Abstract: Objectives: We sought to compare the therapeutic benefits of ThermaCare Heat Wrap combined with an education program to an education-only program on reducing pain and disability from acute work-related low back pain. Methods: Forty-three eligible patients, aged 20 to 62 years who presented to an occupational injury clinic, were randomized into one of two intervention arms: 1) education regarding back therapy and pain management alone or 2) education regarding back therapy and pain management combined with three consecutive days of topical heat therapy (104[degrees]F or 40[degrees]C for 8 hours). The primary endpoints in this trial were measures of pain intensity and pain relief levels obtained approximately four times per day for the three consecutive working days of treatment, followed by measures of pain intensity and pain relief levels obtained in three follow-up visits at day 4 and 14 from treatment initiation. The secondary measures were overall impairment due to injury and disability caused by low back pain assessed at Intake, Visit 2 (day 4), 3 (day 7), and 4 (day 14). Results and Conclusion: A total of 18 individuals enrolled in the education-only group and 25 in the treatment group completed the intervention and all follow-up visits. The general linear model adjusting for age, sex, baseline pain intensity, and pain medication indicated that the topical heat therapy had significantly reduced pain intensity, increased pain relief, and improved disability scores during and after treatment. Journal of Occupational & Environmental Medicine. 47(12):1298-1306, December 2005.

On Tuesday, Gov. George E. Pataki introduced the 2006-2007 budget for New York State which includes a comprehensive workers compensation reform. The bill would amend the workers' compensation law, the executive law and the insurance law, in relation to compensation claims. To read the proposed WC bill click on the link below.

Abstract BACKGROUND AND PURPOSE: Whether vertebroplasty increases the risk of adjacent-level vertebral fractures remains uncertain. Biomechanical and clinical studies suggest an increased risk, but compelling data have not yet been put forth to settle this difficult issue. We believe that an analysis of the time interval between vertebroplasty and subsequent fractures may shed additional light on this debate. We specifically hypothesized that subsequent fractures would occur sooner and more frequently in the vertebrae adjacent to the treated level. METHODS: We performed a retrospective analysis of the risk and timing of subsequent fractures in patients previously treated with vertebroplasty. Multiple linear regression was used to explore factors that influence the time to new fracture following vertebroplasty. Fractures were then divided on the basis of whether they occurred adjacent or nonadjacent to the treated level. Survival analysis was used to compare time to new fracture among the 2 groups, and the relative risk of both types of fracture was calculated. RESULTS: In this study, 186 new vertebral fractures occurred in 86 (19.9%) of 432 patients. Seventy-seven (41.4%) fractures were of vertebrae adjacent to the level treated with vertebroplasty. Median times until diagnosis of new adjacent and nonadjacent level fractures were 55 days and 127 days, respectively. Time to fracture was significantly different between the 2 groups (logrank <0.0001). Distance of the new fracture from the treated level was also significantly associated with time to new fracture (P < .0001). Relative risk of adjacent level fracture was 4.62 times that for nonadjacent level fracture. CONCLUSION: These data demonstrate an association between vertebroplasty and new vertebral fractures. Specifically, following vertebroplasty, patients are at increased risk of new-onset adjacent-level fractures and, when these fractures occur, they occur sooner than nonadjacent level fractures. American Journal of Neuroradiology 27:217-223, January 2006

ABSTRACT OBJECTIVES: We determined whether caloric restriction (CR) has cardiac-specific effects that attenuate the established aging-associated impairments in diastolic function (DF). BACKGROUND: Caloric restriction retards the aging process in small mammals; however, no information is available on the effects of long-term CR on human aging. In healthy individuals, Doppler echocardiography has established the pattern of aging-associated DF impairment, whereas little change is observed in systolic function (SF). METHODS: Diastolic function was assessed in 25 subjects (age 53 ± 12 years) practicing CR for 6.5 ± 4.6 years and 25 age- and gender-matched control subjects consuming Western diets. Diastolic function was quantified by transmitral flow, Doppler tissue imaging, and model-based image processing (MBIP) of E waves. C-reactive protein (CRP), tumor necrosis factor-alpha (TNF- ), and transforming growth factor-beta1 (TGF-ß1) were also measured. RESULTS: No difference in SF was observed between groups; however, standard transmitral Doppler flow DF indexes of the CR group were similar to those of younger individuals, and MBIP-based, flow-derived DF indexes, reflecting chamber viscoelasticity and stiffness, were significantly lower than in control subjects. Blood pressure, serum CRP, TNF- , and TGF-ß1 levels were significantly lower in the CR group (102 ± 10/61 ± 7 mm Hg, 0.3 ± 0.3 mg/l, 0.8 ± 0.5 pg/ml, 29.4 ± 6.9 ng/ml, respectively) compared with the Western diet group (131 ± 11/83 ± 6 mm Hg, 1.9 ± 2.8 mg/l, 1.5 ± 1.0 pg/ml, 35.4 ± 7.1 ng/ml, respectively). CONCLUSIONS: Caloric restriction has cardiac-specific effects that ameliorate aging-associated changes in DF. These beneficial effects on cardiac function might be mediated by the effect of CR on blood pressure, systemic inflammation, and myocardial fibrosis. Abbreviations and Acronyms BMI = body mass index CR = caloric restriction CRP = C-reactive protein DF = diastolic function LV = left ventricle/ventricular MBIP = model-based image processing SF = systolic function TDI = tissue Doppler imaging TGF-ß1 = transforming growth factor-beta1 TNF- = tumor necrosis factor-alpha WD = Western diet J Am Coll Cardiol, 2006; 47:398-402

Two upstate New York based health plans, MVP Health Care of Schenectady and Preferred Care of Rochester, announced today that their proposed merger has been completed creating a major new plan serving three quarters of a million members across upstate New York, Vermont and New Hampshire. "The regulatory and legal steps needed to conclude the merger have been completed, and during the months ahead MVP and Preferred care coworkers will be working together to combine two great health plans into one plan that will be a 'leading player' in the Northeast," said David W. Oliker, president and CEO of MVP Health Care. "I want to reassure current MVP and Preferred Care customers that they will not see any changes in day to day operations as a result of this merger, customers will call the same telephone numbers they've always called, talk to the same people they've always talked to, and see the same doctors and health care providers as they did prior to the merger," said Lisa Brubaker, MVP Health Care executive vice president for Rochester operations, and government programs. "The combination gives us the resources to make needed investments in technology to meet the needs of our customers and providers," she said. The company said: • Members of the two plans will see no change in their products and services; • Members, employers and providers will continue to call the same telephone numbers and work with the same people from the same offices across the new combined service area; • Jobs across the new service area will be preserved; • The new combined organization will continue to operate as a not-for-profit. Its board of directors will be a combination of current MVP and Preferred Care directors; • MVP Health Care president and CEO David W. Oliker is the president and CEO of the combined company, which will continue to operate as both MVP Health Care and Preferred Care. During meetings with employees in both Rochester and Schenectady, Oliker outlined his goals for the combined company including: -- A provider network stretching from Rochester to New Hampshire that will be seamless for members and employers. -- Product offerings that will combine the best of both MVP and Preferred Care products and that can be sold throughout the expanded market area. -- Expansion of Preferred Care Medicare programs into several MVP counties. In addition to Oliker, other members of the senior management team for the combined company are drawn from both company's management teams. Lisa Brubaker, Preferred Care senior vice president and chief operating officer will assume the newly created position of MVP executive vice president, Rochester operations and government programs. Thomas Combs, Preferred Care senior vice president and chief financial officer will become executive vice president and chief financial officer of MVP. David Field, MVP chief financial officer and chief operating officer will be the executive vice president and chief operations officer for the combined company. Dennis Allen, M.D, MVP executive vice president and chief medical officer; will have the same role in the combined company. Scott Averill, MVP executive vice president and chief marketing officer will be the chief marketing and sales officer for the combined company. Denise Gonick, Esq., MVP executive vice president and chief legal officer will hold the same position in the combined company. "These executive vice president appointments reflect a blending of the talent of the two organizations," Oliker said. This is a leadership team that will make MVP the perfect example of a well-managed and successful, regional health benefits company," Oliker said. The combined company's service area covers upstate New York, the Hudson Valley, the entire state of Vermont and southern New Hampshire.

ABSTRACT Objectives: To determine if stressful experiences in childhood are associated with an increased risk of chronic back problems later in life. Methods: We conducted a prospective cohort study in the Canadian household population. Study participants were respondents to the first 3 cycles of the National Population Health Survey in Canada who were 18 years of age or older at baseline (n = 9552). Cases of chronic back pain during a 4-year follow-up period were ascertained with an interviewer-administered questionnaire. Stressful experiences in childhood were measured by an index consisting of 7 questions. Results: In multivariate analyses, the risk of back pain was 1.17 (95% confidence interval 0.97-1.41) for 1 stressful event and 1.49 (95% confidence interval 1.21-1.84) for 2 or more events. The effect was consistent across subgroups defined by gender, socioeconomic status, and health status. Specific events associated with an increased risk included fearful experiences, prolonged hospitalization, and parental unemployment. Discussion: Our study shows that persons reporting multiple stressful experiences in childhood are at increased risk of developing chronic back problems. Clinical Journal of Pain. November/December 2005; Vol. 21, No. 6, pp. 478-483.

ABSTRACT Background Findings from epidemiological studies suggest an inverse relationship between individuals’ protein intake and their blood pressure. Methods Cross-sectional epidemiological study of 4680 persons, aged 40 to 59 years, from 4 countries. Systolic and diastolic blood pressure was measured 8 times at 4 visits. Dietary intake based on 24-hour dietary recalls was recorded 4 times. Information on dietary supplements was noted. Two 24-hour urine samples were obtained per person. Results There was a significant inverse relationship between vegetable protein intake and blood pressure. After adjusting for confounders, blood pressure differences associated with higher vegetable protein intake of 2.8% kilocalories were –2.14 mm Hg systolic and –1.35 mm Hg diastolic (PConclusions Vegetable protein intake was inversely related to blood pressure. This finding is consistent with recommendations that a diet high in vegetable products be part of healthy lifestyle for prevention of high blood pressure and related diseases. Archives of Internal Medicine 2006;166:79-87

Abstract Back pain is now recognised to occur early in childhood and is associated with high prevalence rates when estimated by survey. This review paper considers the risk factors associated with back pain in children aged 11–14 years, and particularly those present in a school setting. The risk factors most significantly associated with back pain are primarily characteristics of the individual with less strong associations with factors present in the school environment. The majority of intervention studies undertaken in a school setting have focussed on the effect of school furniture on posture and comfort and were of short-term duration. There is a need for further research in order to achieve a better understanding of the risk factors present in a school environment and to address ways to reduce the currently recognised perceived problem of back pain among school children. A strategy for an evidence-based longitudinal intervention study is proposed, with the content outlined under the headings: policy, school equipment and furniture, individual and family. For full text click on the link to the right: FULL TEXT

ABSTRACT Objective: To determine how accurately patients with neck pain and/or headache can recall the mechanics of their cervical spine manipulative therapy immediately after its administration. Methods: A survey analysis of immediate patient recall after cervical spine manipulative therapy was performed in a private clinic. The group consisted of 94 sequentially presenting neck pain and/or headache patients with 54 (57%) females and 40 (43%) males. The mean age of the patients was 41.9 years (SD = 13.8; range, 17-96 years). Patients received diversified cervical spine manipulative therapy using a standardized set-up of lateral flexion coupled with flexion. Immediately after the cervical spine manipulative therapy, each patient completed a one-page questionnaire regarding the mechanics of the procedure. Patient responses were analyzed to determine the accuracy of their recall of head positioning. Results: Among the patients, 78.7% reported that they experienced a component of rotation and/or extension, although the technique used involved a premanipulative set-up of lateral bending coupled with flexion. Conclusion: Patients with primary complaints of neck pain and/or headache, when asked to recall the mechanics of their recently applied cervical spine manipulative therapy, displayed a low rate of accuracy. Rotation and/or extension of the cervical spine were the most frequently given incorrect responses. Journal of Manipulative and Physiological Therapeutics. November 2005; Vol. 28, Iss. 9, pp. 708-712.

ABSTRACT Background Screening for prostate cancer is done commonly in clinical practice, using prostate-specific antigen (PSA) tests or digital rectal examination (DRE). Evidence is lacking, however, to confirm a survival benefit among screened patients. We evaluated the effectiveness of PSA, with or without DRE, in reducing mortality. Methods We conducted a multicenter nested case-control study at 10 Veterans Affairs medical centers in New England. Among 71 661 patients receiving ambulatory care between 1989 and 1990, 501 case patients were identified as men who were diagnosed as having adenocarcinoma of the prostate from 1991 through 1995 and who died sometime between 1991 and 1999. Control patients were men who were alive at the time the corresponding case patient had died, matched (1:1 ratio) for age and Veterans Affairs facility. The exposure variable (determined blind to case-control status) was whether PSA testing or DRE was performed for screening prior to the diagnosis of prostate cancer among case patients, with the same time interval for control patients. The association of screening and overall or cause-specific (prostate cancer) mortality was adjusted for race and comorbidity. Results A benefit of screening was not found in our primary analysis assessing PSA screening and all-cause mortality (adjusted odds ratio, 1.08; 95% confidence interval, 0.71-1.64; P = .72), nor in a secondary analysis of PSA and/or DRE screening and cause-specific mortality (adjusted odds ratio, 1.13; 95% confidence interval, 0.63-2.06; P = .68). Conclusions These results do not suggest that screening with PSA or DRE is effective in reducing mortality. Recommendations for obtaining "verbal informed consent" from men regarding such screening should continue. Arch Intern Med. 2006;166:38-43.

New evidence-based guidelines issued by the American College of Chest Physicians (ACCP) provide the most comprehensive recommendations for the diagnosis and management of cough in adults and children, including specific recommendations for the prevention of whooping cough in adults. Diagnosis and Management of Cough: Evidence-Based Clinical Practice Guidelines is published as a supplement to the January issue of CHEST, the peer-reviewed journal of the ACCP. “Cough is the number one reason why patients seek medical attention. Although an occasional cough is normal, excessive coughing or coughing that produces blood, or thick, discolored mucus is abnormal,” said Chair of the guidelines Richard S. Irwin, MD, FCCP, University of Massachusetts Medical School, Worcester, MA “The new ACCP guidelines define how physicians should diagnose and manage cough associated with everything from the common cold to chronic lung conditions. The guidelines also are the most comprehensive evidence-based recommendations for treating cough in children.” The ACCP cough guidelines put new emphasis on the prevention of whooping cough in adults and address the role of over-the-counter (OTC) cough medications in both adults and children. The guidelines also include more than 200 recommendations for diagnosing and managing acute cough (a cough that lasts for less than 3 weeks), subacute cough (a cough that lasts 3 8 weeks), and chronic cough (a cough that lasts for more than 8 weeks) in adults and children. WHOOPING COUGH The guidelines strongly recommend that adults up to 65 years old receive a new adult vaccine for whooping cough (pertussis), a highly contagious type of subacute cough that gets its name from the loud “whooping” noise patients make when they cough. Because antibiotics are only effective early on in the infection, preventing whooping cough with a vaccine is the only way to eventually eliminate the disease. Once whooping cough takes hold, the coughing patient is at risk of serious complications of coughing, such as vomiting, breaking ribs, passing out, and passing the infection on to others. “Most of us think of whooping cough as a childhood disease, yet 28 percent of whooping cough cases in the United States is in adults,” said Dr. Irwin. “Although most of us were vaccinated against whooping cough when we were children, the older vaccine only gives protection for less than 10 years. Because the older vaccine caused serious side effects when given to older children and adults, it was only given to children. Fortunately, there is a now a new safe and effective whooping cough vaccine that can prevent adults from contracting this disease.” OTC COUGH MEDICATION The guidelines also stress that most over-the-counter cough expectorants or suppressants, including cough syrups and cough drops, do not treat the underlying cause of the cough. Therefore, the guidelines recommend that for adults with acute cough or upper airway cough syndrome (previously named postnasal drip syndrome), an older variety antihistamine with a decongestant is the preferred therapy. “There is no clinical evidence that over-the-counter cough expectorants or suppressants actually relieve cough,” said Dr. Irwin. “There is considerable evidence that older type antihistamines help to reduce cough, so, unless there are contraindications to using these medicines, why not take something that has been proven to work?” PEDIATRIC RECOMMENDATIONS The ACCP guidelines are the first to provide comprehensive, specific, evidence-based recommendations for the diagnosis and management of cough in children. Although the guidelines address all types of pediatric cough, they make a strong recommendation against the use of OTC cough and cold medications for children age 14 years and younger. “Cough is very common in children. However, cough and cold medicines are not useful in children and can actually be harmful,” said Dr. Irwin. “In most cases, a cough that is unrelated to chronic lung conditions, environmental influences, or other specific factors, will resolve on its own.” Of the estimated 829 million visits to office-based physicians in the United States, approximately 29.5 million are for cough. Additional recommendations address the most common causes of chronic cough, including upper airway cough syndrome (previously named postnasal drip syndrome), asthma, and gastroesophageal reflux disease (GERD). Chronic cough also may be a result of smoking or taking angiotensin-converting enzyme (ACE) inhibitors. An acute cough is generally caused by a “common cold”; a subacute cough can linger after a cold or may persist due to a respiratory tract infection, such as whooping cough or other postinfectious cough. “Chronic cough can significantly compromise quality of life for patients. However, patients with chronic cough do not have to continue suffering from their condition,” said W. Michael Alberts, MD, FCCP, President of the American College of Chest Physicians. “The new ACCP guidelines provide clinicians with proven methods of identifying and treating the underlying causes of chronic cough, ultimately, leading to more effective management of chronic cough and better quality of life for patients.” Endorsed by the American Thoracic Society and the Canadian Thoracic Society, the new ACCP cough guidelines were developed by an international committee of individuals with expertise and research experience related to cough from the fields of adult and pediatric pulmonology and respirology, pharmacology, neurology, speech and swallowing, and anatomy and physiology. CHEST is a peer-reviewed journal published by the ACCP. It is available online each month at www.chestjournal.org. The ACCP represents 16,500 members who provide clinical respiratory, sleep, critical care, and cardiothoracic patient care in the United States and throughout the world. The ACCP’s mission is to promote the prevention and treatment of diseases of the chest through leadership, education, research, and communication. For more information about the ACCP, please visit the ACCP Web site at:

Summary Background Vitamin D insufficiency is common in women of childbearing age and increasing evidence suggests that the risk of osteoporotic fracture in adulthood could be determined partly by environmental factors during intrauterine and early postnatal life. We investigated the effect of maternal vitamin D status during pregnancy on childhood skeletal growth. Methods In a longitudinal study, we studied 198 children born in 1991–92 in a hospital in Southampton, UK; the body build, nutrition, and vitamin D status of their mothers had been characterised during pregnancy. The children were followed up at age 9 years to relate these maternal characteristics to their body size and bone mass. Findings 49 (31%) mothers had insufficient and 28 (18%) had deficient circulating concentrations of 25(OH)-vitamin D during late pregnancy. Reduced concentration of 25(OH)-vitamin D in mothers during late pregnancy was associated with reduced whole-body (r=0•21, p=0•0088) and lumbar-spine (r=0•17, p=0•03) bone-mineral content in children at age 9 years. Both the estimated exposure to ultraviolet B radiation during late pregnancy and the maternal use of vitamin D supplements predicted maternal 25(OH)-vitamin D concentration (p<0•0001 and p=0•0110, respectively) and childhood bone mass (p=0•0267). Reduced concentration of umbilical-venous calcium also predicted reduced childhood bone mass (p=0•0286). Interpretation Maternal vitamin D insufficiency is common during pregnancy and is associated with reduced bone-mineral accrual in the offspring during childhood; this association is mediated partly through the concentration of umbilical venous calcium. Vitamin D supplementation of pregnant women, especially during winter months, could lead to longlasting reductions in the risk of osteoporotic fracture in their offspring. The Lancet 2006; 367:36-43

Abstract Vitamin D status differs by latitude and race, with residents of the northeastern United States and individuals with more skin pigmentation being at increased risk of deficiency. A PubMed database search yielded 63 observational studies of vitamin D status in relation to cancer risk, including 30 of colon, 13 of breast, 26 of prostate, and 7 of ovarian cancer, and several that assessed the association of vitamin D receptor genotype with cancer risk. The majority of studies found a protective relationship between sufficient vitamin D status and lower risk of cancer. The evidence suggests that efforts to improve vitamin D status, for example by vitamin D supplementation, could reduce cancer incidence and mortality at low cost, with few or no adverse effects. American Journal of Public Health, 10.2105/AJPH.2004.045260

ACA’s HHS Lawsuit Continues to Reap Benefits for Chiropractic Profession (Arlington, Va. - Dec. 14, 2005) The U.S. Court of Appeals has reversed a lower court decision allowing medical doctors and osteopaths to perform “manual manipulation of the spine to correct a subluxation” on Medicare beneficiaries, paving the way for chiropractors to pursue further hearings on the issue under a new administrative review process enacted in 2003. The Dec. 13 decision represents a major step in the American Chiropractic Association’s (ACA) landmark lawsuit against the U.S. Department of Health and Human Services (HHS) and comes at a critical time as millions of Medicare patients are choosing Medicare managed care plans as part of their new prescription drug benefit. “The ACA is extremely pleased that the District Court’s ruling allowing M.D.s and D.O.s to provide a uniquely chiropractic service was nullified,” announced ACA President Richard Brassard, DC. “We are happy that the issue is now whether or not a practitioner is ‘qualified,’ not whether or not a practitioner is simply licensed. The ACA’s position has been and remains that only chiropractors are qualified by education and training to correct subluxations. Because of the appeals court’s decision, chiropractors can continue to fight to safeguard their right to be the sole providers of this service and to ensure Medicare patients’ rights to access doctors of chiropractic.” In its Dec. 13 opinion, a three-judge appeals panel overturned an Oct. 14, 2004 District Court ruling that stated: “The court will simply reiterate its conclusion that 42 U.S.C. 1395x(r) does not prevent doctors of medicine and osteopaths from performing a ‘manual manipulation of the spine to correct a subluxation.’” The appeals panel ruled that the District Court lacked the jurisdiction to make this decision and that the final decision must be made through a newly revised appeals process. Through this process, individual chiropractors file complaints on behalf of their Medicare patients through the managed care organization. From there, complaints move to an administrative law judge. The appeals panel further questioned the District Court’s opinion on the issue of which health care providers are qualified to provide the chiropractic service – not simply which providers have a license to do so. “The regulation states that ‘[I]f more than one type of practitioner is qualified to furnish a particular service, the HMO ... may select the type of practitioner to be used.’ ... (emphasis added). The HMO’s invocation of this provision would squarely present the question of whether medical doctors and osteopaths, as well as chiropractors, are ‘qualified to furnish’ the service of manual manipulation of the spine to correct a subluxation.” According to ACA’s legal team, this language suggests that simply possessing a medical or osteopathic license will not be sufficient to provide the chiropractic service; the MD or osteopath must prove that they are qualified to do so by education and training. “The appeals court decision is especially significant as seniors are being encouraged to join Medicare managed care programs in which they will find no meaningful chiropractic services,” added Dr. Brassard. “Doctors of chiropractic nationwide must familiarize themselves with the new appeals process and report on any Medicare HMO that does not offer chiropractic services through doctors of chiropractic.” The ACA is exploring ways it can assist individual doctors of chiropractic through the administrative review process and provide them with the resources and materials they need to establish their unique qualifications to an administrative law judge, if necessary. Earlier court rulings in ACA’s lawsuit against HHS, filed in 1998, have also resulted in “monumental victories for Medicare patients,” according to Dr. Brassard – the most important being the decision prohibiting physical therapists from providing manual manipulation of the spine to correct a subluxation to Medicare patients. “Before ACA filed its lawsuit,” Dr. Brassard explained, “Medicare HMOs were given the green light to misappropriate taxpayer dollars to pay non-physician physical therapists to deliver the chiropractic physician service of 'manual manipulation of the spine to correct a subluxation’ under Medicare – or to deny the service to beneficiaries altogether. That unfair and illegal practice has ended as a direct result of our lawsuit.” Other victories that occurred as a direct result of the HHS lawsuit were: The preparation and release of a government study showing the virtual elimination of chiropractic services to Medicare beneficiaries entering the Medicare Managed Care system where there is a medical doctor gatekeeper requirement; And, a government mandate that all Medicare Managed Care plans must make available and pay for manual manipulation of the spine to correct a subluxation. “The ACA and the National Chiropractic Legal Action Fund (NCLAF) thank the thousands of supporters and contributors who have stood with us through this monumental legal battle,” said Dr. Brassard. “Because of your commitment, we will continue to work together to ensure that Medicare beneficiaries receive the safe and effective chiropractic care they need and deserve.” For a copy of the Dec. 13 decision, additional information on Medicare managed care plans, and resources on the Medicare administrative review process, visit ACA’s Web site at:

ABSTRACT Background: Previous studies have suggested that the obstructive sleep apnea syndrome may be an important risk factor for stroke. It has not been determined, however, whether the syndrome is independently related to the risk of stroke or death from any cause after adjustment for other risk factors, including hypertension. Methods: In this observational cohort study, consecutive patients underwent polysomnography, and subsequent events (strokes and deaths) were verified. The diagnosis of the obstructive sleep apnea syndrome was based on an apnea-hypopnea index of 5 or higher (five or more events per hour); patients with an apnea-hypopnea index of less than 5 served as the comparison group. Proportional-hazards analysis was used to determine the independent effect of the obstructive sleep apnea syndrome on the composite outcome of stroke or death from any cause. Results: Among 1022 enrolled patients, 697 (68 percent) had the obstructive sleep apnea syndrome. At baseline, the mean apnea-hypopnea index in the patients with the syndrome was 35, as compared with a mean apnea-hypopnea index of 2 in the comparison group. In an unadjusted analysis, the obstructive sleep apnea syndrome was associated with stroke or death from any cause (hazard ratio, 2.24; 95 percent confidence interval, 1.30 to 3.86; P=0.004). After adjustment for age, sex, race, smoking status, alcohol-consumption status, body-mass index, and the presence or absence of diabetes mellitus, hyperlipidemia, atrial fibrillation, and hypertension, the obstructive sleep apnea syndrome retained a statistically significant association with stroke or death (hazard ratio, 1.97; 95 percent confidence interval, 1.12 to 3.48; P=0.01). In a trend analysis, increased severity of sleep apnea at baseline was associated with an increased risk of the development of the composite end point (P=0.005). Conclusions: The obstructive sleep apnea syndrome significantly increases the risk of stroke or death from any cause, and the increase is independent of other risk factors, including hypertension. The New England Journal of Medicine. November 10, 2005; Vol. 353; No. 19, pp. 2034-2041.

(Embargoed) CHAPEL HILL -- People without enough selenium in their bodies face a higher risk of knee osteoarthritis, a first-of-its-kind new study suggests. University of North Carolina at Chapel Hill Thurston Arthritis Center medical scientists and colleagues conducted the research. It focused on the knees of 940 participants enrolled in the Johnston County (N.C.) Osteoarthritis Project, a continuing, federally supported investigation of osteoarthritis that began 15 years ago and is headquartered at UNC. Scientists found that for every additional tenth of a part per million of selenium in volunteers' bodies, there was a 15 percent to 20 percent decrease in their risk of knee osteoarthritis. Those who had less of the trace mineral than normal in their systems faced a higher risk of the degenerative condition in one and both knees. The severity of their arthritis was related to how low their selenium levels were. "We are very excited about these findings because no one had ever measured body selenium in this way in relationship to osteoarthritis," said study leader Dr. Joanne Jordan of UNC. "Our results suggest that we might be able to prevent or delay osteoarthritis of the knees and possibly other joints in some people if they are not getting enough selenium. That's important because the condition, which makes walking painful, is the leading cause of activity limitation among adults in developed countries." Jordan is associate professor of medicine and orthopaedics at the UNC School of Medicine. Also associate director of the school's Thurston Arthritis Research Center, she is principal investigator of the long-term Johnston County Osteoarthritis Project. That investigation is the largest and longest of its kind ever done and has involved some 4,400 volunteers, both blacks and whites, whose experiences with arthritis doctors follow and analyze. Jordan and colleagues will present results of their study in San Diego Tuesday (Nov. 15) at the annual meeting of the American College of Rheumatology. Co-authors are UNC statistician Fang Fang; Dr. Lenore Arab of the University of California at Los Angeles; Dr. Steven J. Morris of the University of Missouri in Columbia; Dr. Jordan Renner, professor of radiology and allied health sciences at UNC; Dr. Charles G. Helmick of the Centers for Disease Control and Prevention (CDC) in Atlanta; and Dr. Marc C. Hochberg, professor of medicine at the University of Maryland. The team got interested in the possibility that selenium might play a role in preventing osteoarthritis in part because in severely selenium-deficient areas of China, people frequently develop Kashin-Beck disease, which cause joint problems relatively early in life. The U.S. study involved comparing the extent of knee osteoarthritis in each subject as shown on carefully examined X-rays with how much selenium was in their systems. At the University of Missouri, Morris determined the latter from toenail clippings taken during physical examinations in North Carolina. He employed a complicated nuclear technique known as Instrumental Neutron Activation Analysis. "We found that when we divided the participants into three groups, those with the highest selenium levels faced a 40 percent lower risk of knee osteoarthritis than those in the lowest-selenium group," Jordan said. "Those in the highest selenium group had only about half the chance of severe osteoarthritis or disease in both knees. Some of the findings were even stronger in African-Americans and women." The bottom line was that there appears to be a clear relationship between selenium and osteoarthritis, she said. "The next step will be in the laboratory to see how selenium affects cartilage," Jordan said. "It might act as a protective antioxidant. Later, we'll want to expand the study with larger samples and see whether selenium supplementation reduces pain or other symptoms." Most people get enough selenium in their diets in the United States if those diets are varied and include foods that come from different regions, she said. "If you were just growing most of your own food in soil that did not have much selenium and not eating vegetables and meat from elsewhere, you could potentially get in trouble with selenium deficiency," Jordan said. Osteoarthritis, the most common form of arthritis, afflicts almost a million North Carolinians and more than 21 million people nationally, including many adults over age 65, the physician said. Some estimates suggest that as many as 70 million Americans will suffer from some form of arthritis within the next 20 years as baby boomers age. ### Support for the research came from the CDC and the National Institute of Arthritis and Musculoskeletal and Skin Diseases.

Arlington, VA -- A new study finds that chiropractic and medical care have comparable costs for treating chronic low-back pain, with chiropractic care producing significantly better outcomes. A group of chronic low-back patients who underwent chiropractic treatment showed higher pain relief and satisfaction with the care and lower disability scores than a group that underwent medical care, according to an October 2005 study in the Journal of Manipulative and Physiological Therapeutics (JMPT). Although several cost-effectiveness studies outside the United States have favorably compared chiropractic to medical care, this new study is one of the first to compare low-back treatment costs and outcomes within the structure of the American health care system. In the United States alone, back pain associated costs are estimated to reach $48 billion this year, and, at any given time, 80 percent of the U.S. population suffers from back pain – statistics that make this study especially pertinent, according to the authors. Specifics of the study: The study involved 2780 patients with mechanical low-back pain who referred themselves to 60 doctors of chiropractic and 111 medical doctors in 64 general practice community clinics in Oregon and one in Vancouver, Wa. Chiropractic care included spinal manipulation, physical therapies, an exercise plan, and self-care patient education. Medical care consisted of prescription drugs, an exercise plan, self-care advice, and a referral to a physical therapist (in approximately 25 percent of cases). The costs of treatment and patients' pain, disability, and satisfaction with their health care were assessed at 3 and 12 months after the initial visit to the doctor. The office costs alone for chiropractic treatment of low-back pain were higher than for medical care. However, when costs of advanced imaging and referral to physical therapists and other providers were added, chiropractic care costs for chronic patients were 16 percent lower than medical care costs. The differences between medical and chiropractic total costs were not statistically significant for acute or chronic patients. The study did not include over-the-counter drug, hospitalization, or surgical costs. Both acute and chronic patients showed better outcomes in pain and disability reduction and higher satisfaction with their care after undergoing chiropractic treatment. The advantage of chiropractic care was clinically significant in the chronic patient group at 3 months' follow-up, but smaller in the acute group. Improvements in patients' physical and mental health were comparable in both the chiropractic and the medical group, with the exception of physical health scores in the acute patients in the chiropractic group, which showed an advantage over the medical group. "With their mission to increase value and respond to patient preferences, health care organizations and policy makers need to reevaluate the appropriateness of chiropractic as a treatment option for low-back pain," concluded the study authors. The Journal of Manipulative and Physiological Therapeutics, the premier biomedical publication in the chiropractic profession and the official scientific journal of the American Chiropractic Association, provides the latest information on current research developments, as well as clinically oriented research and practical information for use in clinical settings. The journal's editorial board includes some of the world's leading clinical researchers from chiropractic, medicine, and post-secondary education.

GREELEY, Colo. — National Board of Chiropractic Examiners (NBCE) President Peter D. Ferguson, D.C., announced today that, in accordance with a vote of the full Board of Directors, the NBCE will reduce its examination fees effective in 2006. The board made this decision at its fall board meeting in Charlotte , N.C. The NBCE will reduce fees for its Parts I, II and III examinations by $25 each and for the Part IV Examination by $100. These reductions correspond to an overall seven percent decrease in the current price of each exam. In 2006, the NBCE will reduce exam fees by: NBCE EXAM / FEE REDUCTION Part I / $25.00 Part II / $25.00 Part III / $25.00 Part IV / $100.00 The new fee structure will be included in the spring 2006 applications, available at www.nbce.org by Nov. 15 and mailed to chiropractic colleges by mid-December. “One factor that made this decision possible is the commitment by the Board of Directors to reduce costs following its annual meeting in May. The board has taken a hard look at our budget during this fiscal year,” Dr. Ferguson explained. “By reducing costs where possible, we have enacted substantial savings that we can pass on to our examinees.” In addition, the NBCE has worked to reduce the cost of administering its exams. For example, by making exam applications and brochures available online, the NBCE has saved substantially on printing costs. The board’s decision is also due to an increase in the number of new students enrolling at chiropractic colleges. The NBCE relies on revenues from its exams to cover its costs. With increased enrollments, revenue streams will increase during the next few years as more students take NBCE exams. “We are very excited about passing these fee cuts on to the students,” said Dr. Ferguson. “I can assure our examinees that we will continue to keep a watchful eye over our budget. By employing a conservative fiscal approach, we hope to pass along savings not just in 2006 but into the future as well.” Headquartered in Greeley, Colo., the NBCE is the international testing organization for the chiropractic profession. Established in 1963, the NBCE develops, administers, and scores standardized written examinations for candidates seeking chiropractic licensure throughout the United States and in several foreign countries. The NBCE also produces and administers a practical skills examination for use in chiropractic licensure.

Over Thirty Charged in Scheme to Bilk Insurance Companies of $12M Westchester County District Attorney Jeanine Pirro was joined by New York State Police Major Frank Koehler, Yonkers Police Commissioner Robert Taggart, Westchester County Police Commissioner Thomas Belfiore, New York City Police Department Deputy Inspector Alan Cooper, New York State Insurance Frauds Bureau Director Charles Bardong, the National Insurance Crime Bureau, the New Jersey Attorney General’s Office and numerous insurance carriers to announce the results of a three-year investigation into the systematic fraudulent billing of no-fault accident claims by a major medical mill operating in Westchester County. It is alleged that Elm Street Medical, PC operating out of One Elm Street, Tuckahoe, New York, bilked insurance companies by exploiting the no-fault provisions of the New York State Comprehensive Motor Vehicle Insurance Reparations Act. (This act entitles persons injured in automobile accidents to a minimum of $50,000 of medical coverage regardless of who is at fault.) Over a period of approximately three years, Elm Street Medical bilked dozens of insurance companies by upcoding (i.e. the submission of claims containing codes for expensive medical services never provided) or by submitting bogus claims for medical services on behalf of patients who had not been in a car accident. Elm Street’s physicians would routinely recommend numerous tests or treatments including physical therapy treatment; chiropractic services; dental evaluations, testing and treatment; orthopedic evaluations; psychiatric evaluations and treatment; psychological evaluations and treatment; neurological evaluations and testing; durable medical goods; and excessive diagnostic testing all provided for at the Elm Street facility. Some of the procedures that were billed for were never performed and others were shams. Additionally, a simple five minute procedure would be routinely upcoded and billed for a more complicated and longer higher reimbursement procedure. All of the patients were required to assign all insurance payments to Elm Street. Patients also received a promise of proceeds from any potential lawsuit as a result of their injuries. In order to further the operation, LEONARDO VELEZ, an emergency room employee at Saint Joseph’s Hospital in Yonkers and BARRY SUAREZ, a paramedic employed at Empress Ambulance Service, forwarded confidential patient information about individuals involved in accidents from numerous Westchester County hospitals to co-defendant BRUCE NIXON. Nixon, posing as a doctor or hospital patient care coordinator, would refer these patients, most of whom were in minor fender bender accidents, for unnecessary follow-up medical treatment at Elm Street. Nixon would make approximately $1,500 for each referral. Another defendant, JEAN RICHARDSON, actively participated in this criminal enterprise by setting up fictitious accidents. It is alleged that Richardson, while a shelter director at Westhab, Inc., a non-profit organization that administers the daily operation of Westchester County’s homeless shelter system, used Westhab employees and residents to pose as injured car accident victims for the purpose of creating false insurance claims. Not only did uninjured Westhab residents and employees pose as injured patients, but they were also shuttled to the Elm Street offices in official Westhab vans. Richardson is no longer employed by Westhab, Inc. The Elm Street Enterprise, through its office managers, ALEXANDER KARSHENBOYM and SERGEY CHIZHOV, paid runners (recruiters), including, BRUCE NATHANIEL NIXON, JEAN RICHARDSON and others, to steer claimants to medical clinics owned and operated by the Elm Street Enterprise. The runners paid BARRY SUAREZ and LEONARDO VELEZ, and others to steal confidential patient information to permit the runners to contact the patients and turn them into claimants at the medical clinics owned by the Elm Street Enterprise. Many of these claimants had been in real, but minor automobile accidents. Others, such as ROBERT WECHSELBLATT and runner JEAN RICHARDSON, were not in automobile accidents, but knowingly permitted their names and pedigree information to be placed on fictitious accident reports and thereafter told insurance carriers and others that they had been involved in actual automobile accidents. In order to legitimatize the false insurance claims submitted by the Elm Street enterprise, it is alleged that SHARON DAVIS, a former New York City Police Department Administrative Aide, and LORETTA STOKES, a former New York City Police Department Administrative Aide, assisted in the creation of forged police accident reports by knowingly entering false data about fictitious accidents into the New York City Police Department database, so that an accident report number could be assigned. These defendants received up to $300 per report for their criminal activity. They are charged with Criminal Facilitation in the Fourth Degree. The enterprise also included corrupt medical professionals and staff employed by the Elm Street Enterprise, including VLAD MEISHER, MD; JOHN GELFAND, MD; YEFIM SOSONKIN, MD; TOBIAS SHKLOVER, MD; HERBERT FENTON, DDS and others, purportedly rendering and providing medical treatment to these claimants and creating reports documenting the services they purportedly provided. The fraudulent reports and claims submitted to insurance carriers detailed fictitious, unnecessary and/or underperformed medical visits and procedures as well as treatment contrary to generally accepted medical practice. On June 23, 2004, the Westchester County District Attorney’s Office, the New York State Police, and the New York State Insurance Frauds Bureau executed three search warrants resulting in the seizure of hundreds of patient files from the Elm Street Medical offices. It is believed that the Elm Street operatives received over $12 million dollars during a five year period from 1999 to 2004 as a result of running this criminal enterprise. Of the 34 charged, fourteen (14) individuals and six (6) corporations were indicted. All twenty (20) indicted defendants were part of the Elm Street enterprise operating to defraud insurance carriers through the submission of fraudulent no-fault automobile claims. Those indicted were ALEXANDER KARSHENBOYM; SERGEY CHIZHOV; ELLA CHIZHOV; VLAD MEISHER, MD; JOHN GELFAND, MD; TOBIAS SHKLOVER, MD; YEFIM SOSONKIN, MD; HERBERT FENTON, DDS; BRUCE NATHANIEL NIXON; BARRY SUAREZ; LEONARDO VELEZ; JEAN RICHARDSON and ROBERT WECHSELBLATT. One indicted individual remains at large. Corporate summons were also issued for six corporations owned and operated by the enterprise; ELM STREET MEDICAL, PC; ELM NEUROLOGICAL CARE, PC; COMPAS MEDICAL, PC; BOGART AVENUE MEDICAL, PC; ANDA MANAGEMENT CORPORATION; and ALL-SHURE CORPORATION. Moreover, the following 14 individuals were arrested and charged by felony complaint: ANDREW CHEVANNES, ALLAN BAILEY, SHEENA GRAVES, KEVIN GOEFF, GISELLE RIVAS, ROSE ORTIZ, VINCENT JENKINS, LEON AKERY, SHARON CLARK, ANDRE CABAN, KEN COLEMAN, DENISE AHMAD, IBRAHIM AHMAD and PATRICIA TERRY. The investigation is continuing. Among the crimes charged against defendants are Enterprise Corruption, Insurance Fraud in the First Degree and Money Laundering in the First Degree, all class “B” felonies, as well as Insurance Fraud in the Second Degree and Grand Larceny in the Second Degree, class “C” felonies. If convicted, those defendants charged with class “B” felonies face a maximum of twenty-five years in state prison. District Attorney Jeanine Pirro thanked the following insurance companies for their investigative assistance: Allstate, GEICO, Liberty Mutual, Nationwide, Countrywide, State Farm, Progressive, One Beacon and AutoOne. DA Pirro also thanked Lawrence Hospital, the Westchester Medical Center, Saint Joseph’s Hospital, Saint John’s Riverside Hospital, Mount Vernon Hospital, Sound Shore Hospital, Empress Ambulance Service and the NYPD Fraudulent Accident Investigation Unit. DA Pirro also thanked the New York State Motor Vehicle and Insurance Fraud Prevention Board for their assistance. -END – In compliance with Disciplinary Rule 7-107A of the Code of Professional Responsibility, you are advised that a charge is merely an accusation and that a defendant is presumed innocent until and unless proven guilty.

On Friday, October 21, NYSCA Board member, Lynn Pownall, DC, DACBN presented a letter to the New York State Board for Chiropractic addressed to the State Board chair, Ali M. Jafari, DC on behalf of NYSCA President, Mariangela Penna, DC. The letter addressed a number of professional issues that have an impact on the State Education Department’s mission “[t]o protect the public by fostering high standards of professional . . . practice.” The Association stated that it “believes that public protection and patient safety are not being served by the current state of professional practice by any state agency, including the State Education Department, and such altruistic sentiments as contained in the SED mission statement and goals are not being met.” “Patient protection and the standards of practice for chiropractic and the other licensed professions generally, are within the purview of the State Education Department,” Dr. Penna noted, “but the professions are not only affected by the laws and regulations of the SED, but by all of laws and all of regulations of all of the state agencies combined. In view of the current state of professional practice, the NYSCA submits that SED’s attitude in view of its stated mission to ‘protect the public’ by ‘fostering high standards of professional . .. practice’ without looking at the totality of the laws and regulation that affect patient safety and professional practice is agency-centric -- more inclined to protect the status quo rather than being patient-centered/ public safety conscious or concerned about establishing ‘high standards of professional . . . practice.’ As laudable as they are, patient protection/public safety and standards of professional practice are missions and goals that cannot be met or compartmentalized solely the province of the SED without an examination of all areas of law and regulation of the state in their totality. The NYSCA submits that the SED, as well as the other state agencies, have surrendered important regulatory and standards setting responsibilities collectively to the whims of the market place.” The NYSCA letter noted that the utilization review practices of health plans, insurers, HMOs and MCOs, Individual Practice Associations (IPAs) and independent Utilization Review agents based on proprietary guidelines not open to public scrutiny amounted to a “defacto regulation of the profession” by self-interested, private enterprises – entities raking in record profits and whose only interest is their own financial bottom for the benefit of their shareholders and does not represent “quality” health care or “high standards of professional practice.” “Who is minding the fox?,” Penna asked. The NYSCA also charged that the termination practices by plans amounted to a constructive, albeit financial, delicensing of chiropractic professionals. “Health care is everyone’s responsibility – patient, provider, employer, insurer, government and governmental agency,” Penna noted. “Health care needs to be patient-centered, evidence-based, efficacious, efficient, cost-effective, patient-responsible and transparent for everyone’s benefit. Presently, this is not the case. But the State Boards can help, including the State Board for Chiropractic," Penna said. “The development of practice guidelines and standards and written review criteria are within the ambit of the regulatory functions of a disinterested State Education Department charged with establishing and maintaining “high standards of professional . . . practice” for the public’s protection, and that the promulgation of these guidelines and standards, Penna stated, should be developed and disseminated in concert with all interested parties.” Dr. Penna’s statement was joined by a statement expressing similar sentiments by the American Chiropractic Association (ACA) given by ACA downstate delegates, H. William Wolfson, DC who is also the NYSCA District 7 President (Suffolk County).