Chinese herb Berberine lowers cholesterol in new way

Berberine, a Chinese herb lowers LDL ("bad") cholesterol in anew way from drugs like Lipitor or Zocor, a new study shows. The herb has a history of medicinal use in both Ayurvedic and Chinese medicine. Click on the link below for more:

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Footwear Style and Risk of Falls in Older Adults

ABSTRACT Objectives: To determine how the risk of a fall in an older adult varies in relation to style of footwear worn. Design: Nested case-control study. Setting: Group Health Cooperative, a large health maintenance organization in Washington state. Participants: A total of 1,371 adults aged 65 and older were monitored for falls over a 2-year period; 327 qualifying fall cases were compared with 327 controls matched on age and sex. Measurements: Standardized in-person examinations before fall occurrence, interviews about fall risk factors after the fall occurred, and direct examination of footwear were conducted. Questions for controls referred to the last time they engaged in an activity broadly similar to what the case was doing at the time of the fall. Results: Athletic and canvas shoes (sneakers) were the styles of footwear associated with lowest risk of a fall. Going barefoot or in stocking feet was associated with sharply increased risk, even after controlling for measures of health status (adjusted odds ratio=11.2, 95% confidence interval (CI)=2.4-51.8). Relative to athletic/canvas shoes, other footwear was associated with a 1.3-fold increase in the risk of a fall (95% CI=0.9-1.9), varying somewhat by style. Conclusion: Contrary to findings from gait-laboratory studies, athletic shoes were associated with relatively low risk of a fall in older adults during everyday activities. Fall risk was markedly increased when participants were not wearing shoes. Journal of the American Geriatrics Society Volume 52 Issue 9 Page 1495 - September 2004

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Dairy intakes affect bone density in the elderly

ABSTRACT Background: Race and sex differences in the effect of diet on bone mineral density (BMD) at the hip in the elderly are unknown. Objectives: This study related cross-sectional nutrient and dairy product consumption to hip BMD in white and black men and women aged >60 y and evaluated the influence of nutrient and dairy product consumption on changes in BMD in a white cohort participating in a calcium, vitamin D, or placebo trial. Design: The Health Habits and History Questionnaire was used in 289 white women and 116 white men who participated in the trial and in 265 black women and 75 black men to predict total hip and femoral neck BMD or changes in BMD. Results: Blacks had higher calcium intakes than did whites (700 and 654 mg/d, respectively; P = 0.0094), and men had higher calcium intakes than did women (735 and 655 mg/d, respectively; P = 0.0007). For men, the correlation between total hip BMD and dairy calcium intake after adjustment for age, race, and weight was 0.23 (P < 0.005); this relation was not significant in women (r = 0.02, P = 0.12). Similar results were found for femoral neck BMD. In the longitudinal study, calcium supplementation reduced bone loss from the total hip and femoral neck in those who consumed Conclusions: Cross-sectional results indicated that higher dairy product consumption is associated with greater hip BMD in men, but not in women. Calcium supplementation protected both men and women from bone loss in the longitudinal study of whites. American Journal of Clinical Nutrition, Vol. 80, No. 4, 1066-1074, October 2004

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Risk of Community-Acquired Pneumonia and Use of Gastric Acid–Suppressive Drugs

ABSTRACT Context Reduction of gastric acid secretion by acid-suppressive therapy allows pathogen colonization from the upper gastrointestinal tract. The bacteria and viruses in the contaminated stomach have been identified as species from the oral cavity. Objective To examine the association between the use of acid-suppressive drugs and occurrence of community-acquired pneumonia. Design, Setting, and Participants Incident acid-suppressive drug users with at least 1 year of valid database history were identified from the Integrated Primary Care Information database between January 1, 1995, and December 31, 2002. Incidence rates for pneumonia were calculated for unexposed and exposed individuals. To reduce confounding by indication, a case-control analysis was conducted nested in a cohort of incident users of acid-suppressive drugs. Cases were all individuals with incident pneumonia during or after stopping use of acid-suppressive drugs. Up to 10 controls were matched to each case for practice, year of birth, sex, and index date. Conditional logistic regression was used to compare the risk of community-acquired pneumonia between use of proton pump inhibitors (PPIs) and H2-receptor antagonists. Main Outcome Measure Community-acquired pneumonia defined as certain (proven by radiography or sputum culture) or probable (clinical symptoms consistent with pneumonia). Results The study population comprised 364 683 individuals who developed 5551 first occurrences of pneumonia during follow-up. The incidence rates of pneumonia in non–acid-suppressive drug users and acid-suppressive drug users were 0.6 and 2.45 per 100 person-years, respectively. The adjusted relative risk for pneumonia among persons currently using PPIs compared with those who stopped using PPIs was 1.89 (95% confidence interval, 1.36-2.62). Current users of H2-receptor antagonists had a 1.63-fold increased risk of pneumonia (95% confidence interval, 1.07-2.48) compared with those who stopped use. For current PPI users, a significant positive dose-response relationship was observed. For H2-receptor antagonist users, the variation in dose was restricted. Conclusion Current use of gastric acid–suppressive therapy was associated with an increased risk of community-acquired pneumonia. Author Affiliations: Department of Gastroenterology, University Medical Center St. Radboud, Nijmegen, the Netherlands (Drs Laheij and Jansen); and Department of Medical Informatics (Drs Laheij, Sturkenboom, Dieleman, and Stricker and Mr Hassing), Pharmacoepidemiology Unit, Department of Epidemiology and Biostatistics (Drs Sturkenboom and Stricker), and Internal Medicine (Dr Dieleman), Erasmus MC University, Medical Center Rotterdam, Rotterdam, the Netherlands. JAMA. 2004;292:2012-2013.

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Eight NYSCA members have been selected by the New York State Department of Health to serve on the Department’s Medical Record Access Review Committee. Five members were selected to serve on a Downstate Committee and three (3) members were assigned to an Upstate Committee. The Committee members chosen by the Department are the following: ▪ Downstate Committee Members • Gary L. Haber, DC of Manhattan • Lloyd Kupferman, DC of Greenvale • Malcolm L. Levitin, DC, FACC of Rockville Centre • Donald Littlejohn, DC, of Chester and • Richard W. Scher, DC of Wantagh. ▪ Upstate Committee Members • Brian D. Justice, DC, DABCO of Rochester • Lynn B. Pownall, DC, DACNB of Jamestown, and • Richard J. Tesoriero, DC, DABCO of Oswego. The members of these committee will be convened by the Department when required to resolve disputed between chiropractic professionals and persons qualified to receive medical records. "Qualified person" pursuant to New York Public Health Law, Article I, Title II, § 18 Access to patient information, (1) Definitions means “any properly identified subject, or a guardian appointed pursuant to article eighty-one of the mental hygiene law, or a parent of an infant, or a guardian of an infant appointed pursuant to article seventeen of the surrogate’s court procedure act or other legally appointed guardian of an infant who may be entitled to request access to a clinical record pursuant to paragraph (c) of subdivision two of this section, or an attorney representing or acting on behalf of the subject or the subject’s estate.” Under Subsection (4) Medical record access review committees, the law provides, "The commissioner shall appoint medical record access review committees to hear appeals of the denial of access to patient information as provided in paragraph (e) of subdivision three of this section. Members of such committees shall be appointed by the commissioner from a list of nominees submitted by statewide associations of providers in the particular licensed profession involved; . . . . Such medical record access review committees shall consist of no less than three nor more than five licensed professionals. The commissioner shall promulgate rules and regulations necessary to effectuate the provisions of this subdivision." Under subsection (3) of the Public Health Law, providers may limit a qualified persons access to patient information for certain itemized reasons. The Committee members above will assist the Department resolve disputes between DCs and qualified persons requesting access to patients records.

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New York’s Medicare Carriers have reported that they will be sending the 2005 Medicare Physician Fee Schedule (MPFS) on a CD-ROM this month to all those providers who usually receive the Fee Schedule in booklet format. Watch for additional information on your carrier’s website. This change comes as a result of a successful pilot project conducted a year earlier.


The Centers for Medicare and Medicaid Services (CMS) released yesterday, four sites CMS will use for a chiropractic demonstration projected required under section 651 of the Medicare Prescription Drug, Improvement, and Modernization Act. Making the announcement, CMS Administrator, Mark B. McClellan, M.D., Ph.D., announced that Medicare will conduct a demonstration project in Maine, New Mexico, Illinois and Virginia expanding coverage of chiropractic services for neuromusculoskeletal conditions. “We recognize that many Medicare beneficiaries seek the services of chiropractors for back pain and other conditions,” McClellan said. “This demonstration provides the opportunity to evaluate whether expanding coverage of chiropractic services reduces overall Medicare expenditures for neuromusculoskeletal conditions.” Beginning in April 2005, chiropractors that are located in the demonstration areas will be able to provide services to any beneficiary enrolled under Medicare Part B. The demonstration will expand coverage for the services that chiropractors provide for the care of neuromusculoskeletal conditions, including diagnostic and other services such as the provision of x-rays and therapy services. Current Medicare coverage for chiropractic care is limited to manual manipulation of the spine to correct a subluxation, which is defined as a malfunction of the spine. Treatment may only be provided for the active correction of a documented subluxation, and not for prevention or health maintenance. Treatment for the subluxation must be related in terms of a neuromusculoskeletal condition where there is a reasonable expectation of recovery or functional improvement. The goal of the demonstration is to evaluate the feasibility and desirability of covering additional chiropractic services under Medicare beyond the current coverage. CMS has scheduled an Open Door Forum on November 18 to solicit input from interested groups regarding benefits of this demonstration and implementation of its budget neutrality requirements. The demonstration will be conducted in the entire states of Maine and New Mexico, and in the Chicago Metropolitan Statistical Area (MSA) and 17 central counties in Virginia. The statue specified that the demonstration must include four sites, two urban and two rural, and one site of each must be in a health professional shortage area (HPSA). The statute requires an evaluation of the demonstration to assess cost effectiveness, cost benefit, beneficiary satisfaction, and other issues as the Secretary of Health and Human Services determines to be appropriate. ▪ ACA Concerns After fighting hard to have the demonstration project language included in the language of the Medicare Prescription Drug, Improvement, and Modernization Act, the ACA notes with some chagrin that is has some concerns with how the proposed demonstration project may be carried out. ACA staff met with CMS officials last Friday, November 6, to receive information on the status of planning for the demonstration. Subsequently, the ACA has identified several areas of concern with regard to the design, including possible infringements on full scope of practice under existing Medicare program benefits. ACA is preparing a formal and detailed response to CMS that will be available prior to CMS's November 18th, Open Door Forum on the chiropractic demonstration project. More on the project will be forthcoming in the not too distant future.


The Centers for Medicare and Medicaid Services (CMS) released yesterday, four sites CMS will use for a chiropractic demonstration projected required under section 651 of the Medicare Prescription Drug, Improvement, and Modernization Act. Making the announcement, CMS Administrator, Mark B. McClellan, M.D., Ph.D., announced that Medicare will conduct a demonstration project in Maine, New Mexico, Illinois and Virginia expanding coverage of chiropractic services for neuromusculoskeletal conditions. “We recognize that many Medicare beneficiaries seek the services of chiropractors for back pain and other conditions,” McClellan said. “This demonstration provides the opportunity to evaluate whether expanding coverage of chiropractic services reduces overall Medicare expenditures for neuromusculoskeletal conditions.” Beginning in April 2005, chiropractors that are located in the demonstration areas will be able to provide services to any beneficiary enrolled under Medicare Part B.


A Randomized Trial of Medical Care With and Without Physical Therapy and Chiropractic Care With and Without Physical Modalities for Patients With Low Back Pain: 6-Month Follow-Up Outcomes From the UCLA Low Back Pain Study


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Arlington, Va. (Oct. 19, 2004) — The American Chiropractic Association (ACA) has vowed to appeal a recent decision by a U.S. District Court judge to dismiss its lawsuit against the Department of Health and Human Services (HHS), a lawsuit that protects the very heart of the chiropractic profession’s services under Medicare – manual manipulation of the spine to correct a subluxation. ACA officials said they would continue the battle until doctors of chiropractic are the only providers who can offer the profession’s core service. “While we are understandably disappointed in the judge’s decision, we take pride in the fact that our lawsuit has already put an end to years of discrimination against doctors of chiropractic and their patients,” said ACA President Dr. Donald J. Krippendorf. “Before we filed our lawsuit, 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. We strongly believe that we owe it to our patients – and have a strong legal basis – to continue our battle in an effort to prohibit medical doctors and osteopaths from correcting subluxations, a service that is uniquely chiropractic.” Dr. Krippendorf also noted the “monumental victories for Medicare patients” already achieved through the lawsuit, including: • Compelling the government to prepare and release a study showing the virtual elimination of chiropractic services to Medicare beneficiaries entering the Medicare Managed Care system; • Prohibiting federal payments to physical therapists providing manual manipulation of the spine to correct a subluxation to Medicare patients; • And, mandating that all Medicare Managed Care plans must make available and pay for manual manipulation of the spine to correct a subluxation. In his Oct. 14 decision, U.S. District Judge John Garrett Penn granted HHS a motion for summary judgment, stating that Congress did not intend for only chiropractors to provide “manual manipulation of the spine to correct a subluxation” when it established the Medicare program in 1972, and that the Medicare statute is “neither silent nor ambiguous” in this regard. According to ACA officials, the judge’s rationale is “perplexing,” given the fact that even the U.S. government itself admitted ambiguity in the 32-year-old language governing the Medicare program – and, according to the government’s own position with the court, that “Congress has not directly spoken to the precise issue of who may provide manual manipulation of the spine to correct a subluxation to Medicare beneficiaries.” “We have a responsibility to our Medicare patients to continue this fight. They deserve to have chiropractic services delivered by doctors of chiropractic,” added Dr. Krippendorf. “We believe the use of the term ‘subluxation’ at the time it was inserted in the Medicare statute was meant to assign the correction of the subluxation exclusively to doctors of chiropractic.” The ACA first filed its lawsuit in November 1998, claiming that HHS guidelines unlawfully allowed Medicare Managed Care plans to substitute the services of other health care providers for services that should legally be performed by doctors of chiropractic and that chiropractic services were not being provided under Medicare Managed Care programs. Specifically challenged in ACA's lawsuit was a 1994 “Operational Policy Letter” stating: “Managed care plans contracting with Medicare are not required, however, to offer services of chiropractors, but may use other physicians to perform this service. In addition, managed care plans may offer manual manipulation of the spine as performed by non-physician practitioners, such as physical therapists, if allowed under applicable state law.” In January 2002, as a direct result of the ACA lawsuit, HHS issued a new policy directive that, under Medicare, physical therapists could not be reimbursed for providing manual manipulation of the spine to correct a subluxation, and also added that manual manipulation to correct a subluxation must be provided by Medicare managed care plans. In a revision to the 1994 Operational Policy Letter, Medicare's Center for Beneficiary Choices wrote: “The (Medicare) statute specifically references manual manipulation of the spine to correct a subluxation as a physician service. Thus, Medicare+Choice organizations must use physicians, which include chiropractors, to perform this service. They may not use non-physician physical therapists for manual manipulation of the spine to correct a subluxation.” (emphasis added) In addition, the new policy provides: “As a standard of Medicare Part B benefit, manual manipulation of the spine to correct a subluxation must be made available to enrollees in Medicare+Choice plans.” (Updated OPL#23, Jan. 15, 2002 emphasis added.) The ACA has 30 days to file a notice of appeal to the U.S. Court of Appeals for the District of Columbia – a court that has been coined “the second highest court in the land” because many of its judges are ultimately appointed to the U.S. Supreme Court. From there, the court will issue a briefing schedule. Typically, the U.S. Court of Appeals for the District of Columbia makes a decision on cases within 12 months. “We thank the thousands of supporters and contributors within the chiropractic profession who continue to stand with us through this monumental legal battle,” Dr. Krippendorf said. “Because of your commitment to the cause, we will continue to ensure that Medicare beneficiaries receive the safe and effective chiropractic care they need and deserve, and that they receive it only from health care providers appropriately trained and skilled to provide manual manipulation of the spine to correct a subluxation – doctors of chiropractic.” FOR MORE INFORMATION: Angela Kargus or Felicity Feather Clancy 800.986.4636 | [email protected] Copy of the opinion can be found at:



The New York State Chiropractic Association's Fall Conference at the Fort William Henry Resort in Lake George, New York was a resounding success! The conference convened Friday afternoon, October 1 through mid-day Sunday, October 3 and offered doctors a Practice Enhancement Program (PEP) and roughly 33 credits of continuing education from a list of outstanding speakers, including a class on the HIPAA Security Rule, the next evolution in the HIPAA compliance series (enforcement of the Security Rule begins April 20, 2005). Saturday evening ended with an awards dinner cruise and social sponsored by McCarthy, Chechanover & Rosado, LLP Law Firm, aboard the Adirondac, a new cruise ship on scenic Lake George. The NYSCA extends is sincere appreciation to McCarthy, Chechanover & Rosado, LLP and the many other vendors who helped make the conference such a success including: OUM Chiropractor Program, American Specialty Health Networks, Harvey Professional Supply, Tri-State Diagnostics, Meditek, Inc., PMR Products, New York Chiropractic College, Islandia MRI/East Manhattan Diagnostic, Dale Professional Supply, Jack S. Beige & Associates, LLP, Scheine, Furey & Associates, LLP, NCMIC Chiropractic Solutions, McCarthy, Chechanover & Rosado, PRI Physicians’ Reciprocal Insurers, Bee Sure Distributors, Open MRI of DeWitt, D’Youville College, HUM Division of MLMIC, Harlan Health Products, and Empire Medicare Services. The next NYSCA convocation is scheduled for January 28, 29 and 30, 2005 at the fabulous Mohegan Sun Casino and Resort in Uncasville, Connecticut. We look forward to seeing you there! As the April 20, 2005 enforcement deadline approaches, doctors should start taking the necessary steps now to come into compliance with the HIPAA Security Rule. Plan on attending the January Mohegan Sun Conference now!

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NYCC Students to Provide Care at SUNY Buffalo Student Health Center

Beginning October 11, interns at the Depew Health Center will be providing chiropractic services to students at the State University of New York at Buffalo (UB). This affiliation is the culmination of a two-year undertaking originally born as a result of a presentation on chiropractic made to the doctors and staff of the UB Student Health Center. Dr. Frank Carnevale, the Director of the Center, is excited about the new program and expects it will quickly become a success. The UB Student Health Center satellite clinic will expose NYCC student interns to an additional patient population that will enhance their clinical education. Hours of operation will be Mondays from 1:00 to 7:00 PM and Wednesdays from 1:00 to 5:00 PM, and appointments will be booked through the UB Student Health Center. Integrating chiropractic services with the UB Student Health Center’s medical and social services will be yet another example of NYCC’s multidisciplinary efforts aimed at benefiting patients. A byproduct of this affiliation will be the education of medical counterparts and U.B. students who come in for care. The University of Buffalo is the largest and most comprehensive university in the SUNY system. The large UB student body – more than 27,000! – will mean a busy schedule for student interns at the satellite clinic.

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Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder Dysfunction and Pain

A Randomized, Controlled Trial Background: Dysfunction of the cervicothoracic spine and the adjacent ribs (also called the shoulder girdle) is considered to predict occurrence and poor outcome of shoulder symptoms. It can be treated with manipulative therapy, but scientific evidence for the effectiveness of such therapy is lacking. Objective: To study the effectiveness of manipulative therapy for the shoulder girdle in addition to usual medical care for relief of shoulder pain and dysfunction. Design: Randomized, controlled trial. Setting: General practices in Groningen, the Netherlands. Patients: 150 patients with shoulder symptoms and dysfunction of the shoulder girdle. Interventions: All patients received usual medical care from their general practitioners. Only the intervention group received additional manipulative therapy, up to 6 treatment sessions in a 12-week period. Measurements: Patient-perceived recovery, severity of the main complaint, shoulder pain, shoulder disability, and general health. Data were collected during and at the end of the treatment period (at 6 and 12 weeks) and during the follow-up period (at 26 and 52 weeks). Results: During treatment (6 weeks), no significant differences were found between study groups. After completion of treatment (12 weeks), 43% of the intervention group and 21% of the control group reported full recovery. After 52 weeks, approximately the same difference in recovery rate (17 percentage points) was seen between groups. During the intervention and follow-up periods, a consistent between-group difference in severity of the main complaint, shoulder pain and disability, and general health favored additional manipulative therapy. Limitations: The sample size was small, and assessment of end points was subjective. Conclusion: Manipulative therapy for the shoulder girdle in addition to usual medical care accelerates recovery of shoulder symptoms. SUMMARIES FOR PATIENTS September 2004 issue of Annals of Internal Medicine | Volume 141 Issue 6| Pages 432-439


Folic acid supplementation enhances repair of the adult central nervous system

ABSTRACT Folic acid supplementation has proved to be extremely effective in reducing the occurrence of neural tube defects (NTDs) and other congenital abnormalities in humans, suggesting that folic acid can modulate key mechanisms for growth and differentiation in the central nervous system (CNS). To prevent NTDs, however, supplemental folate must be provided early in gestation. This suggests that the ability of folic acid to activate growth and differentiation mechanisms may be confined to the early embryonic period. Here, we show that folic acid can enhance growth and repair mechanisms even in the adult CNS. Using lesion models of CNS injury, we found that intraperitoneal treatment of adult rats with folic acid significantly improves the regrowth of sensory spinal axons into a grafted segment of peripheral nerve in vivo. Regrowth of retinal ganglion cell (RGC) axons into a similar graft also was enhanced, although to a smaller extent than spinal axons. Furthermore, folic acid supplementation enhances neurological recovery from a spinal cord contusion injury, showing its potential clinical impact. The results show that the effects of folic acid supplementation on CNS growth processes are not restricted to the embryonic period, but can also be effective for enhancing growth, repair, and recovery in the injured adult CNS. Ann Neurol 2004;56:221-227

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The Relation of Breastfeeding and Body Mass Index to Asthma and Atopy in Children: A Prospective Cohort Study to Age 6 Years

ABSTRACT Objectives We investigated the relationship between breastfeeding, asthma and atopy, and child body mass index (BMI). Methods From a prospective birth cohort (n = 2860) in Perth, Western Australia, 2195 children were followed up to age 6 years. Asthma was defined as doctor-diagnosed asthma and wheeze in the last year, and atopy was determined by skin prick test of 1596 children. Breastfeeding, BMI, asthma, and atopy were regressed allowing for confounders and the propensity score for overweight. Results Using fractional polynomials, we found no association between breastfeeding and overweight. Less exclusive breastfeeding was associated with increased asthma and atopy, and BMI increased with asthma. Conclusions Less exclusive breastfeeding leads to increases in child asthma and atopy and a higher BMI is a risk factor for asthma. Wendy H. Oddy and Jill L. Sherriff are with the Department of Nutrition, Dietetics and Food Science, Curtin University of Technology, Perth, Australia. Wendy H. Oddy, Nicholas H. de Klerk, Garth E. Kendall, Peter D. Sly, and Fiona J. Stanley are with the Centre for Child Health Research, University of Western Australia, Telethon Institute for Child Health Research, West Perth, Australia. Lawrence J. Beilin, Kevin B. Blake, and Louis I. Landau are with the Faculty of Medicine and Dentistry, University of Western Australia, West Perth. Correspondence: Requests for reprints should be sent to Wendy H. Oddy, PhD, MPH, Telethon Institute for Child Health Research, PO Box 855, West Perth, Western Australia 6872, Australia (e-mail: [email protected]).

A Potential Natural Treatment for Attention-Deficit/Hyperactivity Disorder: Evidence From a National Study

ABSTRACT Objective We examined the impact of relatively "green" or natural settings on attention-deficit/hyperactivity disorder (ADHD) symptoms across diverse subpopulations of children. Methods Parents nationwide rated the aftereffects of 49 common after-school and weekend activities on children’s symptoms. Aftereffects were compared for activities conducted in green outdoor settings versus those conducted in both built outdoor and indoor settings. Results In this national, nonprobability sample, green outdoor activities reduced symptoms significantly more than did activities conducted in other settings, even when activities were matched across settings. Findings were consistent across age, gender, and income groups; community types; geographic regions; and diagnoses. Conclusions Green outdoor settings appear to reduce ADHD symptoms in children across a wide range of individual, residential, and case character Frances E. Kuo is with the Department of Natural Resources and Environmental Sciences and the Department of Psychology, University of Illinois at Urbana-Champaign. Andrea Faber Taylor is with the Department of Natural Resources and Environmental Sciences, University of Illinois at Urbana-Champaign. Correspondence: Requests for reprints should be sent to Frances E. Kuo, PhD, Human Environment Research Laboratory, University of Illinois at Urbana-Champaign, 1103 S Dorner Dr, Urbana, IL 61801 (e-mail: [email protected]).

Oral Erythromycin and the Risk of Sudden Death from Cardiac Causes

Wayne A. Ray, Ph.D., Katherine T. Murray, M.D., Sarah Meredith, M.B., B.S., Sukumar Suguna Narasimhulu, M.B., B.S., M.P.H., Kathi Hall, M.S., and C. Michael Stein, M.B., Ch.B. ABSTRACT Background Oral erythromycin prolongs cardiac repolarization and is associated with case reports of torsades de pointes. Because erythromycin is extensively metabolized by cytochrome P-450 3A (CYP3A) isozymes, commonly used medications that inhibit the effects of CYP3A may increase plasma erythromycin concentrations, thereby increasing the risk of ventricular arrhythmias and sudden death. We studied the association between the use of erythromycin and the risk of sudden death from cardiac causes and whether this risk was increased with the concurrent use of strong inhibitors of CYP3A. Methods We studied a previously identified Tennessee Medicaid cohort that included 1,249,943 person-years of follow-up and 1476 cases of confirmed sudden death from cardiac causes. The CYP3A inhibitors used in the study were nitroimidazole antifungal agents, diltiazem, verapamil, and troleandomycin; each doubles, at least, the area under the time–concentration curve for a CYP3A substrate. Amoxicillin, an antimicrobial agent with similar indications but which does not prolong cardiac repolarization, and former use of erythromycin also were studied, to assess possible confounding by indication Results The multivariate adjusted rate of sudden death from cardiac causes among patients currently using erythromycin was twice as high (incidence-rate ratio, 2.01; 95 percent confidence interval, 1.08 to 3.75; P=0.03) as that among those who had not used any of the study antibiotic medications. There was no significant increase in the risk of sudden death among former users of erythromycin (incidence-rate ratio, 0.89; 95 percent confidence interval, 0.72 to 1.09; P=0.26) or among those who were currently using amoxicillin (incidence-rate ratio, 1.18; 95 percent confidence interval, 0.59 to 2.36; P=0.65). The adjusted rate of sudden death from cardiac causes was five times as high (incidence-rate ratio, 5.35; 95 percent confidence interval, 1.72 to 16.64; P=0.004) among those who concurrently used CYP3A inhibitors and erythromycin as that among those who had used neither CYP3A inhibitors nor any of the study antibiotic medications. In contrast, there was no increase in the risk of sudden death among those who concurrently used amoxicillin and CYP3A inhibitors or those currently using any of the study antibiotic medications who had formerly used CYP3A inhibitors. Conclusions The concurrent use of erythromycin and strong inhibitors of CYP3A should be avoided. Source Information: From the Division of Pharmacoepidemiology, Department of Preventive Medicine (W.A.R., S.M., K.H.), and the Departments of Medicine and Pharmacology, Divisions of Cardiology (K.T.M.), Clinical Pharmacology (K.T.M., S.S.N., C.M.S.), and Rheumatology (C.M.S.), Vanderbilt University School of Medicine; and the Geriatric Research, Education, and Clinical Center, Nashville Veterans Affairs Medical Center (W.A.R.) — both in Nashville. Address reprint requests to Dr. Ray at [email protected].

A Decisive Win for NYSCA President Dr. Dan Quatro

Dr. Dan Quatro, New York State Chiropractic Association (NYSCA) president wins a decisive victory in Tuesdays Republican Primary for the Monroe County 15th Legislative District. Quatro’s opponent was Webster Town Councilman James Carlevatti garnished 258 to Quatro’s 578 votes. “I never expected to win the primary by such a large margin, but we had the right message,” said Quatro. Dr. Quatro was appointed to the 15th District seat in July after the death of County Legislator Ray Santirocco. There is no time to sit back for County Legislator Dan Quatro and enjoy his victory as the November Election is less then two months away. His Democratic opponent in the November Election is Dolly Kujawa. Quatro will also run on the Independent and Conservative lines on the November ballot.

Reminder: New Requirements for Chiropractic Billing of Active/Corrective Treatment and Maintenance Therapy.

According to CMS, “Chiropractors have been submitting a very high rate of incorrect claims to Medicare. Medicare only pays for chiropractic services for active/corrective treatment (those using HCPCS codes 98940, 98941, or 98942). Claims for medically necessary services rendered on or after October 1, 2004, must contain the Acute Treatment (AT) modifier to reflect such services provided or the claim will be denied. Read more in the Members' Only Section. Not a member? Click on the application on the left of your screen and stay informed.

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Chiropractors gaining new respect across the U.S.

Q. My mother is super-active for a woman past 80. She insists on cutting her lawn and regularly runs errands for neighbors, who largely are shut-ins. Still, she complains of “achy legs” and plans now on seeing some local chiropractor. Is this wise? A. The day has long past when chiropractors were regarded solely as “bone crackers” and shunned as pariahs, to be held outside the bounds of scientific medicine. There are many hospitals today with chiropractors on staff. Moreover, Medicare reimburses for “spinal manipulation” therapy. In effect, this places the federal government’s approval seal on both manipulator and his or her treatment. Now, having said this, I quickly add that a conservative, even deliberate, approach to most matters of health and medicine strikes me as appropriate. For example, let’s together examine the matter of chronic pain in the back, which could in fact also cause someone to suffer “achy legs.” First, accept that more than 70 percent of American adults, at some point in their lives experience what medicine labels “significant lower-back pain.” (Aside: the first rule for treatment of back pain: the pain almost always goes away, with or without treatment.) Next, know that the rush to treatment for back pain is good business. Indeed, the current estimate for this medical care is more than $26 billion annually. Disabling back pain commonly occurs between the ages of 45 and 64, when many people are anxious to return to work to prove they’re still fit. The result: a rush to surgery, in particular the lower-lumbar spinal fusion. There were more than 150,000 such operations performed last year, and while critics of medicine acknowledge this surgery is excellent for patients with fractured spines or spinal cancers, no one is absolutely sure how effective it is for lower back pain. Yet, these fusions continue-and no one steps up to suggest we call a temporary halt, at least until we have persuasive proof. Plainly, faith in medicine runs very deep in today’s America. Now, before someone yells “Doctor hater” or insinuates a bias exists in favor of chiropractors, let me state: 1) no relatives, or close friends, practice chiropractic medicine; 2) however, a beloved son, Paul R. Lindeman, is a board-certified internist. Further, I once worked inside the House of Medicine, referring to the headquarters building of the American Medical Association (AMA) in Chicago. During these years, there was an aggressive committee whose full-time mission was to uncover failings, mishaps and errors committed by chiropractors. In my role as editor-in-chief of Today’s Health, the AMA’s consumer magazine, I understood the subject represented trouble, editorially speaking. Chiropractors were considered imposters, or “fakes.” (Aside: this was just 30 years ago.) Thus, the lessons for today: Back pain is common, it’s expensive and there oftentimes is a rush to treat it “now!” Meanwhile, medical science knows not nearly enough about the origin and/or cause of this trauma. “We know more about the surface of the moon than we do how to treat the bad back,” continues as popular wisdom. For too long, chiropractors have worked under a shadow, in a dark place where bias holds currency. At a time when all science is moving faster and faster, why not invite these professionals to the main banquet: challenge the supposed newcomers (the discovery of chiropractic dates to September, 1895) to “show us what you got!” And please publish all findings in the accepted medical literature. Consider, our compelling need to do better: the United States spends more than $4,500 per person per year on health care. Costa Rica, with half as many doctors per capita, spends just $300 per person every year. Yet life expectancy at birth is all but identical in both countries? Here then are a number of reason why we’re “sick:” an estimated 127 million Americans, of all ages, are obese or overweight, while 47 million still smoke, risking any number of cancers. Additionally, 14 million abuse alcohol, and 16 million use addictive drugs. Plainly, we need a serious, continuing national campaign promoting good health habits, so how about this for a first proposal: a cut in Medicare premiums and taxes for those older adults who demonstrate they’re avoiding the leading risks to a healthful lifestyle? In summary, they’re living right. Finally, this free advice to chiropractors: join the good health practices campaign. Tell your senior patients to exercise (nearly everyone can walk), eat smart, be sociable, volunteer, read and learn. Too few medical doctors, pressured for time, follow this common sense regimen. Bard Lindeman welcomes questions from readers. Although he cannot respond to each one individually, he will answer those of general interest in his column. Write to Bard at 5428 Oxbow Rd., Stone Mountain, GA 30087-1228; fax to 404-815-5787; or send e-mail to [email protected]. Reprinted with permission of Bard Lindeman, article in the Gwinnett Daily Post. Bard Lindeman covers issues faced by seniors, including family, health, retirement, elder care and aging. He has received the American Society on Aging National Media Award.