Psoriatic Arthritis List NEWSLETTER

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

PSORIATIC ARTHRITIS NEWS AND VIEWS
VOLUME- 4 ISSUE- 02 January 31, 2004
PSORIATIC ARTHRITIS MEDICAL NEWS

FOUR POPULAR DIETS HEART HEALTHY
Whether It's Atkins, Ornish, Weight Watchers or Zone, It's the Pounds That Matter, Say Experts - By Peggy Peck-WebMD Medical News

(Orlando, Fla.) -- Pound for pound, four very popular weight loss diets are all good for shedding weight and lowering the risk of heart disease, say researchers, with one important caveat: You have to stick with the diets, not just start them.

The diet scene has heated up in the past year with low-carb and low-fat diets battling it out. But until now no one actually compared four of the most popular diets -- Atkins, Ornish, Weight Watchers and the Zone -- to find out which was really better for weight loss and lowering the risk of a heart disease.

It turns out, says Michael L. Dansinger, MD, assistant professor of medicine at Tufts University, New England Medical Center in Boston, Mass. that as long as the pounds are shed, heart health improves.

"Losing 20 pounds corresponded to about a 30% reduction in heart risk score," he says. Although he explains that at this point "it isn't clear if a 30% reduction in risk score is the same as a 30% reduction in heart attacks." Dansinger presented his results here at the American Heart Association's Scientific Sessions 2003.

THE CONTENDERS
The Atkins diet -- a low-carb diet consisting primarily of protein and fat. In the first two weeks, carbohydrates are severely restricted but then are introduced back into the diet in the form of fiber-rich carbohydrates.

The Ornish diet -- a high-carb, low-fat vegetarian diet of mostly beans, fruits, grains, and vegetables. Dairy products are eaten in moderation and meats are discouraged.

Weight Watchers -- a low-fat, high-carb diet where each food is assigned a point value and participants are allowed a certain number of points per day.

The Zone -- a diet based on a 40-30-30 system where participants eat 40% of their calories from "favorable" carbohydrates such as vegetables and beans, 30% from low-fat proteins, and 30% from unsaturated fats, such as olive and canola oils, nuts, and avocados.

LOW- CARB VS. LOW- FAT
Dansinger studied 160 overweight men and women who volunteered to participate in a yearlong diet study. Forty volunteers were assigned to each diet, he says. Dansinger says he was "just testing the diets, not any exercise or other lifestyle modifications that are part of the entire diet program." The researchers also calculated a score to estimate a person's heart disease risk -- based on common heart disease risk factors, such as cholesterol and blood pressure. The benefits from the diets were limited to those who carefully followed them -- and following the diets was no easy task since the drop out rate for each diet was 22% at two months. By one year half of the volunteers assigned to Atkins or Ornish had dropped out as had 35% of those assigned to Weight Watchers or Zone diets.

Participants following the Atkins, Weight Watchers, and Zone diets achieved significant reductions in the heart risk score. Those following the Ornish diet did not show any significant improvement in the heart disease risk score.

Dansinger tells WebMD that this does not mean that the "Ornish diet doesn't reduce heart disease risk. I have great faith in the Ornish diet, but it did not meet the statistical test in this study."

ORNISH RESPONDS
Dean Ornish, MD, founder and president of the Preventive Medicine Research Institute in Sausalito, Calif., was immediately critical of the results.

Ornish tells WebMD that the people assigned to his diet "lost more weight, had greater reductions in LDL (the 'bad' cholesterol), and were the only dieters to significantly lower insulin -- even though the Atkins and Zone diets claim to be specifically designed to lower insulin." Lower insulin levels indicate a lower risk of developing diabetes, another powerful heart disease risk factor.

Dansinger, who joined Ornish in fielding questions from reporters, agrees that the Ornish diet posted impressive results for those who stayed the course for a year: a nearly 20% reduction in insulin levels while the Atkins diet dropped insulin by about 8% and the Zone was associated with a 17% drop in insulin.

Likewise, the Ornish diet reduced LDL cholesterol by 17%, while the Atkins dieters reduced LDL by 9%, followed by Weight Watchers dieters at 8% and Zone dieters at 7%.

GOOD CHOLESTEROL: HOW IMPORTANT IS IT?
But the heart disease risk score is based on the ratio between LDL cholesterol and HDL "good" cholesterol.

"The Ornish diet does not increase HDL, while the other diets do achieve significant increases in HDL," says Dansinger. The Atkins and Zone diets increased HDL by 15%, while Weight Watchers posted an 18.5% gain. But the Ornish diet increased HDL by just 2.2%.

Ornish says HDL is not really a factor because "HDL is really like a garbage truck that goes around picking up the garbage, which is bad cholesterol. When you don't have as much bad cholesterol -- garbage -- you don't need as many garbage trucks." He adds, "raising HDL is easy: eat a stick of butter. That will drive up your HDL, but it's not good for you."

Dansinger says HDL is a little more complicated. For example, "exercise increases HDL and we do think that low HDL is a risk factor for heart disease," he says.

"The good news about this study is that we have demonstrated that all these diets work. That means that physicians can work with patients to select the diet that is best suited to the patient. For example, if you have a patient who likes meat, it is unlikely that he or she will comply with the Ornish diet," says Dansinger.

"In the short run, I think weight loss trumps everything. If you lose weight, it doesn't matter how you lose it. But in the long run we don't know the effect of the macronutrients [carbohydrates, fats, and proteins] that you are eating," says Robert H. Eckel, MD, chair of the American Heart Association's Nutrition, Physical Activity, and Metabolism Council and professor of medicine at the University of Colorado Health Sciences Center. Eckel was not involved in the study.

Source: American Heart Association Scientific Sessions 2003, "One Year Effectiveness of Atkins, Ornish, Weight Watchers and Zone Diets in Decreasing Body Weight and Heart Disease Risk," Michael Dansinger, MD, Tufts; Dean Ornish, MD, Prevention Medicine Research Institute; Robert H. Eckel, MD, chair, AHA Nutrition, Physical Activity, and Metabolism Council.

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FIGHTING FATIGUE? GET A BETTER LIFE
By Jeanie Lerche Davis WedMD Feature Reviewed By Michael Smith, MD

Feeling tired, zapped of energy? You're not the Lone Ranger.

Doctors see it all the time: "Women with four kids, a full-time job, and they get up at 5 to get everybody ready for the day. Their lives are very hectic, they only get four hours of sleep. They expect their bodies to do more than is realistic for one person," says Sharon Horesh, MD, primary care specialist with the Emory Clinic in Atlanta.

Fatigue has many origins. For women, heavy menstrual cycles may cause anemia. An underactive thyroid also causes fatigue. A cold, sinus infection, or virus can drag you out -- even for three or four weeks.

But all too often, you're not taking care of yourself. It's as simple, and as difficult, as that.

"The first thing I ask is, 'What time do you go to bed? When do you wake up? What's your day like?'" Horesh tells WebMD. As trite as it may sound, you need to sleep more, eat healthy, take care of yourself -- "commonsense things," she says. "It's not a medical problem, it's a lifestyle issue."

LOOK AT YOUR OPTIONS
First step, take stock of your life. If you can't juggle it all, get some perspective. "Decide whether you're putting yourself under unnecessary stress," says Inyanga Mack, MD, professor of primary and community medicine at Temple University School of Medicine in Philadelphia.

"Some people can successfully carve out a year or two to achieve a goal. But others push themselves to meet unrealistic demands that are not really necessary," Mack tells WebMD.

Assess your priorities, rank their importance, then make some decisions. "Maybe a therapist can help," she says. "Maybe you need to look for help with childcare or financial problems. Maybe you need to make better spending decisions so you're not stressed financially. Some people buy a truck first, then figure out how pay for it."

You do have options, Mack says. "If you're a young woman with young children, trying to finish school, trying to work, you don't have somebody to take care of the kids, can't afford to stop working, and are working a low-pay job -- you're not actually trying to do something extravagant. They are wonderful goals, but you may need more time to do it. You may need to take fewer classes during the semester."

TAME ANXIETY, DEPRESSION
For many people -- especially women in their 30s and 40s -- severe anxiety and depression are leading causes of fatigue, says Horesh. "Anxiety puts your body into overdrive and wears down the immune system. Some people even have medical symptoms like chest pain, racing heart, heart palpitations because their bodies are in overdrive. They're getting shots of adrenaline all the time."

Depression sets up a vicious cycle. "A lot of people don't see a doctor until they're really, really sick, because they don't want to take care of themselves, can't concentrate, can't get pleasure. They become completely withdrawn, sometimes suicidal, unable to help themselves," she says.

An imbalance of hormone levels could be causing these mood disturbances, she tells WebMD. Antidepressants, psychotherapy, meditation, or yoga can help reduce stress and restore emotional balance. "Different things work for different people," she says.

EXERCISE -- IT’S SOUL-SATISFYING
Exercise is a great stress-relief aide -- even if you're too tired for it, says Mack. "If you're feeling overwhelmed, tired for whatever reason, exercise might be the last thing you feel like doing. But moderate amounts of exercise can actually help your mood. You will have more energy and require less sleep. Exercise will make you more tired at night, and you will fall into a deeper sleep, get better rest."

Despite your busy life, push yourself to do this one extra thing, Mack says. "You just have to get yourself going. It does make a difference. It's worthwhile adding on that one extra thing. It can make a big difference -- not just in fatigue, but in your overall outlook, and can act as a very good stress reliever."

GET PLENTY OF PROTEIN
Even if you're trying to eat right, you may be doing it wrong. "Diet is important," says Horesh. Fruits and vegetables fill you up with fewer calories. But they won't give you the long-lasting energy that you get from proteins and complex, starchy carbohydrates like whole-grain breads, pasta, rice, and beans.

"A diet that is very heavy in sugars -- too many sweets, junk food, cookies -- is going to give you surges in energy," she says. "But you're also going to have a sudden drop in energy.”For energy, you need a diet that is better balanced -- higher in protein, higher in complex carbohydrates, but low in sugars and, of course, fats," she tells WebMD.

LOG THOSE Z's
Yawn, it's the old saw: "If you're not getting enough sleep, nothing else will work," says Mack. "You can't ask your body to work on three to four hours a night and not have some physical complaint. Your body can just take so much."

You absolutely need those seven to eight hours of Z's every night, she tells WebMD. "And it needs to be good rest. You need to feel better when you wake up," she says.

Many people suffer from sleep apnea and don't realize it, says Horesh. "If you snore, if you have ever woken up gasping for air, if you wake up feeling not well rested, if you're so tired you fall asleep behind the steering wheel -- those are all signs that your airway is getting blocked during sleep. You're not getting full REM sleep that you need to feel rested. Unfortunately, people take it as normal. They say, 'I'm a bad sleeper.'"

For the rest of us, caffeine can be a big problem. It's easy to sip eight or nine cups of coffee through the day -- just to get the buzz you once got on two or three cups. If there's also Mountain Dew or tea at night, you're likely to have trouble sleeping, says Mack.

"Drinking two or three cups a day is OK," she tells WebMD. "But very large amounts from multiple sources -- tea, iced tea, soft drinks -- all that counts as caffeine. Drink too much, and you get into trouble."

Good "sleep hygiene" is essential: That means going to bed and waking up at the same time, not drinking a lot of caffeine or alcohol (it also disturbs sleep). Also, don't use the bed for much more than sleep. No eating, watching TV, or reading in bed.

WHEN SHOULD YOU WORRY?
If fatigue has lasted more than a month -- and your lifestyle is in fairly good shape -- then see a primary care doctor, advise both Mack and Horesh.

If blood sugars are chronically high, a sign of diabetes, you will feel chronically tired.
Cancer will also make you feel rundown. That's good reason to get routine screening mammograms and other screening tests. Fibromyalgia, lupus, and other autoimmune diseases also have fatigue as a symptom.
Chronic fatigue syndrome is more than it may sound. "The term is really misused. Many people think that if they are always tired, they have chronic fatigue. People who truly have it are completely debilitated, they are up and functioning only about two hours a day, just can't move otherwise -- severely fatigued."

SOURCES: Sharon Horesh, MD, primary care specialist, Emory Clinic, Atlanta • Inyanga Mack, MD, professor of primary and community medicine, Temple University School of Medicine, Philadelphia. © 2003 WebMD Inc. All rights reserved

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CHRONIC FATIGUE SYNDROME (CFS) WHAT IS IT?

We all get tired. Many of us at times have felt depressed. But the mystery known as chronic fatigue syndrome (CFS) is not like the normal ups and downs we experience in everyday life. The early sign of this illness is a strong and noticeable fatigue that comes on suddenly and often comes and goes or never stops. You feel too tired to do normal activities or are easily exhausted with no apparent reason. Unlike the mind fog of a serious hangover, to which researchers have compared CFS, the profound weakness of CFS does not go away with a few good nights of sleep. Instead, it slyly steals your energy and vigor over months and sometimes years.

How does CFS begin, and what are CFS symptoms?
For many people, CFS begins after a bout with a cold, bronchitis, hepatitis, or an intestinal bug. For some, it follows a bout of infectious mononucleosis, or mono, which temporarily saps the energy of many teenagers and young adults. Often, people say that their illnesses started during a period of high stress. In others, CFS develops more gradually, with no clear illness or other event starting it.Unlike flu symptoms, which usually go away in a few days or weeks, CFS symptoms either hang on or come and go frequently for more than six months. CFS symptoms include: headache, tender lymph nodes, fatigue and weakness, muscle and joint aches, inability to concentrate.

Who gets CFS?
CFS was once stereotyped as a new "yuppie flu" because those who sought help for and caused scientific interest in CFS in the early 1980s were mainly well-educated, well-off women in their thirties and forties. Similar illnesses, known by different names, however, date back at least to the late 1800s. The modern stereotype arose. Since then, doctors have seen the syndrome in people of all ages, races, and social and economic classes from several countries around the world.

Still, CFS is diagnosed two to four times more often in women than in men, possibly because of biological, psychological, and social influences. For example, CFS may have a gender difference similar to diseases such as systemic lupus erythematosus and multiple sclerosis, which affect more women than men.Women may be more likely than men to talk with their doctors about CFS-like symptoms.

Some members of the medical community and the public do not know about or are skeptical of the syndrome. An increasingly diverse patient group will likely emerge as more doctors see CFS as a real disorder.

How many people have CFS?
Because there is no specific laboratory test or clinical sign for CFS, no one knows how many people this illness affects. CDC estimates, however, that as many as 500,000 people in the United States have a CFS-like condition.

What causes CFS?
While no one knows what causes CFS, for more than a century, doctors have reported seeing illnesses similar to it. In the l860s, Dr. George Beard named the syndrome neurasthenia because he thought it was a nervous disorder with weakness and fatigue. Since then, health experts have suggested other explanations for this baffling illness.
Iron-poor blood (anemia), low blood sugar (hypoglycemia), environmental allergy, a body wide yeast infection (candidiasis).

In the mid-1980s, the illness became labeled "chronic EBV" when laboratory clues led scientists to wonder whether the Epstein-Barr virus (EBV) might be causing this group of symptoms. New evidence soon cast doubt on the theory that EBV could be the only thing causing CFS. High levels of EBV antibodies (disease-fighting proteins) have now been found in some healthy people as well as in some people with CFS. Likewise, some people who don’t have EBV antibodies, and who thus have never been infected with the virus, can show CFS symptoms.

How is CFS diagnosed?
Doctors find it difficult to diagnose CFS because it has the same symptoms as many other diseases. When talking with and examining you, your doctor must first rule out diseases that look similar, such as multiple sclerosis and systemic lupus erythematosus in which symptoms can take years to develop. In follow-up visits, you and your doctor need to be alert to any new cues or symptoms that might show that the problem is something other than CFS.

When other diseases are ruled out and if your illness meets other criteria as well, your doctor can diagnose you with CFS.

The CFS case definition
The EBV work sparked new interest in the syndrome among a small group of medical researchers. They realized they needed a standard way to describe CFS so that they could more easily compare research results.

In the late 1980s, CDC brought together a group of CFS experts to tackle this problem. Based on the best information available at the time, this group published in the March 1988 issue of the scientific journal, Annals of Internal Medicine, strict symptom and physical criteria -- the first case definition -- by which scientists could evaluate CFS study patients.

Not knowing the cause or a specific sign for the disease, the group agreed to call the illness "chronic fatigue syndrome" after its primary symptom. "Syndrome" means a group of symptoms that occur together but can result from different causes. (Today, CFS also is known as myalgic encephalomyelitis, postviral fatigue syndrome, and chronic fatigue and immune dysfunction syndrome.)

After using this definition for several years, CFS researchers realized some criteria were unclear or redundant. An international group of CFS experts reviewed the criteria for CDC, which led to the first changes in the case definition. This new definition was published in the same journal in December 1994.

Besides revising the CFS case criteria -- which reduced the required minimum number of symptoms to four out of a list of eight possible symptoms -- the newer report also proposed a conceptual outline for studying the syndrome. This outline recognizes CFS as part of a range of illnesses that have fatigue as a major symptom. Although primarily intended for researchers, these guidelines should help doctors better diagnose CFS.

How can I cope with and manage the CFS?
There is no effective treatment for CFS. Even though there is no specific treatment for CFS itself, you may find it quite helpful to treat your symptoms. Nonsteroidal anti-inflammatory drugs, such as ibuprofen, may help get rid of any body aches or fever, and nonsedating antihistamines may help relieve any prominent allergic symptoms, such as runny nose.

Learning how to manage your fatigue may help you improve the level at which you can function and your quality of life despite your symptoms. A rehabilitation medicine specialist can evaluate and teach you how to plan activities to take advantage of times when you usually feel better.

The lack of any proven effective treatment can be frustrating to both you and your doctors. If you have CFS, health experts recommend that you try to maintain good health by:

Eating a balanced diet and getting adequate rest
Exercising regularly but without causing more fatigue Pacing yourself -- physically, emotionally, and intellectually -- because too much stress can aggravate your symptoms. The course of CFS varies from patient to patient
For most people, CFS symptoms plateau early in the course of illness and thereafter wax and wane. Some people get better completely, but it is not clear how frequently this happens. Emotional support and counseling can help you and your loved ones cope with the uncertain outlook and the difficulties of this illness.

New studies seem to show that cognitive behavioral therapy and graduated exercise programs can greatly help many. Others are helped by antidepressants.

Because well-designed clinical studies have found that patients with fibromyalgia (an illness similar to CFS) benefit from low-dose tricyclic antidepressants, doctors often prescribe these drugs for people with CFS with generally positive results. Some researchers believe that these drugs improve the quality of sleep. Patients also have benefited from other kinds of antidepressants, including the newer serotonin reuptake inhibitors. Therapeutic doses of antidepressants often increase fatigue in CFS, so doctors may have to increase the dosage very slowly, or prescribe more active antidepressants. In addition, some people with CFS benefit from the benzodiazepines, a class of drugs used to treat acute anxiety and sleep problems. Patients often try more than one drug before finding one that works and can be tolerated.

Conclusion
CFS seems to involve interactions between the immune and central nervous systems, interactions about which scientists know relatively little. Scientists' concerted efforts to penetrate the complex nervous system and immune system events in CFS have created a challenging new concept of the pathology of this and other illnesses.

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Editors note: The following information is provided for those readers who want to discuss the use of AMEVIVE (Alefacept) with their health care specialists

ALEFACEPT (Pronunciation: ah LEH fa cept) BRAND NAME: AMEVIVE

What is the most important information I should know about alefacept? • Alefacept reduces levels of certain white blood cells in the body. If the level of these white blood cells falls too low, treatment with alefacept may need to be withheld temporarily or discontinued. Your doctor will monitor your white blood cell levels during treatment. • Alefacept may increase the risk of developing cancer. Do not use alefacept without first talking to your doctor if you have cancer or a history of cancer. • Alefacept reduces certain actions of the immune system and may increase the risk of developing a new infection or reactivating a chronic infection that has been latent (inactive). Contact your doctor immediately if you develop symptoms of an infection such as fever or chills, sore throat, coughing, or burning with urination.

What is alefacept?
• Alefacept is a protein that reduces specific actions of the immune system that are involved in causing psoriasis.
• Alefacept is used for the treatment of moderate to severe chronic plaque psoriasis in people who are candidates for systemic therapy or phototherapy.
• Alefacept may also be used for purposes other than those listed here.

What should I discuss with my healthcare provider before using alefacept?
• Do not use alefacept without first talking to your doctor if you
• have had a previous allergic reaction to alefacept;
• have heart or blood vessel problems;
• have cancer or a history of cancer;
• have an infection or a history of chronic infection; or
• are taking another immunosuppressive medication or are receiving phototherapy.
• You may not be able to use alefacept, or you may require a dosage adjustment or special monitoring during treatment.
• Alefacept is in the FDA pregnancy category B. This means that it is not expected to be harmful to an unborn baby. Do not use alefacept without first talking to your doctor if you are pregnant or could become pregnant during treatment.
• It is not known whether alefacept passes into breast milk. Do not use alefacept without first talking to your doctor if you are breast-feeding a baby.

How should I use alefacept? • Use alefacept exactly as directed by your doctor. If you do not understand these instructions, ask your doctor, nurse, or pharmacist to explain them to you.
• Alefacept is administered by a healthcare provider as an intravenous (into the vein) or intramuscular (into the muscle) injection. • Alefacept is usually administered once a week for a twelve week period. Your doctor will give you detailed information on the best treatment regimen for you.
• It is important to use alefacept regularly to get the most benefit. • Alefacept reduces levels of certain white blood cells in the body. If the level of these white blood cells falls too low, treatment with alefacept may need to be withheld temporarily or discontinued. Your doctor will monitor your white blood cell levels during treatment.
• Your doctor will want you to have blood tests or other medical evaluations during treatment with alefacept to monitor progress and side effects
• Alefacept will be stored by your healthcare provider as directed by the manufacturer.

What happens if I miss a dose?
• Contact your doctor if you miss a dose of alefacept.

What happens if I overdose?
• An overdose of alefacept is unlikely to threaten life. Seek emergency medical attention or contact your doctor immediately if an overdose of alefacept is suspected.
• Symptoms of an alefacept overdose may include chills, headache, joint pain, stuffy nose, and low white blood cell counts.

What should I avoid while using alefacept?
• Talk to your doctor before receiving vaccinations during treatment with alefacept. It is not known whether alefacept will reduce the actions of vaccines that use a live strain of the virus (e.g., measles, mumps, and rubella or MMR) if administered during treatment with alefacept.

What are the possible side effects of alefacept?
• Alefacept reduces levels of certain white blood cells in the body. If the level of these white blood cells falls too low, treatment with alefacept may need to be withheld temporarily or discontinued. Your doctor will monitor your white blood cell levels during treatment.
• Alefacept may increase the risk of developing cancer. Do not use alefacept without first talking to your doctor if you have cancer or a history of cancer.
• Alefacept reduces certain actions of the immune system and may increase the risk of developing a new infection or reactivating a chronic infection that has been latent (inactive). Contact your doctor immediately if you develop symptoms of an infection such as fever or chills, sore throat, coughing, or burning with urination.
• Stop using alefacept and seek emergency medical attention if you develop symptoms of an allergic reaction such as difficulty breathing; closing of the throat; swelling of the lips, tongue, or face; or hives.
• Other less serious side effects may be more likely to occur. Continue to use alefacept and talk to your doctor if you experience
• sore throat or cough;
• dizziness;
• headache
• nausea;
• itching;
• muscle aches;
• chills; or
• pain, discomfort, or inflammation at the injection site. • Side effects other than those listed here may also occur. Talk to your doctor about any side effect that seems unusual or that is especially bothersome.

What other drugs will affect alefacept?
• Talk to your doctor before receiving vaccinations during treatment with alefacept. It is not known whether alefacept will reduce the actions of vaccines that use live strains of the virus (e.g., measles, mumps, and rubella or MMR) if administered during treatment with alefacept. • Other medications that affect the immune system may interact with alefacept. Talk to your doctor and pharmacist before taking any other prescription or over-the-counter medications, including vitamins, minerals, and herbal products during treatment with alefacept.

Remember, keep this and all other medicines out of the reach of children, never share your medicines with others, and use this medication only for the indication prescribed.

Every effort has been made to ensure that the information provided by Cerner Multum, Inc. ('Multum') is accurate, up-to-date, and complete, but no guarantee is made to that effect. Drug information contained herein may be time sensitive. Multum information has been compiled for use by healthcare practitioners and consumers in the United States and therefore Multum does not warrant that uses outside of the United States are appropriate, unless specifically indicated otherwise. Multum's drug information does not endorse drugs, diagnose patients or recommend therapy. Multum's drug information is an informational resource designed to assist licensed healthcare practitioners in caring for their patients and / or to serve consumers viewing this service as a supplement to, and not a substitute for, the expertise, skill, knowledge and judgment of healthcare practitioners. The absence of a warning for a given drug or drug combination in no way should be construed to indicate that the drug or drug combination is safe, effective or appropriate for any given patient. Multum does not assume any responsibility for any aspect of healthcare administered with the aid of information Multum provides. The information contained herein is not intended to cover all possible uses, directions, precautions, warnings, drug interactions, allergic reactions, or adverse effects. If you have questions about the drugs you are taking, check with your doctor, nurse or pharmacist. Copyright 1996-2003 Cerner Multum, Inc. Version: 2.01.

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Good health to all,

Jack Nicholas
Newsletter Editor
Cornishpro @aol.com

Issue 2004 01/31/04-02