"When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov
''Once you tell people there's a cure for something, the more likely they are to pressure doctors to prescribe it.'' -Robert Ehrlich, drug advertising executive.
"Opinions are like sphincters, everyone has one." - Chris Rangel
The study, conducted by the Centers for Disease Control and Prevention and reported in the current edition of its Morbidity and Mortality Weekly Report, found that in 1971 women ate 1,542 calories on average, compared with today's 1,877, while men went from 2,450 calories a day to 2,618. Those numbers dwarf the government's recommendations of 1,600 calories a day for women and 2,200 for men.
Cookies, pasta, soda and other carbohydrates appear to be mostly to blame. Among women, carbohydrates jumped from about 45 percent of the daily caloric intake to almost 52 percent. For men, they grew from 42 percent to 49 percent.
'This just confirms that Americans need to be more focused on a total calorie decrease,' said Jacqueline Wright, an epidemiologist at the disease control centers and the author of the study.
Psychology of Pain: The old canard that women handle pain better than men is false, but women do have to work harder to inflict pain:
Pain hurts less when it is inflicted by a woman, researchers have found.
Students were asked to put their fingers in a clamp which was tightened until the pain was unbearable.
Researchers from the University of Westminster found that people allowed women to turn the clamp much further than men.
Dr David Williams, who led the research said the study suggested people do not expect women to inflict as much pain.
... 'This effect is likely to be a result of what participants subconsciously expect, based on socially acquired gender stereotypes - people feel that they are less likely to experience intense pain from a stimulus given by a woman rather than a man.
'This effect is less likely to be down to males trying to appear macho in front of a female - a conscious and deliberate act - as the result applied to both genders.'
He said the fact there were no differences in how men and women responded to the test suggested women do not actually handle pain better.
Dr Williams said people's sensitivity to pain was also shown to depend on their surroundings.
In the study, people appeared to suffer more if there was a poster on the wall which might trigger negative feelings, such as a chart of wounds or a poster calling for blood donors.
Dr. Williams suggests that perhaps we should perform painful procedures in pleasant environs. That's not a bad idea. I noticed this phenomenon during my residency training. The hospital I trained at had a very old labor and delivery suite. Most of the patients labored in standard hospital rooms and were moved to a separate delivery room when it came time to deliver the baby. (Today's birthing rooms were just beginning to catch on.) There were two delivery rooms. One had a modern table with comfortable leg rests. The other had poles with slings. It looked like a medieval torture device. Patients did a lot worse when they had to go to the second room. Universally. posted by Sydney on
2/06/2004 08:23:00 AM
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Influenza History: How the Spanish flu epidemic of 1918 got started:
The key first stage of infection is for the flu virus to attach itself to the cells in which it will breed.
It does this by using spike-like molecules called Hemagglutinins (HA) that bind to particular receptors on the surface of cells in the body.
Human and bird virus HAs interact with different cell receptors and therefore bird viruses do not usually infect humans.
However, the NIMR team has studied the HA of the 1918 virus in close detail, and found that only minor changes in its structure were required for it to start to bind with human cells as well as bird cells.
This gave it the ability to pass from birds to humans, and then between humans - with devastating results.
The American Heart Association's "Go Red for Women" will kick-off on Friday nationwide. You are encouraged to wear red in an effort to draw attention to heart disease, which is women's greatest threat. Clemmons adds, "Women at times have forgotten themselves to take care of other people, so it's time we start taking care of ourselves."
I'm not convinced that women as a class sacrifice themselves for others more than men, but if the publicity campaign for heart disease will make women place a higher priority on preventing heart disease than preventing breast cancer (which gets a lot more press), go for it. posted by Sydney on
2/06/2004 08:15:00 AM
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Butting Heads: Michelle Malkin runs up against vaccine orthodoxy when she tries to make an informed medical decision:
In the end, we concluded that some of the vaccines were more worth the risks than others. At my son's 2-month checkup, the pediatrician expected him to receive a triple-combination shot called Pediarix (consisting of Hep B, inactivated polio and DTaP, which covers diphtheria, tetanus and acellular pertussis), as well as HiB (for certain bacterial infections) and Prevnar (for meningitis and blood infections). I reiterated my refusal of Hep B, accepted DTaP and HiB and asked to put off polio and Prevnar.
In response, I received a threat: Get all the vaccines or get out of our practice.
"Informed consent''? Ha. This was uninformed coercion. We're leaving for another practice, a little bitter but wiser.
That, unfortunately, is a common attitude among physicians. Those same physicians also often look askance at doctors who cooperate with patients who refuse immunizations, as if it's their fault their patients have decided against universal immunization.
Malkin's decision not to have her child immunized against hepatitis B is actually a reasonable one. It's difficult to argue that those shots are necessary for school attendance. Actually, it's impossible. There is no reason they should be mandatory, since 1) hepatitis B isn't a disease common in childhood and 2) it isn't easily communicable the way other disease like polio, diphtheria, and measles are. When hepatitis B vaccines became mandatory, that's when I noticed more of my patients becoming skeptical of childhood vaccines in general.
The pneumonia vaccine, Prevnar, is a little trickier. It protects against bacterial infections caused by Streptococcus pneumoniae which causes 3,000 cases of meningitis and 500,000 cases of pneumonia a year. Vaccinating children not only reduces these illnesses in them, but in the adults around them, too. The bacteria also causes over 7 million cases of ear infections a year, but the shot isn't very good at preventing those. So, in the long run, it's probably a worthwhile vaccine to get, but the diseases it protects against aren't as deadly or widespread as those the older, traditional childhood vaccines protect against (like polio or diphtheria.)
The polio vaccine is one that I would definitely recommend. Polio is still endemic in some parts of the world, although its incidence is declining. With today's easy international travel, I'd be hesistant to leave a child unprotected.
Still, whether or not to have a child vaccinated is a decision that every parent has the right to make. (We are even required by law to give them handouts that explain the pros and cons of each vaccine so that no one gets a vaccine without informed consent.) Dismissing someone who actually reads them and makes an informed decision isn't going to make them change their mind. But it might turn them away from traditional medicine forever.
Dedicated Public Servant: How many doctors, or their wives, would do this?
Angry and frustrated, Goldberger would not give up trying to persuade his critics that pellagra was a dietary disorder, not an infectious disease. He hoped that one final dramatic experiment would convince his critics. On April 26, 1916 he injected five cubic centimeters of a pellagrin's blood into the arm of his assistant, Dr. George Wheeler. Wheeler shot six centimeters of such blood into Goldberger. Then they swabbed out the secretions of a pellagrin's nose and throat and rubbed them into their own noses and throats. They swallowed capsules containing scabs of pellagrins' rashes. Others joined what Goldberger called his 'filth parties,' including Mary Goldberger. [the doctor's wife -ed.] None of the volunteers got pellagra. Despite Goldberger's heroic efforts, a few physicians remained staunch opponents of the dietary theory of pellagra.
We now know that a niacin or tryptophan deficiency causes pellagra. It was especially prevalent in the South where the ravages of the Civil War had left a good deal of the population in poverty and starvation. But, Southerners were loathe to admit they couldn't feed their own, least of all when that suggestion was made by a Northeastern Jewish immigrant. He died before he could see his theory vindicated. posted by Sydney on
2/05/2004 07:32:00 AM
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A Woman's Tender Heart: The American Heart Association issued, or will be issuing, guidelines for preventing heart disease in women:
The new prevention guidelines aimed at women urge at least 30 minutes of moderate physical activity most days; quitting smoking; and that high-risk women receive cholesterol-lowering drugs, preferably statins, and take omega 3 and folic acid supplements.
Isn't that the same advice women have been getting already? (Although the folic acid recommendation isn't as solid as the others, see post below.) The CNN story says they're also telling women to avoid hormone replacement therapy. It's impossible to tell what the guidelines really say, since they aren't available at the Circulation web site yet, but this UPI story suggests what they really say is that you shouldn't expect your hormone replacement therapy to save you from heart disease:
The panel urged post-menopausal women:
-- not to begin combined, estrogen-plus-progestin hormone therapy to prevent cardiovascular disease;
-- not to continue estrogen-plus-progestin therapy to prevent cardiovascular disease, and
-- not to begin or continue other forms of post-menopausal therapy to prevent cardiovascular disease, pending the findings of ongoing clinical trials.
Blow to a Theory: The theory that lowering homocysteine levels will reduce vascular diseases such as strokes was recently dealt a blow:
Taking high doses of vitamins after a stroke to lower levels of an artery-damaging amino acid does not reduce the risk of having a second stroke, according to a new study.
Research published today in the Journal of the American Medical Association found nearly identical rates of recurrent strokes and heart attacks between patients taking a high dose of folic acid and vitamins B6 and B12 and those taking a low dose combination.
Critics say that the study didn't give vitamins enough time to make a difference, and that it was begun too late in the disease process. Those are valid criticisms, but more studies need to be done before testing for and treating homocysteine levels becomes routine practice. (The test averages around $53 a pop.)
Dodging Germs: How the candidates stay healthy on the campaign trail. Leiberman eats something called Clif Bars and uses Purell liberally, Clark eats Cheetos, Kerry plays hockey (which I guess explains why he lost in South Carolina), Edwards drinks Diet Coke, Dean doesn't do much of anything, Kucinich has a plan to keep us all healthy and Sharpton does it by sheer willpower. posted by Sydney on
2/05/2004 07:11:00 AM
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Two for the Price of One: Pfizer is planning to introduce a combination pill for hypertension and cholesterol. It's Norvasc and Lipitor wrapped up in one. While combination medications do improve compliance, they allow for less leeway in making dosage changes in one drug without changing the other. They also tend to be expensive, though less expensive than taking the two drugs separately (unless you take generic):
Pfizer did not disclose the price. Analysts said the company likely would set the price just below the combined cost of Norvasc and Lipitor. Thirty Lipitor tablets sell for about $60 wholesale or about $260 retail while 30 tablets of Norvasc sell for about $45 or $200 retail, various Internet sites show.
That's quite a mark-up from wholesale to retail. Maybe it's not the drug companies but the drug stores that are the source of our drug pricing woes. posted by Sydney on
2/05/2004 07:08:00 AM
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More Cancer Tests: In other news, researchers have announced that C-reactive protein (CRP), a marker for inflammation somewhere, anywhere, in the body, can predict colon cancer risk:
High levels of C-reactive protein, or CRP, in a patient's blood "could become a very good early marker" for predicting the colon disorder, said Northwestern University cancer specialist Dr. Boris Pasche.
...The Hopkins researchers, who published their report today in the Journal of the American Medical Association, analyzed blood samples from a long-term study of people in Washington County.
They compared 131 people who got colon cancer with 262 people who did not. "People with high levels of CRP had a significantly higher risk of developing colon cancer sometime in the future," said Dr. Thomas Erlinger, the study's lead author.
The abstract is here, but it doesn't give much in the way of concrete information. (My copy of JAMA hasn't arrived yet, so I can't scrutinize the data.) But, using C-reactive protein as a screening test for anything is a worrisome trend. It can be elevated in any sort of condition that is associated with inflammation - from arthrities it Alzheimer's. So its prognostic value is severely limited. As one doctor puts it in the article:
"It's like smoke going up - you know there's a fire somewhere, but you don't know where." posted by Sydney on
2/04/2004 08:17:00 AM
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Finding Cancer: The New York Times reported yesterday on a new test for ovarian cancer that's almost set to go:
The new test, expected to be available in the next few months, could have a big effect on public health if it works as advertised. That is because when ovarian cancer is caught early, when it is treatable by surgery, more than 90 percent of women live five years or longer. But right now, about three-quarters of cases are detected after the cancer has advanced, and then only 35 percent of women survive five years.
Ah, but here's the rub. If ovarian cancer is detected early, do those women get cured, or do they end up living the same number of years as women whose cancer is discovered later, at more advanced stages? In other words, do all they get from the test is the advantage (?) of living their asymptomatic years with the knowledge that they have cancer?
But, even putting that concern aside, there's plenty of reason to doubt the usefulness of this test:
When the technique was first tried on 116 blood samples from women whose disease status was already known, it correctly detected all cases of ovarian cancer, including 18 in the earliest stage. It classified only 5 percent of the noncancerous samples as cancerous. When the results were published in the medical journal Lancet in 2002, it suggested a powerful testing method was at hand.
...But experts say OvaCheck must give virtually no false positives to make it useful for general screening. Fifteen women out of 100,000 get ovarian cancer each year, said Dr. Beth Y. Karlan, director of gynecologic oncology at Cedars-Sinai Medical Center in Los Angeles.
So if OvaCheck were used for yearly checks on the whole population, even a 1 percent rate of false positives would mean 1,000 false diagnoses for every 15 cases detected.
When you consider that a false postive can only be determined by performing a biopsy (which for ovaries means abdominal surgery), you realize at what a high cost they come, both in terms of money and health risk. But that's not all. The test isn't exactly reliable, even in the lab:
The Lancet data could not be reproduced exactly even by the test developers. They found that the mass spectrometer they used, which was made for research, not high-volume work, produced different patterns even when the same samples were tested on different days. So they switched to a new machine.
Sounds like a lot of false hope, and a chance for some to make a handsome profit off the worried well. (The test is expected to cost from $100 to $200)
Letter of the Law: The Edwards campaign has been getting some suspicious donations - most of them from (suprise!) law firms:
Thomas Sanchez said he was not aware that he had donated to the Edwards campaign. “Wasn’t me,” he said. “You’ve got the wrong guy.” His wife said she gave one check to the Edwards campaign for $4,000 from both herself and her husband.
Mr. Sanchez is a registered Republican. So is Mrs. Sanchez. But, she's also a paralegal at a law firm that specializes in insurance liability and HMO litigation. The maximum individual donation is $2,000. Shouldn't Mr. Sanchez have made his own donation?
Medicating Teenage Angst: The FDA continues to look at the popular SSRI anti-depressants and their use in teenagers. They've yet to find any evidence that they truly increase the risk of suicide, although parents with opposite experiences are lobbying hard:
Its own analysis so far suggests 109 patients experienced one or more possibly suicide-related behaviors, FDA medical reviewer Dr. Thomas Laughren said. But some clearly weren't.
Among 19 patients classified as cutting themselves, for instance, almost all were superficial, with little bleeding. So the FDA has hired Columbia University to help determine exactly how much true suicidal behavior occurred before it proposes next steps at a second public hearing in late summer.....
....But that didn't satisfy parents who demanded warnings on the drugs' labels.
"You have an obligation today ... from preventing this tragic story from being repeated over and over again," said Mark Miller of Kansas City, Mo., whose 13-year-old son Matt hanged himself in his bedroom closet after taking his seventh Zoloft pill.
"Please, save our children," said Todd Shivak of Michigan, whose 11-year-old son Michael slashed his wrists in class, but survived, while taking Paxil.
But other parents have different stories to tell:
"I ask that you appreciate the enormous benefit these medicines have had," said Sherri Walton of Arizona, whose daughter Jordan, 14, has used SSRIs in a yearslong battle with obsessive-compulsive disorder and depression. "Her medicines were sometimes the only things she could depend on to help her."
Which is why policy shouldn't be founded on anecdotal evidence.
There is a tendency, however, for adults to want to medicate away the normal angst of adolescence. And, like the pressure to prescribe antibiotics for viral conditions, or Ritalin for bad grades, it's all too easy for a doctor to succumb to the pressure to medicate away all bad feelings and behavior. Which is why this sentiment isn't a bad idea:
"'We want to put a speed bump in the road,' said panel chair Dr. Matthew Rudorfer of the National Institute of Mental Health. 'The concern that many of us felt today was that the way the SSRIs and other newer antidepressants are being used now is such that the warnings as they exist in the current labeling are not adequate or are not being taken seriously.'
Bioterror Threat: Ricin found in Senator Frist's office. Maybe:
A congressional source said the powder was found in an envelope in Frist's office suite. The Dirksen building is one of three structures occupied by senators and their staffs.
Although Gainer said the material had been found on the fourth floor, he said it was unclear what envelope or package may have contained the powder.
One initial test conducted at the scene came back positive for the presence of ricin, a toxin made from the castor bean. Gainer said police initially believed the first result was a so-called 'false positive' and tested the material again.
Although the second test was reportedly negative, police removed a sample of the powder for a more detailed and 'professional' round of testing. Two of those three tests also indicated the powder was ricin.
Officials said they were awaiting a final, more definitive test conducted at Fort Detrick in Maryland to confirm the presence of ricin.. posted by Sydney on
2/03/2004 07:13:00 AM
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Different strains of the flu broaden their options further by swapping genetic material with other flu viruses. They also can jump between species -- while some live in birds, some prefer pigs and some seek out people, some strains can move from one type of creature to another and further meld and swap genes. This is how new varieties of flu arise.
Often, these new strains require relatively familiar medical action; there might be a different type of flu vaccine loaded into the flu shot you get one particular winter, and unexpected strains, such as this winter's Fujian A, can cause more severe flu outbreaks than usual. In a few instances, such as the major flu outbreaks of 1918, 1957 and 1968, a new strain can kill thousands to millions of people.
....Most avian flus have shown to be less ready to blend with human flus. Sunday, however, World Health Organization officials confirmed a ``possible'' case of human-to-human transmission in Vietnam, which would mark the first such incidence during this outbreak. Limited person-to-person transmission occurred during a 1997 avian flu outbreak in Hong Kong.
Among people who do get infected, bird flu is often deadly. In the 1997 Hong Kong outbreak, which saw 18 people hospitalized, six died. In the current outbreak, at least 12 have died -- many of them children. That virulence, if blended into a flu that easily infects humans, worries doctors.
A report compiled by federal officials said nurses at Martin Luther King Jr.-Drew Medical Center left critically ill patients unattended for hours at a time and were ordered to lie about patients' conditions.
Some of those left alone died, according to the Centers for Medicare and Medicaid Services report. County officials said the findings could lead to a criminal investigation into the hospital's practices.
The Los Angeles hospital, owned by the county, is in danger of losing its federal funding because of severe lapses in care:
If the problems are not immediately corrected, the hospital could lose all federal funding, which accounts for about half its $430 million annual budget.
The Los Angeles County hospital, established as a response to the 1965 Watts riots, is the only public hospital in the South Los Angeles area and serves a largely poor population. It receives $13.8 million a year from the county.
An accrediting group last year stripped the hospital of its ability to train aspiring surgeons and radiologists and recommended closing the neonatology training program.
Chances are they have trouble collecting enough to cover their budget, even with full federal funding. And when budgets are tight, unfortunately one of the first things to get cut is staffing. And according to the LA Times version, it's staffing that appears to be the problem:
A federal health official familiar with King/Drew, who declined to be identified, said the problems found and the number of questionable deaths were highly unusual.
Nurses told inspectors, for instance, that their supervisors had ordered them to downplay the conditions of critically ill patients to subvert rules requiring that the sickest patients get more nursing care.
...As a result, inspectors said, nurses sometimes struggled to care for four times as many patients as the state allowed. Crucial medications and treatments were often delayed for hours. Nurses also did little to help patients who were in severe pain, according to the findings.
On one shift reviewed by inspectors, nine of the 16 patients should have been classified at the sickest level, which would have required one nurse for every two patients.
One patient was bleeding and required multiple transfusions, five required ventilators to aid their breathing and one of those patients had a temperature as high as 104 degrees, inspectors found. Four more patients were waiting to be admitted from the emergency room.
Yet there were only two registered nurses assigned to the unit — one for every eight patients, according to the report. One less skilled licensed vocational nurse, though not qualified for the task, was left to watch the cardiac monitors. When nursing administrators were asked for help, they told the nurses on duty that no help was available, the report said.
How unqualified was that person to watch the monitors? Very unqualified:
When nurses went to his room, they found a "flat line" on the cardiac monitor and no heart rate, the report said. He died within hours.
The employee assigned to watch the monitors "had not notified the nurse prior to being alerted by the patient's family" that the man's heart had stopped, according to the report.
...When inspectors visited King/Drew on Dec. 23, the nurse assigned to watch the cardiac monitors told them she "did not feel comfortable" with use of the devices. Her employee file also lacked proof that she had been trained to operate them or spot abnormal heart rhythms, the report said.
While inspectors spoke to the nurse, the monitors for all six patients in 4B showed a red X next to the "pulse" read-out. None of the three nurses in 4B at the time knew the X meant that the alarm, designed to alert them to dangerous dips in patients' heart rates, was off.
Martin and another nurse, Alan Noel, acknowledged that patient care at the hospital had slipped to unacceptable levels, but blamed the decline on severe staffing shortages. Noel said a single nurse might be left in charge of as many as 14 patients, more than double a normal load.
Under such conditions, he said, patients were often neglected and it became impossible to administer decent care.
'You have 14 patients and one patient crashes, you have to spend all your time with that patient,' Noel said.
Since the change in nursing management, he said, more nurses have been on duty, although there are still too few nurses working the night shift."
An adequate and well-trained nursing staff is the cornerstone of good hospital care. That's what's so worrying about the call for mandated computer systems to "reduce hospital errors." The money to pay for those systems has to come from somewhere. Chances are, it will come from staff reductions. And a good nurse can never be replaced by a computer.
posted by Sydney on
2/02/2004 08:04:00 AM
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Asian Viruses Update: Looks like SARS is back, at least in China, which recently confirmed its fourth case. All f our occurred in January, and all four are doing well and fully recovered, you'll be glad to hear. Only time will tell if this one will mutate like last year's into a more contagious and deadly version.
Meanwhile, the WHO is not happy with the Chinese. Not only were they slow to report their SARS cases, but they're not doing so good at containing their bird flu, either. posted by Sydney on
2/02/2004 07:59:00 AM
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"American Indians and Alaska natives are more likely to smoke than any other group in the United States, with 40 percent of adults defined as smokers, the Centers for Disease Control and Prevention said this week.
...Among adults, 25 percent of blacks said they were smokers, compared with nearly 26 percent of whites and 26.5 percent of the population overall. Among youths, 16 percent of whites and 7 percent of blacks said they smoked, compared with 13.8 percent overall.
The article says that public health specialists see this as a call for more Native American-oriented anti-smoking messages. But, it will take more than focused public health ads to get results. Cigarettes are a lot cheaper on the reservations - they're tax free. posted by Sydney on
2/02/2004 07:55:00 AM
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Undervalued Headaches: New research suggests that migraine headaches may be more than just a pain:
Researchers have identified brain lesions in migraine victims, a finding that could indicate the severe headaches are a progressive brain-damaging disease in some cases, new research suggests.
The research, which has possible implications for treatment, involved 295 Dutch adults aged 30 to 60, some of whom had migraines with visual disturbances and some migraines without eye problems. They were compared to 140 similar people who were migraine-free.
Using magnetic resonance images, the researchers found that for patients with both migraines and visual problems the risk of cerebral infarction -- tissue which has died due to lack of oxygen when a blood clot blocks an artery -- was 13 times higher than the group which had no migraines at all.
The problem increased with the frequency of migraine attacks.
Patients with migraine but no eye trouble had more than seven times the risk that would normally be expected. The problem occurred in the cerebellar region of the brain, which controls motor motions.
Yikes. That's bad news. Oh, but wait. It's not as bad as it sounds. Here's what the study found:
"We found no significant difference between patients with migraine and controls in overall infarct prevalence (8.1% vs 5.0%).
They did see a higher incidence of what are called "white matter lesions", or WML in the paper, in the region of the brain supplied by the posterior cerebral artery, in people who had migraines associated with visual disturbances. But even then, the numbers were small - 0.7% of controls had lesions in this area, vs. 5.4% of all patients with migraines and 8.1% of migraine sufferers with visual auras. So, 92% of people with the highest risk types of migraine have no lesions at all.
There actually is some physiological basis for these findings. We don't really have a good understanding of the physiology of migraines, but it's believed that they occur when part of the brain gets too little oxygen, either because of small clots or a spasm in a small artery. If you click on that "aura" link, you'll see that the visual aura is often associated with loss of visual fields, a condition that could be caused by oxygen deprivation to visual centers in the brain. Some migraines are even associated with stroke-like symptoms, (although this type of migraine was not included in the study). And the worst migraines, those associated with neurological symptoms, appear to involve the posterior circulation of the brain. So, it makes sense that MRI abnormalities would show up in those regions in people who suffer from visual disturbances with their migraines. The wonder is that only 8% of them have it.
There's one other thing about the research. Although small areas of damage were found in a minority of migraine sufferers, there's no indication of the functional importance of these lesions. Is there a higher incidence of dementia in migraine sufferers? Of incapacitating strokes? For all we know, people can live with these lesions, and their migraines, for the rest of their lives with no lasting untoward effects. posted by Sydney on
2/02/2004 07:53:00 AM
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Sunday, February 01, 2004
Heartfelt Thanks: Many thanks to all of you who donated to the Amazon tip jar this past month. Your donations are greatly appreciated. I would send out personal thank you's, but Amazon doesn't tell me who you are. posted by Sydney on
2/01/2004 01:20:00 PM
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