Internal Medicine News articles from June 2005

Internal Medicine News archives from June 2005

Wiring a paperless office, step by step.(News)
June 1, 2005... SAN FRANCISCO -- There is a cost-effective way to go paperless and make a profit for your group practice, Jeffrey P. Friedman, M.D., said at the annual meeting of the American College of Physicians. Dr. Friedman, an internist and founding...

Top 10 diagnoses by internists in 2004.(VITAL SIGNS)(Brief Article)
June 1, 2005... Top 10 Diagnoses by Internists in 2004 Hypertension 15.6% Diabetes mellitus 6.5% Hyperlipidemia 6.0% Hypercholesterolemia 2.5% Routine medical exam 2.3% Depressive disorder 2.1% Esophageal...

Coalition defines set of 26 clinical care measures: performance criteria may be used in 2006.(News)
June 1, 2005... Taking a crucial first step in an effort to make pay for performance work for office-based physicians, a coalition of physician groups, insurers, and the federal government has endorsed a set of 26 clinical-performance measures for the...

Toxic Clostridium difficile strain seen in nine states.(Infectious Diseases)
June 1, 2005... LOS ANGELES -- Discussion about the spread of a highly toxic new strain of Clostridium difficile dominated a recent meeting of infectious disease specialists and hospital epidemiologists, who cautioned that widespread reports of the aggressive...

At 3 years, progress to Alzheimer's is similar for donepezil, placebo.(News)
June 1, 2005... MIAMI BEACH -- Neither donepezil nor vitamin E prevented significantly more patients with mild cognitive impairment from converting to Alzheimer's disease at 3 years, compared with placebo, according to a study presented at the annual meeting...

Mass. coalition test drives electronic health records.(News)
June 1, 2005... BOSTON -- Three Massachusetts communities will soon be wired for electronic health record systems as part of a $50 million pilot project. The idea, being undertaken by the Massachusetts eHealth Collaborative, is to test out the...

Nearly half of patients unwilling to pay for online communication with their physician.(DATA WATCH)
June 1, 2005... Nearly Half of Patients Unwilling to Pay for Online Communication With Their Physician Don't know 21% Unwilling to pay 44% Would be willing to pay something 36% Note: Based on a...

Group to introduce certification of EHR products.(News)
June 1, 2005... BOSTON -- A coalition of private sector informatics groups plans to launch a process for certifying electronic health record products late this year. Certification will bring some predictability into the market for physicians, vendors, and...

Retainer physicians earn more, work less.
June 1, 2005... DALLAS -- Physicians in retainer practices are reporting better quality of care and fewer hassles, but the new approach is not without its flaws, according to a survey presented at a national conference on concierge medicine. Retainer...

Survey examines disclosure of medical errors.(Brief Article)
June 1, 2005... CHICAGO -- Four percent of primary care physicians and third-year medical students surveyed in a regional study reported that they made errors resulting in a patient's death but did not disclose them to their institution, reported Lauris C....

New guidelines target CVD in dialysis patients.(cardiovascular disease)
June 1, 2005... WASHINGTON -- New guidelines released by the National Kidney Foundation focus on the management of hypertension and other forms of cardiovascular disease in patients on renal dialysis, William L. Henrich, M.D., said at a meeting sponsored by...

New criteria detect 10 times more early kidney disease.(guidelines for diagnosing)
June 1, 2005... WASHINGTON -- Current guidelines for diagnosing chronic kidney disease identify far more people in the early stages of the disease, compared with previous criteria, according to data presented at a meeting sponsored by the National Kidney...

Successful kidney transplant can triple life expectancy.
June 1, 2005... Long-term survival for patients who undergo kidney transplantation is significantly better than for patients who are listed for transplantation but remain on dialysis, results from a 10-year study have shown. In fact, the projected life...

Pain relievers.(Opinion)(Cartoon)
June 1, 2005... "The fact that you're a malpractice lawyer aside, I'm going to schedule every medical test known to mankind."

The rest of your exercises.(Letter to the Editor)
June 1, 2005... I enjoyed the recent article on exercise and would like to add a few more tips that I share with my patients ("Making Exercise Part of Your Routine," The Rest of Your Life, March 15, 2005, p. 80): * Make it fun. I recommend the physical...

Smokers, obese should pay more.(LETTERS)(Letter to the Editor)
June 1, 2005... The article about Medicare reimbursement misses the point, as do all other discussions on the topic ("Docs to Congress: Fix the Medicare Formula First," March 15, 2005, p. 76). The issue isn't the quality and efficiency of health care...

The business of health care.(LETTERS)(Letter to the Editor)
June 1, 2005... I am so glad we have experts like Dr. Regina Herzlinger to advise us about how to run health care ("Consumer-Driven Care Should Improve Quality," March 1, 2005, p. 80). Those of us who care for patients know that what they want is just...

Mobile stroke screening may be unsafe.(LETTERS)(Letter to the Editor)
June 1, 2005... I was appalled at the blithe and uncritical report about mobile stroke screening ("Mobile Ultrasound Screening Gains Acceptance," March 1, 2005, p. 55). The question of which diseases to screen for and which patients to screen is a very...

Medicare's 'new math' doesn't add up.(LETTERS)(Letter to the Editor)
June 1, 2005... According to the AMA Member Connect survey, if Medicare payments are cut by 5% in 2006, 54% of medical practices will defer the purchase and implementation of medical information technology. INTERNAL MEDICINE NEWS reported that Medicare...

New drugs on the horizon for VTE.(venous thromboembolism)(Editorial)
June 1, 2005... The development of new antithrombotic agents for venous thromboembolism is changing the way we treat venous thrombosis and pulmonary embolism. The incidence of deep venous thrombosis and pulmonary embolism has remained nearly constant...

Will health savings accounts leave people vulnerable to bankruptcy?
June 1, 2005... YES When we studied more than 900 people who had filed for personal bankruptcy, more than half cited medical causes (Health Aff. [Millwood] Feb. 2, 2005; [Web exclusive]). This was true even though three-quarters of the debtors had health...

Health, fractures guide bisphosphonate decision.(postmenopausal woman treatment )
June 1, 2005... NEW YORK -- While bone mineral density T scores clearly are predictive of a postmenopausal woman's osteoporotic fracture risk, treatment decisions should take into account other factors, including her overall health and history of previous...

Turnover rate is major factor in bone strength.
June 1, 2005... NEW ORLEANS -- Of all the factors that contribute to bone strength, the rate of turnover may be most clinically relevant, David Dempster, Ph.D., said at the annual meeting of the International Society for Clinical Densitometry. At the same...

Bisphosphonates cut fractures but compliance is often poor.
June 1, 2005... WASHINGTON -- Postmenopausal women with osteoporosis can reduce their risk for fractures by 26% if they stick to their bisphosphonate regimens, Ethel Siris, M.D., reported in a poster presented at an international symposium sponsored by the...

Hip osteoarthritis higher in women on statins.
June 1, 2005... A new study has added a twist to the theory that statins may serve dual purposes in patients with inflammatory diseases that affect both the joints and heart. Findings from the study of 5,678 women aged 65 and older suggest that the use of...

In 71%, RA responded to swap in biologics.(Rheumatology)
June 1, 2005... BIRMINGHAM, ENGLAND -- Evolving real-world experience with biologic therapies for rheumatoid arthritis is validating the concept of switching from one agent to another when response is inadequate or when adverse effects occur, Ramesh N. Jois,...

Cat's claw for arthritis.(ALTERNATIVE MEDICINE)
June 1, 2005... History and Rationale for Use In the medicinal system of the Ashaninka Indians of Peru, the human being is made up of body and spirit--flesh (ivatsa) and "deepest being" (isancane). As with many traditional systems, health is considered to...

Intermittent steroids an option in mild asthma.(Pulmonary Medicine)
June 1, 2005... Treating patients with mild persistent asthma with short, intermittent courses of inhaled and oral corticosteroids as needed may be a viable treatment approach, according to results from the Improving Asthma Control Trial. Although...

Exhaled nitric oxide measures asthma activity: this simple test gauges disease activity with greater sensitivity than lung function tests or symptoms.(Pulmonary Medicine)
June 1, 2005... SAN ANTONIO -- Exhaled nitric oxide, a marker of airway inflammation, is a much better measure of asthma than the assessment of symptoms or lung function tests, according to Joseph Spahn, M.D. "Measures like symptoms and lung function lack...

Sublingual immunotherapy eases symptoms of dust mite allergy.(Pulmonary Medicine)
June 1, 2005... SAN ANTONIO -- Adults with dust mite allergy who are using standard allergy medications benefit from the addition of sublingual immunotherapy, according to Italian researchers. "The clinical efficacy of sublingual immunotherapy has been...

IgE levels validate rise in allergy.
June 1, 2005... SAN ANTONIO -- The prevalence of allergic disease has increased markedly over the past 10 years, with dust mite sensitivity leaping furthest ahead, according to a new study. "There have been numerous reports of increases in the rates of...

Inhaled cyclosporine cut posttransplant deaths: enrollment criteria excluded fungal infections, bronchial stenosis, and mechanical ventilation.
June 1, 2005... PHILADELPHIA -- Lung transplant patients who received inhaled cyclosporine on top of standard immunosuppression had improved survival compared with those who received placebo inhalations in a controlled study with 56 patients, Aldo T. Iacono,...

Primary graft dysfunction redefined by infiltrates, oxygen ratio.(Pulmonary Medicine)
June 1, 2005... PHILADELPHIA -- A new definition and grading system for primary graft dysfunction following lung transplantation have been finalized by a panel of experts, Jason D. Christie, M.D., said at the annual meeting of the International Society for...

Intrathecal agents combined for pain control.
June 1, 2005... PALM SPRINGS, CALIF. -- Intrathecal therapies for pain control are increasingly being used in combination, capitalizing on the body's own complex network for recording and transmitting pain signals, Peter S. Staats, M.D., said at the annual...

Pearls offered for end-of-life pain treatment.(Neurology)
June 1, 2005... SAN FRANCISCO -- Opioids are the mainstay of pain treatment at the end of life, but using them in this population presents some challenges, Janet L. Abrahm, M.D., said at the annual meeting of the American College of Physicians. Dr....

Just 45% of OxyContin prescriptions are taken as directed.(Neurology)
June 1, 2005... PALM SPRINGS, CALIF. -- Just 45% of prescriptions for the opiate OxyContin (oxycodone HCl controlled release) are taken as directed by patients being treated for nonmalignant pain, according to a study of urine samples from approximately 5% of...

Dopamine antagonists effective for acute migraine: these drugs provide a good alternative to opioids or vasoactive agents such as triptans and ergotamines.(Neurology)
June 1, 2005... LAS VEGAS -- Dopamine antagonists appear quite effective in the treatment of acute migraine, John F. Rothrock, M.D., said at a symposium sponsored by the American Headache Society. "I think there's no question that these so-called dopamine...

Closure of patent foramen ovale or atrial septal defect may help relieve migraines.
June 1, 2005... Transcatheter closure of patent foramen ovale and atrial septal defects completely resolved or markedly improved the frequency and severity of migraine in two separate retrospective studies. The benefit of closing these arterial shunts was...

Metoclopramide works well for adult migraine.(Brief Article)
June 1, 2005... Metoclopramide is an effective migraine treatment for adults--one in four migraine patients will experience significant pain reduction with the drug. But other drugs may have more effect on migraine-related nausea, according to Ian Colman,...

TIA presages stroke within 3 months in 15%.(transient ischemic attack)
June 1, 2005... Close to 15% of people who have a transient ischemic attack will experience a stroke within the next 3 months, with a 6% risk of a recurrent event in the first 2 days, according to findings from a large population-based study that included both...

Morbid obesity doubles health care costs.
June 1, 2005... CHICAGO -- Health care costs for morbidly obese adults are nearly double those of normal-weight adults, according to a study presented at the combined annual meeting of the Central Society for Clinical Research and the Midwestern section of the...

Gestational diabetes rising in all ethnic groups.
June 1, 2005... Gestational diabetes is on the rise. The finding is not surprising given the major increases in obesity and type 2 diabetes in recent years, but until now few studies have examined trends in gestational diabetes mellitus (GDM) in populations...

First incretin mimetic, Byetta, approved for diabetes: exenatide is formulated for self-administered subcutaneous injection within 1 hour of meals.
June 1, 2005... The Food and Drug Administration has approved Byetta injection as an adjunctive therapy for patients with type 2 diabetes who have not achieved adequate blood glucose control on metformin and/or a sulfonylurea. The drug is the first of a...

Individualize diabetes care in the elderly for good glucose control.
June 1, 2005... SAN FRANCISCO -- Treatment of diabetes in the elderly patient should be aggressive, but it should also be individualized, Sanford R. Mallin, M.D., said at the annual meeting of the American College of Physicians. Among the benefits of good...

Exercise plus diet beats exercise alone for metabolic syndrome.(Brief Article)
June 1, 2005... ORLANDO, FLA. -- Moderate-intensity exercise coupled with caloric restriction was better than exercise alone for reducing waist circumference in women in a recent study. This dual lifestyle modification was particularly beneficial for...

Tap peers to teach adults with new diabetes Dx.
June 1, 2005... LOS ANGELES -- Looking to make your adult diabetes education program more effective? Consider enlisting the help of patients with controlled diabetes to lead group sessions and educate patients newly diagnosed with the disease, America Bracho,...

Panic: common in diabetes, and linked to depression.
June 1, 2005... VANCOUVER, B.C. -- Panic symptoms affect many patients with diabetes and are associated with depression and diabetes-related disability, Evette Ludman, Ph.D., and her associates reported in a poster presentation at the annual meeting of the...

Metformin with diet reduced cardiovascular risk in PCOS.(polycystic ovary syndrome)
June 1, 2005... WASHINGTON -- Metformin combined with a reduced-calorie diet lowered cardiovascular risk in a study of 791 women with polycystic ovary syndrome, Mofiz Haque, M.D., reported in a poster presented at the Clinical Research 2005 meeting. The...

Women aged 20 years and older who are obese, 2000-2002.(DATA WATCH)
June 1, 2005... Women Aged 20 Years and Older Who Are Obese, 2000-2002 Note: Women with body mass index [greater than or equal to]30 are considered obese. Source: Women's Health and Mortality Chartbook (www.cdc.gov/nchs/datawh/statab/chartbook.htm)...

Predicting postmenopausal CV risk.(cardiovascular)(Brief Article)
June 1, 2005... Screening for an enlarged waist in combination with elevated triglycerides appears to be a simple, effective tool to flag postmenopausal women at increased risk for accelerated atherogenesis and related adverse outcomes, reported Laszlo B....

Obesity-related mortality.(mortality reports)(Brief Article)
June 1, 2005... Obesity was associated with an estimated 111,909 excess deaths in the United States in the year 2000, reported Katherine M. Flegal, Ph.D., of the National Center for Health Statistics, Hyattsville, Md., and her associates. A study by the...

Middle-aged obesity and dementia risk.(Brief Article)
June 1, 2005... People who are obese or overweight at middle age are at significantly greater risk for dementia in later life than normal-weight people, reported Rachel A. Whitmer, Ph.D., of the division of research, Kaiser Permanente, Oakland, Calif. The...

Obesity rising for all income levels.(CLINICAL CAPSULES)(Brief Article)
June 1, 2005... Obesity has largely been considered a problem for people with lower income levels, but new data suggest that the waist-lines of people with higher income levels are catching up, reported Nidhi Maheshwari, M.B., of the University of Iowa College...

Eating disorders with substance abuse require integrated treatment.(Psychiatry)
June 1, 2005... MONTREAL. -- Comorbid eating disorders and substance abuse are intertwined behaviorally and biologically, so the treatment of both problems must be an integrated effort, Cynthia M. Bulik, Ph.D., said at an international conference sponsored by...

Psychiatric disorder rate high among regular opioid users.(Psychiatry)
June 1, 2005... VANCOUVER, B.C. -- Psychiatric disorders are common among people taking opioid medications, Mark D. Sullivan, M.D., reported at the annual meeting of the American Psychosomatic Society. Data from the first population-based investigation of...

Physician substance abuse relapse.(Psychiatry)(Brief Article)
June 1, 2005... For physicians and other health professionals, the risk of substance abuse relapse was greater in those who used major opioids, had a coexisting psychiatric illness, or had a family history of substance abuse, Karen B. Domino, M.D., and her...

Drug-related emergency department visits from June to December 2003.(DATA WATCH)(Brief Article)
June 1, 2005... Drug-Related Emergency Department Visits From June to December 2003 Adverse reaction, 25% Overmedication, 17% Seeking detox, 10% Suicide attempt, 6% Alcohol only, 4% Accidental ingestion, 3%...

Stressors differ for reservists, active-duty troops.
June 1, 2005... COLORADO SPRINGS -- As U.S. troops rotate home from Iraq, the psychosocial problems they bring with them tend to differ depending upon whether they are active duty or National Guard reservists, Thomas L. Jewitt, M.D., said at a symposium on...

Thorough history can explain incomplete antidepressant response.(Psychiatry)
June 1, 2005... SAN FRANCISCO -- The goal of antidepressant treatment should be remission, but most clinical trials use a 50% response in 50% of patients as the criterion for effectiveness. Only about 20%-30% of patients achieve complete remission, and this...

Study disputes delayed onset of antidepressant effect.(Brief Article)
June 1, 2005... There appears to be relatively little delay before a true antidepressant effect takes hold, despite the widespread belief that the drugs require several weeks to work, according to a study by Michael A. Posternak, M.D., and Mark Zimmerman,...

Zoloft was the leading SSRI/SNRI in 2004.(DATA WATCH)(Brief Article)
June 1, 2005... Zoloft Was the Leading SSRI/SNRI in 2004 Zoloft 28% Effexor XR 23% Lexapro 16% Celexa 9% Paxil CR 8% All Others 16% Note: Based on share of total wholesale purchases for selective serotonin reuptake...

Giving birth vaginally doubles incontinence risk.(Women's Health)
June 1, 2005... RANCHO MIRAGE, CALIF. -- Women who had delivered vaginally were more than twice as likely to report stress urinary incontinence as were women who had delivered only be cesarean section in a study of 271 sets of identical twin sisters. In a...

Simvastatin trial points to benefits in PCOS.(Women's Health)(polycystic ovarian syndrome)
June 1, 2005... LOS ANGELES -- Simvastatin lowered testosterone levels by 41%, normalized gonadotropin levels, and reduced cardiovascular risk factors in a small, randomized, controlled trial, suggesting that statins may be a potential treatment for polycystic...

Controversy erupts over proteomics studies.(Women's Health)
June 1, 2005... Systematic bias in the design of several underlying studies raises doubt over whether a serum proteomics test based on those studies can accurately identify ovarian cancer, two independent biostatisticians have argued. The researchers,...

Counseling helps women at risk for ovarian cancer take action.(Women's Health)(Brief Article)
June 1, 2005... NEW YORK -- Enhanced counseling can help women at high risk of ovarian cancer make better use of the information they receive from genetic testing for BRCA1 and BRCA2 mutations, according to a study presented in poster form at a cancer...

Hypothyroidism tied to lower breast ca risk.(Women's Health)
June 1, 2005... Women treated for hypothyroidism were less likely to develop primary breast carcinoma--and more likely to have more indolent disease when they did develop cancer--than women with normal thyroid function in a retrospective, case-control study....

Study identifies novel breast cancer prognostic markers.(Women's Health)(Brief Article)
June 1, 2005... ATLANTA -- New data suggest that the Notch signaling genes--Notch1 and Jagged1--are potential prognostic markers for breast cancer, Michael Reedijk, M.D., reported at a symposium sponsored by the Society of Surgical Oncology. "Patients...

African Americans just as likely as whites to pursue BRCA test.(Women's Health)(genetic testing for breast cancer )
June 1, 2005... GRAPEVINE, TEX. -- African American women are almost as likely to pursue genetic testing for breast cancer as are white women, North Carolina researchers found. "There is a perception in the genetic counseling field that African Americans...

Breast MRI shows promise for high-risk women.(Women's Health)
June 1, 2005... NEW YORK -- Breast MRI may have difficulty keeping up with the "potentially logarithmic demand" for its use as a cancer screening tool, experts said at a cancer symposium sponsored by New York University and by the Lynne Cohen Foundation for...

MRI screening can serve as complement to mammography.(Women's Health)
June 1, 2005... CHICAGO -- Magnetic resonance imaging detects more breast cancers than mammography in high-risk women, according to the first international study comparing the two screening methods. "Our results support the benefit of MRI screening, not as...

Patients who had a mammogram during preceding 2 years.(DATA WATCH)(Illustration)
June 1, 2005... Patients Who Had a Mammogram During Preceding 2 Years Highest Screening Rates Rhode Island 85.4% Delaware 84.2% Lowest Screening Rates Mississippi 67.6% Idaho 67.0% Note: Based on estimated data...

FDA okays ropinirole for restless legs syndrome.(Rx)
June 1, 2005... MIAMI BEACH -- The antiparkinsonism drug ropinirole is now indicated for the treatment of adults with moderate to severe restless legs syndrome. The Food and Drug Administration approved the new indication based on three randomized,...

Testosterone replacement for male hypogonadism.(DRUG UPDATE)
June 1, 2005... Testosterone replacement therapy is approved by the Food and Drug Administration for men with hypogonadism resulting from the failure of the testes to produce testosterone. Men with true bypogonadism have symptoms of sexual dysfunction, low...

Progress slow for online clinical trial registries.(pharmaceutical companies agreed to set up Web sites )
June 1, 2005... NEW YORK -- When questions were raised about possible concealment of clinical trial data, two pharmaceutical companies agreed last year to set up Web sites where such data would be posted. It appeared at that time that others in the...

Transdermal and intranasal delivery systems now in pipeline for treating depression, ED.(Rx)
June 1, 2005... NEW YORK -- Two new transdermal and intranasal drug delivery systems, for which approval is foreseeable, may have utility in treating depression and erectile dysfunction, Donald S. Robinson, M.D., said at a meeting on psychopharmacology...

Catheter ablation of atrial fib effective.(Cardiovascular Medicine)
June 1, 2005... ORLANDO, FLA. -- A single session of catheter ablation of atrial fibrillation backed up by antiarrhythmic drug therapy proved markedly more effective than antiarrhythmic drugs alone at preventing atrial arrhythmia recurrences in the first-ever...

Propafenone called drug of choice for rhythm control in atrial fib.(Cardiovascular Medicine)
June 1, 2005... ORLANDO, FLA. -- Propafenone outperformed sotalol for long-term maintenance of sinus rhythm in patients with recurrent atrial fibrillation in a randomized, single-blind, placebo-controlled trial, Nikos E. Igoumenidis, M.D., reported at the...

Warfarin: real world stroke prevention doesn't match trials.(Cardiovascular Medicine)
June 1, 2005... NEW ORLEANS -- Real world experience with warfarin suggests that it is not as good at preventing strokes in patients with atrial fibrillation as clinical trial results suggested, especially among African Americans. A review of more than...

CorCap helps even without mitral valve surgery.(Cardiovascular Medicine)
June 1, 2005... PHILADELPHIA -- Surgical placement of the CorCap cardiac support device led to significant but modest improvements in heart failure patients who did not undergo concurrent mitral valve surgery. The moderate benefit in patients with severe...

Support device enhances MV surgery outcomes.(Cardiovascular Medicine)
June 1, 2005... SAN FRANCISCO -- Mitral valve surgery in patients with mitral regurgitation and advanced systolic heart failure induces reverse ventricular structural remodeling, a major benefit that's further augmented by implantation of the CorCap cardiac...

Poor kidney function portends anemia in heart failure patients.(Cardiovascular Medicine)(Brief Article)
June 1, 2005... NEW ORLEANS -- Poor kidney function is the strongest indicator for anemia in heart failure patients, according to the results of a large study of HMO patients. A reduced glomerular filtration rate emerged as the strongest risk factor for...

Use of BNP to guide heart failure Tx reduced deaths.(Cardiovascular Medicine)(B-type natriuretic peptide levels to guide medical therapy )(Brief Article)
June 1, 2005... ORLANDO, FLA. -- Use of serial plasma B-type natriuretic peptide levels to guide medical therapy for systolic heart failure was linked to significant reductions in heart failure-related deaths and hospitalizations, Patrick Jourdain, M.D.,...

Intensive statin Tx most effective in older patients.(Cardiovascular Medicine)
June 1, 2005... ORLANDO, FLA. -- Intensive statin treatment produced a bigger benefit in elderly patients at high risk for coronary artery disease than in younger patients, based on a new analysis from the PROVE IT-TIMI 22 study. Intensive statin...

Coenzyme [Q.sub.10] eased statin-induced muscle pain.(Cardiovascular Medicine)(Brief Article)
June 1, 2005... ORLANDO, FLA. -- Coenzyme [Q.sub.10] markedly reduced statin-induced myopathic pain in a randomized, double-blind controlled trial with 41 patients. "I was surprised at the strength of the outcome. I'd been skeptical," Patricia Kelly,...