Healthy Start | Winter 2006

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Cook Children’s Medical Center

Spring 2006

Cook Children’s Adds Pediatric Urgent Care Services in Lewisville

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ediatric urgent care services are opening in Lewisville early in 2006 at the new Cook Children’s Urgent Care Center, located at 401 North Valley Parkway. Commerciallyinsured children with minor illnesses and injuries, including flu, colds, lacerations and sprains, can be seen here by physicians.

Daily hours of 11 a.m. to 10 p.m. provide parents urgent pediatric health care when their child’s own primary care physician may be unavailable. The addition of urgent care in this location supplements Cook Children’s services already offered in Lewisville, which include

Special Needs Children with special needs, such as treatment for cancer, diabetes or behavioral health care, may be seen

by Cook Children’s specialists adjacent to the urgent care center. Specialties represented include: ■

Endocrinology for the treatment of diabetes, growth and metabolic issues

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Genetics counseling

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Hematology/oncology or childhood cancers and blood disorders

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Nephrology for children with renal disease

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Neurology for the treatment of diseases, disorders and injuries to the developing brain, spinal cord, nerves and muscles; epilepsy

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Psychology and psychiatry

specialty care at the same location and primary care at 751 Hebron Parkway.

“We’re opening during the busiest season of the year when emergency rooms and hospitals are often overloaded with cases of flu and asthma,” says Gary Floyd, MD, medical director of pediatric urgent care centers and public policy for Cook Children’s. “We hope to keep some of those visits down by offering help to kids in respiratory distress and with dehydration often caused by the two illnesses.

The use of monitored nebulizer treatments and rehydration can often prevent more serious long-term care.”

The most common procedures offered are routine X-rays, blood tests, urinalyses and tests for respiratory syncytial virus (RSV), rotavirus, influenza and mononucleosis. The staff communicates with lab staff at the main campus of Cook Children’s Medical Center in Fort Worth and may refer children needing special tests to the downtown facility at any time.

Cook Children’s Urgent Care Centers

The Lewisville Urgent Care Center is located in the same building as the Cook Children’s Specialty Care Clinic. are open daily and are staffed by physicians with pediatric experience.

Urgent care centers also are located in Fort Worth and Hurst. The new Lewisville center includes four exam rooms and one procedure room. Up to six additional rooms are available afterhours and on weekends in the adjacent specialty clinic area. A lab and a radiology center are on site to expedite tests.

Cook Children’s entered the Lewisville market in the mid 1990s with behavioral health services. In 1997, Cook Children’s Physician Network opened a primary care clinic in Lewisville. ❖

To Learn More For more information about Cook Children’s Urgent Care Center in Lewisville, call 972-434-0035. For more information about specialty care and primary care physicians available throughout the area, visit our Web site, www.cookchildrens.org.

Techniques for Taming Tantrums Take steps to avoid them, but if that fails, know what calms your child

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our little one is having a kicking, screaming mega-meltdown in the frozen-food aisle. And you’re sure everyone in the market is thinking, “Why is that child carrying on, and how come the parent isn’t doing something to stop it?”

The period from 14 to 30 months is a peak time for tantrums, says Lynn Wegner, MD, FAAP, a developmental and behavioral pediatrician and adjunct professor at the University of North Carolina in Chapel Hill. Toddlers that age are learning to verbalize their feelings.

“Tantrums are a normal occurrence in toddlers,” adds Julian Haber, MD, developmental and behavioral pediatrician for Cook Children’s Medical Center. “In many young

Julian Haber, MD, is a developmental and behavioral pediatrician with Cook Children’s Medical Center.

children, tantrums are an act of frustration caused when children just beginning to learn language cannot fully express their needs.”

Young children whose “wants” are being blocked are apt to lose control, especially when hungry, tired or overstimulated. Parents in a chaotic public setting, focusing on the task at hand, are less likely to notice shifts in their child’s mood. This means they may miss the chance to defuse matters before a fullblown tantrum breaks out.

“Never have an adult temper tantrum in response to your child’s tantrum,” continues Dr. Haber. “A parent yelling, screaming and showing signs of frustration accomplishes very little. Try to stay calm and defuse the ruckus.”

Dr. Haber goes on to warn parents not to reward a child by giving in to his or her demands. “Doing this might foster a learned behavior and cause more tantrums.”

Preventing a tantrum is much easier than stopping one. So before you step out with your child: Try to plan your outing for a time when crowds are few. That helps you avoid long lines and reduces embarrassment if it all falls apart anyway.

■ Ensure you and your child are well-fed, comfortably dressed and rested before you leave.

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Bullies Go High-Tech Talk with your child about online harassment

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Model used for illustrative purposes only.

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ou can now add bullying to the list of things made easier by technology.

The teasing and taunting of one child or teen by another through an electronic device is called cyber-bullying, e-bullying or online bullying. This 21st-century form of an age-old threat came with the rise of the “alwaysconnected” generation.

Two out of five children have been bullied online, according to a 2004 survey by the nonprofit i-SAFE America, which promotes kids’ Web safety. Bullies use e-mail, instant messaging and text messaging on cell phones to reach victims.

“Cyber-bullying is escalating as children embrace technology,” says Mary Worthington, elementary education coordinator for the Network of Victim Assistance (NOVA). “There’s a growing

trend to use technology to annoy, harass and torment.”

So the bully bent on malice has new weapons. Their nameless nature can make the bully bolder. The victim can be reached anytime, anywhere. A child can flee a school-yard bully just by leaving, but that won’t work in cyberspace.

“Cyber-bullying is escalating as children embrace technology.”

—Mary Worthington, elementary education coordinator, Network of Victim Assistance (NOVA) Parents often don’t know of the problem because children hesitate to report it.

“Awareness is the first step,” says Ms. Worthington, “and education the key.”

Offer some run-around time before you confine your child to a shopping cart or stroller.

■ Bring toys, snacks or books to entertain and distract.

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Even with preparation and planning, tantrums are bound to happen at times. When they do: Make sure the environment is safe if your child is kicking, flailing or throwing things. Remove the child if sharp corners, breakables or other objects pose injury risks.

■ Remove your child if you want to avoid disturbing others or ease your own stress. It may be easier to calm the child in a quiet place.

■ Don’t worry about other people’s reactions. Focus on your child, Dr. Wegner says. Pick actions based on your child’s unique needs and temperament. Some youngsters respond to being held or to a parent’s calm, repetitive words.

Others do best with watchful waiting.

■ Stay centered, take deep breaths and remember: This too shall pass.

Hopefully, soon! ❖ ■

[ health bits ] Kids’ Shots Are Often Late Nearly two out of five U.S. children are “undervaccinated” for more than six months during their first two years of life, a study found. “It’s really important that kids get vaccinated on time, especially during the first two years, because that’s when they are at highest risk for many of the vaccine-preventable diseases,” says study author Elizabeth Luman, PhD, a National Immunization Program disease expert. Children need about 15 to 20 shots to head off measles, mumps and chickenpox before their second birthday. While 73 percent of children get all the shots they need, just 9 percent get them all on time, researchers wrote in the Journal of the American Medical Association. To check the vaccination schedule, ask your doctor or visit www.cdc.gov/nip.

Spacers on Inhalers Curb Asthma Attacks Fighting a child’s asthma attack could be as simple as sliding a plastic tube onto the end of an inhaler, University of Florida researchers say. Yet a lot of doctors don’t give parents this option, they add. The plastic tube is a holding chamber, or spacer. Using a metereddose albuterol inhaler with a spacer and increasing the number of puffs to treat breathing trouble works as well as a nebulizer, studies show. It also causes fewer side effects.

“Most doctors and patients misbelieve that a nebulizer is more effective than an inhaler,” says Florida professor Leslie Hendeles, PharmD, lead author of a report in the American Journal of Health-System Pharmacy. A nebulizer turns albuterol into a fine mist that patients breathe in through tubes. An inhaler uses albuterol at a lower dose. The spacer makes the inhaler more effective.

Air Bags Can Harm Kids 14 and Under So what’s a parent to do? It may not be possible to make a child bully-proof, but here are some ideas: ■ Place the computer in a common family room to keep an eye on its use.

■ Remind your child: — Don’t open e-mails or accept instant messages from unknown senders.

— Don’t share your phone number, password or e-mail address.

— Don’t reply to any bullying or disturbing message.

— Tell an authority figure at once if a threatening message shows up.

■ Report threatening contact right away to the service provider.

■ Watch for changes in a child’s behavior that can signal problems like bullying.

“That way,” Ms. Worthington says, “parents can actively partner with their children and make good decisions.” ❖

Children 14 and younger shouldn’t sit in the front seat of cars with air bags, says a study in Pediatrics. Federal rules say carmakers must warn of a risk for air bag injuries for children 12 and younger. But researchers looked at an eight-year sample of 3,790 children ages 1 month to 18 years who were seated in the right front seat during crashes. The study found kids 14 and younger were at high risk for serious injury from air bags. Air bags tended to protect children ages 15 and up. “When my 13-year-old nephew wants to sit in the front seat now, I won’t let him,” says study lead author Craig Newgard, MD, an emergency medicine researcher at Oregon Health & Science University.

Inactive Girls Gain Weight Inactive teen girls gained an average of 10 to 15 pounds more than active girls during a 10-year study, The Lancet reports. At ages 9 and 10, there were slight differences in body mass index — about 4 to 5 pounds — between active and inactive girls. But the gap grew by the time the 2,379 girls in the study turned 19. The girls’ calorie intake rose just a bit and did not seem to be tied to the weight gains. “Just preventing the decline in physical activity that currently occurs among adolescent girls may be enough to prevent obesity,” says research nutritionist Eva Obarzanek, PhD, of the National Heart, Lung, and Blood Institute.

For child health and safety information, check out the Cook Children’s Web site at www.cookchildrens.org.

Healthy Start, Spring 2006 3

Cook Children’s Expands Heart Center New facilities have increased access for children with heart defects or abnormalities

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OR MANY YEARS, children with heart defects and other heartrelated anomalies have been coming to Cook Children’s Medical Center for diagnosis and treatment.

In October, the doors to the newly expanded Cook Children’s Heart Center opened, providing more than double the existing space and more amenities to allow clinical staff to better serve a growing patient base. The new 14,000square-foot facility now includes two catheterization labs, four echocardiography suites and two cardiothoracic surgery operating rooms. The linking of all three facilities into one area makes the Cook Children’s Heart Center one of the more sophisticated heart centers in the United States.

Cook Children’s Heart Center offers diagnostic and treatment options for most congenital heart defects and heart conditions. Cardiologists, cardiothoracic surgeons and a team of clinicians care for newborns, infants, children and young adults from across the United States, and occasionally from foreign countries.

Echocardiography suites There are four echocardiography suites in the Heart Center, double the number in the former facility.

Echocardiography is a diagnostic imaging procedure that allows physicians to observe cardiac anatomy, blood circulation and heart pumping function, and is an important tool in evaluating children with heart problems. It also assists cardiologists checking for heart defects in a fetus prior to birth or monitoring a patient’s heart function following openheart surgery.

The introduction of new, 3D echocardiography improves the clarity of images, which helps physicians

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diagnose heart defects more precisely.

Now, cardiologists can digitally record a patient’s echocardiogram, improving the quality of each image.

In addition, new data ports allow realtime digital images to be downloaded and viewed by multiple physicians and technicians while the procedure is under way. These images also can be stored online and viewed during later procedures to determine changes that have occurred.

The Heart Center’s two cardiothoracic surgery operating rooms have the latest technology. Digital images from the echo rooms can be uploaded and displayed on one of the flat-screen monitors, while real-time images from the surgery are viewed on the others.

More than 11,000 echocardiograms were performed last year at the medical center and at several Cook Children’s facilities in Fort Worth and across North and West Texas.

Catheterization labs The expanded Heart Center’s two new catheterization labs will allow physicians to double the number of cath procedures performed at the medical center. Cook Children’s is a national leader in the use

of pediatric heart cath procedures to treat abnormal heart rhythms, called arrhythmias. Physicians thread a thin, sterile catheter through a vein to the heart to pinpoint the origin of an irregular heartbeat, then either freeze or use electromagnetic energy to destroy the abnormal tissue causing the arrhythmia.

In 1999, Cook Children’s was the first pediatric facility in the nation to install Ensite3000 cardiac mapping software. This software helps physicians find the source of abnormal heart rhythms. In 2003, Paul Gillette, MD, medical director of cardiology at Cook Children’s Medical Center, performed the country’s first pediatric cryoablation catheter procedure.

The new catheterization labs have the most advanced technology available to date, with flat-panel detectors for patient safety, image quality and table-side control for imaging, as well as radiation safety. The new equipment allows staff to see several views of the patient so that adjustments can be made and areas of concern can be addressed during the procedure. This is more comfortable for the child and more convenient for the parents. A glass-enclosed viewing area allows staff and students to observe the procedure without entering the room.

Children with a number of anatomic congenital heart defects are treated in the catheterization labs to correct problems without open-heart surgery. Heart Center staff now are able to perform simultaneous electrophysiology cases and cardiac catheterizations or cardiac interventions, which allows families greater flexibility in scheduling their procedures.

Last year, more than 430 heart catheterization procedures were performed at the medical center. Over the past five years, use of the heart cath lab has increased by 30 percent.

The Heart Center’s two new catheterization laboratories have the most advanced technology available to date, with flat-panel detectors for patient safety, image quality and table-side control for imaging, as well as radiation safety. The glass-enclosed viewing area allows students and staff to observe the procedure without entering the room.

Cardiothoracic surgery operating rooms With two new cardiothoracic surgery operating rooms, the expanded Heart Center now can serve more children who need surgery for defects of the heart and circulatory system. Both large operating rooms include sterilization units for immediate or special needs during surgery. Digital images from the patient’s echocardiogram can be uploaded and displayed on one of the flat-screen monitors during surgery, right next to the real-time images of the actual surgery.

Vincent K.H. Tam, MD, medical director of cardiothoracic surgery at Cook Children’s, is a specialist in repairing complex pediatric heart defects, especially hypoplastic left heart syndrome (HLHS). HLHS, one of the more common heart defects, requires a series of three surgeries over several years to restore

proper circulation and function.

Dr. Tam and his team also perform surgeries to correct atrial septal defects, ventricular septal defects, tetralogy of Fallot, pulmonary atresia, transposition of the great arteries and more.

More than 325 heart surgeries were performed at the medical center last year.

Other amenities The new Heart Center waiting room offers families comfort and privacy. Its close proximity to the procedure areas allows convenient interaction between parents, physicians and other medical staff before, during and after procedures.

The facility also includes a preprocedure and recovery unit. Parents can stay with their child until surgery and simply walk a few feet down the hall to the waiting room once the child goes into the procedure room.

A physician is always on call in the Cook Children’s Heart Center and the new physician on-call room gives physicians a quiet, private area where they can work, read or sleep — just steps away from their patients.

“We’re excited to offer families a lovely new facility that more than doubles our capacity to treat children with heart conditions,” says Dr. Gillette.

“In an area that is growing as fast as North Texas, it’s important to keep up with the demand for services. This new facility offers the latest in technology and a highly trained staff to serve the children of our community.” ❖

To Learn More For more information, go to www.cookchildrens.org.

Healthy Start, Spring 2006 5

Is It Time for Contacts?

Maturity, not age, should be your focus

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hat’s the right age for contact lenses?

That’s a tricky question — there is no “right age,” experts say. Your children are ready for contacts when they’re emotionally mature enough to handle them.

“I’ve had some young people at 20 and 21 that I wouldn’t fit,” says Barry Weiner, OD, a member of the American Optometric Association (AOA) Contact Lens and Cornea section. He’s also fitted contacts for children as young as 8 — a very mature 8.

“The child has to be ready,” says Dr. Weiner, who often gives children their first contacts around age 12 or 13. How can you tell? “I think the biggest thing is if they take responsibility for themselves at home,” he says — in their appearance, their bedtime or their homework, for instance.

With today’s disposable contacts, says Dr. Weiner, the doctor can teach your kids proper lens care and send them home with a pair to see how they handle the responsibility.

Eric Packwood, MD, is an ophthalmologist with Cook Children’s Medical Center.

If your children abuse the lenses, it’s no great loss to pull the plug.

Dr. Weiner says an eye-care professional also will assess your child’s vision needs when considering contacts. Personal wear and care regimens may depend on the type of contact prescribed, the nature of the vision problem and the child’s eye chemistry.

“Listen to the eye doctor’s recommendation as to lens care,” he adds.

Eric Packwood, MD, an ophthalmologist with Cook Children’s, agrees with Dr. Weiner, but adds that contact lens-related infections, typically resulting from lack of adherence to the safety tips listed below, can cause scarring.

“Central scarring of the cornea (front of the eye) can result in devastating, permanent vision loss and/or can require cornea transplant surgery,” warns Dr. Packwood. “The most dangerous situation is one in which individuals obtain, without a prescription, colored contact lenses from retail stores or friends. We too frequently see these patients when they have developed corneal ulcers. Some will never regain normal vision.” ❖

Safety Tips ■

Visit a reputable eye-care professional for a complete eye exam at least once a year.

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Disinfect your lenses after removal before wearing them again.

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Wash and rinse your hands with nonperfumed hand soap before handling lenses.

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Use only FDA-approved tinted lenses prescribed by a licensed practitioner.

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Never swap lenses with another person.

“The big problem is swapping eye infections,” says Dr. Weiner.

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Don’t use saliva, non-sterile homemade saline, distilled water or tap water for lens care.

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Don’t wear lenses longer than prescribed, or when sleeping, unless otherwise directed.

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Use doctor-recommended solutions. Not all can be mixed or used for all lenses.

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If eyes become red or irritated, remove lenses immediately and consult your doctor.

To avoid contamination, don’t let your solution’s bottle tip touch any surface, including your contacts.

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Replace contacts regularly. Toss disposable lenses after the recommended period.

Clean, rinse and air-dry your lens case each time lenses are removed.

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SOURCE: The Contact Lens Council

Take the Asthma Quiz This chronic lung condition affects many children

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hat do Ludwig van Beethoven, Jackie Joyner-Kersee and John F. Kennedy have in common? Asthma!

Inflamed airways cause asthma and its recurrent or chronic breathing problems. The National Institute of Allergy and Infectious Diseases estimates that asthma affects about 7.7 million children under age 18.

“The reported incidence of asthma has increased significantly in the past several decades in both children and adults,” says Nancy Dambro, MD, medical director of pulmonology at Cook Children’s Medical Center. “The more parents know about asthma, the better they can help their child control it. Patient education and a prescribed

Babies Need “Tummy Time” Put infants to sleep on their backs, but act to avoid flat heads while they’re awake

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simple piece of advice in 1992 cut the death rate from sudden infant death syndrome (SIDS) by more than half. That was the year the American Academy of Pediatrics (AAP) told parents to put babies to sleep on their backs.

Now, the experts have some new advice to reduce the odds of flattened heads, a possible result of babies spending so much time on their backs.

No one’s sure how common flat heads are. Statistics vary a great deal, “from one in five cases for a mild form to one in 500 to 600 cases,” says AAP spokesman John Persing, MD, a professor and chief of plastic surgery at Yale University School of Medicine.

Answer: c. Half of all cases develop in childhood. Many cases vanish by adulthood, but it may come back again later in life.

2. Asthma symptoms: a. Vary b. Include coughing, wheezing, chest

tightness and shortness of breath c. Can signal a severe asthma attack d. All of the above

Answer: d. “While the type, frequency and severity of asthma symptoms vary from one patient to the next, they’re all related to difficulty in breathing,” says Mario Castro, MD, of the Washington University Asthma Center in St. Louis. action plan are essential to helping patients with asthma lead normal lives.”

3. Asthma triggers include: a. Allergens (pollen, mold, dust, pet

4. Proper asthma management includes: a. Avoiding asthma triggers b. Taking prescribed medications c. Watching asthma to notice signs

that it’s worsening d. Knowing what to do e. All of the above

Answer: e. The National Heart, Lung, and Blood Institute says you should take these steps to care for asthma even when symptoms don’t exist.

5. Children with asthma should: a. Never exercise b. Limit exercise c. Work with their doctor on a plan to

head off exercise-induced attacks Answer: c. Under the supervision of their doctors, children can maintain a healthy, active lifestyle that includes exercise. ❖

dander)

See how much you know:

b. Strong odors (perfumes, paints,

cleaners)

1. Asthma is the leading cause of chronic

illness in children. When does it usually show up? a. At birth b. Before age 5 c. Before age 10 d. Before age 15

c. Colds, flu and respiratory

infections d. All of the above

Answer: d. Other triggers include weather changes, medicines, indigestion, pollution, food and second-hand smoke.

When babies are awake, put them on their tummies for a while. This eases pressure on the back of the head and helps babies build shoulder and neck strength. “This time must be supervised, 100 percent of the time,” Dr. Persing says. “Don’t even run to the bathroom and leave an infant on the tummy.”

■ Relieve pressure on the back of the head when you lay an infant down for sleep “by very gently turning his or her head 45 degrees to the left one night, then 45 degrees to the right the next night,” says Dr. Persing.

■ Change the crib’s position a few times a week. As your child looks around the room, the head will be in a new position because of that change.

■ Don’t overuse car seats when the child is not in a car. When in a car, move the car seat often from one side to the other.

■ If your child develops a flat spot on the head, see your doctor. Such flat spots usually form on the back or side of the head.

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But doctors have seen a “significant increase” in flat heads in the past decade, says a 2003 article Dr. Persing wrote in Pediatrics.

“It’s very important for infants to get some tummy time when they are awake and supervised,” says John Kattwinkel, MD, chairman of the AAP Task Force on SIDS and a pediatrics professor at the University of Virginia School of Medicine.

To avoid a flat head, Drs. Persing and Kattwinkel offer these tips: ■

Parents should still place babies on their backs for sleep.

Nancy Dambro, MD, is the medical director of pulmonology at Cook Children’s Medical Center.

“In addition to the avoidance of a flat head, ‘tummy time’ also is important for the healthy development of infants,” says Chanda Simpson, MD, a neonatologist at Cook Children’s Medical Center.

“Strengthening the baby’s neck and shoulder muscles help your baby achieve important developmental milestones, such as sliding on their bellies, pushing up on their hands and knees, and crawling.”

“We can’t emphasize enough, however, the importance of supervising babies while they are on their tummies,” adds Dr. Simpson.

The AAP Web site offers information on Tummy Time at www.aap.org, or go to www.cookchildrens.org for a link to the AAP Web site. ❖

Chanda Simpson, MD, is a neonatologist at Cook Children’s Medical Center.

Healthy Start, Spring 2006 7

801 Seventh Avenue Fort Worth, TX 76104

For address changes or if you do not wish to receive these materials, please send updated information to: Cook Children’s Health Care System Attn: Public Relations 801 Seventh Ave. Fort Worth, TX 76104 or call 1-800-934-COOK (2665).

www.cookchildrens.org

Teaching the Next Generation of Healers

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eaching future doctors how to provide child-friendly and family-centered care is as much an art as it is a science. While few in number, children’s hospitals train almost one-third of our nation’s pediatricians and half of all pediatric specialists, such as neurologists or cardiologists. If you have children, they’ve probably been cared for by a pediatrician or a family practice physician who trained at a children’s hospital at some point in his or her career.

Because children’s hospitals often take care of children with very serious and complex conditions, such as cancer,

To Learn More To learn more about the importance of graduate medical education to children’s health and children’s hospitals, visit www.childrenshospitals.net or www.cookchildrens.org.

cystic fibrosis or heart transplants, they must provide the most technologically advanced care available. Doctors in training at children’s hospitals get specialized education and unique experience that no other hospital can provide.

But teaching great physicians takes time and money. While Medicare pays for training physicians in adult hospitals, children’s hospitals don’t qualify for this funding because they don’t treat adult patients. That’s why, in 1999, the National Association of Children’s Hospitals (NACH) successfully lobbied Congress to create the Children’s Hospitals Graduate Medical Education payment program. This program provides federal funding to nearly 60 children’s hospitals that train physicians and ensures children’s hospitals can continue to provide quality care while they train the next generation of healers.

However, NACH and children’s hospitals must appeal to Congress for this

funding each year.

Ask your children’s hospital how you can help make sure children’s hospitals get the money they need to train the doctors who care for children.

Children’s hospitals also train nurses, occupational therapists, social workers, dentists and other health care professionals. By receiving professional training in a children’s hospital, our nation’s future health care professionals gain an appreciation for the specialized needs of children and develop the skills and compassion needed to care for families. ❖

NACHRI National Association of Children’s Hospitals and Related Institutions www.childrenshospitals.net

Articles in this newsletter are written by professional journalists or physicians who strive to present reliable, up-to-date information. But no publication can replace the care and advice of medical professionals, and readers are cautioned to seek such help for personal problems. ©2005 Health Ink Communications, 780 Township Line Road, Yardley, PA 19067, 267-685-2800. Some images in this publication may be provided by ©2005 PhotoDisc, Inc. All models used for illustrative purposes only. Some illustrations in this publication may be provided by ©2005 The Staywell Company; all rights reserved. (106)