Tuesday, September 6, 2016

Exclusive: Clinton charities ignore law requiring them to disclose millions from foreign donors!

NewsNet5 ABC Cleveland ^ | September 6, 2016 | By Mark Greenblatt 

New York Attorney General Eric Schneiderman has the power to force the Clinton Foundation and the Clinton Health Access Initiative to publicly disclose the names of foreign governments and the millions they donate each year to the charities but he’s not doing it, a Scripps News investigation has found.

Schneiderman’s failure to require compliance with New York law and written instructions from his own office keeps the public in the dark about whether the foreign governments that gave money to the Clinton charities also had special access to Hillary Clinton when she was secretary of state, experts in private foundation law say. New York state has long required more transparency from non-profits operating within its borders than many other regulators.

A Scripps Washington Bureau review of tax returns and regulatory filings found that year after year the Clinton charities have ignored New York law and related instructions. However, the office of Attorney General Schneiderman, a Democrat whom Hillary Clinton named to her campaign's “leadership council” in New York, did not respond to Scripps’ questions about the Clinton Health Access Initiative (CHAI), which has never publicly disclosed in New York filings the identity of its foreign government contributors or the amounts they give each year. Scripps also discovered CHAI did not report hundreds of millions of dollars in foreign government donations to the state. . .
(Excerpt) Read more at newsnet5.com ...

In Laos, Obama Apologizes for U.S. Bombings (what CRAP)

 breitbart.com ^ | Sep. 6, 2016 | CHARLIE SPIERING 

Obama continued his international apology tour for American deeds overseas, traveling to the Asian country of Laos to deliver a speech. Obama acknowledged that the United States dropped more than two million tons of bombs in the country, intervening in the country’s civil war.

He sorrowfully noted that “villages and entire valleys were obliterated” as a result of the bombing, including the “ancient Plain of Jars.”

“That conflict was another reminder that, whatever the cause, whatever our intentions, war inflicts a terrible toll, especially on innocent men, women and children,” Obama said. “Today, I stand with you in acknowledging the suffering and sacrifices on all sides of that conflict.”

(Excerpt) Read more at breitbart.com ...

Trump, Republicans and the 'Principles' Question

Townhall.com ^ | September 6, 2016 | Dennis Prager 

All #NeverTrump conservatives maintain that their decision to never vote for Donald Trump is guided by their principles. I have no doubt that this is true.
But some of them seem to imply, or at least might think, that conservatives who vote for Trump have abandoned their principles. Indeed, the charge of compromising on principle is explicitly levied at Republican politicians and members of the Republican "establishment" who support Trump.
I cannot speak for all conservatives who are voting for Trump, but I can speak for many in making this assertion: We have the same principles as the #NeverTrumpers, especially those of us who strongly opposed nominating Trump. That's why we opposed him, after all. Almost everything that prevents #NeverTrumpers from voting for Trump also troubled us about the candidate. (I should note that some of us are less troubled today.)
So where do we differ?
We differ on this: We hold that defeating Hillary Clinton, the Democrats and the left is also a principle. And that it is the greater principle.
Obviously, the #NeverTrumpers do not believe that. On the contrary, some of the most thoughtful #NeverTrumpers repeatedly tell us that the nation can survive four calamitous years of Clinton-Democrat rule. And then, they say, conservatism will have cleansed itself and will be able to take back the nation, whereas if Trump wins, he will be the de facto face of conservatism, and then conservatism will have been dealt a potentially fatal setback.
This argument is profoundly mistaken.
It assumes that America can survive another four years of Democratic rule.
And it depends on what "survive" means. If it means that there will be a country called the United States of America after another four years of a Democratic presidency, and after, quite possibly, another four decades of a left-wing Supreme Court (as well as dozens of lifetime appointments to the equally important lower federal courts), then country will surely survive.
But I do not believe that the country will surely survive as the country it was founded to be. In that regard, we are at the most perilous tipping point of American history.
It is true that the country was threatened with survival in the 1860s, and only a terrible civil war kept it whole. But with the colossal and awful exception of slavery, neither side challenged the founding principles of America.
That is not the case today. One side seeks to undo just about every founding principle that made America exceptional. Important examples include small and limited government; preservation of the power of the states to serve as political and social laboratories; a belief in individual responsibility; a society rooted in Judeo-Christian morality -- one composed of people who nearly all affirmed in God and Bible-based moral teachings; and a deep sense of a unifying American identity and destiny.
The left is successfully undoing every one of those founding principles.
In fact, the left and the Democratic Party (which are now indistinguishable) boast of their aim to do so. As then-Senator Barack Obama accurately prophesied in 2008,
"We are five days away from fundamentally transforming the United States of America."
And for the first time in American history, a man calling himself a socialist won the great majority of young people's votes in the Democratic presidential primaries. Sen. Bernie Sanders' new political movement is accurately named "Our Revolution."
Of course, for conservatives "our revolution" occurred in 1776. So the left is in fact leading a counter-revolution.
Therefore, with another four years of Democrat-left rule -- meaning a nearly permanent left-wing Supreme Court and left-wing-controlled lower courts; the further erosion of federalism; an exponential growth in the power of the federal government; further leftist control of education; and the de-Americanization of America in part by effectively eliminating its borders, in part by substituting multiculturalism for American identity and in part by giving millions of illegal immigrants citizenship -- America will not be America.
We conservatives who will vote for Trump understand that he is the only vehicle we have to prevent this. We recognize that though there are some fine individuals who hold left-wing views, leftism is a terminal cancer in the American bloodstream and soul. So our first and greatest principle is to destroy this cancer before it destroys us. We therefore see voting for Donald Trump as political chemotherapy needed to prevent our demise. And at this time that is, by far, the greatest principle.

The pilot who stole a secret Soviet fighter jet (40 yrs since Mig-25 defection)

BBC future ^ | 5 September 2016 | Stephen Dowling 

On 6 September 1976, an aircraft appears out of the clouds near the Japanese city of Hakodate, on the northern island of Hokkaido. It’s a twin-engined jet, but not the kind of short-haul airliner Hakodate is used to seeing. This huge, grey hulk sports the red stars of the Soviet Union. No-one in the West has ever seen one before.
The jet lands on Hakodate’s concrete-and-asphalt runway. The runway, it turns out, is not long enough.
The jet ploughs through hundreds of feet of earth before it finally comes to rest at the far end of the airport.
The pilot climbs out of the plane’s cockpit and fires two warning shots from his pistol – motorists on the road next to the airport have been taking pictures of this strange sight. It is some minutes before airport officials, driving from the terminal, reach him. It is then that the 29-year-old pilot, Flight Lieutenant Viktor Ivanovich Belenko of the Soviet Air Defence Forces, announces that he wishes to defect.
It is no normal defection. Belenko has not wandered into an embassy, or jumped ship while visiting a foreign port. The plane that he has flown 400-odd miles, and which now sits stranded at the end of a provincial Japanese runway, is the Mikoyan-Gurevich MiG-25. It is the most secretive aircraft the Soviet Union has ever built.
Until Belenko’s landing, that is.
The West first became aware of what would become known as the MiG-25 around 1970. Spy satellites stalking Soviet airfields picked up a new kind of aircraft bring tested in secret. They looked like enormous fighter planes, and the West’s militaries were concerned by one particular feature; they sported very large wings.
(Excerpt) Read more at bbc.com ...

Black Lives Matter Protesters Ground All Flights At London City Airport

HP ^ | 9-6-2016 | Aubrey Allegretti 

Black Lives Matter protesters who staged a demonstration grounding all flights at London City Airport have now been removed.
Police were called to the east London airport at 5:40am to reports of nine activists getting on to the runway.
Black Lives Matter posted a picture from the tarmac
The BLM group said it had been occupying the tarmac to “protest the UK’s environmental impact on black people”.
Seven people have been arrested, while the fate of the other two removed protesters has not been disclosed by police.
Police were scrambled to the scene early this morning
“Black people are the first to die, not the first to fly, in this racist climate crisis,” a statement released by the group to coincide with their action said.
“The action was taken in order to highlight the UK’s environmental impact on the lives of black people locally and globally.”
(Excerpt) Read more at huffingtonpost.co.uk ...

Donald Trump Earns Backing of Nearly 90 Military Figures

NYT ^ | 9/6/2016 | Maggie Haberman 

Donald J. Trump’s campaign will release an open letter on Tuesday from about 90 retired generals and military officials endorsing his presidential campaign, urging a “long overdue course correction in our national security posture.”
The letter in support of Mr. Trump, signed by 88 retired military figures, will come as the campaign prepares for a week focused on national security, with a forum hosted by NBC and MSNBC on Wednesday evening alongside Hillary Clinton, the Democratic presidential nominee.
“The 2016 election affords the American people an urgently needed opportunity to make a long overdue course correction in our national security posture and policy,” the letter states.
(Excerpt) Read more at nytimes.com ...

FBI's 302 Report Proves Complicity in Clinton Email Scandal

American Thinker ^ 

The biggest and most damning takeaway from Hillary Clinton's July interview with the FBI, at least as it concerns the FBI itself and by extension the rectitude of our government, is, to borrow from Arthur Conan Doyle, the dog that didn't bark. That is, there is no indication that in the course of the interview, FBI agents once asked the former secretary of state about emails to and from Clinton aides regarding Clinton Foundation business.

Clinton's lawyers deliberately withheld these emails from the public and forced the FBI to recover them. They clearly demonstrate Clinton's motive in setting up the server, thereby intentionally endangering the classified material that she and her cohorts knew would inevitably be sent through it. This motive and intent is further demonstrated by Clinton's obfuscations, lies, and destruction of evidence that followed in the course of over a year.

(Excerpt) Read more at americanthinker.com ...

The Liberal Media’s Soviet Style Disinformation Campaign Against Trump

US Defense Watch ^ | September 5, 2016 | Ray Starmann 

Trump is simply the greatest threat to the Establishment since JFK.
The Establishment defined as the military-industrial complex, Wall Street and the corporate and political elite.
The Establishment robber barons hate Trump because he’s uncontrollable. They know Trump will never be a puppet if he’s elected President. And, if he is elected, the Establishment’s gravy train: the endless, unwinnable wars, the Wall Street crony capitalism, the lousy trade deals that bring in billions to the elite and garrote the American worker, will be a thing of the past.
Therefore, Trump must be destroyed at all costs.
Enter the Establishment’s best friend, the liberal mainstream media.
Seventy-five percent of the media despises Trump because of what he stands for: Americanism, red-blooded American guts and glory and the destruction of political correctness; the lifeblood, the tonic that fuels the left.
The liberal mainstream media has been conducting a disinformation and deception campaign against Trump that is so widespread, so intricate and so insidious it would have been envied by former KGB Chief, Yuri Andropov.
The mainstream media’s Soviet style active measures against Mr. Trump involve seven different tenets.
1.Paint Trump as a Racist – This is undoubtedly the media’s favorite tag to hang on Trump. According to the media, Trump is a racist because he wants to build a wall that will stop the flow of millions of illegals from Mexico and Latin America into this country. Trump is a racist because he wants to deport and fine and deny American citizenship to the 11 million illegals who are here ILLEGALLY. Trump is a racist because he called Mexicans convicted of rape, rapists. Trump is a racist because he referred to Mexican criminals in America as criminals. Trump is a racist because he visits black communities and asks them for their vote in exchange of his promises to fix their economic predicaments.
2.Paint Trump as a Sexist – What really drives the liberal media crazy is that Trump is a man not of this time. Trump has none of the characteristics of the modern American man; effeminate quirkiness and passiveness. Trump is brash and daring and honest. His off the cuff comments sound like something a guy would have said during Coach Stelnicki’s water polo practice in 1970. Trump is high octane testosterone and the average American male, who has been bludgeoned to death by pajama boys and political correctness can’t get enough of Trump’s regular guy stature. Trump is the blue collar billionaire who dines on KFC on his private jet while watching the NFL.
To the mindless trolls of the leftist media, Trump is Don Draper, Mike Ditka and Patton all wrapped in one. They continue to try and discredit Trump to one of the biggest voting blocks he is having trouble with; suburban soccer moms. The liberal media knows that soccer moms are over-protective helicopter parents who yearn for Mr. Sensitive, aka the Tim Kaine’s of the world. But, reality states that the Tim Kaine’s of the world belong to a political party that is crushing suburbia. A Pleasant Valley Sunday is becoming a 24/7 nightmare for the middle class. Gradually, soccer moms are realizing that Trump is the guy who will make sure the economy hums, the mortgages on their four bedroom houses are paid on time and their kids are safe.
The left’s attempts to call Trump a sexist have been largely unsuccessful. Trump has hired and promoted and paid very well, thousands of women in his companies. How is Trump a sexist?
On the contrary, Madame Secretary and her criminal enterprise, aka the Clinton Foundation accepted donations in the millions from places like Saudi Arabia that place women one notch above laboratory rats.
3.Paint Trump as a Hot Head – The liberal media loves to portray Trump as a hot head who will take us to nuclear war if he’s elected. This sounds strangely familiar to the left’s attempts to destroy Reagan during the 1980 election. Yet, has Trump thrown objects at people in the White House? Has Trump called Secret Service and military personnel every foul mouthed word in the dictionary? Does Trump have a reputation as having a violent and erratic temper?
No, certainly not. But, Hillary Clinton has and does.
4.Paint Trump as Inexperienced – Trump is consistently painted as the amateur without the requisite political or national security experience to be President. Yet, Hillary Clinton accomplished nothing as a junior Senator from New York and was a walking, talking nightmare as Secretary of State. Anarchy reigns across much of the Middle East today thanks to Hillary Clinton and Barack Obama.
5.KGB False Flag Urban Chaos 101 – One of the most important aspects of the active measures being conducted against Trump is the use of radical anarchists like BLM and local communists to attack people at Trump rallies, vandalize police cars and incite general violence. When chaos ensues, the media blames it all on Trump and his supporters who are accused of being violent racists. In fact, the real violence is being supported and funded by Soros and his leftist minions. In fact, the real racism is preached and practiced by BLM.
6.The GOP Establishment Hacks – Republican Establishment hacks are dutiful servants of the left wing media as they appear on countless news programs explaining their disgust for Trump. With their club ties, Church’s cordovan loafers and smug Thurston Howell III accents, they tell the world how the thought of voting for a nouveau riche Neanderthal like Trump is abhorrent.
7.Control Information – A successful disinformation campaign cannot be waged unless information is tightly controlled. The liberal media does its best to ensure that any positive information concerning Trump is flushed into the DC sewer system. A great example of this is the police officer and Trump supporter who saved a small child from a hot car. When interviewed on HLN, the officer was dressed in a Trump t-shirt. HLN deliberately blotted out the logo on the man’s t-shirt, not to protect any copyright infringement, but to deny Mr. Trump any semblance of good publicity.
Yesterday, Reuters ordered its cameraman to cut live footage of Trump receiving praise from African-American Bishop Wayne T. Jackson in Detroit.
And, every day, liberal panels and pundits galore delight in railing against Trump.
The Establishment knows that in order for the fleecing of America to continue, Hillary must win. They will continue to utilize the willing lapdogs of the leftist media to prop up a physically ill criminal who is morally bankrupt and a despot straight from an Elizabethan Era dungeon.
Will the liberal media’s Soviet style disinformation operation succeed? Perhaps not; no matter what lies they propagate about Trump. Donald Trump’s greatest gift is his unpredictable nature. No matter how much the left attempts to control and manipulate the news cycle against Trump, Trump can usually sidestep them.
Also, the media has one thing going against them; Hillary Clinton’s crimes, which are plentiful and horrible and popping up every 24 hour news cycle like some haunted Jack in the Box from Julian Assange’s House of Horrors.

Adie's Syndrome: A Possible Explanation for Hillary Clinton's Cough

J Neurol Neurosurg Psychiatry ^ | March, 1998 | J Kimber 

I'm not trying to construct a crazy hypothetical, but I can't examine Hillary Clinton, so here's one possible explanation for her cough. Holmes-Adie Syndrome. It also falls in line with the neurologist who apparently shines a flash light for her, when she's walking. I contend that the problems Hillary is having might be from her inability to see when she is in bright light, in addition to a neurological problem affecting her physical mobility--two of the features seen in Adie's Syndrome.
Adie syndrome is a rare neurological disorder that usually affects the pupil of one eye or occasionally both eyes. Usually, the pupil constricts in the presence of bright light, or when focusing on nearby objects. The pupil usually dilates in light that is dim or in darkness, when focusing on far away objects, or when a person becomes excited. In Adie syndrome, these usual reactions to darkness and light do not happen.
In the majority of people with Adie syndrome, the affected pupil is larger than usual all the time and does not constrict very much or at all in response to light stimulation. The person's pupil constricts slowly when focusing on objects close to view. In some people with the syndrome; however, the opposite is true - the pupil stays smaller than usual all the time. Most people with Adie syndrome have poor or absent reflexes as well.
I've looked at several photos of Hillary's Eyes, and the pupils are equal, but you would have to shine a light on each and then look for the response to rule out an Adi pupil.
Pupils appear equal in this photo. Don't know when it was taken.

Here's one of several scientific articles on a condition, commonly called Adie's Syndrome. (See:https://www.google.com/#q=Cough+and+Adie%27s+syndrome for additional). The article presents five cases, that involve a chronic dry cough that is unaffected by treatment. The cough is worsened by public speaking and associated with photophobia. Read the article and the cases presented and judge for yourself.
The Holmes-Adie syndrome consists of unilateral or bilateral tonic pupils with near light dissociation and tendon areflexia. It is associated with autonomic disturbances affecting sudomotor and vasomotor function. Five such patients are reported on who also had a troublesome chronic dry cough, which was of unknown aetiology and was resistant to a range of treatments. The cough may be related to involvement of afferent or efferent pathways in the vagus. Chronic cough may be an accompaniment in the Holmes-Adie syndrome, like other forms of autonomic dysfunction.
The Holmes-Adie syndrome1 2 (tonic pupil, near-light dissociation, and tendon areflexia) has been associated with a range of autonomic disturbance that includes orthostatic hypotension,3 impairment of cardiovascular reflexes,4 5 segmental6 and generalised hypohydrosis (Ross’s syndrome),7 carotid gustatory syndrome,8 and chronic diarrhoea.9 Limited histological studies in this condition indicate loss of ganglion cells in the parasympathetic ciliary ganglia10 which correlates with the pupillary abnormalities. Degeneration of the dorsal root ganglia or the fasciculus gracilis and cuneatus may explain the absent tendon reflexes.11 Autonomic dysfunction has been variously ascribed to lesions of both afferent and efferent sympathetic and parasympathetic neurones.
Although Holmes-Adie syndrome is considered to be benign and of unknown aetiology, troublesome symptoms may result from autonomic dysfunction; these include hyperhydrosis, heat intolerance, and syncope. We report a further feature in five patients with Holmes-Adie syndrome in whom there was a persistent dry cough, of unknown aetiology.
The patients are described individually. None had a history of exposure to irritant chemicals or impairment of exercise tolerance. All had bouts of paroxysmal dry coughing during the day, with lesser frequency at night. Cough was not provoked by lying flat. None was taking angiotensin converting enzyme inhibitors, and all underwent detailed cardiovascular autonomic function tests with thermoregulatory sweat testing12 (table 1). Pulmonary function testing and other investigations to determine possible causes for their cough are shown in table 2. In all the chest radiograph was normal. Thorax CT was questionably abnormal in patient 4, with peribronchial shadowing in the right upper zone that may have represented localised bronchiectasis, but bronchoscopy was normal. There were no features of gastro-oesophageal reflux and all were treated with H2antagonists with no benefit. In the three who underwent cine-video fluoroscopy, there was no evidence of laryngeal aspiration. In three, capsaicin challenge indicated increased cough sensitivity. Laboratory testing to exclude secondary causes of autonomic dysfunction included glucose, erythrocyte sedimentation rate, serum electrophoresis, autoantibody screen, treponemal serology, and brain MRI, and the results were normal in each case. Where Holmes-Adie syndrome was not previously documented, patients also underwent pupillography and EMG (to show absent or reduced H waves) to confirm further the diagnosis.
Patient 1 was a 39 year old white man, a non-smoker, who had been investigated when aged 21 for anisocoria and a tonic right pupil that was unresponsive to light. When aged 35 he developed hyperhydrosis affecting the right arm and trunk; a right cervical sympathectomy was performed with only minimal improvement. He then developed symptoms of postural hypotension and was bothered by frequent paroxysms of coughing that resulted in syncope on several occasions. There was no history of lung disease.
Examination indicated a dilated right pupil with near-light dissociation. Other cranial nerves were normal. Tendon reflexes were absent bilaterally. Sweating was marked in the right axilla. There were no respiratory system abnormalities. Cardiovascular autonomic testing suggested an afferent baroreceptor lesion. Paroxysmal coughing during head up tilt resulted in a fall in blood pressure from 151/99 to 98/70 mm Hg, inducing presyncope. He was treated with a high salt intake and fludrocortisone to improve orthostatic tolerance. Probanthine (15 mg thrice daily) and clonidine (25 mg thrice daily) were used to reduce hyperhydrosis but were stopped due to a dry mouth. Investigation of cough (table 1) indicated no identifiable aetiology. The cough was refractory to therapeutic trials of inhaled, nasal, and oral steroids, lignocaine spray and nebuliser, local anaesthetic lozenges, and oral H2 antagonists. The patient is currently on proprietary antitussive agents (containing morphine, capsiacin, and ipecachuana).
 Patient 2 was a 58 year old white woman, who had stopped smoking 15 years previously. When 51, she noticed inequality of pupils. Two years later she developed asymmetric facial sweating and paroxysmal coughing attacks, particularly while eating and during prolonged talking. She had occasional dyspnoea but no wheezing and on investigation was diagnosed as having late onset asthma. Although bronchodilator treatment improved the dyspnoea it did not prevent coughing. She had been hypertensive and noted that treatment with an angiotensin converting enzyme inhibitor exacerbated her cough and the drug was withdrawn. Examination confirmed a left tonic pupil with near light dissociation, hemifacial anhydrosis, and tendon areflexia. Cardiovascular and respiratory examination was unremarkable. Cardiovascular autonomic testing showed minor abnormalities. Investigations for cough indicated mild reversible airway obstruction. Treatment with inhaled bronchodilators and steroids (salbutamol, salmeterol, beclomethasone) produced a partial reduction in coughing. Oral H1 (loratadine) and H2 antagonists (ranitidine) and nasal steroids (fluticasone and beclomethasone drops) produced no further benefit. The patient noted that coughing, especially during public speaking, was markedly reduced after taking lomotil (diphenoxylate hydrochloride and atropine sulphate); inhaled ipratropium bromide (40 μg four times a day) has been initiated with moderate benefit.
Patient 3 was a 59 year old white woman, a non-smoker with a 20 year history of postural dizziness. Previous investigation at the age of 40 had documented bilateral tonic pupils in association with tendon areflexia. Subsequently she developed facial anhydrosis and a chronic dry cough. Examination confirmed small irregular pupils with near light dissociation and tendon areflexia with no other CNS abnormality. Cardiovascular and respiratory systems were unremarkable. Cardiovascular autonomic testing indicated baroreceptor dysfunction (orthostatic hypotension, blocked blood pressure response to Valsalva’s manoeuvre, and exaggerated pressor responses). Investigations for cough identified no obvious aetiology. Treatment with proprietary antitussive drugs resulted in some improvement of symptoms.
Patient 4 was a 31 year old woman, a non-smoker of mixed (white-AfroCaribbean) origin. On presentation at the age of 26 she had a 2 year history of posture induced syncope together with paroxysmal throbbing headaches and epistaxis provoked by prolonged recumbency. She had had mild asthma since childhood and used a salbutamol inhaler intermittently. Examination indicated a right tonic pupil with near light dissociation. Tendon reflexes in the lower limbs were reduced. There were no other neurological abnormalities. Cardiovascular and respiratory examination was normal. Cardiovascular autonomic testing confirmed orthostatic hypotension and pressor stimuli raised blood pressure at times to 250/120 mm Hg suggesting impaired baroreceptor afferent activity. Methyldopa (250 mg twice daily) reduced the paroxysmal hypertensive episodes. A prominent symptom was persistent dry coughing that was refractory to increasing bronchodilator treatment and this was investigated further (table 2). Treatment with inhaled and nasal steroids (fluticasone inhaler (200 μg twice daily); fluticasone nasal spray (50 μg/nostril daily)) partially improved her cough. Oral H1 (chlorpheniramine) and H2 antagonists (ranitidine) were of no further benefit. She continued to have an unremitting dry cough.
Patient 5 was a 66 year white woman who was a non-smoker. She had presented 12 years previously with a troublesome dry cough. She had also noticed a unilateral dilated pupil and began having episodic diarrhoea up to 12 times daily. Panendoscopy plus large bowel biopsies failed to identify a cause. She then also noted truncal hyperhydrosis and postural dizziness. She had dry eyes and hypostomia with no history of joint or skin inflammation and no reduction in exercise tolerance. Further serological investigation indicated positive anti-Ro antibodies, suggesting primary Sjögren’s syndrome. Examination showed near light dissociation of the right pupil and tendon areflexia. Truncal sweating was prominent bilaterally. There were no other abnormalities. Cardiovascular autonomic function tests indicated no abnormalities and investigation of her cough identified no obvious cause. She had been treated with numerous courses of antibiotics for presumed upper respiratory tract infections and with antirhinitis treatment and cough suppressants containing opiates without effect. Proprietary antitussive agents containing capsaicin are currently being assessed.
Chronic cough is a common symptom and may be caused by various stimuli which range from neoplasms, inflammatory lung disease, and postnasal drip to increased cough sensitivity resulting from respiratory tract infections, asthma, gastro-oesophageal reflux, and drugs such as angiotensin converting enzyme inhibitors.13Despite extensive investigation, a proportion of patients have no diagnostic reason to explain their cough. Our findings suggest that the Holmes-Adie syndrome may be a disorder associated with a chronic dry cough.
All our patients had typical ocular findings and tendon areflexia indicative of Holmes-Adie syndrome. They also had associated autonomic impairment, either cardiovascular or sudomotor, and this combination presumably reflects the interests of the referral units. All were investigated in detail for autonomic dysfunction and also for a cause for their coughing. Coughing was provoked in each patient by deep breathing or hyperventilation during autonomic testing, suggestive of increased cough reflex sensitivity. This was formally tested in three. All were investigated for asthma. One patient had had mild asthma as a child and another was a probable late onset asthmatic; asthma may cause chronic cough and increased cough sensitivity, but there was no relation between coughing and indices of airflow limitation and furthermore the cough did not respond to effective asthma treatment. Treatment with H2 antagonists for occult gastro-oesophageal reflux, and H1 antagonists and topical steroids for rhinitis, were of no benefit.
Consideration of the cough reflex pathways enables speculation on the mechanism of cough in these patients. Afferent pathways carry stimuli from receptors in the trachea, larynx, and larger bronchi to the dorsal medulla via the vagus nerve. The motor (efferent) reflex arc innervates the muscles of the larynx, diaphragm, and chest wall. Efferent pathways for bronchiolar smooth muscle and mucosal glands are also vagal in origin. In Holmes-Adie syndrome, cardiovascular4 5 14and tendon reflex abnormalities suggest an impairment of the afferent reflex arc. This alone is an unlikely explanation as in animals with neuropathy induced by acrylamide(affecting vagal myelinated afferent fibres), and in diabetic patients with peripheral autonomic neuropathy, the cough response to mechanical stimulation15 and citric acid is diminished.16 Whether impaired afferent activity resulted in a relative increase in vagal efferent traffic cannot be discounted.
An increased sensitivity of airway cough receptors is a possible explanation as cough reflex sensitivity using capsaicin challenge was increased in each of the three patients tested. This may have been due to changes in the local environment of sensory nerves in the airway, particularly bradykinin and prostaglandin production17 as has been noted in cough induced by angiotensin converting enzyme inhibitor .13 In the three patients who underwent cine-video fluoroscopic examination of swallowing, there were minor abnormalities of coordination that may have provided an abnormal stimulus for coughing; there was, however, no clear association with swallowing or eating except in patient 2, and in none was there evidence of laryngeal aspiration.
One patient responded to an oral and later an inhaled anticholinergic agent and the mechanism may have been through reduced vagally stimulated (muscarinic) effects on bronchial secretions. In patients with refractory epilepsy fitted with vagal nerve stimulators, a proportion experienced coughing corresponding to the stimulator “on” period.18 A therapeutic trial of anticholinergic agents, as in patient 2, may help to determine the vagal efferent component to the cough.
There is uncertainty about the CNS component of the cough reflex. In Holmes-Adie syndrome there is no known evidence of a clear central abnormality, and although it cannot be discounted or tested this seems less likely.
Although chronic cough is a common symptom, detailed investigation in each of our patients with Holmes-Adie syndrome showed no obvious aetiology for their cough; in four out of five patients the coughing seemed temporally related to the onset of other autonomic features. In Holmes-Adie syndrome the autonomic features affecting cardiovascular and sudomotor function favour a patchy involvement, with resultant exaggerated activity, such as increased pressor responses in some and compensatory hyperhidrosis in others. Whether a similar process affects the autonomic control of the respiratory tract and involves the pathways involved in the cough reflex in such patients can only be speculated on at this stage. However, in all five patients, chronic cough produced appreciable morbidity. We conclude that these findings indicate yet another troublesome symptom, the mechanism of which needs to be further elucidated, to add to abnormalities of the somatic and autonomic nervous system previously described in the Holmes-Adie syndrome.
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