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

PSORIATIC ARTHRITIS NEWS AND VIEWS
VOL. 3 ISSUE 9 May 31, 2003
PSORIATIC ARTHRITIS MEDICAL NEWS

HEALTHY, VIBRANT AGING - WHAT WORKS?
Erica Goode, M.D. University of California - San Francisco

"In ancient times, people understood universal energy and the numbers of heaven. They understood how to choose and control their diet. They knew what time to wake up and what time to go to sleep. They did not exhaust their minds and physical bodies. Their body and mind were harmonized, which meant they could live for over 120 years." - Chi Po, Scholar to Huangdi, the Yellow Emperor of China

No one can say for sure what healthy aging is. With the average age of death advancing in the United States, the focus often shifts to quality of life, especially when illnesses emerge and we feel challenged to reconsider our relationship to our bodies.

One lovely example of a healthy older person is that of Belle, a 109-year-old African-American woman from rural Texas who lived alone in a cabin without running water until the ripe old age of 100. At that time, she moved into a Houston nursing home. She is lean, alert, amusing and reasonably active. She had none of the "advantages" in terms of supplements, skin creams, spa retreats, surgery and the myriad other "youth-enhancing behaviors" that many people pursue.

What we know about the characteristics of the healthy elderly comes from studies like that reported by Dr. Albert Rosenfeld, who summarized the findings of a l990 survey of 1,200 centenarian Social Security recipients.

Dr. Rosenfeld said, "It was clear that, though these individuals worked hard and enjoyed their work, there was a marked lack of high ambition. They had tended to live relatively quiet and independent lives, were generally happy with their jobs, their families, and their religion, and had few regrets. Nearly all expressed a strong will to live and a high appreciation for the simple experiences and pleasures of life."

Another interview study conducted by Dr. Stephen Jewett as reported by Deepak Chopra, included 79 people of 87 years of age or more. Jewett found no particular "longevity personality" per se, and stated that subjects could be "selfish, sarcastic, and unsociable." The common threads were an ability to be self-sufficient, to possess a superior native intelligence, and a keen interest in current events, along with a degree of optimism and a good sense of humor. Subjects also had limited illnesses, maintained fairly steady weight through adulthood and engaged in moderate activity. None was preoccupied with death.

However, not everyone evolves with the equanimity of these subjects and many people face daunting challenges to healthy aging. Hence, for most adults, the need for some health care maintenance and treatment is obvious. However, the raging debate in the 21st century between the longevity people (those advocating early use of growth hormone and multiple supplements) versus those who have serious doubts about the extension of life misses the point. Many of us would prefer quality over extreme quantity.

Thousands of rigorous studies have been conducted that prove the beneficial effects of taking certain vitamins, minerals and herbs. While these studies may generate controversy among some of my more conservative colleagues, here is my list of recommendations for maintaining good health.

Weight Management
Weight should be maintained at plus or minus l0 percent of optimum. Weight changes should be made slowly and consciously through exercise and nutritious diets, which include high fiber, fruit and vegetables (organic if possible), some protein (range-fed animals are preferred if meat is eaten), ample liquids, limited saturated fat, no trans-fatty acids, adequate omega 3 (linolenic acid) fats, and two to five servings of red wine, red grapes or grape juice a week. Meals should be fairly regularly times and whole grains should be emphasized along with low or nonfat, certified, or organic dairy products. This may sound boring, but using cookbooks like Laurel's Kitchen, Chez Panisse Cooking or Whole Foods Cookbook, can make meal preparation and consumption exotic, delightful and healthy.

Eye Care
Macular degeneration is best avoided through the ingestion of lutein and other carotenoids derived from spinach, kale, collards and broccoli. Measurable improvement has occurred in patients with early advanced macular degeneration (AMD) who eat these foods. For cataracts, protection from ultraviolet rays, avoidance of tobacco, a diet rich in vitamin C and antioxidants protects the eyes as they age.

Optimum Bone Density
Calcium (from dietary sources supplemented with calcium magnesium citrate capsules to a level of l,200 milligrams for men and 1,500 milligrams for post-menopausal women, plus adequate folate, vitamin B-6 and B-12 to avoid increased homocysteine (which interferes with collagen cross-linking) and weight-bearing exercise, is enough for healthy bone maintenance. With osteoporosis, etidronates for osteoclast blockade (Fosamax, Actonel), or the new teriparatide, an osteoblast stimulant (Forteo) are often necessary. Calcitonin is of less benefit. Toning several times a week helps improve arm and leg strength.(H) Vitamin D at 400 to 800 international units (iu) a day is also recommended.

Skin Care
Avoid tobacco and stay out of the mid-day sun. Use sunscreens to protect against ultraviolet A and B wavelengths that produce glycation, collagen-elastin damage, and enhanced free-radical injury. Retinyls such as Retin-A cream enhance apoptosis of aged cells. Nicholas Perricone, MD, has developed both a vitamin C ester cream (which enhances collagen and elastin formation) and alpha lipoic acid cream, (which acts as an antioxidant). My favorite skin-care product for sunburn is aloe liquid from the aloe vera leaf, or 95 percent aloe gel. An inexpensive and effective brand is Lily of the Desert. Be warned, however, that this product does not protect against sunburn.

Cardiovascular Health
An excellent life-long anti-aging remedy for cardiovascular health is a diet rich in Omega-3 fats and low in saturated and trans-fatty acids. One and a half tablespoons of ground flax seed supplies approximately two grams of Omega-3 fats. Ground flax seed can be eaten in cereal, cottage cheese, salad, soup or yogurt and it tastes like wheat germ. It should be fresh ground seed or purchased in a vacuum-packed container and always refrigerated after opening. Hawthorne leaves or flowers act as an inotrope in mild congestive heart failure (CHF). The recommended dose is 100 milligrams twice a day.

Coenzyme Q-l0 is a normal component of cells but declines with age. Because it facilitates muscle metabolism and acts as an antioxidant, many studies have shown its benefit in the elderly, particularly post-myocardial infarction (MI) and pre-operatively for those undergoing cardiac surgery. The recommended dose is l20 milligrams taken with meals containing some fat. Low dose aspirin has a proven track record for decreasing stroke and cardiac arrest through platelet inhibition in men and women. Willow bark may do this as well, but no standardized aspirin equivalent exists. To enhance circulation, ginkgo biloba at approximately 120 milligrams per day has been shown to improve brain circulation, and in some studies, to assist with claudication. Folate (from a healthy diet or supplemented with the usual 400 milligrams found in an adult multivitamin), prevents harmful elevation of homocysteine levels. Red yeast rice, (not currently available in the U.S.) is an hydroxy-3-methl-glutaryl-coenzyme A (HMG-CoA) reductase inhibitor used by the older Chinese in several provinces prior to it's development as Mevacor, Lipitor and other drugs in this class.

Vitamin E (400 iu mixed tocopherols) despite "iffy" studies, is very likely cardio-protective. A large hypertension trial showed that adequate dietary calcium, magnesium, potassium and omega-3 fats all are useful in maintaining normal blood pressure.

Digestive System Health
Ample fiber - water-soluble and insoluble - ample liquids, vegetables, and fruits, and adequate, balanced calcium and magnesium help to keep the digestive system eliminating properly. If this doesn't keep bowels soft, two to three teaspoons a day of aloe liquid will. Epidemiological studies have shown a statistical reduction in colon carcinoma in those taking low-dose aspirin and adequate dietary calcium.

Joint Care
Glucosamine sulfate may be insufficiently produced or otherwise interfered with in people who develop osteoarthritis. A dose of 1,500 milligrams a day can help significantly with pain, stiffness and possibly osteoarthritic progression. Omega-3 fats (flaxseed, eicosopentanoic acid (EFA) and decosa hexanoic acid (DHA), all suppress inflammation. Some patients find further pain relief from the gamma linolenic acid found in borage, evening primrose, or black currant seed oils.

Finally, SAM-e (s-adenosyl methionine) at 400 milligrams to 1,200 milligrams a day often helps joint or tendon pain and inflammation. It must be an individually foil-wrapped product, such as that by Nature Made, Natrol or Twin-Lab, and must be taken with water. I advise taking SAM-e in the early morning, even a few minutes before breakfast, as some people experience sleep delay if it is taken in the evening.

Brain Functioning
Lecithin in 1,200 milligram capsules acts as an acetylcholine source. In some people, it is apparently transported across the blood brain barrier. Ginkgo biloba at 120 milligrams to 80 milligrams per day of the flavonoglycoside extract enhances brain circulation. SAM-e provides a notable mood improvement. It is my experience that this is true for roughly 40 percent of mildly depressed patients. SAM-e is a normal component of cells, so we infer that suboptimal production of this substance leads to mood disorders.

Muscle Maintenance
Muscle function is sometimes compromised due people losing large amounts of weight, experiencing poor digestive absorption, or following a prolonged illness, including CHF. Carnitine, which is often limited in these debilitated individuals, facilitates muscle access to intracellular fats for contractility and can be supplemented in the range of one gram twice per day. Following vigorous exercise, micro-tears and inflammation occur routinely, but symptoms can be relieved by pre-and post-exercise and taking 800 to 1,000 international units of vitamin E for two days.(20) Mixed tocopherols are best, and several brands are available. Carnosine, a putative membrane-protective antioxidant, also is helpful in some older individuals beginning an exercise program.

Prostate Health
Prostate size almost universally increases in older men and may cause delayed stream, nocturia and sleep-disruption. It can be significantly improved through the intake of saw palmetto (Serenoa repens. The recommended dose is l60 milligrams once or twice per day.

Immune System
Optimal immune system functioning is supported broadly by the aforementioned healthy diet, plus zinc supplements of 15 to 30 milligrams a day to enhance T-cell function. I generally recommend a good multivitamin/mineral capsule with 10 milligrams or less of iron, for everyone over the age of 50. Several components help with immune and other physiological system functions.

Finally, on an intriguing note, since 1998, increasing research has demonstrated the gene for telemerase, which maintains and rebuilds telomeres. In normal aging with each replication of a gene, the ends of the DNA molecule tend to shorten. This is thought to be prime reason for aging. These studies may eventually lead to meaningful prolongation of healthy cell lines in humans. If stem cell research is freed up politically, we may indeed make major strides in the business of anti-aging remedies. Stem cell research also could provide retinal cells, chondrocytes, and possible relief for Parkinson's' disease and other afflictions.

A final quote from one of the oldest humans, ever:

"I had to wait 110 years to become famous, and I intend to enjoy it as long as possible." - Jean Calment, age 120

Erica T. Goode, M.D., MPH, nutrition, works with patients with a variety of nutritional and medical illnesses at the Institute for Health and Healing at CPMC in San Francisco. She teaches in the department of family and community medicine at UCSF.

*****************************************************

NOVEL CYTOKINE TIED TO RHUEUMATOID ARTHRITIS
NEW YORK (Reuters Health)

The recently re-evaluated group box chromosomal protein (HMGB-1), a nuclear DNA binding protein, appears to play a "pivotal" proinflammatory role in rheumatoid arthritis, Japanese researchers report in the April issue of Arthritis and Rheumatism.

Dr. Ikuro Maruyama of Kagoshima University and colleagues note that this abundant, widely known protein is involved in functions including DNA transcription. However extracellularly it is now "considered a mediator of delayed endotoxin lethality and systemic inflammation."

To determine what role this might play in arthritis, the researchers examined synovial fluid and serum from 30 patients with rheumatoid arthritis and another 30 with osteoarthritis.

HMGB-1 concentrations were significantly higher in the synovial fluid of rheumatoid arthritis patients than in that of those with osteoarthritis.

Furthermore, when stimulated with HMGB-1, synovial fluid macrophages expressed the protein's specific receptor for advanced glycation end products (sRAGE) and released tumor necrosis factor (TNF) alpha, interleukin (IL)- 1 beta and IL-6. Blockade by sRAGE inhibited the release of TNF alpha.

Thus, the researchers conclude, "blocking proinflammatory cytokine release with HMGB-1 stimulation using sRAGE might prove useful for the treatment of rheumatoid arthritis." Arthritis Rheum 2003; 18:971-981.

*******************************************************

ONE TWO MOLECULAR PUNCH AT ROOT OF COMMON ARTHRITIS
From ArthritisSupport.com

Scientists have discovered in unprecedented detail the molecular forces that conspire to damage bone in patients with psoriatic arthritis, a disease that affects an estimated 500,000 to 1 million people in the United States. New findings show that people with the disease are awash in a type of cell that specializes in dissolving bone, and their joints have high amounts of a protein that persuades those cells to settle into joints, where most damage is done. Discovery of the one-two punch helps doctors understand why patients are responding so well to new medicines, and it opens the door to new remedies -- all for a disease that had no approved treatment little more than a year ago. The work by scientists at the University of Rochester Medical Center appears in the March 15 issue of the Journal of Clinical Investigation.

The findings come at a time of tremendous change in the treatment of the disease, which is less known but can be just as crippling as rheumatoid arthritis. The autoimmune condition mostly affects people who have psoriasis -- doctors estimate that 10 to 15 percent of people who have psoriasis also develop psoriatic arthritis, usually in their 20s or 30s. Patients usually have a great deal of pain, swelling and inflammation as the disease literally eats away at their joints, causing some bones or digits such as fingers or toes to shrink or literally disappear while also triggering abnormal, disfiguring and disabling bone growth in their hands, feet, spine, and other joints.

The researchers studied 30 patients with the disease and 12 healthy people to understand the events that lead to bone destruction. A team led by Christopher Ritchlin, M.D., director of the Clinical Immunology Research Unit at the university's Strong Memorial Hospital, analyzed blood samples and examined cells from the synovium, the joint lining that normally nourishes a joint but becomes invasive and destructive in patients with psoriatic arthritis. The work expands on basic research previously performed in genetically modified knockout mice.

Ritchlin's team uncovered two key molecular steps. First, they found that compared to people without the disease, patients with psoriatic arthritis have circulating in their bloodstream 45 times as many osteoclast precursors, which eventually form osteoclasts that specialize in breaking down or eroding bone.

But an over-abundance of these cells is only part of the story. Scientists also found that patients have high amounts of a molecule known as RANKL in their joints. It's the presence of RANKL that prompts osteoclast precursors to mature into full-fledged fledged osteoclasts, which settle onto a bone surface like little suction cups and begin pumping out acid to dissolve bone.

Such activity on a limited basis happens in healthy people every day: Osteoclasts help to remodel or remake 10 percent of our skeleton each year. Just as roadways need to be maintained every year, so do our bones -- osteoclasts strip off the worn or old layer of bone, clearing the way for cells known as osteoblasts to come in and lay down fresh, healthy bone. RANKL is like a molecular flagman that tells precursor cells to mature into osteoclasts, settle onto the bone surface, and begin their work. In patients with psoriatic arthritis, the osteoclasts are running amok -- there are too many of them, and they're munching and eroding bone where they should not.

In addition to uncovering the molecular roots of the disease, Ritchlin's team also showed that the assault on a patient's joint comes on two fronts, from within the joint, as expected, but also from inside the bone. "We've found nests of osteoclasts deep within the bone, just perched and ready to attack. These are big monster cells -- giant compared to other nearby cells. They appear to migrate toward the joint, where they do their damage," says Ritchlin.

Currently the team is working on ways to use the new information to diagnose, track and possibly predict the course of the disease in patients much more quickly than possible today. This might involve a rapid blood test to predict how the disease will progress in certain patients, or to determine the effectiveness of a new medication. The research may also open up new drug strategies, such as a compound that reduces RANKL or increases a substance called osteoprotegerin (OPG), which Ritchlin's team found counters the effects of RANKL on osteoclast precursors in psoriatic arthritis patients.

Ritchlin is excited by the results, which come on the heels of recent new treatments. Until early last year there were no medicines approved to treat the condition; last year the drug Enbrel was approved to treat the disease, and several other agents are either being tested or are available because they have been approved to treat other forms of arthritis.

"The change in these patients' lives is dramatic," says Ritchlin, a rheumatologist who treats hundreds of patients with psoriatic and rheumatoid arthritis, a related disorder where Ritchlin suspects some of the same molecular players are involved.

"Within days of beginning treatment most people have less pain, swelling and stiffness, and they have more energy and mobility. It's amazing to watch -- suddenly their complaints involve muscle strains and other symptoms of over-activity. It's really the metamorphosis of a human being. It's been very satisfying to see, especially with a disease that was neglected for so long."

When Ritchlin started studying psoriatic arthritis nine years ago, doctors had little understanding of its causes. With funding from the National Institutes of Health (NIH), Ritchlin has become an expert on the disease -- he was the first to describe the key role of tumor necrosis factor (TNF) alpha, a compound that rouses other immune cells to attack the patient's body. Most of the new treatments are based on targeting TNF, which plays a role in creating the greater numbers of osteoclast precursor cells. The team also showed in parallel studies that mice with more TNF have more osteoclast precursor cells, and that the drugs currently used to treat the disease knock down the number of these bone-damaging osteoclasts in the bloodstream anywhere from 79 to 96 percent.

"This is a great illustration of taking advances in the laboratory and bringing them to patients' lives," says Ritchlin. "The work in transgenic mice matched perfectly what we were seeing in patients, and the two have come together to help us understand and hopefully improve upon a very effective therapy."

Also leading the research effort was Edward Schwarz, Ph.D., of the Center for Musculoskeletal Research. Other members of the team included Rochester researchers Sally Haas-Smith and Ping Li, and former Rochester bone pathologist David Hicks, now at the Cleveland Clinic. In addition to the NIH, funding from the Howard Hughes Foundation helped support the work. Pro Health, Inc.

*****************************************************

UNINSURED HOSPITAL PATIENTS CHARGED MORE THAN INSURED
Wall Street Journal On Line - 2003

People who don't have health insurance are often charged far more for their medical care than large insurers, health-maintenance organizations or even the U.S. government.

For example, a hospital could bill HMOs about $2,500 for a procedure such as an appendectomy with a two-day hospital stay but a patient with no health insurance could be charged $14,000, plus doctors' fees, for the same procedure. According to the report, government programs such as Medicaid and Medicare pay the hospital $5,000 and $7,800, respectively, for the same procedure.

While most major U.S. hospitals are required to set charges for their services, the set charges are rarely charged to insurance companies or the government. This is because hospitals agree to discount or ignore their set charges when getting paid by institutions. Uninsured individuals, however, get charged the set amount.

Meanwhile, hospital charges have increased significantly in recent years, partly because of the increasing costs of drugs and procedures, though some hospitals say they are raising charges to make up for the low reimbursements they receive from HMOs, insurers and the government.

The inequity in health care pricing prevails despite its roots in a policy designed to prevent such inconsistencies. In many cases, hospitals have raised charges far beyond what is necessary to cover the costs of treatment, and in most states, deregulation of the hospital industry has removed limits on charges. In California, for example, charges have increased to 178 percent above costs.

According to the report, charges beyond costs of treatment can even include the Bad Debt and Charity Care Pool, a state fund that compensates hospitals for caring for the uninsured. While insurance companies and the government have negotiating power against these costs, people without insurance have no one to negotiate for them.

Hospitals say they have to give discounts to HMOs and insurers in order to do business with them. They also note that many uninsured patients don't pay their bills, yet hospitals are required to treat all emergencies regardless of insurance status.

Nonetheless, supporters of the uninsured say that low-income people without insurance should receive the same rates that Medicaid pays. The Wall Street Journal Online - 2003

***********************************************************

OPIOIDS EFFECTIVE AGAINST NEUROPATHIC PAIN -Long-shunned drugs found to be a good treatment
By Amanda Gardner - HealthScoutNews Reporter

Opioid medications, long stigmatized by patients and physicians alike, may now be poised for greater acceptance in the field of pain management.

A study appearing in the March 27 issue of The New England Journal of Medicine found that higher doses of the morphine-like medication levorphanol reduced neuropathic pain significantly more than lower doses of the same medicine.

A second study, this one appearing in the March 25 issue of Neurology, found that another opioid, OxyContin, decreased pain and improved sleep quality for people with diabetic neuropathy.

Neuropathic pain emanates from injury to the central or peripheral nerves and affects more than 2 million Americans. There are no clear guidelines on how to treat the condition, and many available drugs have had disappointing results, writes Dr. Kathleen M. Foley in an editorial accompanying The New England Journal of Medicine study.

Three broad categories of drugs are available to treat neuropathic pain, explains Dr. Russell K. Portenoy, lead author of the Neurology article and chairman of the department of pain medicine and palliative care at Beth Israel Medical Center in New York City. They are opioids, non-opioids and adjuvant analgesics, which are drugs that are for something else (for example, local anesthetics and antidepressants) but have been shown to work against pain.

Among those three groups, opioids have been the most controversial. "The positioning of opioid therapy for patients for chronic pain of all types, not just neuropathic, is evolving very quickly," Portenoy says. "Fifteen years ago, opioids were considered to be inappropriate for most patients with chronic pain.

Now, in 2003, we have consensus statements from many medical societies that say opioids should be considered."

One reason for opioids' position on the margins of medicine is, of course, their association with addiction. They are classified as narcotics and are regulated by the Drug Enforcement Administration, which in itself is enough to make some doctors squeamish. There have also been issues regarding side effects and a perception that patients would develop a tolerance to the drugs, causing them to be ineffective, Portenoy says.

Another reason is that about a decade ago, some studies indicated that opioids were ineffective against nerve pain. "That controversy stood in contrast to a lot of clinical observation," Portenoy says.

Fast forward to 2003 and The New England Journal of Medicine article. In this study, 81 adults with neuropathic pain were randomly assigned to receive either high-strength (0.75 milligrams) or low-strength (0.15 milligrams) capsules of levorphanol for eight weeks.

The study authors picked the lesser known drug levorphanol over high-profile drugs such as methadone or morphine precisely because they wanted to bypass as much as possible any preconceived notions. Although the consent form clearly stated this was an opioid, the researchers felt levorphanol didn't have the same stigma.

Participants could regulate their own doses within certain limits so as to achieve the best balance between pain relief and side effects.

The high-strength capsules reduced pain by 36 percent, whereas the low-st rength dosage reduced pain by 21 percent. These results are comparable to the effects of tricyclic antidepressants and the anticonvulsant gabapentin, both of which are commonly used to treat pain.

On average, patients in the high-strength group took 11.9 capsules per day while patients in the low-strength group took 18.3 a day, which was close to the

21-a-day upper limit allowed. Functioning and sleep were improved in both groups. And even though the trial lasted only eight weeks, participants did not seem more likely to escalate their dose by the end of the study, indicating that they were not developing a tolerance to the drug.

"Our study shows that [the drugs] clearly are effective," says study author Dr. Michael Rowbotham, a professor of clinical neurology and anesthesia at the University of California, San Francisco, and director of the school's Pain Clinical Research Center. "The higher-dose levels were more effective at relieving pain than the lower-dose levels, but it carried a price in terms of side effects."

Before the study ended, 59 patients (27 percent) withdrew, mostly because of various side effects, and more people dropped out in the high-dose group. The side effects of irritability and personality changes occurred only in the higher-strength arm of the study.

Certain types of pain disorders were also easier to treat than others. Only three out of 10 patients with brain injury-related pain (such as stroke) were able to complete the study. Individuals with pain from spinal cord injury or multiple sclerosis seemed to benefit greatly from the high-dose capsules.

Even though the drug didn't help everyone, it helped enough to earn it a place in the arsenal of pain medications, the authors state.

"The fundamental thing that was shown in these studies is that opioids can work for neuropathic pain. You can get adequate pain relief and you can do that without intolerable toxicities," Portenoy reports. "All of these controlled trials are creating a very strong evidence base that is refuting the perspective

that neuropathic pain is unresponsive to opioids. It's very reasonable for doctors to now think about trying opioids."

For more on the use of opioids in pain management, visit the American Pain Society or the American Academy of Pain Medicine.

SOURCES: Russell K. Portenoy, M.D., chairman, department of pain medicine and palliative care, Beth Israel Medical Center, New York City; Michael Rowbotham, M.D., professor, clinical neurology and anesthesia, University of California, San Francisco, and director, UCSF Pain Clinical Research Center; The New England Journal of Medicine. Copyright © 2003 ScoutNews, LLC. All rights reserved.

***************************************************

PHYSICIANS FEEL CRUNCHED FOR TIME

NEW YORK (Reuters Health) May 07 - A growing percentage of U.S. physicians feel they don't have enough time with patients, even though they're devoting more of their week to patient care, according to study results reported Wednesday.

Physicians spent 46.6 hours a week on direct patient care in 2001, about two more hours than in 1997, according to the Center for Studying Health System Change. Still, more than one in three physicians, or 34 percent, reported having inadequate time with their patients, up 6 percentage points from 1997.

Overall, doctors are working fewer hours, the study found. Their average workweek shrank by more than an hour to 54.4 hours.

"With more diagnostic and treatment options available, physicians' increased time in direct patient care may reflect more time spent on patient care activities other than face-to-face visits with patients," a report by the Washington-based health policy think-tank suggests.

Physicians also may feel pressed for time because of fewer managed care restrictions limiting physician access, the complexities of coordinating care for people who are living longer with chronic diseases, and an expanding list of recommended preventive care services. The study is available online at www.hschange.org.

*******************************************************

A group of professional people posed this question to a group of 4 to 8-year-olds, "What does love mean?" The answers they got were broader and deeper than anyone could have imagined.

Here's one of them I know we can all appreciate.

"When my grandmother got arthritis, she couldn't bend over and paint her toenails anymore. So my grandfather does it for her all the time, even when his hands got arthritis too. That's love." Rebecca - age 8

Good Health to All,

Jack Nicholas
Newsletter Editor
Cornishpro@aol.com
Issue 2003 5/31/03 -9