Matt's Blog

Liver project a rare success story
The St Vincent's hospital liver unit this month undertook it's 500th transplant,
writes Maeve Sheehan
Sunday November 18 2007
IN a month when dirty hospitals, cancer misdiagnosis blunders and cutbacks in
the health service dominated the headlines, the liver transplant programme at St
Vincent's Hospital in Dublin quietly passed the 500th mark.
Its success has never been more relevant. As debate rages about streamlining
hospitals in specialist centres of excellences for breast cancer and other
diseases, the liver programme at St Vincent's has been performing the
multi-disciplinary approach to health care since it first opened in 1993.
One of its first transplant patients, Tony Gartland, has gone on to become a
multi-medal winning athlete at the World Transplant Games, while its most recent
transplant patient, Derek Kavanagh was recovering well just days after his
procedure last week.
It makes for good news in a litany of healthcare horror stories. It's success is
tempered, however, not by health cutbacks or by a lack of resources but by a
continuing shortage of donors. Between 25 and 35 patients are waiting for a new
liver at any one time. So far this year, three patients in need of a liver
transplant died while waiting for a suitable organ to be donated.
For Professor John Hegarty, consultant physician at the liver unit, celebrating
the significant milestone also provides the opportunity to highlight the need
for donors. The need has never been so high.
"The work level has gone up because of the awareness that transplantation can
offer people with end stage liver disease," he said. "Any liver that was
suitable for transplantation has been used in this country. Even to the extent
that we do three in 48 hours and utilise all the resources that that would
require."
The cases he has seen include troubled teenagers who have suffered serious liver
damage as a results of taking overdoses of household drugs like paracetamol.
"To see them on deaths door and to survive and go on to have normal lives is
extremely gratifying ... they were young people from 14 through 18, who have
fights with their parents, or fights with their girlfriends, who spontaneously
take an overdose," he said.
Amongst the most devastating cases was a young man who developed an alcohol
problem as a teenager and died aged 21 while waiting for a liver transplant.
Despite the recent upsurge in Irish drinking habits, alcohol-related liver
disease accounts for between 20 and 30 per cent of liver transplants performed
at St Vincent's. Most patients suffer forms of hepatitis, cancers and
abnormalities.
That could change. In the past decade, alcohol consumption in Ireland increased
by 17 per cent. Alarmingly, the number of people discharged from hospitals with
alcohol-related liver disease went up 147 per cent over the 10 years. According
to Professor Hegarty, it could be another decade or more before the impact of
that alcohol consumption becomes apparent.
The unit has come a long way since the mid-1980s, when consultants pushed for a
liver transplant unit in Ireland. In the early days, patients deemed suitable
for transplant were flown along with an Irish team of surgeons and physicians to
the specialist unit at Kings Hospital in London. The dedicated unit opened at St
Vincent's in 1993.
"Over the years, the number of transplants carried out has increased steadily
and we are now doing somewhere between 65 and 70 a year which is 15 to 16 per
million of the population," said Professor Hegarty.
"We see not just patients who need transplants. We have a whole wide spectrum of
patients with advanced liver disease and rare liver disease who are now referred
to us. Our non-transplant workload has increased hugely, together with the
transplant work."
According to Professor Hegarty, the liver transplant unit was "ahead of its
time" in its approach, with teams of specialists assessing cases and intensive
auditing of the outcomes by the hospital, the HSE and the UK transplant service.
Indeed, one of the surgeons who performed the first transplants in the very
early years was Professor Niall O'Higgins, whose report on centres of excellence
for breast cancer is now the template adopted by the HSE.
"This is a multi-disciplinary centre of excellence. If you are a public patient,
you cannot have a centre of excellence five miles from your home. Centres of
excellence are the only way to provide complex multi-disciplinary treatment and
that goes across the whole spectrum of disease," said Professor Hegarty.
This centre of excellence is staffed by a multi-disciplinary team of physicians,
surgeons, specialist registrars and nurses, accessible to anyone who needs the
service, including after hours and at weekends.
Patients from around the country are referred by their GP. While the official
hospital website says cases will be seen within four to six weeks, Professor
Hegarty said they are often seen within a week, depending on the case. "In terms
even of access, anyone can get in here. At any time of day or night, there is
the facility available to discuss issues and admit," he said. "Access is
certainly one of the aspects of the service that we are certainly very proud of.
Equitable access, provided on the basis of need."
One of the staunchest admirer of the service was the late Fine Gael TD, Jim
Mitchell, who had a liver transplant in 2000 after contracting a rare form of
cancer. He was so grateful, he asked his doctor what he could to help. "More
nurses," was the response. Despite his successful transplant, Mr Mitchell's
cancer returned. He died two years later, but not before fulfilling his promise.
"We got the nurses," said Professor Hegarty.
http://www.independent.ie/health/liver-project-a-rare-success-story-1222434.html

Rudi Schmid, 85, Leading Liver Researcher, Is Dead
By JEREMY PEARCE
Published: November 19, 2007
Dr. Rudi Schmid, a liver specialist and medical educator who was an early
champion of establishing organ transplant centers to make donor livers widely
available, died on Oct. 20 in Kentfield, Calif. He was 85.
The cause was pulmonary failure, his family said.
Dr. Schmid became medical dean at the University of California, San Francisco,
in 1983. That same year - 16 years after the first successful liver transplant -
he led a panel convened by the National Institutes of Health to consider the
efficacy of performing liver transplants on a larger scale. The panel found that
increasing survival rates supported the notion of offering transplants
nationwide.
The panel did not discuss the costs of establishing the centers or of the
transplant operations themselves; its focus was on medical advances and
capabilities. But its conclusions were generally accepted by physicians and have
helped encourage use of the procedure.
In 1983, the survival rate in the first year after a liver transplant was 20
percent to 25 percent; today it is 85 percent to 90 percent. About 100
facilities around the country perform the operation.
Dr. Schmid's work in hepatology began in the 1950s with studies of porphyrias, a
group of disorders in which enzymes of the heme, contained in the hemoglobin,
are disrupted. The disorders can cause neurological problems and mental
disturbances. Dr. Schmid and others developed a method to induce porphyria in
rats, and by doing so established a successful animal model for studying the
diseases.
He later investigated the chemistry of bilirubin, a byproduct of the normally
occurring breakdown of heme. With Dr. Ivan F. Diamond, a neurologist, and
others, Dr. Schmid looked at ways to prevent bilirubin from passing into the
brain in cases of child jaundice, an event that can cause brain damage.
Dr. Schmid was dean of San Francisco's medical school from 1983 to 1989. During
that time, some students raised concerns that the school was emphasizing
research at the expense of basic medical education. In response, he introduced
faculty evaluations, undertook an initiative to improve the effectiveness of the
teachers and helped establish a track in the curriculum for the study of primary
care and community medicine. He also promoted an international exchange program
for students and faculty members, particularly with Peking Union Medical
College.
Rudi Schmid, the son of two general practitioners, was born in Ennenda,
Switzerland. He received a medical degree from the University of Zurich before
earning a doctorate in medical sciences from the University of Minnesota in
1954, when he became an American citizen.
Dr. Schmid taught medicine for more than 35 years, beginning at Harvard before
moving to the University of Chicago and finally to San Francisco. He retired in
1995.
He was a former president of the American Association for the Study of Liver
Diseases and the Association of American Physicians and was a member of the
National Academy of Sciences.
He is survived by his wife, the former Sonja Wild. The couple lived in
Kentfield, a San Francisco suburb.
He is also survived by a son, Peter, of Daly City, Calif.; a daughter, Isabelle
Franzen of Cape Town, South Africa; and a grandchild.
http://www.nytimes.com/2007/11/19/us/19schmid.html?ref=us

Hepatitis Found Again Among Doctor's Patients
By PAUL VITELLO
Published: November 20, 2007
Nassau County health officials yesterday reported another positive test for
hepatitis among the patients of an anesthesiologist on Long Island whose faulty
infection-control practices put hundreds of people at risk.
The officials will not know for several weeks, they said, whether the hepatitis
B was contracted in the doctor's office or somewhere else.
The officials also said that they were urging 200 more patients who were treated
by the anesthesiologist, Dr. Harvey Finkelstein, to be tested for two types of
hepatitis and H.I.V.
Last week, 34 months after investigators uncovered the doctor's lapses, state
health officials sent out letters to 628 of Dr. Finkelstein's patients
recommending that they be tested for the blood-borne illnesses. The state
officials had found that Dr. Finkelstein was misusing syringes, leading to the
infection of at least one patient with hepatitis C. Dr. Finkelstein corrected
his practices in 2005.
Cynthia Brown, a spokeswoman for the Nassau County Health Department, said that
the patient who tested positive for hepatitis B would be retested immediately.
If the test result is confirmed, the department will conduct an epidemiological
investigation to determine how he was infected.
Consumer advocates said yesterday that Dr. Finkelstein, who has settled 10
malpractice lawsuits with patients in the last 10 years, was among a very small
number of doctors in New York who have been sued so often and that his case
illustrated the lax monitoring of the medical profession.
"This case perfectly illustrates how poorly the medical profession is watched
and regulated," said Arthur A. Levin, the director of the New York-based center
for Medical Consumers.
After Dr. Finkelstein's lapses were discovered by the State Health Department,
an investigation was conducted by the Office of Professional Medical Conduct,
the department agency charged with investigating allegations of misconduct
against physicians. Dr. Finkelstein was not disciplined by the office because he
had changed his infection control methods to conform with recommendations issued
by the Centers for Disease Control and Prevention.
The level of scrutiny given to Dr. Finkelstein, Mr. Levin said, means that "no
one is really looking very hard."
The 34-month delay between the discovery of Dr. Finkelstein's lapses and the
notification of the bulk of his patients last week has been widely criticized;
Gov. Eliot Spitzer called it "deeply troubling."
On its Web site, the medical conduct office lists Dr. Finkelstein as having
settled 10 malpractice cases from 1998 to 2007. The list does not specify what
the suits alleged, or give dollar amounts of the settlements. Of the 10,
however, 5 were for amounts described by the office as "above average" for New
York anesthesiologists.
Dr. Sidney Wolfe, director of the health research group Public Citizen, a
nonprofit organization that has monitored malpractice records nationwide since
1990, said "the smallest fraction" of doctors have such extensive records of
payments.
In a 2003 survey of malpractice settlements in New York, Dr. Wolfe said, doctors
with 10 or more settlements in a decade accounted for just a tenth of 1 percent
of the total. The survey showed that 81 percent of New York doctors made no
malpractice payments in the previous 10 years.
"Ten settlements in 10 years should be a red flag to any medical review board,"
he said.
In fact, the office of the state comptroller issued a report in August
criticizing the Health Department's medical conduct office for being "not
proactive" enough in seeking out cases of medical misconduct for review.
For instance, the report said, the office does not routinely monitor lists of
doctors excluded from Medicaid and Medicare programs because of abuse. It did
not routinely review the files of doctors with more than three medical
malpractice settlements in 10 years - a standard used in some states - and did
not keep up-to-date records of malpractice settlements.
Claudia Hutton, a spokeswoman for the State Health Department, said the agency's
director, Keith Servis, would file a formal reply to the comptroller's report
but would not comment publicly. She pointed out that he had been in charge of
the agency only since the start of 2007.
She said the department was conducting an internal review to explore the "gaps
in communication" between state epidemiologists' investigation of the spread of
infection and the Office of Professional Medical Conduct's investigation of
doctors who might be the sources of infection, as in the case of Dr.
Finkelstein.
"One issue is that since 2004, the number of complains against physicians has
gone up 30 percent, while the number of staff on the O.P.M.C. has remained the
same," she said.
http://www.nytimes.com/2007/11/20/nyregion/20doctor.html?_r=1&ref=nyregion&oref=\
slogin

Regulus Gets Patent on Hep C Treatment
Associated Press 11.19.07, 8:50 AM ET
NEW YORK - Regulus Therapeutics, a joint venture of Alnylam Pharmaceuticals Inc.
and Isis Pharmaceuticals Inc., said Friday the U.S. Patent and Trademark Office
issued the venture a patent covering methods for targeting the hepatitis C
virus.
The joint venture is focusing on microRNA technology, which controls protein
production within cells and could be used to turn off certain genes, in effect
treating a condition at the genetic level.
The patent issued covers methods for targeting a specific microRNA to stop the
Hepatitis C virus from replicating.
Shares of Cambridge, Mass.-based Alnylam closed at $33.96, and shares of
Carlsbad, Calif.-based Isis closed at $16.75 Friday.
http://www.forbes.com/feeds/ap/2007/11/19/ap4353848.html

HIV-1 Vaccine Might Increase Infection Risk in Certain Subgroups
The HIV-1 vaccine used in the STEP trial has already been shown to be
ineffective, but might it actually cause harm?
Researchers are now concerned that the experimental HIV-1 vaccine used in the
STEP trial might increase susceptibility to HIV-1 infection in certain
populations. Previous analyses from the trial focused exclusively on the 1500
study participants who had low levels of preexisting immunity to the vector used
in the vaccine (adenovirus serotype 5 [Ad5]). When the vaccine failed to prevent
HIV-1 infection in these individuals, the Data and Safety Monitoring Board
recommended that immunizations be halted (ACC Oct 1 2007), and researchers began
to analyze data from the larger study population, which also included people
with higher levels of preexisting Ad5 immunity.
Overall, 49 cases of HIV-1 infection occurred among the 914 men who received at
least one dose of vaccine, compared with 33 cases among the 922 men who received
placebo. Among the 1058 men who had low baseline levels of Ad5 immunity (titer
200 units), the number of new HIV infections did not differ substantially
between the vaccine and placebo groups (28 vs. 24). However, a more pronounced
difference (21 vs. 9) was seen among the 778 men who had high baseline levels of
Ad5 immunity (titer
identical; for example, the population with high Ad5 titers was younger, less
likely to live in the U.S., and less likely to be circumcised. Thus, confounding
factors could not be ruled out. Nevertheless, these results suggest that the
vaccine might have increased susceptibility to HIV-1 infection in individuals
with high levels of preexisting immunity to Ad5.
The mechanisms underlying these puzzling results are not clear, and further
studies are needed. In the meantime, the study participants are being told
whether they received vaccine or placebo and what their adenovirus titers were.
They will also receive additional risk-reduction counseling and will continue to
be followed by study investigators.
Comment: Several points are worth noting. First, the vaccine itself did not
cause HIV infection, although it may have made some people more vulnerable.
Second, the individuals who became infected during this study (whether in the
vaccine group or the placebo arm) continued to engage in very high-risk sexual
behavior. In contrast, those who reduced such behavior did not become infected,
thereby reinforcing the importance of risk-reduction measures. Finally, I think
that the study investigators did the right thing by unblinding the participants.
Doing otherwise would have offered some statistical and scientific advantages,
but the safety of the volunteers comes first, and, to that end, unblinding was
best.
Overall, these results have massive implications for future vaccine trials.
Before the findings were released, the HIV Vaccine Trials Network (which
cosponsored this study with Merck) was poised to start PAVE 100, a large trial
using a DNA prime/Ad5 boost vaccine developed by the NIH. However, this trial is
now on hold, and the AIDS Vaccine Advisory Committee will meet soon to decide
how to proceed.
- Carlos del Rio, MD
Dr. del Rio is the Principal Investigator for the Atlanta site of the STEP trial
and is an HIV Vaccine Trials Network co-investigator.
Published in AIDS Clinical Care November 19, 2007

Hospital admission is a relevant source of hepatitis C virus acquisition in
Spain.
Marti Nez-Bauer E, Forns X, Armelles M, Planas R, Solà R, Vergara M, Fàbregas S,
Vega R, Salmerón J, Diago M, Sánchez-Tapias JM, Bruguera M; The Spanish Acute
HCV Study Group.
Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, Ciber de Enfermedades
Hepáticas y Digestivas (Ciberehd), Spain.
BACKGROUND/AIMS: Isolated cases of acute hepatitis C, as well as hepatitis C
outbreaks transmitted by health-care related procedures, have directed attention
to nosocomial transmission of HCV. METHODS: To investigate the current relevance
of nosocomial HCV infection, we performed a retrospective epidemiological
analysis of all cases of acute hepatitis C diagnosed in 18 Spanish hospitals.
Between 1998 and 2005, 109 cases were documented. RESULTS: The most relevant
risk factors registered during the 6-month period preceding the diagnosis of
acute hepatitis C were: hospital admission in 73 (67%) cases, intravenous drug
use in 9 (8%), accidental needle stick in 7 (6%) and sexual contact in 6 (5%).
Among the 73 patients in whom hospital admission was the only risk factor, 33
underwent surgery and 24 were admitted to a medical emergency unit or a medical
ward; the remaining 16 patients underwent an invasive diagnostic or therapeutic
procedure. Sixty two patients underwent antiviral therapy and 51 (82%) achieved
a sustained virological response. In 47 patients treatment was not indicated (in
24 due to spontaneous resolution of HCV infection). CONCLUSIONS: In most
patients with acute hepatitis C the only documented risk factor associated with
the infection is hospital admission. These results stress the need for strict
adherence to universal precaution measures. Fortunately, most cases of acute
hepatitis C either resolve spontaneously or after antiviral therapy.
PMID: 17998149 [PubMed - as supplied by publisher]
http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=179981\
49&dopt=AbstractPlus

Interesting site!
http://www.epidemic.org/theFacts/viruses/theOriginsOfViruses/

I hope that many of you take the opportunity to put a comment on one of the
numerous NewsDay posts that have come out about Hep C and the Doctor in NY.
Here is one that I posted. Let's jump on this opportunity to educate the
public! So far the one Hep C patient they have interviewed has said that if
you *make it to 5 years it gets better*, that he *puts a rubber band on his
glass so his family won't drink out of it and catch it*, and his daughter has
stated that *there is no treatment for it*. EGADS! These people need to
educate themselves before they speak out!!
http://www.topix.net/forum/source/newsday/TN2DUC7NP4MUM42OI/p16

Hey this is BIG news here..at least for maybe another day or so. If I
see anything I feel might be newsworthy, Ill let ya know :-)
_____

With no vaccine, hepatitis C is a silent threat
BY DELTHIA RICKS | delthia.ricks@...
November 18, 2007
Among viral infections that have reached epidemic proportions worldwide,
hepatitis C ranks high on the list of public health threats because it lacks a
protective vaccine, such as the one that has helped limit infections with its
microbial cousin, hepatitis B.
The alphabet of viruses -- A, B, C, D and E -- comprises a highly infectious
family of pathogens that have made the most-wanted list of federal virus
hunters, who are tracking their incidence in the population -- and in health
care and food service settings, sites where outbreaks have been spawned.
While hepatitis A is a gourmand's nightmare, transmitted through fecal matter
that contaminates food, B and C remain worrisome for a variety of reasons. They
are transmitted through blood-to-blood contact, and in rare instances, have been
communicated through contaminated medical equipment.
Analyses have shown hepatitis B to be 100 times more infectious than HIV, and
numerous studies have characterized hepatitis C as a tidal wave expected to
crest in only a few years.
By 2015, the Centers for Disease Control and Prevention predicts a 279 percent
nationwide increase in the incidence of liver damage due to hepatitis C, a 528
percent increase in the need for liver transplants, and a 223 percent increase
in the liver-related death rate.
"Hepatitis C is typically a silent disease," said Dr. Melissa Palmer, a
Plainview liver specialist who has tested new treatments for various forms of
hepatitis. "But it is also the only form of hepatitis that can be cured."
Treatments involving injections of the immune booster pegylated interferon, plus
doses of the antiviral Ribavirin, have been known to force the infection into
retreat.
Both hepatitis C and B can lead to liver cirrhosis, Palmer said, and eventually,
liver cancer and the need for a transplant.
For some people, however, the power of a healthy immune system can trigger a
hepatitis C infection to resolve on its own. "This is the only form of hepatitis
for which this occurs," Palmer said.
Yet hepatitis C remains an international public health issue of breathtaking
magnitude because not every patient can be cured. The infection sometimes
smolders for two decades before symptoms are recognized.
The World Health Organization estimates 170 million people around the globe
carry the virus, 4 million of them in the United States.
"The actual lab work to identify whether hepatitis B or C is present in the
blood does not take that long and can be turned around very quickly," said
Joseph Perz, a health care epidemiologist at the CDC. He, like other experts,
worries about hepatitis C's growing impact.
In 2005, the state convened a meeting in Manhattan about the rise in hepatitis C
infections statewide. Of chief concern was the growing problem of dual
infections involving HIV and hepatitis C, which have reached epidemic
proportions in New York City. Public health officials from Long Island also
cited an upward trend in hepatitis C infections.
Earlier this month at the annual meeting of the American Public Health
Association, experts emphasized the need for impeccable infection control
measures in health care settings, particularly in light of the prevalence of
blood-borne viruses in the population.
Sloppy techniques have stirred health authorities and instilled fear in patients
who've been notified of possible exposure. Transmission in health-care settings,
though said to be rare, is not new. A 2003 study highlighted a spate of
infections involving hepatitis B and C in outpatient settings nationwide, two of
them in New York City.
One centered on a Manhattan physician's colonoscopy practice, where 12 patients
contracted the hepatatis C virus. The second involved a Manhattan pain treatment
center where 38 patients were infected with hepatitis B. Both outbreaks involved
medication drawn from multi-use vials. More than 2,000 patients received letters
about possible exposure in the two cases.
In 2004, a scare rippled across Long Island when the North Shore University-Long
Island Jewish Health System notified 177 patients that endoscopic tubes inserted
through patients' mouths, allowing doctors to view the upper gastrointestinal
tract, had not been properly disinfected.
North Shore spokesman Terry Lynam said last week that letters were sent to
patients as a precaution and there were no infections. But as health care
institutions work to refine methods of infection control, scientists are still
seeking to better understand the genetics of the viruses that cause hepatitis.
Hepatitis C remains an area of intense research because for decades it had been
among the most elusive. Until 1989, it had escaped detection, making it a
looming -- and potentially deadly -- presence in the blood supply. Scientists at
Chiron Corp. first identified it, paving the way for blood-supply screening and
patient diagnosis.
http://www.newsday.com/news/local/ny-hshepa1118,0,1233489.story?coll=ny_news

State reviews patient lists in hepatitis scare
BY MICHAEL AMON | michael.amon@...
8:03 PM EST, November 17, 2007
State Department of Health investigators returned to the offices of a Long
Island anesthesiologist Saturday to find out if additional patients should be
notified that they are at risk for HIV and hepatitis by the doctor's reuse of
syringes.
The visits to Pain Care of Long Island in Plainview and Long Island Surgicenter
in Melville were prompted by more than two dozen calls to the health department
in the past week from former patients of Dr. Harvey Finkelstein who were not
among the 628 urged in letters last week to get tested for bloodborne diseases,
department spokeswoman Claudia Hutton said.
Also Saturday, the health department issued a clarification saying that "most
likely" only one patient -- not two as it had indicated last week -- was
infected directly because of Finkelstein's reuse of syringes. The second
confirmed hepatitis patient had probably contracted the disease before visiting
Finkelstein's office and was "likely" the source of the hepatitis transmission
to another patient, Hutton said.
The two hepatitis C patients had back-to-back appointments on the same day in
2004, Hutton said. The first patient was injected twice with the same syringe,
contaminating a multiple-dose medicine vial, Hutton said. The disease was passed
on to the second patient with an injection from the same multidose vial, Hutton
said.
"There was only one transmission," Hutton said.
The visits to Finkelstein's offices come as the health department tries to
determine whether it contacted all the right people.
Hutton said the department believed it had sent letters to every patient who had
received an injection from Finkelstein from Jan. 1, 2000, to Jan. 15, 2005 --
the time when he told investigators he was reusing syringes.
However, the department received many calls from patients who had been injected
but had not received notification letters -- many of them not on the initial
mailing list, Hutton said, leading investigators to believe some patients have
not been notified who should have been.
Hutton urged anyone who had not received a notification letter to call the state
Health Department at 1-800-278-2965 to find out what step to take next.
It's not clear how some patients would not have been notified. The Health
Department gained access to Finkelstein's files in July after an eight-month
battle with his attorneys. Some of the callers could be mistaken, Hutton said,
though it's also possible that "we made an error."
"The calls that we've received saying, 'Hey, we haven't gotten the letter,' are
worrisome to us," Hutton said. "We're going back to ensure we got all the
records."
Finkelstein, 52, was cooperating Saturday, accompanying investigators into his
office, Hutton said. The Dix Hills resident did not return a phone message
seeking comment.
About 375 patients had received the certified notification letters as of Friday
afternoon, Hutton said. And at least 60 of them have set up appointments for
free testing with the Nassau County Health Department.
Maria Pasquariello, 65, of Plainedge, got results back Friday afternoon showing
that she did not have any blood-borne diseases.
"We jumped in the air more than once. We thanked God," said her husband, Augusto
Pasquariello, 69, who said he spent two days worrying about his wife. "We went
through hell."
http://www.newsday.com/news/local/longisland/ny-lihepa1118,0,3685130.story?coll=\
ny_home_rail_headlines

Look what you made me do Dorothy! ROFLOL
http://www.topix.net/forum/source/newsday/TLP0O8DI1FQQ626OU#lastPost
http://www.topix.net/forum/source/newsday/TN2DUC7NP4MUM42OI
http://www.topix.net/forum/source/newsday/TN2DUC7NP4MUM42OI/p16#lastPost
http://www.topix.net/forum/source/newsday/TLP0O8DI1FQQ626OU/p2
Peace and Love
(`'·.¸(`'·.¸ ¸.·'´) ¸.·'´)
«´¨ *Pam* ¨`»
(¸.·'´(¸.·'´ `'·.¸)`' ·.¸)
¸.·´
( `·.¸
`·.¸ )
¸.·)´
(.·´
`*.
*.
Mahatma Gandhi put it well: "Be the change you want to see in the
world." It always begins with one person.

You can read all the stories at newsday.com
Let me know if that doesn't work for you.
_____

Email me the stories tomy email please!
Thank you!
Dorothy <dorv@...
Newsday has a few more stories about the doctor here on Long
Island. If nothing else, it's making the public aware of the HCV crisis in
this country.
http://www.newsday.com/news/local/ny-hshepa1118,0,1233489.story?coll=ny_news
_local_promo
I do intend to write to Newsday, however, to complain about the Google Ad
Links that have been imbedded in the story such as:
<http://pagead2.googlesyndication.com/pagead/iclk?sa=l&ai=BqEZOZ0JAR97kDKDk4
QLoj-3iCpap8zfK5IPTA8CNtwHwkwkQBRgFIKjxoQYoBTgAUOTP-6oEYMmml4vApNgPoAGmgPf3A
6oBDG5ld3NkYXlfbmV3c7IBD3d3dy5uZXdzZGF5LmNvbcgBAdoBRWh0dHA6Ly93d3cubmV3c2Rhe
S5jb20vbmV3cy9sb2NhbC9ueS1oc2hlcGExMTE4LDAsNDQyNzgwMixwcmludC5zdG9yeYACAagDA
egDowPoA4AC6AMt9QMAAAAA9QMAAAEA&num=5&adurl=http://www.thecureforhepatitis.c
om&client=ca-tribune_news3_html
All-Natural Recipe Works
<http://pagead2.googlesyndication.com/pagead/iclk?sa=l&ai=BqEZOZ0JAR97kDKDk4
QLoj-3iCpap8zfK5IPTA8CNtwHwkwkQBRgFIKjxoQYoBTgAUOTP-6oEYMmml4vApNgPoAGmgPf3A
6oBDG5ld3NkYXlfbmV3c7IBD3d3dy5uZXdzZGF5LmNvbcgBAdoBRWh0dHA6Ly93d3cubmV3c2Rhe
S5jb20vbmV3cy9sb2NhbC9ueS1oc2hlcGExMTE4LDAsNDQyNzgwMixwcmludC5zdG9yeYACAagDA
egDowPoA4AC6AMt9QMAAAAA9QMAAAEA&num=5&adurl=http://www.thecureforhepatitis.c
om&client=ca-tribune_news3_html
Gone overnight?? Why are we all knocking ourselves out with interferon and
ribavirin??? When we can use a simple overnight all-natural recipe???

Today's Sunday Newsday has a few more stories about the doctor here on Long
Island. If nothing else, it's making the public aware of the HCV crisis in
this country.
http://www.newsday.com/news/local/ny-hshepa1118,0,1233489.story?coll=ny_news
_local_promo
I do intend to write to Newsday, however, to complain about the Google Ad
Links that have been imbedded in the story such as:
<http://pagead2.googlesyndication.com/pagead/iclk?sa=l&ai=BqEZOZ0JAR97kDKDk4
QLoj-3iCpap8zfK5IPTA8CNtwHwkwkQBRgFIKjxoQYoBTgAUOTP-6oEYMmml4vApNgPoAGmgPf3A
6oBDG5ld3NkYXlfbmV3c7IBD3d3dy5uZXdzZGF5LmNvbcgBAdoBRWh0dHA6Ly93d3cubmV3c2Rhe
S5jb20vbmV3cy9sb2NhbC9ueS1oc2hlcGExMTE4LDAsNDQyNzgwMixwcmludC5zdG9yeYACAagDA
egDowPoA4AC6AMt9QMAAAAA9QMAAAEA&num=5&adurl=http://www.thecureforhepatitis.c
om&client=ca-tribune_news3_html
All-Natural Recipe Works
<http://pagead2.googlesyndication.com/pagead/iclk?sa=l&ai=BqEZOZ0JAR97kDKDk4
QLoj-3iCpap8zfK5IPTA8CNtwHwkwkQBRgFIKjxoQYoBTgAUOTP-6oEYMmml4vApNgPoAGmgPf3A
6oBDG5ld3NkYXlfbmV3c7IBD3d3dy5uZXdzZGF5LmNvbcgBAdoBRWh0dHA6Ly93d3cubmV3c2Rhe
S5jb20vbmV3cy9sb2NhbC9ueS1oc2hlcGExMTE4LDAsNDQyNzgwMixwcmludC5zdG9yeYACAagDA
egDowPoA4AC6AMt9QMAAAAA9QMAAAEA&num=5&adurl=http://www.thecureforhepatitis.c
om&client=ca-tribune_news3_html
Gone overnight?? Why are we all knocking ourselves out with interferon and
ribavirin??? When we can use a simple overnight all-natural recipe???

Well said!! I didn't want to say that the guy is a jerk and was milking the
disease...........so you did!!! LOL
I agree totally. But as I said, since I have HCV for getting close to 40 years
and have had few symptoms until just the last couple of years, I wouldn't say
that someone who became infected 3 years ago couldn't be suffering from some
debilitating symptoms........but I don't believe it for a minute!
Dorothy

Nov 16, 2007 9:24 am US/Pacific
L.A. Officials Plan Hepatitis Coordinator Position
(CBS) LOS ANGELES The Los Angeles County Department of Public Health announced
Friday the creation of the country's first-ever Hepatitis Coordinator position.
Officials planned to discuss the position Friday at the daylong Fifth Annual
Hepatitis C Summit being held at the California Endowment Center in downtown Los
Angeles.
The summit is designed to focus attention on the Hepatitis C epidemic, which
affects an estimated 180,000 people nationwide, 30 percent of whom are also
infected with HIV.
"Hepatitis C is a major global health issue -- a 'viral time time bomb,"' said
Dr. Robert Kim-Farley, director of Communicable Disease Control and Prevention
in the county's Public Health Department.
"With the additional resource of a coordinator, we will be able to expand and
enhance our current activities," he said.
L.A.'s Public Health Department says there are more people living in the county
who are infected with Hepatitis C than with HIV and that sharing syringes and
men having unprotected sex with other men are broadening the scope of the
epidemic.
"The new Coordinator's position is essential to addressing the needs of those
with Hepatitis C and stopping the spread of the blood-borne illness," said Brian
Risley, co-chair, Hepatitis C Task Force for L.A. County.
http://cbs2.com/health/local_story_320124221.html

Hicksville man says doctor gave him 'death sentence'
BY PATRICK WHITTLE | patrick.whittle@...
November 15, 2007
Raymond Bookstaver sought Dr. Harvey Finkelstein's help to ease the pain in his
aching back. Bookstaver left, he says, with a disease that he could have for the
rest of his life.
Bookstaver, 49, a former mechanic from Hicksville, identified himself as one of
at least two people the state says contracted hepatitis C from Finkelstein. He
later sued Finkelstein, claiming the doctor gave him the disease during an
epidural treatment in July 2004.
"You never expect to come out of that office with a death sentence," Bookstaver
said. "And it could be."
In a statement Wednesday, Finkelstein said the state investigated him and found
no misconduct and did not discipline him. The doctor said he has since "enhanced
his infection control practices" and continues to practice medicine.
Bookstaver is one of as many as 200 million people in the world who lives with
hepatitis C, a viral disease of the liver. About a quarter of sufferers will
face life-threatening symptoms, and most people have it for life, though some
can be cured.
The father of two, whose only income is from disability checks and worker's
compensation from the back injury, added that it makes him "aggravated that this
man is allowed to practice medicine, with a slap on the wrist. Who's to say he
hasn't done this before?"
Bookstaver, who had worked for United Parcel Service, said his weight dropped
from 260 to 200 pounds in a year after he contracted the disease. He said he
threw up two, sometimes three times a day. He would sleep for 10 hours, wake up
for three, and find himself too tired to stand.
Today, he is doing a little better, he said, thanks to a steady diet of drugs
and painful biopsies in which a doctor inserts a needle into his liver.
But he cannot go out to eat with his wife because he never knows when the
disease will flare up and he will become sick. Family vacations are out of the
question, Bookstaver said.
Fear of infecting other family members is constant. Bookstaver puts a rubber
band around his drinking glasses so his children will know not to drink from
that glass.
"It's affected all of us. The kids, when they come up to you and say 'Is daddy
dying?' how do you respond to that?" said his wife, Lori.
Hepatitis can be spread within a household, but this doesn't happen often,
according to the federal Centers for Disease Control and Prevention. If the
disease is spread within a household, it is most likely because of direct
exposure to the blood of an infected household member, the CDC says.
Other Finkelstein patients fear Bookstaver's fate. A 53-year-old Suffolk
resident, who declined to be named, said he was shocked when he received a
letter several days ago telling him he should be tested for Hepatitis C,
Hepatitis B and HIV.
"My family doesn't even know about it. I'm a little nervous," he said.
Bookstaver's attorney, Jeffrey Kimmel of Woodbury, said he is seeking "fair and
reasonable compensation" and medical costs for his client. Kimmel criticized the
state Department of Health for acting slowly after Bookstaver was diagnosed.
State Health Commissioner Dr. Richard Daines said yesterday his office first
advised patients to be treated for hepatitis C in May 2005, immediately after
becoming aware of the two cases related to the doctor.
Bookstaver said the doctor should be punished.
"He gets a slap on the wrist," Bookstaver said, "and I get this for life."
http://www.newsday.com/news/local/ny-lifear1115,0,4383809.story?coll=ny_home_hea\
d_1

'HEP C' DOC TREATED COPS
By PERRY CHIARAMONTE and CLEMENTE LISI
November 17, 2007 -- Twenty-three NYPD officers were treated by a Long Island
physician under investigation for spreading hepatitis by dipping syringes more
than once into medicine vials, officials say.
Dr. Harvey Finkelstein is accused of using needles multiple times on the same
patients and of possibly contaminating vials of medications when the syringes
were reinserted.
"While the risk of transmission of hepatitis and HIV from such exposure is very
low, we strongly advise members of the service who may have received treatment
from this practitioner during the period to be tested for hepatitis B and C and
HIV," said Dr. Eli Kleinman, the NYPD's chief surgeon.
http://www.nypost.com/seven/11172007/news/regionalnews/hep_c_doc_treated_cops_55\
379.htm

New York State Department of Health (NYSDOH) Stops a World First U.S. - Egyptian
Collaborative Study on Hepatitis C and Blood Ozonation
New York, NY - Nov 17, 2007 (PRN): Recently coming to light is the involvement
of the New York State Department of Health (NYSDOH) in stopping a world-first
U.S. - Egyptian collaborative study on hepatitis C in Egypt.
According to one of its principals, Dr. Gerard Sunnen, the study, bringing
together the Egyptian National Research Centre (NRC) and Medizone International,
Inc., a US - based company, sought to evaluate new therapeutic options for
stimulating natural immune factors in fighting the disease. "Blood ozonation is
an innovative technique of interfacing blood with minuscule amounts of
ozone/oxygen mixtures that enhance natural cytokine and interferon production
for purposes of viral clearing. This process, if successful, could greatly
reduce the cost of current treatments for hepatitis C," states Dr. Sunnen. In
2002, the NYSDOH stopped the study. "It is a sad day for the some estimated 5
million Egyptian patients, and some 170 million worldwide," he added.
Hepatitis C (HCV) is a chronic affliction caused by a lipid-enveloped virus with
a high mutation rate. All pathogenic viruses with high mutation rates are major
threats to humanity because they are more likely to behave as they never had
before. HCV's wide genetic spectrum and mutational thrust are responsible for
its expanding prevalence base and its growing worldwide distribution. By some
estimates, hepatitis C world prevalence will reach a quarter billion in a few
years.
Hepatitis C preferentially invades the liver, but it can also affect other organ
systems, including the bone marrow and the kidneys. Progressive liver
destruction may lead to cirrhosis and liver cancer. Indeed, after 20 years,
about 25% of hepatitis C patients develop cirrhosis, and another 5% liver
cancer. Up to 20% of patients, however, conquer the disease, presumably due to
the adaptability and creativity of their immune systems.
The hepatitis C virus is spread by body fluid transmission. Like many other
viruses, its life cycle shows fluctuations of relative dormancy alternating with
viremic episodes when blood is virally flooded. It is estimated that in any one
viremic hepatitis C episode, up to 10 billion viral particles may be generated
daily. The immune system in hepatitis C is thus perennially challenged.
Clinically, in the first few years, hepatitis C is often manifested by vague
symptoms of fatigue, headache, and gastrointestinal malaise. Later on, the
extent of organ damage determines the severity of its symptom profile.
Medications for hepatitis C include interferons, which are natural cellular
products that activate neutrophils, macrophages, and natural killer (NK) cells,
and drugs that inhibit enzymes responsible for viral replication (e.g.,
ribavirin). Success rate is variable and relapses are common. Frequently, these
drug cocktails are poorly tolerated leading to discontinuation.
Blood ozonation may initially sound like a toxic process. It is not. Decades
ago, German clinicians thought that ozonation could clear blood of pathogens,
much as it does water. They devised methods of interfacing ozone with blood so
that its cellular elements (e.g., red and white blood cells, platelets) retained
their integrity. Immune models have surpassed this early notion of ozone's
direct viral clearance. In the miniscule doses in which ozone is administered to
blood, it is now firmly documented that blood ozonation stimulates immune system
components to produce natural interferons and cytokines capable of initiating
viral kill.
It may appear surprising--or even preposterous--to suggest that our own bodies
utilize endogenously-generated reactive oxygen molecules, one of which is ozone,
to destroy constantly invading microbes. A greatly underappreciated study from
the Scripps Institute in California found that ozone is indeed created by our
own white blood cells to function as a natural virucidal agent.
The prevalence of hepatitis C is variable in different regions of the world. In
the U.S., about 1% of the population is affected, an estimated 4 million
carriers. In Egypt, the prevalence rate is the highest in the world. Fully 20%
of the population is or has been afflicted by hepatitis C.
In view of this hepatitis C emergency, the National Research Centre (NRC) in
Cairo contacted Medizone International, a leader in ozone-based therapeutics.
Egyptian health authorities were interested in new therapeutic approaches for
hepatitis C, one being innovative technologies of oxygen/ozone administration.
With great enthusiasm, and hope, an NRC - Medizone investigative study was
designed, and officially named "Safety and Efficacy of Ozone in the Treatment of
Patients with Chronic Hepatitis C."
The study was to involve 66 patients. The main objectives of the study were to
measure and evaluate, among other things, hepatitis C viral load reduction with
blood ozonation, liver enzyme recovery, and clinical improvement, as measured by
scales of health and well-being
Officially, the investigators for this study were:
Principal Investigator: Professor Dr. M.Y. Estefan, M.D., MRCP
Clinical Team:
Prof. Dr. Mouchira A-Salam, M.D.
Prof. Dr. Said Shalaby, M.D.
Dr. Hala Zaki Raslan, M.D.
Dr. Seif W. Morcos, MRCP
Dr. Ibrahim M. Kamal, M.S.
Dr. Yasser A. El-Houssary, M.S.
Laboratory Team:
Prof. Shadia A. Ragab, M.D.
Prof. Mostafa El-Awadi, Ph.D.
Dr. Azza A. Ali, M.D.
Dr. Hanaa R. Mohamed, M.D.
Chemical Engineering Team:
Prof. Gizeen El-Diwany, Ph.D.
Dr. Maaly Khedr, Ph.D.
Statistics:
Dr. Emad El Din Samala, M.D.
Research Designer:
Prof. Dr. Maher Y. Estefan, M.D., MRCP
Study Progress Monitor: The Egyptian and Foreign Committees
Patronage: Egyptian Ministry of Health and Population
The study was well under way as regard the selection of participating patients
and the readying of NRC personnel and laboratory facilities where the study was
to take place. In 2002, however, through various actions -- and for reasons that
can, as of now, only be speculated -- the New York State Department of Health
(NYSDOH) stopped this study. As a result, millions of patients lost a unique
opportunity for better health care.
Furthermore, the fruits of this research would have extrapolated far beyond the
treatment of hepatitis C. Immune function enhancement is a bonus for a host of
diseases. In addition, it appears that those viruses that are lipid-enveloped
have increased vulnerability to ozone exposure. Ozone-based therapeutics,
administered via innovative technologies, could thus well complement current
treatment options for viruses such as hepatitis B, HIV, and influenza, among
others.
Promising future directions for ozone-based therapeutics also includes external
ozone applications for the enhanced healing of diabetic skin ulcers, all types
of poorly healing wounds, and war wounds.
For more information, contact:
Gerard Sunnen, MD
President, OZONICS INTERNATIONAL, LLC
200 East 33 Street, Suite 26J
New York, NY 10016-4831 USA
Tel. 1-212-6790679
Fax 1-212-6798008
Email: GSunnen@...
Website: http://www.Ozonicsint.com
http://www.pressreleasenetwork.com/newsroom/news_view.phtml?news_id=2314

Two liver transplants this month are first ever at Allegheny General Hospital
Saturday, November 17, 2007
By Joe Fahy, Pittsburgh Post-Gazette
Two patients who had liver transplants this month were the first to have the
surgery at Allegheny General Hospital.
Christine Berman, 28, of Robinson became the first patient to have a liver
transplant at the hospital Nov. 1, officials announced this week.
Another patient who had a transplant Nov. 8 also is recovering, said hospital
spokesman Dan Laurent. That patient's name was not disclosed.
Both surgeries were performed by Dr. Thomas Cacciarelli, director of liver
transplantation at the hospital, and Dr. Mark Roh, chairman of surgery.
Mr. Laurent emphasized Dr. Cacciarelli's experience in liver transplantation. He
also is the chief liver transplant surgeon at the VA Pittsburgh Healthcare
Center.
Allegheny General also has hired another liver transplant surgeon, Dr. Ngoc
Thai, formerly of the University of Pittsburgh Medical Center. Dr. Thai will
also perform transplants at Allegheny General after a noncompete provision of
his contract with UPMC expires June 30, Mr. Laurent said.
Allegheny General, which already performs heart, kidney and pancreas
transplants, announced plans to establish a liver transplant program last year
even though UPMC has one of the world's foremost liver transplant centers.
Mr. Laurent said Allegheny General annually refers 20 to 30 patients to other
hospitals for liver transplantation evaluation. Some have been served by
hospitals in other cities because their health insurance doesn't cover
procedures at UPMC.
Allegheny General hopes to keep those patients and attract others by offering an
alternative.
Traveling to another center for evaluation, particularly in another state, can
be a hardship for very sick patients, said Dr. Paul Lebovitz, director of
gastroenterology at the hospital.
"The ability to now meet their transplantation surgical needs is a tremendous
advantage."
More than 17,000 people in the U.S. are waiting for liver transplants, including
more than 1,400 in Pennsylvania, according to the United Network for Organ
Sharing.
Joe Fahy can be reached at jfahy@... or 412-263-1722.
http://www.post-gazette.com/pg/07321/834708-85.stm

Management of the Decompensated Cirrhotic Patient with HCV
Sakib K. Khalid, M.D.
Guadalupe Garcia-Tsao. M.D
(To see the figures and illustrations in this article, please download the pdf
version.)
Cirrhosis represents the end-stage of any chronic liver disease. The hepatitis C
virus (HCV), along with alcohol, is a leading cause of cirrhosis in the United
States. Cirrhosis leads to two major syndromes: portal hypertension and hepatic
insufficiency.
Additionally, peripheral and splanchnic vasodilatation with the resulting
hyperdynamic circulatory state is typical of cirrhosis and portal hypertension.
Cirrhosis can remain compensated for many years prior to the development of a
decompensating event. Decompensated cirrhosis is marked by the development of
any of the following complications: jaundice, variceal hemorrhage, ascites or
encephalopathy.
Jaundice results from hepatic insufficiency and, other than liver
transplantation, there is no specific therapy for this complication. It is
however important to recognize and treat superimposed entities (e.g., alcoholic
hepatitis, drug hepatotoxicity) that may contribute to the development of
jaundice. The other complications of cirrhosis occur as a consequence of portal
hypertension and/or hepatic insufficiency. Gastroesophageal varices result
almost solely from portal hypertension, although the hyperdynamic circulation
contributes to variceal growth and hemorrhage. Ascites results from sinusoidal
hypertension and sodium retention, which is, in turn, secondary to
vasodilatation and activation of neurohumoral systems. The hepatorenal syndrome
results from severe peripheral vasodilatation that leads to renal
vasoconstriction. Hepatic encephalopathy is a consequence of both portal
hypertension (shunting of blood through portosystemic collaterals) and hepatic
insufficiency.
Antiviral Therapy in HCV Decompensated Cirrhosis
There is limited published data regarding antiviral therapy in patients with
decompensated HCV cirrhosis. According to the 2002 NIH Consensus Conference
Statement, the primary therapy recommended for patients with decompensated liver
disease due to hepatitis C should be referral for liver transplantation [1].
Interferon and ribavirin therapy (the standard antiviral therapy for HCV) is
potentially dangerous in the setting of decompensated cirrhosis because of the
increased risk of life-threatening infections and the concern that treatment
might accelerate hepatic decompensation [2]. For these reasons, and due to
limited published literature, interferon therapy for patients with decompensated
cirrhosis due to HCV should be considered experimental and within the confines
of clinical trials [3]. However, the small percentage of patients with
decompensated cirrhosis who achieve a sustained virological response remain
virus-free post-transplantation, as opposed to universal recurrence of HCV
infection in those who are virus-positive pre-transplantation [4]. Therefore,
studies identifying the subgroup of patients with decompensated cirrhosis most
likely to benefit from therapy will be essential.
Management of Decompensating Events of Cirrhosis
Patients with decompensated cirrhosis should be referred for liver
transplantation. Until the time of transplant, therapy of the patient with
decompensated cirrhosis should focus on the management of each individual
decompensating event.
Acute variceal hemorrhage
Patients with cirrhosis who present with upper gastrointestinal hemorrhage
should have a diagnostic endoscopy performed to investigate the possibility of
variceal hemorrhage, as indicated by the presence of: active bleeding from a
varix, a "white nipple" overlying a varix, clots overlying a varix, or varices
with no other potential source of bleeding [5]. Bacterial infections occur
frequently in cirrhotic patients admitted with gastrointestinal hemorrhage and
the use of short-term (7 days) antibiotic prophylaxis has been shown to decrease
the rate of infections and to improve survival [6]. Although the recommended
antibiotic is norfloxacin administered orally at a dose of 400 mg twice a day
[7], equal efficacy has been observed with ciprofloxacin at a dose of 500 mg
orally twice a day [8]. In patients in whom it cannot be administered by mouth
or by nasogastric tube, systemic quinolones can be administered [9;10].
Endoscopic therapy, either sclerotherapy or variceal band ligation (VBL) is the
therapy of choice in the control of acute variceal hemorrhage [11], although it
has recently been suggested that pharmacological therapy (somatostatin,
terlipressin, octreotide) is as effective as endoscopic therapy [12]. The
association of pharmacological therapy, used as soon as the diagnosis is
suspected (even prior to endoscopy) and continued for 5 days after the diagnosis
is established, may represent the best approach to treatment [13]. However,
until the efficacy of somatostatin analogues is confirmed in ongoing trials, the
only pharmacological therapy available in the United States in the setting of
acute variceal hemorrhage is the combination of vasopressin and nitroglycerin
that can only be used for a maximum of 24 hours. Shunt surgery or the
transjugular intrahepatic portosystemic shunt (TIPS) is indicated in patients in
whom hemorrhage from esophageal varices cannot be controlled or in whom bleeding
recurs in spite of two sessions of endoscopic therapy (associated or not with
pharmacological therapy) [14]. In patients who bleed from gastric fundal
varices, failure of one sclerotherapy session should be enough to indicate the
performance of shunt therapy. Balloon tamponade should be limited to patients
with uncontrollable bleeding in whom a more definitive therapy (e.g., TIPS) is
being planned.
Prevention of recurrent variceal hemorrhage
Patients surviving an episode of acute variceal hemorrhage have a very high risk
of rebleeding and death. The median rebleeding rate in untreated individuals is
around 60% within one to two years from the index hemorrhage, with a mortality
of 33% [15]. Patients who have recovered from an episode of acute variceal
hemorrhage and who have had no evidence of hemorrhage for at least 24 hours and
in whom pharmacological therapy for the control of acute variceal hemorrhage has
been discontinued should be considered candidates for this prophylactic therapy.
Pharmacological therapy with a combination of ?-blockers and nitrates or
endoscopic therapy with VBL are effective therapies in the prevention of
variceal rebleeding. Both therapies appear to be equivalent and the choice will
depend on factors such as expertise, compliance, tolerance and patient
preference [16-18]. Notably, patients in whom portal pressure (as determined by
the hepatic venous pressure) can be reduced significantly with pharmacological
therapy have the lowest risk of rebleeding and the greatest survival benefit
[16]. In patients who re-bleed on pharmacological therapy or on EVL, the
combination of EVL and pharmacological therapy should be considered [19]. TIPS
is only indicated in patients in whom rebleeding recurs despite combined
endoscopic and pharmacological therapy. In patients who are surgical candidates,
shunt surgery can be considered even prior to TIPS in centers where the
expertise is available.
Management of spontaneous bacterial peritonitis (SBP)
SBP is an infection of ascites that occurs in the absence of a contiguous source
of infection (e.g., intestinal perforation, intraabdominal abscess). The
prevalence of SBP in hospitalized cirrhotic patients ranges between 10-30%. The
diagnosis should be suspected in any patient with ascites who develops local or
systemic signs of infection, encephalopathy or renal dysfunction and the
diagnosis confirmed with the presence of an ascites polymorphonuclear (PMN)
count
antibiotics, mainly cefotaxime or another third generation cephalosporin
(ceftriaxone, ceftazidime) or the combination of a b-lactam/b-lactamase such as
amoxicillin/clavulanic acid [7]. The intravenous preparation of
amoxicillin/clavulanate is not available in the United States and therefore the
combination of ampicillin/sulbactam could be used instead. In patients with
community-acquired SBP, no encephalopathy and a normal renal function, orally
administered quinolones with a high bioavailability (ofloxacin, levofloxacin)
are an acceptable alternative [20], provided that the local prevalence of
quinolone-resistant organisms is low. In patients with renal dysfunction, either
at baseline or during treatment, plasma expansion with albumin should be used as
an adjunct to therapy [21]. Treatment should be administered for a minimum of 5
days, preferably for 8 days. A control paracentesis performed 48 hours after
starting therapy is generally necessary to assess the response to therapy and
the need to modify antibiotic therapy and/or to initiate investigations to rule
out secondary peritonitis. In the presence of an obvious clinical improvement,
control paracentesis may not be necessary.
Prevention of recurrent SBP
In patients who survive an episode of SBP, the one-year cumulative recurrence
rate is high, at about 70%. It is therefore essential that patients that who
survive an episode of SBP be started on antibiotic prophylaxis to prevent
recurrence prior to discharge from the hospital. Long-term prophylaxis with oral
norfloxacin at a dose of 400 mg every day (or 250mg/day of ciprofloxacin
everyday) has been shown to be very effective in preventing recurrent SBP [22],
and is therefore indicated in patients who have recovered from an episode of
SBP. The once a week use of quinolones has been shown to be less effective and
to have a higher development of quinolone-resistant organisms compared to daily
norfloxacin [23] and is therefore not recommended. Prophylaxis should be
continuous until disappearance of ascites (i.e., patients with alcoholic
hepatitis) or transplant. In patients intolerant to quinolones (a rare event),
prophylactic therapy with trimethoprim/sulfamethoxazole can be recommended.
Long-term prophylaxis is currently not recommended in patients with ascites who
have never had SBP, independent of the presence or not of refractory ascites
and/or a low ascites protein content [7].
Management of ascites
Ascites is one of the most frequent complications of cirrhosis. In compensated
cirrhotic patients, ascites develops at a 5-year cumulative rate of about 30%.
Patients with new onset ascites and normal renal function, in whom spontaneous
bacterial peritonitis has been ruled out, should receive treatment with sodium
restriction and/or diuretics. Patients with a small amount of ascites and a
reasonable urinary sodium excretion (
restriction alone. Patients with moderate/tense ascites and avid sodium
retention should be treated with sodium restriction and diuretics. In patients
who decrease food intake because of the non-palatable salt-restricted diet, it
is preferable to liberalize sodium intake and implement measures to increase
sodium excretion through the use of diuretics, rather than to compromise
nutrition. The preferred diuretic schedule is to initiate therapy with
spironolactone alone at a single daily dose of 100 mg and to increase it in a
stepwise fashion to a maximum of 400 mg/day. If weight loss is not optimal or if
hyperkalemia develops, furosemide is then added at an initial single daily dose
of 40 mg, increased in a stepwise fashion to a maximum of 160 mg/day [24]. In
order to minimize the rate of complications, weight loss in patients without
edema should be maintained at a maximum of 1 lb/day (0.5 Kg/day), while in
patients with edema a weight loss of 2 lb/day (1 Kg/day) is allowable. In a
hospitalized patient with moderate/tense ascites in whom other complications
have been resolved, it is reasonable to initiate therapy with total paracentesis
with concomitant albumin infusion followed by the administration of diuretics,
as this will accelerate discharge from the hospital. Serial monitoring of
urinary sodium is unnecessary in patients who are responding adequately to
diuretics, as assessed by daily weights.
In cirrhotic patients with ascites who fail to respond to diuretics or who
present complications that preclude the administration of adequate doses of
these drugs (refractory ascites), repeated large volume paracenteses plus
intravenous albumin (LVP+A) is first choice. Albumin is infused at a dose of 6-8
g per liter of ascites removed. In patients in whom <5L are being removed,
synthetic plasma expanders can be used instead of albumin [25] and it has been
suggested that plasma volume expansion may not be necessary in this situation.
Sodium restriction and diuretics should be used concomitant to LVP. TIPS has
been compared to LVP+A in two large multicenter trials [26;27] and, although
associated with a slower recurrence of ascites, TIPS is associated with higher
rates of severe encephalopathy and no differences in mortality. Therefore, as
mentioned in a recent consensus conference, TIPS should be relegated to patients
with refractory ascites who require very frequent sessions of LVP (
month) and in whom a favorable post-TIPS evolution can be predicted, i.e.,
patients with a Child score of <12 points [28].
Treatment of hepatorenal syndrome (HRS)
HRS is the result of extreme vasodilatation with an extreme decrease in
effective blood volume that leads to maximal activation of vasoconstrictive
systems, renal vasoconstriction and renal failure. HRS has been divided into
type 1 and type 2. Type 1 HRS is characterized by rapidly progressive renal
failure with a doubling of serum creatinine to a level greater than 2.5 mg/dl or
a halving of creatinine clearance to less than 20 ml/min in less than two weeks.
The prognosis of type 1 HRS is extremely poor with a median survival of about 2
weeks [29]. In type 2 HRS serum creatinine is greater than 1.5 mg/dl and/or
creatinine clearance is less than 40 ml/min but renal failure is more slowly
progressive and it has a better prognosis. The definitive treatment for HRS in
patients with cirrhosis is likely to remain liver transplantation. Anecdotal
studies show that vasoconstrictors together with albumin or TIPS may be useful
in reversing HRS but this remains to be confirmed in randomized controlled
trials.
Treatment of hepatic encephalopathy (HE)
As recently defined in a consensus conference [30], HE reflects a spectrum of
neuropsychiatric and psychometric test performance abnormalities occurring in
patients with significant liver dysfunction after exclusion of other known brain
diseases. The initial management of acute, episodic, HE involves two steps. The
first and primary step is the identification and correction of precipitating
causes [31]. Careful evaluation should be performed to determine the presence of
hypovolemia, gastrointestinal bleeding, infections, including SBP, intake of
sedatives or tranquilizers. The second step is the administration of lactulose
(orally or by enema). Patients with chronic HE should be treated with oral
lactulose at a dose adjusted to obtain 2-3 soft bowel movements/day. In patients
with chronic HE who are not tolerant or do not respond to lactulose, the
addition of neomycin (starting at 1-3 g per day in 3 doses) or metronidazole
(starting at 250 mg PO BID) may be of benefit. Long-term protein restriction
should be avoided and a protein content of 1-1.5 g/kg/day protein diet is
recommended. Protein from dairy or vegetable sources may be preferable to
animal-derived protein.
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furosemide in the treatment of moderate ascites in nonazotemic cirrhosis. A
randomized comparative study of efficacy and safety. J Hepatol 2003, 39:187-192.
25. Gines A, Fernandez-Esparrach G, Monescillo A, Vila C, Domenech E, Abecasis
R, Angeli P, Ruiz-del-Arbol L, Planas R, Sola R, Gines P, Terg R, Inglada L,
Vaque P, Salerno F, Vargas V, Clemente G, Quer J C, Jimenez W, Arroyo V, Rodes
J: Randomized trial comparing albumin, dextran-70 and polygeline in cirrhotic
patients with ascites treated by paracentesis. Gastroenterology 1996,
111:1002-1010.
26. Gines P, Uriz J, Calahorra B, Garcia-Tsao G, Kamath P S, Ruiz-del-Arbol L,
Planas R, Bosch J, Arroyo V, Rodes J, for the International Study Group on
Refractory Ascites in Cirrhosis: Transjugular intrahepatic portosystemic
shunting versus repeated paracentesis plus intravenous albumin for refractory
ascites in cirrhosis: A multicenter randomized comparative study.
Gastroenterology 2002, 123:1839-1847.
27. Sanyal AJ, Genning C, Reddy K R, Wong F, Kowdley K V, Benner K, McCashland
T, North American Study for the Treatment of Refractory Ascites Group: The North
American Study for the Treatment of Refractory Ascites. Gastroenterology 2003,
124:634-641.
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ascites in cirrhosis: report on the consensus conference of the International
Ascites Club. Hepatology 2003, 38:258-266.
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Claria J, Rimola A, Arroyo V, Rodes J: Incidence, predictive factors, and
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Gastroenterology 1993, 105:229-236.
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the Members of the Working Party: Hepatic encephalopathy - Definition,
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http://www.hcvadvocate.org/hcsp/articles/Khalid_Garcia-Tsao-1.html

Blue Cross paid former CEO $16.4 million in retirement benefits
By RODRIQUE NGOWI
Associated Press Writer
BOSTON
Blue Cross and Blue Shield of Massachusetts paid its chairman, William C. Van
Fassen, $2.96 million in salary and incentives last year, along with an
additional $16.4 million in a lump sum retirement cash benefit, according to a
Thursday filing with state regulators.
Van Faasen's retirement package reflects the extraordinary work he did for the
company that lost $8 million on the year he became its CEO in 1992, turning it
into the state's largest health insurance company that generated $265 million in
profits in 2005 - the last year he worked as its chief executive officer, said
company spokesman Chris Murphy.
State Sen. Mark Montigny, who has led the Senate's insurance, health care as
well as ways and means committees, criticized the $7 billion nonprofit health
insurance company's executive compensation as "outrageous."
"There's a lot of room, to me, for abuse, particularly when we are in the
climate where we are trying to get people to sign up for the plan and Blue Cross
is the dominant player in the state," Montigny said, referring to the state's
mandatory universal health insurance program.
"The plans are not affordable and yet we have to tell struggling people 'buy
this plan from this charity, and by the way this is the kind of compensation
that their top executives make,'" said Montigny. "It's just wrong."
Murphy said the company has to offer an attractive package to compete with
public, private, for-profit and not-for-profit companies.
"We need to pay a competitive industry wage to get the best talent to run our
business," he said. "And this amount of money we are referring to was analyzed
and approved by several independent human resource firms."
Blue Cross and Blue Shield generated $110.4 million in profits in the third
quarter of this year, compared with $140.1 million in the period last year -
which included $51 million in tax gains from a favorable resolution to a dispute
with the IRS, Murphy said.
Current President and Chief Executive Officer Cleve Killingworth Jr. received
nearly $2.3 million in salary and incentives, together with $598,398 in benefits
and $58.043 in other unspecified compensation, according to the filing with
regulators.
Chief Financial Officer Allen P. Maltz received nearly $1.1 million in salary
and other income, $16,000 in benefits and $32,102 in other unspecified
compensation, according to the filing.
"What I am arguing is, if you are going to operate in this state as a charity,
you should be fully transparent, you should be seriously regulated and audited,
there should be compensation limits, lobbying limits, and there are none,"
Montigny said.
http://www.theledger.com/article/20071115/APF/711150992

A feel-good effort for a new kind of tourist
Leaders wager $125,000 to attract medical tourists
By LIZ FLAISIG, The Times-Union
In the past five years, Jacksonville's economy has gotten a $5.2 million boost
from health and medical industry meetings.
More money is pumped into the area when patients come to the Mayo Clinic, Shands
Jacksonville and other high-profile hospitals.
On Thursday, the city, its tourism agency and the local medical community
unveiled a combined effort to capitalize on this growing industry called medical
tourism.
"Jacksonville: America's Health Center" is the slogan that will launch the
$125,000 branding campaign created by the Dalton Agency for Visit Jacksonville.
Patients and their families, medical associations and others who hold meetings,
as well as medical product manufacturers, are the target markets for the
campaign. Specific geographic areas from which to attract patients haven't been
identified yet, said Jim Dalton, president and CEO of the Dalton Agency.
Dalton presented the campaign in a meeting at the Hyatt Regency Jacksonville
Riverfront hotel. Its preliminary advertisements promote Jacksonville's natural
surroundings, such as one showing a family walking together in the woods. At the
top of the frame is a tongue depressor with "open wide and say aaaaaaaaahhh" on
it.
The marketing and advertising push will begin in January and be tied to Visit
Jacksonville's new Web site, which also debuts at the beginning of the year. A
steering committee of tourism, medical and university professionals will help
guide the effort.
Funding for the campaign will come from $100,000 of Visit Jacksonville money,
available after the tourism agency's marketing budget was increased earlier this
year by the Duval County Tourist Development Council.
Major medical facilities will fund another $25,000 for the campaign by paying
$5,000 each to be "partners."
As partners, they will be featured prominently on the Web site, used in
advertisements and have access to use of the logo and slogan.
Other membership categories in the initiative - participants and affiliates -
won't have associated fees. Any business related to the medical or tourism
industries can be participants who will have listings on the Web site and in
brochures. Health care and medical businesses will be affiliates, who will have
those listings and use of the logo.
Because the medical tourism site will be combined with Visit Jacksonville,
visitors coming to the city for medical treatment or business will be able to
schedule travel arrangements online, including airplane and hotel reservations
and tickets to local attractions.
Mayor John Peyton told the group the city must capitalize on the strength of its
medical industry and the opportunity its tourism presents.
Whether "by accident or a real smart strategy," Peyton said Jacksonville has the
opportunity to grow its medical tourists.
"People want to live longer and feel better," Peyton said.
liz.flaisig@... , (904) 359-4640
http://jacksonville.com/tu-online/stories/111607/bus_218100537.shtml

In Florida, Addicts Find an Oasis of Sobriety
By JANE GROSS
Published: November 16, 2007
DELRAY BEACH, Fla. - Whitney Tower, 56, a scion of the Whitney, Vanderbilt and
Drexel fortunes, squandered his trust fund and sold family treasures to support
a $1,000-a-day heroin habit before landing in a tough-love facility near here
seven years ago and never leaving. "If I went back to New York I'd be dead in
two weeks," he said.
In some ways Mr. Tower, who spent three decades in and out of treatment, remains
a creature of his pedigree. He favors foppish linen suits and drops names of the
fast crowd he once ran with.
But his social life these days is dinner at home with sober friends who have
settled here in what experts consider the recovery capital of America. He is
studying addiction counseling, and he works as an unpaid intern at a local drug
treatment center.
Delray Beach, a funky outpost of sobriety between Fort Lauderdale and West Palm
Beach, is the epicenter of the country's largest and most vibrant recovery
community, with scores of halfway houses, more than 5,000 people at 12-step
meetings each week, recovery radio shows, a recovery motorcycle club and a
coffeehouse that boasts its own therapy group.
Recovery communities are springing up outside the walls of rehab centers for
alumni seeking the safety in numbers.
The prototype community is in Minnesota, near the Hazelden clinic. But
recovering substance abusers are also sinking roots in Arizona, Southern
California and the Gold Coast of Florida - places with more sizzle and better
weather. Lindsay Lohan spoke hopefully of finding eternal rehab in the Wasatch
mountains of Utah, near Provo, where some graduates of her latest drug treatment
center have moved.
Delray Beach is in a class by itself, experts say, because of its compact
geography and critical mass of recovering addicts who cross paths daily in the
shops and bistros along Atlantic Avenue. They fly beneath the radar of tourists
oblivious to telltale signs of addiction, like unapologetic chain smoking. But
they see one another everywhere:
On the patio at Starbucks, reading the "Big Book," the bible of Alcoholics
Anonymous. At the Longhorn restaurant, pushing tables together for Friday night
gatherings. At the Crossroads Club, the headquarters for 115 12-step meetings a
week, where gossip is of romance between recovering addicts, overdoses, suicides
and friends who have successfully moved back home.
"This community is one big helping hand that is always open," said Mike Devane,
a new halfway house owner, who lost his job and family in New Jersey before
coming south five years ago to get sober.
This society-within-a-society gets mixed reviews from addiction experts. A few
find it insular and cultish. "Cutting off contact with the outside world, is
that a sign of mental health?" asked Stanton Peele, a psychologist and author
who challenges much conventional wisdom in the field.
But many more experts note that a recovery community like Delray Beach may
provide a promising environment for certain addicts. While such communities have
not been studied, there is consensus that substance abuse is a chronic and
relapsing disease, comparable to diabetes or high blood pressure. It thus
requires permanent lifestyle changes that may be easier in a new environment.
Relapse rates range from 90 percent, for short treatment programs with no
follow-up care, to 40 percent when treatment is comprehensive and long-lasting.
And even then, new research shows that sustained addiction can lead to changes
in the brain that make relapse all but inevitable, experts say. Success, for
those entrenched addicts, is measured by longer and more productive periods of
sobriety and shorter and less damaging periods of substance abuse.
A. Thomas McLellan, director of the Treatment Research Institute at the
University of Pennsylvania, said the way to judge the wisdom of retreating to a
bubble of sobriety like Delray Beach was to ask: "Where were they before? This
may be their best available option."
Harold Jonas, 52, kicked a heroin habit two decades ago in this beachfront city,
far from his native Philadelphia, and decided to stay. He married a fellow
addict, raised a family, earned a doctorate and opened a halfway house for
substance abusers making the transition from residential care to independent
living.
Steadily, Dr. Jonas and his wife, Dawn, expanded their cottage industry. They
organized an association of halfway house owners and opened KoffeeOkee, the
coffeehouse-karaoke bar.
Mr. Devane was among 20 Delray Beach residents who gathered at the cafe one
recent night for a weekly counseling session. One "normie" - their word for the
65,000 year-round town folk - wandered in unawares and was allowed to stay.
First-timers sat at the periphery of the circle, avoiding eye contact with
others.
But Jeannie Saros, a onetime addict and now a therapist who sees private
patients in a cottage behind KoffeeOkee, soon had everyone sharing closely
guarded secrets. One admitted resuming a "sick relationship" with a drug-abusing
lover. Another, although sober, said she continued to steal from friends. Mr.
Devane, his voice a whisper, confessed to having been a bad father.
Many here have lost custody of their children. Among them is Jennifer Boeth
Whipple, 53, a journalist who arrived in the clutches of alcoholism in 1998. Ms.
Whipple said she "took to heart" - during her third effort at rehabilitation -
"that some people have to change their lives completely to maintain sobriety."
So she stuck around, following a carefully phased program, known as the Florida
Model, from residential treatment to a halfway house and a "recovery job" at
Home Depot. Eventually she bought a condominium and worked for an art dealer.
For six years, Ms. Whipple said, she "felt very safe here, surrounded by people
who'd been through what I'd been through" - detoxing in the same roach-infested
apartments, cycling through recovery centers familiar to New Yorkers, like
Silver Hill or Four Winds.
Then a year ago, "after I'd gotten my sea legs," Ms. Whipple returned to New
York City, where her son lives with his father. All is well, she said, except
she is lonely. She talks to her friends often. "At times," Ms. Whipple said,
"Florida still beckons."
It is difficult to count the recovery population here because only residential
treatment beds are licensed by the state. As of Nov. 1, almost 3,500 people were
being treated as in-patients in Palm Beach, Broward and Miami-Dade Counties in
southeastern Florida, by far the largest concentration in the state.
Halfway houses, by contrast, are unregulated. But Dr. Jonas said there were
about 1,200 halfway house beds in this city alone. With rent averaging $175 a
week, these businesses generate almost $11 million a year.
Low-wage jobs for people in recovery are plentiful in a tourist economy.
Recovering addicts make smoothies at Ben and Jerry's, and sell housewares at
Crate and Barrel. Among the current worker bees are an executive chef and a
professional baseball player, both busing tables.
"Just about every business in town has at least one of us, whether they know it
or not," said Susan Miller, sober for 13 years and executive director of the
Crossroads Club, command central for newcomers seeking meetings, housing,
transportation - for those with too many D.W.I.'s to drive - and legal help.
Typically modest bungalows, halfway houses provide structure and supervision -
curfews, random urine tests, the requirement that tenants have jobs and attend
meetings. Still, unscrupulous owners prey on tenants by "flipping" the same bed,
insisting on several months' rent up front, then evicting someone for rules
violations and re-renting the room. Some owners also put rule-breakers out on
the curb, with no alternative housing, which can lead to crime and an outcry
from neighborhood homeowners.
A movement to ban halfway houses in residential neighborhoods has so far been
unsuccessful, with courts ruling that such restrictions violate the Americans
with Disability Act. The association of halfway-house owners is trying
self-regulation, and its members are required to find a placement for an evicted
tenant, often at a discounted rate in a motel Dr. Jonas owns.
A bigger concern, said Detective Gary Martin in the Palm Beach County Sheriff's
Office, is drug overdoses - 218 in 2006 and 241 during the first nine months of
2007. "I consider close to one overdose every 36 hours a big problem," Detective
Martin said.
The overdoses highlight the high risk of relapse. Indeed, even owners of halfway
houses fall off the wagon, leaving tenants like Katrina W., 28, clean for a few
months of a heroin and crack cocaine addition, suddenly in charge. One resident,
testing Katrina's limits, came home smoking crack and blew smoke in her face.
Katrina got the resident out without incident and managed to hold on to her
fragile sobriety.
Sobriety is the tightrope addicts walk, even years into recovery. Claire Condon
arrived here at age 19, a six-foot beauty withered to 100 pounds by heroin. But
in Delray Beach she got sober, got a modeling job, a "normie" boyfriend, a
condominium and two dogs.
Then, a year ago, at age 27, everything unraveled. Ms. Condon battled
depression, smoked marijuana to take the edge off her misery, then upgraded to
cocaine and OxyContin. She text messaged friends from recovery, urging them to
stay away.
"I didn't want to be a tornado in their lives," she said. "But every time they
heard someone died, they thought it was me."
Ms. Condon resumed treatment, however, and returned to her regular meetings at
the Crossroads Club. Back at Square 1, she still hopes to leave here one day.
She misses the mountains and the seasons of Connecticut.
"That's my goal," Ms. Condon said. "But what pulls on my heart is the people
here, the connections I made at a time of desperation."
http://www.nytimes.com/2007/11/16/us/16recovery.html?_r=2&ref=health&oref=slogin\
&oref=slogin

Rheumatoid Arthritis Patients Have Increased Risk of Stroke: Presented at ACR
By Ed Susman
BOSTON, MA -- November 9, 2007 -- Researchers said that people living with
rheumatoid arthritis have a 67% greater risk of suffering a stroke than the
general population -- suggesting that the disease causes an extra 1,000 strokes
a year in the United Kingdom, where the study was conducted.
"If the same were true of the population of the United States, then an
additional 5,000 strokes might occur each year due to rheumatoid arthritis,"
said Christopher Edwards, MD, Consultant Rheumatologist and Honorary Senior
Lecturer, Department of Rheumatology, Southampton General Hospital, Southampton
University Hospitals NH Trust, Southampton, England, United Kingdom.
Dr. Edwards accessed data in the United Kingdom General Practice Research
Database and determined that the incidence of stroke among those 7 million
persons whose medical records were available for analysis was 2.94 per 1,000
persons per year.
"This gives a hazard ratio of 1.67," said Dr. Edwards during a press briefing at
the American College of Rheumatology (ACR) Annual Meeting. He said the finding
reached statistical significance at P <.001.
"Stroke appears to be another consequence of the detrimental effects of
long-term systemic inflammation that comes with rheumatoid arthritis," he said.
"The effect was still present after controlling for other risk factors including
lifestyle factors, hypertension, diabetes, and the treatment of those risk
factors."
Patients who took corticosteroids had a further increase in stroke risk, but
that was not the case with disease-modifying agents. Dr. Edwards said, however,
that the data appeared to show a nonsignificant trend toward more risk in the
patients taking methotrexate.
Dr. Edwards said his data suggest that inflammation that occurs in rheumatoid
arthritis is the culprit in raising the stroke rates and therefore patients
should work to control inflammation and protect the rest of the body against
collateral damage.
"Despite the traditional concentration on joint damage, rheumatoid arthritis is
a systemic disease with widespread effects on other parts of the body," he
noted.
The study received no industry support.
[Presentation title: The Risk of Stroke in Patients With Rheumatoid Arthritis
Compared to the General Population. Abstract 684]
http://www.docguide.com/news/content.nsf/news/852571020057CCF68525738E006968D7?O\
penDocument&id=638FB949611A029785256916000DF34C&c=&count=10

Like a mall for Medicare
Tropicana Field is filled to its lopsided brim with Medicare managed-care
vendors ready to enroll.
By KRIS HUNDLEY, Times Staff Writer
Published November 16, 2007
ST. PETERSBURG - WellCare Health Plans was handing out back-scratchers. CarePlus
had coffee and doughnuts. CitrusCare was pouring orange juice. And Humana pulled
out all the stops with exercise guru Richard Simmons, who tossed out kisses and
off-color comments.
Welcome to the Medicare gold rush, which began in earnest Thursday during the
Senior Friendly Extravaganza at Tropicana Field. Although the free event
featured dozens of vendors with senior-centered services vein surgery, anyone?
and Frankie Avalon crooning Venus, at front and center were major Medicare
managed-care companies.
Their timing was flawless: Thursday marked the start of open enrollment for 2008
Medicare plans. And every Medicare beneficiary who walked into the expo
represented potential revenues of more than $800 per month in government
reimbursements.
The competition is fierce: There are more than 150 drug and health plans to
choose from in the Tampa Bay area. Seniors have until Dec. 31 to pick a
standalone prescription drug plan. And they have until March 31 to switch plans
if they enroll in a Medicare Advantage program.
People who are satisfied with their existing plans do not have to do anything to
maintain their coverage. And that seemed to be the sentiment of the day among
expo visitors.
"Why jump around if you're happy?" asked Roselyn Oursler, 65, of Lutz, who
belongs to a Humana plan.
Although companies are prohibited from making cold calls, seniors were freely
trading contact information with sales reps Thursday in exchange for free
T-shirts or pill boxes. At the bottom of one company's "registration form" was
fair warning: "A salesperson may call."
The sales season this year is particularly interesting because one of the
biggest local players is under federal and state investigation. WellCare of
Tampa was raided on Oct. 24 by more than 200 investigators who seized documents
and electronic data.
The nature of the investigation is not known, and WellCare said the incident is
not interfering with customer service or claims payments to its more than
1-million Medicare members.
Conversations with several expo visitors suggested that seniors are far less
concerned about the cloud over WellCare than might be imagined. Florence Davis,
66, of Palm Harbor has been on WellCare for two years and intends to stay.
"So many businesses have issues with certain things, but it doesn't mean the
whole company is bad," she said. "I feel pretty confident they'll be okay."
While WellCare may be able to retain happy customers, it may not be easy to
attract new ones. Gary Niles, 67, of Brooksville is considering alternatives to
his Humana plan. But WellCare is not one of them.
"When the government starts checking people out, stay away from it," he said.
Kris Hundley can be reached at hundley@... or (727) 892-2996.
http://www.sptimes.com/2007/11/16/Business/Like_a_mall_for_Medic.shtml

This is dedicated to you Dorothy........ it is on the comment page........
Quotes in stars *Fear of infecting other family members is constant. Bookstaver
puts a rubber band around his drinking glasses so his children will know not to
drink from that glass.*
He certainly doesn't know very much about his own disease or he would know that
it is ONLY spread by blood to blood transmission not by sharing a drinking
glass!!
*But he cannot go out to eat with his wife because he never knows when the
disease will flare up and he will become sick. Family vacations are out of the
question, Bookstaver said*
They make pills for nausea and I hope he asks his doctor for some. Restaurants
have rest rooms if one needs to vomit. Putting off dinners, vacations or
anything else that you might want to do in life is ludicrous. Those of us with
Hepatitis C (and I already have cirrhosis) should be living each day to the
FULLEST and keeping our glasses half full.
I have probably had Hepatitis C for 40 years. Someone who *thinks* they
acquired it a mere three years ago is either exaggerating any symptoms he thinks
he has or is padding things for a law suit!
While I agree that the Doctor should be held accountable for any universal
precautions that he failed to take - I am also getting completely fed up with
people who think lawyers and $$ are the answer to all their problems. What is
becoming of this country?!?!?
Mr. Bookstaver is 49 years old. A baby boomer. Did he even snort a drug
ONCE in his life? Did he have a blood transfusion prior to 1992? Did he
serve in the military? Did he share a razor or toothbrush with someone?
Does he have a tattoo? Has he ever been incarcerated? If he is having as
many symptoms as he alludes to then he has had Hepatitis C since he acquired it
ON HIS OWN MANY years ago - not 3 years ago.
Most people with Hepatitis C do have a CLUE where they acquired it.
You should be tested for Hepatitis C if you:
* received a blood transfusion or solid organ transplant before July 1992
* were notified that you received blood from a donor who later tested positive
for hepatitis C.
* have ever injected illegal drugs, even if you experimented only one time many
years ago (or snorted any drugs)
* were a recipient of clotting factor(s) made before 1987
* have ever been on long-term kidney dialysis
* have had tattoos or body piercings
* had sexual activity that involved contact with blood
* have had vaccinations administered with pneumatic jet injectors
* are a veteran (especially Viet Nam)
* have shared razors, toothbrushes, nail clippers, tweezers, etc. with an
infected person
* are a health care worker exposed to needle sticks or first responders
* also 5%-10% of babies born to infected mothers will get Hepatitis C
* have ever been incarcerated
Hepatitis C patients outnumber HIV patients almost FIVE TO ONE! Hepatitis C is
the leading cause of liver transplants in the U.S. and 2/3 of patients will die
waiting for a liver because there are not enough to go around. Please sign your
organ donor cards!
Doctors do not test for Hepatitis C on a routine physical exam. Please ask your
doctor to test you if you have any of the risk factors or if you are concerned.
Remember that HIV dies when it hits the air but Hepatitis C can live in the air
on a variety of surfaces for up to 4 or 5 days so if a positive person is nicked
by nail clippers in a salon and then someone else is nicked with that same
clipper that is a blood to blood transfer! Just like picking up a bloody kleenex
from an infected person with a cut on your hand would be a blood to blood
transfer. Be careful, be safe and BE TESTED!

To: NIHPRESS@...
Sent: Friday, November 16, 2007 8:51 AM
Subject: FAMILY MEMBERS OF PATIENTS WHO DIE IN THE ICU REPORT GREATER
SATISFACTION WITH COMMUNICATION AND INVOLVEMENT THAN FAMILY MEMBERS OF ICU
SURVIVORS
U.S. Department of Health and Human Services
NATIONAL INSTITUTES OF HEALTH NIH News
National Institute of Nursing Research (NINR) <http://www.ninr.nih.gov/
For Immediate Release: Friday, November 16, 2007
Contact: Ray Bingham, 301-496-0207, <e-mail: binghamr@...
FAMILY MEMBERS OF PATIENTS WHO DIE IN THE ICU REPORT GREATER SATISFACTION WITH
COMMUNICATION AND INVOLVEMENT THAN FAMILY MEMBERS OF ICU SURVIVORS
Family members of loved ones who died in the intensive care unit (ICU) tend to
be more satisfied with the care they and the patient received than family
members of ICU survivors, according to a study published in the November 13,
2007, issue of the journal "Chest". Family members of all ICU patients tended to
rate the physical care of the patient highly. But those of ICU decedents tended
to be more pleased with their involvement in decision-making and communication,
as well as the emotional support, respect, compassion, and consideration they
and the patient received, than those of survivors. This study was funded by the
National Institute of Nursing Research (NINR), a component of the National
Institutes of Health (NIH), along with funding from the Robert Wood Johnson
Foundation and the American Lung Association.
The ICU is a highly stressful environment for patients and their families. Most
ICU patients are unconscious or incapacitated. Their care involves constant
vigilance by skilled clinicians, complex technologies, and unfamiliar and often
frightening medical interventions, and the outcome is fraught with uncertainty.
For these reasons, family members are often closely involved in care decisions,
so the scope of ICU care has to include the whole family.
"Our research team has focused on improving the quality of care delivered to
critically ill patients and their family members," said J. Randall Curtis, MD,
MPH, the principal investigator of the study. "In one of our prior studies, we
noticed that families of patients dying in the ICU were more satisfied with the
ICU experience than families whose loved one survived their ICU stay. We found
this surprising and, therefore, we decided to further explore the reasons for
this difference."
"Most patients admitted to an ICU are very sick and near death. The ICU
clinicians are adept at using their skill and knowledge to try to save the
patient's life. As indicated by the survey, families appreciate this life-saving
care," said NINR Director Patricia A. Grady, PhD, RN, FAAN. "However, in the
pressure of the ICU, clinicians may overlook certain aspects of care and
communication that can help family members to better understand and be involved
with what is happening to their loved one."
The study involved several hospitals in the Seattle area. The researchers used a
24-item family satisfaction in the ICU (FS-ICU) questionnaire to survey 539
family members of ICU patients. The FS-ICU was divided into items focused on
satisfaction with patient-centered aspects of care and satisfaction with
family-centered aspects of communication and decision-making. Of the
respondents, 51 percent were from family members of ICU decedents, and 49
percent from family members of survivors.
Family members of the decedents tended to be Caucasian, older, and an adult
child of the patient, compared to family members of survivors. On 12
questionnaire items, the family members of decedents rated their satisfaction
higher than the family members of survivors; on the other 12 items no
differences were noted. There were no items that family members of survivors
rated higher. The largest differences of ratings occurred in the responses to
family-centered items: inclusion in decision-making; clinician communication;
emotional support; staff respect and compassion; willingness of staff to answer
questions; and consideration of family needs.
"Up to 20 percent of all deaths in the United States occur in or shortly after
an ICU stay. Many of these patients are surrounded by family members who
experience stress, fear, anxiety and depression," said Dr. Curtis. "The desire
for information and emotional support is a common theme among all ICU families,
regardless of whether the patient lives or dies. In fact, clinician-family
communication is possibly the most important factor driving family satisfaction
in the ICU."
"These findings do not necessarily indicate that dying patients in the ICU
receive better care, but they suggest that ICU clinicians may devote extra time
and attention to the needs of patients and their families when death is
imminent," said Dr. Grady. "This information can point to ways to improve the
ICU experience and decrease stress for all ICU patients and their families."
The primary mission of the NINR, one of 27 Institutes and Centers at the
National Institutes of Health, is to support clinical and basic research and
establish a scientific basis for the care of individuals across the life span.
For additional information, visit the NINR web site at <www.ninr.nih.gov
The National Institutes of Health (NIH) - The Nation's Medical Research Agency -
is comprised of 27 Institutes and Centers and is a component of the U. S.
Department of Health and Human Services. It is the primary Federal agency for
conducting and supporting basic, clinical, and translational medical research,
and investigates the causes, treatments, and cures for both common and rare
diseases. For more information about NIH and its programs, visit <www.nih.gov

Hepatitis C and Diabetes
Hi everyone. The last link I sent you didn't work right. There are only TWO
questions. Can you please take a moment and go to this link (again) and answer
the two questio