Psoriatic Arthritis List NEWSLETTER

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News & Views Newletter
edited by Jack Nicholas, cornishpro@aol.com

PSORIATIC ARTHRITIS NEWS AND VIEWS
VOL. 3 ISSUE 8 May 15, 2003
PSORIATIC ARTHRITIS MEDICAL NEWS

SOMETIMES PATIENTS ARE THE BEST GAUGE OF ARTHRITIS TREATMENTS
By Colette Bouchez HealthScoutNews Reporter

What's the best way for doctors to know if an arthritis medication is working?

Ask the patient.

That's the simple but important conclusion of a new, multi-center study that compared the effectiveness of a patient questionnaire to a laundry list of clinical observations and tests.

"Oftentimes it's the most simple things in medicine that produce the best results. And that seems to be the case when figuring out what works and what doesn't for these patients," says Dr. Theodore Pincus, lead author of the study that appears in the April issue of Arthritis and Rheumatism.

Although there's no universally accepted system of assessing a patient's response to treatments for rheumatoid arthritis, the most accepted method is a criteria established by the American College of Rheumatology for use during clinical trials of a drug.

Known as the ACR20, the criteria involves seven sets of measures that include detailed clinical observations of a patient's condition, including joint size and degree of swelling, as well as some detailed laboratory tests.

As good as the system can be, it is complicated, costly and time-consuming, and, doctors say, in many respects has little relevance in a clinical setting.

"The more complicated things get in assessing a patient's condition, the more room for error there is, particularly when the examination involves multiple joint measurements," says Pincus, a professor of medicine at Vanderbilt University in Nashville, where some of research took place.

The solution, Pincus says, may lie in one-page questionnaire to be filled out not by doctors, but by rheumatoid arthritis patients themselves, as they sit in their doctor's waiting room. The questions, which were adapted from the ACR20, focus on specific signs that predict how well a drug is working --- including a patient's overall well-being, level of pain and quality of life.

"We ask a patient, 'Can you turn on the faucet? How hard is it to open a door knob? Can you get in and out of your car?' The answers to these kinds of questions are much more meaningful when it comes to figuring out how this patient is really doing, in real life," says Pincus.

For Dr. Steven B. Abramson, the study represents a step forward in the standardization of diagnostic criteria that could ultimately help ensure that rheumatoid arthritis patients get the most out of their medical care.

"The ACR20 is an excellent criteria, but it really was not developed for clinical use, so it's not really that useful in a clinical setting," says Abramson, director of rheumatology at New York University Medical Center.

By streamlining the diagnostic criteria and allowing for a standardized system of assessing a patient's condition, Abramson believes the new questionnaire holds great promise for more efficient -- and maybe even less costly -- care.

"It would also be a big help in, for example, justifying to insurance companies why a particular patient may need a more expensive drug. The questionnaire would make it easy to show what works and what doesn't. And it's easy for everyone to interpret and understand," Abramson says.

The study looked at 480 patients diagnosed with rheumatoid arthritis, each of whom filled out the one-page questionnaire prior to having any treatment. The patients were then divided into three groups, with each one taking either a placebo, or one of the two arthritis medications known as leflunomide or methotrexate. At various intervals, their progress was monitored using either the more complicated ACR20 system or the new one-page questionnaire. The end result: The questionnaire was shown to be as accurate as the ACR20 in predicting the effectiveness of the medications. And it was equally effective at pinpointing quality of life issues affected by the disease and aided by the medications.

While Abramson says he's not certain doctors will implement the new questionnaire into their practice immediately, he believes it's "an important option worth considering."

SOURCES: Theodore Pincus, M.D., professor, medicine, Division of Rheumatology/Immunology, Vanderbilt University Medical Center, Nashville, Tenn.; Steven B. Abramson, M.D., director, rheumatology, New York University Medical Center and the Hospital for Joint Diseases, and professor, New York University School of Medicine, New York City; April 2003 Arthritis and Rheumatism

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STUDIES PILE UP EVIDENCE FOR EFFICACY OF BIOLOGICS
Peggy Peck Medscape Medical News 2003. © 2003 Medscape

(San Francisco) - In study after study, researchers delivered the same message here at the 61st annual meeting of the American Academy of Dermatology: biologics work.

"Biologics are here," Alice B. Gottlieb, MD, PhD, from the University of Medicine and Dentistry New Jersey (UMDNJ)-Robert Wood Johnson Medical School Clinical Research Center in New Brunswick, told Medscape. "These drugs are safe and effective, and they offer real hope to our patients."

Dr. Gottlieb is one of the forces that can be credited for the arrival of these new therapies: she is investigator or coinvestigator of a handful of studies.

One of these, a long-term, open-label study of efalizumab, demonstrate that it is safe and effective for treatment of severe psoriasis. The efalizumab study, which was supported by Genentech, Inc., enrolled 339 patients with at least a six-month history of moderate to severe plaque psoriasis. Criteria included a Psoriasis Area and Severity Index (PASI) score of at least 12.0 at screening with plaque psoriasis covering at least 10% of their total body surface area.

These patients received 12 weeks of therapy with 2 mg/kg of subcutaneous efalizumab with or without additional use of corticosteroids between days 56 and 84. Those who achieved at least a 50% improvement in their PASI score or an Overall Lesion Severity (OLS) grading of mild, minimal, or clear by the end of this treatment period were eligible to enter an open-label maintenance period, which was analyzed in up to five 12-week treatment segments.

Maintenance therapy consisted of up to 144 weeks of 1 mg/kg weekly subcutaneous injections of efalizumab. Patients whose PASI scores increased by 50% or more could have the dose increased to 2 mg/kg.

After the first 12 weeks of efalizumab therapy, 41% of patients achieved at least a 75% improvement in PASI score, and 82% achieved at least a 50% improvement. Of the original 339 patients, 290 went on to the second phase of the study.

Efalizumab therapy continued to provide efficacy at least as well as that obtained during the first 12 weeks for an additional 60 weeks. At week 60, 228 patients were still taking this therapy. Of these, 80% maintained 50% or more improvement in PASI, and 65% maintained a 75% or more improvement. Overall, mean improvement in PASI from baseline was more than 70%.

Adverse events most commonly seen with efalizumab were headache, nonspecific infections, fever, chills, nausea, vomiting, and myalgia. With time, the proportion of patients experiencing at least one adverse reaction dropped from 57% to 47%.

In other presentations, results of two phase III trials suggest that alefacept (Amevive) is as effective for severe psoriasis as it is for moderate disease. Barry Ticho, MD, PhD, a staff researcher with Biogen, Inc., which funded the study, presented the findings.

Patients who participated in these trials had a range of body surface area (BSA) involvement of 6% to 98%. The median BSA was 22% to 24% across the two trials. The median baseline PASI score ranged from 13.2 to 15.2 across the trials.

In one trial, the investigators gave subjects 7.5 mg of alefacept or placebo intravenously once weekly for 12 weeks. Patients received two courses of therapy with at least a 12-week hiatus between treatments. In the other trial, patients received either 10 or 15 mg of alefacept intramuscularly or placebo once weekly for 12 weeks, with a 12-week observation period afterward.

The physician global assessment (PGA) considered several factors, including severity, disability, and psychosocial impact. PGA scores showed that more than 80% of patients in these trials had moderate, moderate to severe, or severe disease. Regardless of baseline BSA, PASI, or PGA, the investigators found alefacept to be efficacious, Dr. Ticho said.

"More alefacept-treated patients received 75% or greater PASI reduction from the baseline at any time during treatment or follow-up than those who received placebo," he said. "Among patients who had a BSA exceeding 30%, 21% responded to alefacept 7.5 mg compared with 5% for placebo in the intravenous study. In the intramuscular study, 30% responded to 15 mg of alefacept compared with a 16% response for placebo."

"Alefacept was superior to placebo in all analyses that considered baseline disease severity," said Dr. Ticho. "These results are consistent with the original primary efficacy endpoint outcomes of the two phase III trials."

Gerald Krueger, MD, professor of dermatology at the University of Utah Health Sciences Center in Salt Lake City, addressed positive results from these and other studies in a seminar presentation. He explained that the biologic treatments are unique because they "pinpoint certain immune responses that are involved in psoriasis, not the entire immune system."

Dr. Krueger told Medscape that he expects most dermatologists "to convert most patients to biologic therapy." But Drs. Krueger and Gottlieb both noted that managing patients receiving biologic treatment is work-intensive for physician practices. "I expect that this will take more time initially and that is going to be unreimbursed time," said Dr. Krueger, "but I think this will evolve." He noted, for example, that "currently there is no code for Medicare billing for these infusions."

Dr. Krueger added that "the good news, too, is that patients will have a choice of in-office infusions versus at home injections."

Dr. Gottlieb added that "most patients who are offered a biologic want this treatment."

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VEIN CLOTS & ARTERIAL DISEASE

David Bloom, 39, co-anchor of NBC's "Today" weekend edition, recently died in Iraq of a pulmonary embolism. What apparently happened was that a blood clot (thrombus) formed in a deep vein in his leg. The clot then broke free (as an embolus) and traveled through the bloodstream to his lungs, where it caused respiratory distress and death.

The Research: In this study, ultrasound was done to measure atherosclerosis in the carotid artery (in the neck) in people with deep vein thrombosis. The people with deep vein thrombosis proved to have more carotid-artery disease, indicating that there is an association between deep vein thrombosis and atherosclerotic disease.

Perspective: It is thought this may be due to activation of the coagulation (clotting) system which contributes to both atherosclerosis and venous thrombosis. On a practical level, the statins (to lower cholesterol) and antiplatelet agents (to prevent clotting) may help prevent both the arterial and venous disease.

People who have developed blood clots in their legs -- a condition sometimes known as "economy class syndrome" -- appear to be more likely to have blockages in neck arteries that could increase the risk of stroke, researchers said Wednesday.

The findings suggest that clogging of the arteries, which can increase the risk of both heart attack and stroke, may encourage the formation of blood clots in the legs, they said, or it's possible that a third factor ups the risk of both conditions

Blood clots in the limbs, known as venous thrombosis, can develop during long-distance travel, earning the condition the name "economy class syndrome." In truth, any type of immobility or cramped condition can encourage blood clot formation, including extended time in bed after surgery. Pregnancy, cancer, estrogen use and a leg trauma or fracture can also increase the risk of the potentially life-threatening clots.

If a blood clot breaks free and travels to the lungs or brain, it can block blood flow and be rapidly fatal.

In the new study, Dr. Paolo Prandoni of the University of Padua in Italy performed ultrasounds on the carotid arteries of 449 patients, some of whom had been treated for venous thrombosis in the legs. The carotids are a pair of arteries found in the neck that are the main supply of blood to the brain.

The presence of plaque in the carotid arteries is considered a marker of artery disease throughout the body. However, none of the patients had symptoms of atherosclerosis, such as heart attack and stroke.

The researchers found that people who had been diagnosed with unexplained venous thrombosis were almost twice as likely to have a fatty plaque in a neck artery as those without the condition.

Among the study participants, 146 had developed venous thrombosis and had certain risk factors linked to the condition, such as cancer, leg trauma, or had been immobilized for more than one week. Another 153 patients had venous thrombosis that was considered "spontaneous", meaning they had no known risk factors of the condition.

In up to 30 percent of patients with venous thrombosis, doctors are unable to pinpoint a cause.

Overall, 47 percent of the patients with spontaneous venous thrombosis had at least one plaque in their carotid arteries, relative to only 27 percent of those with a risk factor for the condition.

At least one carotid artery plaque was detected in 32 percent of people who were free of venous thrombosis, the authors report. The findings are published in Thursday's issue of The New England Journal of Medicine. The fi ndings suggest that treating problems in the arter\

ies may help prevent the formation of blockages in the veins of the legs, the researchers conclude.

The relationship between atherosclerosis and venous thrombosis appeared even stronger when the researchers confined their analysis only to elderly patients, who studies show are at increased risk of both conditions.

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TIRED TO THE MAX -- AND THEN SOME Chronic fatigue syndrome may get new name to reflect scope of illness
By Linda Searing HealthScoutNews Reporter

Everyone knows what it's like to have a really bad case of the flu.

Think, then, what it also must feel like to have severe muscle and joint pain, headaches and sore lymph nodes. On top of that, you can't concentrate, and you're tired, really tired, most of the time -- a sense of exhaustion that just won't go away, no matter how long you sleep.

Some half a million Americans don't have to imagine it. They feel that way day after day, year after year.

Called chronic fatigue syndrome, this illness comes with a laundry list of symptoms and complaints, but an absence of absolute answers. Cause? Unknown. Diagnosis? Uncertain. Treatment options? Unclear.

But the effects? Very real.

"I missed an entire quarter of my junior year [in high school] because my mom couldn't get me out of bed in the morning," says 27-year-old Jessica Klein, of Sterling, Va. She dropped out of college for a while for the same reason, and earlier this year she had to quit her job as a self-described "computer guru."

"They wanted me to stay for 8 1/2 hours a day, plus a 45-minute commute, and I couldn't stay awake that long," says Klein, who has lived with this condition since she was 8 years old, although it wasn't diagnosed as chronic fatigue syndrome (CFS) until recently.

"It's not a normal tired," she says. "You run into a wall. You can't keep your head up or your eyes open." Klein describes it as "having bricks tied to your arms and legs, to your eyelids and the back of your head."

Sometimes, she says, she's afraid to fall asleep because she might not be able to get up in time for appointments.

The crushing tiredness apparently is universal, but other symptoms are not the same for everyone, says Leonard Jason, director of the Center for Community Research at DePaul University in Chicago and a member of the federal government's CFS Advisory Committee.

Some sufferers feel faint when they stand up, others have feverish symptoms, and for some, inflammation is the hallmark.

"When you look at a group of people with CFS, you never find 100 percent of the people with the same thing," Jason says.

Their illness takes different paths to the same endpoint: "They feel very, very sick, extremely sick, extremely debilitated," he says.

If the constant fatigue lasts for six months or more, with at least four other symptoms -- such as concentration problems, muscle pain, sore lymph nodes or disturbed sleep -- then a diagnosis of CFS is justified, Jason explains.

Still, no specific diagnostic tests for CFS are available, according to the U.S. Centers for Disease Control and Prevention, leaving doctors to diagnose by exclusion, meaning they resort to ruling out other possibilities.

Medical treatment generally focuses on relieving whatever a person's specific symptoms might be, but it also can include such options as exercise, lifestyle changes and behavioral therapy. Support groups abound.

For many, though, just getting diagnosed correctly is a struggle.

As Klein explains, "When we come in and start complaining, [doctors] basically think we're nuts, and that makes me mad."

Part of the problem may lie with the name -- chronic fatigue syndrome -- which many CFS experts say is inadequate and disparaging.

"Over 90 percent of the patient community hates that name," says Jason, adding that it prompts many doctors to "roll their eyes and not take it seriously."

"A name that sounds kind of technical or medical will have people feeling that the person is sicker than if the name is a little bit trivializing -- like saying you have 'chronic cough syndrome' rather than bronchitis or emphysema," says Jason, who has published research on the effect of the name "chronic fatigue syndrome."

However, CFS might not be the official designation for this illness much longer.

A group of scientists and patients has been working for the past two years to come up with a new name and expects to present it to the federal government's CFS Advisory Committee in the next few months. With committee approval, it would go on to the U.S. Secretary of Health and Human Services, Tommy Thompson, who can make it official, Jason says.

The new name -- neuroendocrineimmune dysfunction syndrome, or NDS -- better represents the illness, Jason says.

"The term is broad enough to encompass the most commonly reported symptoms [which] are associated with or referable to the neurologic, neuroendocrine and immunologic systems," states a paper prepared by the group proposing the name change.

Continued use of the term "syndrome" recognizes that it's a "collection of signs and symptoms that in their totality define this illness," the group says.

And, the group adds, that also should help NDS to gain acceptance by the medical community.

"If you feel you have a medical illness and are looking for strategies to help," Jason says, "you don't want to be referred to a psychiatrist."

SOURCES: Leonard Jason, Ph.D., psychology professor, director, Center for Community Research, DePaul University, Chicago, and member, board of directors, American Association for Chronic Fatigue Syndrome; Jessica Klein, Sterling, Va.

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FIBROMYALGIA TRIAL DESIGN, ENDPOINTS WILL BE DISCUSSED BY FDA-AAC

FDA's Arthritis Advisory Committee will discuss clinical trial design for fibromyalgia at its June 23 meeting.

The committee will consider clinical trial design issues, including important disease endpoints, for the development of therapies and treatments for fibromyalgia.

FDA presented fibromyalgia as a potential model during the Arthritis committee's July 29-30, 2002 meeting on general chronic pain indications.

Clinical trial design has been a problem in fibromyalgia studies. No drugs have been approved for the musculoskeletal pain/fatigue disorder.

Currently, the chronic pain condition is treated with a combination of drugs, including norepinephrine and serotonin antidepressants, sleep agents, NSAIDs, opioids, GABA agonists, and sodium and calcium channel blockers.

There are a number of agents in Phase II trials for fibromyalgia; products in the pipeline include estrogen, serotonin/norepinephrine agents, muscle relaxants, GABA and gamma hydroxybutyrate.

The committee will review an ankylosing spondylitis indication for Wyeth/Amgen's Enbrel on the following day.

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ANAKINRA SEEN SAFE IN TYPICAL RHEUMATOID ARTHRITIS PATIENTS WITH CO-MORBIDITIES

NEW YORK (Reuters Health) Apr 25 - Anakinra (Kineret; Amgen), a human recombinant form of interleukin I receptor antagonist, is safe and well tolerated in a diverse group of patients with rheumatoid arthritis (RA), study results indicate.

Anakinra alone or in combination with methotrexate has previously been shown to provide significant symptomatic improvement in RA patients and to slow disease progression.

To further characterize the safety of anakinra, Dr. Roy M. Fleischmann, who is with St. Paul University Hospital in Dallas, Texas, and colleagues randomly assigned 1414 "typical" RA patients with numerous comorbid conditions and a wide range of disease activity to daily subcutaneous injections of anakinra (100 mg) or placebo for 6 months. This was the initial phase of a long-term safety study.

In the April issue of Arthritis and Rheumatism, the investigators say it is "noteworthy" that the safety profile of anakinra in this study did not differ meaningfully from that observed in previous studies with more restrictive patient populations.

Most patients treated with anakinra developed mild to moderate skin rash at the injection site, consistent with previous studies of this and other injected biologic agents.

There were no between-group differences in the rates of adverse events, with the exception of serious infectious episodes, which were observed more often in the anakinra than placebo arm (2.1% vs. 0.4%). Again, the 2.1% figure mirrors that seen in past studies.

"Of most importance," Dr. Fleischmann said, anakinra posed "no problem in patients with cardiac disease and there was no development of opportunistic infections including tuberculosis in this study," as opposed to trials of other biologic response modifiers. Anakinra also does not appear to cause hepatic toxicity or serious hematologic events.

He and his colleagues conclude that anakinra is safe "in a diverse population of patients with RA, including those with comorbid conditions and those using multiple combinations of concomitant therapies."

Dr. Fleischmann also mentioned that this trial, which is ongoing, is the "largest safety study by far" of a biologic response modifier in a clinical setting intended to resemble typical rheumatology practice. Arthritis Rheum 2003;48:927-934.

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JOINT PAIN IGNORED IN U.S. NEW YORK (Reuters Health)

About one in five American adults with chronic joint symptoms have never seen a health care provider for the problem, according to a report released Thursday by the U.S. Centers for Disease Control and Prevention (CDC).

Of the estimated 47.5 million adults with chronic joint symptoms in 2001, 10.3 million had never seen a health care provider for treatment, the CDC found. Moreover, 2 million of these adults had symptoms serious enough to limit their daily activities.

Arthritis and chronic joint symptoms are leading cause of disability among Americans.

People who don't seek care for these aches and pains are "missing opportunities to limit joint damage and disability and to improve health and functional status," write Dr. J. Bolen and colleagues at the CDC.

Respondents were classified as having chronic joint symptoms if they reported having symptoms in the last year that were present on most days of at least one month. In addition, participants were asked whether they had received medical care for their symptoms and whether the symptoms limited their physical activity.

The researchers found that younger adults, men and Hispanic individuals were among those least likely to seek care. People with no health insurance or less education, as well as those in good overall health, were also less likely than others to have their joint woes treated.

Geographically, people living in southern or western states were least likely to seek care, while those in the Northeast got themselves to the doctor most often.

Their findings, based on a national telephone survey of more than 200,000 adults in 2001, are published in the CDC's Morbidity and Mortality Weekly Report.

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LONG-TERM STEROID USE INCREASES HEART DISEASE RISK
By Stephen Pincock GLASGOW (Reuters Health)

People on long-term treatment with high doses of anti-inflammatory steroids are up to three times as likely to develop heart disease than those who never take the drugs, Scottish researchers reported on Monday.

Professor Brian R. Walker from the University of Edinburgh and colleagues used a database of prescriptions given to 164,000 Scots over the age of 40 to measure the cardiovascular risks linked to corticosteroids.

Doctors are well aware that the significant benefits of the drugs against diseases like asthma and arthritis are accompanied by side effects that include obesity, diabetes and high blood pressure--all of which also increase the risk of heart disease.

But it is important to quantify this risk and know whether there is a dose threshold at which the effect would occur, Professor Walker told Reuters Health ahead of the British Endocrine Society meeting in Glasgow where the results were presented.

Nearly half of the study population had received at least one dose of steroids in the course of the 4-year study period. About 2% of the population were receiving significant oral doses--more than 7.5 milligrams of prednisolone or the equivalent daily.

For those who were not prescribed the drugs, the cardiovascular event rate was 19.2 per 1000 person-years, Professor Walker reported. For those exposed to steroids of any variety, that risk increased to 32.5 per 1000 persons-years.

"The worst case scenario are those who are exposed to the highest doses for the longest period and in that group, the relative risk is approaching 3 to 1," Professor Walker told Reuters Health. "These individuals might have a risk as high as 1-in-2 of an event over a 10-year follow-up period."

"How worried should those people be? Provided that their doctor has a good reason to be treating them then it's a matter of balancing up these risks against the benefits," the researcher said. People with life-threatening asthma or debilitating rheumatoid arthritis might consider the risks worth taking, he said.

"It does mean that we should be emphasising to doctors that they should be paying attention to cardiovascular risk," he added. "It is arguable given this information that we should be even more aggressive about treating blood pressure, lipids and diabetes in patients taking steroids."

At the other end of the scale, the researchers found no evidence of increased risk in people taking inhaled steroids for asthma or steroid creams for conditions like dermatitis. Copyright - Reuters Health 2003

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RHEUMATOID ARTHRITIS ASSOCIATED WITH ARTERIAL STIFFNESS
By Will Boggs, MD NEW YORK (Reuters Health) May 07

In rheumatoid arthritis patients, increased arterial stiffness may contribute to the increased cardiovascular mortality seen in this population, according to a report in the May Annals of the Rheumatic Diseases.

Previous epidemiological research has linked disease activity in rheumatoid arthritis with increased cardiovascular mortality, the authors report, but the cause of the link is unclear.

Because arterial stiffness is an independent risk factor of cardiovascular disease, Dr. Rainer Klocke from the Royal National Hospital for Rheumatic Diseases in Bath, UK and associates used pulse wave analysis (PWA) to assess the function of large arteries in 14 patients with late and deforming rheumatoid arthritis (but no evidence of cardiovascular disease or other risk factors) and in 14 healthy controls.

The mean augmentation index, a measure of arterial stiffness, was significantly higher in the rheumatoid arthritis patients (26.2%) than in the control group (18.9%), the authors report.

Rheumatoid arthritis patients also had a higher mean central blood pressure (91.3 mm Hg) than did the healthy controls (88.2 mm Hg), the report indicates.

Although the augmentation index correlated weakly with disease duration, the researchers note, there was no significant correlation with age, disease activity, erythrocyte sedimentation rate (ESR), or C-reactive protein (CRP) concentrations.

"It is important to realize that pulse wave analysis parameters depend on a number of variables," Dr. Klocke told Reuters Health, "which is probably the main reason that at present no clear cut-off levels of normal and abnormal values exist that would allow PWA-derived measures such as the augmentation index to be used for cardiovascular risk stratification both in rheumatoid and cardiovascular risk patients in general."

"Having said that," he continued, "given the ease of performance and 'bed-side' nature of this method, I would consider it a question of time until pulse wave analysis of parameters relating to arterial stiffness will be used in everyday clinical practice for cardiovascular risk stratification."

Also, the findings underline the importance of taking the well-established cardiovascular risk factors seriously in rheumatoid arthritis patients, Dr. Klocke concluded "This is clearly the most important message of this study...and it suggests, furthermore, that rigorous treatment of rheumatoid arthritis joint inflammation is not only important to prevent future joint damage and disability, but is also likely to reduce the risk of cardiovascular death." - Ann Rheum Dis 2003;62:414-418.

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The mind is like a parachute; it works much better when it's open.

Good Health to All,

Jack Nicholas
Newsletter Editor
Cornishpro@aol.com
Issue 2003 5/15/03 -8