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

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.

Childhood immunizations are under greater levels of scrutiny by the public. Media stories publicizing the possible link of autism to vaccinations have resulted in parental refusal of immunizations for their young children. A recent study of pediatricians' attitudes toward patients who question the need for childhood immunizations found that many pediatricians would prefer to discharge patients who did not comply with their recommendations. Click on the URL below for the rest of this story:

Non-Narcotic Analgesic Dose and Risk of Incident Hypertension in US Women John P. Forman*; Meir J. Stampfer; and Gary C. Curhan Abstract Acetaminophen, ibuprofen, and aspirin are the most commonly used drugs in the United States. Although the frequency of their use has been associated with hypertension, prospective data examining the dose of these drugs and risk of hypertension are lacking. Furthermore, whether certain indications for analgesic use, particularly headache, mediate the association is unclear. We conducted 2 prospective cohort studies among older women 51 to 77 years of age (n=1903) from the Nurses’ Health Study I and younger women 34 to 53 years of age (n=3220) from the Nurses’ Health Study II who completed detailed supplemental questionnaires pertaining to their analgesic use and who did not have hypertension at baseline. We analyzed incident hypertension according to categories of average daily dose of acetaminophen, nonsteroidal anti-inflammatory drugs, and aspirin. Information on indications for analgesic use as well as relevant confounders was also gathered prospectively. Compared with women who did not use acetaminophen, the multivariable adjusted relative risk for those who took >500 mg per day was 1.93 (1.30 to 2.88) among older women and 1.99 (1.39 to 2.85) among younger women. For nonsteroidal anti-inflammatory drugs, similar comparisons yielded multivariable relative risks of 1.78 (1.21 to 2.61) among older women and 1.60 (1.10 to 2.32) among younger women. These associations remained significant among women who did not report headache. Aspirin dose was not significantly associated with hypertension. Higher daily doses of acetaminophen and nonsteroidal anti-inflammatory drugs independently increase the risk of hypertension in women. Because acetaminophen and nonsteroidal anti-inflammatory drugs are commonly used, they may contribute to the high prevalence of hypertension in the United States. From the Renal Division (J.P.F., G.C.C.), Department of Medicine, Brigham and Women’s Hospital, Boston, Mass; Channing Laboratory (J.P.F., M.J.S., G.C.C.), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Mass; and Department of Epidemiology (J.P.F., M.J.S., G.C.C.), Harvard School of Public Health, Boston, Mass. Hypertension published August 15, 2005, 0.1161/01.HYP.0000177437.07240.70

ABSTRACT Background: Ad libitum, low-carbohydrate diets decrease caloric intake and cause weight loss. It is unclear whether these effects are due to the reduced carbohydrate content of such diets or to their associated increase in protein intake. Objective: We tested the hypothesis that increasing the protein content while maintaining the carbohydrate content of the diet lowers body weight by decreasing appetite and spontaneous caloric intake. Design: Appetite, caloric intake, body weight, and fat mass were measured in 19 subjects placed sequentially on the following diets: a weight-maintaining diet (15% protein, 35% fat, and 50% carbohydrate) for 2 wk, an isocaloric diet (30% protein, 20% fat, and 50% carbohydrate) for 2 wk, and an ad libitum diet (30% protein, 20% fat, and 50% carbohydrate) for 12 wk. Blood was sampled frequently at the end of each diet phase to measure the area under the plasma concentration versus time curve (AUC) for insulin, leptin, and ghrelin. Results: Satiety was markedly increased with the isocaloric high-protein diet despite an unchanged leptin AUC. Mean (±SE) spontaneous energy intake decreased by 441 ± 63 kcal/d, body weight decreased by 4.9 ± 0.5 kg, and fat mass decreased by 3.7 ± 0.4 kg with the ad libitum, high-protein diet, despite a significantly decreased leptin AUC and increased ghrelin AUC. Conclusions: An increase in dietary protein from 15% to 30% of energy at a constant carbohydrate intake produces a sustained decrease in ad libitum caloric intake that may be mediated by increased central nervous system leptin sensitivity and results in significant weight loss. This anorexic effect of protein may contribute to the weight loss produced by low-carbohydrate diets. American Journal of Clinical Nutrition, Vol. 82, No. 1, 41-48, July 2005 © 2005 American Society for Clinical Nutrition

Effect of Soybean Protein on Blood Pressure: A Randomized, Controlled Trial Jiang He, MD, PhD; Dongfeng Gu, MD, MS; Xigui Wu, MD; Jichun Chen, MSc; Xiufang Duan, MD; Jing Chen, MD, MSc; and Paul K. Whelton, MD, MSc ABSTRACT Background: Objective: Design: Setting: Patients: Intervention: Measurements: Results: Limitations: Conclusions:

ABSTRACT Objective. Each year, children die from heat stroke after being left unattended in motor vehicles. In 2003, the total was 42, up from a national average of 29 for the past 5 years. Previous studies found that on days when ambient temperatures exceeded 86°F, the internal temperatures of the vehicle quickly reached 134 to 154°F. We were interested to know whether similarly high temperatures occurred on clear sunny days with more moderate temperatures. The objective of this study was to evaluate the degree of temperature rise and rate of rise in similar and lower ambient temperatures. In addition, we evaluated the effect of having windows "cracked" open. Methods. . In this observational study, temperature rise was measured continuously over a 60-minute period in a dark sedan on 16 different clear sunny days with ambient temperatures ranging from 72 to 96°F. On 2 of these days, additional measurements were made with the windows opened 1.5 inches. Analysis of variance was used to compare how quickly the internal vehicle temperature rose and to compare temperature rise when windows were cracked open 1.5 inches. Results. . Regardless of the outside ambient temperature, the rate of temperature rise inside the vehicle was not significantly different. The average mean increase was 3.2°F per 5-minute interval, with 80% of the temperature rise occurring during the first 30 minutes. The final temperature of the vehicle depended on the starting ambient temperature, but even at the coolest ambient temperature, internal temperatures reached 117°F. On average, there was an 40°F increase in internal temperature for ambient temperatures spanning 72 to 96°F. Cracking windows open did not decrease the rate of temperature rise in the vehicle (closed: 3.4°F per 5 minutes; opened: 3.1°F per 5 minutes or the final maximum internal temperature. Conclusions. Even at relatively cool ambient temperatures, the temperature rise in vehicles is significant on clear, sunny days and puts infants at risk for hyperthermia. Vehicles heat up rapidly, with the majority of the temperature rise occurring within the first 15 to 30 minutes. Leaving the windows opened slightly does not significantly slow the heating process or decrease the maximum temperature attained. Increased public awareness and parental education of heat rise in motor vehicles may reduce the incidence of hyperthermia death and improve child passenger safety. To read the full report click on the link below. Full Text PEDIATRICS Vol. 116 No. 1 July 2005, pp. e109-e112

A new study funded by the Canadian Institute for Health Information’s Canadian Population Health Initiative shows that Old Order Mennonite children from Ontario living a similar lifestyle to that of previous generations tend to be fitter, stronger and leaner than children living a contemporary Canadian lifestyle—this despite the fact they do not have physical education classes and do not participate in organized sports. New analyses by obesity expert Dr. Mark S. Tremblay and a group of researchers from the University of Saskatchewan and University of Lethbridge found a strong link between contemporary lifestyles in Canadian children and reduced physical activity and fitness. “What this study proves is that you don’t need to do triathlons to stay fit and active,” says Dr. Tremblay, a Professor of Kinesiology at the University of Saskatchewan. “Children living traditional lifestyles have exercise embedded in their daily lives. In contrast, today’s children engage more in passive activities, such as video games. This may go a long way in explaining why they are less physically fit.” The study found that Old Order Mennonite children, on average, do up to 18 minutes more moderate or vigorous physical activity a day than urban and rural contemporary children. Researchers estimate that, all else being equal, this translates into a caloric difference between the Old Order Mennonite children and children living a contemporary lifestyle of approximately 15,000 kcal per year—or over 40 pounds of fat per person, per decade. The Old Order Mennonite children in the study also had leaner triceps than urban Saskatchewan children, a greater aerobic fitness score than rural Saskatchewan children, and greater grip strength than both rural and urban Saskatchewan children. These findings were true for girls and boys. Researchers attribute the Old Order Mennonite children’s strength and fitness to the fact they get a great deal of physical activity through walking, traditional farming activities and household chores. “Since obesity can lead to life-long health problems, including diabetes and heart disease, it may well be worthwhile to look at how aspects of modern lifestyles may contribute to childhood obesity,” says Lisa Sullivan, Manager of Research and Policy at the Canadian Population Health Initiative. “This research gives us a unique glimpse into the past that may help to explain the rising rates of obesity over the past few decades.” Approximately 30% of all the children in the study were classified as overweight—a figure that is consistent with nationally representative data. Methodology A cross-sectional study design was used to examine physical fitness and activity characteristics of three groups of children aged 8 to 13: Old Order Mennonite children from Ontario; Urban Saskatchewan children; and Rural Saskatchewan children. The data collection for this study took place from September to December 2002. Researchers assessed fitness by collecting height, weight, triceps skin fold, grip strength, push-ups, partial curl-ups and aerobic fitness measurements. Also, physical activity levels were measured for seven consecutive days using an accelerometer—an instrument that measures the intensity of body acceleration—and estimated from a self-reported physical activity questionnaire for older children. Canadian Population Health Initiative The Canadian Population Health Initiative (CPHI), which is part of the Canadian Institute for Health Information (CIHI), funded the research described in this media release. CPHI supports research to advance knowledge on the determinants of health in Canada and to develop policy options to improve population health and reduce health inequalities. Canadian Institute for Health Information (CIHI) The Canadian Institute for Health Information (CIHI) is an independent, pan-Canadian, not-for-profit organization working to improve the health of Canadians and the health care system by providing quality health information. CIHI’s mandate, as established by Canada’s health ministers, is to coordinate the development and maintenance of a common approach to health information for Canada. To this end, CIHI is responsible for providing accurate and timely information that is needed to establish sound health policies, manage the Canadian health system effectively and create public awareness of factors affecting good health. Media contacts: Leona Hollingsworth (613) 241-7860, Ext. 4140 Cell: (613) 612-3915

Today we celebrate the 229th birthday of the United States of America. On July 4, 1776, the Second Continental Congress unanimously adopted the Declaration of Independence, as we claimed our independence from Britain. On behalf of the NYSCA’s Officers, we want to wish you and your family a Happy 4th of July. To celebrate 4th of July with your own fire works show, click on the “Fire Works” below. Fire Works Also, examine the US Constitution by clicking on this link.

Abstract: Ambulatory Care Visits for Treating Adverse Drug Effects in the United States, 1995–2001: Zhan, Chunliu; Arispe, Irma; Kelley, Edward; Ding, Tina; Burt, Catharine W.; Shinogle, Judith; Stryer, Daniel Background:: Adverse drug events (ADEs) are a well-recognized patient safety concern, but their magnitude is unknown. Ambulatory visits for treating adverse drug effects (VADEs) as recorded in national surveys offer an alternative way to estimate the national prevalence of ADEs because each VADE indicates that an ADE occurred and was serious enough to require care. Methods: A nationally representative sample of visits to physician offices, hospital outpatient departments, and emergency departments was analyzed. VADEs were identified as the first-listed cause of injury. Results: In 2001, there were 4.3 million VADEs in the United States, averaging 15 visits per 1,000 population. VADE rates at physician offices, hospital outpatient departments, and hospital emergency departments were at 3.7, 3.4, and 7.3 per 1,000 visits, respectively. There was an upward trend in the total number of VADEs from 1995 to 2001 (p < .05), but the increases in VADEs per 1,000 visits and per 1,000 population were not statistically significant. VADEs were lower in children younger than 15 and higher in the elderly aged 65–74 than in adults aged 25–44 (p < .01) and were more frequent in females than in males (p < .05). Discussion: Although methodologically conservative, the study suggests that ADEs are a significant threat to patient safety in the United States. Joint Commission Journal on Quality and Patient Safety, July 2005, vol. 31, no. 7, pp. 372-378(7)

New study confirms conclusions from earlier studies linking sleep disorders and inattention in children. Children who snore may be at greater risk of becoming hyperactive later in life than those who sleep quietly. The study, published in the journal Sleep, corroborate earlier conclusions linking sleep disorders and hyperactivity, with snoring coming first followed by hyperactivity. ABSTRACT Autonomic Dysfunction in Children with Sleep-Disordered Breathing Louise M. O’Brien, PhD; David Gozal, MD - Kosair Children’s Hospital Research Institute, and Division of Pediatric Sleep Medicine, Department of Pediatrics, University of Louisville, Louisville, KY Study Objectives: To measure sympathetic responses in children with and without sleep-disordered breathing. Design: Prospective, observational study. Setting: Kosair Children’s Hospital Sleep Medicine and Apnea Center. Participants: Subjects were prospectively recruited from children undergoing overnight polysomnographic assessments and were retrospectively grouped according to the results of the polysomnogram. Sleep-disordered breathing was defined as an apnea-hypopnea index >5 and children were assigned to the control group if their apnea-hypopnea index was < 1. Intervention: N/A. Measurements and Results: During quiet wakefulness, pulse arterial tonometry was used to assess changes in sympathetic activity following vital capacity sighs in 28 children with sleep-disordered breathing and 29 controls. Each child underwent a series of 3 sighs, and the average maximal pulse arterial tonometry signal attenuation was calculated. Further, a cold pressor test was conducted in a subset of 14 children with sleep-disordered breathing and 14 controls. The left hand was immersed in ice cold water for 30 seconds while right-hand pulse arterial tonometry signal was continuously monitored during immersion and 20-minute recovery periods. Signal amplitude changes were expressed as percentage change from corresponding baseline. Results: The magnitude of sympathetic discharge-induced attenuation of pulse arterial tonometry signal was significantly increased in children with sleep-disordered breathing during sigh maneuvers (74.1%±10.7% change compared with 59.2%±13.2% change in controls; P<.0001) and the cold pressor test (83.5%±7.3% change compared with 74.1%±11.4% change in controls; P=.039). Further, recovery kinetics in control children were faster than those of children with sleep-disordered breathing. Conclusion: Children with sleep-disordered breathing have altered autonomic nervous system regulation as evidenced by increased sympathetic vascular reactivity during wakefulness. Journal SLEEP Volume 28/ Issue 6, June 1, 2005, Pages 747-752

Information Leaflet and Antibiotic Prescribing Strategies for Acute Lower Respiratory Tract Infection Paul Little, MD; Kate Rumsby, BA; Joanne Kelly, BSc; Louise Watson, PhD; Michael Moore, MRCGP; Gregory Warner, MRCGP; Tom Fahey, MD; Ian Williamson, MD ABSTRACT Context Acute lower respiratory tract infection is the most common condition treated in primary care. Many physicians still prescribe antibiotics; however, systematic reviews of the use of antibiotics are small and have diverse conclusions. Objective To estimate the effectiveness of 3 prescribing strategies and an information leaflet for acute lower respiratory tract infection. Design, Setting, and Patients A randomized controlled trial conducted from August 18, 1998, to July 30, 2003, of 807 patients presenting in a primary care setting with acute uncomplicated lower respiratory tract infection. Patients were assigned to 1 of 6 groups by a factorial design: leaflet or no leaflet and 1 of 3 antibiotic groups (immediate antibiotics, no offer of antibiotics, and delayed antibiotics). Intervention Three strategies, immediate antibiotics (n = 262), a delayed antibiotic prescription (n = 272), and no offer of antibiotics (n = 273), were prescribed. Approximately half of each group received an information leaflet (129 for immediate antibiotics, 136 for delayed antibiotic prescription, and 140 for no antibiotics). Main Outcome Measures Symptom duration and severity. Results A total of 562 patients (70%) returned complete diaries and 78 (10%) provided information about both symptom duration and severity. Cough rated at least "a slight problem" lasted a mean of 11.7 days (25% of patients had a cough lasting 17 days). An information leaflet had no effect on the main outcomes. Compared with no offer of antibiotics, other strategies did not alter cough duration (delayed, 0.75 days; 95% confidence intervals [CI], –0.37 to 1.88; immediate, 0.11 days; 95% CI, –1.01 to 1.24) or other primary outcomes. Compared with the immediate antibiotic group, slightly fewer patients in the delayed and control groups used antibiotics (96%, 20%, and 16%, respectively; P<.001), fewer patients were "very satisfied" (86%, 77%, and 72%, respectively; P = .005), and fewer patients believed in the effectiveness of antibiotics (75%, 40%, and 47%, respectively; P<.001). There were lower reattendances within a month with antibiotics (mean attendances for no antibiotics, 0.19; delayed, 0.12; and immediate, 0.11; P = .04) and higher attendance with a leaflet (mean attendances for no leaflet, 0.11; and leaflet, 0.17; P = .02). Conclusion No offer or a delayed offer of antibiotics for acute uncomplicated lower respiratory tract infection is acceptable, associated with little difference in symptom resolution, and is likely to considerably reduce antibiotic use and beliefs in the effectiveness of antibiotics. Author Affiliations: Primary Medical Care Group, University of Southampton, Highfield (Drs Little, Watson, and Williamson, and Mss Rumsby and Kelly); Nightingale Surgery, Romsey, Hants (Dr Warner); Three Swans Surgery, Salisbury (Drs Moore and Fahey), England; and Department of Primary Care, Dundee University, Dundee, Scotland (Dr Fahey). JAMA. 2005;293:3029-3035

ABSTRACT Background Premenstrual syndrome (PMS) is one of the most common disorders of premenopausal women. Studies suggest that blood calcium and vitamin D levels are lower in women with PMS and that calcium supplementation may reduce symptom severity, but it is unknown whether these nutrients may prevent the initial development of PMS. Methods We conducted a case-control study nested within the prospective Nurses’ Health Study II cohort. Participants were a subset of women aged 27 to 44 years and free from PMS at baseline in 1991, including 1057 women who developed PMS over 10 years of follow-up and 1968 women reporting no diagnosis of PMS and no or minimal menstrual symptoms. Intake of calcium and vitamin D was measured in 1991, 1995, and 1999 by a food frequency questionnaire. Results After adjustment for age, parity, smoking status, and other risk factors, women in the highest quintile of total vitamin D intake (median, 706 IU/d) had a relative risk of 0.59 (95% confidence interval, 0.40-0.86) compared with those in the lowest quintile (median, 112 IU/d) (P = .01 for trend). The intake of calcium from food sources was also inversely related to PMS; compared with women with a low intake (median, 529 mg/d), participants with the highest intake (median, 1283 mg/d) had a relative risk of 0.70 (95% confidence interval, 0.50-0.97) (P = .02 for trend). The intake of skim or low-fat milk was also associated with a lower risk (P<.001). Conclusions A high intake of calcium and vitamin D may reduce the risk of PMS. Large-scale clinical trials addressing this issue are warranted. Given that calcium and vitamin D may also reduce the risk of osteoporosis and some cancers, clinicians may consider recommending these nutrients even for younger women. Author Affiliations: Department of Public Health, University of Massachusetts, Amherst (Dr Bertone-Johnson); Channing Laboratory (Drs Hankinson, Willett, and Manson) and Division of Preventive Medicine (Dr Manson), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Mass; Departments of Epidemiology (Drs Hankinson, Willett, and Manson) and Nutrition (Dr Willett), Harvard School of Public Health, Boston; GlaxoSmithKline Consumer Healthcare, Parsippany, NJ (Dr Bendich); and Department of Obstetrics and Gynecology, The University of Iowa, Iowa City (Dr Johnson). Arch Intern Med. 2005;165:1246-1252.

IMMEDIATE ACTION REQUIRED Earlier this week, Senate Bill S.3169a and Assembly Bill A.5622a, legislation that would grant physical therapists “direct access” in New York state were amended to “A” prints and started to move. The former Senate Bill, S.3169, contained protections penned into the legislation by the NYSCA and the Medical Society in the Fall of 2002. These protections have been completely discarded in the “A” print of S.3169 – now S.3169a. The companion legislation in the state Assembly, A. 5622a, has been amended to mirror the Senate legislation making the possibility of passage of Physical Therapy Direct Access more probable. YOU NEED TO ACT NOW. For more information, click on the link below.

One of the most common disorders of premenopausal women is premenstrual syndrome (PMS) however, women that get plenty of calcium and vitamin D may prevent PMS. ABSTRACT Background Premenstrual syndrome (PMS) is one of the most common disorders of premenopausal women. Studies suggest that blood calcium and vitamin D levels are lower in women with PMS and that calcium supplementation may reduce symptom severity, but it is unknown whether these nutrients may prevent the initial development of PMS. Methods We conducted a case-control study nested within the prospective Nurses’ Health Study II cohort. Participants were a subset of women aged 27 to 44 years and free from PMS at baseline in 1991, including 1057 women who developed PMS over 10 years of follow-up and 1968 women reporting no diagnosis of PMS and no or minimal menstrual symptoms. Intake of calcium and vitamin D was measured in 1991, 1995, and 1999 by a food frequency questionnaire. Results After adjustment for age, parity, smoking status, and other risk factors, women in the highest quintile of total vitamin D intake (median, 706 IU/d) had a relative risk of 0.59 (95% confidence interval, 0.40-0.86) compared with those in the lowest quintile (median, 112 IU/d) (P = .01 for trend). The intake of calcium from food sources was also inversely related to PMS; compared with women with a low intake (median, 529 mg/d), participants with the highest intake (median, 1283 mg/d) had a relative risk of 0.70 (95% confidence interval, 0.50-0.97) (P = .02 for trend). The intake of skim or low-fat milk was also associated with a lower risk (P<.001). Conclusions A high intake of calcium and vitamin D may reduce the risk of PMS. Large-scale clinical trials addressing this issue are warranted. Given that calcium and vitamin D may also reduce the risk of osteoporosis and some cancers, clinicians may consider recommending these nutrients even for younger women. Archives of Internal Medicine 2005;165:1246-1252.