BIOMEDICAL RESEARCH POLICY COMMITTEE REPORT WAS PUBLISHED AS A SUPPLEMENT TO THE AUGUSTJOURNAL OF MEDICAL EDUCATION. A REPRINT IS ENCLOSED. REQUESTS FOR ADDITIONAL COPIES SHOULD BE ADDRESSED TO THISOFFICE. -COPIES ARE BEING SENT TO MEMBERS OF CONGRESS AND THE KEY MEMBERS OF THE ADMINISTRATION. CALLING UPON-YOUR SENATORSAND CONGRESSMEN TO TELL THE STORY OF THE ROLE. OF MEDICAL SCHOOLS IN BIOMEDICAL RESEARCH AND HEALTH CARE IS IMPORTANT.I STRONGLY URGE THAT YOU MAKE AN 411 APPOINTMENT TO SEE YOUR CONGRESSIONAL REPRESENTATIVES WHILE YOU ARE IN WASHINGTON FOR THE COUNCIL MEETINGON OCTOBER 29. UPON REQUEST WE CAN SUPPLY THE NAMES OF APPOINTMENT SECRETARIES AND PHONE NUMBERS OF YOUR SENATORS AND CONGRESSMEN. APPROPRIATIONS COMMITTEE ACTED WITH EXTRAORDINARY ALACRITY THIS YEAR. THE-NIH APPROPRIATION WAS INCREASED BY 242 MILLION DOLLARSOVER 1971, REPRESENTING A 142 MILLION DOLLAR INCREASE OVER. THE ADMINISTRATION BUDGET, THE BLUE SHEET ASCRIBES APPROPRIATIONS OUTCOME TO THE EFFECTIVENESS OF THE COALITION FOR HEALTH FUNDING UNDER THE LEADERSHIP OF JOHN A. D. COOPER.

The Association of American Medical Colleges

BACKGROUND—Two recent reviews have assessed the effect of parental smoking on respiratory disease in children.
METHODS—The results of the systematic quantitative review published as a series in Thorax are summarised and brought up to date by considering papers appearing on Embase or Medline up to June 1998.The findings are compared with those of the review published recently by the Californian Environmental Protection Agency (EPA). Areas requiring further research are identified.
RESULTS—Overall there is a very consistent picture with odds ratios for respiratory illnesses and symptoms and middle ear disease of between 1.2 and 1.6 for either parent smoking, the odds usually being higher in pre-school than in school aged children. For sudden infant death syndrome the odds ratio for maternal smoking is about 2. Significant effects from paternal smoking suggest a role for postnatal exposure to environmental tobacco smoke. Recent publications do not lead us to alter the conclusions of our earlier reviews. While essentially narrative rather than systematic and quantitative, the findings of the Californian EPA review are broadly similar. In addition they have reviewed studies of the effects of environmental tobacco smoke on children with cystic fibrosis and conclude from the limited evidence that there is a strong case for a relationship between parental smoking and admissions to hospital. They also review data from adults of the effects of acute exposure to environmental tobacco smoke under laboratory conditions which suggest acute effects on spirometric parameters rather than on bronchial hyperresponsiveness. It seems likely that such effects are also present in children.
CONCLUSIONS—Substantial benefits to children would arise if parents stopped smoking after birth, even if the mother smoked during pregnancy. Policies need to be developed which reduce smoking amongst parents and protect infants and young children from exposure to environmental tobacco smoke. The weight of evidence is such that new prevalence studies are no longer justified. What are needed are studies which allow comparison of the effects of critical periods of exposure to cigarette smoke, particularly in utero, early infancy, and later childhood. Where longitudinal studies are carried out they should be analysed to look at the way in which changes in exposure are related to changes in outcome. Better still would be studies demonstrating reversibility of adverse effects, especially in asthmatic subjects or children with cystic fibrosis.

https://thorax.bmj.com/content/thoraxjnl/54/4/357.full.pdf

Health effects of passive smoking-10: Summary of effects of parental smoking on the respiratory health of children and implications for research.

The effects of maternal smoking during pregnancy and childhood environmental tobacco smoke (ETS) exposure on asthma and wheezing were investigated in 5,762 school-aged children residing in 12 Southern California communities. Responses to a selfadministered questionnaire completed by parents of 4th, 7th, and 10th grade students were used to ascertain children with wheezing or physician-diagnosed asthma. Lifetime household exposures to tobacco smoke were assessed using responses about past and current smoking histories of household members and any history of maternal smoking during pregnancy. Logistic regression models were fitted to cross-sectional data to estimate the effects of in utero exposure to maternal smoking and previous and current ETS exposure on the prevalence of wheezing and physician-diagnosed asthma. In utero exposure to maternal smoking without subsequent postnatal ETS exposure was associated with increased prevalence of physician-diagnosed asthma (OR, 1.8; 95% CI, 1.1 to 2.9), asthma with current symptoms (OR, 2.3; 95% CI, 1.3 to 4.0), asthma requiring medication use in the previous 12 mo (OR, 2.1; 95% CI, 1.2 to 3.6), lifetime history of wheezing (OR, 1.8; 95% CI, 1.2 to 2.6), current wheezing with colds (OR, 2.1; 95% CI, 1.3 to 3.4) and without colds (OR, 2.5; 95% CI, 1.4 to 4.4), persistent wheezing (OR, 3.1; 95% CI, 1.6 to 6.1), wheezing with exercise (OR, 2.4; 95% CI; 1.3 to 4.3), attacks of wheezing causing shortness of breath (OR, 2.4; 95% CI, 1.3 to 4.4) or awakening at night in the previous 12 mo (OR, 3.2; 95% CI, 1.7 to 5.8), and wheezing requiring medication (OR, 2.1; 95% CI, 1.2 to 3.7) or emergency room visits during the previous year (OR, 3.4; 95% CI, 1.4 to 7.8). In contrast, current and previous ETS exposure was not associated with asthma prevalence, but was consistently associated with subcategories of wheezing. Current ETS exposure was associated with lifetime wheezing (OR, 1.3; 95% CI, 1.1 to 1.5), current wheezing with colds (OR, 1.6; 95% CI, 1.3 to 2.0) and without colds (OR, 1.5; 95% CI, 1.1 to 1.9), wheezing with exercise (OR, 1.7; 95% CI, 1.3 to 2.2), attacks of wheezing causing shortness of breath (OR, 1.6; 95% CI, 1.2 to 2.1) or awakening at night (OR, 1.5; 95% CI, 1.1 to 2.0), and wheezing requiring medication (OR, 1.4; 95% CI, 1.1 to 1.8) or emergency room visits within the previous year (OR, 1.9; 95% CI, 1.2 to 3.0). The effects of current ETS exposure on subcategories of wheezing were most pronounced among children exposed to two or more smokers and remained significant after adjusting for maternal smoking during pregnancy. We conclude that maternal smoking during pregnancy increases the occurrence of physician-diagnosed asthma and wheezing during childhood. In contrast, current ETS exposure is associated with wheezing, but not physician-diagnosed asthma. Taken together, our findings support the hypothesis that ETS operates as a cofactor with other insults such as intercurrent infections as a trigger of wheezing attacks, rather than as a factor that induces asthma, whereas in utero exposure acts to increase physician-diagnosed asthma

https://www.atsjournals.org/doi/pdf/10.1164/ajrccm.163.2.2006009

Effects of maternal smoking during pregnancy and environmental tobacco smoke on asthma and wheezing in children.

The U.S. chronic illness burden is increasing and is felt more strongly in minority and low-income populations: in 2005, 133 million Americans had at least one chronic condition. Prevention and management of chronic disease are best performed by multidisciplinary teams in primary care and public health. However, the future health care work-force is not projected to include an appropriate mix of personnel capable of staffing such teams. To prepare for the growing chronic disease burden, a larger interdisciplinary primary care workforce is needed, and payment for primary care should reward practices that incorporate multidisciplinary teams.

https://www.commed.vcu.edu/Chronic_Disease/2009/The_future_jan09.pdf

Confronting The Growing Burden Of Chronic Disease: Can The U.S. Health Care Workforce Do The Job?

Several authors have considered the importance of exposure timing and how this affects the outcomes observed, but no one has systematically compiled preconceptional, prenatal, and postnatal developmental exposures and subsequent outcomes. Efforts were undertaken to examine the information available and to evaluate implications for risk assessment for several areas: a) respiratory and immune systems, b) reproductive system, c) nervous system, d) cardiovascular system, endocrine system, and general growth, and e) cancer. Major conclusions from a workshop on "Critical Windows of Exposure for Children's Health" included a) broad windows of sensitivity can be identified for many systems but detailed information is limited; b) cross-species comparisons of dose to target tissue and better data on the exposure-dose-outcome continuum are needed; c) increased interaction among scientific disciplines can further understanding by using laboratory animal results in designing epidemiological studies and human data to suggest specific laboratory studies on mechanisms and agent-target interactions; and d) thus far, only limited attention has been given to peripubertal/adolescent exposures, adult consequences of developmental exposures, and genome-environment interactions. More specific information on developmental windows will improve risk assessment by identifying the most sensitive window(s) for evaluation of dose-response relationships and exposure, evaluation of biological plausibility of research findings in humans, and comparison of data across species. In public health and risk management, information on critical windows may help identify especially susceptible subgroups for specific interventions.

Identifying critical windows of exposure for children's health

Unexpected growth in medication use has escalated demand for pharmacists that has outpaced supply. Responses to the pharmacist shortage include larger workloads and greater use of pharmacist extenders and technology. As the profession has moved from a product orientation (dispensing medications) to a patient focus, clinical training re- quirements have expanded. However, structural and process barriers, particularly in com- munity and retail pharmacies, must be addressed to improve the medication-use process. These issues merit greater attention from health care leaders and policymakers.

Challenges To The Pharmacist Profession From Escalating Pharmaceutical Demand For forty years the pharmacy profession has been moving from dispensing medications to providing certain clinical services.

Background Asthma is the most common chronic disease in childhood. The prevalence of asthma is especially high in inner city children. The occurrence of asthma may be associated with many environmental factors, including involuntary exposure to maternal smoking. Objectives This study reports prevalence of asthma and wheezing in a sample of public school students in Chicago and examines the association between maternal smoking during pregnancy and childhood asthma. Methods A total of 705 fifth grade students from 13 public schools participated in the study. A slightly modified International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire was administered in classrooms to assess students' wheezing and asthma prevalence. Results Overall, 34.5% of children reported ever wheezing, 28.9% reported wheezing in the past year, 21.1% reported exercise-related wheezing in the past year, 23.6% reported physician-diagnosed asthma, 16.1% reported taking asthma or wheezing medication in the past 2 weeks, and 15.2% reported visiting emergency rooms for treatment of asthma in the past year. After adjusting for confounding variables in a logistic model, maternal smoking during pregnancy was significantly associated with children's asthma (adjusted odds ratio = 1.9; 95% confidence interval: 1.1 to 3.5). Conclusions This study reports high prevalence of asthma and wheezing among the students and suggests that maternal smoking during pregnancy may increase the risk of asthma in children.

Prevalence of asthma and wheezing in public schoolchildren: association with maternal smoking during pregnancy.

Unexpected growth in medication use has escalated demand for pharmacists that has outpaced supply. Responses to the pharmacist shortage include larger workloads and greater use of pharmacist extenders and technology. As the profession has moved from a product orientation (dispensing medications) to a patient focus, clinical training requirements have expanded. However, structural and process barriers, particularly in community and retail pharmacies, must be addressed to improve the medication-use process. These issues merit greater attention from health are leaders and policymakers.

Judith A. Cooksey

Papers

Challenges To The Pharmacist Profession From Escalating Pharmaceutical Demand For forty years the pharmacy profession has been moving from dispensing medications to providing certain clinical services.

Prevalence of asthma and wheezing in public schoolchildren: association with maternal smoking during pregnancy.

Challenges to the pharmacist profession from escalating pharmaceutical demand.

The state of the medical geneticist workforce: findings of the 2003 survey of American Board of Medical Genetics certified geneticists.

Concern about AIDS among hospital physicians, nurses and social workers.