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The National Children’s Study will address, among other illnesses, the environmental causes of both incident asthma and exacerbations of asthma in children. Seven of the Centers for Children’s Environmental Health and Disease Prevention Research (Children’s Centers), funded by the National Institute of Environmental Health Sciences and the U.S. Environmental Protection Agency, conducted studies relating to asthma. The design of these studies was diverse and included cohorts, longitudinal studies of older children, and intervention trials involving asthmatic children. In addition to the general lessons provided regarding the conduct of clinical studies in both urban and rural populations, these studies provide important lessons regarding the successful conduct of community research addressing asthma. They demonstrate that it is necessary and feasible to conduct repeated evaluation of environmental exposures in the home to address environmental exposures relevant to asthma. The time and staff required were usually underestimated by the investigators, but through resourceful efforts, the studies were completed with a remarkably high completion rate. The definition of asthma and assessment of disease severity proved to be complex and required a combination of questionnaires, pulmonary function tests, and biologic samples for markers of immune response and disease activity. The definition of asthma was particularly problematic in younger children, who may exhibit typical asthma symptoms sporadically with respiratory infections without developing chronic asthma. Medications confounded the definition of asthma disease activity, and must be repeatedly and systematically estimated. Despite these many challenges, the Children’s Centers successfully conducted longterm studies of asthma. Key words: asthma, children, Children’s Centers, environmental health, National Children’s Study, pregnancy.

In this article we outline information from the Centers for Children’s Environmental Health and Disease Prevention Research (Children’s Centers) that have conducted studies related to asthma. We do not include information on sampling strategies because the goal of the monograph is to inform the National Children’s Study. Rather, we focus on major issues related to the identification of asthma, asthma-related symptoms and end points, relevant exposures, biologic markers, and follow-up requirements.

By Thomas Similowski, William A. Whitelaw, Jean-Philippe Derenne, eds. New York, NY: Marcel Dekker, 2002, 1072 pp; $250

COPD is currently the sixth-leading cause of death worldwide, and it has been estimated that it will climb to the third spot by 2020. Current treatment is, without doubt, unsatisfactory; in spite of the recent Global Initiative on Chronic Obstructive Lung Diseases guidelines, a nihilistic approach is often adopted. The very fact that nearly 1,100 pages are required for Clinical Management of Chronic Obstructive Pulmonary Disease reflects on the far-from-happy situation that we are in today. Having said that, this brilliant and decidedly valuable tome systematically takes the reader from diagnosis through management, and includes a panoramic view of the approach to management throughout the globe.

Three distinguished editors have succeeded in recruiting recognized experts from all over the world to present up-to-date and well-established information that can easily be assimilated by the reader. This elegantly structured book has 10 parts, which have further been subdivided into 45 chapters. The first part, centered on diagnosis and follow-up, comprises 10 chapters that systematically acquaint the reader with the clinical approach to a patient with COPD. The diagnostic aspects include essential investigations such as pulmonary function and imaging, while the follow-up section contains information ranging from assessment and management of dyspnea to the impact of health-related quality of life studies in COPD, to disability evaluation. An entire chapter is included on treatment recommendations for the general practitioner.

In 1998, recognizing that exposure to hazardous environmental conditions can be particularly detrimental to the health of children, the NIEHS, the U.S. Environmental Protection Agency (EPA), and the Centers for Disease Control and Prevention initiated the Centers for Children’s Environmental Health and Disease Prevention Research program. This highly successful program promotes the translation of basic research findings into applied intervention and prevention methods. In the past five years, researchers have discovered that

* blood and urine specimens from pregnant women show measurable levels of pesticides, which means that the fetus is exposed to these chemicals during early development;

* children in urban and rural environments are exposed to a complex mix of agricultural and household pesticides, environmental tobacco smoke, and polycyclic aromatic hydrocarbons that, in combination with social factors, can impact their early growth;

* exposures to lead in the urban environment can have life-long effects such as behavioral problems and criminal behavior in adulthood;

* exposure to polychlorinated biphenyls can affect cochlear function, which may cause hearing loss in early life;

* air pollution can cause inflammation in the lung, and its effects can be seen in school-age children as exacerbation of asthma symptoms and more days absent from school; and

* asthma symptoms in children can be reduced by reducing allergens from dust mites and cockroaches in the home.

The NIEHS and the EPA announce the continuation of funding for six centers and the start of one new center. There are also four existing centers. The research at these centers includes toxicological, epidemiological, exposure assessment, genetics, and community-based participatory methods to address pressing questions related to children’s susceptibility and exposure to harmful environmental agents and their health consequences. There are close ties with community organizations that assist in the dissemination of research findings to the community. The program also includes opportunities to develop new and creative strategies to inform health care practitioners, policy makers, and the public about environmental health concerns relevant to children.

This study was undertaken to evaluate the association of intensity or length of activity to coronary heart disease. The study population included 39,372 women aged 45 or older. The women were enrolled between 1992 and 1995 with a follow-up period until 1999. There were 244 cases of coronary heart disease during this time period. Vigorous exercise activities were associated with the lowest relative risk of coronary heart disease (RR= 0.63). Walking was also able to predict a lower risk in women who had no history of a vigorous exercise program or activity. Walking for up to 1 hour a week compared with no walking had a RR of 0.86. The RR for 1-1.5 hours and 2 or more hours were 0.49 and 0.48, respectively. They also analyzed the pace of the walk which ranged from 2-3 mph. They concluded that the length of time spent walking was the most important factor in reducing the risk, not the pace and that light to moderate exercise from walking is associated with a positive health benefit.

Comment: It is well accepted that exercise reduces the risk and occurrence of coronary heart disease. What is not absolutely certain is what is the appropriate level of exercise. Most exercise advice recommends a minimum of 20 minutes of exercise with a 5 minute warm up and 5 minute cool down phase 4 to 5 times per week. Although this study did not specify whether the exercise could be done in multiple blocks of time or all at once, most individuals could find 1 hour per week to walk, and at a reasonable pace of 2-3 mph. I find this study encouraging news for my patients who have a great deal of difficulty creating a lifestyle that includes regular exercise.

Introduction

Broth, made from the bones of animals, has been consumed as a source of nourishment for humankind throughout the ages. It is a traditional remedy across cultures for the sick and weak. A classic folk treatment for colds and flu, it has also been used historically for ailments that affect connective tissues such as the gastrointestinal tract, the joints, the skin, the lungs, the muscles and the blood. Broth has fallen out of favor in most households today, probably due to the increased pace of life that has reduced home cooking in general. Far from being old-fashioned, broth (or stock) continues to be a staple in professional and gourmet cuisine, due to its unsurpassed flavor and body. It serves as the base for many recipes including soup, sauces and gravy. Broth is a valuable food and a valuable medicine, much too valuable to be forgotten or discounted in our modern times with our busy ways and jaded attitudes.

Definition

In general, broth is a liquid made by boiling meat, bones, or vegetables. There are many types of broths, based on what is being cooked. For example, Bieler Broth, a vegetable broth made with green beans, zucchini, and celery is a supportive remedy used in detoxification or cleansing protocols. ConsommE, a rich broth made from meat, is another example. It is prepared by reducing, or prolonged simmering. Stock is another word used synonymously with broth, though some chefs denote stock as being made from bones whereas broth is made from meat. In this paper the two names are used interchangeably. Soup is a similar term referring to simmered vegetables, meat, and seasonings, and is defined by Random House Webster’s Dictionary as a liquid food. (1) The difference is that soup contains solids such as meat, beans, grains or vegetables (sometimes disguised by a puree) while a broth is the liquid in which solids have been simmered and then discarded. Soup is what we think of as having for a meal. Broth is a starting ingredient for soup, and must be prepared separately beforehand.

Method

The ingredients are as follows: bones from an animal, with or without meat and skin, enough water to just cover the bones, a splash of vinegar, and optional assorted vegetables or their scraps. Making broth requires almost no work, just put the bones in a pot, add water and vinegar, bring it to a simmer and walk away. No chopping or tending is needed.

Oral Health America has announced the formation of the National Periodontal Disease Coalition that unites providers, insurers, advocacy groups and government agencies in tackling periodontal disease. This effort grew out of a meeting attended by ADAA’s President Kristy Borquez, CDA, RDAEF, FADAA, and more than 50 business and professional leaders. The group addressed issues surrounding periodontal disease, an infection that afflicts most adults, but is virtually ignored outside of dentistry.

President Borquez reports that the coalition will work to make Americans start thinking about periodontal disease and its relation to overall health. Attendees at the first of its kind meeting included a diverse array of opinion leaders and decision makers from practices, associations, insurance companies, pharmaceutical companies, industry, advocacy groups, universities, government agencies, and foundations.

Points of discussion included the state of periodontal disease research; impact on overall health; general recognition, identification and treatment patterns; economic considerations; and public, professional, and business involvement.

Models for the future of healthcare in the U.S. can be arrayed along a continuum with two very different end points. On one end, healthcare becomes a market good with access based on ability to pay, and on the other hand it is recognized as a societal right with access provided without regard to ability to pay. Regardless of where our society finally ends up on the continuum, the creation of a national health information network (NHIN) is a fundamental necessity.

The debate about who is going to pay for it is far from over, but there is no debate about whether or not substantial benefits can be derived from such an implementation. The benefits to be derived from disease management and population health improvements can play a valuable role in building the case for investment in an NHIN. Conversely, our ability to predict, prevent and manage disease is greatly hampered in the absence of such a network.

The Healthcare Model: Market Good or Societal Right?

The market good and consumer accountability model states that insurance coverage must be coupled with significant personal contributions so as to control “moral hazard” (see box). According to this model, personal accountability for one’s health status and for cost sharing based on one’s own usage of the system is the best option. This is an actuarial view of insurance, where people pay into the system in proportion to what they use. Proponents of this model argue that the current system is more like social insurance. The social insurance model is viewed, at this end of the continuum, as a model that penalizes the healthy–and serves as a crushing tax on those who are well.

This point of view is based on the assumption that a lack of personal accountability for costs incurred raises moral hazard to unacceptable levels. Left unchanged, it is argued, the current system will result in more chronic conditions and cause healthcare costs to rise to unacceptable levels. This would place the U.S. economy at a considerable disadvantage relative to the rest of the industrialized world.

Health & Disease in Britain: From Prehistory to the Present Day. Charlotte Roberts and Margaret Cox. Sutton Publishing. [pounds sterling]25.00. xix + 476 pages. ISBN 0-7509-1844-6. This important study, jointly written by an archaeologist and an archaeologist-anthropologist sets out ‘to assess the health and disease of the population of Britain from prehistory to the present’. It is a mammoth task for, as the authors write, ‘health and disease are necessary parts of life and death’. The first chapter acts as an extended introduction to the nature of health and disease and to the means by which both can be studied in the British Isles. In itself this first chapter is worth the price of the book. After this the authors follow a chronological approach and each chapter is itself introduced with a discussion of the factors that affected the health of people in that period, factors such as environment, climate, economy, diet, living conditions, hygiene, population, occupations and historical events that affect health, e.g. war. The book not only gives one a wonderful understanding of the subject but a wealth of facts. In the pre-Roman period (10500 BC to 43 AD) men got shorter whilst women got taller. Between c. 1559 and c. 1850, as unplanned urbanisation led to lower standards of hygiene, childhood killers such as measles increased whilst tuberculosis replaced smallpox and plague as the major causes of death. In recent years we have made significant progress in some fields, such as infant mortality, but regressed in others, such as smoking related illnesses. There is a wealth of information in this study that any student of history will find invaluable to a fuller understanding of British life. (J.M.)

ONE is the No. 1 single cause of death to Blacks in the United States. The other is No. 3. Together, the twin assassins of heart disease and stroke kill 9,000 Blacks every month–more deaths to African-Americans than all other diseases combined.

But as devastating as cardiovascular disease is, research has shown that Blacks are actually more afraid of cancer and AIDS than heart disease. And most Black women believe that breast cancer (which kills 1 in 25 women) is their greatest health risk, although heart disease and stroke claim 1 in every 2 women.

In fact, the disparities in heart disease are widest for African-American women, who have a 69 percent higher death rate than White women. The reasons for the disparities include a higher prevalence of hypertension, diabetes and obesity among Black women.

But there is good news. Doctors say the risk of having a heart attack–even in people who already have coronary heart disease or have had a previous heart attack–can be reduced by preventing or controlling certain risk factors.

One of the greatest risks is smoking. Cigarettes greatly increase the risk of fatal and nonfatal heart attacks in both men and women. Smoking also increases the risk of a second heart attack among survivors. Women who smoke and use oral contraceptives have an even greater risk than smoking alone.

The good news is that quitting smoking greatly reduces the risk of heart attack. One year after quitting, the risk of having a heart attack drops to about one-half that of current smokers and gradually returns to normal in people without heart disease. Even among people with heart disease, the risk also drops sharply one year after quitting smoking and it continues to decline.

Another factor that increases the risk of heart attack is high blood pressure. Also called hypertension, high blood pressure makes the heart work harder than it should. Although it has no symptoms, hypertension is the most common form of cardiovascular disease. Two out of every three Blacks will develop hypertension by the time they are 60. Those who have high blood pressure have an 80 percent higher stroke mortality rate, a 50 percent higher heart disease mortality rate and a 320 percent greater rate of kidney disease than in the general population.

Vaccines: Preventing Disease Protecting Health does not provide the type of vaccine-specific information as Plotkin and Orenstein’s Vaccines (1), nor does it provide the details on the immune system of Bloom and Lambert’s The Vaccine Book (2). The book does not cover every important vaccine issue, such as ethical issues in vaccine trials and the conduct of clinical trials; most critically, it lacks an index. But these limitations are minor compared to what the book provides.

This relatively small book provides state-of-the-art information by those who are directly involved with vaccine and immunization programs. The book evolved from a meeting held November 25-27, 2002, in Washington, D.C., at which many of the world’s top vaccine scientists reported on their research. As the book jacket states, the roster of authors reads like a Who’s Who in vaccine research and public health immunization programs. This publication comes from the Pan American Health Organization (PAHO), the World Health Organization (WHO) Regional Office, which has been at the forefront of almost every major vaccine initiative for the past 30 years, including the eradication of polio, elimination of measles, and strategies to control rubella and neonatal tetanus. These programs have served as models emulated by other WHO regions in the world. The editor, Ciro A. de Quadros, former director of PAHO’s Vaccine and Immunization Program, has a scholarly hand, as well as an eye towards what is practical and useful. This book conveys not only what has been achieved in the arena of vaccine-preventable diseases in the 30 years since the first such conference was convened by PAHO in 1970 but also what is most likely to happen during the next 30 years.