ATW1H%ASUACAD.BITNET@oac.ucla.edu (Dr David Dodell) (09/12/89)
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Volume 2, Number 33 September 11, 1989
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Editor: David Dodell, D.M.D.
St. Joseph's Hospital and Medical Center
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Telephone (602) 860-1121
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T A B L E O F C O N T E N T S
1. Medical News
Medical News for Week Ending September 11, 1989 ....................... 1
2. Center for Disease Control Reports
[MMWR 9-7-89] Measles - United States, 1988 ......................... 5
Surgeon General's - Recommendations of Medication Working Group ....... 8
Cadmium/Lead Exposure with Pharmaceuticals Imported from Asia ......... 11
Publication of Guide for Developing Policies for HIV-Infected Students 14
3. Dental News
ADA Voices Concern Over "Whitening" Toothpastes ....................... 15
4. Articles
Heart Transplants Increase 10 Times, But Lack of Donors Persists ...... 16
Tissue Transplants Increase Despite Screen for Infectious Agents ...... 18
Health InfoCom Network News Page i
Volume 2, Number 33 September 11, 1989
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Medical News
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Medical News for Week Ending September 11, 1989
Copyright 1989 - USA TODAY/Gannett National Information Network
Reproduced with Permission
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Sept. 5, 1989
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SEARCH WIDENS FOR MEDICAL CURES:
The next breakthrough for treating AIDS or cancer might come from a tuber
that grows in an African rain forest or an exotic chemical excreted by
starfish in the South Pacific. To find new drugs for these diseases, the
National Cancer Institute has begun screening thousands of plants, marine life
and microorganisms for their life-saving potential. (From the USA TODAY Life
section.)
CHECKUPS A MUST FOR KIDS:
Parents are encouraged to make speech, language and hearing checkups a part
of back-to-school preparation for children, says the American Speech-Language-
Hearing Association. The organization recommends early detection and treatment
of these disorders to reduce their impact on a child's social and academic
development.
TREATMENT ENDS VARICOSE VEINS:
Virtually all spider veins and smaller varicose veins can be removed
quickly and without pain by a non-surgical technique called sclerotherapy. The
procedure involves injecting saline or sodium tetradecyl sulfate into the
vein, causing the vein to collapse and eventually dissolve, says an article in
the September issue of Prevention.
FUTURE OF SKIN DAMAGE CONTINUES:
Melanoma, a deadly form of skin cancer, could become the most common form
of cancer in the world by the year 2000, predict experts from the Presbyterian
Medical Center in Philadelphia. Those at risk: fair-skinned people;
individuals with moles. Large, irregular shaped and colored moles should be
screened twice a year for changes in development.
SELF-HELP BOOKS REALLY DO HELP:
Some self-help books really do help. A new study by a psychologist at the
University of Alabama reveals that reading a self-help book can be as
effective as consulting a psychotherapist. Two-thirds of mildly depressed
adults participating in a study at the school showed significant improvement
after reading a book on ways to overcome depression.
PSYLLIUM - FOOD OR DRUG:
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Volume 2, Number 33 September 11, 1989
The Kellogg Co.'s new oat-based cereal, Heartwise, contains psyllium, which
is supposed to reduce cholesterol. Thus the question: Is psyllium a food, or a
drug. Also, how far can food companies go in making health claims for their
products? The FDA is monitoring the issue.
HONEY SWEETER THAN SUGAR:
Honey is growing in popularity among health-conscious consumers and food
manufacturers. Honey is 33 percent sweeter than granulated sugar and contains
fewer calories for its sweetening power, said an executive of the National
Honey Board.
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Sept. 6, 1989
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MID-AGE WOMEN NOT AT HIGH RISK:
Millions of middle-aged women who used birth control pills in their mid-20s
or later aren't at unusually high risk for breast cancer, a major new study
shows. But the Harvard Medical School study - the largest yet, with 100,000
women followed for 10 years - offers no reassurance for pill users now under
age 40. (From the USA TODAY Life section.)
CONSUMERS BACK GENERIC DRUGS:
Despite the recent charges of fraud and mismanagement, consumers are
standing by the generic drug industry. Pharmacists report that customers are
asking questions about the drugs they're getting, but few are switching to
brandname products.
ANTI-AIDS DRUG IN ALGAE:
Researchers at the National Cancer Institute in Frederick, Md., have
discovered a substance in blue-green algae from Hawaii with anti-AIDS
activity. The finding was reported recently in the Journal of the National
Cancer institute.
TREAT CHILD, NOT THERMOMETER:
A Johns Hopkins Children's Center study of 68 children with chicken pox
showed that while the drug acetaminophen reduces fever, it may prolong the
illness. Some pediatricians are now advising parents to withhold the fever-
reducing medicine, if the child is comfortable, so that recovery will be
faster.
COMPOUND FOR CANCER TREATMENT:
Ondansetron, a compound known as serotonin antagonists, is under
investigation as an agent that shows promise for the treatment of nausea and
vomiting, associated with chemotherapy used to treat cancer patients. Research
results were presented Tuesday during the Fifth European Conference on
Clinical Oncology in London.
HEPATITIS B VACCINE IMPROVED:
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Volume 2, Number 33 September 11, 1989
Clinical testing of an improved hepatitis B vaccine is expected to begin
within a few months, reports the Weizmann Institute of Science. The institute
said the product would be inexpensive and might help lower the incidence of
liver cancer in those who've suffered from acute hepatitis B.
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Sept. 8-10, 1989
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MEASLES CASES AT RECORD HIGH:
The measles epidemic of 1989 threatens to make this the biggest year for
the disease in the 1980s, the federal Centers for Disease Control says.
Measles cases through Aug. 28 total 9,650. That total could surpass the
previous high: 13,506 cases in 1980, says CDC epidemiologist Dr. William
Atkinson. (From the USA TODAY Life section.)
COMPANY EXPANDS TRIAL SITES:
Trimedyne Inc. said Thursday it has received approval from the U.S. Food
and Drug Administration to set up four additional coronary clinical trial
sites. Laserwire, Lasercoil and Lasercath devices, which use laser energy to
vaporize plaque (fatty deposits) inside blood vessels, will be tested at these
sites.
RICE BRAN FIGHTS CHOLESTEROL:
Rice bran, found in brown rice, is expected to become the next weapon in
the battle against high cholesterol, said Dr. John Hunnell, assistant vice-
president, director of research and development of Riviana Foods Inc.,
Houston. He says that brown rice is a source of carbohydrates, Vitamins B and
E, and is sodium-free.
ORPHAN DRUGS GET CLOSER LOOK:
Sometimes a disease only affects a group of under 200,000. When this
happens, drugs that cure that disease get little attention. Not any more. The
Pharmaceutical Manufacturers Association, Food and Drug Administration and the
National Organization for Rare Disorders will compile a comprehensive list of
so-called orphan drugs now in development.
DRUG APPROVED FOR HYPERTENSION:
Pfizer Inc. said Wednesday the U.S. Food and Drug Administration had
approved Procardia XL for the treatment of angina and hypertension. Procardia
X - a calcium channel blocker -has a controlled release formula over 24 hours
and causes minimal side effects. The drug will be launched shortly, Pfizer
Inc. said.
BREAST IMPLANTS CAUSE HARM:
A new study, published in the Sept. 1 issue of Annals of Internal Medicine,
shows that silicone might escape from gel-filled prostheses, causing systemic
sclerosis (inflammation and hardening of tissue). Sclerosis remained after the
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Volume 2, Number 33 September 11, 1989
implants were removed because leakage into lymph tissue had already taken
place, the report says.
BONE-MASS LINKED TO FRACTURES:
The amount of bone mass in the forearm's radius predicts future fractures,
says a new study published in the Sept. 1 issue of Annals of Internal
Medicine. In a group of more than 500 women, a single measurement of bone mass
in the radius was related to the non-spine fractures. A slight decline in bone
mass could increase fracture risk by 120 percent, the study says.
RESEARCHERS MAKING TOUGH TEETH:
By borrowing technology from the auto industry, dental researchers at the
University of Florida are trying to make false teeth, crowns and other ceramic
dental appliances tougher by exposing them to a heat-tempering process used to
make car windshields shatter-resistant. The technique makes dental porcelain
disks crack-, chip- and fracture-resistant.
FISH KEEPS HEART HEALTHY:
After studying 852 men in the Dutch town of Zutphen, Greenland, over a 20-
year period, scientists conclude that consumption of as little as one or two
fish dishes per week might help prevent coronary disease, says an article in
the September issue of consumer Reports Health Letter.
FISH OIL PREVENTS CLOTTING:
Studies show that high doses of omega-3 fatty acids, found in fish oils,
interfere with clotting by making blood platelets less sticky. Thus, the
platelets don't form clots, which in coronary arteries triggers most heart
attacks, says an article in the September issue of Consumer Reports Health
Letter.
Health InfoCom Network News Page 4
Volume 2, Number 33 September 11, 1989
===============================================================================
Center for Disease Control Reports
===============================================================================
Morbidity and Mortality Weekly Report
Thursday September 7, 1989
Current Trends
Measles -- United States, 1988
In 1988, a provisional total of 3411 measles cases was reported to the
Division of Immunization, Center for Prevention Services, CDC, 7% less than
the 3652 cases reported during the same period in 1987 (Figure 1) (1). The
overall incidence rate for 1988 was 1.4 cases per 100,000 population. Nine
states reported greater than or equal to 100 cases and accounted for 2802
(82.1%) cases: California (836), Pennsylvania (542), New Jersey (402), Texas
(287), Virginia (239), Florida (170), Colorado (117), Ohio (109), and New
Hampshire (100). Seven states had incidence rates greater than 2.0 per 100,000
population: Montana (10.7), New Hampshire (9.2), New Jersey (5.2),
Pennsylvania (4.5), Virginia (4.0), Colorado (3.5), and California (3.0).
Thirty-six states and 211 (6.7%) of the nation's 3138 counties reported
measles cases.
A total of 3176 (93.1%) cases met the standard clinical case definition
for measles,* and 1001 (29.3%) were serologically confirmed. The usual
seasonal pattern was observed with cases peaking during weeks 18-25 (May and
June).
Eighty-seven (2.6%) cases were known to be imported from other countries.
An additional 126 (3.7%) cases were epidemiologically linked to imported cases
within two generations. Fifty-seven outbreaks (five or more epidemiologically
linked cases) were reported and accounted for 89.3% of all cases. Six
outbreaks had greater than 100 cases and accounted for 52.7% of all reported
cases. Most outbreaks occurred among school-aged children. The largest
outbreak (611 cases) occurred in Los Angeles among unvaccinated preschool-aged
children.
The incidence rate of measles decreased between 1987 and 1988 for 0-4-, 5-
9-, and 10-14-year-olds, and increased in 15-19- and 20-24-year-olds. The
highest incidence rate (5.8 per 100,000) occurred in 15-19-year-olds (Table
1).
Complications were reported in 408 (12.0%) cases. Otitis media was
reported in 183 (5.4%); diarrhea, in 128 (3.8%); pneumonia, in 93 (2.7%); and
encephalitis, in four (0.1%). Three hundred sixty-eight (10.8%) persons were
hospitalized. Three measles-attributable deaths were reported (case-fatality
rate: 0.9 deaths per 1000 cases).
Of the 2179 (63.9%) patients for whom setting of transmission was
reported, 871 (40.0%) acquired measles in primary or secondary schools; 267
(12.3%), in colleges or universities; 553 (25.4%), at home; 127 (5.8%), in
medical settings; 69 (3.2%), in day care; and 292 (13.4%), in a variety of
other settings.
A total of 1548 (45.4%) patients had been vaccinated on or after the first
birthday (Table 2), including 729 (21.4%) who were vaccinated at 12-14 months
of age. One thousand eight hundred sixty-three (54.6%) persons were not
vaccinated on or after the first birthday. Of these, vaccination would have
been routinely indicated** for 803 (23.5%). Six hundred twenty-eight (18.4%)
cases occurred in persons for whom vaccine was not routinely indicated, and
432 (12.7%) were unvaccinated for other reasons.
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Volume 2, Number 33 September 11, 1989
Of the 3411 reported cases, 1942 occurred among school-aged children. Of
these, 1339 (68.9%) had been appropriately vaccinated. Most of the vaccine
failures occurred in persons 12-19 years of age (Figure 2).
Reported by: Div of Immunization, Center for Prevention Svcs, CDC.
Editorial Note: Since 1983, the number of reported measles cases increased
annually until 1986, then decreased in 1987 and slightly in 1988 (Figure 1).
In 1988, the age distribution of cases was similar to those in previous years.
As in previous years, primarily two types of outbreaks occurred: those among
highly vaccinated (vaccine coverage greater than 90%) school-aged children and
those among unvaccinated preschool-aged children (2).
The epidemiology of measles points to two major impediments to measles
elimination--unvaccinated preschool-aged children, allowing large outbreaks in
inner-city areas, and vaccine failures, accounting for outbreaks in highly
vaccinated school-aged populations. Therefore, in January 1989, the
Immunization Practices Advisory Committee (ACIP) issued revised
recommendations (3). First, ACIP lowered the age for routine measles
vaccination in inner-city areas to as low as 9 months so that children would
be vaccinated before they could be exposed to measles, and coverage would
therefore be increased. Second, ACIP recommended that, for outbreaks in
schools, previously vaccinated persons in specific target groups be
revaccinated in affected schools and unaffected schools at risk for
transmission. The groups targeted for revaccination are persons vaccinated
before 1980 or vaccinated at 12-14 months of age. The rationale for choosing
the 1980 date has been described (3). Data from four recent outbreak
investigations have shown that persons vaccinated before 1980 are at increased
risk for measles (Table 3). This is believed to be due primarily to a higher
rate of failure of initial seroconversion for persons vaccinated before that
time. Although children vaccinated between 12 and 14 months of age are at
higher risk than are children vaccinated at older ages, only a minority of
children with measles in most outbreaks have been vaccinated between these
ages (1).
Implementation of these new outbreak-control recommendations during 1989
has been expensive because of the large number of outbreaks and cases. In the
first 26 weeks of 1989, 8553 cases were reported, a 392% increase over the
same period in 1988. More than 90 outbreaks have been reported; most have
occurred in secondary schools and colleges. Seventy-one colleges have
reported at least one case of measles. The largest outbreak has occurred in
Houston, with greater than 1700 cases, primarily among unvaccinated preschool-
aged children. Several states have spent several hundred thousand dollars each
to revaccinate young adults in secondary schools and colleges.
Because of continued outbreaks among school-aged children, in May 1989,
the ACIP decided to recommend a routine two-dose measles vaccination schedule.
The second dose will be administered at entry to kindergarten or first grade
(children 4-6 years of age). A two-dose schedule will decrease primary vaccine
failures and thus the number of susceptibles and measles outbreaks in school-
aged children. In add ition, outbreak-control measures will be simplified.
Detailed recommendations for this schedule and outbreak control are being
formulated and will be published in the fall of 1989. Until then, the
previously published schedules and recommendations should be followed. The
American Academy of Pediatrics has also developed a routine two-dose measles
vaccination schedule, which recommends that the second dose be given at entry
to middle or junior high school (7).
The two-dose schedule will not affect outbreaks in inner-city areas among
Health InfoCom Network News Page 6
Volume 2, Number 33 September 11, 1989
unvaccinated preschool-aged children. Prevention of such outbreaks requires
intensive efforts directed at increasing age-appropriate immunization levels,
which are being initiated by CDC and state and local health departments. These
include activities in service delivery, assessment, information/education,
operational research and surveillance. The two-dose schedule and intensive
efforts to raise age-appropriate immunization levels should facilitate the
goal of measles elimination in the United States.
References
1. CDC. Measles--United States, 1987. MMWR 1988;37:527-31.
2. Markowitz LE, Preblud SR, Orenstein WA, et al. Patterns of transmission in
measles outbreaks in the United States, 1986-1987. N Engl J Med 1989;320:75-
81.
3. ACIP. Measles prevention: supplementary statement. MMWR 1989;38:11-4.
4. Hutchins SS, Markowitz LE, Mead P, et al. A selective measles revaccination
policy during a school-based measles outbreak (Abstract). In: CDC.
Proceedings of the 1988 EIS Conference. Atlanta: US Department of Health and
Human Services, Public Health Service, 1988:29.
5. Mast EE, Berg JL, Hanrahan LP, Davis JP. Measles in a highly vaccinated
population: possible causes of measles vaccine failure (Abstract). In: CDC.
Proceedings of the 1989 EIS Conference. Atlanta: US Department of Health and
Human Services, Public Health Service, 1989:70.
6. Rullan JV, Pozo F, Gamble WB Jr, Jackson K, Parker RL. Measles in a highly
vaccinated South Carolina school population (Abstract). In: CDC. Proceedings
of the 1987 EIS Conference. Atlanta: US Department of Health and Human
Services, Public Health Service, 1987:24.
7. American Academy of Pediatrics. Measles: reassessment of the current
immunization policy. AAP News 1989;(July):6-7.
*Fever greater than or equal to 101 F (greater than or equal to 38.3 C), if
measured; generalized rash lasting greater than or equal to 3 days; and at
least one of the following: cough, coryza, or conjunctivitis.
**Cases in persons who were eligible for vaccination but who were not
vaccinated.
Health InfoCom Network News Page 7
Volume 2, Number 33 September 11, 1989
Progress in Chronic Disease Prevention
Surgeon General's Workshop on Health Promotion and Aging: Summary
Recommendations of the Medication Working Group
The "Surgeon General's Workshop on Health Promotion and Aging" met in
Washington, D.C., on March 20-23, 1988. This workshop provided health
professionals with recommendations and proposals for health promotion that
address the needs of the elderly. The recommendations of the Alcohol Working
Group have been summarized (1). Following is a summary of recommendations from
the Medication Working Group.
SUMMARY RECOMMENDATIONS OF THE MEDICATION WORKING GROUP
Education and Training
o More training and continuing medical education courses should be provided
that emphasize the resources available to the prescriber, understanding of
age-related physiologic metabolic changes, nonjudgmental patient-
counseling skills, and interdisciplinary communication skills.
o Social service providers, home caregivers, family members of older adults,
and older adults should be trained in medication management and educated
about the potential for adverse medication reactions.
o The role of pharmacists in management of and education about geriatric
medications should be expanded, and sites for prescribing information in
all practice settings should be identified.
Service
o Reimbursement for pharmacy services for the elderly should be independent of
dispensation or cost of the product.
o Reimbursement patterns should encourage better access to medical care for
persons needing complex medication regimens and for isolated patients.
o Access to medicines and pharmaceutical services should be included as a
basic part of health-care programs for the elderly and should include
access to medicines for the geographically isolated and mobility-impaired.
o Community-based programs should strengthen efforts to ensure that older
Americans have the information necessary to participate with their health-
care providers in medication management.
Research
o Cross-sectional and longitudinal studies and other pharmacoepidemiologic
research should emphasize nonlethal side effects, efficacy, risks,
compliance, and cost-effectiveness of medications.
o National data sets should be studied further to assess medication-use
patterns among older adults.
o Studies should focus on cost-effective means of educating the consumer and
the home caregiver on proper use of medications and monitoring of side
Health InfoCom Network News Page 8
Volume 2, Number 33 September 11, 1989
effects and on the standardization of medication profile and drug
interaction information.
Policy
o The federal government should implement quickly the recently passed
medication provisions of the Medicare Catastrophic Coverage Act of 1988
(100 PL 360; 1988 H.R. 2470).
o Regulatory agencies should explore fraud and quackery by reviewing the
marketing of certain drugs, vitamins, food stuffs, and nutritional
supplements used as medications.
o The Food and Drug Administration (FDA) should complete development and
implementation of proposed guidelines for drugs for use in the elderly,
especially elderly subgroups at risk, and should emphasize not excluding
persons from participating in clinical trials on the basis of age alone.
o Drug labeling should be enforced and should emphasize patient education by
including specific instructions for the elderly.
Reported by: Office of the Surgeon General, Public Health Svc. Cardiovascular
Health Br, Div of Chronic Disease Control and Community Intervention, Center
for Chronic Disease Prevention and Health Promotion, CDC.
Editorial Note: Most (60%) adverse reactions from drugs are pharmacologic
(2,3), and many of these may be preventable with more careful prescribing,
monitoring, and patient education. Elderly patients have a higher risk for
developing adverse drug reactions than do persons in the general population
(4,5); use of multiple drugs may be the strongest of several factors that
predispose older persons to this excess risk. Thus, one important strategy for
preventing adverse drug reactions among elderly persons is to limit the number
of drugs used. This approach can reduce side effects, the possibility of drug
interactions, and noncompliance (6). Furthermore, noncompliance appears to be
associated more with the number of prescribed drugs taken than with increasing
patient age (7).
Understanding of drug reactions in the elderly is based on multicenter
collaborative drug surveillance programs, voluntary reporting to the FDA,
cohort studies, control phase of intervention demonstrations, institutional or
population-specific prevalence surveys, and computerized record linkage of
secondary data sets. FDA data now indicate an overall rate of 8.5 adverse drug
reaction reports per 100,000 population; the rate among persons aged greater
than or equal to 65 years is 16.0, nearly double this rate (5).
Antihypertensive diuretics provide an important illustration of the
current problems and the potential solutions in the area of geriatric
medications. When FDA data from 1968 through 1982 were tabulated to identify
medications associated with untoward effects in older patients (4),
antihypertensive diuretics ranked fifth among the generic drug classes with
the highest reported number of adverse drug reactions. Studies on
hypertension in the elderly have demonstrated the importance of attentive
monitoring during treatment (8,9). Such monitoring is important because these
medications are so frequently implicated in adverse drug reactions among the
elderly (7).
A major recurring theme in the recommendations of the Surgeon General's
Workshop is education of health professionals, home caregivers and family
Health InfoCom Network News Page 9
Volume 2, Number 33 September 11, 1989
members, and the elderly patients themselves. Implementing the recommendations
of the Medication Working Group should help reduce the number of adverse drug
reactions and increase medication compliance among the elderly.
References
1. CDC. Surgeon General's Workshop on Health Promotion and Aging: summary
recommendations of the Alcohol Working Group. MMWR 1989;38:385-8.
2. Burnum JF. Preventability of adverse drug reactions (Letter). Ann Intern
Med 1976;85:80-1.
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