unlined hairless skin of a boy . . . while the passage from girlhood to early womanhood is experienced by many women as their downfall- for women are trained to want to continue looking like girls forever, (pp. 199-200)

According to Elissa Melamed (Freedman, 1986), appearance anxiety has its origins in early childhood, when girls are taught to value their physical appearance over all else. This anxiety escalates in puberty and reaches a new high at middle age, when cosmetics, creams, and hair dye can no longer cover the fact that the body is changing as it ages. The issue for most women then becomes learning to view themselves as acceptable even when they no longer fit the ideal of beauty of society in the United States. It is at this point that the myth of eternal youth must be examined.

THE INFLUENCE OF THE MEDIA

A new term was coined at the conference, “VintAge 2001: Positive Solutions to an Age-Old Problem,” which was held in Manhattan in October 2001. The term silver ceiling was used to refer to the new ceiling affecting older persons in the entertainment business (Tolkoff, 2001). This term is especially relevant to women, particularly those who seek employment as actresses. Male actors are employed to play “love interest” roles well into their 60s; examples include Paul Newman, Robert Redford, Jack Nicholson, and Sean Connery (Grogan, 1999). These actors are often paired with much younger women, as exemplified by Jack Nicholson, 61, and Helen Hunt, 35, in As Good As It Gets; Michael Douglas, nearly 60, with Gwyneth Paltrow, young enough to be his daughter, in A Perfect Murder; and Harrison Ford, in his 50s, with Anne Heche, in her late 20s, in Six; Days, Seven Nights. Older women are seen infrequently in films, usually portraying asexual, unattractive characters (Grogan, 1999).

The media in our culture reflect images of thinness and link this image to other symbols of prestige, happiness, love, and success for women. Because these images are repeatedly viewed over a lifetime (between 400 and 600 ads per day; Dittrich, 2002b), the standard becomes internalized and leads many women to feel fulfilled and satisfied only when they are working toward or succeeding at the achievement of that standard. This exploitation by the media is also aimed at women’s fears of real and imaginary wrinkles, which is connected to fear of age discrimination, being passed over in the workplace, and rejection or abandonment by romantic partners or mates (Pearlman, 1993).

A recent example of the unwritten standards of the media for women regarding physical appearance is the treatment of Katherine Harris, Florida’s secretary of State. Harris first appeared in the national media during the certification of then Governor George Bush as the next president of the United States. “The Boston Globe said maybe she was planning to unwind at a drag bar, because of all her makeup, and the Boston Herald called her a painted lady” (Rivers, 2000, 4). The Washington Post reported that she “applied her makeup with a trowel” (Rivers, 2000, 4), and the texture of her skin was comparable to a plastered wall (Rivers, 2000). Seldom, if ever, are men’s physical traits even mentioned in media reports of their activ\ities. Rather, the focus is on their ideas or philosophy and even their sexual exploits, but rarely on their weight or dyed or “comb over” hair.

The media feed the culture a steady diet of youth and sex, as is strikingly apparent in television, where in 2001 “only 24% of all women’s roles on prime time television went to women over 40” (Boyd & Rand, 2002, 2). In a survey taken of the top 10 American movies during a 1 -week period in 2001, when characters over the age of 40 appeared, 16 were male and only 3 were female. Only 2 of these films had women over 40 while 9 had men over 40 (HuffmanParent, 2001).

This underrepresentation of older women affects not only the actresses searching for employment, but also the number of role models available for younger women. If the majority of actresses they see in the media are young, this youthful image becomes the ideal for which they strive. As a result, young women will begin the battle against the aging process early and will continually support the companies advertising the cosmetics, creams, and surgeries available to keep them young. This becomes an increasingly frustrating struggle as the body ages and women begin to experience less and less satisfaction with themselves, because they fail to meet the standard of beauty as defined by our culture (Huffman- Parent, 2001). This perceived failure of women to achieve an unattainable standard raises many problematic issues for older women, especially in the area of self-esteem.

WOMEN AND SELF-CONCEPT

Research shows that women begin their concern with body image early in life (Grogan, 1999). According to Rutgers University psychologist Jeannette Haviland, being attractive is ranked at the top of the average female’s concerns from the age of 10 on (Pogrebin, 1996). With weight as the second most important concern of aging women (following memory loss; Rodin, Silberstein, & Striegel-Moore, as cited in Clarke, 2001), the impact of body image invariably plays an important role in the increase or decline of an aging woman’s self-concept. The relevance of this issue depends on how much a woman has based her identity on physical/sexual attractiveness. If a woman has been strongly influenced by the media and the views of Western culture in general, her feelings about herself will reflect her disappointment with the physical appearance of her body. Even women who have not been overly concerned with body image in their younger years will report an astonishment at their aging bodies (Pearlman, 1993). Although a person might feel the same on the inside, the outer shell has changed, and identity confusion results. A feeling of losing control of their bodies is also reported by many women, particularly those in the midst of a midlife crisis (Mackin, 1995). This loss of control, along with the accumulation of failed expectations and feelings of being overwhelmed at home and at work, contributes to the tendency to describe this developmental stage as a crisis. Also, women have noted that when they are no longer viewed as young and desirable (ageism), they begin to struggle to regain a sense of self, one that is not dependent on the views of others (Pearlman, 1993). This struggle can lead to anxiety and depression if the woman is not able to discover her own inherent value, beyond her physical body.

It is difficult for women to realize that they are aging and can thus no longer fit the feminine stereotype in our culture-young and beautiful. A solution to this, as suggested by Niemel and Lento (1993), is for women to start exploring their feelings and fulfilling their true needs. If women

can create for themselves a sense of inner beauty, they will gradually require less and less approval from a society obsessed with youthful outer beauty.

IMPLICATIONS FOR COUNSELING AGING WOMEN

Ageism and Women

The impact of ageism on women should be explored and issues that could be affected by this cultural bias should be discussed. Many older women will exhibit signs of depression or anxiety, which could be a direct result of discrimination because of their age and gender. Also, aging as a continuing process may affect women powerfully, because of the pressures from society to stay young and vibrant. They must continually “work on themselves” to be seen as valuable members of a society devoted to productivity, beauty, and youth.

Assertiveness training has been suggested as a valuable component of a treatment plan for women who have the illusion that their worth is decreasing with age (McBride, 1990). Because our culture often regards assertiveness in women as a negative trait, it is important to explore society’s perception of assertive women and help the client understand possible ramifications from any change in behavior. A combination of assertiveness training and cognitive restructuring would be most effective in helping a woman to develop a resistance to external influences that influence her perception of herself as a valued member of society.

The use of metaphor is also a valuable tool to help women create a more positive attitude toward aging. For example, Clark and Schwiebert (2001) proposed the use of Penelope’s loom (a Greek myth) as a metaphor for women’s development during midlife. The loom helps the client see that each life is unique, with myriad threads coming together to form a life tapestry. These threads may include issues related to empty nest, menopause, vocational and educational goals, intimate relationships, and multiple roles and expectations. Also, the counselor can help the client unravel and reweave her tapestry in midlife, focusing on her experiences of the world from her perspective as a woman. This technique is especially valuable for counselors dealing with women whose life experiences are either difficult to understand using the traditional theories or are outside the personal experiences of the counselor. The benefit of metaphor is illustrated by an old proverb (Chien, as cited in Clark & Schwiebert, 2001): “give people a fact . . . and you enlighten their minds; tell them a story and you touch their souls” (p. 164). As counselors, one of our priorities should be to use every opportunity to help clients connect with their souls.

Unattainable Beauty

Because females in our society are taught how to make use of their looks to get ahead in the world (Sepaugh, 2002), when women enter middle age, they will need help in acknowledging changes in their physical appearance and in dealing with the emotions associated with these changes. Cognitive-behavioral approaches have been shown to be effective with this population, especially when these approaches are focused on the need many women have for approval from others (Loeffler & Fiedler and Stake, Deville, & Pennell, as cited in McBride, 1990). Another helpful approach might be to help women understand that there is nothing inherently pathological or irrational about wanting to achieve a culturally valued appearance (Wolszon, 1998). Because of internalized oppression, it is extremely rare to find a woman of any age who has not been affected by the messages of our society and the resulting feelings of selfhate, inferiority, body image problems, and depression. Women are also socialized to attribute their problems to feminine personality traits, genetics, PMS, various personality disorders, or, most kindly, to dysfunctional family systems. Most women fail to examine the effects of growing up in the toxic environment of a violent, male-dominated world (Jamieson, 2000) and are taught how to make use of their looks to get ahead in the world (Sepaugh, 2002). From a psychological perspective, “women become internally oppressed through stereotyping (‘all women are catty’), cultural domination (male-centered and sexist language, institutions, art, literature, and popular culture), and sexual objectification (as in pornography)” (Jamieson, 2000, 6).

If women are allowed to express feelings of discontent with themselves, perhaps they can begin to develop and accept an individualized standard of beauty, however different that might be from society’s standard. Also, through their association with other women struggling with the same issues (support groups), women are better able to learn to accept themselves and understand their role in the world. The anxiety that has resulted from trying to live up to society’s standards will begin to dissipate, and the aging process will become a satisfying transition rather than a stressful battle of self versus society.

Because, for most women, menopause is an area that raises issues concerning physical changes, problems related to this topic should also be addressed as part of the overall counseling plan for an aging woman. Huffman and Myers (1999) proposed a seven-phase process to help women define their own experience of this “change of life” and to learn to respond in a more positive, proactive manner. These stages are education, recognizing the importance of biomedical issues, self-assessment, dialogue and definition, using resources and creating a plan, implementing the plan, and reevaluation and adjustments. The stages may be rearranged, modified or combined to meet the needs of the individual client. The purpose is to help the client adapt to this phase of life by providing guidance through the physical, emotional, and psychological changes that a woman faces as she ages.

Influence of the Media

Because the media use fear tactics to convince women that they are lacking in some essential way, counselors should help women examine the issues surrounding these fears, whether related to ageism or lookism in the workplace, relationship issues, or personal value. It is especially important in this “information age” to help clients realize that their longing for love, connection, or worth cannot be fulfilled by solutions suggested by the media messages. Assisting clients to learn about their fears and needs ca\n help them focus on these areas and become more aware of the impact of the media on their feelings of self-worth.

Society’s emphasis on youth, as illustrated by the media’s use of young models and the continuous marketing of youthenhancing concoctions, may also cause shame in women. In one survey, women reported feeling more embarrassed about their age than by their masturbation practices or same-gender sexual encounters (Kinsey, as cited in Dittrich, 2002a). Much of this shame comes from the standards that women have unconsciously accepted throughout their lives, especially from the 40 to 50 million ads they will have seen by the time they are 60 years old (Dittrich, 2002b). Investigating the possible internalization of the cultural standards can also be an important part of a woman’s understanding of the role society has played in the formation of her belief system. Women can be encouraged to view the media and its emphasis on youth and beauty with a more critical eye and to view the marketing schemes emphasizing eternal youth as Madison Avenue hype and nothing more. Discussing this issue with other women might help decrease feelings of individual victimization by society and allow women to begin to understand their role in controlling culture’s influence. As women develop a deeper sense of self through self-exploration, they will be less affected by the media’s portrayal of aging and more confident in their own intrinsic value. Opportunities also exist for women to take an active position against an ageist, sexist media, which might prevent them from feeling like helpless victims.

Feminist therapy could also be beneficial in helping women to deal with the influence of the media because it encourages the expression of anger toward injustices and teaches assertiveness. Examining the role of power is an important aspect of the feminist approach to solving problems (Herb, 2000), and the media in our culture certainly hold tremendous power over most of the population, especially the female portion. As women learn to realize the impact that the media have had on their self-concept, they may be better able to view the media more critically. This would allow them to prevent further internalization of the images that surround them in U.S. society and begin to see more clearly the truth about their intrinsic value as human beings.

Self-Concept

Counselors need to develop an awareness of the interaction of individual, biological, and sociocultural influences on women in midlife (Lippert, 1997) and to examine their own myths and beliefs about women at this stage of life. Attention should be given to resolving developmental conflicts among this population, especially as they relate to the mixed messages women receive from society (Lippert, 1997). One technique cited in the literature is construction of meaning. This meaning-making process involves several strategies, including consideration of any broader psychological issues, analysis of the nature of events in the lives of these women and their meaning, empowerment through support, affirmation of commitments, and self-exploration (Cook, as cited in Lippert, 1997). The use of this process could help women begin to feel better about the choices they have made throughout their lives and to accept the roles that they have to fill in their middle years. Acceptance can lead to more positive feelings about self and to a high level of satisfaction with one’s life circumstances.

Another technique that may help women become more conscious of dissatisfaction with their self-concept is values clarification. This process can help women realize that incongruence of values with behavior and circumstances can cause conflicting emotions about their ideas of who they really are. According to Howell (2001), when women’s values were congruent with their behaviors and circumstances, they reported feeling happy, satisfied, and comfortable, whereas incongruence in these areas resulted in feelings of guilt, sadness, anger, anxiety, fear, and loneliness. The positive aspect of the negative feelings is that this is often the impetus for a woman to begin the process of assessing changes in her environment. Because intense emotions are often a predictable and natural component of this developmental stage and can sometimes help clients discover the areas of discontent in their lives, practitioners may want “to weigh the benefits of emotion-reducing exercises or medications against the therapeutic value of discomfort. Rather than treat emotional distress as something to reduce, the counselor and client might use it as an indicator of potential areas for values congruence work” (Howell, 2001, p. 64).

Women can be guided to begin to think of midlife as a time for reevaluation, not crisis. They should be encouraged to become more realistic and to reappraise their goals and their ability to meet them [Mackin, 1995]. The issue of self-esteem should be addressed in women of all ages, but especially women who are middle-aged and older. These women are dealing with multiple changes and need direction in determining their evolving roles in the various areas of their lives. Many women believe they have previously defined their identities in terms of their relationship roles-mother, partner, daughter (McQuaide, 1998). They may feel an urgency to separate the true self from the false self, a process that may result in insecurity and anxiety about their place in society. By discussing this journey toward self-awareness, women may be less tempted to settle for another false self and will feel supported and understood as they struggle to achieve individuality. They can also begin to feel valuable as human beings and realize that neither age, nor beauty, nor productivity is the sole determining factor of their worth. If self-respect is encouraged in women, many problematic issues of aging can be avoided. By supporting a woman as she moves through the normal transitions of life, the counselor can assist her in developing internalized values that will support her through the aging process.

CONCLUSION

The issues confronting aging women are influenced by many factors, most of which are societal. The implication seems to be that because women are held to higher standards of physical attractiveness throughout their lives, they are more negatively affected by ageism and the aging process. This affects many aspects of women’s lives, including their self-concept and general mental health. Because the culture in the United States perpetuates the belief that youth and beauty are necessary for acceptance, most women continuously struggle with the issue of body image. They need to find ways to combat the feelings of oppression and self- criticism so they can function as valuable and contributing members of our society. To assist women in this process, counselors can focus on two major goals: “(a) supporting clients who work to refute negative cultural stereotypes and (b) inviting and promoting the active participation of the client in her own personal growth and development” (Degges-White,2001,p. 10).

The process of becoming more autonomous will be difficult for women unless they are able “to accept the variations in bodies of women of different ages as acceptable and beautiful rather than trying to conform to the unrealistic ideals promoted by advertisers and the fashion and diet industries” (Wolf, as cited in Grogan, 1999, p. 190). As counselors, our job is to facilitate this process and, by doing so, help women learn to value themselves for their inner selves, rather than for their outer shells.

REFERENCES

Armbrust, R. (2001]. Professional women dedicate confab to arts/ media ageism. Backstage, 42(39], 3-4.

Boyd, C., & Rand, R. (2002]. Ageism in Hollywood. Focus Over Fifty. Retrieved September 11, 2002, from http://www.family.org/ focusoverfifty/articles/a0021893.cfm

Clark, S. H., & Schwiebert, V. L. (200I]. Penelope’s loom: A metaphor of women’s development at midlife. Journal of Humanistic Counseling, Education K Development, 40, 161-169.

Clarke, L. H. (2001). Older women’s bodies and the self: The construction of identity in later life. Canadian Review of Sociology K Anthropology, 38, 441-464.

Degges-White, S. (2001). Midlife transitions in women: Cultural and individual factors. Adultspan Journal, 3, 4-11.

Dittrich, L. (2002a). About-Face facts on body image. About- face. Retrieved November 22, 2002, from http://about-face.0rg/r/ facts/bi.shtml

Dittrich, L. (2002b). About-Face facts on the media. About-Face. Retrieved November 22, 2002, from http://about-face.0rg/r/facts/ media.shtml

Freedman, R. (1986). Beauty bound. Lexington, MA: D.C. Heath.

Grogan, S. (1999). Body image. London: Routledge.

Herb, E. D. (2000). Feminist therapy groups for women with disordered eating. (Available from Health Psychology Associates, 2400 Moorpark Ave., #208, San Jose, CA 95218)

Howell, L. C. (2001). Implications of personal values in women’s midlife development. Counseling and Values, 46, 54-65.

Huffman, S. B., & Myers, J. E. (1999). Counseling women in midlife: An integrative approach to menopause. Journal of Counseling & Development, 77, 258-266.

Huffman-Parent, D. A. (2001). The effects of images in the media on the female audience. Unpublished manuscript, Washington College, Chestertown, MD.

Jamieson, N. L. (2000). Not another crumb for patriarchy. CONNSACS [Connecticut Sexual Assault Crisis Services]. Retrieved November 22, 2002, from http://www.connsacs.org/library/ patriarchy.html

Lippert, L. (1997). Women at midlife: Implications for theories of women’s adult development. Journal of Counseling K Development, 76, 16-22.

Mackin, J. (1995). Women, stress and midlife. Human Ecology Forum, 23(4), 20-22.

McBride, M. C. (1990). Autonomy and the struggle for female identity: Implications for counseling women. Journal of Counseling & Development, 69, 22-26.

McQuaide, S. (1998). Discontent at midlife: I\ssues and considerations in working toward women’s well-being. Families in Society: The Journal of Contemporary Human Services, 79, 532-542.

Niemel, P., & Lento, R. (1993). The significance of the 50th birthday for women’s individuation. In N. D. Davis, E. Cole, & E. D. Rothblum (Eds.), Faces of women and aging (pp. 117-127). Binghamton, NY: The Haworth Press.

Pearlman, S. F. (1993). Late mid-life astonishment: Disruptions to identity and self-esteem. In N. D. Davis, E. Cole, & E. D. Rothblum (Eds.), Faces of women and aging (pp. 1-23). Binghamton, NY: The Haworth Press.

Pocuca, N. (2002). Ageism. Articles & Opinion. Retrieved September 11, 2002, from http://www.i-resign.com/uk/workinglife/ viewarticle_20.asp

Pogrebin, L. C. (1996). Getting over getting older: An intimate journey. New York: Little, Brown & Company.

Pope, H. G., Phillips, K. A., & Olivardia, R. (2000). The Adonis complex: The secret crisis of male body obsession. New York: Free Press.

Rivers, C. (2000). Mockery of Katherine Harris shows double standard. Women’s eNews. Retrieved September 22, 2002, from http:// www.womensenews.org/article.cfm/dyn/aid/356/context/archive

Robinson, B. (1994). Ageism. Retrieved September 21, 2002, from http://socrates.berkeley.edu/~aging/ModuleAgeism.html

Sepaugh, S. (2002). All women are beautiful. The Re-evaluation Counseling Communities. Retrieved November 22, 2002, from http:// www.rc.org/publications/present_time/pt94/pt94_49_ss.html

Sherman, S. R. (1997). Images of middle-aged and older women: Historical, cultural, and personal. In J. M. Coyle (Ed.), Handbook on women and aging (pp. 14-28). Westport, CT: Greenwood Press.

Sontag, S. (1979). The double standard of aging. Retrieved September 21, 2002, from http://www.crab.rutgers.edu/~deppen/Aging/ Gender_Aging.htm

Tolkoff, E. (2001). Smashing through the “silver ceiling”: A coterie of talented artists searches for solutions to ageism and prejudice. Back Stage West, 42(43), 5-6.

Wolszon, L. R. (1998). Women’s body image theory and research: A hermeneutic critique. American Behavioral Scientist, 41, 542-557.

Woolf, L. M. (1998). Ageism: An introduction. Retrieved September 21, 2002, from http://www.webster.edu/~woolflm/ageism.html

Maggi G. Saucier, Counseling Program, Western Carolina University. The author thanks Michael T. Garrett for his assistance and support. Correspondence concerning this article should be addressed to Maggi G. Saucier, 103 Hamburg Mountain Road, Weaverville, NC 28787 (e-mail: [email protected]).

Copyright American Counseling Association Fall 2004

Abstract

“Do you have any history of cardiac disease?” A positive response to this question on the health history is only the beginning of an appropriate evaluation of the patient’s cardiac status. Focused questioning, along with an understanding of the nature and categories of cardiac disease, allow the dentist to better evaluate the patient’s preoperative and intraoperative cardiac considerations, and to obtain a more accurate medical consultation when indicated.

DESPITE ADVANCES in both prevention and treatment, cardiac disease remains the most common cause of death in the United States (38.5% of all deaths, or 1 of every 2.6 deaths). It is estimated that 20 million Americans are now living with some aspect of this disease.1 Dentists called upon to treat these patients must be able to render safe, appropriate and effective treatment with full consideration of the patient’s cardiac condition.

A positive response on the medical history questionnaire to the question, “Do you have heart disease?” is only the first step in obtaining an accurate picture of cardiac status. Further questioning may elicit a complex cardiac history and a bewildering array of medications, and, often, even the patient is uncertain as to the true nature of his or her disease. New medications and rapid changes in interventional therapies may make the patient’s cardiac condition seem more serious than it actually is. Conversely, casual assumptions, coupled with a too brief review of the medical history, may result in less than optimum care and unnecessarily increase the risk of a perioperative or postoperative cardiac event.

Thankfully, accurate preoperative assessment of the nature and severity of the patient’s cardiac disease (for purposes of evaluating the cardiac risk during dental treatment) can generally be determined by a careful medical history and review of symptoms. This knowledge, coupled, if indicated, with some basic physical observations (Table 1), will also facilitate communication between dentist and physician if a medical consultation is deemed necessary; and, thus, the usefulness of the resulting medical consult will be enhanced. In addition, medical consultations are always more productive when the treating dentist is able to propose a treatment plan with appropriate modifications regarding cardiac disease to the consulting physician rather than the other way around. Both patient and dentist will benefit when the treating dentist is confident in his or her assessment of the need for limitations (or lack of) in treatment.

TABLE 1

Physical Observation (The following may be useful in determining patient’s cardiac status.)

Though there are many causes of cardiac disease (congenital, coronary artery disease, hypertension, inflammatory and immunologie myopathy, alcohol and drug abuse, etc.), it is important to understand that cardiac disease manifests itself in four broad categories: ischemic, valvular, arrhythmic and myopathie (congestive heart failure). While cardiac patients often present with more than one category of disease, evaluating them separately allows for a clearer understanding of the extent of the disease.

Below, each of these categories is presented with a brief discussion of its etiology, pathology, common presenting medical history (including the types of medication generally used to treat the disease), and relevant signs and symptoms depending upon the degree of impairment. Careful review of this material will enable the practitioner to accurately assess the nature of the disease and its degree of severity.

Ischemic Cardiac

This particular form of heart disease refers to a lack of blood flow and/or oxygen to the heart muscle from blockage or stricture of the coronary arteries as the result of atheromas, or plaques. The etiologies of atherosclerotic disease are generally believed to be the result of hyperlipedemia, hypertension, hypercoagulability, hyperglycemia and/or smoking. One possible model of the formation of atheromatous plaques considers them to be an inflammation of the vascular intima, which may have sources other than atherosclerotic arteries, including systemic inflammation (for example, connective tissue diseases) and local infections (for example, gingivitis, prostatitis, bronchitis, urinary tract infections and gastric inflammation).

Patients with a history of ischemic disease may present with no history of symptoms or treatment, but usually report a past or present history of angina (chest pain, pressure or burning, often with radiation to the arm, throat or jaw-occasionally, jaw pain alone may be angina mimicking odontaglia), myocardial infarction (MI), angioplasty and stent placement, or coronary artery bypass graft surgery (CABG). Symptoms may include angina on exercise (known as stable angina) or even rest (unstable angina). Further questioning may reveal the use of occasional or frequent sublingual nitroglycerine to relieve the symptoms.

TABLE 2

Some Common Medications Used for Ischemic Disease

Common medications used to treat ischemic disease are listed in Table 2, and may aid categorizing the disease. It’s worth noting that some medications are useful for more than one category of cardiac pathology.

Chairside evaluation of these patients should be made by taking a careful history of medications and procedures, with special attention paid to the history of chest pain during exercise. While no absolute surety is possible, the degree of exercise tolerance before angina is one marker of the severity (or lack of) ischemic cardiac disease. Patients who have chest pain on “less than ordinary activity”2 (for example, one flight of stairs) and/or frequent use of sublingual nitroglycerin are at significant risk for angina or even myocardial infarction during treatment; and treatment should be deferred until appropriate medical stabilization is obtained.3

Patients with unstable angina should immediately be referred for further evaluation. Special attention should be paid to those patients with a history that includes a recent change of symptoms, medication regimen and/or recent cardiac procedures (angioplasty, stent, CABG), as their current status may be in doubt. Patients with a history of cardiac disease, especially ischemic cardiac disease, who are being followed by a physician, will generally have regularly scheduled, periodic stress tests. Valuable information and increased confidence in cardiac status may be obtained by determining the date of the last stress test, and whether the results reflected any significant improvement in the patient’s cardiac status, or, instead, resulted in a change in medication or a suggestion for further workup or procedure (the latter result being a cause for concern).

As a general rule, elective treatment should be deferred for six months post MI and three months post CABG. Should treatment need to be rendered before this interval, or if any uncertainty still exists regarding the patient’s cardiac status, medical consultation is indicated.

Treatment considerations for these patients is directed at avoiding increasing cardiac oxygen demand-generally, in the dental chair, avoiding increased tachycardia by limiting the use of epinephrine-containing drugs and limiting as much as possible the stress associated with dental treatment. Patients who use nitroglycerin should have that available. Nasal oxygen, with or without nitrous oxide, is a useful adjunct if tolerated.

Valvular

Mitral, aortic, pulmonary or tricuspid heart valve disease is a disruption in the function of the heart valves that contribute to efficient action of the heart as a pump. The etiology of valvular disease may be congenital, infectious or inflammatory, degenerative, secondary to ischemic heart disease or age-related.

The history will be positive for valve disease, heart murmur, and/ or mitral valve prolapse, and may include cardiac valve surgery or even valve replacement. The need for preoperative prophylaxis must be addressed. Patients with valvular replacement may be taking anti- coagulation medication or medication to decrease clotting (Table 3).

TABLE 3

Some Anticoagulant Medications-Valvular Disease, Atrial Fibrillation

Patients with valvular disease may also have associated arrhythmias and be at risk for or have some degree of congestive heart failure (see below). Valvular disease without further sequelae should not need alterations in the normal dental treatment plan beyond appropriate premedication if indicated and the standard considerations associated with the use of anti-thrombotic medications and dental treatment.

Cardiac Arrhythmias

Arrhythmias may occur in the otherwise healthy heart. Arrhythmias, or disturbances of cardiac rhythm, imply a deviation from the normal pattern (sinus rhythm). They may be intrinsic, or they may be caused by stress, smoking, alcohol or caffeine, or other triggers. However, they are often associated with the sequelae of cardiac disease-damaged myocardium, previous or concurrent infarction, or valvular disease.

During an arrhythmia, the heart may beat too rapidly (tachycardia); too slowly (bradycardia); or it may beat irregularly. This can cause the heart to be unable to pump blood effectively; and the blood pressure may drop to a level that is life threatening. Patients with these problems will give a positive history of arrhythmia-skipping be\ats, fluttering sensation in the chest (palpitations), light-headedness, a fainting spell (syncope), chest pain or shortness of breath.

Although arrhythmias may go unnoticed, they can be serious. Patients who admit to a history of arrhythmias may have had a 24- hour Holler or other type of ambulatory cardiac monitoring to determine the incidence and frequency of arrhythmias. Diagnostic and therapeutic regimens may vary from none at all to avoidance of triggering factors, medication (Table 4), invasive cardiac electrophysioloeical testing and radiofrequency ablation (destruction of areas of the myocardium associated with the arrhythmia), and placement of an internal pacemaker and/or defibrillator.

TABLE 4

Some Common Anti-arrhythmics

Further evaluation by history can be directed at determining the nature, site of origin and frequency of the occurrence of arrhythmia. Premature atrial or ventricular beats (PAC’s, PVC’s) are perhaps the most common arrhythmias sometimes associated with valvular disease (see above) and are generally benign and not treated. In general, certain common atrial arrhythmias, such as atrial fibrillation, are of minimal concern, beyond the requirement of anti-thrombotic medications (Table 4). Ventricular arrhythmias, especially ventricular tachycardias, are generally looked upon with more concern and have the potential to be life threatening.

Treatment modifications usually need only be limited to avoiding arrhythmic triggers, chiefly avoiding overuse of epinephrinecontaining anesthetics events so as to prevent an epinephrineinduced tachycardia. Some cardiologists advise premedication prophylaxis for the first three to six months post pacemaker/defibrillator placement.

Congestive Heart Failure

Congestive heart failure (CHF) is a condition in which the heart is unable to pump enough blood to adequately supply physiological requirements. This may be a result of cardiac ischemic, myocardial damage due to infarction, valvular disease, untreated hypertension, cardiomyopathy due to viral or other causes, or structural changes (for example, left ventricular hypertrophy). The patient’s medical history will often reflect these events. Various drugs are used to treat congestive heart failure (Table 5). Recently, pacemaker/ defibrillator therapy has been used as well.

TABLE 5

Congestive Heart Failure

TABLE 6

WHO Definitions And Classifications of Blood Pressure Levels

Patients with CHF may evince the following symptoms: fatigue; shortness of breath, especially while laying flat or with any exertion; swollen legs or ankles; weight gain; decreased urination during the day and increased urination at night. The degree of failure is reflected in the severity-or lack-of the above symptoms. Patients in mild-to-moderate failure should require no significant treatment changes other than judicious use of epinephrine, as an epinephrine-induced tachycardia can interfere with left ventricular filling and exacerbate the CHF. Care should be taken to identify any other antecedent cardiac pathology present.

Arterial Hypertension

Hypertension, thought to afflict more than 50 million Americans, is a syndrome with multiple causes; but it is often both a cause and co-morbid factor in heart disease and, so, deserves mention here.

Hypertension is generally defined as an arterial pressure of greater than 140/90 mmHg for an extended period of time. Untreated, it can lead to renal disease and stroke, as well as cardiac disease. Patients with uncontrolled hypertension should seek medical care prior to treatment whenever possible. And elective treatment should be deferred for patients with severe hypertension. Judicious use of epinephrine is appropriate for those who are under treatment and/or with mildly elevated pressures (Table 6).

Regarding the phrase “judicious use of epinephrine,” the joint conference of the American Heart Association and the American Dental Association noted, “the typical concentrations of vasoconstrictors contained in local anesthetics are not contraindicated with cardiovascular disease so long as preliminary aspiration is practiced, the agent is injected slowly, and the smallest effective dose is administered.”7

It should be understood that the exact amount of epinephrine that is safe to use on the “cardiac” dental patient is dependent upon the specific type and degree of cardiac disease present, as well as the patient’s weight and age. However, it is generally accepted that the total dosage of epinephrine be limited to 0.04 mg within a 15- minute period in cardiac risk patients.3,4 This equates to approximately two cartridges of 1:100,000 epinephrine-containing local anesthetic. Levonordefrin (neo-cobefrin) is considered to be roughly one-fifth as effective a vasoconstrictor as epinephrine and is, therefore, used in a 1:20,000 concentration and should be considered to carry the same clinical risks as 1:100,000 epinephrine.4,7 The benefits of maintaining adequate anesthesia for the duration of the procedure far outweighs the risks in almost all patients with a cardiac history. This general rule is even further enhanced if a thorough preoperative cardiac history is obtained and appropriately evaluated. Careful case selection, as outlined above, will allow the dentist to proceed with treatment with increased confidence of a positive and safe outcome.

The author thanks Arthur Meltzer, M.D., and Larry Inra, M.D., for their assistance in reviewing this article.

REFERENCES

1. Cardiovascular Disease Statistics, American Heart Association Statistics 2001. American Heart Association Publication.

2. Cecil Essentials of Medicine, Fourth Edition. WB Saunders Co. 1997:11.

3. Roser S, McCabe J. Evaluation and Management of the Cardiac Patient for Surgery. In Oral and Maxillofacial Surgery Clinics of North America. August 1998:429-443.

4. Pearson T, et al. Markers of inflammation and cardiovascular disease. Circulation 2003;107:499. AHA/CDC Scientific Statement.

5. Budenz AW. Local anesthetics and medically complex patients. J California Dental Association (online) August 2000.

6. The Merck Manual, 16th Edition. Merck Labs. 1992:367-555.

7. Working Conference of ADA and AH A on Management of Dental Problems in Patients with Cardiovascular Disease. JADA 1964;68:333- 42.

Frederick M. Lifshey, D.D.S.

Copyright Dental Society of the State of New York Nov 2004

PORT ANTONIO, Jamaica – Name the affliction, and Lloyd “Lee” Henry swears he can beat it. Chronic headaches? Cured in a couple of days. Kidney stones? Kicked in a few weeks. AIDS? Well, that one he’s working on.

Henry hasn’t stumbled on some breakthrough in modern medicine.

Rather, the 42-year-old dreadlocked healer relies on centuries- old herbal remedies passed down by African slaves – so-called bush medicine – to treat Jamaicans for everything from ear infections to erectile dysfunction.

“The bush man doesn’t provide pain relief, he provides a cure,” insists Henry, one of a growing number of herbalists and physicians in Jamaica who say the key to long-lasting health lies in the plant, not the pill.

While medical science is wary of herbalists like Henry, a dozen or more people line up each morning outside his makeshift clinic to seek his services.

It’s no wonder. Bush doctors usually charge less than public clinics and most offer same-day treatment – a rarity in a poor country where hospital waiting rooms are usually packed and there are only 13 doctors for every 10,000 people.

“In Jamaica, going to the hospital isn’t always the best option, so that’s where we come in,” Henry says, wearing a big grin and an old stethoscope at his clinic in Port Antonio, a sleepy seaside town 60 miles northeast of the capital, Kingston.

Inside, tall sacks of dried herbs and roots lean against the wall alongside dozens of plastic jugs filled with dark elixirs with names like “Anticancer Treatment, Multi-action Blood Purifier” and “Female Delight.”

After harvesting the herbs, Henry infuses them into tonics that he sells in discarded soda bottles for $4 to $6 each.

Tending to a female patient, Henry ticks off a list of ills he claims can be cured by his treatments – kidney ailments, arthritis, headaches, back pain, even some forms of cancer.

“From the first bottle he gave me I was a changed person,” says Lana Brown, a 41-year-old vegetable seller who recounts how she started seeing Henry last year after doctors warned she could lose her left eye from glaucoma.

She says her vision is so improved she no longer makes monthly trips to Kingston for treatment. “For me, the herbal medicine just works better than the hospital kind.”

Others interested in bush medicine include young men looking to improve their sexual performance. For that, Henry prescribes a tonic of rosemary, blood root and other herbs called “Strong Man Back.”

“Viagra simply can’t compete with this stuff,” Henry boasts of the red-brown liquid. “It’ll stay in your system for months.”

Henry, however, says he has his eye on a larger prize – finding a cure for AIDS. He says he’s treated dozens of victims and is experimenting with a new combination of herbs.

“I’m very confident I’ll find a cure someday,” he says. “You just have to believe in the power of the plant.”

Not everyone does.

At a recent symposium, Dr. Alverston Bailey, vice president of the Medical Association of Jamaica, said there is a “significant mushrooming” of herbal medicine use in Jamaica – as many as 30 percent of all patients – but that most doctors “still aren’t sold as to the efficacy of these treatments.”

“We’re not condemning alternative treatment options, but whenever people are offered them they should ask for evidence that it is safe and effective,” Bailey said.

Still, Henry says that doctors from as far away as Britain, Belgium and Germany have come to study his treatments and that some Jamaican physicians and pharmacists send patients to herbalists when conventional medicine fails.

Dr. Daniela Speck, who runs a private practice in Port Antonio, calls herself a believer in herbal medicine and has recommended Henry to dozens of people with high blood pressure, skin infections and benign tumors.

“Many people prefer herbal medicine because they know it’s from their forefathers and they’re not comfortable putting all the chemicals into their body,” says Speck, a native of Loerrach, Germany, who has lived in Jamaica 13 years.

Jamaica’s government also has a new interest in herbal medicines. It recently called for more research into such treatments, seeking to cash in on the multibillion-dollar “nutraceutical” industry by promoting the island’s medicinal herbs.

Bush medicine first flourished in Jamaica among slaves imported from Africa. It was later developed by the Maroons, a fierce band of runaway slaves whose descendants still live in semiautonomy in remote mountain settlements.

The island’s lush landscape and tropical climate proved ideal for growing herbs, and today Jamaica is home to more than 300 varieties of medicinal plants.

And what about Jamaica’s most famous plant – marijuana?

“I’ll prescribe a little ganja for my patients once in a while,” Henry says. “The law is against it, but its curative powers are incredible.”

THE run-up to Christmas is one of the most stressful times of year.

But if the nightmare of last-minute shopping, cooking and family rows isn’t bad enough, new research shows that everyday stress can put years on you.

Experts at the University of California say their findings are the first to demonstrate that stress can speed up the ageing process of the body by as much as 10 years.

They tested 58 mothers and discovered that the immune systems of women under stress had undergone the equivalent of ten years’ ageing.

British psychologist, Professor Cary Cooper of Lancaster University adds: “This research is proof of the dangers of ignoring stress, and that it is something to think about, especially at this time of year.

“It’s estimated that 31million working days are lost every year in this country due to stress, so it’s a very big problem.”

But what can we do about it? Try our stress test to find out how many years you might be losing. And try to have a calm Christmas …

1 Your boss asks you to stay late to finish an important task, but you were meant to be going to your child’s parents’ evening at school. Do you…

a) Stay late and finish the work without complaining, but feel angry?

b) Call the school and explain you’ll be late, finish your work, rush to the school and arrive late at the parents’ evening?

c) Explain to the boss that you cannot work late that night, but you’ll come in early tomorrow?

2 You are running very late for an appointment and you haven’t even started getting ready. Do you…

a) Try to calm down, get ready and make your way there as quick as you can.

b) Call, apologise and say you will be late. Then get ready without panicking.

c) Rush out of the house without even brushing your hair.

3 You are shopping in the supermarket on your lunch break, but there are lots of long queues. Do you…

a) Stay patiently in one queue and chat to other people to ease your frustration.

b) Rush from one queue to another, trying to find the shortest one.

c) Wait in one queue but get angry and complain to the staff.

4 You are driving towards traffic lights in a rush to get to work. The lights turn amber as you approach. Do you…

a) Stop at the lights, but kick yourself because you could have saved time by driving on.

b) Accelerate before the lights turn red.

c) Stop at the lights, put the radio on and accept that you have to wait for a couple of minutes.

5 5 A colleague approaches you and angrily criticises your work. Do you…

a) Become defensive, point out all their faults and have a big row with them.

b) Politely disagree with them, controlling your anger.

c) Listen quietly to what they have to say. Then deal with the problem later when you have thought it through.

6 You get a phone call at work to say your child is ill, but you have an important meeting. Do you…

a) Call the people you’re meeting, cancel and rush home.

b) Arrange for your partner or a family member to look after the children and attend the meeting.

c) Call the people you’re meeting and explain that you’re going to be late, then try to make alternative arrangements.

7 7 There’s a huge queue on the motorway, but you’re running late. Do you…

a) Get anxious, but call your friends on the hands-free to tell them how frustrated you are.

b) Put on some music, accept you have no control over the situation, and wait for the traffic to move.

c) Drive down the hard shoulder to get to the nearest exit.

8 You’ve been away from work and when you return there are 200 emails waiting for you. Do you…

a) Look through each email carefully, but accept you cannot hope to read them all today.

b) Open and read every single message as quickly as you can, because you could miss something important.

c) Pick out priority messages, and deal with the rest tomorrow.

9 9 Your teenage daughter gets home far too late. Do you…

a) Have a huge row.

b) Try to tell her calmly how worried you were, and why she shouldn’t do this.

c) Tell her that you will discuss this with her tomorrow, and go to bed. Then have a chat the next day.

10 There are rumours of redundancies at work. Do you…

a) Gossip to your colleagues about what might be going on.

b) Wait for the inevitable, and accept you’re in for some sleepless nights.

c) Ask your bosses what’s going on.

SORT YOURSELF OUT

PROFESSOR Cooper’s top stress-busting tips:

PERSPECTIVE: If there’s a situation that’s upsetting you, put it into context. It’s probably not a matter of life or death. Think about how bad things could really be.

REDUCE: Ask yourself what three things you can do right now to reduce the stress you’re experiencing. If you can’t find the answer straight away, keep going until you get an answer.

ANALYSE: Look at the root causes. It’s always helpful to ask yourself exactly what made you feel stressed in the first place. Be honest with yourself.

LEARN: One of the greatest gifts you can give yourself is to learn from difficult situations. What can you learn from your current situation that will help you avoid a repeat occurrence?

MODEL: Think of people you know who’ve faced similar challenges and have overcome huge hurdles – and see what they did.

RELAX: Plan some “me” time into your schedule and do whatever helps you relax.

SUPPORT: Protect your new-found self-confidence by surrounding yourself with supportive friends. Look after yourself with plenty of sleep, a balanced diet and exercise.

ANSWERS

NOW check how many years you’d gain or lose:

1(a)-1 (b)zero (c)+1 2(a)zero (b)+1 (c)-1 3(a)+1 (b)-1 (c)zero 4(a)zero (b)-1 (c)+1 5(a)-1 (b)zero (c)+1 6(a)-1 (b)+1 (c)zero 7(a)zero (b)+1 (c)-1 8(a)zero (b)-1 (c)+1 9(a)-1 (b)zero (c)+1 10(a)zero (b)-1 (c)+1

Summary

This article provides an overview of diabetic ketoacidosis, a life-threatening complication of diabetes mellitus. It highlights the signs, symptoms and acute management of this condition.

Key words

* Diabetes

* Diabetes: health promotion

* Diabetes: nursing

* Metabolic system and disorders

These key words are based on the subject headings from the British Nursing Index. This article has been subject to double- blind review.

DIABETIC KETOACIDOSIS (DKA) is a life-threatening complication of diabetes mellitus. It is predominantly associated with type 1 diabetes, but people with type 2 diabetes can experience ketoacidosis during severe infections and other illnesses (Williams and Pickup 2004). DKA accounts for 14 per cent of all diabetic- related hospital admissions and has a mortality rate of 5-10 per cent (Pickup and Williams 2003). It is classed as a medical emergency. Rapid identification is necessary to improve patient outcome. Gillespie and Campbell (2002) suggest patient outcomes are affected by the nurse’s ability to recognise the clinical features of DKA. It is important, therefore, for nurses to understand the signs, symptoms and treatment of the condition.

National Service Framework for Diabetes

The National Service Framework for Diabetes (DoH 2003) aims to address inequalities in health care by setting minimum standards for diabetes care. Standard 7 is relevant to DKA. It states that the NHS will develop, implement and monitor protocols for rapid and effective treatment of diabetic emergencies by appropriately trained healthcare professionals. Protocols will include the management of acute complications and procedures to minimise the risk of recurrence. The risk and severity of DKA can be reduced by giving advice and guidance to people with diabetes on how to manage blood glucose control during other illnesses (the sick-day rules discussed later). It Is important not to lose sight of the person who lives with diabetes and to whom these targets relate (MacKinnon 2003).

Diabetic ketoacidosis

DKA is a metabolic complication of diabetes mellitus. It consists of three concurrent abnormalities: hyperglycaemia, hyperketonaemia and metabolic acidosis (Miller 1999). It can be confirmed by blood glucose greater than 12mmol/l (216mg/dl) and the presence of ketonuna, and an arterial blood pH of less than 7.35 (Singh et al 1997).

Fourteen per cent of all diabetic-related hospital admissions are due to DKA (McIntyre 1996). Any age group can be affected. However, younger people with type 1 diabetes are typically affected (Williams and Pickup 2004). Potentially avoidable episodes occur in patients with established diabetes because of dosing errors or discontinuation of insulin therapy. In a study of 3,000 people with type 1 diabetes, 9 per cent were admitted with DKA one or more times in a 12-month period (EURODIAB IDDM Complications Study Group 1994).

DKA is a life-threatening medical emergency and without medical treatment it can lead to coma and death (Pickup and Williams 2003). Before the discovery of insulin, DKA was invariably fatal, the most common cause of death being ketoacidotic coma. After the introduction of insulin in 1922, mortality fell to approximately 30 per cent (Page and Hall 1999). Mortality declined further in the 1960s and 1970s due to earlier recognition, enhanced patient care and improved patient management (Pickup and Williams 2003). There is currently a 5-10 per cent mortality rate in Western societies (Pickup and Williams 2003). DKA remains the highest cause of death for patients with diabetes aged under 20 (Marinac and Mesa 2000). Mortality can be as high as 50 per cent in older people (Pickup and Williams 2003). Delays in presentation and treatment increase mortality.

Ketoacidosis occurs as a result of insulin deficiency and counter- regulatory hormone excess (Pickup and Williams 2003). Lack of insulin leads to decreased uptake of glucose by the tissues, increased hepatic glucose production from glycogen (glycogenolysis) and increased glucose synthesis from amino acids (gluconeogenesis), resulting in hyperglycaemia. Hyperglycaemia leads to an increased urine output, due to osmotic diuresis. Counter-regulatory hormones (such as glucagon) enhance fat breakdown into fatty acids. Oxidation of fatty acids leads to the formation of ketones, which deplete the body’s acid buffers (Lewis 2000).

Complications include (Page and Hall 1999):

* Cerebral oedema – this is often fatal, accounting for 50 per cent of deaths in newly presenting cases of DKA.

* Adult respiratory distress syndrome (ARDS).

* Thromboembolism.

* Gastric stasis.

* Mediastinal surgical emphysema.

Causes

The common precipitating causes of DKA are (Williams and Pickup 2004):

* Infection (30-40 per cent). Even minor infections, such as urinary tract infections, can be enough to upset diabetic control.

* Treatment errors (15-30 per cent). These might include giving the wrong dose of insulin, omitting dose(s) or failing to increase the dose during episodes of illness.

* Newly presenting type 1 diabetes (10-20 per cent).

* Myocardial infarction (1 per cent).

* Miscellaneous (5 per cent). This could include drugs and alcohol misuse.

* There is no obvious cause in approximately 40 per cent of cases.

* Diarrhoea and vomiting can also cause DKA.

* Recurrent DKA affects a small subgroup of patients, most of whom are women under 20. Deliberate omission of insulin is likely to be common among such patients (Williams and Pickup 2004). Page and Hall (1999) suggest deliberate omission of insulin among adolescent girls is a way to seek attention. This group often have an eating disorder. Pickup and Williams (2003) suggest that adolescent girls with an eating disorder and diabetes are associated with non- concordance, omission or underdosing of insulin, to induce weight loss. A study by Biggs et al (1994) found that up to 80 per cent of adolescent girls with diabetes admitted to binge eating. One-third of these regularly omitted or decreased their insulin dose in an attempt to control weight and compensate for binge eating.

Signs and symptoms

Signs include dehydration, hypotension, tachycardia, hyperventilation and hyperthermia (Williams and Pickup 2004). Symptoms include (Williams and Pickup 2004):

* Polyuria and polydipsia due to osmotic diuresis.

* Kussmaul respiration (deep, rapid breathing) due to metabolic acidosis.

* Ketotic breath. As well as being excreted in the urine, ketones are also excreted via the lungs, leading to ketotic or ‘pear drop’ breath (Lewis 2000).

* Nausea and vomiting due to hyperketonaemia.

* Weight loss as a a result of tissue catabolism and dehydration.

* Generalised weakness.

* Abdominal pain.

* Drowsiness.

* Coma (10 per cent of cases).

Treatment

Because DKA is a life-threatening condition, prompt, skilled management is crucial. Insulin deficiency is the principal cause of DKA, and insulin needs to be replaced with an intravenous (IV) infusion (Goldberg et al 2004). The aims of treatment are to rehydrate the patient, correct hypotension, decrease blood glucose levels to 10mmol/l (180mg/dl) or less within 24 hours, correct electrolyte imbalances and correct acidosis (Jerreat 2003).

It may be useful to remember the first seven letters of the alphabet in relation to treatment:

* Airway support: depending on the degree of coma or level of consciousness.

* Breathing: administer high-flow oxygen and monitor respiratory rate and rhythm.

* Circulation: monitor blood pressure and pulse – patients with DKA are usually hypotensive and tachycardic. Assess for signs of hypokalaemia, which may present as small T waves on an electrocardiogram (Houghton and Gray 2001).

* Drug therapy: insulin replacement is an essential part of treatment. This is achieved by commencing an IV sliding-scale insulin regimen. This will help to lower serum glucose, inhibit ketone production and reverse metabolic acidosis (Page and Hall 1999).

* Electrolyte replacement: sodium and potassium are lost through osmotic diuresis and vomiting. They need to be replaced using a slow IV infusion.

* Fluid resuscitation: replace intra- and extracellular fluid, dilute glucose levels in the blood and correct dehydration.

* Gases (arterial blood gases): pH can fall as low as 6.9 with severe acidosis, because the bicarbonate buffer system is unable to neutralise increasing hydrogen ions.

Sick-day rules Intercurrent illness causes hyperglycaemia and deterioration of diabetic control. This usually requires an increased insulin dose even if the patient is not eating. A common cause of severe DKA is misplaced advice given by healthcare professionals to stop insulin during intercurrent illness, when the patient is vomiting or not eating (Diabetes UK 2004). All patients requiring insulin need to be aware of sick-day rules (Box 1) – the most important of which is ‘never stop taking insulin’ (Page and Hall 1999).

Nursing care

On admission, there are several immediate nursing priorities (Gillespie and Campbell 2002). If the patient is comatose, an artificial airway will need to be inserted to prevent asphyxia. To prevent aspiration of vomitus, a nasogastric tube should be inserted, aspirated and left on free drainage. Breathing must be supported. High-flow oxygen should be administered to correct hypoxia. Regular blood pressure and pulse measurements are necessary. A cardiac monitor should be connected to the patient to \detect the effects of potassium replacement (hypokalaemia can lead to heart block, hyperkalaemia can cause ventricular fibrillation). Assessment of neurological function must also be made. The Glasgow Coma Score should be used to assess for responsiveness. Rapid acting insulin should be administered via an IV sliding scale to correct hyperglycaemia and ketonaemia.

Box 1. Sick-day rules

Blood glucose should be monitored hourly to evaluate response to insulin therapy. Sodium and potassium need to be replaced due to losses caused by vomiting and diuresis. Potassium is mainly an intracellular ion and there is always depletion of total body potassium. Once insulin is commenced, levels in the blood will fall further. IV fluids are prescribed to rehydrate the patient and correct hypovolaemia. Monitoring central venous pressure, blood pressure and hourly urine volumes will give an indication of the effects of rehydration. A urinary catheter will need to be inserted if the patient is unconscious or oliguric. A thorough nursing assessment is essential in the management of DKA to help identify precipitating factors. This can be obtained from relatives if the patient is unable to provide it. Once identified, these factors may help to avoid recurrence of DKA.

Patient education

In line with standard 3 of the National Service Framework for Diabetes (DoH 2003), the emphasis of patient education is empowerment and self-care. Self-care is also explored in the NHS Plan (DoH 2000), where the aim is for patients to be active participants and decision-makers in health care. It is essential that patients have a good understanding of diabetes to effectively self-manage their condition. Diabetes UK (2004) advocates that all people with diabetes should receive education and support to enable self-management. The education provided must be ongoing, consistent, up-to-date and individualised. Most cases of DKA can be prevented by effective self-management, thus reducing incidence, morbidity and mortality. Jervell (1996) claims that education can prevent 70 per cent of DKA episodes. Patients, therefore, need to be well informed about diabetes management to prevent further episodes of DKA. On discharge from hospital, it is imperative that patient education is reinforced by primary care follow-up. Gillespie and Campbell (2002) suggest that knowing the correct management during concurrent illness and regularly monitoring blood glucose levels enable patients to prevent further admissions with DKA.

Conclusion

Diabetic ketoacidosis is a medical emergency that without treatment can lead to coma and death. Prompt, skilled management is crucial. The nurse’s ability to recognise the clinical features of DKA can have a positive effect on patient outcomes. It is therefore important for nurses to understand the signs, symptoms and treatment of this condition

Acknowledgement

The author would like to acknowledge the advice and support provided by Cassie Dean, staff nurse and Niki Robinson, practice development nurse for diabetes.

Palmer R (2004) An overview of diabetic ketoacidosis. Nursing Standard. 19, 10, 42-44. Date of acceptance: September 16 2004.

Online archive

For related articles and author guidelines visit our online archive at: www.nursing-standard.co.uk and search using the key words above.

REFERENCES

Biggs M et al (1994) Insulin withholding for weight control in women with diabetes. Diabetes Care. 17, 10, 1186-1189.

Department of Health (2003) National Service Framework for Diabetes Delivery Strategy. London, The Stationery Office.

Department of Health (2000) The NHS Plan: A Plan for Investment, A Plan for Reform. London, The Stationery Office.

Diabetes UK (2004) Position Statement. Education of People with Diabetes to Support Effective Self-management. www.diabetes.org.uk/ infocentre/stat e/pwdselfmanage.htm (Last accessed: October 13 2004.)

EURODIAB IDDM Complications Study Group (1994) Microvascular and acute complications in IDDM patients: the EURODIAB IDDM Complications Study. Diabetologia. 37, 3, 278-285.

Gillespie G, Campbell M (2002) Diabetic ketoacidosis. Rapid identification, treatment, and education can improve surviva rates. American Journal of Nursing. 102, 9 Suppl, 13-16.

Goldberg P et al (2004) Implementation of a safe and effective insulin infusion protocol in a medical intensive care unit. Diabetes Care. 27, 2, 461-467.

Houghton A, Gray D (2001) Making Sense of the ECG: A Hands-on Guide. London, Arnold.

Jerreat L (2003) Diabetes for Nurses. London, Whurr.

Jervell J (1996) Education is as important as insulin, oral drugs and proper food for people with diabetes. Practical Diabetes International. 13, 5, 142.

Lewis R (2000) Diabetic emergencies: Part 2. Hyperglycaemia. Accident and Emergency Nursing. 8, 1, 24-30.

MacKinnon M (2003) Empowering people with diabetes helps them make informed choices. Professional Nurse. 19, 3, 168-170.

Marmac J, Mesa L (2000) Using a severity of illness scoring system to assess intensive care unit admissions for diabetic ketoacidosis. Critical Care Medicine. 28, 7, 2238-2241.

McIntyre R (1996) Diabetes. In Alexander M et al (Eds) Nursing Practice Hospital and Home: the Adult. London, Churchill Livingstone.

Miller J (1999) Management of diabetic ketoacidosis. journal of Emergency Nursing. 25, 6, 514-519.

Page S, Hall G (1999) Diabetes: Emergency and Hospital Management. London, BMJ Books.

Pickup J, Williams G (Eds) (2003) Textbook of Diabetes. Third edition. Oxford, Blackwell Science.

Singh R et al (1997) Hospital management of diabetic ketoacidosis: are clinical guidelines implemented effectively? Diabetic Medicine. 14, 6, 482-486.

Williams G, Pickup J (2004) Handbook of Diabetes. Third edition. Oxford, Blackwell Science.

Richard Palmer RN, Dip HE is staff nurse, St Richard’s Hospital, Chichester, West Sussex.

Copyright RCN Publishing Company Ltd. Nov 17-Nov 23, 2004

Histoplasma capsulatum is an important pathogen that is the most commonly diagnosed endemic mycosis in the gastrointestinal tract of immunocompromised hosts. Failure to recognize and treat disseminated histoplasmosis in AIDS patients invariably leads to death. Gastrointestinal manifestations frequently involve the terminal ileum and cecum, and depending on the layer of bowel wall involved present as bleeding, obstruction, perforation, or peritonitis. Because they can be variable in appearance, they may be mistaken for Crohn’s disease or malignant tumors. Four distinct pathologic patterns of GI histoplasmosis have been described that all have differing clinical presentations. We report a case of a non-AIDS patient who presented with a near-obstructing colonic mass suspicious for advanced malignancy but was found to have histoplasmosis on final pathology. The patient underwent successful operative resection, systemic anti-fungal therapy, and extensive workup for immunosuppressive disorders, which were negative. The patient was from an area in Mexico known to be endemic for histoplasmosis. This is the first report of a colonic mass lesion occurring in a non-AIDS patient, and review of the worldwide literature regarding GI histoplasmosis reveals excellent long-term survival with aggressive therapy. We discuss the surgical and medical management of colonic histoplasmosis in this report.

HISTOPLASMA CAPSULATUM is the most commonly diagnosed endemic mycosis in the gastrointestinal tract of immunocompromised hosts, specifically AIDS patients.1 In the immunocompetent patient, inhalation of spores leads to a self-limited respiratory infection, but in the immunocompromised patient, disseminated histoplasmosis can occur. Gastrointestinal involvement occurs in 50-70 per cent of cases of disseminated histoplasmosis due to hematogenous seeding of the GI tract and manifests as a wide variety of clinical presentations.2 The terminal ileum and cecum are typically involved, and patients present with nonspecific findings such as bleeding, obstruction, or chronic pain. In this report, we discuss a case of a nonimmunocompromised patient who presented with a nearobstructing colonic mass suspicious for malignancy but demonstrated histoplasmosis on final pathology.

Case Report

A 52-year-old female with end-stage renal disease due to hypertension and type II diabetes complained of 3 months of constipation, vague abdominal pain, mild weight loss, and fatigue. Physical examination revealed a thin female with normal vital signs and normal abdominal findings. Rectal exam did not reveal any masses, but she was found to have guaiac-positive stools. Laboratory results were white blood cell count 5900/cc, hemoglobin 11.3 g/dL, hematocrit 33.5 per cent, platelet count 399,000/cc, alkaline phosphatase 84 TU/L, serum albumin 2.7 g/dL, and CEA 0.8 g/L. Upper endoscopy showed mild gastritis, and colonoscopy showed a near- obstructing, fungating mass in the midtransverse colon as well as an irregular mass in the cecum, both suspicious for malignancy (Fig. 1). Biopsies were done, and the transverse colon mass demonstrated tubular adenoma, and the cecal mass biopsy showed tubular adenoma with severe dysplasia. The cecum and distal transverse colon appeared thickened on a CT scan of the abdomen and pelvis (Fig. 2), but there was no evidence of metastatic disease or lymphadenopathy. Surgical intervention was discussed with the patient and her family in order to relieve the obstruction as well as for definitive treatment of a presumed malignancy.

FIG. 1. Endoscopic view of transverse colon muss suspicious for malignancy. Biopsy showed tubular adenoma. Final surgical pathology demonstrated histoplasmosis.

After bowel preparation, the patient underwent exploratory laparotomy and subtotal colectomy with ileosigmoid anastomosis. Intraoperative findings included the cccal and transverse colon mass suspicious for malignancy as well as peritoneal studding throughout the mesentery and small bowel consistent with carcinomatosis. The patient recovered in the postoperative period without incident. Histopathologic analysis revealed a Tl adcnocarcinoma of the eeeal mass with O out of 20 lymph nodes positive for malignancy, making the stage TlNOMx. The transverse colon mass interestingly did not demonstrate carcinoma, and instead histoplasmosis was identified in the thickened, narrowed colon.

FIG. 2. Conipiiled tomography scan of abdomen and pelvis showing thick-walled cecum that on final pathology was a T1 adenocarcinoma with evidence of histoplasmosis throughout colonie specimen.

Infectious disease consultation was obtained, and the patient was noted Io be from an area of Mexico endemic for histoplasmosis. Her urine Hisloplamna antigen was positive at 1.38 units, and her serum Hisloplcisma antibody was 0.57 units. Chest X-ray and chest CT did not show pulmonary manifestations of histoplasmosis. She was treated with amphotericin B initially and then switched to oral itraconazole as an outpatient. Serum HIV test was negative on three separate occasions, and she has been doing well 1 year postoperatively without any evidence of recurrence.

Pathology

The specimen consisted of a 75-cm length of right, transverse, and left colon that was 13 cm in maximum diameter. On cut section there was a tan-brown hemorrhagic, soft mass measuring 9 8 4 cm in the cecum, with 4 cm of proximal free margin of terminal ileum. The serosal surface near this mass appeared thickened. Multiple small nodules, ranging from 0.2 to 0.5 cm, as well as extensive ulceration were noted within the mucosa. The transverse colon stricture measured three by 6 cm and was located near the splenic flexure (Fig. 3). It showed marked diffuse thickening of the colonie wall and was noted to be nearly obstructing with focal ulcerations.

Final pathology of the cecal mass showed adenocarcinoma arising from a villous adenoma with superficial invasion of the submucosa. No tumor was identified in 20 lymph nodes. No carcinoma noted in the peritoneal biopsies, making the pathologic stage of the cecal cancer TlNOMx . Most of the lymph nodes did contain caseous necrosis and granuloma formation with histoplasmosis present (Fig. 4). Histoplasmosis was found scattered throughout the terminal ileum, cecum, and rest of the colon (Figs. 5 and 6). Small pseudopolyps found in the ascending colon mucosa demonstrated lymphoid aggregates that contained histoplasmosis-containing histiocytes. The transverse colon stricture was found to have histiocytic nodules in the mucosa and caseating granulomata involving the muscularis propria, subserosa, and multiple lymph nodes. The terminal ileum and appendix were also involved with hisloplasmosis, but the proximal margin of the specimen was free of infection.

FIG. 3. Gross picture of transverse colon specimen showing stricture and wall thickening with dilated proximal segment and collapsed distal bowel.

FIG. 4. Transverse eolon stricture due Io hisloplasmosis. Low- power view showing caseating granuloma in the muscularis propria as well as transmural inflammation with pericolitis (H&E stain, magnification 31).

FIG. 5. High-power view of strictured colon segment demonstrating intracellular Histoplasma. The organisms are loeated within histiocytes (black arrow) and multinuclcated giant cells (clear arrow). Note the characteristic halo surrounding the organism (H&E stain, magnification 1560).

Discussion

Histoplasma capsulatum is a ubiquitous soil-dwelling saprophyte that is found worldwide, but in the United States is endemic to the Ohio, Missouri, and Mississippi River Valleys. The respiratory tract is the primary site of infection. When the disease becomes disseminated, there is hematogenous seeding into the GI tract that is highly morbid if left untreated.1 More than 70 per cent of AIDS patients will have presence of GI histoplasmosis in the colon found on autopsy, but clinical symptoms will typically develop in only 10- 45 per cent of patients.2 Disseminated histoplasmosis is exceedingly rare in the immunocompetent patient, and presentation in this setting requires an extensive workup for an immunocompromised state.

FIG. 6. Electron microscopy of Histoplasma organism showing nucleus, mitochondria, and capsule (magnification 20,000).

The diagnosis is most accurately established by tissue culture or histological identification of the biopsy specimen. Urine assay for the antigen can be performed rapidly, which is highly sensitive in establishing the diagnosis and assessing the therapeutic response in patients with disseminated histoplasmosis. Serum antibody titers are less sensitive, and serologies may not even be positive in the AIDS patient. Isolating the organism in blood or bone marrow is time- consuming and sometimes takes up to 8 weeks for identification.

The mainstay of therapy for disseminated histoplasmosis with GI involvement is systemic antifungal therapy. Amphotericin is given with a recommended cumulative dose of I to 2 g followed by long- term suppressive therapy with oral itraconazole. The risk of relapse is significantly reduced by maintenance therapy.3 The disease is highly treatable, a\nd most patients remain symptom-free after therapy for 12 to 24 months, emphasizing the importance of accurate diagnosis and prompt treatment.

Pour distinct patterns of GI histoplasmosis have been described each with differing clinical presentations.”4 First, subclinical infection without gross abnormality but the presence of fungi in the lamina propria can be found on biopsy. The second variety involves the presence of small pseudopolyps and plaques that is due to aggregates of parasitized macrophages. A third group is characterized by discrete ulcerations in the mucosa. Last, there can be focal thickening of the bowel, similar to the patient in this report, that mimics a colonie mass suspicious for malignancy or Crohn’s disease and can lead to obstructive symptoms

The presentation of GI histoplasmosis as a colonie mass or stricture is rare, and review of the literature reveals less than 20 patients who have this clinical picture (Table I). The diagnosis of histoplasmosis for such patients is usually is made after surgical resection, and it has been suggested that this subset of patients is unlikely to resolve with antibiotics alone.5 In a review of 52 patients at one hospital with disseminated GI histoplasmosis, three (6%) presented with an obstructing colon mass and required surgical resection.6 Out of 77 patients in a review of the literature of disseminated histoplasmosis, six (8%) presented as an obstructive mass or stricture in the colon.2 In some of these patients, the obstructing mass was their first presentation of AIDS, and they initially underwent attempted curative surgical resection with the presumed diagnosis of malignancy. All of the previous patients described in the literature had a documented immunocompromiscd state.

Our patient is interesting in that she is the first ease report of colonie histoplasmosis presenting as a mass or stricture without a documented immunodeficiency, such as AIDS, Job’s syndrome, chronic steroid use, or chemotherapy (Table 1). Although this patient did have renal failure requiring dialysis, such patients are typically not prone to develop opportunistic infections unless they are transplant recipients or have concomitant HlV infection.7 This patient also had a Tl adenocarcinoma of the cecum, and the previously described cases in the literature did not reveal any other synchronous malignancies. Like many of the previous cases, the diagnosis of histoplasmosis was only made after surgical resection.

In summary, the varied presentations of GI histoplasmosis in the immunocompromised patient require prompt and aggressive treatment. Any HIV-positive patient with nonspecific abdominal complaints is at risk for opportunistic infections of the colon, and histoplasmosis should be in the differential. Also, the diagnosis should be considered in patients not known to be immunocompromised but from an endemic area of histoplasmosis. Colonoscopy and biopsy should be obtained that confirm the diagnosis. Urine assay for Histoplasma antigen and serum antibody liters also aid in the diagnosis. Although antibiotics are effective, failure to improve or inability to rule out malignancy mandates surgical resection as if the lesion is a cancer. Long-term maintenance therapy with antifungal medication should be instituted to prevent relapse.

TABLE 1. Reported cases of Colonie Histoplasmosis Presenting as a Mass-Like Lesion

REFERENCES

1. Suh KN, Anekthananon T, Mariuz PR. Gastrointestinal histoplasmosis in patients with AIDS. Clin Infect Dis 2001;32: 483- 91.

2. Cappell MS, Mandell W, Grimes MM, Neu HC. Gastrointestinal histoplasmosis. Dig Dis Sei 1988;33:353-60.

3. Wheat J, Hafner R, Wulfsohn M, et al. Prevention of relapse of histoplasmosis in patients with AIDS. Ann Intern Med 1993; 118:610- 6.

4. Spivak H, Schlasingcr MH, Tabanda R, Ferstenberg H. Small bowel obstruction from GI histoplasmosis in AIDS. Am Surg 1996;62:369-72.

5. Graham BD, McKinsey DS, Driks MR, Smith DL. Colonie histoplasmosis in AIDS. Dis Colon Rectum 1991;34:185-90.

6. Lamps LW, Molina CP, West AB, et al. The pathologic spectrum of gastrointestinal and hepatic histoplasmosis. Am J Clin Pathol 2000; 113:64-72.

7. Ahuja TS. O’brien WA. Special issues in the management of patients with ESRD and HIV infection. Am J Kidney Dis 2003; 41:279- 91.

8. Hertan H, Nair S, Arguello P. Progressive gastrointestinal histoplasmosis leading to colonie obstrusction two years after initial presentation. Am J Gastroenterol 2001;96:221-2.

9. Hung CC, Wong JM, Hsueh PR, et al. Intestinal obstruction and peritonitis resulting from gastrointestinal histoplasmosis in an AIDS patient. J Formes Med Assoc 1998;97:577-80.

10. Mullick SS, Mody DR, Schwartz MR. Cytology of gastrointestinal histoplasmosis. Acta Cytol 1996;40:989-94.

11. Hofman P, Mainguene C, Heurre M, et al. Colonie histoplasma capsulatum pseudotuinor in AIDS. Arch Anat Ctyol Palhol 1995;43:140- 6.

12. Cimponeriu D, LoPresti P, Lavelanet M, et al. Gastrointestinal histoplasmosis in HIV infection. Am J Gastroenterol 1994; 89:129-31.

13. Balthazar EJ, Megibow AJ, Barry M, Opulencia JF. Histoplasmosis of the oclon in patients with AIDS. AJR 1993; 161: 585-7.

14. Khalil M, Iwatt AR, Gugnani HC. African histoplasmosis masquerading as carcinoma of the colon. Dis Colon Rectum 1989; 32:518-20.

15. Alberti-Flor JJ, Granda A. Ileocecal histoplasmosis mimicking Crohn’s disease in a patient with Job’s syndrome. Digestion 1986;33:I76-80.

16. Lee SH, Barnes WG, Hodges GR, Dixon A. Perforated granulomatous colitis caused by Histoplasma capsulatum. Dis Colon Rectum 1985;28:171-6.

17. Miller DP, Everett ED. Gastrointestinal histoplasmosis. J Clin Gastroenterol 1979; 1:233-6.

18. Eee KR, Lin F. Gastrointestinal histoplasmosis. Am J Gastroenterol 1975;63:255-65.

JASON T. LEE, M.D.,* MATTHEW R. DIXON, M.D.,* ZURI MURRELL, M.D.,* VIKEN KONYALIAN, M.D.,* RODOLFO AGBUNAG, M.D.,* SASSAN ROSTAMI, M.D.,[dagger] SAMUEL FRENCH, M.D.,[dagger] RAVIN R. KUMAR, M.D.*

From the * Department of Surgery and [dagger] Department of Pathology, Harbor-UCLA Medical Center, Torrance, California

Presented at the Annual Meeting, Southern California Chapter of the American College of Surgeons, January 16-18, 2004, Santa Barbara, California.

Address correspondence and reprint requests to Ravin R. Kumar, M.D., Chief, Division of Colorectal Surgery, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 25, Torrance, CA 90509.

Copyright The Southeastern Surgical Congress Nov 2004

IT’S the season for a bit of Christmas cheer but that doesn’t have to mean a few weeks of hangovers and shameful behaviour.

You could actually benefit from a moderate tipple because new research shows it can help you live longer and be 30 per cent more likely than a teetotaller to survive a heart attack. You can also expect to enjoy better general health, too.

Sensible drinking can provide a range of other surprising health benefits. So, as we enter the season to be merry, here are some festive favourites that are actually good for you…

MULLED WINE

Protects against heart disease

MAKE this your occasional tipple at Christmas and you’ll look after your heart.

Red wine drinkers could reduce their risk of heart disease by as much as 50 per cent.

In moderation, any alcohol can raise levels of “good” cholesterol in the blood.

But the extra benefit of red wine comes from the flavonoid antioxidants it contains, which help prevent clots and protect against artery damage.

SHERRY Lowers cholesterol

SPANISH scientists established that drinking a glass of sherry every day could decrease the amount of bad cholesterol in the body, because the drink is packed with antioxidants.

BUCKS FIZZ

Fights a cold

MAKE a bucks fizz with 125ml of orange juice and champagne and you’ll get the full recommended daily allowance of immune-enhancing vitamin C.

Small quantities of alcohol are also known to enhance immunity, so the combo is perfect if you’re feeling under the weather.

SEA BREEZE Prevents cystitis

THE cranberry juice helps fight urinary infections such as cystitis. About 300ml (equivalent to a couple of large cocktails) significantly reduces the incidence of infections in women, according to research in the Journal Of The American Medical Association.

Cranberries contain proanthocyanidins, which stop infection- causing bacteria such as Ecoli sticking to the bladder wall.

BEER Boosts your bones

RESEARCH at King’s College and St Thomas’ hospital in London found that silicon in the diet is directly linked to bone strength.

As beer is one of the richest sources of silicon, a pint a day may be an effective way to keep your bones strong and protect against osteoporosis.

And taking out the alcohol doesn’t remove the nutrients, so you can have low-alcohol beers and still benefit.

GIN Beats the bloat

THE juniper berries which flavour gin were originally a herbal remedy for diseases of the kidneys and liver.

They have a diuretic action that make you need the loo more often. Because of this, gin can offer a short-term solution to bloating – especially in women with PMS.

CIDER Fights anaemia

CIDER can reduce your chances of developing iron-deficiency (symptoms include weakness, fatigue, lack of concentration and dizziness).

That’s because just one pint of sweet or dry cider supplies one fifth of the recommended daily allowance of iron.

WHISKY Helps you sleep

DOCTORS often recommend a hot toddy to help induce sleep.

It works because the whisky helps you relax and the warm drink is soothing to your sinuses.

Adding a spoonful of honey and lemon will also help to beat a sore throat.

A Scotch is also one of the most waistline-friendly alcoholic drinks, with a single shot supplying only 55 calories.

VODKA Good for allergies

IT’S so highly distilled and purified that even people with a sensitive gut or multiple allergies can tolerate it.

So if you’re gagging for a drink but need a sugar-free, yeast- free option, go for vodka.

It’s also less likely to give you a hangover – one analysis found that vodka had only one six-thousandth of the content of headache- inducing toxic methanol as bourbon.

GUINNESS Helps you convalesce

ALL that talk about Guinness being good for anaemia is blarney (the black colour comes from roasted, malted barley, not iron). But there’s truth in the idea that Guinness can help you convalesce.

It taste good and, like all alcohol, it boosts appetite, so if you’ve lost yours due to illness, it can help build you up again.

WHITE WINE Eases joint pain

THIS contains substances called tyrosol and caffeic acid, which are also in extra virgin olive oil.

According to Italian studies, these can help suppress the inflammatory reaction that occurs in rheumatoid arthritis.

BLOODY MARY Protects against cancer

TWO Bloody Marys containing 125ml tomato juice each provides the recommended daily intake of lycopene – an antioxidant linked with lower rates of prostate cancer in men. Lycopene can also protect against lung, colon and breast cancer.

LAGER Good for low-carb dieters

MOST standard lagers have only a trace of carbohydrate (compared with 12.4g in a pint of bitter) so they’re perfect if you’re following an Atkin’s-style diet.

But premium lagers have as much or more carbs than beers, so you’ll need to look for a special low-carb version.

SHAKEN MARTINI Fights ageing

CANADIAN scientists found that James Bond’s favourite tipple had, for some reason, better antioxidant properties than a stirred one.

They also found that the mixed ingredients – equal parts vermouth and gin – were better at combating free radicals (linked with cancer and premature ageing) than either drink on its own. Which could explain why 007 always has so much energy…

..and here are a few tipples you may regret

JACK DANIEL’S

A BOURBON, which means it has been aged in charred oak barrels and picked up lots of chemical extracts along the way.

As a result, it has one of the worst reputations for giving you a hangover.

BAILEYS

IN a 50ml serving there are 175 calories and 7.8g of fat.

That’s one fifth of a woman’s and one sixth of a man’s daily guideline intake of saturated fat.

If you can’t resist, drink only in pubs, where the measures are controlled.

BRANDY ALEXANDER

COMBINE brandy – a drink with a high chance of giving you a hangover – with fattening cream, plus creme de cacao, and you get a hefty old drink. Best in strict moderation.

ALCOPOPS

IT’S too easy to knock them back as you would a soft drink – and an average bottle has around 200 calories and 1.5 alcohol units. So opt for Diet Bacardi Breezer instead at only 96 calories.

Geraldine Green is living proof that you can do anything you put your mind to.

The 57-year-old Green, the mom of hip-hop star Busta Rhymes, recently lost more than 100 pounds and uses her experience as an example for others fighting obesity.

On November 1, 2002, Green began her diet weighing 328 pounds. She is 5foot-9. She reached her goal weight of 183 pounds August 6,2003, and has kept off the 145 pounds for more than a year now. “It wasn’t easy, but with dedication, lots of prayers and exercise, I made it,” Green tells JET.

One of the events that persuaded her to take on a diet plan occurred in 1997. Green was diagnosed with diabetes. “My husband is a diabetic and I said one of us has to be healthy to take care of the other, so I decided I was going to try to lose weight,” Green relates.

“It took three months of me praying and thinking day and night about this diet and finally coming to terms with myself, because it’s all in your head.”

Green keeps a strict routine to help keep the pounds off. “I don’t call it a diet, this is my new lifestyle,” she explains. “I’m maintaining by cutting out [carbohydrates], having vegetables and salads and I watch portion size. When I do have fruit, if it’s a big apple, I will have a half. I drink a lot of water. I eat beans and fish. I don’t cook with a lot of grease; I bake, broil, I steam, I rarely fry. No cakes, no bread, no pasta, nothing like that. I go to the gym five days a week and run four miles on the treadmill and lift weights Monday through Friday before I come to work.

* Geraldine Green is happy she reached her goal size 12 from a size 28 after grudgingly changing the way she eats and exercising. She is thrilled to share her experience with others fighting obesity. “I thank God every day for the new me and the healthy lifestyle I have chosen,” she says.

* After being diagnosed with diabetes, Green began her diet weighing 328 pounds. “I did it one day at a time, baby steps, and for eight months and one week, I never cheated once.”

* After being diagnosed with diabetes, Green began her diet weighing 328 pounds. “I did it one day at a time, baby steps, and for eight months and one week, I never cheated once.”

* Green’s son, rapper/actor Busta Rhymes, was one of her biggest supporters in the early days of her new “lifestyle” and still is. “Every day my children and husband tell me how proud they are of me.”

“Can you see me girl dancing at the club now with my 3-inch heels, dancing all night, running up the stairs, running down the stairs? It’s a new me!”

Green, who no longer needs to take diabetes medication, urges others to take it one day at a time and to take baby steps.

“Anyone who wants to lose weight, they can do it. It is so hard, and cold turkey is not for everyone,” says the New Yorker, who went from a size 28 to 12. “It took me praying about it day and night, so I was mentally prepared. You have to plan your meals. You can’t wait until you’re hungry because you’ll cheat. Cut back and eat less carbs every day and less starch per week. Start to fill up on broth, salads and vegetables. It’s all a game, you just have to stick to it and you will lose weight. It takes discipline and perseverance. I’m living proof.”

Green adds that when she goes to the gym, it helps to not consider it a chore. “I pretend it’s a party. I listen to my favorite CDs. I get my Best of James Brown and C+C Music Factory. I get there, close my eyes and pretend I’m dancing at a party. It’s a blessing and I’m grateful every day for the strength.”

Copyright Johnson Publishing Company Nov 22, 2004

FACED WITH THE PROSPECT OF IMMINENT DEPARTURE TO SERVE IN THE Confederate army, North Carolina farmer John Fletcher Flintoff instructed his family on life and faith in his diary entry of March 10, 1864: “I desire that you live on the premises I leave you and work the land to make your support-Rember my Father was a poor man- He was not able to leave his children anything to start upon the journey of life but I leave you 217 acres of land, 7 negroes, 3 good horses, 6 head of cattle 15 hogs and wagons, house & kitchen well furnished, plantation tools, etc.-a years supply of everything-I exhort you to be industrious, kind, persevering, thoughtful, economical, love and serve God and good to each other.”1 Fortunately, the forty-year-old Flintoff saw only local service, survived the war, and lived into the new century, all the while living as he preached, by hard work and through love of family and God. As the postwar years passed, his estate grew, revealing, he believed, God’s favor in his ability to work for his children and their families and help them through their “journey of life.”

Flintoff knew hard, manual labor as a young farmhand, as a struggling farm owner, and even as an elderly patriarch content with his fields, barns, and work stock. In reflections in his diary, especially on the anniversary of his birth, he recalled his early struggles in North Carolina and Mississippi, when he worked for wages or managed relatives’ farms and plantations. Fondly did he hope that laboring for others would not be the lot of his children. As a poor boy, faith sustained him. He later urged his children to be religious and join the church when young, as he did by becoming a Methodist at age ten. Believing that education bolstered faith and opened opportunities, he attended Centenary College in Jackson, Mississippi, for two years. Back in North Carolina in 1850, he married Mary Pleasant of Caswell County and began to acquire slaves and livestock. Four years later at age thirty-one, having toiled long and hard, saved, purchased slaves, and borrowed heavily, he bought a farm and house of his own. Working beside his slaves, he performed all of the tasks necessary on a small piedmont farm: he raised corn, wheat, and oats; grew fodder for his animals; primed, topped, wormed, and harvested substantial tobacco crops; hewed logs and built houses, barns, wagons, and outbuildings; hauled logs and tobacco; and in winter made shoes for the family. And he prospered. “I want to try to make money to pay my debts. I work hard to do this with my heart raised up to God to his blessing,” he recorded in 1856. Postwar labor adjustments proved difficult; in his view free blacks would not work honestly or steadily for wages, while whites faced the rigors of excessive work from dawn to dark. He resented idleness, even when found in his dearly beloved wife, whom he feared lived too much the life of a lady. In 1890 Flintoff boasted of a good year’s work for his age and in 1891 recorded that “I am at work now in the field with the hoe 9 to 10 hours per day and am very thankful 1 am as well as 1 am and humbly trust in God for the future.”2

Flintoff’s life, steeped in faith and focused on hard, manual labor of the sort performed by slaves, reflected not one iota of the dictum that southerners derogated manual labor because it was, in the common idiom of the day, “nigger work.” Flintoff was not a planter, and he was not rich; neither was he representative of the southern rural masses since his achievements in accumulating slaves and property and passing his wealth to his children were substantial. His work ethic, however, was shared by the masses of rural plain folk from whom he had emerged-those who worked with their hands and performed field labor even though some of them also benefited from ownership of a small number of slaves. Flintoff knew hard work and believed it honorable. On the one hand, his work was not menial labor. That was drudgery performed for another or directed by another, for which the worker received minimal benefit and profited but little in the long run-work typically performed by slaves. Manual labor performed at one’s own behest and for the benefit of one’s own family, on the other hand, was admirable. Mucking out one’s barn, surely among the least pleasant farm tasks, was part of honorable work, given the right circumstances. Honorable work enabled Flintoff and his peers to attain that secure, independent existence that was the minimal goal of all. Logically a slave society might be expected to diverge significantly from Max Weber’s Protestant ethic and reject outright many of Benjamin Franklin’s precepts, but at the heart of the antebellum southern farmer, respect for hard work, independence, and the ability to provide for one’s own were core values. Antebellum southern spokesmen might celebrate the leisured lifestyle of a planter elite and proclaim the virtues of an aristocratic existence even as Yankees and a few southerners denounced lazy white “trash,” but farmers who earned their red necks honestly by steady labor, in season and out, understood the value and rewards of daily toil. Plain-folk endorsement of hard work, part of plain-folk honor, created a discordant note that was at best ill suited to those who championed a distinctly non-Yankee South dedicated to gracious living. An examination of the labor of the plain folk and their attitudes and values, however, reveals that John Flintoff’s work ethic was shared by the southern masses. Many of these attitudes resonated deep into the elite by the late antebellum period.

While the omega of historical insight into the work ethic has not been reached, the alpha originated with Max Weber in The Protestant Ethic and the Spirit of Capitalism, the famous essay that inaugurated a one-hundred-year debate (or hopelessly futile academic squabble) over the spirit of capitalism and the nexus of capitalism and religion. Weber’s Protestant ethic emphasized the moral obligation to work to glorify God and the methodical use of every God-given moment of time. God called everyone to productive labor- to a world of hard, unending, physical or mental work-and the greatest of sins was idleness. Because the result of labor might be wealth and consequent idleness, asceticism became a way of life-an asceticism that rejected leisure and the spontaneous enjoyment of life.3 While critics of Weber’s thesis have dominated the scholarly melee, one recent authority maintains that “it is just as difficult to demolish Weber’s thesis as it is to substantiate it.”4 Despite partisan contention, the thesis has influenced scholarly thinking as well as popular conceptions concerning the relationship of economic progress, the valuation of work, and religious faith. Weber’s idea has been used to buttress historical images of Yankee drive and southern sloth. Although Weber intended his analysis as an objective evaluation and not as an admiring moral judgment, many antebellum Americans (and some scholars since) attached their own positive value to the key traits that Weber identified as forming the Protestant ethic.

Weber and subsequent writers located the strongest bastion of the Protestant ethic in Puritan New England and Quaker Pennsylvania, but few had anything positive to say about the moral value of work in the land of cotton and slaves. Historian Edmund S. Morgan, however, voices a dissenting view, arguing that the Puritan ethic-that cluster of values, ideas, and attitudes advanced by Weber- influenced all Americans by the time of the Revolution. Nevertheless, Morgan emphasizes “the evil effect of slavery on the industry and frugality of both master and slave . . . .” Among southerners, he holds, slavery “eroded the honor accorded work . . . .”5 But did the plain folk, whom Morgan does not discuss, suffer from the stigma on work supposedly inherent in a slave society? Both Rhys Isaac and Christine Leigh Heyrman suggest that yeomen developed immunity to slavery’s presumed debilitating effect, stressing the influence of the First Great Awakening in fostering a more Weber- like attitude in the South. Conversion to an evangelical faith encouraged, even sanctified, a simple life richer in spiritual than material rewards and thus challenged if not transformed the hedonistic lifestyle of the planter leadership.6

Although the intensity of religiosity in early New England and the concept of work as God’s calling declined as the country embraced secularization in the age of Jackson, the Second Great Awakening in both the North and South rekindled earlier faith. Simultaneously, a market revolution encouraged dedication to work and economic advancement. Many people lived with both a secular ethic and an ethic attuned to faith; sometimes an individual’s work ethic had a reinforcing religious dimension, though at other times it did not, leaving a Weberian ethic without asceticism. According to Daniel T. Rodgers, a work ethic remained “the core of the moral life,” finding its strongest affirmation among the Protestant bourgeoisie. It was “the distinctive credo of preindustrial capitalism” entrenched in “artisans’ shops, farms, and countinghouses.” Rodgers identifies four ingredients in the midnineteenth-century work ethic: “the doctrine of usefulness”; “an intense, nervous fear of idleness” (b\oth of which were “legacies of the Reformation”); “the dream of success”; and “a faith in work as a creative act.” The South, Rodgers discovers, was considered a deviant society. When the dignity of labor emerged as a distinctive feature of northern politics and culture, Republican leaders and other middle-class spokesmen savaged the South for its perversion of values, poverty and degradation of the masses, and general economic backwardness. Abolitionist criticism and Republican rhetoric best encapsulated the southern ethic: “shiftlessness and exploitation were the rule.” The South reflected “a nightmarish inversion of Northern work values, where idlers ruled and laborers stood in chains.”7

In 1967 David Bertelson’s The Lazy South pronounced judgment upon the South’s work ethic. Bertelson argues that southerners’ penchant for leisure and idleness was caused by what he labels the doctrine of “allurement,” not by the traditional suspects of slavery, climate, disease, or parasites. The virgin lands of the earliest southern colonies attracted Englishmen with the allure of fortunes to be made in the international tobacco trade. When the Old World’s demand for tobacco met the opportunity abounding in the new lands, unrestricted freedom to enrich oneself resulted in fortunes for many and created a rigid adherence to individualism with a consequent lack of community spirit that boded poorly for socially useful labor. Thus southerners were attentive to self-interest, not the common good; the inducement to work came not from within but from the promise of material reward. Virginians, Marylanders, and later South Carolinians and other southerners busily set about exploiting natural resources and labor and expanding farms and plantations; the end of labor was personal wealth and leisure, not salvation, godly community, or local or regional economic development.8

C. Vann Woodward joined this discussion in 1968, arguing for the existence of a distinct southern ethic within a Puritan world. Woodward’s southern ethic deviates from the concepts of Weber or maxims of Franklin and scores high on leisure or laziness, depending on whether one opts for “an attractive” or “an unattractive countenance” of the mythical “Janus-faced” South. With his typically telling and witty commentary on the relevant literature, especially the work of Bertelson and Morgan, Woodward offers several hypotheses in explanation of the southern leisure-laziness ethic but attributes special salience to the impact of slavery. Evidence of southern distinctiveness, in this instance leisure-laziness, was everywhere: “Where there is so much smoke-whether the superficial stereotypes of the Leisure-Laziness sort, or the bulky literature of lamentation, denial, or celebration that runs back to the seventeenth century, or the analytical monographs of the present day-there must be fire.”9

For most historians who have analyzed agriculture, labor conditions, and slavery in the Old South, the existence of a flawed work ethic-if there was a work ethic at all-is axiomatic. Some stress the leisured aspects of the South, others the lazy aspects. To Eugene D. Genovese, writing in 1965, a dominant planter elite, commanding politics and setting the tone for social life, fastened aspirations to luxury and ease upon the Old South. Even aggressive, nouveau southwestern planters, the southern Yankees, reflected merely a time lapse and not a strong work ethic; these hardworking farmers, planters to be, were only a generation removed from refinement and aristocratic graces. Genovese concludes that slavery inevitably produced feelings of contempt for all labor and especially menial labor-labor performed for another.10

Leisure and laziness surface in extreme form in the works of historian Grady McWhiney, who argues that planters and plain folk alike, as descendants of Celts notoriously unburdened by a work ethic, avoided steady labor-rigorously, constantly, and conscientiously. McWhiney agrees with one visitor to the South who concluded that the word haste was not in the southern vocabulary. Careless, unhurried farmers and herdsmen lived lavishly upon the abundance of field and forest and the labor of an ample supply of bondpeople; but McWhiney’s special interpretation emphasizes how inherited cultural traits-rather than slavery, climate, disease, or parasites-explain attitudes and values that the masses considered rational and superior.

Being lazy to Celts and Southerners did not mean being indolent, shiftless, slothful, and worthless; it meant being free from work, having spare time to do as they pleased, being at liberty, and enjoying their leisure. When a Celt or a Southerner said that he was being lazy he was not reproaching himself but merely describing his state of comfort. He suffered no guilt when he spent his time pleasantly-hunting, fishing, dancing, drinking, gambling, fighting, or just loafing and talking.11

To outsiders, an unambitious plain folk lived in squalor, but to the white rural masses, enjoying an easy living from livestock that roamed in the woods and a sufficiency of fish and game, there was no pressing need to labor as long as they possessed an abundance of tobacco, liquor, and food.

The views of Genovese, McWhiney, and many others might appropriately be called the conventional historical wisdom of the 1970s and 1980s, despite the earlier, somewhat-novel view of Frank L. Owsley and his students, who emphasized steady labor and seriousness of purpose among the plain folk.12 Much of the conventional wisdom stressed the hegemony of the planter class and popular images of gentlemen and refined ladies. Nevertheless, yeomen and community studies in the 1980s and 1990s eroded the so-called Big House interpretation of the South and enormously expanded our understanding of the values and attitudes of the plain folk. Instead of seeing them as “no account folk,” lazy hellions, a miserable underclass lacking an ethic of work and success, or the willing dupes or deferential underlings of planters, we have an image of a sturdy, industrious, self-sufficient folk, tough, proud, and fiercely independent. In fact, the republican independence of the plain folk, a desire to control their own destiny and scorn of being controlled, plays a pivotal role in every study of yeoman communities.13 The accumulation of a certain level of wealth provided the basis of independence, but the primary goal was acquisition of respectability achieved through personal independence and family self-sufficiency, often augmented by status within a religious community. Plain-folk farmers exhibited a typically American faith in upward mobility-that hard work paid over time and that it was not unreasonable to expect an increase in wealth as one approached middle age. Farming was both an honorable occupation, worthy in and of itself, and an opportunity for advancement that drew many middle-class and lower-middle-class farmers, men on the make, to the piney-woods frontier.14 Work, if not an end in itself, surely was the means to republican independence and self- sufficiency and was the major daily activity of yeomen and their wives. It was not a degrading sign of slave-like status but rather a means of differentiating themselves from slaves by achieving and maintaining independence.

This last point has not been fully appreciated because of popular misconceptions about the lazy South, the ide fixe that white society scorned manual labor as “nigger work,” and a lack of consensus among the historians conducting community studies. Some in the latter group continue to stress the importance of leisure-time activities, especially hunting, drinking, and fighting. In a fine study of North Carolina’s “common whites,” Bill Cecil-Fronsman argues that given a choice of work or leisure, North Carolina piedmont farmers came down on the side of leisure; they did what work they had to do, then stopped.15 Whether the findings of community studies of the 1980s and 1990s (which stress yeoman independence and work) will supplant the conventional wisdom of a leisured-lazy South has yet to be determined.

Clearly, the antebellum South had a troubled approach to labor and its value and exhibited no single, unified, socially approved work ethic. Dissonance is palpable. Many planters and their wives endorsed and honored values of diligence and thrift in their everyday routines, and even those who professed to value some degree of leisure did not want to be considered lazy. As in the American middle class as a whole, they were raised on maxims of work and thrift inculcated by parents, ministers, schoolmasters, editors, essayists, and other authority figures. Nevertheless, the region’s population undoubtedly included wealthy southerners who seldom performed physical labor because of the work of overseers, drivers, and slaves. The fact is that a considerable number of primary sources apparently document a lazy South. The lamentations of southern agricultural editors, who forged a prescriptive literature for planters, emphasized the lack of active and scientific farm management and the incompetence and neglect of overseers. Antebellum travel literature, replete with the exaggerated likes and dislikes of outsiders who expected to encounter the exotic, contributed to stereotypical images of laziness. For example, the most famous Old South tourist, the strongly antislavery Frederick Law Olmsted, argued that slavery destroyed the capacity to work and that the slovenly, careless work of slaves set the southern standard.16 Perhaps most important, attacks by abolitionists and Republicans, who denounced the brutalized slave drudgery that damaged all ranks and aspects of southern society, were answered by proslavery partisans and southern apologists, who glorified a superior way of life embodied by gentlemanly Cavaliers. The antebellum sectional conflict was perfect for shaping powerful mythologies of a \southern way that diverged from Yankee norms. One marvels that Woodward would stress smoke over fire.

The purpose of this essay is to reaffirm the centrality of work and its importance in the antebellum South. Most southerners experienced the harsh reality of endless physical labor, especially slaves and plain-folk families. They knew hard work. Attitudes toward work and the esteem placed upon steady labor with one’s hands provided a fault line that challenged southern unity, dividing a small but articulate and influential part of the planter elite from self-working farmers and their families-those who knew, accepted, and lived by the toils of field and household labor. Work was an essential part of plain-folk identity; here was the core of southern life.

The yeomen of the South never celebrated the mythical leisure ethic of the Old South because they were too busy working to put food on the table, maintain their homes, and structure lives that would guarantee independence and respectability. This yeomanry, the plain folk of the Old South, varied enormously in wealth and status. Some possessed only a few acres of land while others had several hundred. Though most owned no slaves or just a small number, a few grew prosperous from the labor of as many as ten or more. Whether they eked out a bare subsistence on a few acres in the piedmont or piney-woods wiregrass or accumulated land and a handful of slaves in the South Carolina Lowcountry and aspired to join the elite, the lowest common denominator among plain-folk men was that they performed agricultural field labor for all or a significant portion of the year. They were selfworking farmers.17 To be sure, upwardly mobile, slave-owning farmers performed less field work while shouldering additional supervisory tasks, but their callused hands were all too familiar with plows, hoes, axes, shovels, pitchforks, and saws. Long hours of manual labor under the hot southern sun- plowing, hoeing, weeding, picking, ditching, clearing land, and chopping wood-became the common burden of the plain folk and the subject of loud lamentations and complaints or proud boasts of toughness and achievement.18 While not always blessed, manual labor was one of the ties that bound many southern males.

Honorable work and respect for independence blurred class lines. White men and women who owned but a few slaves labored beside their bondmen and bondwomen, experiencing the lot of the field workers and domestic help-sore hands and backs, sweat-stained vision, and a nighttime weariness that sometimes precluded sleep. Even most planters, who as boys had worked with plows and hoes, walked the fields and actively supervised a labor force engaged in work they had once performed. Those in the slave-owning class who escaped the burdens of manual labor or active management-indeed they might aspire all of their lives to employ more slaves and better overseers- could not forget their origins or the fact that successful farming was the source of their profits. Perhaps the vaunted white southern unity of the antebellum period rested upon the farmers’ world of work as well as a dedication to slavery and maintenance of the racial status quo.

Most rural southerners inhabited a world of work, not leisure and play. Of the more than sixteen hundred Tennessee Civil War veterans who were questioned via mail by historians in the 1910s and 1920s, slightly over 80 percent emphasized that hard work was the common lot of the plain folk.19 These Tennessee veterans, largely of the yeoman class, gave responses in writing to precise questions about the amount of work and leisure in rural Tennessee life, the kinds of labor their parents performed, the value and honor accorded physical labor, and the accuracy of historians’ portrayal of a lazy South. Although some might belittle the significance of their testimony given the passage of years and the veterans’ tendencies toward nostalgia and self-praise, several yeomen diaries, the memoirs and autobiographies of antebellum rural ministers, and the varied sources dealing with the lives of antebellum farmwives support the veterans’ memories. Unfortunately, the diarists and autobiographers have also drawn criticism as reliable sources because, it is said, they are few in number and unrepresentative of the non-literate yeomanry. While it is good to be cautious regarding sources, it is not helpful to be hastily and unfairly dismissive. The diary- keeping farmers and autobiographers performed the same work as the Tennessee veterans, and the values exhibited by the former reflect the spirit of the age, finding confirmation in the prescriptive literature of the era, the piety and morality of southern evangelicals, and yes, the voices of the Tennessee veterans. In the end, the varied sources left by the plain folk tell a common story: endless, exhausting work was a way of life for non-elite southerners, a people who accepted hard labor, rejected leisure and aristocratic values, and discovered self-esteem and reputation in their work-related accomplishments and independence.

The vast majority of yeoman farmers across the South-whether in the Lowcountry, piedmont, backcountry, or frontier-were masters of many tasks. Survival and independence, to say nothing of material progress, depended on expertise in the varied duties of homestead farming and skillful employment of family labor as much as on soil conditions and crop prices. Success for farm families began with their household economy-planting, tending, and harvesting crops; feeding and clothing themselves; clearing forests and grubbing stumps for farmland; cutting down trees for building materials and firewood for cooking and heating; constructing homes, barns, and outbuildings; and raising animals for power, meat, and hides. Much of what they produced they immediately consumed, thus census takers would find little record of a substantial part of their labor.20 If farmers successfully marketed a small money crop or had the good fortune to sell an excess of corn or garden produce in the local town to earn money for hardware or luxury items, they faced the temptation of expanding their cash-crop activities. Eventually they might buy more and produce less of what they consumed.21

The seven-year diary of Joseph B. Lightsey, who in 1847 at age sixteen began work as a full hand on his father John’s 150-acre farm in southeastern Mississippi, details the work life of a yeoman farmer-the varied tasks, diverse crop mix, and the plodding dedication to dreary labor.22 Joseph received $10 a month and the use of five to six acres, on which he raised cotton and produce for the local market by working for himself on Saturday mornings and weekday mornings before breakfast. Because of the poor health of their father, Joseph and his brother, working alongside eight adult slaves, composed the labor force that typically worked one hundred acres in corn, twenty-five in cotton, five in potatoes, eight or nine in rice, and one in peanuts. The family also grew oats, wheat, rye, a small amount of sugar cane, peas, cucumbers, watermelons, and other garden produce. Each day Joseph recorded his work. Plowing, planting and replanting after torrential rains, hoeing and weeding, and picking corn and cotton consumed a major portion of his year, but other crops and farm duties required many days as well. Everything had to be hauled; days were spent carting corn to the local mill or market or hauling timber, firewood, or manure. Fields had to be ditched and cleared, logs rolled, and brush burned. Lightsey cut firewood and timber and split rails to make fences. Typically he spent three or more weeks in late July and early August pulling fodder.23 By age twenty-two Lightsey was a skilled and accomplished farmer, but his diary reveals that he was something of a jack-of-all-trades. He helped build a house and chimney, cover a roof, and dig a well; he repaired guns and knives, fixed a floodgate and a gate, and repaired farm implements in a blacksmith’s shop; and he built pens to catch small game and worked sporadically over a period of three years making a fish pond.24

Lightsey’s diary offers little evidence of idleness except for an infrequent admission of “knocking about today.”25 Inclement weather or sickness might keep him from his six full days of labor per week, but there were times when he worked in the rain or with a slight fever. Otherwise, only a rare trip to town for a circus, a murder trial, or a barbecue and election frolic took him from his labors. On one occasion, he recorded a community comshucking at night after a full day’s work, and increasingly he satisfied his passion for the hunt by hunting at night. Mostly, however, daily life for him meant field labor, as typical diary entries indicate: “I dug potatoes all day long,””I hoed cotton again today all . . . day long,””I ploughed again all day long,””I pulled fodder all day,” and “I dropped corn again all day long.”26

For most southern farmers, life amounted to unrelenting toil. To be sure, field work slowed temporarily in late summer or early fall when crops were laid by and normally came to a halt when it rained, although outdoor labor was then usually replaced by household tasks. Work rhythms responded to the slow pace of valuable draft animals that needed to be watered and rested. Indeed, plowing mules, horses, and oxen probably received more rest than the men who trudged behind them. Nevertheless, daily work, even if delayed by rain or at a pace less than feverish, was unending. The hours were long-from daybreak to dark, and sometimes beyond. For Tennessee veterans William Denier Hardin and William Sidney Hartsfield, labor from dawn to late at night seemed a normal activity; for South Carolina yeoman James Sloan, who owned land valued at $1,000 but no slaves, night work was occasional but unavoidable. William E. Orr, whose father farmed about 130 acres nearOhita, Arkansas, recalled how his mother would take “us kids” at night to the new ground and “spred down an old quilt for us to play or sleep on while she burned the big brush piles while my father cut timber and made poplar & oak rails.””Honesty industry and frugality with plenty of sticktooativeness never fails,” he concluded.27 Basil Armstrong Thomasson, a poor, non- slave-owning farmer in the North Carolina piedmont, even worked on the day of his wedding. “Clear and hot,” he recorded in his diary. “Bound oats till 10 o’clock, then put on my Sunday [best?] and went over to Mr. Bell’s and got married!”28

Everyone worked, the young and the old. In early- nineteenthcentury rural America, children were economic assets, and many an aging farmer boasted of the tender years when he plowed his first furrows. “I was in the field dropping corn when I shed my first two teeth April before I was six in November,” recalled Jeptha Marion Fusion, the son of a non-slaveholding farmer and blacksmith. It was not uncommon for young boys to become plow hands at eight, nine, or ten years of age and to begin working as full field hands in their early teens. The fact that school terms were irregular, being built around periods of peak labor, proved to be a signal indication of the importance of labor over all else. Girls rivaled boys in assuming adult tasks at an early age; they were simultaneously apprentices to their mothers and full work hands in sewing, washing, cooking, gardening, and all the myriad and unending tasks of running a homestead. Entry into adulthood was associated with participation in the household economy.29

Children of substantial slaveholders frequently performed field labor, either because additional hands were always needed or because actual labor was the best instruction for future farm management. Many parents insisted that the virtue of hard work was a lesson all should learn. T. J. Howard, the son of a farmer who owned ten slaves and two thousand acres, boasted how his father “was opposed to idleness and trained his boys to work and the necessity for it. We were taught and required to do every kind of farm work the slaves did and consider it an honor in stead of disgrace.”30

Work did not cease with old age but only with sickness and infirmity. William C. Anderson, who had farmed and worked in a hotel in the South Carolina piedmont, expressed annoyance at being a consumer rather than a producer, and at age seventy-six he sought full-time employment. James Sloan worked into his eighties. For William Woodall, a poor farmer in Halifax County, North Carolina, work served as therapy for a troubled soul and mind. To his brother he confessed that “difficulties and trials” had harassed him almost to distraction and madness “but for my close application to hard work.” Yet what was good for his mind had a debilitating effect on his physical health, for later that year he reported that his hard work and exposure to the sun had laid him low with “Neuralgea, Dyspepsia and all their horrid consequences.”31

Yeomen, of course, did not work every God-given moment of their lives, but aside from church attendance, most respectable social or quasi-recreational activities were work-centered. Hunting and fishing, a genuine pleasure to most, provided food for the table. Self-working farmers and their wives joined neighbors and kin in house- and barnraising, corn-shucking, rail-splitting, log-rolling, wheat-threshing, and quilting.32 The grandson of one of the South’s famous preachers recalled that amusements of the 182Os and 183Os were conducted with an eye to something useful: “The young people had their cotton-pickings, and at these there would be a good deal of mirth and gayety, but a large quantity of cotton picked also. At the quiltings they would have a lively time, chatting, joking, and courting: but there was a pretty quilt to show when all was over. House-raising and log-rolling involved so much hard work, that one would think they could not have been regarded as holidays, but they were nevertheless.”33

Although self-working farmers were the most public and visible half of a plain-folk culture that emphasized hard work, women played a vital role in the success of yeoman establishments. Unfortunately, not everyone has understood this point, then or now. A few farmers apparently placed a premium upon field work to the detriment of inside work, trivializing work within the house. Several of the farmers’ accounts cited herein elaborately record the activities of outdoor work and the products of fields, orchards, and pastures but neglect the activity of the household.34 Nevertheless, it is easy to argue that women worked as hard as, if not harder than, men. The daily drudgery of maintaining a large family that owned no slaves meant that farmwives, aided by their children, labored full-time as cooks, cleaning women, washerwomen, gardeners, and essential hands for raising poultry and running a small dairy and perhaps a household manufacturing concern. In addition they carried, gave birth to, and cared for children. With good reason, a few sons saw the labor of their mothers as slave-like. Their work was the same, and their pay (shelter, clothing, and food to maintain their health) was the same. Their labor, however, was willingly performed, for they worked in their own houses and for their own children and husbands and took pride in tidy kitchens, bountiful gardens, fancy preserves, and warm and attractive quilts.35

Few labor-saving devices eased their toil; they toted heavy pots, skillets, and water buckets and sweated over wood-burning stoves and fireplaces to prepare meals, make bread and biscuits, preserve food for winter consumption, and heat water for laundry. “The kitchen was the nerve center for farm activity,” asserts historian Claudia Bushman. “Workers prepared meals there; dishes and preserves, candles and containers, pots and supplies of all kinds filled the shelves. The women compounded medicines, tried out tallow, made candles and soap, and washed dishes in this stressful and crowded atmosphere.”36 Washday was grueling; women worked outdoors, often in extreme heat or cold, spending hours “soaping, boiling, beating, and hand rubbing until the clothes became reasonably clean.”37 Women made and repaired clothes by spinning, weaving, knitting, and sewing flax, wool, or cotton. Seventy-seven-year-old Tennessee veteran William C. Dillihay recalled that his “mother did her washing and cooking as well as other household duties including weaving coverlids and clothes for the family. Such work as she did would be a cu[r]iosity to women today. I sleep under two of her coverlids that was woven by her 65 years ago.”38 Many women even worked in the fields when necessity dictated the use of additional hands, and when husbands became incapacitated or died, women became full-time field workers. Zachary Taylor Dyer, a poor farmer from Giles County, Tennessee, after the death of his father learned about the world of work from his mother, who taught him “to plow, hoe, to spin, knit, weave, sew, milk, cook, wash, fill quills, make-up bead [bed] and anything that came to hand and I can do it now thank God for such a mother.”39 Women also sold garden produce, eggs, milk, clothing, quilts, fancy sewing, and other items produced at home, and the proceeds from their expertise, diligence, and frugality might amount to the most sizable portion of a farmer’s cash income. The independence of frontier and upcountry yeomen, in part, reflected dependence on wives and children, a conclusion also reached by Stephanie McCurry for the yeomen of the supposedly aristocratic South Carolina Lowcountry.40

With sweaty brows and dirty hands, southern farmwives were admired as paragons of industry. “Hard work to the end” epitomized “a female life well lived,” as is illustrated by a Mrs. Henry Boughton of Virginia, mother of nine. Without slaves or servants, Mrs. Boughton did the cooking, washing, milking, sewing, and mending for her entire family and also took in weaving and sewing to increase the family’s income. Often in delicate health, she eventually “succumbed to breast cancer after suffering for four or five years.” Virginia planter Bernard Walker “greatly respected this” industrious and energetic person, whom he praised as a woman of enormous worth and integrity despite her position “in the lower walks of life.”41

Agricultural newspapers applauded plain-folk mothers and wives for well-kept homes, kitchens, and gardens, praised their decorum and manners, and heralded their efficient work, which stood in distinct contrast to the uselessness of fashionable ladies.42 The Baltimore American Farmer even argued that “women were ‘more happily circumstanced’ than men because ‘the important and fatiguing advocations [sic] of men necessarily impose seasons of inactivity. . . .’ Women, on the other hand, need never cease their labors; while visiting or ‘resting’ they could do their practical sewing.”43 One Tennessee veteran in particular captured the image of the farmwife ideal: “Mother was very industrious,” he fondly remembered. “Clothed her family by work. Spun and wove cloth, carded her own wool. Knit all the socks and stockings worn by the family. I never seen my mother sit down and be idle and do nothing. Always had work in her hand. I had the best mother.”44 Given the contributions of farmwives (and also children, who were apprentice farmers or homemakers), it may be that historian Eugene D. Genovese’s rule about slave labor, that “all hands” must “be occupied at all times,” is as appropriate for slaveless yeoman households as for the slaves on plantations.45

Because the middle and upper-middle classes in nineteenth- century America knew household chores to be exhausting, those who could afford domestic help, in both the North and South, seldom skimped on hiring or owning extra hands to ease women’s domestic burd\ens. In the South, with some notable exceptions, yeoman families with a small number of slaves assigned a slave or two to the most onerous household tasks. Often working side by side with their slaves, these farmwives experienced firsthand some of the drudgery of domestic slavery.46 Fortunate as they were to have domestic help, it arrived encumbered with the task of slave supervision, which was then added to their own demanding physical chores.

In the world of the plain folk, a woman’s reputation rested on a well-kept home and steady production of ample clothing and food. For men, the hard work of daily life-even more than the no-holds- barred, eye-gouging fight or the drunken frolic celebrated by many southern historians-established a man’s reputation and tested his virility, toughness, and independence.47 Neighbors were judged by their industry: farmers won recognition for steady work, the earliest crops, the largest yields, or the straightest furrows while farmwives received praise for well-kept kitchens, productive gardens, and accomplishments in sewing.48 It has become something of a clich that southern yeomen, whether solidly middle class or poor, joined the South’s circle of honor because they were free and white in a slave society, but much more was involved in establishing reputation and status. To be free was one thing. However, enjoying the full benefits of freedom required independence, and that necessitated work. The external world of honor-status and reputation- was derived from struggles to achieve and maintain independence, but honor was also matched by an internal world of values-the farmers’ self-esteem-that was predicated upon survival and triumph in a world of unrelenting toil that tested a man’s skills, steadiness, and toughness and a woman’s stoic regard for faith, production, and labor and sacrifices for family.

“[W]e were working people,” proclaimed T. L. Johnson; “A working man stood as high in the commun[i]ty as any body.” The Tennessee veterans believed that honest workers were “the bone and seneou [sinew]” of the country and that honest toil-“respectable and honorable”-was essential “to good citizenship.” Being a willing worker “was a mark of distinction”; a man who worked industriously stood high in his neighborhood society. “[I]t was the hard enerjetic [sic] people was the respected ones,” pronounced Joe C. Brooks, a poor farm boy from McNairy County, Tennessee.49 William Anderson Wilson, the son of a slaveless farmer and mechanic, boasted, “I worked on the farm and did every kind of work . . . and never [k]new what idleness was and can say the same for my three brothers and all the rest of the family-can all so say that the man or woman boy or girl who did not do their part was a rare exception.”50

Many Tennessee veterans stated emphatically that they worked as hard as slaves and labored beside them in the fields as well. George A. Rice, from Decatur County, even implied a certain rough equality of condition among whites and blacks when he wrote of his early life:

Plowed oxens and horses, also hoed, and during summer months hauled barral staves 16 miles with 4 yoke cattle on Linen . . . wagon 4 trips a week. . . . Father taught school and worked on farm, seeing after us boys and nigars slaves. Mother cooked on fire place used pot racks, scilits kettle etc and spone and weaved cloth to make all of everyday clothing also cut and made our cloths. . . . [W]e all worked as hard as our slaves and give the same to eat we got[.]

John H. O’Neal and Peter Donnell recorded similar experiences. “My father had 7 boys 6 of them older than myself,” and “We all went to the field, same as the Negroes . . . .””I worked . . . with the darkes-plowed howed mowed-cut wheat oats split rales don anything the darkes don.”51

The diary of Basil Armstrong Thomasson provides a fine example of the way in which one yeoman developed a strong self-concept and a prescription for a happy life from years of hard labor. A young farmer working sixty improved acres in Iredell County in the western piedmont of North Carolina, Thomasson each day recorded accomplishments in field, barn, and orchard and not infrequently affirmed his prescription for a successful life. Although poor-his farm and livestock were valued at only $200 in the 1860 census, and there were periods when food was in short supply-Thomasson was a Ben Franklin-and Bible-quoting farmer who waxed poetic about the benefits of home sweet home and the delights of farming. All work was honorable, he believed; all must work who wished to be happy. He advised his fellow man to be “industrious, honest and frugal”; “Make a good, and proper use of your time, reader, if you wish to be ‘healthy, wealthy and wise.'” Six days a week he labored hard, but Sunday was a day of rest for the soul and improvement for the mind. He rejected idle chat, lived frugally, and avoided borrowing because it threatened his independence, and he criticized the use of liquor, tobacco, and coffee but indulged in the purchase of books and agricultural newspapers for self-improvement.52

Thomasson usually rose before dawn and attended diligently to the varied tasks confronting a self-working farmer. “Ploughing is hard work,” he admitted, but he lived by the motto that if something was worth doing, it was worth doing well. On occasion his need for cash forced him to experiment with other occupations, such as clerking, school-teaching, and carriage-making, but he always returned to farming as the occupation that best offered secure returns.

I fear tho’ that trade would not pay as well as farming. Dr. Ben. Franklin said, “Keep thy shop and thy shop will keep thee.” The bible says, “He that tilleth his land shall have plenty of bread.” Now I believe I had rather risk the Bible and the farm; tho’ the man who keeps his shop may live well, but the man [who] tills the soil will be certain to have bread to eat.53

Thomasson scorned leisure and luxury, and as historian Paul D. Escott concludes, he appears to have been more like the conscience- driven, self-regulating Yankee than the honor-seeking, self- regarding southerner depicted by Bertram Wyatt-Brown in Southern Honor.54 In all economic decisions, Thomasson “sought independence, respectability, and progress rather than the values of aristocracy,” and his self-sufficiency enabled him to avoid entanglement in the vagaries of the cash-based market economy. Still, like other yeomen he could never achieve complete independence since a shortage of labor and cash necessitated swapping work with family and friends to secure additional hands for essential farm tasks such as harvesting, log-rolling, and erecting barns and outbuildings. Here Thomasson amassed significant moral capital; a reputation for steady and efficient labor was a vital, marketable commodity. Although other yeomen seldom kept diaries, Thomasson was unusual only in his rigid notions regarding liquor, coffee, and tobacco; his dedication to labor and independence, concern for his work reputation, and avoidance of idleness echoed among the southern plain folk.55

The pride in work resonating throughout plain-folk society did not exist in the abstract, for it was coupled with a belief in upward mobility as the product of industry and economy. Here was a very practical reason for daily labor. Most Tennessee veterans believed that the hardworking, industrious poor could save to insure a competence, perhaps to buy a farm, a business, or a slave or two.56 W. A. Duncan, the son of a non-slaveholding farmer owning but fifty acres, readily affirmed how poor folks, if they were good workers and managers, could purchase a small farm or go into business even if they started with nothing.57 Of course, mobility might not always be upward, but Tennessee’s veterans and farmers expressed faith in their society and its rewards. W. J. Tucker of Maury County, a farmer and veteran whose father had owned no slaves but could claim solid, middle-class status, reflected how “It dos seem that the rich boy in many cases would loose and became poor, while the poor boy had become rich. Many cases in my knowing that way. The hustler gets these[.]”58

In the same breath that common whites praised the virtue of hard work, they used contemptuous, pillorying terms for those who shirked honest toil and a full day’s labor, labeling them worthless, mean, trashy, or trifling. “A man who did not work was not considered much account,” said Edwin M. Gardner. “[I]t was a bad county for fops,” declared George W. Samuel, while Thomas M. Patterson noted that a lazy person sometimes slipped into his community but did not last long, moving on to Arkansas to hunt and fish. Isaac Nelson Rainey emphasized that “The loafer, rich or poor, was despised.”59 Drones, vagabonds, bums, deadbeats, deadheads, nobodies, damned rapscallions, and baser specimens of the community were some of the other unflattering terms applied to the able-bodied who did not work. Folks expressed strong views on this subject: “if a man didnt work neither should he eat”; the few that would not work were “not respected and hated by rich and poor”; and “a man that did not work either with his hands or his head was not regarded as a man atall.”60

Many Tennessee veterans took umbrage at the myth of southern laziness, especially when reminded in the questionnaires that “certain historians” believed white farmers avoided heavy field labor. “[H]istorians are verry rong when they say whi[t]e men would not work,” declared J. L. Walton, while R. T. Mockbee accused such historians of ignorance or willful falsification. A farmer and tanner from Rhea County, Edward Gannaway labeled “certain historians” either “natural born” fools or likely candidates for the penitentiary “for malicious lying.” Mississippi-born Gentry Richard McGee, whose parents owned an eighty-acre farm and six slaves, recalled how he and all of his acquaintances did all of the \usual farmwork. “The historians who say Southern white men did not work before the Civil War belong to the Annanias Club,” he concluded.61

When plain folk admitted idleness in their communities, they most often had in mind a small minority of disreputable, poor people or a few rich planters and their kin, sometimes described as effete fops or dandies. An essayist in the Jonesborough Tennessee Farmer cast scorn upon “a wandering tribe of work-haters,” serious pests to any community, who roved about under the pretense of getting jobs, but it was the job of eating, not work, they sought.62 It is noteworthy that Tennessee veterans seldom mentioned the South’s stereotypical white trash, but when they did, their scorn was stinging. A few veterans attributed the South’s reputation for laziness to these worthless, “whiskey drinking degenerates” and thugs, the wild and reckless few who would not work. These low-down people had no status; they had sunk so low that slaves would not associate with them, and it was the slaves, white farmers insisted, who were most likely to call them poor white trash.63 The verdict was inescapable, concluded a Tennessee veteran from a modest home that had known its share of both hard work and foxhunting: the white trash brought “opp[ro]brium upon themselves by being too lazy to work and too thriftless to save.”64 Fortunately, trashy whites were few, perhaps one in twenty, ventured G. W. Park, son of a modest farmer who owned no slaves.65 Moreover, hardworking farmers, slaveholders and slaveless alike, saw idleness (and the poverty stemming from it) as an individual flaw, a failure of character, and not a stigma of class or an unfortunate result of slavery or slave competition.

Tennessee veterans more often located the South’s idle people among the wealthy rather than at the lower end of the social scale. A few poor farmers, perhaps out of envy, claimed with considerable extravagance that slave owners enjoyed leisurely lives because poor folk, whites and blacks, did all of the work of their communities. Drones in the planter class spent their time in hunting, fishing, and riding around the country.66 A writer in the Jonesborough Tennessee Farmer contrasted the honest industry of the farmer with the activities of an elite of brainless dandies, useless females, and social butterflies.67 Even a working planter directing his slaves might be criticized. A classic incident from Hinds County, Mississippi, in the 1830s reveals the resentment directed toward planters who failed to soil their hands or work up a sweat while slaves and whites did hard field work. In this incident, the father of Susan Dabney Smedes, a wealthy planter who had moved there from Virginia, came to the aid of a neighbor by loaning twenty slaves to help clear a grassy field. The farmer showed little appreciation for this neighborly kindness, complaining that “if Colonel Dabney had taken hold of a plough and worked by his side he would have been glad to have his help, but to see him sitting up on his horse with his gloves on directing his Negroes how to work was not to his taste.”68 The farmer was angry because of the colonel’s refusal to join him as an equal and no doubt resented the implied superiority in the planter’s distancing himself from the farmer, especially when the planter’s instructions to his slaves might by implication be aimed at the farmer himself. Such feigned superiority (consciously adopted or otherwise) could easily offend working people while simultaneously affirming and justifying the self-esteem of those with callused hands, red necks, and sturdy backs.

Although idleness among large slaveholders-most of them active managers who had once worked in the fields and who currently worked their own sons-was not the rule, wherever it surfaced it was denounced in no uncertain terms. Perhaps 2 percent were idle, estimated Joel L. Henry, but they were fools if they did not believe honest toil was respectable. A few rich men’s idle sons, labeled “worthless curs” by William Grant, did not amount to much. “Some persons never worked,” reported Thomas Jefferson Howard, but “they became vagabonds and died in misery and want” following the war.69

Much harder to bear than the simple knowledge of idleness among some of the wealthy was the occasional hint that idle slaveholders and rich folk derogated the hard work of the yeomen. Contrary views about the nobility and significance of labor-especially on the part of the wealthy-surfaced infrequently among Tennessee veterans, a situation understandable in a democratic society of isolated communities in which large landowners and slaveholders wanted and needed the votes, popular acclaim, and economic support of the masses. The wealthy who disparaged honest toil, asserted Zachary Taylor Dyer, had more “money than brains.” R. H. Mosley, the son of a non-slaveholding farmer in Williamson County, Tennessee, and one of the few who revealed considerable resentment of wealthy slave owners whom he claimed did nothing, accused the rich of viewing farming as a “low” calling and referring to poorer folks as clodhoppers.70 Perhaps a bit more common among the elite was the attitude that while manual labor was not in itself disreputable, it was a sign that the person who spent a lifetime in field work “lacked brains, education, or money.”71 Still, this view was not expressed often.

In general, most plain folk recognized the important contributions and labor of slave owners and others who might do little actual physical work. Those who earned an honest living through farm management, mental labor, or community service as doctors, lawyers, or preachers were held in high esteem. Idleness was the culprit, and it drew strong condemnation. When wealthy, slaveholding planters revealed themselves as busy, productive, and knowledgeable about crops, draft animals, farm implements, fertilizer, and the myriad difficulties of running a farm, the plain folk could easily accord honor and respect to active farm management.

In light of the esteem associated with hard work, a sense of guilt sometimes troubled those self-working farmers who failed their communities as paragons of diligence. One example of a self-working farmer, John Osbourn (or Osbourne), stands in distinct contrast to Lightsey, Thomasson, the Tennessee veterans, and the others cited here because he would just as soon go on a drinking spree as complete a day’s work. Osbourn typically labored alongside a small number of slaves on his three North Carolina farms, but in numerous diary entries, he confessed to drinking too much and gadding about and indicated his intention to reform. Rather than pride in his frolics, he showed a sense of guilt and clearly understood his duty and what would win respect.72 Similarly, the Reverend William E. Hatcher recalled the acute embarrassment and pain that his childhood stubbornness and renunciation of dirt farming caused his father, “a stalwart old farmer” who worked a small plantation with a few slaves and primitive equipment. The hardworking father, who could foresee none of his offspring’s future success in the pulpit, believed his young son was “grievously and unpardonably lazy.” What was God’s purpose in creating a son so devoted to idleness? With a sorrowful mien, Hatcher’s father reached his conclusion-that God created him “to starve, as a warning for all idle boys that may come on later.”73

Unending physical labor structured the lives of plain-folk families most of their waking hours, but for many the world of work was inseparable from a religious faith that supported, justified, and commended daily toil. When Richard Enos Sherrill, a Tennessee veteran and the son of a modestly affluent slaveholder, recalled his youth, he boasted of working “on the farm did all kinds of work plowed hoed any thing come to hand all the neighbors in our neighborhood did all kind of farm work[.]” Was honest toil respected? “[Y]es, it was,” he responded, “we lived in a Christian . . . community 2 miles from Old ‘Mt. Carmel Church’ widley known strickly Blue Stocking Presbyterian.”74 What Sherrill alluded to- the connection between labor and evangelical faith-the Reverend Watkins of the “Old Pine Farm,” a South Carolina country minister who served four rural congregations while farming three hundred acres, made explicit: “Faithfulness to secular engagements is a part of religion, and in observing this we render an acceptable service to God. . . . one may serve God in his field, his storehouse, or his workshop.”75 In Georgia’s Cherokee territory in the 1830s, Zillah Haynie Brandon also affirmed the role of faith in everyday toil. Brandon cheerfully endured struggles and hardships because she felt sustained by Him who “from the heights of heaven””stooped to listen to my complaints and number my tears.” In her memoirs she confided, “My health seemed entirely impa[i]red, yet I was compelled from unavoidable circumstances to perform from year to year, that amount of labor sufficient for three able hands, in order to maintain a character, as Christian and mother to which I felt I was justly entitled.”76

The spirit of Wesley, Calvin, and Luther survived in the antebellum South, and yeoman farmers, as ministers, deacons, and elders, along with farmwives, who outnumbered men in church membership, testified to the links among hard, steady labor in field and household, evangelical faith, and a belief in a simple way of life joined to a gospel of work. Such lives were highly esteemed-in fact, sometimes praised as almost saint-like. For example, eighty- one-year-old David Shires Myers Bodenhamer, originally of Giles County, Tennessee, lauded the self-sacrificing qualities of his tireless mother, who rose early and worked “willingly and diligently with her own hands.” The thirty-first chapter of Proverbs, which he loosely quoted, captured her essential nature: “She layeth her hands to the distaff andher hands hold the spindle . . . the hum of industry [is] in her home and in the kitchen garden, poultry yard and cow lot there is busy work. . . . The Sabbath is kept sacred . . . the Bible is first in her home. . . . Her children rise up and call her blessed.”77 In describing Republican culture in the North, Eric Foner noted that “the moral qualities which would ensure success in one’s calling-honesty, frugality, diligence, punctuality, and sobriety-became religious obligations.” Such words would be applicable below, as well as above, the Mason-Dixon line. 78

It had not always been so, not in the colonial world of the gentleman planter; but by the late eighteenth century, the dissenting churches of upstart Baptists, Methodists, and Presbyterians challenged the dominance of the established Anglican and elite culture. The ascetic, church-based social and religious lifestyle of many plain-folk communities clashed with an aggressive, worldly, hedonistic culture of honor stereotypically associated with the planter elite. Unfortunately, popular images of a violent South and enduring myths of moonlight, magnolias, and mint juleps reveal that too much attention has been directed toward the power, prerogatives, and pleasures of stereotypical planters. Among the more-numerous plain folk of the antebellum period and even within the ranks of the planters, an evangelical lifestyle influenced daily activity, although it never vanquished the extremes of male excesses on the dueling grounds or in the gaming pits, barrooms, and brothels. Evangelicals, who had begun as dissenters, modified many of their pristine practices and values to enter the mainstream by the 1830s, with the result that most people lived under the sway of religion, regardless of whether they attended church or participated in church activities.79 Although it may be true that only one-fifth to one-third of all antebellum southerners were church members, mostly Baptist, Methodist, and Presbyterian, congregations were two- to-four-times larger than the actual number of church members. In certain areas of the South, evangelicalism had spread to a majority of households.80 “To a remarkable degree,” concludes John B. Boles, “evangelical religion shaped the mentalit of antebellum southerners, rich and poor, slaveholder and nonslaveholder. By 1830 the ‘Solid South’ was more a religious than a political reality.”81 Even in Lowcountry South Carolina, the bastion of southern wealth and class- consciousness, evangelical churches, which were essentially yeoman institutions, set the tone of society.82

Ministers were revered community leaders called to serve in the rural South more often because of their faith and personal characteristics than their education or theological training. Although the level of education steadily improved among the clergy, itinerant, poorly trained lay preachers, especially among Baptists and Methodists, often filled rural pulpits on a rotating schedule of Sundays as they traveled from one isolated crossroads church to another. As late as 1860, lay preachers outnumbered ordained preachers among Virginia Methodists.83

Whether lay preachers or ordained ministers, most rural preachers relied upon outside work, at least in part, to support themselves and their families since congregations were poor and salaries inadequate or even non-existent.84 In frontier regions of the South, it would not be unusual for farmer-preachers to do the heaviest of farm labor and to hunt and fish for food.85 In lieu of a salary, many ministers received free-will offerings, usually an amount as uncertain as it was inadequate, but some backcountry evangelical congregations and ministers believed in principle that preaching the Lord’s word should not require financial remuneration of any sort. The experience of Reuben Davis’s father, a farmer-preacher of limited means with only a pioneer’s rudimentary education, provides a case in point. A well-respected Baptist minister, he busied himself “during the week . . . with ordinary farm labor” and would never accept compensation for services to the church. Such, he considered, was “serving the Lord for hire.”86

Highly respected bi-vocational ministers displayed strong faith and strong character, setting examples of proper deportment and the ennobling discipline of work. For such preachers, work was both necessary and honorable. One minister, whose “heart was set on” the work of the church, still “considered his duty to his family paramount, remembering that the sacred volume placed those who did not provide for their families lower than the infidel himself.”87 The Reverend Watkins titled his autobiography The Old Pine Farm because he labored there diligently, raising corn and livestock to support his family and secure the means to tend to his four congregations. Although his house was essentially two log pens and two backroom sheds, with a passage through the center and a piazza in front (an architectural style common among the plain folk), he boasted that its neatness, cleanliness, and furnishings “marked the refined taste of the preacher and his family.” The operation of his farm, he believed, was “conducted in a manner creditable to” his industry and good judgment.88 The Reverend William Capers, a future Methodist bishop, also expressed pride in his achievements in field and pulpit. The son of a Lowcountry planter, he came to know the hardships and struggles of a circuit-riding minister after his father’s sudden death left him without an inheritance or financial security. Later, with a family to support, he secured a church and then turned to the task of earning an income.

The house ready for occupancy, I became too much interested in the field to be only a manager, and betook myself to the plough; which having done, I must prosecute it diligently for example’s sake. . . . I had never done an hour’s work in a field in my life

As a young child, Spenser Theberge discovered that his gift came with unwanted side effects.

Boys wrestle. Squash bugs. Shoot imaginary guns. But some of them, like Theberge, also enjoy dancing, which isn’t as popular come recess time. By third grade, in fact, Theberge began feeling ostracized because of his passion for expressive movement to music.

In fourth grade, the taunting became so insidious that Theberge changed elementary schools to get away from the teasing. He didn’t mention dance to his new classmates for several weeks until he had established strong friendships in fear of how the other boys would respond.

“That was kind of sad,” Theberge said. “That I thought I had to hide (dance) because I thought I wouldn’t have any friends.”

Theberge says instead of succumbing to grade-school ridicule, it made him more resolved in his love for the art form. He developed the necessary defenses, then let go of the hope that all of his peers would understand.

Now 18, Theberge will perform the primary male roles, the ones usually reserved for guest professionals, next month in Columbia Dance’s version of “The Nutcracker.”

He will probably graduate this spring with a perfect grade point average and as co-valedictorian of the Vancouver School of Arts and Academics. He says the magnet school became for him the place where he finally felt accepted and highly encouraged to pursue his creative interests.

“Spenser’s dance is a metaphor for his life,” his mother, Sarah Theberge, said. “You can see and hear the differences in him over the past few years. When he is dancing, there’s an air of confidence and competence. As he’s grown into his role as a dancer, grown into his commitment, dance has provided a foundation (for the other aspects of his life).”

These final local performances of “The Nutcracker,” she said, will for him be “a rite of passage as he goes into his next place.”

Big move to Big Apple

That next place at this point will be New York City, where Theberge already has been offered a spot at The Juilliard School while he’s waiting to hear from New York University. Professional dance companies are offering him work, too.

Bodyvox hired Theberge earlier this year to perform in the Portland company’s collaboration with Opera Pacific in Costa Mesa, Calif. Theberge was 17 at the time; the next youngest dancer was 25 years old.

Co-founder Ashley Roland traveled to California to see the show in Opera Pacific’s 2,000-seat theater, and she said it took her at least 20 minutes to recognize Theberge, with whom she last worked at Columbia Dance three years ago.

“I couldn’t figure out who he was,” she said. “He acted like the most seasoned, mature dancer on the stage. He’s a big kid. A talented kid, and I really thought it was an older man. When I figured out it was Spenser, I was blown away. He was dancing with women almost twice his age, and he was doing everything as well, if not better, than all of the core members.”

Roland added: “He’s definitely a big fish in the small dance pond of the Portland scene. Soon, he’ll get to see what it’s like in the different pond that is New York.”

Theberge has done well in such intense situations so far.

At the summer camp in 2003 at Juilliard, one of New York’s most prestigious arts institutions, Theberge was the only one out of 40 who was offered early admission to the school. He decided instead to return to Vancouver for his junior year.

At the Broadway Theater Project in Florida this past summer, guest instructor Desmond Richardson, whom Theberge calls his idol, specifically pulled him aside for words of encouragement, and camp founder, Ann Reinking, who choreographed such acclaimed shows as “Chicago” and “Fosse,” offered him a job in “Fosse,” only to find out later that Theberge was 17 and therefore ineligible for the position.

During his senior year at VSAA, Theberge was determined to make himself an even better dancer.

He can do switch-split leaps that consistently get him more than 50 inches off of the ground. He can lift girls, sometimes as much as 135 pounds, over his head for long periods of time, even running across the stage holding his partner in the air. During a master class in Utah two years ago, he performed nine pirouettes in a row, setting a personal record.

Paying his dues

But he wasn’t born with the greatest feet, he acknowledges. He constantly has to stretch and build strength in each foot for the aesthetics of certain poses. He also wants to be more versatile, being able to better transition from lyrical moments to the most masculine and powerful of jumps.

Russell Capps, co-founder of Washington State Ballet, worked with Theberge on Vancouver Dance Theatre’s version of “The Nutcracker” in the late 1990s and early 2000s. He has been in camps and classes with him since and sees tremendous potential.

“With someone like Spenser, you could have put him in a pro- level show at 10 years old,” Capps said. “He’s also one of the few kids in this area who has been willing to put in the training, paid the dues (to reach the next level). If he stays healthy, he’s headed for the right place. He’s always had acting ability. I’ve heard a lot of people vouch for his singing ability. He’s so strong in his jazz presence, that with his dancing, he’ll be totally unstoppable in musical theater.”

Theberge said Columbia Dance’s version of “The Nutcracker” next month, Dec. 10-12, will be the 13th such production of his career, including the four years during which he performed for both Columbia Dance and Vancouver Dance Theatre.

Keep on dancin’

He acknowledged that there were times he wanted to give up on dance, but those were because of the stresses of the commitment.

“I never wanted to quit because of people calling me names,” he said. “There were times when I wanted a more ‘normal’ high school experience. Times I wanted to spend with friends (instead of in a studio). Some days, I wanted to come home from school and sit on the couch and stay there until it was time for bed. But those moments never lasted long.

“I persevered through all of that stuff in elementary school. Now, I have the responsibility to show why it was worth it. As an upperclassman, a lot of the younger kids look up to the seniors. I want to show other boys what we can do and that it’s cool.”

He added, “There are a lot of times, when we’re piecing together ‘The Nutcracker,’ and I’ll be doing my part, that I’ll see the younger guys imitate my movement on the side. Really, that just reminds me how far I’ve come since I’ve started dance, and it reminds me that what I’m doing has a bigger impact.”

Did you know?

“The Nutcracker” was first staged in 1892 at the Mariinsky Theatre of Russia.

The Juilliard School will mark its 100th anniversary in 2005-06 with a yearlong program of national tours and exhibits.

FITNESS FOCUS

Neighborhood gyms offer guys quick cardio and strength programs

Bob Siegrist has never had a weight problem. But when at age 47 he found he had gained a few pounds and couldn’t go up a flight of steps without getting winded, he knew he needed to become active.

About two months ago, a men-only gym called Cuts Fitness for Men opened near his home in Albuquerque’s Northeast Heights. Siegrist decided to give it a try.

Similar to the popular Curves for Women program, Cuts is one of several studio-type gyms that feature structured circuit workouts.

Cuts members make three circuits of a 16-station workout that alternates hydraulic weight machines with cardiovascular equipment.

The entire process takes about 30 minutes, plus a cool down and stretch.

Another circuit-based workout fairly new to Albuquerque is The Blitz.

Also in the Northeast Heights, The Blitz combines strength training with boxing and martial arts in a 20-minute workout.

After two months on his program, Siegrist says, it’s “something I can stick with.” He has lost some weight and he says he has noticed a difference in his strength and stamina.

Think corner pub

On a recent Monday night, a steady stream of men filed into the small but bright Cuts studio on Montgomery Boulevard NE.

All were greeted by name by franchise owner Heather Naro.

A petite Canadian native in her 30s, Naro says she and her husband, Mitch, were looking for a business opportunity in the States after spending 12 years overseas teaching.

Mitch Naro grew up in Albuquerque and the couple decided the weather was better in New Mexico than in Canada, so they settled here.

While researching options that would suit them — Heather has a master’s degree in physical education and Mitch’s degree is in history — they found Cuts and decided it was a match.

According to the company’s Web site, Cuts is based on the principal that fitness promotes a healthy lifestyle and that exercise in a comfortable, safe and friendly environment is the key to success for many men typically uninspired by traditional gym settings.

Heather Naro says she views the gym as a “local pub” facility, where everyone knows each other and that is close enough to members’ houses for them to drop in on the way home from work.

Just do it

Chuck Marple, 58, says he found out about the gym when he painted a sign for the business.

He says he has belonged to several gyms in the past, but the attractive part of the Cuts program is that there is no wasted time in the workout.

“You get in, do your 30 minutes and you’re out.”

The equipment adjusts automatically to the participant’s fitness level and uses double positive resistance, Naro says, which not only works opposing muscle groups but also alleviates soreness.

Each new member is given an extensive orientation on the machines as well as an analysis of body fat, and measurements are taken. Re- testing is done every five weeks, Naro says.

While some of Naro’s clients haven’t been active before, many are looking for “something different” and something that doesn’t take a lot of time.

“They are busy men who are trying to juggle a family and work and they’re stressed,” she says.

Donna Pedace, who with her husband, Bill, owns The Blitz on Juan Tabo NE, agrees.

“The biggest draw is that it is an effective and time-efficient workout.”

Ready to get fit

Greg Valdez, 44, says he found his way to this new type of workout because of high triglycerides. “I had been a runner, but knee problems stopped me. I was looking for something that would give me some strength training as well as a cardio workout.”

In the past two months, he has reduced his triglyceride number from 800 to 250 and says he feels much better.

According to the U.S. Census, 45- to 54-year-olds are the fastest- growing age group, and increased education and publicity are driving the aging population to focus on their physical fitness.

In fact, recent health club memberships grew 118 percent among people age 55 and older, the largest increase of any age group.

Cuts Fitness for Men is open 6:30 a.m.-1 p.m. and 3-8 p.m. Mondays through Fridays, and 7 a.m.-1 p.m. Saturdays.

Memberships cost $29 monthly with a year’s commitment; $39 month to month, plus an initiation fee.

The Blitz is open 6:30 a.m.- 1 p.m. and 4-8 p.m. Mondays through Thursdays; 6:30 a.m.-1 p.m. and 4-6 p.m. Fridays; and 6:30 a.m.-1 p.m. Saturdays.

Membership is $30 a month with a year’s commitment; $40 month to month, plus an initiation fee.

For information, call Cuts Fitness for Men at 275-2887 and The Blitz at 292-7540.

VENTURA, Calif., Nov. 30 /PRNewswire/ — In a new study conducted at Kaiser Permanente in San Diego, researchers using the VivoMetrics(R) LifeShirt, a light weight lycra garment used to monitor respiratory and cardiopulmonary function, have discovered biofeedback techniques that can help treat recurrent abdominal pain (RAP) in children, a condition that affects 10-20% of the population.

Conducted by pediatric gastroenterologist, Warren Shapiro, MD, in collaboration with clinical health psychologist, Richard Gevirtz, PhD and doctoral health psychology student, Erik Sowder, MS both of Alliant International University in San Diego, the study involved 36 children ranging in age from seven to eighteen. The primary focus was to examine the use of biofeedback techniques — a method where people are trained to improve their health by using signals from their own bodies, in this case breathing patterns — to treat RAP. Children wore the LifeShirt to monitor their breathing and then participated in six biofeedback sessions to slow down their respiratory rate and lower the intensity and frequency of pain associated with RAP. After the six week period researchers used the LifeShirt once more to assess the physiologic changes of the children after the biofeedback sessions. Follow-up data indicated that 56% of children were pain free one month to two years after biofeedback treatment.

Erik Sowder, M.S., BCIAC, the lead researcher of the study explains, “Children often do not realize that breathing can affect their stomach pain. By wearing the LifeShirt the children were able to actually see how the breathing patterns changed how they felt, thereby increasing compliance with the biofeedback techniques we recommended, and motivating them to continue their treatment.”

The study began in August of 2003 and complete results of the study will be released in early 2005.

For more information about the LifeShirt, please visit http://www.vivometrics.com/.

About the LifeShirt System

The LifeShirt System is the first non-invasive, ambulatory monitoring system that continuously collects, records and analyzes a broad range of cardiopulmonary parameters. Users wear a lightweight, machine washable garment with embedded sensors that collect pulmonary, cardiac, posture and activity signals. Data collected by integrated peripheral devices measure blood pressure, blood oxygen saturation, EEG/EOG, periodic leg movement, temperature, end tidal CO2 and cough. An electronic diary captures subjective user input and all physiologic and subject data are correlated over time. The LifeShirt System has received FDA clearance and EMEA approval (CE Mark).

About VivoMetrics

VivoMetrics, founded in 1999, provides ambulatory monitoring products and services for the collection, analysis and reporting of subject-specific physiologic data. Pharmaceutical companies use VivoMetrics’ technologies to improve the speed and economics of clinical research. The company’s offerings also enable academic researchers to discover new clinical signatures of disease, and U.S. Government agencies to protect the lives of military and civilian first responders.

Contact information:

Elizabeth Gravatte

Director of Marketing

VivoMetrics Inc.

805.275.5834

[email protected]

Gita Chandra

Connors Communications

for VivoMetrics

212.798.1420

[email protected]

VivoMetrics

CONTACT: Elizabeth Gravatte, Director of Marketing, VivoMetrics Inc.,+1-805-275-5834, [email protected]; Gita Chandra of ConnorsCommunications, +1-212-798-1420, [email protected], for VivoMetrics

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

Knight Ridder Newspapers

WASHINGTON – A highly toxic heart drug continues to be prescribed to millions of patients nationwide without the detailed consumer warnings promised by the U.S. Food and Drug Administration more than a year ago.

Each bottle of the drug, amiodarone, is supposed to include a new advisory that warns of its many risks and symptoms of fatal side effects and explains how the medication is supposed to be used. But the advisory, planned since October 2003, remains in draft form, bouncing back and forth between the FDA and the drug maker assigned to write it.

The delay comes as the FDA is being questioned about its slowness in protecting Americans from deadly drugs, including the arthritis drug Vioxx, which was pulled off the market this fall.

“How many people are dying right now as we speak as a result of their procrastination?” asked Karen Muccino of Los Alamitos, Calif., whose father died Feb. 20 of lung damage caused by amiodarone. Despite his training as an obstetrician, Muccino’s father never realized his dry cough was a symptom of a potentially fatal side effect, Muccino said.

She said she’s livid that the FDA didn’t immediately issue the patient warnings last fall. “He would have been taken off the drug three months earlier and his life would have been saved,” she said.

Sen. Charles Grassley, chairman of the Senate Finance Committee, said Tuesday that he will look into the delays in the amiodarone warnings.

“What’s happening with this drug goes to the heart of questions about how long it takes the FDA to act when known risks or dangers exist,” said Grassley, R-Iowa. “The FDA and drug companies might know about risks, but it doesn’t do any good if doctors and patients don’t know about them too.”

Like most patients, Muccino’s father was taking amiodarone for atrial fibrillation, a common condition in which the heart beats out of rhythm. The FDA never approved the drug to treat that condition.

Patients taking amiodarone have died from lung and liver damage, gone blind or suffered from other side effects. Yet it’s routinely prescribed for common heart rhythm problems despite the availability of safer alternatives. The FDA has approved amiodarone only for more severe disorders, called ventricular arrhythmias, and then only as a treatment of last resort.

According to recent data, doctors wrote more than 2 million prescriptions in a single year for atrial fibrillation and other heart conditions that amiodarone wasn’t approved to treat. A Knight Ridder investigation last year found that those prescriptions represented 82 percent of all the amiodarone dispensed from retail pharmacies during the 12-month period ending July 31, 2003.

Earlier this month, a class-action lawsuit was filed in New Jersey that accuses drug makers of promoting amiodarone for common heart ailments in an effort to boost profits. The suit contends that more than 1,000 people died, 100 had vision problems and thousands of others suffered severe medical complications.

FDA officials didn’t respond to repeated requests for interviews about amiodarone and its efforts to protect consumers. An FDA spokeswoman instead referred questions to Wyeth, the drug maker assigned to write the advisory.

Wyeth spokesman Chris Garland said the FDA could approve its advisory as early as next month. Wyeth, which sells the drug under the brand name Cordarone, was given the job of writing the informational guide because it was the first company to sell the drug. Amiodarone is sold by several generic manufacturers, as well as under another brand name, Pacerone.

When the FDA approved amiodarone for sale in the United States, it recognized that it was a dangerous drug and told doctors to be careful about its use.

Dr. Valentin Fuster, the chairman of the American College of Cardiology’s treatment guidelines committee for atrial fibrillation, said amiodarone shouldn’t be the first drug a doctor tries when treating the disorder.

“You don’t use amiodarone as a drug for this except after everything else fails,” said Fuster, who’s also director of the cardiovascular institute at Mount Sinai Medical Center in New York City. “Amiodarone carries a higher risk than other drugs.”

Knight Ridder found that patients routinely got little information about its risks or alternative therapies. Over the years, the FDA has cited various manufacturers for downplaying the drug’s risks and for promoting it as a first-line therapy.

In October 2003, Dr. Janet Woodcock, who at the time ran the FDA’s drug division, said the agency would take the rare action of requiring the advisory in all amiodarone prescriptions.

Because of the dangers posed by the drug, Woodcock said the information would be written and distributed quickly, certainly by early 2004. “Obviously this drug is a very risky drug,” she said then.

Woodcock, now the FDA’s acting deputy commissioner for operations, didn’t respond to requests for an interview over the past week. Nor would anyone at the FDA respond to written questions about the appropriateness of allowing a drug maker to be in charge of writing warnings that may reduce its sales, or whether the delays are excessive.

Meanwhile, patients taking amiodarone continue to die.

Doctors in St. Paul, Minn., told 48-year-old Bob Hanson only that amiodarone was “difficult to tolerate” when it was prescribed last December to treat a slight atrial fibrillation, said his widow, Mary McGurran.

Hanson underwent successful heart valve replacement surgery Dec. 3 but died Dec. 19 of liver failure, with amiodarone listed in the autopsy report as a possible cause.

“I’m thinking ‘difficult to tolerate,’ that means it’s going to make him nauseous,” said McGurran, who lives with the couple’s three children in Minneapolis.

Despite asking detailed questions about all her husband’s medications, McGurran said no one told her the drug wasn’t approved to treat his atrial fibrillation, nor did they discuss any of the risks.

“I questioned everything. That’s what kills me. I questioned everything and I swear it didn’t do any good,” said McGurran, a geriatric social worker.

Dear Cindy,

I love exercising out-of-doors in warm weather, but once the weather becomes unpredictable and cold, I move indoors. I have been inside now for about a month, taking classes and using resistance machines – but I am becoming more paranoid by the minute. With this year’s flu-shot shortage, and the fact that I am a healthy 44-year- old, I am not eligible for the flu shot which I would normally get. Am I crazy to imagine that I may be doing more damage than good by going to a crowded gym? Should I stay away? – Sherry

Dear Sherry,

You are certainly not alone – or crazy – in your concern, based on the number of e-mails and phone calls I have received lately. You’ve asked a valid question, given the fact that a typical workout facility can be a breeding ground for germs that are as strong as the biceps and triceps they live on.

In fact, germs love the gym. Well, really, they love the moisture that is produced in them – shower stalls, pools, steam rooms and just plain old sweat.

The University of Texas Health Science Center at Houston found that it really wasn’t sweat that is the real culprit but rather the moisture from the sweat that helps germs grow. That means there is only a small possibility that germs can be passed along via sweat.

Typically, the germs also have a short life span. The problem comes in when germs are left to grow for extended periods of time when surfaces are not sanitized regularly.

All members at workout centers across the nation should get involved and ask that the environment in which they train be as germ- free as possible. But it is a job that cannot be done by the gym staff alone. It requires mutual cooperation by those working for the gym as well as those working out in the gym.

Their responsibility

Here is what you can expect your exercise facility to do:

* Keep workout areas well ventilated to prevent stale air from being continually recycled.

* Clean the entire facility regularly with a disinfectant solution.

* Make spray disinfectants or wipes readily available to members to use on equipment.

* Adhere to hot tub, whirlpool and swimming pool inspections to make certain that proper levels of germ-fighting chlorine and bromine are maintained.

* Make certain locker rooms, bathrooms, saunas and steam rooms are similarly cleaned and inspected.

* Encourage anyone (staff or members) to avoid coming into the gym when they are sick.

* Supply clean towels and make it mandatory for members to wipe off their equipment when leaving it for the next member.

* Identify the areas of most concern and clean them more often – areas such as stair-climber and bicycle grips, doorknobs, weights and water fountain handles.

Most workout facilities are aware of what it takes to maintain a sanitary gym environment and are diligent about it. But even impeccable cleaning regimens can miss determined germs. This is where the members must take some responsibility in this effort.

Your responsibility

Here is what you should be doing:

* Cover any scrapes or abrasions with a bandage before going to the gym.

* Always bring two different-looking towels (so you can keep them separate) from home. Use one to wipe the sweat from your body and the other to wipe your equipment down once you’ve finished using it.

* Once your workout begins, never touch your face – nose, eyes, mouth – until you’re workout is completed and you have washed your hands thoroughly.

* Use disinfectant supplied by the gym to spray your equipment. If it is not supplied, ask that it be or bring your own.

* Wear shower slippers or flip-flops on pool decks, showers, saunas and steam rooms.

* Bring a clean towel from home to sit on if you use the steam room or sauna. (Flu season may not be the optimum time to use these two rooms.)

* If you are not feeling well, stay away from the gym. If you have cold symptoms from the chin up, take a week off; if you have cold symptoms from the chin down, take two weeks off.

* Carry a gym bag that is washable and wash it often. Take sweaty towels and clothing out of the bag and wash them after each workout.

* Wash your hands thoroughly before and after your workout.

* Carry an alcohol-based hand sanitizer to use if you feel the need.

* Cover your mouth if you should sneeze or cough.

Gee, with all that in mind, it may not seem worth it. But, Sherry, if you are otherwise healthy, I have to tell you that it is worth going. Maintaining your fitness level is the way you stimulate your immune system, and the benefits outweigh the risks.

Remember that the gym setting is not the only place these germs reside. They are in every setting, including your home, so it is impossible to eliminate all risk during flu season. Regular exercise and the benefits it brings you will be your greatest ally in this germ warfare.

Even if you do end up with a cold or a virus or even a bacterial infection – those who are fit are usually affected less and recover faster.

Go to the gym prepared to practice good gym etiquette. It is up to you and the staff to share the responsibility so that you and others can stay healthy and strong all year long.

Cindy Boggs, a free-lance fitness professional and state director of Activate America has been an ACE-certified fitness coordinator/ instructor at the Charleston Family YMCA since 1989. Have a question pertaining to health and/or fitness? E-mail [email protected] or visit her at www.cindysays.com.

IT may still be associated with seedy clubs and strippers, but pole dancing has become the latest weapon in the fight to curb Scotland’s obesity crisis.

Fitness instructors are now adding the craze to their training regimes and classes in response to “phenomenal” demand. Instructors in Edinburgh and Glasgow say their unorthodox keep-fit sessions have attracted students, lawyers and even primary schoolteachers.

This week in Glasgow a new drive will be launched by DIY Divas in an attempt to prise desk-bound workers away from the office and on to the pole. The hour-long fitness classes, to be run at Cube nightclub in the city centre, will start at 5.30pm in a bid to attract workers who would normally head home at that time to a microwave meal and the television.

Polestars, which runs classes in Edinburgh, is also in talks with Glasgow arts venue The Arches to hold weekly sessions there.

A third company, Birmingham-based PoleCats, wants to take pole dancing into mainstream gyms in Scotland. In the last few months, its poles have been installed in Fitness First gyms in Burton-on- Trent and Coventry in a bid to gauge demand. A spokeswoman for Fitness First said demand had been so high for the classes, which also include erotic dancing, that more were now being made available.

Dawn Love, of DIY Divas, who also runs classes at Peppermint Studios in Glasgow’s west end, said: “Demand for this is phenomenal. We’ve had doctors, nurses and policewomen. We also had a lawyer who would step out of her pinstripe suit and into her hotpants for an hour and a half.”

Love, a former pole dancer at Stringfellows in London, said those who joined her six-week beginners’ course were given a white garter. Then, as the classes become more strenuous and complex, the students work their way towards a red and eventually a black garter.

“When they can go upside down and do star jumps and windmills on the pole they get their black garter. It’s just like judo.

“The idea of the new classes is to go for office workers who are stuck behind a desk all day. Instead of going home and doing nothing, they can go to the classes straight after work and still be home for seven. Why shouldn’t they stick their head in the door and swing on a pole before going home? It’s fun and great for fitness. Their whole body shape changes in six weeks.”

Although the classes are currently women-only, Love is to open a men-only class in Edinburgh next year.

Jill Anderson, a fitness instructor who runs two-hour classes at Edinburgh’s Ego nightclub, said students start with 30 minutes of warming up and stretching.

“Once we do that we get changed into our shorts and heels. I break down the moves for the students and then it’s a warm-down and more stretching. Because it’s ladies only they don’t have to worry about men coming along for a peek.

“The aim is to steer pole dancing way from the seediness that’s attached to it. We’ve got a bit to go but people are slowly beginning to open up their minds to it. It’s a tough sport and great for fitness. You don’t just swing around a pole.”

Anderson added that the classes were great for building women’s confidence. “Other than the fitness aspect, I’ve seen girls who have been so shy and would not say ‘boo’ to a goose. By the end of it they are spinning round that pole and being really chatty.

“The purpose of our classes is not to train girls for dancing in clubs. It’s for fun, fitness and confidence-building. It’s for everyone, from size eight to 18 and all ages.”

The instructors believe they are cashing in on increasing numbers of people who are turning away from traditional workouts on treadmills and exercise bikes. But they also hope to attract women who have never before set foot in a gym of any sort.

One woman, a 49-year-old mother of two from Glasgow, joined Love’s west end classes for the first time this year. At the classes, women are encouraged to adopt a stage name to make themselves feel sexy when they are on the pole.

The woman, who works as a secretary in a large company, uses the pseudonym Candy, after her mother’s dog. Alongside her in the classes were women of all ages whose stage names included Hollywood, Malibu and Sambuca.

“I was a complete beginner but it was something that I wanted to do. I just thought it was wonderful, it was so empowering and the fitness aspect was great.

“There are an awful lot of women who would be frightened to do it just because it’s got a bit of a reputation.

“In the beginning I told one good friend and that was all. Now more friends know, but I work for quite a big company and I wouldn’t want them to find out.

“Another woman who went along to the classes taught in a primary school and she was worried about what people would think. But there is nothing awful in it.”

More than half of Scotland’s population is overweight and experts say the problem stems from the fact that many do not take enough exercise.

Six out of 10 men and seven out of 10 women do not even meet the minimum levels of activity, resulting in nearly 2500 people dying prematurely every year, the experts claim. Problems associated with obesity are expected to cost Scotland (pounds) 16 billion over the next 10 years alone, maintaining the country’s reputation as the sick man of Europe.

Sarah Davis, a fitness instructor who runs the PoleCats company, said: “I’m on the look-out for Scottish instructors because there has been such a huge demand for this.

“We have quite a lot of females but a lot of guys are coming now as well. People don’t realise how hard the exercise is, especially on the upper body. It’s great for toning.”

The pole dancing craze is also leading to women buying poles to instal in their own homes.

A host of celebrities are also taking up the art, including Kelly Brook, who installed a pole in her home to practise for a role in a play. Others known to have tried the pole dance workout include Hollywood actresses Sadie Frost, Jennifer Aniston and the model Kate Moss.

ROCHESTER HILLS, Mich., Nov. 29, 2004 (PRIMEZONE) — Millennium Natural Health, a growing Oakland County health and wellness company, announced today it has launched a new corporate web site http://www.millenniumnaturalhealth.com. The web site offers premium nutritional supplements, such as antioxidants that help prevent cancer, herbal supplements, and a variety of other vitamins and minerals. The site also provides educational resources such as articles and other materials that provide information about health and wellness.

“Our customers are very loyal to our products, and the new web site makes it easy for them to order through our e-commerce system,” said Vincent Salvia, president of Millennium Natural Health. “The site also provides users with a variety of articles and reference information so people can learn about nutritional supplements and ways to stay healthy.”

The products available on the site are very high quality, premium nutritional supplements that are manufactured specifically for Millennium Natural Health. The product line includes familiar supplements such as Vitamin C, Echinacea, and deodorized Garlic, and also contains new, exclusive products such as PhytoCopia(tm), a concentrate of nutrients with vitamins, minerals, enzymes and antioxidants.

“Educated consumers are increasingly looking for a balanced line of results-oriented nutritional products,” said Salvia. “Our bodies are being ravaged every day by disease-carrying organisms and toxins we absorb from our food, water, and air. Using the right high-quality supplements can combat these effects and help us maintain or even improve our health.”

The new Millennium Natural Health web site, created by Hartland marketing firm Five Sparrows (http://www.fivesparrows.com), is part of an overall marketing partnership designed to introduce Millennium Natural Health’s premium products to consumers. Site visitors can also expect new products and resource information to be added regularly to the site.

About Millennium Natural Health

Millennium Natural Health provides a complete line of high-quality nutritional supplements and health products manufactured specifically for Millennium Natural Health. The company is located in Rochester Hills, Michigan. For more information call 800.317.6425 or visit our web site at http://www.millenniumnaturalhealth.com.

CONTACT: Millennium Natural Health (800) 317-6425 http://www.millenniumnaturalhealth.com

Copyright © 2004 PrimeZone Media Network, Inc.

A recent study indicates a powerful form of aspirin appears to help prevent colon cancer in mice without raising the incidence of gatrointestinal bleeding.

The drug is called nitric oxide-donating aspirin, or nitroaspirin. Researcher Dr. Basil Rigas, chief of the Division of Cancer Prevention at SUNY Stony Brook, N.Y., says that while the studies are preliminary, nitroaspirin also may have a positive effect against cardiovascular disease and help ease the pain of arthritis. The compound, he said, is much more powerful than regular aspirin, and much safer.

Rigas said the difference between common aspirin and nitroaspirin is that the molecule of aspirin has been modified to release nitric oxide. That, in turn, has multiple effects on the cardiovascular and respiratory systems, as well as cancer.

The full text of a HealthDay news service story on Rigas’ study, as well as more information on “superaspirin,” can be found at www.healthday.com. Search Archive using the keyword “aspirin.”

CINCINNATI, Nov. 29 /PRNewswire/ — The U.S. Food and Drug Administration (FDA) has given marketing clearance to the new PillCam(TM) ESO, a miniature color video camera in a pill that helps doctors diagnose and evaluate diseases of the esophagus such as gastroesophageal reflux disease (GERD), erosive esophagitis and Barrett’s esophagus, a pre-cancerous condition, according to InScope, a division of Ethicon Endo-Surgery, Inc., a Johnson & Johnson (JNJ) company.

The PillCam(TM) ESO was developed and is manufactured by Given Imaging and will be marketed by the InScope Division of Ethicon Endo-Surgery.

Every year millions of Americans undergo procedures to examine the esophagus. The most common procedure involves advancing a long, flexible tube (endoscope) into the mouth, down through the throat into the esophagus. The procedure, known as traditional endoscopy, requires sedation and hours of recovery.

The PillCam(TM) ESO is the first non-invasive diagnostic alternative to traditional endoscopy that has been shown in clinical trials to have accuracy comparable to traditional endoscopy. However, the 20-minute office procedure requires no sedation and recovery is immediate.

“This is a technology that could revolutionize how esophageal disease is identified and evaluated,” said Blair Lewis, MD, a gastroenterologist at the Mount Sinai School of Medicine in New York City. “More patients are willing to swallow a pill than go through a traditional endoscopy.”

The PillCam(TM) ESO is a smooth plastic capsule about the size of a large vitamin pill that has tiny video cameras at each end. A patient lies on his or her back and swallows the pill with water. The pill then glides down the esophageal tract taking about 2,600 color pictures (14 per second), which are transmitted to a recording device worn by the patient. After 20 minutes, the doctor has enough video images to make a definitive diagnosis. The disposable capsule is passed naturally, usually within 24 hours.

According to health experts, most of the 19 million GERD sufferers do not monitor their condition despite the fact that 5% to 15% of GERD patients may have Barrett’s Esophagus, a condition that increases the risk of developing esophageal cancer, the fastest growing type of cancer in America. About 700,000 people have Barrett’s Esophagus.

GERD sufferers are often treated with prescription or over-the-counter antacids. However, treatments that control symptoms do not prevent the progression of disease.

“Millions of people are chronic antacid users and have never been evaluated for esophageal disease,” said Brian Fennerty, MD, a gastroenterologist from Oregon Health & Science University in Portland who has used PillCam(TM) ESO on scores of patients during clinical trials. “We think that the PillCam ESO(TM) will make it easier for people at risk to get that evaluation sooner and keep esophageal disease in check.”

The American College of Gastroenterology (ACG) recommends that patients with long-standing GERD symptoms, particularly those 50 and older, should have upper endoscopy to detect Barrett’s Esophagus.

The PillCam ESO(TM) is not for everyone. People with dysphagia or other swallowing disorders, pacemakers or with known or suspected gastrointestinal obstruction, strictures or fistulas are not candidates.

For more information on PillCam(TM) ESO, please visit http://www.pillcam.com/, or call toll free 866-InScope.

Another version of the camera pill for the small bowel, PillCam(TM) SB, was cleared by the FDA in 2001 and has been used in more than 150,000 patients. The PillCam(TM) SB video capsule is the only naturally ingested method for direct visualization of the entire small intestine.

About InScope, a Division of Ethicon Endo-Surgery

InScope, a division of Ethicon Endo-Surgery, Inc., is focused on developing and marketing technologies that enable diseases of the gastrointestinal tract to be diagnosed and treated without the need for incisions.

Ethicon Endo-Surgery, Inc. develops and markets a broad portfolio of advanced surgical instruments and medical devices for minimally invasive and traditional surgery. The Company’s mission is to help physicians around the world transform patient care through innovation. The Company’s focus is on designing innovative, procedure-enabling medical devices for interventional diagnosis and treatment of various diseases and conditions in the areas of general and thoracic surgery, breast disease, gynecology, oncology, and urology. For more information, visit http://www.ethiconendo.com/.

InScope

CONTACT: Keith Taylor of InScope, +1-212-527-7537

Web site: http://www.ethiconendo.com/http://www.pillcam.com/

BREAK THE EVIL CHAINS

Doom threat letters cause no real harm

CHAIN letters have been making the rounds for years now, often causing stress and fear to the recipients by threatening disaster to those who do not send them on.

If one arrives to your home my advice is to just throw it in the bin.

Chain emails with “ghost photos” are a new internet phenomenon, I found one, containing the picture above, circulating recently.

The text of the letter read: “The picture was taken in one of the rooms of Our Lady Of Charity hospital in Toluca, Mexico, while one of the patients was asleep.

“The patient had been involved in a multiple car accident and the lady under the bed was the only one person who died in the same accident.

“Her body was taken to the morgue, then the patient’s brother captured this image with his own camera.

“The picture has been seen around the world and has been authenticated by the research centre in Chicago, Illinois.

“It is said that when you receive this image and do not send it to at least five people, the woman will look for you during the night to collect your soul.

“People in Laredo, Texas, received this image and did not send it and were killed outside a bar; it looked as if this woman killed them.

“Send it to five people or the woman will look for you.”

Photos like this are easily put together using double exposure or computer manipulation.

In short, they are fakes and they – and indeed chain letters of any kind – cannot “curse” or exercise any magical power over their recipients.

And whoever concocted this particular chain letter was very lazy… They even stole the photo from a 2003 horror movie made in Thailand, called The Unborn or The Mother.

Untangle yoga

Dear Sandra,

I NOTICE that you recommend yoga a lot.

I decided to try it out, but there are so many different classes. Can you tell me what the differ-ences are?

Michelle, Sandyford.

Dear Michelle

HERE is a quick guide to the most popular types of yoga that may be right for you.

HATHA yoga is based on breathing techniques and can encompass many of the physical types of yoga.

It is a good starting point as it tends to be slow-paced and gentle, a good introduction to the basic yoga poses.

VINYASA means breath-synchronized movement, and tends to be more vigorous.

A series of poses called Sun Salutations are used in which movement is matched to the breath.

This warms up the body for more intense stretch-ing which is done at the end of class.

ASHTANGA, which means eight limbs in Sanskrit, is a fast-paced, intense style of yoga practice which uses a set series of poses always performed, always in the same order.

Ashtanga practice is very physically demand-ing, because of the constant movement from one pose to the next.

Ashtanga is also the inspiration for what is often called Power Yoga.

IYENGAR practice usually emphasises holding poses over long periods of time and encourages the use of props, such as yoga blankets, blocks and straps in order to bring the body into alignment.

KUNDALINI uses rapid, repetitive movements rather than holding poses for a long time, and the teacher will often lead the class in call and response chanting.

l A Holistic Fair will be held today from 11am to 7pm in the Arklow Bay Hotel, Arklow, Co Wicklow.

I will be there with a selection of rare, energised crystals, gemstones, jewellery and healing products.

Ireland’s top holistic therapists, psychics and Tarot readers will also be available for consultation.

IN THE HOT SEAT: Condoleeza Rice

US controller hides a fear

Name: Condoleeza Rice

Profession: Secretary of State, U.S.A.

Date of Birth: November 14, 1954

Star sign: Scorpio

MS RICE’S chart shows she was born to be a public figure.

First House Mars rules her Sun, revealing that she has felt intense pressure to rise from the depths of the 1950’s south to be powerful and respected for her beliefs (Mercury in 9th) and writings, and she truly seems to be the “power behind the throne”.

She has a singular sense of purpose and needs total control.This can easily turn to ruthlessness and aggression when she is challenged.

She can eloquently express ideas that President Bush is incapable of, and is one of the most powerful advocates of the controversial Bush doctrine of pre-emptive action against countries thought to be a threat the USA.

Her fear of failure is a dangerous weakness, as the dark side of Scorpio and Mars have a sinister square to Saturn. When the time comes, I feel she will be unwilling to take the blame for the carnage and atrocities of the American troops.

She is an extremely clever and powerful woman who has her sights firmly set on becoming America’s first female president.

Her intimate relationship with George Bush will eventually become public knowledge which may prove an obstacle to her political aspirations.

CLINICAL Q&A

Our team of experts tackle some of your commonly seen medical queries

Q Is there any evidence that long-term use of Depo-Provera can cause significant bone loss? Is it safe to continue long term and are there any tests that should be done?

A Because Depo-Provera causes ovarian suppression, concern has been growing about bone loss in long-term users.

However, studies have shown conflicting results (J Fam Plann Reprod Health Care 2002; 28:7-11). A major problem is that women who choose, or are advised to use, Depo-Provera seem to be likely to have known risk factors for osteoporosis, such as smoking, low socio- economic status or family history. This tends to make comparisons with other contraceptives difficult.

It is possible that the observed differences in bone density are due to these risk factors, not the Depo-Provera itself. Meanwhile, the best way to assess a woman’s risk is to measure her bone density when she reaches her forties.

It has been suggested that measurement of serum oestradiol should be carried out in long-term users.

However, no published studies show a linear relationship between oestradiol levels and bone mineral density, and two studies have shown no correlation at all.

Instead, long-term users of Depo-Provera could be assessed on the basis of their other risk factors for osteoporosis, rather than their use of Depo-Provera.

Long-term users of Depo-Provera are generally happy with it and are not keen to change to another contraceptive. Also, the bone- conserving option of the combined Pill may be contraindicated if they are smokers over the age of 35.

If a woman is approaching the menopause, is a smoker, and perhaps has other risk factors, one could suggest that she start HRT early.

Dr Anne Szarewski, clinical consultant, Department of Epidemiology, Mathematics and Statistics, Cancer Research UK and senior clinical medical officer, Margaret Pyke Centre, London

Q One of my patients is an overweight woman of 42 who has had a cerebellar stroke. She wants to lose weight and has asked about drug treatments. Sibutramine is contraindicated because she has hypertension and she is on a statin already. Would orlistat be suitable for her?

A For obese patients, losing about 10 per cent of body weight has many benefits, including a reduction in mortality and improvements in vascular risk factors.

It is therefore important to encourage patients to lose weight. The patient seems to be well motivated to do so.

Orlistat is licensed for use as an adjunct to lifestyle modification in obesity. As this woman has complications, she is eligible for treatment if she has a body mass index of greater than 28kg/m^sup 2^ and can show that she can modify her diet successfully.

Clinical trials have found that orlistat is more effective than lifestyle modifications alone, so it is reasonable to consider it.

However, there is not yet any research to show that weight loss achieved through the use of orlistat will lead to benefits beyond two years.

Using orlistat with a statin does not pose a problem. Early reports suggested that orlistat might potentiate the hypolipidaemic effects of pravastatin but no adverse effects were reported in more extensive studies.

Dr Sudesh Kumar, consultant physician, Heartlands Hospital, Birmingham

Q My patient had abdominal pain and vomiting but no other signs. I thought it was a GI infection, but the following day he was admitted with a ruptured appendix. Are there any questions I should have asked that might have pointed to appendicitis?

A With appendicitis, the patient commonly suffers pain for 24 hours, although symptoms may only be present for a few hours. Pain may fluctuate in intensity but is always present and there is usually anorexia, nausea or vomiting. I usually ask the patient if they would be up to eating their favourite meal. A ‘no’ response confirms anorexia. If eating is followed by a recurrence of pain, this also supports a diagnosis of appendicitis.

Mr Dugal Heath, consultant gastroenterologist and laparoscopic surgeon, The London Clinic

GPonline.com

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Long-term users of Depo-Provera could be assessed on the basis of their other risk factors for osteoporosis

Copyright Haymarket Business Publications Ltd. Nov 5, 2004

Study objectives: We sought to assess the outcomes of COPD lung transplant recipients who had previously undergone lung volume reduction surgery (LVRS), and to compare these patients to those COPD lung recipients who had not previously undergone LVRS.

Design: Retrospective analysis of the United Network for Organ Sharing transplant database over the period between October 25, 1999, and December 31, 2002.

Patients: All COPD patients who were listed and underwent transplantation during the time period were analyzed and categorized according to who did and did not have a history of LVRS. The two groups were compared for demographics, severity of illness, and various measures of outcomes after transplantation, including survival.

Results: There were 791 COPD patients who underwent transplantation, of whom 50 had a history of LVRS. The two groups had similar demographics and severity of disease. There was no difference in the need for reoperation, hospital length of stay, or survival between the groups.

Conclusion: A history of LVRS does not impact on outcomes after lung transplantation and should not influence a patient’s candidacy for transplantation. Similarly, a patient’s potential need for lung transplantation should not impact on the decision-making process for undergoing LVRS. (CHEST 2004; 126:1569-1574)

Key words: chronic obstructive lung transplantation; cohort studies; mortality: pneumonectomy; pulmonary disease; pulmonary emphysema; surgery; survival analysis

Abbreviations: LVRS = lung volume reduction surgery; NETT = National Emphysema Treatment Trial; OPTN = Organ Procurement and Transplantation Network; QOL = quality of life; UNOS = United Network for Organ Sharing

COPD is now the fourth-leading cause of death in the United States, with 123,550 deaths reported per annum and an estimated prevalence of 3.1 million.1 Medical therapy and pulmonary rehabilitation are useful palliative measures and can improve a patient’s symptoms and quality of life (QOL); however, they do not alter the natural history of the disease.2 Transplantation is now well established as a viable option for patients who have disease of sufficient severity, are of an appropriate age, and do not have any contraindications. A second surgical option is lung volume reduction surgery (LVRS) or pneumoreduction. This procedure came to the fore in the early 1990s, but, despite numerous reports3-5 attesting to its utility, its role has remained controversial. To address this issue, the National Emphysema Treatment Trial (NETT), cosponsored by Medicare and the National Institutes of Health, was undertaken.6 The results of this landmark study have verified that there is a subgroup of patients who have significant improvements in their lung function, exercise tolerance, and QOL.7 In addition, there also appears to be a smaller subgroup that may derive a significant survival benefit from the procedure.

An unanswered question, however, is what impact the one procedure may have on the outcomes of the other. Specifically, does a history of LVRS impact on the outcomes of COPD patients who ultimately require transplantation? With this as our objective, we performed an analysis of the United Network for Organ Sharing (UNOS)/Organ Procurement and Transplantation Network (OPTN) database to assess the outcomes of COPD lung transplant recipients who had a history of LVRS.

MATERIALS AND METHODS

The cohort in this study included all patients with COPD who were listed with UNOS and had undergone transplantation between October 20, 1999, and December 31, 2002. The start of the cohort corresponds to the date that information regarding pneumoreduction began to be collected by the OPTN. Prior to October 25, 1999, only a history of sternotomy or thoracotomy was collected. While some of these latter patients likely had LVRS, it is unknown which of them did. Therefore, to obtain the most homogeneous cohort possible, we included oly COPD lung transplant recipients who underwent transplantation after October 25, 1999. In order to provide adequate follow-up, the cohort included only those transplants performed on or prior to December 31, 2002.

Comparisons were made between those COPD patients with a history of LVRS who had undergone transplantation and those COPD patients who had undergone transplantation during the same period, but who had not undergone LVRS. Demographic measures, including age sex, race, gender, and type of transplant procedure, were compared for the two groups. They were also compared for disease severitv based on pretransplant pulmonary function test results and pulmonary artety pressures. Their waiting times on the transplant list were contrasted, as was their incidence of pneumothoraces while waiting. Postoperative outcomes were compared for incidence of prolonged graft ischemia, prolonged graft dysfunction, bronchopleural fistulas, the need for reoperation, hospital length of stay, and survival. Comparisons of categoric factors were made using the χ^sup 2^ test or the Fisher exact test. Comparisons of continuous factors were made using the Wilcoxon test. Survival rates were computed using the Kaplan-Meier method and were compared using the log-rank test.

RESULTS

During the study time period, there were 1,922 COPD patients added to the transplant waiting list. Of these, 1,663 patients had not undergone LVRS, 95 patients had a history of LYRS, and the LYRS status of the remaining 164 patients was unknown. There did not appear to be any substantial difference in terms of disposition on the list between the LVRS transplant candidates and their COPD non- LVRS counterparts (Fig 1, 2).

There were a total of 791 transplants performed in COPD patients during the study period. Of these, 50 patients had a history of LVRS (6.3%). Demographic data for the two groups are shown in Table 1. In the non-LVRS group, 22% (162 of 741 patients) had bilateral/double- lung transplants, while in the LVRS group 28% (14 of 50 patients) had bilateral transplants (p = 0.31). Of the LVRS patients, 62% had the procedure prior to being listed for transplant, while 20% underwent the procedure after being listed but prior to transplantation. The remaining 18% were reported to have LVRS both prior to listing, and between listing and undergoing the transplant. There were a total of 31 centers that were responsible for the 50 transplants in the LVRS patients. Of these, 29 performed between one and three of the procedures, while the two centers with the highest volume performed live and six of the lung transplants.

FIGURE 1. Outcomes on the waiting list for adult COPD patients added between October 25, 1999, and December 30, 2002 for the non- LVRS group.

There was no difference in disease severity between the two groups based on their pulmonary function study findings and pulmonary artery pressures at the time of transplantation (Table 2). The LVRS patients appeared to have a slightly longer waiting period (median waiting time, 353 days) compared to that of the non-LVRS group (median waiting time, 211 days; p = 0.014). In the LVRS group, 8% had a history of pneumothorax between listing and transplant vs 1.5% in the non-LVRS group (p = 0.01).

There was no difference in grail ischemic time between groups, with a median of 3.9 h for the non-LVRS patients (interquartile range, 3.0 to 4.8) and 4.0 h for the LVRS patients (interquartile range, 3.0 to 5.1; p = 0.76). Two percent of both groups required posttransplant cardiac reoperation (p = 0.99). Similarly, there was no difference in other surgical procedures required by both groups (non-LVRS patients, 13%; LVRS patients, 12%; p = 0.99). The incidence of posttransplant prolonged graft dysfunction was similar between the two groups (non-LVRS patients, 9%; LVRS patients, 7%; p = 0.8), as was the incidence of posttransplant bronchopleural fistulas (non-LVRS patients, 0.8%; LVRS patients, 0%). There was no significant difference in postoperative length of stay from transplant to hospital discharge between the two groups, with a median stay of 19.7 days for the non-LVRS patients and 18.3 days for the LVRS patients (p = 0.4).

FIGURE 2. Outcomes on the waiting list for adult COPD patients added between October 25, 1999, and December 30, 2002 for the LVRS group.

Table 1-Patient Demographics Stratified by LVRS

Survival times for the two groups of patients are shown via Kaplan-Meier curves in Figure 3. There was no significant difference in survival within 1 month, 3 months, or 1 year (p = 0.5, p = 0.4, and p = 0.4, respectively). The 1-year survival rate of the cohorts was 88.1% for the LVRS patients and 82.4% for the non-LVRS transplant recipients. For an overall comparison of survival for the entire follow-up period, the p value was 0.1, with the LVRS group having a higher survival rate at all time points. There was no significant differences in cause of death between the two groups (p = 0.8), but as there were only six deaths in the LVRS patient group, the sample size may have been too small to draw any definitive conclusions.

Table 2-Physiologic Parameters in the LVRS and Non-LVRS Patients at Transplantation*

FIGURE 3. Posttransplant survival.

The 1-year Kaplan-Meier survival rates for the LVRS patients were 91.7% for double-lung recipients (95% confidence interval, 76.0 to 100.0%) and 87% for si\ngle-lung recipients (95% confidence interval, 75.1 to 99.0%). Survival rates for the two groups were not significantly different (p = 0.6), but there is relatively low power to detect a difference due to the small number of transplants in each group.

DISCUSSION

Lung transplantation is generally regarded as a last-resort option for patients with many forms of end-stage lung disease. All other treatment options, both medical and surgical, should be explored before subjecting patients to the inherent risks of transplantation. COPD patients form the largest group of patients in whom lung transplantation is performed.8 For select patients with COPD, LVRS is another surgical option that might be considered prior to lung transplantation.

LVRS gained popularity in the mid-1990s as a potential palliative surgical option for some patients with advanced COPD.3-5 However, since the efficacy of the surgery was thought to be uncertain, Medicare discontinued reimbursing for the procedure, and most private payers followed suit. In a follow-up to this, a large multicenter study, the NETT, was undertaken. From January 1998 until July 2002, 3,777 patients were screened and 1,218 patients were randomized to either LVRS or standard medical care. The outcomes of this landmark study have now been published in two reports.7,9 Aside from the initial high-risk group of patients identified, two independent risk factors (ie, exercise capacity after pulmonary rehabilitation and upper lobe-predominant distribution of disease) were found to be predictive of outcome. Based on these factors, four groups of patients were identified. One group (with low exercise capacity and upper lobe-predominant disease) had the most benefit with improvements in QOL, exercise tolerance, and survival compared to their medically managed counterparts. Two of the groups had more patients (ie, those with upper lobe-predominant disease/high exercise capacity and those with non-upper lobe emphysema/ low exercise capacity) who showed an improvement in their exercise capacity and/or symptoms, but there was no difference in their survival times. The last group constituted by those patients with predominantly non-upper lobe emphysema and a high exercise capacity had a deleterious response with a worse survival compared to their medical treatment counterparts.7

With these groups and their characteristics now identified, it appears likely that there will be a focused resurgence in popularity of the procedure. Some patients who are appropriate lung transplant candidates may also be suitable for LVRS, and it is possible that the need for transplantation might be deferred in such patients, provided that they obtain a successful outcome from LVRS.10-13

The expected duration of benefit from LVRS is yet to be determined. In the NETT, it appeared that most of the benefit was maintained for at least the 2 years of follow-up. In addition, there are reports10,11 attesting to a duration of benefits for as long as 5 years in most patients. However, not all patients maintain the benefit for this long, and once they do deteriorate. LVRS patients might still remain good lung transplant candidates.

The issue that we attempted to address was whether a history of LVRS would have any impact on the postoperative course and prognosis of lung transplant patients. There are theoretic reasons as to why this might be the case. Any surgical instrumentation of the chest cavity results in the subsequent formation of adhesions. This might result in difficulty in removing the native lung during the explant phase of the transplant procedure. The dissection of the adhesions can result in excess bleeding, the need for blood products, hypotension, and hemodynamic instability. Therefore, patients with a history of LVRS may be at a higher operative risk, and this might impact on their short-term prognosis and, hence, on their long-term prognosis. If this were the case, then their potential transplant candidate would need to be addressed at the same time that consideration was being given to LVRS.

For any potential transplant or LVRS candidate to make the appropriate choice, the outcomes that need to be weighed are what their QOL and life expectancy might he with or without the procedure. Furthermore, for LVRS the heterogeneity of response needs to he considered since individual patients might not have a significant improvement. For those patients with COPD, who might be eligible for both LVRS and transplantation, not only does their QOL and life expectancy with LVRS need to be considered, hut also what their life expectancy and course is likely to be posttransplant if they first undergo LVRS and subsequently undergo lung transplantation.

This last consideration may be moot since, contrary to our hypothesis, there does not appear to be anv statistical difference in outcomes between patients who have previously undergone LVRS and their non-LVRS counterparts. If there were any significant increased perioperative risk, we would have expected a difference in mortality at 1 month, which was not seen. Further supportive evidence of a lack of increased morbidity in the LVRS group is the similarity in the posttransplant hospital length of stay between the two groups. It also appears that intermediate-term outcomes are no different, with similar survival rates seen at 12 months. The OPTN does not collect any data that reflect the difficulty of surgery, so differences in the explant part of the procedure could not reliably be distinguished between the two groups. For example, it is possible that the LVRS group required longer operations and more blood products. However, even if either of these were the case, it did not impact on other measures of relevance to the patients postoperative course, including graft ischemic times, the incidence of prolonged graft dysfunction, or the need for reoperation. The latter could possibly he construed as a surrogate for episodes of severe pleural hemorrhage and might therefore indicate that even if this group did have more bleeding, it was not sufficient to require a greater number of reexplorations. Whether there were other differences in their operative and perioperative course that were not captured by the UNOS/OPTN database, remains unanswered.

The two groups of patients that formed our cohorts appeared to he very well-matched by demographics and severity of disease. The one difference between the two groups was the apparent increased incidence of pneumothoraces in the LVRS group while listed. This most likely was related to the fact that 38% of the patients underwent LVRS during this waiting period. The other apparent difference was the longer waiting times in the LVRS group. There are a number of possible reasons for this. It is conceivable, for example, that patients in whom the waiting time was expected to be longer were offered LVRS as a temporizing measure. It is also possible that LVRS patients were more likely to be listed earlier since they were being followed closer. A survival advantage for the LVRS patients appears unlikely to have accounted for the difference since the mortality rate on the waiting list for the two groups was similar, as were their physiologic characteristics at the time of transplantation.

One caution in interpreting these results is that the relatively small sample size of the LVRS group does not provide sufficient power to be able to detect small-to-moderate differences in survival or other outcomes. It is also possible that there was a selection bias in the LVRS group. It is likely that this group of patients was highly motivated and otherwise “pristine” transplant candidates. It is similarly conceivable that some less robust patients who might have otherwise been considered reasonable candidates for lung transplantation were excluded from transplantation because of their prior LVRS. There does not appear to have been a center bias to explain our results as 78% of the procedures were performed at 29 different centers, with the two highest volume centers accounting for the remaining 22%.

With the results of our study, it is enticing to attempt placing LVRS and lung transplantation in context with one another. However, one needs to be cognizant that, as a group, appropriate LVRS candidates have milder disease than lung transplant candidates, which limits the ability to do direct comparisons of outcomes between these two procedures. Patients who present for LVRS may be too early in their course to consider transplantation, and, similarly, the conditions of those who present for transplantation may be too far advanced for LVRS to be an option. However, there is a group of patients who at the time of initial presentation may be candidates for either of the two procedures.12 It is also important to be cognizant of the inclusion criteria of the NETT, as only a minority of all COPD patients were included. The characterization of patients into one of the four groups described depends first on them fulfilling the other inclusion criteria of the study. With these and other caveats in mind, then, in those patients with predominantly upper lobe disease and low exercise tolerance, who choose a surgical option for their COPD, we contend that LVRS should be favored. Similarly, we hypothesize that in the group of patients who have a high exercise capacity with predominantly upper lobe disease, if their symptoms are such that surgery is contemplated, then LVRS should be favored since there are improvements in QOL with a mortality rate of only 16.5% at a median follow-up time of 29 months. This survival time is no different from that seen with medical management and compares very favorably with the expected outcomes after lung transplantation.11 In those patients with predominantly non-upper lobe disease and low exercise tolerance, the mortality rates that can be expected from LVRS and transplantation appear equivalent to67% of the LVRS patients surviving a mean time of 29 months vs a 2-year survival rate of 66% in our cohort of non- LVRS lung transplant recipients.7 In these situations, other factors such as the likelihood and degree of improvement in QOL as well as financial considerations should be factored into the decision. In the two high-risk groups of patients identified in the NETT study, the decision between transplantation and LVRS is quite clearly weighted in favor of the former.

In summary, it appears that a history of LVRS does not impact negatively on patients’ subsequent post-transplant course and, hence, on their candidacy for transplantation. If patients are deemed to be suitable LVRS candidates, there is no evidence to suggest that the possibility of transplantation in the future should impact on this decision. Indeed, based on the NETT results and other reports,12-14 LVRS may help to defer the need for transplantation in some patients.

* From the Inova Heart and Lung Transplant Center (Drs. Nathan, Ahmad, Burton, and Barnett), Falls Church; and the United Network for Organ Sharing (Dr. Edwards), Richmond, VA.

REFERENCES

1 US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Heart, Lung, and Blood Institute. Morbidity and mortality: chart-book on cardiovascular, lung, and blood diseases, 1998. Available at: http:/ /www.nhlbi.nih.gov/resources/docs/cht-book.htm. Accessed October 14, 2004

2 Rennard SI, Farmer SG. COPD in 2001. Chest 2002; 121: 113s- 115s

3 Cooper JD, Trulock EP, Triantafillou AN, et al. Bilateral pneumonectomy (volume reduction) for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1995; 109:106-119

4 Cooper JD, Patterson GA, Sundaresan RS, et al. Results of 150 consecutive bilateral lung volume reduction procedures in patients with severe emphysema. J Thorac Cardiovasc Surg 1996; 112:1319-1330

5 McKenna RJ, Brenner M, Fischel RJ, et al. Should lung volume reduction for emphysema be unilateral or bilateral? J Thorac Cardiovasc Surg 1996; 112:1331-1339

6 Ciccone AM, Meyers BF, Guthrie TJ et al. Long-term outcome of bilateral lung volume reduction in 250 consecutive patients with emphysema. J Thorac Cardiovasc Surg 2003; 125:513-525

7 National Emphysema Treatment Trial Research Group. A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema. N Engl J Med 2003; 348:2059-2073

8 Trulock EP, Edwards LB, Taylor DO, et al. The Registry of the International Society for Heart and Lung Transplantation: twentieth official adult lung and heart-lung transplant report; 2003. J Heart Lung Transplant 2003; 22:625-635

9 National Emphysema Treatment Trial Research Group. Patients at high risk of death after lung-volume-reduction surgery. N Engl J Med 2001; 345:1075-1083

10 Gelb AF, McKenna RJ, Brenner M, et al. Lung function 4 years after lung volume reduction surgery for emphysema. Chest 1999; 116:1608-1615

11 Yusen RD, Lefrak SS, Gierda DS, et al. A prospective evaluation of lung volume reduction surgery in 200 consecutive patients. Chest 2003; 123:1026-1037

12 Meyers BF, Yusen RD, Guthrie TJ, et al. Outcome of bilateral lung volume reduction in patients with emphysema potentially eligible for lung transplantation. J Thorac Cardiovasc Surg 2001; 122:10-17

13 Bavaria JE, Pochettino A, Kotloff RM, et al. Effect of volume reduction on lung transplant timing and selection for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1998; 115:9- 18

14 Zenati M, Keenan RJ, Landreneau RJ, et al. Lung reduction as bridge to lung transplantation in pulmonary emphysema. Ann Thorac Surg 1995; 59:1581-1583

Steven D. Nathan, MD, FCCP; Leah B. Edwards, PhD; Scott D. Barnett, PhD; Shahzad Ahmad, MD; and Nelson A. Burton, MD

Manuscript received December 4, 2003; revision accepted June 21, 2004.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail: [email protected]).

Correspondence to: Steven D. Nathan, MD, FCCP, Medical Director, Lung Transplant Program, Inova Heart and Lung Transplant Center, Inova Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA 22042; e- mail: [email protected]

Copyright American College of Chest Physicians Nov 2004

Background: C-reactive protein (CRP), which has been suggested to directly enhance inflammation in plaques, is rapidly synthesized and secreted in the liver 6 h after an acute inflammatory stimulus. Therefore, serum levels of CRP within 6 h after the onset of acute myocardial infarction (AMI) merely reflect a chronic and persistent inflammatory process and are not due to acute myocardial damage. We hypothesized that the serum CRP level, which would abnormally elevate thereafter, is followed by a plaque rupture in the clinical setting of AMI.

Methods and results: CRP was prospectively measured by high- sensitivity CRP assay (hs-CRP) in 157 consecutive patients (106 patients within 6 h, and 51 patients ≥ 6 h but 3 h but

Conclusions: Serum levels of hs-CRP were significantly higher in patients with an onset of AMI

Key words: acute myocurdial infarction; high-sensitivity C- reactive protein

Abbreviations: AMI = acute myocardial infarction; BMI = body mass index; CRP = C-reactive protein; hs-CKP = high-sensitivity C- reactive protein assay; PCI = percutaneous coronary intervention; TIMI = thrombolysis in myocardial infarction

A growing number of studies1-6 report that inflammation plays a crucial role in the cell biology of atherosclerosis. Pathologic and immunohistochemical staining studies7-9 have clearly shown a preponderance of inflammatory cells in the ruptured plaques of patients who have died of acute coronary syndromes. Inflammation, manifested by elevated serum levels of C-reactive protein (CRP) measured by high-sensitivity CRP assay (hs-CRP) is associated with an increased risk of cardiovascular events.10-12 Little is known, however, whether elevated serum CRP levels reflect an increased tendency for plaque rupture or only a high atherosclerotic burden.

It is well recognized that myocardial damage promotes the synthesis of CRP,13,14 and the level of this CRP has been reported to be associated with poor prognosis after acute myocardial infarction (AMI).15,16 However, CRP is primarily synthesized and secreted rapidly in liver 6 h after an acute inflammatory stimulus.17,18 Thus, serum levels of CRP within 6 h alter the onset of AMI are suggested to offer valuable information with respect to cell biology activity on ruptured plaque without being affected by the effects of myocardial necrosis after AMI.19 Therefore, in the present study, we enrolled patients with AMI undergoing primary percutaneous coronary intervention (PCI) within 6 h of the onset of symptoms in order to evaluate whether serum hs-CRP levels are elevated prior to cardiomyocyte damage following AMI.

MATERIALS AND METHODS

Study Population

In our hospital, all patient with AMI are considered eligible for primary PCI. For the purpose of this study, the hs-CRP of all patients who underwent primary PCI was prospectively measured. A blood sample was drawn alter vascular puncture before coronary augiography was performed in the cardiac catheterization room.

To avoid other variables that could influence the serum levels of hs-CRP, we excluded patients with a history of recent surgery or trauma within the preceding 2 mouths, renal insufficiency (creatinine > 1.5 mg/dL), malignancy, febrile disorders, and acute or chronic inflammatory disease at study entry, as well as those with a history of recent infection. Patients were also excluded it fever (body temperature > 37.5C) was observed in the emergency department Between November 2002 and September 2003 we prospectively investigated and recruited 171 consecutive patients of any age who presented with AMI of

Another 51 patients (32.5%) who experienced AMI with symptom onset of ≥ 6 h before blood sampling; were utilized for further study differences in serum levels of hs-CRP between AMI onset of

Blood Sampling and Laboratory Investigations

Blood samples were obtained once in both healthy volunteers (in the outpatient department) and coronary artery disease control subjects (in the catheterization room prior to coronary angiographic study). Measurement of whole blood counts, biochemistries, and electrolytes was done using standard laboratory methods.

The hs-CRP was measured by immunonephelometry using the BN system (Dade Behring; Newark. DE). The lower detection limit of this test is

Definitions and Data Collection

AMI was defined as typical chest pain lasting for > 30 min with ST-segment elevation > 1 mm in two consecutive precordial or interior leads. Detailed ill-hospital and follow-up data including age, sex, coronary risk factors, Killip score on admission, preinfarction angina, body mass index (BMI), body temperature on admission. WBC counts, creatinine level, serum level of hs-CRP, angiographic findings, and number of diseased vessels were obtained. These data were collected prospectively and entered into a computerized database.

Statistical Analysis

Data were expressed as mean SD. Categorical variables were compared using χ^sup 2^ test or Fisher Exact Test. Univariate analyses were performed using Student t test. Continuous variables were compared using Wilcoxon rank-sum test. Continuous variables among the three groups were compared using one-way analysis of variance for parametric data and Kruskal-Wallis test for nonparametric data. Repeated measures of analysis of variance were used for comparison of age among the three groups. Statistical analysis was performed using SAS statistical software for windows version 8.2 (SAS Institute; Cary, NC). A probability value

RESULTS

Baseline Characteristics of All Subjects

There were no significant differences among the three groups with regard to age, gender, body temperature, BMI, or creatinine level (Table 1). There were also no significant differences between study patients and angina subjects in terms of coronary artery disease risk factors, previous myocardial infarction, and previous stroke. Laboratory investigation demonstrated WBC counts were significantly higher in study patients than in the angina subjects and healthy control subjects. Furthermore, serum levels of hs-CRP that were measured within 6 h after AMI were significantly higher in study patients than in the angina subjects and control subjects. There was no significant difference in serum hs-CRP levels between angina patients and control subjects. However, WBC counts were found to be significantly higher in angina patients than in the control subjects. Angiographic results demonstrated that there was no significant difference in multiple-vessel disease between study patients and angina subjects.

Table 1-Baseline Characteristics of Study Patients, Angina, and Normal Control Groups*

Table 2-Comparison of Baseline Characteristics, Clinical Variables, Laboratory Findings, and Angiographic Results Between the Patients With Onset of AMI ≤ 3 h and Patients With Onset of AMI > 3 h to

Comparison of Baseline Characteristics, Clinical Variables, Laboratory Findings, and Angiographic Results Between the Patients With Onset of AMI ≤ 3 h and Patients With Onset of AMI > 3 \h but

There were no significant differences in terms of age, gender, coronary artery disease risk factors, previous myocardial infarction, previous stroke, body temperature, BMI, preinfarction angina, anterior wall infarction, or cardiogenic shock on admission between patients with an onset of AMI ≤ 3 h and patients with an onset of AMI > 3 h but

Comparison of the Effect of Baseline Characteristics, Clinical Variables, and Angiographic Findings on Serum hs-CRP Levels in 106 Study Patients

The effects of baseline characteristics, clinical variables, and angiographic findings on serum hs-CRP are shown in Table 3. Statistically, weakly significant higher serum hs-CRP levels (p = 0.04) were found to be in women, in patients with hypertension, and in patients without previous myocardial infarction. The effects of other baseline characteristics, clinical variables, and angiographic results on serum levels of hs-CRP did not appear to show any differences among the study patients.

Comparison of Baseline Characteristics, Clinical Variables, Laboratory Finding, and Angiographic Results Between Patients With Onset of AMI

There were no significant differences in terms of male sex, coronary artery disease risk factors, previous stroke or mvocardial infarction. BMI, body temperature, preinfarction angina, anterior wall infarction, or cardiogenic shock on hospital admission between patients with onset of AMI

Table 3-Comparison of the Effect of the Baseline Characteristics, Clinical Variables, and Angiographic Finding on Serum Levels of hs- CRP in 106 Study Patients*

Table 4-Comparison of Baseline, Clinical Characteristics, Laboratory Findings, and Angiographic Results Between Patients With Onset AMI of

DISCUSSION

In the present study, one of the important findings was that the serum hs-CRP level was significantly higher in patients with an onset of AMI ≥ 6 h than in patients with an onset of AMI 3 h but

CRP has been believed to directly participate in initiation and propagation of atherosclerosis.6,20,21 The direct proatherogenic effects of CRP extend beyond the endothelium to the vascular smooth muscle.21 Accumulating evidence from clinical observation suggests that CRP levels are one of the most powerful predictors of atherosclerosis and vascular death,11,12 offering prognostic value exceeding that of low-density lipoprotein cholesterol.22 Therefore, CRP has recently emerged as one of the most important novel inflammatory markers.10-12,16,22-24 This clinical observation10,12,16,22 is further corroborated by growing evidence from in vitro studies17,18,20,21 that have demonstrated that the mechanistic basis of the predictive value of CRP is its ability to incite endothelial dysfunction, stimulate endothelial-1 and interleukin-6 release, up-regulate adhesion molecules, and stimulate inonocyte chemoattractant protein-1 while facilitating macrophage low-density lipoprotein uptake.

Surprisingly, while these basic studies have aroused enthusiasm about CRP in vascular atherosclerosis, the potential impact of the increasing serum CRP triggering vulnerable plaque rupture has rarely been investigated.9 Until recently, only one study from Tomoda and Aoki19 tried to find a correlation between the serum levels of CRP and the vulnerability of culprit coronary lesions within 6 h of onset of AMI. They demonstrated that patients with elevated CRP levels on hospital admission had more vulnerable coronary artery lesions and worse clinical outcomes than patients with normal serum CRP levels. However, this study was retrospective and had no comparison between risk control and healthy control subjects. Therefore, it could not answer whether are different levels of serum CRP among patients with AMI of onset

The main finding of the present study is that the serum level of hs-CRP was more markedly elevated in patients with AMI of onset

Our study hits limitations. First, the exact time of symptom onset was usually difficult to determine in our patients. Therefore, a potentially inaccurate duration from onset of AMI to blood sample could be present. Hence, the effect of myocardial damage on serum hs- CRP would not be completely eliminated in the present study. Second, although the striking impact of serum CRP on long-term outcomes has been investigated,12 our study was not designed to investigate the correlation between serum hs-CRP and short- or long-term clinical outcomes. Theretore, we could not provide evidence other than serum levels of hs-CRP in the clinical setting of AMI. Third, although serum hs-CRP markedly elevated within 6 h alter the onset of AMI in the present study, we did not know whether this elevation was chronic and persistent or only reflected a surge episode. However, it would he impossible to measure serial changes in hs-CKP level in patients before an AMI.

In conclusion, hs-CRP might not only mirror an inflammatory stimulus, hut also have direct effect promoting atherosclerotic propagation and destabilizing plague. Elevated serum hs-CRP levels in patients with AMI

* From the Division of Cardiology, Chang Gung Memorial Hospital, Kaohsiung, Department of Biological Sciences, National Sun Yat-Sen University, Kaohsiung, Taiwan, ROC.

REFERENCES

1 Ross R. The pathogenesis of atherosclerosis: a perspective for 1990s. Nature 1993: 362:801-809

2 Faruqi RM, DiCorleto PE. Mechanisms of monocyte recruitment and accumulation. Br Heart J 1993; 69:S19-S29

3 van der Wal AC, Becker AE. van der Loos CM, et al. Site of intimal rupture or erosion of thrombosed coronary atherosclerotic plaques is cliaracterized by an inflammatory process irrespective of the dominant plaque morpholog. Circulation 1994; 89:36-44

4 Libby P, Geng VJ, Sukhova GK, et al. Molecular determinants of atherosclerotic plaque vulnerability. Ann N Y Acad Sci 1997; 811:134- 145

5 Ross R. Atherosclerosis: an inflammatory discase. N Fngl J Med 1999; 340:115-126

6 Pasceri V, Cluing J. Willerson JT, et al. Modulation of C’- reactive protein-mediated monocyte chemoattractant protein-1 induction in human endothelial cell by anti-atherosclerosis drugs. Circulation 2001; 103:2531-2534

7 Falk E, Shah Pk. Fuster Y. Coronary plaque disruption. Circulation 1995; 92:657-761

S Burke AP, Farb A. Malcom GT. et al. Coronary risk factors and plaque morphologx in men with coronary disease who died suddenly. N Engl J Med 1997; 336:1276-1282

9 Burke AP, Tracy RP, Kologie F, et al. Elevated C-reactive protein values and atherosclerosis in sudden coronary death: association with different pathologies. Circulation 2002; 105:2019- 2023

10 Koe\nig W, Sund M Frohlich M, et al. C-reactive protein, a sensitive marker of inflammation, predicts future risk of coronary heart disease in initially healthy middle-aged men: results from the MONICA Augsburg Cohort Study, 1984 to 1992. Circulation 1999; 99:237- 242

11 Shak PK. Circulating markers of inflammation for vascular risk prediction: are they ready for prime time? Circulation 2000; 101:1758-1759

12 Mueller C. Buettner HJ, Hodgson JM, et al. Inflammation and long-term mortality after non-ST elevation acute coronary syndrome treated with a very early invasive strategy in 1042 consecutive patients. Circulation 2002; 105:1412-1415

13 Kushner I, Broder ML, Karp D. Control of the acute phase response: serum C-reactive protein kinetics alter acute myocardial infarction. J Clin Invest 1978; 61:235-242

14 deBeer FC, Hind CBK, Fox KM, et al. Measurement of serum C- reactive protein concentration in mvocardial ischemia and infarction. Br Heart J 1982; 47:239-243

15 Pietila KO, Harmoinen AP, Jokiniitty J, et al. Serum C- reactive protein concentration in acute mvocardial infarction and its relationship to mortality during 24 months of follow-up in patients under thrombolvtic treatment. Eur Heart J 1996; 17:1345- 1349

16 Ueda S, Ikeda U, Yamamoto K, et al. C-reactive protein as a predictor of cardiac rupture after acute mvocardial infarction. Am Heart J 1996; 131:857-860

17 Morrone C, Ciliberto C. Oliviero S. et al. Recombinant interleukin 6 retaliates the tianscriptional activation of a set of human acute phase genes. J Biol Chem 1988; 263:12554-12558

18 Le J, Vilcek J. Interleukin 6: a multifunctional cytokine regulating immune reactions and the acute phase protein response. Lab Invest 1989; 61:588-602

19 Tomoda H, Aoki N. Prognostic value of C-reactive protein levels within six hours after the onset of acute myocardial infarction. Am Heart J 2000; 140:324-328

20 Pasceri Y, Willerson JT, Yeh ET. Direct proinflammatory effect of C-reactive protein on human endothelial cells. Circulation 2000; 102:2165-2168

21 Verma S, Li SH, Badiwala MV, et al. Endothelin antagonism and interleukin-6 inhibition attenuate the proatherogenic effects of C- reactive protein. Circulation 2002; 105:1890-1896

22 Ridker PM, Rifai N, Rose L, et al. Comparison of C-reactive protein and low-density lipoprotein cholesterol levels in the prediction of first cardiovascular events. N Engl J Med 2002; 347:1557-1565

23 Rider PM. Novel risk factors and makers for coronarv disease. Adv Intern Med 2000; 45:391-418

24 Szmitko PE, Wang CH, Weisel RD, et al. New makers of inflammation and endothelial cell activation: part I. Circulation 2003; 108:1917-1923

Hon-Kan Yip, MD; Chiung-Jen Wu, MD; Hsueh-Wen Chang, PhD; Cheng- Hsu Yang, MD; Kuo-Ho Yeh, MD; Sarah Chua, MD, FCCP; and Morgan Fu, MD

Manuscript received March 10, 2004; revision accepted June 8, 2004.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail: [email protected]).

Correspondence to: Morgan Fu, MD, Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung, 123, Ta Pei Rd, Niao Sung Hsiang, Kaohsiung Hsien, 83301, Taiwan, ROC; e-mail: [email protected]

Copyright American College of Chest Physicians Nov 2004

Are Teeth a Reservoir For Respiratory Pathogens?

Pneumonia and influenza are currently the seventh leading cause of death in the United States, with approximately 65,984 deaths occurring in 2002, for an overall death rate of 22.9 per 100,000 population.1 In the elderly, defined as age ≥ 65 years, pneumonia and influenza are the fifth leading cause of death, with 59,235 deaths and an overall death rate of 166.4 per 100,000. In other words, approximately 90% of deaths related to this disease combination occur at ≥ 65 years of age. More than 98% of these deaths are secondary to pneumonia, with a minor contribution from influenza.

Hospital-acquired pneumonia, a pneumonia subtype defined as occurring ≥ 48 to 72 h after admission to the hospital, can he divided into ventilator-associated pneumonia (VAP) and nonventilator- associated types. It occurs in anywhere from 0.5 to 5% of hospitalized patients,2 and is the second most common hospital- acquired infection in elderly patients after the urinary tract. It is the leading cause of death from nosocomial infections, with an approximate mortality of 16% in the elderly population.3 Nosocomial pneumonia narrowed down to VAP, defined as pneumonia developing at least 48 h after intubation, has an even higher mortality, varying from 17 to at least 50%,4,5 with an attributable cost when matched to other ventilator patients without pneumonia of $11,897 per event.5 Given an aging population and the expense that will only climb with improved technology, understanding the pathophysiology of this type of pneumonia for prevention purposes will help to markedly reduce cost and improve health outcomes.

Currently it is believed that bacterial colonixation of the upper respiratory tract, including the normally sterile trachea and endotracheal tube in intubated patients, is a precursor to aspiration of organisms into the distal lung with the subsequent occurrence of VAP. As the severity of illness increases and the time in a critical care environment adds up the degree of colonization with respiratory pathogens, including Staphylococcus aureus, Streptococcus pneumoniae, and Gram-negative rods (especially Haemophilus influenzae, Enterobacteriaceae, Pseudomonas aeruginosa, and Acinetobacter baumanii) increases to > 70%.6-8 Many studies8-10 have revealed similar organisms in the distal airway of pneumonia patients and the trachea and oropharynx. In particular, one study11 compared the chromosomal DNA pattern of oropharyngeal samples in patients receiving mechanical ventilation prior to the development of VAP and bronchoscopically derived samples after the development of VAP, and found identical genetic matches in 17 of 18 cases in those with acquired pneumonia. This study validates the predominant theory that most but not all cases of VAP are probably secondary to colonization of the trachea or oropharynx with subsequent aspiration, defined as exogenous bacterial colonization. Some bacteria, such as the Enterobacteriaceae, can either reflux from the GI tract (endogenous colonization), colonize the upper airway or trachea, and then develop a subsequent aspiration or start in the trachea or oropharynx and aspirate; both occurred in this study.11 However, the predominant mode of distal lung infection is believed to be exogenous, as occurred in this study.11

Two studies12,13 in ICU patients have suggested that dental plaque can harbor respiratory pathogens. The first study12 found respiratory pathogens present in both dental plaque (18 of 20 with teeth) and buccal mucosa (24 of 34 with and without teeth) in 34 ICU patients in contrast to only 4 of 25 dental patients of similar age. In a second study13 of 57 ICU patients (44 of 57 intubated) followed up on ICU days 0, 5, and 10 with serial cultures of dental plaque (and tracheal aspirates) for aerobic respiratory pathogens, it was found that the percentage of plaque samples with respiratory pathogens increased over time from 23% (13 of 57 samples) to 39% (11 of 28 samples) to 46% (6 of 13 samples), respectively.13 Table 3 of this article reveals acquisition of methicillin-resistant S aureus and pathogenic aerobic Gram-negative rods over time in dental plaques, implying that the plaques are probably picking up these organisms from the surrounding oropharyngeal environment as it becomes populated with these species.13 A focus on the interesting aspect of Table 4 only where the plaque sample culture finding is positive reveals two pneumonias, one with A baumanii and one with P aeruginosa. The positive plaque culture finding predated the tracheal culture and pneumonia. The time sequence suggests dental plaque colonization first with subsequent aspiration of either equilibrating upper airway contents, dislodged dental plaque, or both, and then pneumonia. This is consistent with a substudy13 comparing salivary and dental plaque cultures. They were concordant in 18 of 20 cases implying equilibration of organisms between the dental plaque and the oropharynx in most instances.13

Previous studies14,15 have revealed that in outpatients with severe periodontitis, subgingival Enterobacteriaceae, Pseudomonas, and Acinetobacter are part of the normal flora in 10 to 14% of subjects. In addition, stable nursing home patients have been found to have respiratory pathogens including S aureus, Enterobacter cloacae, and P aeruginosa cultured from dental plaques in 25% of cases.16 These sources may be relatively stable reservoirs harboring respiraton pathogens. Endogenous colonization of the oropharynx and trachea could occur from these sites in patients with poor oral hygiene during an acute illness. Therefore, the possible sources of respiraton pathogens for colonization of the upper airway prior to aspiration and presentation of a hospital-acquired pneumonia include the following: (1) the GI tract in a minority of cases, (2) the teeth themselves, or from (3) the external environment (respiratory therapy equipment, nurses suctioning, etc.).

El-Solh et al, in this issue of CHEST (see page 1575), demonstrate a genetic and bacteriologic match between bronchoscopically obtained BAL respiratory pathogens and dental plaque pathogens. This demonstrates unequivocally that the bacteria- S aureus, Escherichia coli, E cloacae, and P aeruginosa-started in the mouth and went to the lung, since the dental plaque cultures were obtained before the pneumonia developed. One previous study,11 vide supra, found the same genetic match comparing oropharyngeal to BAL samples from VAP as they developed. Neither study answers the following question: Did the oropharynx become colonized first with development of dental plaque colonization, or were respiratory pathogens present on subjects teeth (due to poor dentition and periodontitis), which then colonized the oropharynx when the patients become critically ill? Both studies solidify the concept that proximal airway colonization occurs first with secondary aspiration of these bacteria into the distal airway causing pneumonia.

Edentulous patients, if critically ill, would acquire oropharyngeal colonization with respiratory pathogens even without teeth. This would result in VAP in some patients if they were intubated for other reasons. This then begs the question: Would better oral care of dentate elders prevent or at least reduce the incidence of pneumonia? One study17 attempted to evaluate this question by randomizing 417 elderly nursing home patients without COPD to oral vs no oral care with a 2-year follow-up. The primary outcome variable was the development of pneumonia.17 Ignoring the postrandomization selection bias of 51 dropouts and eliminating the edentulous patients who are not germane to the question (more selection bias), the results were recalculated for the dentate subjects. The relative risk was 1.74 (95% confidence interval, 0.89 to 3.41). This insignificant result suggests there might be a 74% greater chance of developing pneumonia in nursing home patients if they do not receive regular oral care relative to receiving oral care. Consistent with this result, one prospective observational study18 followed up 189 male subject who were at least 60 years old, and noted a 23% increase in the risk of pneumonia over 4 years related to the number of decayed teeth. However, the risk ratio was marginally elevated (odds ratio, 1.23; 955 confidence interval, 1.07 to 1.41), although the study was statistically significant.18 Therefore, the jury is still out on whether or not improving dental hygiene will decrease the risk of pneumonia, although the trend suggests this might be the case.

In conclusion, El Solh et al have added another piece to the pathophysiologic puzzle of how pneumonia develops by demonstrating that VAP can originate from organisms in dental plaque, something that has not been demonstrated before. Like all good studies, it results in asking more questions than it answers. Will improvements in oral hygiene decrease the incidence of pneumonia? Does poor dentition harbor respiratory pathogens that colonize the upper respiratory tract, or does colonization of the respiratory tract result in translocation of bacteria to residual teeth with plaque, or both? Are the edentulous elderly less likely to acquire pneumonia or VAP, and if so should the elderly with a few residual teeth have them removed? The list goes on. Hopefully, with more gains in understand\ing this complex process of colonization and aspiration of respiratory pathogens, we can interrupt the cycle and reduce the incidence of pneumonia and VAP. That time is not yet here.

REFERENCES

1 Kochanek KD, Smith BL. Deaths: preliminary data for 2002. Natl Vital Stat Rep 2004; 52:1-47

2 Craven DE, Barber TW, Steeger KA, et al. Nosocomial pneumonia in the 1990s: update of epidemiology and risk factors. Semin Respir Infect 1990; 5:157-172

3 Emori TG, Banerjee SN, Culver DH, et al. Nosocomial infections in elderly patients in the United States, 1986-1990. Am J Med 1991; 91(suppl 3B):289S-293S

4 Chastre J, Wolff M, Fagon J-Y, et al. Comparison of 8 vs 15 days of antibiotic therapy for ventilator-associated pneumonia in adults: a randomized trial. JAMA 2003; 290:2588-2598

5 Warren DK, Shukla SJ, Olsen MA, et al. Outcome of attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center. Crit Care Med 2003; 31:1312- 1317

6 Johanson WG, Pierce AK, Sanford JP. Changing pharyngeal bacterial flora of hospitalized patients. N Engl J Med 1969; 281:1137-1140

7 Johanson WG, Pierce AK, Sanford JP, et al. Nosocomial respiratory infections with Gram-negative bacilli. Ann Intern Med 1972; 77:701-706

8 Munro CL, Grap MJ. Oral health and care in the intensive care unit: state of the science. Am J Crit Care 2004; 13:25-34

9 Bonten MJM, Gaillard CA, Tiel FHV, et al. The stomach is not a source for colonization of the upper respiratory tract and pneumonia in ICU patients. Chest 1994; 105:878-884

10 de Latorre FJ, Pont T, Ferrer A, et al. Pattern of tracheal colonization during mechanical ventilation. Am J Respir Crit Care Med 1995; 152:1028-1033

11 Garrouste-Orgeas M, Chevret S, Arlet G, et al. Oropharyngeal or gastric colonization and nosocomial pneumonia in adult intensive care unit patients. Am J Respir Crit Care Med 1997; 156:1647-1655

12 Scannapieco FA, Stewart EM, Mylotte JM. Colonization of dental plaque by respiratory pathogens in medical intensive care patients. Crit Care Med 1992; 20:740-745

13 Fourrier F, Duvivier B, Boutigny H, et al. Colonization of dental plaque: a source of nosocomial infections in intensive care unit patients. Crit Care Med 1998; 26:301-308

14 Slots J, Rams TE, Listgarten MA. Yeasts, enteric rods and Pseudomonas in the subgingival flora of severe adult periodontitis. Oral Microbiol Immunol 1988; 3:47-52

15 Slots J, Feik D, Rams TE. Prevalence and antimicrobial susceptibility of Enterobacteriaceae, Pseudomonadaceae and Acinetobacter in human periodontitis. Oral Microbiol Immunol 1990; 5:149-154

16 Russell SL, Boylan RJ, Kaslick RS, et al. Respiratory pathogen colonization of the dental plaque of institutionalized elders. Spec Care Dentist 1999; 19:128-134

17 Yoneyama T, Yoshida M, Ohrui T, et al. Oral care reduces pneumonia in older patients in nursing homes. J Am Geriatr Soc 2002; 50:430-433

18 Langmore SE, Terpenning MS, Schork A, et al. Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia 1998; 13:69-81

Gene R. Pesola, MD, MPH

New York, NY

Dr. Pesola is Associate Attending, Department of Medicine, Section of Pulmonary/Critical Care Medicine, Harlem Hospital/ Columbia University.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail: [email protected]).

Correspondence to: Gene R. Pesola, MD, MPH, Department of Medicine, Harlem Hospital/Columbia University, MLK 14101, 506 Lenox Ave, New York, NY 10037; e-mail: [email protected]

Copyright American College of Chest Physicians Nov 2004

A previously unreported case of a complex congenital cardiac anomaly consisting of coronary and valvular angiodysplasia, complicated by an eosinophilic endomyocardial disease, is described. The disorder presented clinically with congestive heart failure, which was characterized by evidence of floating masses causing severe pulmonary stenosis and dysfunction of the mitral and aortic valves. Symptoms of cardiac failure disappeared following pulmonary valve replacement and steroid therapy. (CHEST 2004; 126:1700-1703)

Key words: cardiac angiodysplasia; eosinophilic endomyocarditis; pulmonary stenosis

Abbreviations: LV = left ventricle, ventricular

Ectasia of the epicardial coronary arteries is a rare abnormality, which is sometimes associated with diffuse dysplastic lesions of intramural vessels and intraventricular sshunting.1,2 Its association with hugely dilated vessels in cardiac valve tissue resulting in images similar to those of extensive vegetation has never been described before. Such a complex vascular malformation may remain unrecognized in the absence of cardiac symptoms and can be complicated by superimposed inflamination/infection.

We report an unusual case of diffuse cardiac angiodysplasia that was detected by the appearance of heart failure related to eosinophilic endomyocarditis, with vasculitis of dysplastie vessels causing pulmonary, aortic, and mitral valve disease.

CASE REPORT

A 60-year-old woman was admitted to the hospital because of dyspnea with minimal effort (New York Heart Association class III). In childhood, a harsh systolic murmur at the upper left sternal border and a mild systolic mnrmnr at the apex radiating toward the axilla were detected. From early adulthood, the patient started to experience episodes of bronchitis and reduced effort tolerance. For this reason, at 40 years of age the patient underwent a cardiologic assessment, including an echocardiograni, which showed mild mitral regurgitation and moderate pulmonary stenosis. Because of the absence of rheumatic disease or systemic infection in the clinical history, the valve lesions were interpreted as being due to a congenital anomaly. Dyspnea with exertion worsened 6 months before the hospital admission in association with the onset of atrial fibrillation. She had neither risk factors for coronary artery disease nor a history of asthma, allergic rhinitis, or systemic disease.

Physical examination revealed congestive heart failure, atrial fibrillation, a 4/6 systolic murmur, and pulsatile hepatomegaly. A chest radiograph showed pulmonary congestion and prominence of the cardiac border. The ECG showed atrial fibrillation (mean heart rate, 75 beats/min) and a right bundle branch block. Hematologic tests showed moderate eosinophilia (600 10^sup 6^ eosinophils/L) with partially degranulated eosinophils. The coproculture was negative for parasitic infections. Echocardiography showed left and right ventricular hypertrophy (interventricular septum, 16 mm; left ventricular [LV] posterior free wall, 13 mm; right ventricular free wall, 22 mm), LV dilation (LV end-diastolic diameter, 61 mm; LV end- systolic diameter, 50 mm), and LV dysfunction (LV ejection traction, 35%). The right ventricular ejection traction was 40%, and a tricuspid regurgitation ratio of 2+/4+ (in which 2+ is the grade of regurgitation and 4+ is the maximal degree of observed severity, rated on a 4-point scale as follows: 1+, minimal; 2+ , mild; 3+ , moderate; 4+ , severe) was present. The pulmonary valve was characterized by the presence of large floating masses resulting in severe valvular stenosis (maximum gradient, 55 mm Hg). An additional mass was adherent to the atrial surface of the anterior mitral valve leaflet, causing a mild stenosis and moderate regurgitation. The aortic valve showed multiple vegetations, causing mild stenosis. Both atria were dilated. The presence of multiple valvular masses first suggested infectious endocarditis, but the results of serial hemocultures and serologic tests, including the assessment of antineutrophil cytoplasmic antibodies, were negative for that condition.

Because of the severe pulmonary stenosis, surgical replacement of the pulmonary valve was planned. Consequently, the patient underwent coronary angiography that revealed a diffuse ectasia of the coronary tree with tortuous vessels. The diameters of the ectasic vessels were its follows: left niainstem, 12 mm; left anterior descending artery, 9 mm; left circumflex artery, 8.4 mm; and right coronary artery, 8.7 mm. Additionally, this angiodysplastic lesion involved intramural arteries supplying a network of teleangectasic vessels shunting into the ventricular cavities (Fig 1).

Surgical findings showed a pulmonary valve that was characterised by the presence of abundant “cauliflower-shaped whitish tissue of elastic consistence (Fig 2, top), obstructing the right ventricular outflow tract. The abnormal valve was replaced with a prosthetic valve (Carpentier-Edwards 25), and the right ventricular outflow tract was reconstructed using a bovine pericardial patch. The abnormal tissue present at the infundibular level was partially excised, and several endomyocardial biopsy samples were obtained from the right ventricle.

FIGURE 1. Left coronary angiography (top) and right coronary angiography (bottomn) showing ectasic vessels spreading into a diffuse network of channels that shunt into the left and right ventricular cavity.

Histologic examination of the pulmonary valve revealed the presence of large, dysplastic vessels, with an artery-like composition of the wall consisting of endothelial, thick medial, and adventitial layers (Fig 2, bottom). Diffuse eosinophilic infiltrates of abnormal vessels were found, together with foci of vessel wall necrosis. The endomyocardial tissue was characterized by the presence of extensive inflammatory infiltrates, mainly represented by degranulated eosinophils and focally associated with necrosis of the adjacent myocytes (Fig 3). Neither epithelioid cells nor giant cells, sparsely distributed or organized in granulomas, were present.

FIGURE 2. Surgical view (top) of the stenotic pulmonary valve showing whitish floating masses that at histology (bottom) consist of large, dysplastic vessels surrounded by dense inflammatory infiltrates (hematoxylin-eosin, original 20).

A diagnosis of eosinophilic endomyocardial disease was made, superimposed on cardiac angiodysplasia involving not only the epicardial but also the intramural coronary arteries and valvular vessels. No abnormal vascularization of other organs was obseized on a total body angio-CT scan. Because of eosinophilic endomyocarditis and vasculitis, the patient was treated with steroids (prednisone, 1 mg/kg/daily for 1 month followed by 0.33 mg/kg daily for 6 months). Within 7 days, the peripheral blood eosinophil count dropped to 80 10^sup 6^ cells/L and degranulation disappeared. After 2 weeks of treatment, the patient’s clinical condition improved remarkably, resulting in a change in New York Heart Association class III to class I. At the 6-month follow-up, echocardiography showed a reduction of LV end-diastolic diameter from 61 to 55 mm, an increase in ejection fraction from 35 to 55%, and the normalization of right ventricular contractility. Mitral and tricuspid regurgitation improved from 2+ to 1+, respectively.

DISCUSSION

Congenital heart diseases are well-known predisposing factors for inflammatory cardiac pathologies. The incidence of inflammation/ infection of the cardiac valves, in particular infectious endocarditis, is about 10 times move frequent in adults with congenital cardiac abnormalities than that in the healthy population.3 We have reported the case of a patient with eosinophilic endomyocarditis superimposed on a rare vascular malformation of the intravalvular cardiac vessels, as well as that of the intramural and epicardial vessels.

FIGURE 3. Specimen from the right ventricular biopsy showing eosinophilic infiltrates associated with the necrosis of adjacent myocytes (hematoxylin-eosin, original 250).

Coronary artery ectasia is a rare congenital or acquired malformation (eg, atherosclerotic or inflammatory malformation), accounting for up to 4.5% of coronary angiograms.1,2 It is associated with a variable prognosis depending on the extension and severity of vessel dilation, and is classified into four major types (the Markis classification).4 In our patient, the extensive intramural network of vessels shunting into the ventricular cavities in the absence of coronary sclerosis or occlusions suggested a congenital origin for the coronary lesion. Moreover, the involvement of the vessels of the cardiac valves, which are usually well- represented in the human fetus and undergo progressive regression from early age to adulthood,5 is highly suggestive of the presence of a complex vascular malformation that, because of the negative systemic CT scan findings, was confined to the heart. The malformation resulted in a thickening of the ventricular walls due to intramural vessel dilation and in masses of vascularized tissue in the cardiac valves, which are more evident in the pulmonary valve, where it led to an outflow obstruction. The valvular lesions were present several years before the hospital admission, since a diagnosis ofcongenital valvular anomaly was made in early adulthood. Nevertheless, it is only when an eosinophilic endomyocardial disease was superimposed on the congenital vascular malformation that the pulmonary stenosis progressed to a critical stage, and the patient s symptoms worsened with the onset of atrial fibrillation and heart failure. The eosinophilic inflammation was detected in the surgically removed pulmonary valve, in right ventricular tissue from the outflow tract, and in right ventricular endomyocardial biopsy specimens.

The cause of the eosinophilia in our patient was considered to be idiopathic, since no parasitic infection or neoplastic disorder was detected, and there was no history of asthma or allergic rhinitis, which is suggestive of Churg-Strauss syndrome. Moreover, the absence of the characteristic histologic markers (ie, granulomas, epithelioid cells, and giant cells) and the negative results of tests for antineutrophil cytoplasinic antibodies ruled out Churg- Strauss syndrome, which also has been described in nonasthmatic cases.6 The disease was still in the active necrotic phase, as documented by the intense endomyocarditis and vasculitis also involving the abnormal intramyocardial and intravalvular vessels. Due to the potential release of cationic proteins from degranulating eosinophils, the use of steroids along with surgical intervention was necessary in order to avert such major cardiovascular complications as malignant arrhythmias, or the recurrence of valvular dysfunction leading to unbeatable heart failure.

CONCLUSION

Cardiac angiodysplasia invoking epicardial, intramural, and intravalvular vessels is a rare abnormality that is susceptible to inflammatory complications, which, in turn, lead to multiple valvular dysfunction and heart failure. The patients may benefit from combined surgical and medical therapy.

* From the Cardio-Thoracic and Vascular Department (Drs. >Chimenti, La Penna, Pieroni, Alfieri, and Maseri) and Pathology Department (Dr. San Vito) San Raffaele Hospital, Milan, Italy; and the Cardiology Department (Dr. Frustaci), Catholic University, Rome, Italy.

REFERENCES

1 Frustaci A, Caldarulo M, Pagliari G, et al. Coronary angiodysplasia causing a left ventricular shunt and myocardial ischemia. Am Heart J 1993; 125:889-891

2 Frustaci A, Chimenti C, Pieroni M, et al. Coronary angiodysplasia of the epicardial and intramural vessels. Chest 2000; 118:1511-1513

3 Thilen U. Infective endocarditis in adults with congenital heart disease. Curr Infect Dis Rep 2003; 5:300-306

4 Markis JE, Joffe CD, Cohn PF, et al. Clinical significance of coronary arterial ectasia. Am J Cardiol 1976; 37:217-222

5 Duran CMG, Cunning AJ. The vascularization of the heart valves: a comparative study. Cardiovasc Res 1968; 3:290-296

6 Val-Bernal JF, Mayorga M, Garcia-Alberdi E, et al. Churg- Strauss syndrome and sudden cardiac death. Cardiovasc Pathol 2003; 12:94-97

Cristina Chimenti, MD, PhD; Elisabetta La Penna, MD; Maurizio Pieroni, MD; Francesca San Vito, MD; Ottavio Alfieri, MD; Attilio Maseri, MD; and Andrea Frustaci, MD

Manuscript received December 11, 2003; revision accepted June 3, 2004.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail: [email protected]).

Correspondence to: Andrea Frustaci, MD, Cardiology Department, Catholic University, Largo A. Gemelli 8, 00168 Rome, Italy; e-mail: [email protected]

Copyright American College of Chest Physicians Nov 2004

Sort out the differences between uterine bleeding that’s abnormal and that which is dysfunctional. Then teach your patient about new treatments that are available for these sometimes-dangerous conditions.

Many women have variations in their menstrual cycle, such as changes in frequency, duration, or amount of flow, or spotting between their periods. This abnormal uterine bleeding (AUB) may have various causes, some of them benign. But when AUB is related to changes in hormones that directly affect the menstruation cycle, the condition is called dysfunctional uterine bleeding (DUB).

Make no mistake, AUB and DUB can be incapacitating because of either the fear of flooding or feeling weak from blood loss. A woman who’s experiencing abnormalities in her menstrual cycle should be evaluated to determine the reason.

What’s normal, what’s not

To better understand abnormal bleeding, let’s first review the normal menstrual cycle. secreted by the pituitary gland, follicle- stimulating hormone (FSH) tells die ovaries to ripen an egg in a follicle and to begin producing estrogen. The presence of estrogen causes he uterine lining to proliferate.

As the estrogen level peaks, the pituitary releases luteinizing hormone (LH), which stimulates the follicle to release the egg. The follicle, now called the corpus luteum, begins producing progesterone to get the uterine lining (endometrium) ready for egg implantation. Fourteen days after egg release, the progesterone level decreases dramatically. Menstruation occurs if the egg wasn’t fertilized.

On average, die menstrual cycle occurs every 21 to 3 5 days and lasts from 2 to 7 days. Normal blood flow is 30 to 80 ml.

Bleeding tiiat’s not normal includes:

* menorrhagia-blood flow of more than 80 ml or that lasts longer than 7 days

* polymenorrhea-bleeding cycles less than 21 days apart

* oligomenorrbea-bleeding cycles more than 3 5 days apart.

Understanding DUB

Dysfunctional uterine bleeding occurs when the normal cycle of menstruation is disrupted, usually due to anovulation (failure to ovulate) that’s unrelated to another illness. Ovulation failure is the most common type of DUB in adolescents and in women who are reaching perimenopause.

In anovulatory DUB, estrogen is continually secreted but an egg never ripens in the follicle. Because an egg is never released, progesterone is never produced from the corpus luteum to counteract the uterine lining proliferation. Eventually die uterine lining outgrows its blood supply and sloughs off at irregular intervals.

Because an egg was never produced, the premenstrual and menstrual symptoms associated with ovulation and progesterone don’t occur, and the uterine bleeding is usually painless. The effects of unopposed estrogen on the uterine lining have been directly linked to endometrial hyperplasia and cancer.

Dysfunctional uterine bleeding can occur with declining estrogen levels at the end of a woman’s reproductive life. Although the ovaries may still be stimulated to produce follicular ripening, they make only a very small amount of estrogen. This results in irregular shedding of the endometrium lining. Because the amount of lining proliferation is less, bleeding is usually less copious.

What’s AUB?

Bleeding that differs in quantity or timing from a woman’s usual menstrual flow is considered AUB. For instance, a woman may bleed more heavily during one period and more lightly the next, spot between periods, or have a shorter or longer interval between periods. Some women may bleed for less than 2 days or more than 7 days.

Women who bleed heavily on a regular basis most likely have an ovulatoiy cycle problem rather than an anovulatory cycle one. Because these women are usually ovulating, they tend to experience premenstrual symptoms and cramping.

So what causes AUB? The most common causes are pregnancy and pregnancy-related conditions. The list of other causes is extensive and includes infections of the genital tract, fibroids, malignancies, medications, blood dyscrasias, and disorders of the thyroid gland, adrenal gland, kidney, or liver. Even stress can cause AUB.

Sorting out risk factors

Any woman is at risk for AUB, while those who are younger than 20 or older than 40 are at higher risk for DUB. That’s because women in these age-groups, who are at die beginning or end of their reproductive lives, are most likely to experience hormonal imbalance and anovulation.

Women at highest risk for DUB include those who:

* are overweight, because hormones involved in ovulation aren’t readily available from fat stores

* exercise excessively, because they don’t have enough body fat to maintain a menstrual cycle

* are under a great deal of stress

* have polycystic ovarian syndrome.

Evaluating your patient

If your patient has a change in her uterine bleeding pattern, take a thorough history and prepare her for a physical examination and diagnostic testing to determine if she has AUB or DUB. When you take her history, find out if she or anyone in her family has a history of cancer, endocrine disorders, or bleeding diseases that could cause AUB. For example, a clotting disorder such as von Willebrand’s disease can cause AUB.

Ask her to use a menstruation calendar to keep track of when periods start and stop, the amount of bleeding, contraceptive use, sexual activity, and any problems such as pain, clots, postcoital bleeding, or bleeding heavy enough to soak a pad or tampon every 2 hours. Also ask her to take her temperature each morning before she gets out of bed and record it on the calendar. A change in body temperature can indicate ovulation.

Ask her if she ever feels light-headed and dizzy, which can be symptoms of anemia related to blood loss. Also document her that and exercise pattern and find out if she’s under any unusual stress.

She’ll need a pelvic and bimanual examination to assess for ovarian or uterine masses and signs of pelvic inflammatory disease. Depending on her symptoms, she may also need lab tests, such as a pregnancy test, complete blood cell count, platelet count, coagulation studies, and levels of ferritin and hormones, such as thyroid-stimulating hormone and prolactin.

Women over age 3 5 and those at high risk for endometrial cancer, such as those with morbid obesity, diabetes, chronic hypertension, or long-standing anovulation, will need an endometrial biopsy. The procedure can cause mild discomfort, but it takes only about 5 minutes. You can tell your patient to take ibuprofen 1 hour before the procedure, unless it’s contraindicated for her.

She’ll also need a transvaginal ultrasound, which may be combined with a uterine saline infusion (transvaginal sonohysterography) for better detection of abnormalities.

How to treat your patient

After your patient has received a diagnosis, she’ll need treatment to stop the bleeding, restore a normal menstrual cycle, and maintain hemodynamic stability. Treatment depends on whether the cause of bleeding is anovulatory or ovulatory. Treatment options include the following.

* Drug therapy. A patient with DUB who’s hemodynamically unstable needs volume resuscitation and intravenous estrogen to make the endometrial lining grow rapidly to cover the exposed epithelial surfaces. Once bleeding is stopped, she can take combined oral contraceptives that contain both estrogen and progesterone. Combination contraceptives prevent prolonged estrogen exposure to the endometrium because they’re a combination of estrogen and progestin. She can also use this treatment if she’s still bleeding, as long as she’s hemodynamically stable.

If she can’t take combined contraceptives due to thromboembolism risk, she can take progestins for 5 to 12 days a month to oppose estrogen’s effect on the endometrium. When she stops taking progestin each month, she’ll have a controlled withdrawal bleed.

Some women benefit from an intrauterine device (IUD) that contains progesterone. This type of IUD works well because it directly counteracts the effects of estrogen on the endometrium and decreases blood loss; it also provides contraception.

Some women with anovulatory DUB may need leuprolide acetate (Lupron), which reduces FSH and LH levels and causes amenorrhea or chemical menopause. Patients typically use this therapy for 6 months or less; they’ll need to be monitored for osteoporosis and other menopause symptoms. The goal of this therapy is to break the anovulatory cycle or prepare the body for further intervention.

If a patient is having ovulation-related AUB, she can take nonsteroidal antiinflammatory drugs (NSAIDs), such as naproxen, ibuprofen, or mefenamic acid, to decrease blood loss. The buildup of the endometrium in die presence of estrogen and progesterone produces prostaglandins. NSAIDs decrease prostaglandin production and ease uterine cramping, decreasing blood flow and pain. These drags are more effective in decreasing die quantity of blood flow in cyclic ovulatory bleeding than in irregular anovulatory bleeding.

Combination estrogen and progesterone contraceptives are also very effective in controlling excessive ovulatory bleeding. These contraceptives also lessen some of die symptoms associated with premenstrual syndrome (and, as a bonus, some even control acne).

* Invasive interventions. Some women with AUB or DUBneed interventions other than medications. If bleeding continues, a hysteroscopy will allow the health care provider to visualize the inside of the uterus. If she doesn’t wish to have children in the future, the patient may be a candidate for endometrial ablation, which uses various techniques such as microwave or radiofrequency energy, or cryoblation to destroy the uterine lining. Ablation has been very successful in decreasing or completely stopping the menstrual cycles and DUB, but it will leave the patient infertile.

If the patient has fibroids that are causing the excessive bleeding, uterine artery embolization stops the blood flow directly to the fibroids. Losing their blood source, the fibroids become ischemic and shrink.

In the past, dilatation and curettage (D&C) was routinely performed for AUB and DUB. But because this procedure doesn’t cure the underlying problem, most patients continued having bleeding problems. For this reason, D&C is now performed only to treat hemorrhage that doesn’t respond to medical therapy.

Hysterectomy was once another common treatment for AUB and DUB, but now it’s used only as a last resort. The ovaries are preserved whenever possible to help prevent menopausal problems.

Welcome relief

Recent advances in the diagnosis and management of AUB and DUB have improved the outcome of these troubling conditions for women of all ages. You play a major role in recognizing these potentially serious problems and educating your patients about the many treatment options available.

The effects of estrogen on the uterine lining have been linked to endometrial hyperplasia and cancer.

SELECTED REFERENCES

Albers, J., et al.: “Abnormal Uterine Bleeding,” American Family Physician. 69(8):1915-1926, April 2004.

Dodds, N., and Sinert, R.: “Dysfunctional Uterine Bleeding,” http://www.emedicine.com/emerg/topiclS5.htm, May 4, 2001.

Queenan, J., and Whitinan~Elia, G.: “Dysfunctional Uterine Bleeding,” http://www.emedicine.coin/med/topic2353.htm, August 26, 2004.

By Denise M. McEnroe Ayers, RN, MSN; Joan E. Stucky Lappin, FIN, MSN; and Linda Mclntosh Liptok, FIN, ACNP, MSN

Denise M. McEnroe Ayers and Linda Mclntosh Liptok are assistant professors of nursing at Kent State University Tuscarawas, and Joan E. Stucky Lappin is practical nurse coordinator at Buckeye Career Center School of Practical Nursing, in New Philadelphia, Ohio.

Copyright Springhouse Corporation Nov 2004

Study objectives: Patients with pulmonary arterial hypertension (PAH) often present with dyspnea and severe functional limitations, but their health-related quality of life (HRQOL) has not been studied extensively. This study describes HRQOL in a cohort of patients with PAH.

Design: Cross-sectional study.

Setting: A tertiary care, university hospital-based, pulmonary hypertension (PH) clinic.

Participants: We studied HRQOL in 53 patients with PAH (mean age, 47 years; median duration of disease, 559 days). Eighty-three percent were women, 53% received epoprostenol, and 72% reported moderate-to-severe functional limitations with a New York Heart Association class 3 or 4 at enrollment.

Measurements and results: We examined HRQOL by administering the Nottingham Health Profile, Congestive Heart Failure Questionnaire, and Hospital Anxiety and Depression Scale. We used the Visual Analog Scale and standard gamble (SG) techniques to measure preferences for current health (utilities). Compared with population norms, participants reported moderate-to-severe impairment in multiple domains of HRQOL, including physical mobility, emotional reaction, pain, energy, sleep, and social isolation. Mean SG utilities were 0.71, suggesting that, on average, participants were willing to accept a 29% risk of death in order to be cured of PH.

Conclusions: PAH is a devastating condition that affects predominately young women in the prime of their life. Understanding HRQOL and preferences are important in the care and management of these patients. Compared with population norms, patients with PAH have substantial functional and emotional limitations that adversely affect their HRQOL. (CHEST 2004; 126:1452-1459)

Key words: attitude to health; epoprostenol; health status; hypertension; pulmonary; quality of life

Abbreviations: CHQ = Congestive Heart Failure Questionnaire; HRQOL = health-related quality of life; HADS = Hospital Anxiety and Depression Seale: mPAP = mean pulmonary artery pressure; NYHA = New York Heart Association; NHP = Nottingham Health Profile; PPH = primary pulmonary hypertension; PAH = pulmonary arterial hypertension; PH = pulmonary hypertension; 6MWT = 6-min walk test; SG = standard gamble; VAS = Visual Analogue Scale

Pulmonary hypertension (PH) is a progressive disorder of the pulmonary vasculature characterized by sustained elevations of pulmonary arterial pressure, right-sided heart failure, progressive dyspnea, and profound functional limitations. Primary PH (PPH) is clinically indistinguishable from PH related to collagen vascular diseases, HIV infection, liver disease, drugs (eg, anorexigens), and toxins. Although underlying disease mechanisms have not been completely elucidated, these conditions are classified as pulmonary arterial hypertension (PAH) by a World Health Organization consensus symposium because of their shared clinical and histopathologic features.1

In the 1980s, the median survival of patients with PPH was 2.8 years from the time of diagnosis.2 Since then, several medical and surgical advances have led to improved survival in patients with PPH. Epoprostenol, a short-acting vasodilator, is the most potent of existing medical therapies. Randomized controlled trials3,4 have shown that epoprostenol improves exercise capacity and pulmonary hemodynamics, and prolongs survival in patients with PAH. However, the drug and delivery system have many adverse effects that may limit its tolerability in some patients.5,6

There is limited information about quality of life in patients with PAH in the literature.3 Factors that may lead to impaired quality of life include dyspnea, functional limitations, adverse effects of therapy, social isolation, and emotional issues such as anxiety and depression. While therapies for PAH improve pulmonary hemodynamics and exercise capacity, they may or may not have a positive impact on functional status and quality of life, which must be evaluated independently. Health-related quality of life (HRQOL) refers to an individual’s satisfaction with the physical, social, and psychological domains of life, insofar as they affect or are affected by health.7,8 In addition to health status, individual differences in perceptions and expectations may lead to differences in HRQOL. HRQOL is an important consideration in the treatment of diseases such as PAH, in which the prognosis is typically poor and available therapies are associated with many adverse effects.

In this cross-sectional study, we aimed to describe HRQOL in a cohort of patients with PAH. We hypothesized that compared with population norms, patients with PAH would report impaired HRQOL in multiple domains. Additionally, in a secondary analysis of nonrandomly assigned treatment groups, we compared HRQOL in patients with PAH who were and were not receiving treatment with epoprostenol.

MATERIALS AND METHODS

We enrolled consecutive adult patients with PPH or PH related to anorexigens or seleroderma spectrum of disease, who were seen at the Stanford University Medical Center PH clinic between July 1, 2001, and April 30, 2002. We included English-speaking patients with a grade 8 or higher education. We excluded all patients who did not provide consent.

We reviewed the medical records to obtain information about demographic characteristics, symptoms, pulmonary hemodynamic measurements, and treatments received. We recorded echocardiography and 6-min walk test (6MWT) results obtained within 3 months of the interview. The interviewer determined the New York Heart Association (NYHA) class assignment at the time of questionnaire completion.

We used three previously validated questionnaires: the Nottingham Health Profile (NHP),9,10 the Congestive Heart Failure Questionnaire (CHQ),11,12 and the Hospital Anxiety and Depression Scale (HADS),13- 15 and two methods for eliciting utilities to describe HRQOL in our study population.

The NHP, a generic measure of HRQOL, is a self-administered questionnaire that consists of 38 items in six domains, including physical mobility, pain, sleep, social isolation, emotional reactions, and energy. The scores in each domain range from 0 (best health) to 100 (worst health).16 Since many symptoms of PH are related to right-sided heart failure, we also administered the CHQ, a disease-specific questionnaire that was developed to study patients with congestive heart failure.17 This interview-hased, 20- item questionnaire has four subscales that measure dyspnea, fatigue, emotional function, and mastery. For each subscale, scores range from 1 (worst) to 7 (best).17 The final questionnaire, the HADS, is a self-administered scale designed to screen for anxiety and depression.18 We chose the HADS because it focuses on psychological symptoms rather than somatic symptoms, which makes it particularly useful for studying depression and anxiety in patients with medical illness.15

Utilities are preference-based global measures of HRQOL, often used to value health outcomes in economic analyses. We measured utilities by using U-Titer,19 a standard utility elicitation software program designed to be adaptable to a specific research question. We used both the Visual Analog Scale (VAS) and the standard gamble (SG) techniques to determine utilities for each patient’s current health state. Utility scores, using either technique, range from 0 (death) to 1 (ideal health).20-25 For the VAS, we asked participants to rate their current health by placing a mark on a horizontal scale with death at one end and ideal health at the other. The SG technique determines the maximum risk a person is willing to accept in order to achieve perfect health. Individuals who do not highly value their current state of health might be willing to accept a greater risk to obtain perfect health, and will have lower utility scores. We offered participants a hypothetical choice between remaining in their current state of health for the remainder of their lives, or taking a gamble with a probability (p) of achieving ideal health but a risk (1 – p) of painless and immediate death (refer to Appendix).21 The probabilities of this gamble were varied until participants expressed indifference in choosing the gamble or the current health state. The probability at this indifference point defines the SG utility score for that patient.13,21-24 We used the ping-pong method as an indifference search procedure.20 Ideal health was described as the “best health imaginable” for the rest of the patient’s natural life.

Data Analysis

We reported means and SDs to describe continuous variables that were normally distributed. For data that were not normally distributed, we reported medians and interquartile ranges. We used frequencies to describe categorical data. We expressed the results of the NHP questionnaire as a percentage of the population norm (with the value of the norm set at 100%), and defined the population norm as the average score in a group of 35- to 49-year-old women with no major health complaints.26 To compare NHP results with population norms, we tested whether the distribution of scores was different from a uniform distribution with a value of 100% by using the Wilcoxon matched-pairs signed-rank test, as has been described previously in a study27 of HRQOL in adults with cystic fibrosis. We used the Mann-Whitney U test t\o compare differences in HRQOL domains and utilities between the epoprostenol and no-epoprostenol groups, and the χ^sup 2^ test statistic or Fisher exact test to compare categorical variables. We used analysis of covariance to adjust mean utilities for observed differences between the groups. We accepted a two-tailed p value

Table 1-Baseline Characteristics of Study Population*

RESULTS

Characteristics of Study Participants

We enrolled 53 participants (Table 1) with a mean age of 47 years, the majority of whom were women (83%). Seventy-four percent were married, and 60% had some college education. Fifty-one percent of participants were white. Eleven percent reported using anorexigens at some time prior to receiving their diagnosis. Twenty- one percent of subjects had concomitant thyroid disease and 17% had mild liver disease at the time of the interview. PH related to scleroderma spectrum of disease was seen in 13% of the study population. Dyspnea was a presenting symptom in all participants. In addition, 43% reported dizziness, 41% had chest pain, and 39% noted fatigue on initial presentation. The mean pulmonary artery pressure (mPAP) for all participants was 57 mm Hg. At the time of the interview, the median duration of disease was 559 days, with 72% of the study population reporting functional limitations with a NYHA class 3 or 4 designation and 51% receiving oxygen.

At enrollment, 28 participants (53%) were receiving epoprostenol and 25 participants (47%) were not receiving epoprostenol (Table 1). The median duration of epoprostenol therapy was 397 days, and the mean dose was 32 ng/kg/min. The two groups were similar in age, marital status, education, ethnicity, prior anorexigen use, frequency of liver disease, asthma, sleep apnea, scleroderma, cancer, diabetes, and oxygen use. Thyroid disease (both hypothyroidism and hyperthyroidism) was seen more commonly in participants treated with epoprostenol (p = 0.03). Participants receiving epoprostenol had a longer duration of disease (738 days vs 336 days, p = 0.002), while the no-epoprostenol group included a higher proportion of people with NYHA class 4 functional status at the time of interview (36% vs 11%, p = 0.05). The 6MWT results were similar for both groups. mPAPs were also similar for both groups. Right ventricular systolic pressure, as measured by echocardiography, was higher in the epoprostenol group (79 vs 66), although this difference was not statistically significant (p = 0.1).

Table 2-HRQOL Domains*

HRQOL Questionnaire Measurements

Participants reported impairment in all NHP domains (Table 2), including energy (median, 67; range, 0 to 100), emotional reaction (median, 22; range, 0 to 89), pain (median, 13; range, 0 to 100), physical mobility (median, 38; range, 0 to 88), sleep (median, 20; range, 0 to 100), and social isolation (median, 20; range, 0 to 100). Compared with population norms (Table 3), scores were significantly lower in all domains, and the degree of impairment was moderate to severe. Although the data were not normally distributed, we report means in Table 3 to allow comparison with mean population norms reported in the literature.

Participants showed moderate impairment in all CHQ domains (Table 2), including dyspnea (median, 4; range, 1 to 7), fatigue (median, 4; range, 1 to 7), emotional function (median, 4; range, 2 to 7), and mastery (median, 5; range, 2 to 7). Median scores on the HADS anxiety and depression subscales were at the upper limit of the normal range as described by the questionnaire developers. Moderate or severe levels of anxiety and depression were reported by 20.5% and 7.5% of participants, respectively.

Table 3-NHP Domains and Population Norms*

Utilities

For all participants, the mean utility score obtained by using the SG technique (0.71; 95% confidence interval, 0.04 to 0.78) was higher than the mean VAS score (0.58; 95% confidence interval, 0.54 to 0.62). The value of the mean SG score suggests that participants were willing to accept a 29% risk of death in order to achieve perfect health.

Secondary Analysis: Epoprostenol and No-Epoprostenol Subgroups

Patients treated with epoprostenol and those not receiving epoprostenol were similar in their respouses to items in the pain, physical mobility, and sleep domains of the NHP. However, the participants who received epoprostenol reported more energy (median score, 33 vs 67; p = 0.03) and were better off emotionally (median score, 11 vs 44; p = 0.005).

On the CHQ, patients who received epoprostenol were less fatigued (median score, 4 vs 3; p = 0.01), had less emotional distress (median score, 5 vs 4; p = 0.003), and greater feelings of control over their disease (median score, 6 vs 4; p = 0.002). Although the two groups reported similar symptoms of dyspnea, participants who did not receive epoprostenol were more likely to report dyspnea with less strenuous activities of daily living such as bathing, dressing, going for a walk, and making a bed. For patients not receiving epoprostenol, there was a trend toward more difficulty with walking uphill and up stairs, which did not reach statistical significance. None of the patients had participated in demanding physical activities such as sports, running, vacuuming and moving furniture during the 2-week period prior to the study, highlighting the functional limitations experienced by most patients with PAH. As measured by the HADS, the no-epoprostenol group had significantly more anxiety (median score, 9 vs 6; p = 0.02) and depression (median score, 8 vs 5; p = 0.003), compared with the epoprostenol group.

Table 4-Adjusted Utilities*

We compared utilities in the two groups by using analysis of covariance (Table 4). The unadjusted mean SG utility for patients receiving epoprostenol was not significantly different from the mean value obtained for the no-epoprostenol group (0.75 vs 0.67, p = 0.4). The VAS technique also yielded utilities that did not differ between the two groups (0.59 vs 0.55. p = 0.5). There was no statistically significant difference between the two groups alter adjustment for age, duration of disease, NYHA class, and treatment assignment.

DISCUSSION

In this cross-sectional study, we aimed to describe the HRQOL of patients with PAH including those receiving epoprostenol and those not receiving the drug. Participants were predominately white women with significant functional limitations (NYHA class 3 and 4) and a diagnosis of PH for a median of 559 days. They reported distress in multiple HRQOL domains, although their anxiety and depression scores were within the range of normal responses.

In a focus group of patients with PH, many identified anxiety, sadness, low self esteem, decreased social interactions, increased dependence on family members, and feelings of loss of control as important contributors to their overall quality of life (S. Shafazand, MD; unpublished data; August 2001). These themes were reflected in the responses to the emotional distress domains of our HRQOL questionnaires, in which patients with PH scored worse than population norms.

The NHP has been used to study HRQOL in various patient populations.9,26,28 Not surprisingly, our patients reported greater distress in all NHP domains compared with population norms. More strikingly, participants receiving epoprostenol appeared to have more distress in all NHP domains than a heterogeneous group of patients 3 months following combined heart and lung transplantation,9 suggesting the considerable impact of PAH on HRQOL even in patients who are receiving the most effective medical therapy. CHQ results obtained in this study are comparable to previously obtained responses of patients with NYHA class III and IV congestive heart failure.29

This is the first study to measure utilities for patients with PAH. Utilities provide a global measure of HRQOL while incorporating patient values and preferences. They are often used in cost- effectiveness analyses of health-care treatments to determine quality-adjusted life-years. In our population, SG utilities were higher than utilities elicited by the VAS technique. This pattern is consistent with previous findings and may be due to the fact that people are, in general, risk averse.30 Individuals who are risk averse are less willing to accept a given risk of death, and therefore value current health more highly.

Findings from other studies of patient preferences help to place our results in context.31 Mean utilities were 0.71 in our study, 0.70 in a study of patients with first recurrence of breast cancer, 0.80 in patients following lung transplantation, and 0.60 in heterogeneous group of patients with congestive heart failure.31

Important limitations of this study are its cross-sectional design and small sample size. In our comparison of patients who did and did not receive epoprostenol, nonrandom treatment assignment created groups that likely differed in ways that were both observable and unobservable. Another potential limitation is that some individuals may have difficulty understanding the SG elicitation procedure. In an effort to reduce this problem, we enrolled people with a minimum grade 8 education. Practice sessions were included in the computerized interview to familiarize subjects with the elicitation procedure and concept of proportions.

Despite severe PH at clinical presentation, longer duration of illness, and adverse effects associated with therapy, participants receiving epoprostenol described more energy, less fatigue, less emotional distress, less anxiety or depression, and greater control over their disease \when compared with the no-epoprostenol group. The two groups reported similar degrees of dyspnea but differed in the activities that led to dyspnea; patients not receiving epoprostenol were more likely to report dyspnea with less demanding activities of daily living. This cross-sectional study was not designed to compare symptoms before and after treatment. Participants receiving epoprostenol may have been more dyspneic than the no-epoprostenol group prior to the initiation of epoprostenol, and may have improved with treatment.

Scores for emotional distress were consistently better for patients in the epoprostenol group. While this may be due to the impact of the medication itself, it is more likely a combination of drug effect and several other factors. The patients receiving epoprostenol had a longer duration of disease at the time of study. Irrespective of treatment, patients with longer duration of disease have had more time to understand their disease, accept their functional limitations, develop coping strategies, and build an adequate social support system. This likely contributes to the relative emotional well-being of the patients receiving epoprostenol. Additionally, due to the complex drug delivery system, patients who receive epoprostenol have more interactions with physicians and nurses; this added attention may lead to a better understanding of the disease and feelings of improved control and mastery. Finally, patients who receive epoprostenol may in part be selected because of their ability to cope with the challenges of such therapy. Differences in coping strategies, although not studied here, may accentuate the positive impact of the drug on symptoms and emotional well-being. Results from the secondary analysis reported above, while intriguing, are exploratory in nature, and longitudinal studies that assess HRQOL and utilities in patients prior to and after starting epoprostenol are needed to confirm our findings.

PAH is a devastating condition that affects predominately young women in the prime of their life. Understanding HRQOL and preferences is important in the care and management of these patients. The results of this study are in keeping with a 12-week randomized trial3 of epoprostenol therapy, in which HRQOL outcomes were secondary end points. In their study, Barst et al3 showed that for the majority of patients who completed the HRQOL questionnaires, there was improvement in all CHQ domains and two of six NHP domains after 12 weeks of epoprostenol therapy. There are no longitudinal data available to suggest whether these differences in HRQOL are persistent beyond the 12 weeks of therapy.

In a recent, 12-week, randomized, placebo-controlled study of sitaxsentan therapy for patients with PAH, Barst et al32 demonstrated an improvement in 6MWT, pulmonary vascular resistance, and NYHA functional class in patients receiving sitaxsentan compared with placebo. However, there were no significant differences between the groups in quality-of-life assessment. This lack of difference highlights the fact that HRQOL measurements provide a unique assessment of an individual’s satisfaction with and perception of the physical, social, and psychological domains of life, insofar as they are affected by health. While therapies for PAH improve pulmonary hemodynamics and exercise capacity, they may or may not have a positive impact on functional status and quality of life.

Our patients with PH, who had a longer duration of illness than participants in the aforementioned trials, reported impairment in all HRQOL domains. Patients treated with epoprostenol described more energy and less emotional distress than patients who did not receive this therapy. Nevertheless, compared with population norms, they continued to have substantial functional and emotional limitations that adversely affected their HRQOL.

* From Division of Pulmonary and Critical Care Medicine (Drs. Shafazand and Doyle) Stanford University School of Medicine, Stanford; VA Palo Alto Health Care System (Drs. Goldstein and Gould), Palo Alto; and Department of Medicine (Dr. Hlatky), Stanford University School of Medicine, Stanford, CA.

Drs. Goldstein and Gould received Career Development Awards from the VA Health Services Research and Development Service.

Dr. Shafazand and this work were supported by National Research Service Award grant number F32 HS11767 from the Agency for Healthcare Research and Quality, and an educational grant from the Vera M. Wall Center for Pulmonary Vascular Disease.

Views expressed are those of the authors and not necessarily those of the Department of Veterans Affairs.

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Shirin Shafazand, MD, MS, FCCP; Mary K. Goldstein, MD, MSc; Ramona L. Doyle, MD, FCCP; Mark A. Hlatky, MD; Michael K. Gould, MD, MS, FCCP

Manuscript received December 23, 2003; revision accepted May 17, 2004.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail: [email protected]).

Correspondence to: Shirin Shafazand, MD, MS, Assistant Professor of Medicine, The George Washington University, Washington Hospital Center, Washington, DC; e-mail: [email protected]

APPENDIX

The VAS is a linear scale with death at one end and ideal health at the other end. On a computer scr\een, the subjects were asked to rate their current health by clicking between these two points. The line was calibrated to enable the program to calculate a score between 0 and 1 based on the position of the marker.

The goal of the SG technique is to determine the maximum risk a person is willing to accept in order to avoid remaining in his/her current health state. The worse the health state, the higher the risk a person is willing to accept and the lower the measured utility. The SG technique offers subjects a hypothetical choice between remaining in the chronic health state (certain outcome) for the remainder of their lives, or taking a gamble that may result in either ideal health for a specified time period (probability, p) or lead to painless and immediate death (probability, 1 – p).21 The probabilities of this gamble are varied until the subject expresses indifference in choosing the gamble or the current health state. This indifference point is the utility score for that health state, which varies between 0 (death) and 1 (perfect health). The SG utility is grounded in von Neumann Morgenstern utility theory. SG utilities may be applied as measures of value of outcome health states in decision analysis and as quality-weighting factors for quality-adjusted life-years.25

In our study, the computerized session began with an assessment of the patient’s functional status as defined by the NYHA classification system. This was followed by a practice session asking participants to rank their health on a VAS while imagining being totally blind in both eyes; patient preferences for total blindness were also elicited using the SG technique. The practice session was designed to familiarize participants with both techniques and the concept of probabilities. During the practice session, the interviewer assisted participants as needed. Once participants were comfortable with both techniques, the computer ended the practice session and asked participants to consider their “current health” and rank their overall HRQOL on the analog scale. This was followed by a determination of their current health preferences using the SG technique. The interviewer had minimal involvement in this phase of the questionnaire, only assisting with any computer-related “technical’ difficulties that arose.

The question posed for the SG technique was as follows:

We want you to think about your current health in terms of risk.

On the next screen, you will get a choice. You can live the rest of your life with your current health, including any health troubles you have right now, or you could receive a magic treatment. If the treatment works, you will live the rest of your life in ideal health. The treatment is free, but there is a chance that it could kill you. Note that if the treatment works, you do not live any longer, just better.

Think about what you might risk to have ideal health for the rest of your life.

In our stydy, ideal health was described as the “best health” imaginable for the rest of the patient’s natural life. We further defined ideal health as a state of excellent mental and physical health, for which there would be no problems with any of the following activities: walking, lifting, bending, thinking, talking, hearing, and seeing. We described death as painless and immediate.

On a subsequent screen, the participants were presented with three choices:

Choice A: Take the treatment with (p) probability (eg, 99%) of living with ideal health for the rest of your life and accept a (1 – p) probability (eg, 1%) of dying painlessly today.

Choice B: Live With your current health for the rest of your life.

Choice C: Choices A and B are about the same to me.

Probability p and 1 – p were varied until the participant picked choice C, the point of indifference. This indifference point was the utility score for the participant’s “current health state” and ranged between 0 (death) and 1 (perfect health).

Copyright American College of Chest Physicians Nov 2004