Summary Background Whether calcium supplementation can reduce osteoporotic fractures is uncertain. We did a meta-analysis to include all the randomised trials in which calcium, or calcium in combination with vitamin D, was used to prevent fracture and osteoporotic bone loss. Methods We identified 29 randomised trials (n=63 897) using electronic databases, supplemented by a hand-search of reference lists, review articles, and conference abstracts. All randomised trials that recruited people aged 50 years or older were eligible. The main outcomes were fractures of all types and percentage change of bone-mineral density from baseline. Data were pooled by use of a random-effect model. Findings In trials that reported fracture as an outcome (17 trials, n=52 625), treatment was associated with a 12% risk reduction in fractures of all types (risk ratio 0•88, 95% CI 0•83–0•95; p=0•0004). In trials that reported bone-mineral density as an outcome (23 trials, n=41 419), the treatment was associated with a reduced rate of bone loss of 0•54% (0•35–0•73; p<0•0001) at the hip and 1•19% (0•76–1•61%; p<0•0001) in the spine. The fracture risk reduction was significantly greater (24%) in trials in which the compliance rate was high (p<0•0001). The treatment effect was better with calcium doses of 1200 mg or more than with doses less than 1200 mg (0•80 vs 0•94; p=0•006), and with vitamin D doses of 800 IU or more than with doses less than 800 IU (0•84 vs 0•87; p=0•03). Interpretation Evidence supports the use of calcium, or calcium in combination with vitamin D supplementation, in the preventive treatment of osteoporosis in people aged 50 years or older. For best therapeutic effect, we recommend minimum doses of 1200 mg of calcium, and 800 IU of vitamin D (for combined calcium plus vitamin D supplementation). Affiliations: Dr Benjamin MP Tang MD a b, Guy D Eslick PhD b, Prof Caryl Nowson PhD c, Caroline Smith PhD a and Prof Alan Bensoussan PhD a a. Centre for Complementary Medicine Research, University of Western Sydney, New South Wales, Australia b. University of Sydney, Nepean Hospital, Penrith, New South Wales, Australia c. School of Exercise and Nutrition Sciences, Deakin University, Victoria, Australia

Abstract: Study Design. An economic evaluation alongside a randomized clinical trial in primary care. A total of 135 patients were randomly allocated to physical therapy added to general practitioners' care (n = 67) or to general practitioners' care alone (n = 68). Objective. To evaluate the cost-effectiveness of physical therapy and general practitioner care for patients with an acute lumbosacral radicular syndrome (LRS, also called sciatica) compared with general practitioner care only. Summary of Background Data. There is a lack of knowledge concerning the cost-effectiveness of physical therapy in patients with sciatica. Methods. The clinical outcomes were global perceived effect and quality of life. The direct and indirect costs were measured by means of questionnaires. The follow-up period was 1 year. The Incremental Cost-effectiveness Ratio (ICER) between both study arms was constructed. Confidence intervals for the ICER were calculated using Fieller's method and using bootstrapping. Results. There was a significant difference on perceived recovery at 1-year follow-up in favor of the physical therapy group. The additional physical therapy did not have an incremental effect on quality of life. At 1-year follow-up, the ICER for the total costs was [Euro sign]6224 (95% confidence interval, -10419, 27551) per improved patient gained. For direct costs only, the ICER was [Euro sign]837 (95% confidence interval, -731, 3186). Conclusion. The treatment of patients with LRS with physical therapy and general practitioners'care is not more cost-effective than general practitioners'care alone. Spine. 32(18):1942-1948, August 15, 2007. (C) 2007 Lippincott Williams & Wilkins, Inc.

The Foundation for Chiropractic Progress is pleased to unveil three new ads to communicate to the chiropractic profession and the general public. These advertisements present both the purpose and successes of the Foundation over the last twelve months. With a focus on the range of methods used to reach the consumer public on the benefits of chiropractic, these ads are another key to help unlock the best kept secret in health care - chiropractic. ”We encourage every state association and chiropractic publication to utilize these ads on a rotating basis,” stated Kent S. Greenawalt, Foundation Chairman. “In doing this, the chiropractic profession can see what is being achieved and more importantly what can be achieved if the entire profession supports the public relations campaign.” Mr. Thomas Collins, known as one of the best copywriters in the world, prepared the ads for the Foundation. Co-founder and creative director of Rapp & Collins, an advertising agency specializing in direct marketing and fundraising appeals, Mr. Collins writes The Makeover Maven, a monthly column in Direct Magazine. In addition, he has compiled 40 advertising makeovers into a book, How I Would Have Done These Ads. The number of positive messages generated by the Foundations’ public relations efforts has exceeded thirty million and continues to grow. The combination of a prominent public relations agency, generating monthly press releases and public service announcements, along with positive ads in national publications is having an enormous impact on this effort. The Foundation for Chiropractic’s public relations campaign is the longest, continuous public relations campaign in the history of the profession. Every dollar received from vendors and doctors will go directly to the advertising/public relations campaign. We invite you to join the Foundation and build on the positive press of this campaign. Contributions can be mailed to P.O. Box 560, Carmichael, California 95609-0560 or please visit: www.foundation4cp.com.

Company refused fair reimbursement for covered services, Department alleges TRENTON – On Monday the Department of Banking and Insurance (DOBI) filed an administrative order levying $9,475,000 in fines against Aetna Health Inc. for refusing to appropriately cover certain services provided by out-of-network health care providers – including emergency treatment – in violation of New Jersey rules and regulations. In June, DOBI received numerous complaints after Aetna issued a letter to health care providers stating that the company had determined what was “fair payment” for services rendered by non-participating physicians and health care facilities and that “additional reimbursement would not be considered.” This included services by non-participating providers that were required under New Jersey law, such as emergency care, services provided by non-participating providers during an admission to a network hospital, and services rendered as the result of a referral or authorization by Aetna. The letter stated that Aetna determined that 125 percent of the Medicare allowable amount was fair payment, and 75 percent for lab fees and durable medical equipment. As a result, many patients were subject to receiving bills for the amount Aetna would not pay, creating significant financial exposure. Under such circumstances, New Jersey regulations state that members of a health maintenance organization (HMO) have the right to “be free from balance billing by providers for medically necessary services…” DOBI Commissioner Steven M. Goldman signed the order requiring Aetna to cease its limited reimbursement practice, to reprocess all claims for services rendered by non-participating providers adversely affected by Aetna’s unfair practices, and make payment to those providers based on the billed amount plus 12 percent interest from the date the claim was initially paid, in addition to the monetary penalty. Aetna has 30 days to request an administrative hearing objecting to the order. If no hearing is requested, the order will then become final.

ABSTRACT Background Widely used models for teaching and assessing communication skills highlight the importance of greeting patients appropriately, but there is little evidence regarding what constitutes an appropriate greeting. Methods To obtain data on patient expectations for greetings, we asked closed-ended questions about preferences for shaking hands, use of patient names, and use of physician names in a computer-assisted telephone survey of adults in the 48 contiguous United States. We also analyzed an existing sample of 123 videotaped new patient visits to characterize patterns of greeting behavior in everyday clinical practice. Results Most (78.1%) of the 415 survey respondents reported that they want the physician to shake their hand, 50.4% want their first name to be used when physicians greet them, and 56.4% want physicians to introduce themselves using their first and last names; these expectations vary somewhat with patient sex, age, and race. Videotapes revealed that physicians and patients shook hands in 82.9% of visits. In 50.4% of the initial encounters, physicians did not mention the patient's name at all. Physicians tended to use their first and last names when introducing themselves. Conclusions Physicians should be encouraged to shake hands with patients but remain sensitive to nonverbal cues that might indicate whether patients are open to this behavior. Given the diversity of opinion regarding the use of names, coupled with national patient safety recommendations concerning patient identification, we suggest that physicians initially use patients' first and last names and introduce themselves using their own first and last names. Arch Intern Med. 2007;167:1172-1176 Gregory Makoul, PhD; Amanda Zick, MA; Marianne Green, MD Author Affiliations: Center for Communication and Medicine (Dr Makoul and Ms Zick) and Division of General Internal Medicine (Drs Makoul and Green and Ms Zick), Northwestern University Feinberg School of Medicine, Chicago, Ill.

Prof Xiaobin Wang, Xianhui Qin, Hakan Demirtas PhD, Jianping Li MD, Guangyun Mao MD, Prof Yong Huo MD, Prof Ningling Sun MD, Prof Lisheng Liu MD and Prof Xiping Xu MD ABSTRACT Background The efficacy of treatments that lower homocysteine concentrations in reducing the risk of cardiovascular disease remains controversial. Our aim was to do a meta-analysis of relevant randomised trials to assess the efficacy of folic acid supplementation in the prevention of stroke. Methods We collected data from eight randomised trials of folic acid that had stroke reported as one of the endpoints. Relative risk (RR) was used as a measure of the effect of folic acid supplementation on the risk of stroke with a random effect model. The analysis was further stratified by factors that could affect the treatment effects. Findings Folic acid supplementation significantly reduced the risk of stroke by 18% (RR 0•82, 95% CI 0•68–1•00; p=0•045). In the stratified analyses, a greater beneficial effect was seen in those trials with a treatment duration of more than 36 months (0•71, 0•57–0•87; p=0•001), a decrease in the concentration of homocysteine of more than 20% (0•77, 0•63–0•94; p=0•012), no fortification or partly fortified grain (0•75, 0•62–0•91; p=0•003), and no history of stroke (0•75, 0•62–0•90; p=0•002). In the corresponding comparison groups, the estimated RRs were attenuated and insignificant. Interpretation Our findings indicate that folic acid supplementation can effectively reduce the risk of stroke in primary prevention. The Lancet 2007; 369:1876-1882

ABSTRACT Objective To test the reproducibility of the finding that early intensive care for whiplash injuries is associated with delayed recovery. Methods We analyzed data from a cohort study of 1,693 Saskatchewan adults who sustained whiplash injuries between July 1, 1994 and December 31, 1994. We investigated 8 initial patterns of care that integrated type of provider (general practitioners, chiropractors, and specialists) and number of visits (low versus high utilization). Cox models were used to estimate the association between patterns of care and time to recovery while controlling for injury severity and other confounders. Results Patients in the low-utilization general practitioner group and those in the general medical group had the fastest recovery even after controlling for important prognostic factors. Compared with the low-utilization general practitioner group, the 1-year rate of recovery in the high-utilization chiropractic group was 25% slower (adjusted hazard rate ratio [HRR] 0.75, 95% confidence interval [95% CI] 0.54-1.04), in the low-utilization general practitioner plus chiropractic group the rate was 26% slower (HRR 0.74, 95% CI 0.60-0.93), and in the high-utilization general practitioner plus chiropractic combined group the rate was 36% slower (HRR 0.64, 95% CI 0.50-0.83). Conclusion The observation that intensive health care utilization early after a whiplash injury is associated with slower recovery was reproduced in an independent cohort of patients. The results add to the body of evidence suggesting that early aggressive treatment of whiplash injuries does not promote faster recovery. In particular, the combination of chiropractic and general practitioner care significantly reduces the rate of recovery. Pierre Côté 1, Sheilah Hogg-Johnson 2, J. David Cassidy 3, Linda Carroll 4, John W. Frank 5, Claire Bombardier 6 1Institute for Work & Health, the University of Toronto, and the Toronto Western Research Institute and Rehabilitations Solutions, Toronto, Ontario, Canada 2Institute for Work & Health, the University of Toronto, and Mt. Sinai Hospital, Toronto, Ontario, Canada 3University of Toronto, and the Toronto Western Research Institute and Rehabilitations Solutions, Toronto, Ontario, Canada 4Alberta Centre for Injury Control and Research, Edmonton, Canada 5Institute for Work & Health, the University of Toronto, and the Institute of Population and Public Health, Toronto, Ontario, Canada 6Institute for Work & Health, the University of Toronto, the Toronto General Hospital Research Institute, and Mt. Sinai Hospital, Toronto, Ontario, Canada Arthritis Care & Research Volume 57, Issue 5, Pages 861 - 868

America’s veterans are one step closer to gaining expanded access to chiropractic services after the U.S. House of Representatives passed legislation on May 23 that includes a provision to expedite expansion of the chiropractic benefit through the Department of Veterans Affairs (VA) health care system. The bill was approved 421:1. The American Chiropractic Association (ACA) and the Association of Chiropractic Colleges (ACC) lobbied successfully for passage of the bill, HR 1470, which requires the VA to have a chiropractor on staff at no fewer than 75 major VA medical centers before the end of 2009 and for all major VA medical centers to have a chiropractor on staff before the end of 2011. “I am proud that ACA and ACC spearheaded the advocacy efforts in support of HR 1470,” said ACA President Dr. Richard Brassard. “The health and well-being of our nation’s veterans is one of America's most important obligations. This legislation builds and expands on ACA’s previous work with Congress and will greatly improve the availability of chiropractic care to veterans young and old.” Congressman Bob Filner (D-Calif.), a strong supporter of extending chiropractic care benefits to military retirees as well as active-duty personnel, worked closely with the ACA in securing support for the legislation. As Chairman of the House Veterans Affairs Committee, Rep. Filner’s leadership was essential to securing House passage of the bill. According to remarks contained in the March 12, 2007, Congressional Record, Rep. Filner said that when writing the legislation he worked closely with “chiropractic patients, particularly our veterans, who know the benefits of chiropractic care and bear witness to the positive outcomes and preventative health benefits of chiropractic.” “I also was pleased to work with the American Chiropractic Association (ACA), the nation’s largest chiropractic organization and the national voice of doctors of chiropractic and their patients,” Rep. Filner said. Through previous congressional action, chiropractic care is now available at 30 VA facilities across the country; however, in the more than 120 facilities without a chiropractor on staff, the chiropractic care benefit that Congress authorized for America’s veterans remains virtually non-existent. Detroit, Denver, and Chicago are a few examples of major metropolitan areas without a doctor of chiropractic available at the local VA facility. ACA leaders believe that integrating chiropractic treatment into the VA health care system would not only be cost-effective, it would also speed the recovery of many of the veterans returning from current operations in Iraq and Afghanistan. A 2006 report from the Veterans Health Administration indicates that nearly 42 percent of veterans returning from the Middle East and Southwest Asia who have sought VA health care were treated for symptoms associated with musculoskeletal ailments – the top malady of those tracked for the report. HR 1470 is now headed to the Senate for consideration.

Abstract BACKGROUND Disclosing errors to patients is an important part of patient care, but the prevalence of disclosure, and factors affecting it, are poorly understood. OBJECTIVE To survey physicians and trainees about their practices and attitudes regarding error disclosure to patients. DESIGN AND PARTICIPANTS Survey of faculty physicians, resident physicians, and medical students in Midwest, Mid-Atlantic, and Northeast regions of the United States. MEASUREMENTS Actual error disclosure; hypothetical error disclosure; attitudes toward disclosure; demographic factors. RESULTS Responses were received from 538 participants (response rate = 77%). Almost all faculty and residents responded that they would disclose a hypothetical error resulting in minor (97%) or major (93%) harm to a patient. However, only 41% of faculty and residents had disclosed an actual minor error (resulting in prolonged treatment or discomfort), and only 5% had disclosed an actual major error (resulting in disability or death). Moreover, 19% acknowledged not disclosing an actual minor error and 4% acknowledged not disclosing an actual major error. Experience with malpractice litigation was not associated with less actual or hypothetical error disclosure. Faculty were more likely than residents and students to disclose a hypothetical error and less concerned about possible negative consequences of disclosure. Several attitudes were associated with greater likelihood of hypothetical disclosure, including the belief that disclosure is right even if it comes at a significant personal cost. CONCLUSIONS There appears to be a gap between physicians’ attitudes and practices regarding error disclosure. Willingness to disclose errors was associated with higher training level and a variety of patient-centered attitudes, and it was not lessened by previous exposure to malpractice litigation. Lauris C. Kaldjian1, 2 , Elizabeth W. Jones1, 3, Barry J. Wu4, Valerie L. Forman-Hoffman1, 3, Benjamin H. Levi5 and Gary E. Rosenthal1, 3 (1) Division of General Internal Medicine, Department of Internal Medicine, 1-106 MEB, University of Iowa Carver College of Medicine, 500 Newton Road, Iowa City, IA 52242, USA (2) Program in Biomedical Ethics and Medical Humanities, University of Iowa Carver College of Medicine, Iowa City, IA, USA (3) Center for Research in the Implementation of Innovative Strategies in Practice, Iowa City VA Medical Center, Iowa City, IA, USA (4) Department of Internal Medicine, Hospital of St. Raphael, New Haven, CT, and Yale University School of Medicine, New Haven, CT, USA (5) Departments of Humanities and Pediatrics, Penn State College of Medicine and Hershey Medical Center, Hershey, PA, USA

(Arlington, Va.) A new literature review finds evidence that patients with chronic neck pain enrolled in clinical trials reported significant improvement following chiropractic spinal manipulation, according to a March/April 2007 report in the Journal of Manipulative and Physiological Therapeutics (JMPT). According to Howard Vernon, DC, PhD, the review’s chief author, “The results of the literature review confirm the common clinical experience of doctors of chiropractic: neck manipulation is beneficial for patients with certain forms of chronic neck pain.” As part of the literature review, Dr. Vernon and his colleagues reviewed nine previously published trials and found “high-quality evidence” that patients with chronic neck pain showed significant pain-level improvements following spinal manipulation. No trial group was reported to remain unchanged, and all groups showed positive changes up to 12 weeks post treatment. No trial reported any serious adverse effects. This literature review did not include studies involving patients with acute neck pain, neck and arm pain, neck pain due to whiplash, or those with headaches. In this review, chronic neck pain was defined as being a minimum of 8 weeks duration. Researchers also found that mobilization therapy was beneficial in improving patients’ pain levels, with many achieving full recovery after six to seven weeks of treatment; however, the current evidence did not support a similar level of benefit from massage therapy. Neck pain is a very common complaint – approximately 15 percent of women and 10 percent of men are estimated to have chronic neck pain at any one time. According to a report issued by the National Board of Chiropractic Examiners, 18 percent of chiropractic patients list neck pain as their chief complaint. Spinal manipulation, also called a chiropractic adjustment, is the main therapeutic procedure performed by doctors of chiropractic. The purpose of manipulation is to restore joint mobility by manually applying a controlled force into joints that have become hypomobile. Chiropractors practice a hands-on, drug-free approach to health care that includes patient examination, diagnosis and treatment. Chiropractic is widely recognized as one of the safest non-invasive therapies available for the treatment of back pain, neck pain, headaches and other neuromusculoskeletal complaints. In addition, a significant amount of evidence shows that the use of chiropractic care for certain conditions can be more effective and less costly than traditional medical care. 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.

ABSTRACT Objective To examine the effects of reduction in dietary sodium intake on cardiovascular events using data from two completed randomised trials, TOHP I and TOHP II. Design Long term follow-up assessed 10-15 years after the original trial. Setting 10 clinic sites in 1987-90 (TOHP I) and nine sites in 1990-5 (TOHP II). Central follow-up conducted by post and phone. Participants Adults aged 30-54 years with prehypertension. Intervention Dietary sodium reduction, including comprehensive education and counselling on reducing intake, for 18 months (TOHP I) or 36-48 months (TOHP II). Main outcome measure Cardiovascular disease (myocardial infarction, stroke, coronary revascularisation, or cardiovascular death). Results 744 participants in TOHP I and 2382 in TOHP II were randomised to a sodium reduction intervention or control. Net sodium reductions in the intervention groups were 44 mmol/24 h and 33 mmol/24 h, respectively. Vital status was obtained for all participants and follow-up information on morbidity was obtained from 2415 (77%), with 200 reporting a cardiovascular event. Risk of a cardiovascular event was 25% lower among those in the intervention group (relative risk 0.75, 95% confidence interval 0.57 to 0.99, P=0.04), adjusted for trial, clinic, age, race, and sex, and 30% lower after further adjustment for baseline sodium excretion and weight (0.70, 0.53 to 0.94), with similar results in each trial. In secondary analyses, 67 participants died (0.80, 0.51 to 1.26, P=0.34). Conclusion Sodium reduction, previously shown to lower blood pressure, may also reduce long term risk of cardiovascular events. Nancy R Cook 1*, Jeffrey A Cutler 2, Eva Obarzanek 2, Julie E Buring 1, Kathryn M Rexrode 1, Shiriki K Kumanyika 3, Lawrence J Appel 4, Paul K Whelton 5 1 Brigham and Women's Hospital, Harvard Medical School, Boston, MA 2 National Heart, Lung, and Blood Institute, Bethesda, MD 3 University of Pennsylvania School of Medicine, Philadelphia, PA 4 Johns Hopkins University, Baltimore, MD 5 Loyola University Health System, Maywood, IL

The New York State Senate today confirmed Governor Eliot Spitzer’s nomination of Eric R. Dinallo as the 39th Superintendent of the New York State Insurance Department. Superintendent Dinallo has been serving as Acting Superintendent since January 2007. “I am honored to have been confirmed as Superintendent of the Insurance Department. I thank Governor Spitzer for nominating me and the Senate for its unanimous vote. I am proud to join the excellent staff of the premier state insurance regulator,” Superintendent Dinallo said. “I pledge to the people of New York State that the Insurance Department will strive to ensure that consumers, both individuals and businesses, are fully informed, have access to the insurance products they need at reasonable prices and are treated fairly in the claims process. The Department will work equally hard to ensure there is a favorable climate in New York for the insurance industry to prosper and grow, including a level playing field. Finally, the Department will strive to regulate in innovative and efficient ways that provide all of the above,” said Superintendent Dinallo. Superintendent Dinallo joined the Department from Willis Group Holdings. Since 2006, he had been General Counsel for the company, the world’s third largest insurance broker. A member of the Partners Group, the company’s global executive management committee, he was the primary legal advisor on value creation matters. His responsibilities included supervising General Counsels, Global Compliance and the Internal Audit Department, as well as implementing corporate strategies, policies and procedures to ensure the effective management of regulatory and litigation matters. From 2003 to 2006, Superintendent Dinallo was the Managing Director, Global Head of Regulatory Affairs for Morgan Stanley. He designed and led top-to-bottom reviews of conflicts and business practices, achieving a major shift in the firm-wide regulatory strategy. At Morgan Stanley, Superintendent Dinallo chaired the Global Conflicts Committee and was the Managing Director on the Law Department Diversity Committee. He was also a member of the Franchise Committee and the Operational Risk Group. Superintendent Dinallo served at the Office of Attorney General Eliot Spitzer from 1999 to 2003. As Chief of the Securities Bureau, he was charged with combining that bureau with the Real Estate Finance Bureau. The resulting Bureau was named the Investment Protection Bureau to reflect its focus, and Mr. Dinallo was named its first Chief. In that capacity, he led the reinvigorated Bureau’s investigations into the Wall Street Cases – conflicts of interest in the financial services industry, including research analyst cases and the spinning of hot initial public offerings. He produced more than 40 major civil and criminal matters, and led the Bureau through the beginning of the mutual fund industry investigations. Before joining the Attorney General’s office, Superintendent Dinallo served as an Assistant District Attorney in the New York County District Attorney’s office from 1995 to 1999. He had primary responsibility for securities fraud and white collar and insider trading investigations and trial. From 1991 to 1995, Superintendent Dinallo was a Litigation Associate with the Manhattan law firm of Paul, Weiss, Rifkin, Wharton & Garrison. From 1990 to 1991, the Superintendent clerked with the Honorable David M. Ebel of the United States Court of Appeals, Tenth Circuit in Denver. Superintendent Dinallo earned a Bachelor of Arts degree in philosophy from Vassar College in 1985, followed by a Master of Arts degree from Duke University School of Public Policy in 1987. In 1990, he earned his law degree from New York University where he was New York University Law Review and Essay Editor and a member of the Order of the Coif. Superintendent Dinallo lives in Manhattan with his wife, Priscilla Almodovar, and children Robert and Amelia. The Superintendent of Insurance is responsible for the monitoring and regulation of more than 1,000 insurance companies with total assets exceeding $4 trillion. The position also includes oversight responsibility for more than 100,000 brokers, agents and financial intermediaries and the management of more than a thousand Department employees. The Superintendent also acts as Receiver of insolvent insurance companies through the New York Liquidation Bureau.

New York State Metro delegate to the American Chiropractic Association (ACA) H. William Wolfson, DC, of Commack, NY, was named a Fellow of the International College of Chiropractors (ICC) at the ACA House of Delegates meeting on March 23, 2007, in Washington, D.C. Election to the ICC is touted as one of the highest honors of service in the chiropractic profession. Dr. Wolfson was presented a plaque commemorating the honor from Dr. Lewis Bazakos, ACA Chairman of the Board of Governors

Chiropractors Must Focus on Improving Documentation Error Rate (Arlington, Va.) The first phase of the historic Medicare Chiropractic Demonstration Project will come to a close this weekend, ending a two-year program to collect cost and other data related to an expansion of chiropractic services offered in Medicare. It is ACA’s hope that the demonstration project will prove effective in convincing Congress to enact permanent legislation to reimburse doctors of chiropractic within Medicare for common services beyond manual manipulation of the spine to correct a subluxation, such as exams, plain X-rays, therapy services and clinical lab services. The Medicare Chiropractic Demonstration Project will officially end on March 31, 2007. Under the next phase of the demonstration project, no additional chiropractic services will be provided within Medicare; the Centers for Medicare & Medicaid Services (CMS) will concentrate on collecting and evaluating claims data – a process expected to require an additional two years. CMS will furnish Congress with a formal analysis and report on the findings of the pilot project in spring 2009. “On behalf of all ACA leadership, I wish to expresses my sincerest appreciation to all who were involved in the Medicare Chiropractic Demonstration Project, especially the individual doctors of chiropractic who elected to participate over the past two years,” said ACA President Richard G. Brassard, DC. “The demonstration project was an unprecedented opportunity for the chiropractic profession to show Medicare officials that the arbitrary limits on chiropractic services are costly to taxpayers and do a great injustice to patients.” At this time, ACA is reminding all doctors of chiropractic to focus on improving the chiropractic documentation error rate within the existing Medicare program. ACA fears that continued high claims error rates will be used as an argument to thwart future efforts to allow chiropractors to provide additional services, even if results from the Medicare Chiropractic Demonstration Project are favorable. ACA offers a number of valuable Medicare resources on its Web site at www.acatoday.org/medicare. In 2003, the U.S. Congress enacted legislation requiring CMS to conduct a “pilot program” allowing doctors of chiropractic to furnish additional services under Medicare. The pilot project, known as the Medicare Chiropractic Demonstration Project, was enacted into law as a direct result of an ACA lobbying campaign. The first phase of the demonstration project has been underway in select geographic areas – including Maine, New Mexico, 26 counties in Illinois, 17 counties in Virginia, and one county in Iowa – since April 2005. “Upon completion of the Medicare Chiropractic Demonstration Project, the chiropractic profession should have solid and reliable data on which to build our case for a permanent expansion within Medicare. If the data are favorable, it will be the pathway to enacting a law that will win us the Medicare coverage we have sought for years,” Dr. Brassard said. Public policy experts agree that changes to the Medicare program routinely roll over into the private sector, where health care plans often model their benefits after Medicare and adopt changes that the government makes to the program. Consequently, any positive results from the chiropractic demonstration that lead to permanent changes in the Medicare program will not only have encouraging implications for senior beneficiaries, they will also have a significant impact on the U.S. health care system for years to come. “The results of the demonstration project could finally mean the end of 30 years of discrimination against millions of patients who have been denied needed chiropractic care for far too long – not only under Medicare, but also under many private insurance plans that use Medicare as a model,” Dr. Brassard noted. For more information about chiropractic in Medicare, including the Medicare Chiropractic Demonstration Project, contact Jaime Mulligan at [email protected] or visit the ACA Web site at:

Recent guidelines issued by the American Heart Association that recommend medication as a last resort for chronic pain patients at risk for heart disease should encourage doctors and patients to first consider non-drug treatments such as chiropractic care, according to the American Chiropractic Association (ACA). “For years, the American Chiropractic Association has advocated restraint against the use of excessive drugs and unnecessary surgeries, because safer and more effective options exist,” said ACA President Richard Brassard, DC. “With recent studies linking many nonsteroidal anti-inflammatory drugs with an increased risk of heart attack and stroke, it is more important than ever for patients to have access to conservative treatments such as chiropractic care. Not only is chiropractic care safer than many medical treatments and procedures, it is also more cost effective.” The scientific statement, released by the heart association on Feb. 26, urged doctors to initially focus on “nonpharmacological approaches” to pain management in patients at risk for heart disease in an effort to avoid the possible cardiovascular complications of nonsteroidal anti-inflammatory drugs – or NSAIDs. Chiropractic is widely recognized as one of the safest drug-free, non-invasive therapies available for the treatment of back pain, neck pain, headaches and other neuromusculoskeletal complaints. In addition, a significant amount of evidence shows that the use of chiropractic care for certain conditions can be more effective and less costly than traditional medical care. Recent research includes: • A study published in the October 2005 issue of the Journal of Manipulative and Physiological Therapeutics (JMPT) found that chiropractic and medical care have comparable costs for treating chronic low-back pain, with chiropractic care producing significantly better outcomes. • A March 2004 study in JMPT found that chiropractic care is more effective than medical care at treating chronic low-back pain in patients' first year of symptoms. • A study published in the July 15, 2003, edition of the medical journal Spine found that manual manipulation provides better short-term relief of chronic spinal pain than does a variety of medications. The American Chiropractic Association is the nation's leading chiropractic organization representing more than 16,000 doctors of chiropractic and their patients. For more information, visit the ACA’s Web site at:

American Chiropractic Association (ACA) member Michael Minardo, DC, was recently featured in a video clip on the popular news Web site MSNBC.com. The story – which was arranged by ACA communications staff – offered advice on how women can avoid back, neck and shoulder pain when carrying a heavy or oversized handbag. The segment, which appeared prominently on the MSNBC.com homepage, was also broadcast on WNBC- 4 of New York City and NBC-5 Dallas, Texas. MSNBC.com is a leader in breaking news and original journalism on the Internet. Serving 4 to 5 million site visitors daily, the news site typically handles 50,000 simultaneous users, with as many as 400,000 site visitors during major breaking news events. This latest television segment is just one of the many media relations efforts conducted by the ACA on behalf of its members. ACA’s public relations team works to increase demand for chiropractic care and ensure that chiropractic receives accurate and favorable exposure in the media. Through proactive news releases, letters to the editor, and other vehicles, the ACA has reached millions of consumers with pro-chiropractic messages. Click here to watch the video. To view additional excerpts of media stories that mention doctors of chiropractic and/or chiropractic care, click below to visit the ACA web site.

Long-term Proton Pump Inhibitor Therapy and Risk of Hip Fracture Yu-Xiao Yang, MD, MSCE; James D. Lewis, MD, MSCE; Solomon Epstein, MD; David C. Metz, MD ABSTRACT Context: Proton pump inhibitors (PPIs) may interfere with calcium absorption through induction of hypochlorhydria but they also may reduce bone resorption through inhibition of osteoclastic vacuolar proton pumps. Objective: To determine the association between PPI therapy and risk of hip fracture. Design, Setting, and Patients: A nested case-control study was conducted using the General Practice Research Database (1987-2003), which contains information on patients in the United Kingdom. The study cohort consisted of users of PPI therapy and nonusers of acid suppression drugs who were older than 50 years. Cases included all patients with an incident hip fracture. Controls were selected using incidence density sampling, matched for sex, index date, year of birth, and both calendar period and duration of up-to-standard follow-up before the index date. For comparison purposes, a similar nested case-control analysis for histamine 2 receptor antagonists was performed. Main Outcome Measure: The risk of hip fractures associated with PPI use. Results: There were 13 556 hip fracture cases and 135 386 controls. The adjusted odds ratio (AOR) for hip fracture associated with more than 1 year of PPI therapy was 1.44 (95% confidence interval [CI], 1.30-1.59). The risk of hip fracture was significantly increased among patients prescribed long-term high-dose PPIs (AOR, 2.65; 95% CI, 1.80-3.90; P<.001). The strength of the association increased with increasing duration of PPI therapy (AOR for 1 year, 1.22 [95% CI, 1.15-1.30]; 2 years, 1.41 [95% CI, 1.28-1.56]; 3 years, 1.54 [95% CI, 1.37-1.73]; and 4 years, 1.59 [95% CI, 1.39-1.80]; PConclusion: Long-term PPI therapy, particularly at high doses, is associated with an increased risk of hip fracture. JAMA. 2006;296:2947-2953. Author Affiliations: Division of Gastroenterology (Drs Yang, Lewis, and Metz), Center for Clinical Epidemiology and Biostatistics (Drs Yang and Lewis), Department of Biostatistics and Epidemiology (Drs Yang and Lewis), and Division of Endocrinology (Dr Epstein), University of Pennsylvania School of Medicine, Philadelphia; and Department of Medicine, Doylestown Hospital Research Center, Doylestown, Pa (Dr Epstein).

The Food and Drug Administration (FDA) today proposed to amend the labeling regulations on over-the-counter (OTC) Internal Analgesic, Antipyretic, and Antirheumatic (IAAA) drug products to include important safety information regarding the potential for stomach bleeding and liver damage and when to consult a doctor. OTC IAAA drug products, commonly known as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen, naproxen and ketoprofen, are used to treat pain, fever, headaches, and muscle aches. To help ensure safe use of OTC products, and to provide consumers with the labeling necessary for them to make more informed medical decisions, FDA is proposing the following label changes: For Products Containing Acetaminophen • To require new warnings which would highlight the potential for liver toxicity, particularly when using acetaminophen in high doses, when taking more than one product with acetaminophen, and when taken with moderate amounts of alcohol; • To require that the ingredient acetaminophen be prominently identified on the product's principal display panel (PDP) of the immediate container, and the outer carton (if applicable). For Products Containing NSAIDs • To require new warnings for products that contain an NSAID which would highlight the potential for stomach bleeding in persons over age 60, in persons who have had prior ulcers or bleeding, in persons who take a blood thinner, when taking more than one product containing an NSAID, when taken with moderate amounts of alcohol, and when taking for longer time than directed; and • To require that the name of the NSAID ingredient and the term "NSAID" be prominently identified on the product's PDP of the immediate container and the outer carton (if applicable). The new labeling would be required for all OTC drug products that contain only an IAAA ingredient, as well as for products that contain an IAAA ingredient with other ingredients, such as cold symptom relievers. Consumers may also be taking IAAA ingredients in their prescription medications, which makes it important to alert them of the contents of their OTC medications, so they do not take too much of an IAAA ingredient. FDA based its proposal for labeling changes on previous Advisory Committee discussions, recommendations, and public comments (see http://www.fda.gov/ohrms/dockets/ac/cder02.htm#NonprescriptionDrugs) and a review of the scientific literature. A number of manufacturers of OTC internal analgesic drug products already have voluntarily implemented labeling changes to identify these potential safety concerns.

New York Chiropractic College conferred the Doctor of Chiropractic degree upon 96 graduates on Saturday, December 2, 2006, during a commencement ceremony held in the Athletic Center Gymnasium of the college’s Seneca Falls campus. Dr. Frank J. Nicchi, president of NYCC, expressed his pride for the new graduates. “It gives me a great sense of satisfaction that this class of new doctors will soon be administering quality care to the many patients in need of chiropractic.” Jennifer Marie Conway and Patricia Marie West were co-valedictorians and had the honor of addressing their class at the commencement ceremony. Tiffany Anne Grace was salutatorian. The commencement address was delivered by Peter D. Ferguson, D.C., past chairman and current member of the NYCC Board of Trustees, whose son, Brian was among the graduates. Dr. Ferguson is a graduate of National College of Chiropractic, has been in practice for 32 years in Ohio, and is licensed in 10 other states. He has served on the Ohio State Board of Chiropractic Examiners, the National Board of Chiropractic Examiners, the Executive Board of Directors of the Federation of Chiropractic Licensing Boards, and the Council of Chiropractic Education Board of Directors. He also sits on the U.S. Department of Defense Chiropractic Health Care Oversight Advisory Committee, which has facilitated the setting up of chiropractic practices at military bases across the United States. In addition, Ferguson is a member of the Advisory Committee on Interdisciplinary, Community Based Linkages for the U.S. Department of Health and Human Services, has served as the chiropractor to the Professional Football Hall of Fames since 1995, and has lectured on various sports chiropractic topics around the country. For further information about New York Chiropractic College’s degree programs in chiropractic, acupuncture and Oriental medicine, and applied clinical nutrition, visit the college’s Web site at:

Abstract Objective: To examine the effects of smoking on cartilage loss and pain at the knee in those with knee osteoarthritis (OA). Methods: We examined 159 men with symptomatic knee OA who participated in a 30-month, prospective, natural history study of knee OA. The more symptomatic knee was imaged using MRI at baseline, 15- and 30-months follow-up. Cartilage was scored using the WORMS semi- quantitative method at the medial and lateral tibiofemoral joint and at the patellofemoral joint. At baseline and follow-up visits, the severity of knee pain was assessed using a visual analogue scale (VAS) pain score (0-100 mm). Results: Among the 159 men, 19 (12%) were current smokers at baseline. Current smokers were younger (mean age ± SD: 62 ± 9 vs. 69 ± 9 years) and leaner (mean body mass index (BMI): 28.9 & [plusmn] 3.2 vs. 31.3 ± 4.8 kg/m2) than men who were not current smokers. Adjusted for age, BMI and baseline cartilage scores, we found that men who were current smokers had an increased risk for cartilage loss, at the medial tibiofemoral joint (odds ratio (OR): 2.3, 95% CI: 1.0 to 5.4) and the patellofemoral joint (OR: 2.5, 95% CI: 1.1 to 5.7). Current smokers also had higher adjusted pain scores at baseline (60.5 vs. 45.0, p<0.05) and follow-up (59.4 vs. 44.3, p <0.05) compared with men who were not current smokers. Conclusions: Men with knee OA who smoke sustain greater cartilage loss and have more severe knee pain than men who do not smoke. Source reference: Amin, S, et al "Cigarette Smoking and the Risk for Cartilage Loss and Knee Pain in Men with Knee Osteoarthritis" Ann Rheum Dis 2006: online: 2053-2060 Shreyasee Amin 1*, Jingbo Niu 2, Ali Guermazi 3, Mikayel Grigoryan 3, David J Hunter 2, Margaret Clancy 2, Michael P LaValley 2, Harry K Genant 3 and David T Felson 2 1 Mayo Clinic College of Medicine, United States 2 Boston University School of Medicine, United States 3 University of California, San Francisco, United States