HICNet Medical News Digest Thu, 30 Jun 1994 Volume 07 : Issue 29 Today's Topics: [MMWR 24 June 94] Arthritis Prevalence and Activity Limitations [MMWR] Injecting-Drug Users and Bleach Use for Disinfection [MMWR] Viral Gastroenteritis Associated with Raw Oysters Oral Pathology Course Parkinson's Disease Conference Obstructive Sleep Apnea Syndrome Cardiology: Today and Tommorrow - Conference New Vaccine May Prevent Tooth Loss +------------------------------------------------+ ! ! ! Health Info-Com Network ! ! Medical Newsletter ! +------------------------------------------------+ Editor: David Dodell, D.M.D. 10250 North 92nd Street, Suite 210, Scottsdale, Arizona 85258-4599 USA Telephone +1 (602) 860-1121 FAX +1 (602) 451-1165 Internet: mednews@stat.com Bitnet: ATW1H@ASUACAD Compilation Copyright 1994 by David Dodell, D.M.D. All rights Reserved. License is hereby granted to republish on electronic media for which no fees are charged, so long as the text of this copyright notice and license are attached intact to any and all republished portion or portions. The Health Info-Com Network Newsletter is distributed biweekly. Articles on a medical nature are welcomed. If you have an article, please contact the editor for information on how to submit it. If you are interested in joining the automated distribution system, please contact the editor. Associate Editors: E. Loren Buhle, Jr. Ph.D. Dept. of Radiation Oncology, Univ of Pennsylvania Tom Whalen, M.D., Robert Wood Johnson Medical School at Camden Douglas B. Hanson, Ph.D., Forsyth Dental Center, Boston, MA Lawrence Lee Miller, B.S. Biological Sciences, UCI Dr K C Lun, National University Hospital, Singapore W. Scott Erdley, MS, RN, SUNY@UB School of Nursing Jack E. Cross, B.S Health Care Admin, 882 Medical Trng Grp, USAF Albert Shar, Ph.D. CIO, Associate Prof, Univ of Penn School of Medicine Martin I. Herman, M.D., LeBonheur Children's Medical Center, Memphis TN Stephen Cristol, M.D., Dept of Ophthalmology, Emory Univ, Atlanta, GA Subscription Requests = mednews@stat.com anonymous ftp = vm1.nodak.edu; directory HICNEWS FAX Delivery = Contact Editor for information ---------------------------------------------------------------------- Date: Thu, 30 Jun 94 21:28:05 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR 24 June 94] Arthritis Prevalence and Activity Limitations Message-ID: Arthritis Prevalence and Activity Limitations -- United States, 1990 Arthritis is a leading cause of work-related disability and the leading cause of disability among persons aged greater than or equal to 65 years in the United States (1). However, there are few national or state-specific estimates and no projections of arthritis prevalence or its impact (2). To develop national and state estimates of arthritis prevalence and physical activity limitation for 1990 and to project these measures through 2020, rates derived from household interview data from the 1989-1991 National Health Interview Survey (NHIS) were applied to the 1990 census population and to census population projections. This report presents the results of that analysis. The NHIS is a probability sample of the civilian, noninstitutionalized population of the United States (3). Estimates of arthritis prevalence were derived by using a random sample of one sixth (n=59,289) of survey respondents, who were asked about the presence of any of a variety of musculoskeletal conditions during the preceding 12 months and for details of these conditions. Each condition was assigned an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), code. Arthritis was classified as a condition that matched ICD-9-CM codes* selected by the National Arthritis Data Workgroup. A total of 8963 (15.1%) persons were classified as having arthritis. Estimates of activity limitation attributable to arthritis were derived by using all 356,592 NHIS respondents, who were asked whether they were limited in or prevented from working, housekeeping, or performing other activities as a result of a health condition(s) and, if so, what specific condition(s) caused the limitation; 10,084 (2.8%) persons reported arthritis as a major or contributing cause of activity limitation. Synthetic state estimates** for 1990 were developed by applying respective regional arthritis rates, stratified by age, sex, race, and ethnicity, to the stratum-specific populations of each state as reported by the 1990 census. National projections through 2020 were determined by applying national arthritis prevalence rates, stratified by age, sex, and race, to the total U.S. population projected by the U.S. Bureau of the Census (4). In 1990, an estimated 15.0% (37.9 million persons) of the U.S. population had arthritis. Estimated prevalence rates were 49.4% for persons aged greater than or equal to 65 years, 5.1% for persons aged less than or equal to 44 years, and 0.5% for children aged less than or equal to 16 years. Arthritis rates age-adjusted to the 1989-1991 population were higher for women (17.1%) than men (12.5%) and for non-Hispanics (15.3%) than Hispanics (11.3%) (Table 1). Rates were similar for blacks and whites. Of persons reporting arthritis, 83.6% had consulted a physician for the problem. In 1990, an estimated 2.8% (7.0 million persons) of the U.S. population had arthritis as a major or contributing cause of activity limitation. Arthritis limited activities in 11.6% of persons aged greater than or equal to 65 years, 0.5% of persons aged less than or equal to 44 years, and 0.1% of persons aged less than or equal to 16 years. Rates of activity limitation, adjusted for age, were higher for women (3.4%) than men (2.0%) and for blacks (4.0%) than whites (2.6%) (Table 1). Age-adjusted rates of activity limitation were twofold higher for persons with 8 or fewer years of education than for persons with a college degree and were threefold higher for persons earning $10,000 or less per year than for persons earning $35,000 or more. Based on region-specific rates and state-specific age, sex, race, and ethnicity distributions, estimated synthetic prevalence rates for self-reported arthritis were lowest in Alaska (10.0%) and highest in Florida (19.1%) (Table 2). Similarly derived rates of arthritis-limited activity were lowest in Alaska (1.5%) and highest in Florida and the District of Columbia (3.8% each). The prevalence rate of self-reported arthritis in the United States is projected to increase from 15.0% of the 1990 population to 18.2% (59.4 million) of the estimated population for 2020. Activity limitation associated with arthritis is projected to increase from 2.8% of the 1990 population to 3.6% (11.6 million) of the 2020 population. Reported by: National Arthritis Data Workgroup. Statistics Br and Aging Studies Br, Div of Chronic Disease Control and Community Intervention, National Center for Chronic Disease Prevention and Health Promotion, CDC. Editorial Note: The findings in this report indicate that both the estimated number of persons with arthritis and the prevalence rate of arthritis have increased since 1985, when 35 million (14.5%) persons had arthritis (5). By 2020, the estimated number of persons with arthritis is projected to increase by 57% and activity limitation associated with arthritis by 66%. These projected increases are largely attributable to the high prevalence of arthritis among older persons and the increasing average age of the U.S. population. The reasons for higher rates of arthritis among women and higher rates of activity limitation among women and persons with low education and low income are not clear. Race and ethnicity are probably risk markers and not risk factors for arthritis. Risk markers may be useful for identifying groups at greatest risk for arthritis and targeting intervention efforts. Although arthritis is more prevalent and a more frequent cause of activity limitation than heart disease, cancer, or diabetes (6), epidemiologic data about this condition are limited. To address this limitation, federal and private groups are collaborating to provide better information about the frequency and impact of arthritis. In addition, some states are gathering data through the Behavioral Risk Factor Surveillance System (7) and making diagnostic, treatment, educational, and rehabilitative services more accessible to all persons with arthritis (8). The findings in this report are subject to at least three limitations. First, the estimates are based on self-reported data that were not validated by a health-care provider. However, because many persons with arthritis do not seek medical care, self-reported data may provide a better indicator of symptomatic arthritis (9). Second, synthetic estimates are not based on direct measurements of state data. Third, synthetic state estimates were not adjusted for income, education, and metropolitan statistical area. In addition, the definition for arthritis used in this report was more comprehensive than that used in the 1985 study and includes additional conditions (e.g., lupus, infectious arthritis, and carpal tunnel syndrome) that persons would identify as arthritis. Further studies are needed to define the frequency of the specific types of arthritis, determine the characteristics of persons who do not seek medical care, and better assess the financial and societal impact of arthritis. In addition, data are needed to better characterize differences in the prevalence and impact of arthritis in demographic subgroups and to provide more direct measures of arthritis for individual states. These data will assist in efforts to reduce the projected impact of arthritis and to direct interventions and services to groups disproportionately affected by arthritis. States can use these synthetic estimates to set priorities and target resources until more direct measures of arthritis prevalence and impact are available. To lessen the projected impact of arthritis, health-care providers should 1) promote primary prevention of arthritis through prevention of obesity and sports-associated or occupational-associated joint injury, and 2) encourage early detection and appropriate management of persons with arthritis, including exercise and educational programs (e.g., the Arthritis Self-Help Course, which has been shown to reduce pain and physician visits [10]). References 1. Pope AM, Tarlow AR, eds. Disability in America: toward a national agenda for prevention. Washington, DC: National Academy Press, 1991. 2. CDC. Prevalence of arthritic conditions--United States, 1987. MMWR 1990;39:99- 102. 3. Massey JT, Moore TF, Parsons VL, Tadros W. Design and estimation for the National Health Interview Survey, 1985-94. Vital Health Stat 1989;2:1-4. 4. Day JC. Population projections of the United States, by age, sex, race, and Hispanic origin: 1993 to 2050. Washington, DC: US Department of Commerce, Bureau of the Census, 1993. (Current population reports; series P25, no. 1104). 5. Lawrence RC, Hochberg MC, Kelsey JL, et al. Estimates of the prevalence of selected arthritic and musculoskeletal diseases in the United States. J Rheumatol 1989;16:427-41. 6. LaPlante MP. Data on disability from the National Health Interview Survey, 1983-1985. Washington, DC: US Department of Education, National Institute on Disability and Rehabilitation Research, 1988. 7. CDC. Prevalence of arthritis--Arizona, Missouri, and Ohio, 1991-1992. MMWR 1994;43:305-9. 8. CDC. Arthritis program--Missouri. MMWR 1988;37:85-7. 9. Edwards S. Evaluation of the National Health Survey diagnostic reporting. Rockville, Maryland: Westat, Inc., December 21, 1992, (report to NCHS). 10. Lorig KR, Mazonson PD, Holman HR. Evidence suggesting that health education for self-management in patients with chronic arthritis has sustained health benefits while reducing health care costs. Arthritis Rheum 1993;36:439-46. *ICD-9-CM codes 95.6, 95.7, 98.5, 99.3, 136.1, 274, 277.2, 287.0, 344.6, 353.0, 354.0, 355.5, 357.1, 390, 391, 437.4, 443.0, 446, 447.6, 696.0, 710-716, 719.0, 719.2-719.9, 720-721, 725-727, 728.0-728.3, 728.6-728.9, 729.0-729.1, and 729.4. **Synthetic estimation obtains state estimates of characteristics by combining regional estimates of the characteristics specific to demographic subgroups with estimates of the proportional distribution of the local population in those subgroups. ------------------------------ Date: Thu, 30 Jun 94 21:29:51 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR] Injecting-Drug Users and Bleach Use for Disinfection Message-ID: Knowledge and Practices Among Injecting-Drug Users of Bleach Use for Equipment Disinfection -- New York City, 1993 Sharing (i.e., multiperson use) of drug-injection equipment among injecting-drug users (IDUs) is a major risk factor in the transmission of human immunodeficiency virus (HIV) and other bloodborne pathogens. Abstaining from injection of drugs eliminates this risk; disinfection of needles and syringes with household bleach can reduce this risk. Because studies suggest the effectiveness of bleach disinfection may be limited, the March 1993 National Institute on Drug Abuse (NIDA) Community Alert Bulletin included recommendations that IDUs who do not stop injecting and sharing injection equipment use full-strength household bleach and keep the bleach in contact with the equipment for at least 30 seconds (1). To determine whether these new recommendations had been disseminated effectively to IDUs, the knowledge of bleach use for disinfection of drug-injection equipment among IDUs participating in a NIDA-sponsored New York City cohort study was assessed during August-December 1993. This report presents data about knowledge of bleach use for disinfection among persons who reported injecting drugs at least once during the 3-6 months preceding the interview. During September 1991-December 1993, cohort members were recruited originally from methadone-maintenance treatment programs (MMTPs) in Manhattan and through flyers and word-of-mouth in Manhattan communities with large numbers of out-of-treatment IDUs. During August-December 1993, 696 cohort members were interviewed during scheduled study visits; 367 (53%) who stated they had not injected drugs during that period and 39 (6%) who were not asked about bleach were excluded from this analysis. At the time of the interview, 304 (83%) of those excluded because they had not injected drugs were enrolled in MMTPs, and eight (2%) were in other types of drug treatment. Respondents were asked, "Should bleach be mixed with water to clean works?" "If yes, how much water are you supposed to mix in with the bleach?"; and "How long do you need to leave the bleach in the syringe in order to kill the AIDS virus?" Respondents also were asked whether they had "injected [drugs] with used needles or shared needles with anyone." Of the 290 active IDU respondents, 232 (80%) were male; the mean age of all persons interviewed was 40 years (range: 22-66 years). Most (230 [79%]) respondents were enrolled in MMTPs at the time of interview; five (2%) were in other types of drug treatment; and 55 (19%) were not in treatment. Overall, 150 (52%) reported average injection frequency of at least once per week during the 3-6 months preceding the interview. The primary drugs injected were heroin, cocaine, or a combination of heroin and cocaine. Needle-exchange programs were reported as the primary source of injection equipment for 118 (41%) during the 3-6 months preceding the interview. Of the 290 respondents, 173 (60%) knew that full-strength bleach should be used to clean used needles, compared with 90 (31%) who thought bleach should be mixed with water; 27 (9%) did not know what strength bleach should be used. One hundred seventy-one (59%) respondents knew that needles and syringes must be in contact with bleach for at least 30 seconds. Approximately one third (102 [35%]) responded correctly to both of these questions. Of 60 persons who reported sharing injection equipment during the preceding 3-6 months, 38 (63%) did not answer both questions correctly. Forty-five (75%) reported either not using bleach or using bleach inconsistently. Four (7%) of those who reported sharing injection equipment responded correctly to both questions and reported always using full-strength bleach. Correct bleach use knowledge did not differ substantially for sex; age; methadone-treatment status; educational level; and recent needle exchange, needle sharing, and bleach use. Reported by: M Marmor, PhD, H Wolfe, MS, S Titus, MPH, New York Univ Medical Center, Dept of Environmental Medicine; DC Des Jarlais, PhD, Beth Israel Medical Center, New York. Behavioral and Prevention Research Br, Div of Sexually Transmitted Diseases and HIV Prevention, National Center for Prevention Svcs; Office of the Associate Director (HIV/AIDS), Office of the Director, CDC. Editorial Note: The findings in this report indicate that only one fifth of the active IDUs reported sharing injection equipment. However, of those who did share, only one fourth used bleach consistently and, of all the active IDUs, only one third knew both recommendations for correct bleach use, regardless of whether they shared injection equipment or used bleach. Because of inconsistent use and incomplete knowledge, active IDUs who reuse syringes that have been used by other IDUs are at high risk for HIV infection. The findings of this study are subject to at least three limitations. First, these findings may not be generalizable to other IDUs in New York City or in other U.S. cities. Second, because the data were gathered 5-9 months after the NIDA bulletin was issued in March 1993, knowledge levels of IDUs since then may have increased. Finally, the sample size was adequate to detect only large effects of many characteristics on knowledge of correct bleach use for disinfection. Because IDUs do not always use sterile equipment, since the mid-1980s HIV-prevention programs for IDUs in the United States have recommended using bleach for disinfection of drug-injection equipment previously used by another person to reduce the possibility of HIV transmission. Bleach was recommended based on its widespread availability, low cost, and ability to inactivate HIV (2). Recent findings have indicated three limitations in the effectiveness of using bleach: 1) the presence of blood or other organic material in the equipment can reduce the effectiveness of bleach (3); 2) there appears to be a minimum contact time needed for bleach to inactivate HIV (4); and 3) many IDUs do not follow recommendations for bleach use for disinfection (5). As a result of these limitations, two national bulletins were issued in early 1993 (1,6) describing disinfection procedures that would increase the likelihood of disinfection. The provisional recommendations included prebleach washing of the syringe to remove organic material, use of full-strength bleach, and presence of bleach in the syringe for at least 30 seconds. HIV-prevention programs that target drug users should inform IDUs 1) not to inject drugs; 2) if they do inject, to use new, sterile needles and syringes for every injection; and 3) if they cannot use sterile equipment, to disinfect the equipment following the recommendations for bleach disinfection. The availability of effective drug-treatment programs and sterile injection equipment are HIV-prevention priorities to assist IDUs who will not or cannot stop injecting drugs (7). References 1. Millstein R. Community alert bulletin. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute on Drug Abuse, March 25, 1993. 2. Martin LS, McDougal JS, Loskoski SL. Disinfection and inactivation of human T lymphotrophic virus type III/lymphadenopathy-associated virus. J Infect Dis 1985;152:400-3. 3. Flynn N, Jain S, Keddie E, et al. Bleach is not enough: giving IV drug users a choice of disinfectants when they share needles and syringes [Abstract]. Vol 3. VI International Conference on AIDS, San Francisco, June 20-24, 1990:279. 4. Shapshak P, McCoy CB, Rivers JE, et al. Inactivation of human immunodeficiency virus-1 at short time intervals using undiluted bleach [Letter]. J Acquir Immune Defic Syndr 1993;6:218-9. 5. Gleghorn AA, Doherty MC, Vlahov D, et al. Insufficient bleach contact time during syringe cleaning among injecting-drug users (IDUs) [Abstract]. Vol 2. IX International Conference on AIDS/IV STD World Congress, Berlin, June 6-10, 1993:872. 6. CDC/Center for Substance Abuse Treatment/National Institute on Drug Abuse. HIV AIDS prevention bulletin. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, April 19, 1993. 7. Lurie P, Reingold A. The public health impact of needle exchange programs in the United States and abroad. Vol 1. San Francisco: Institute for Public Health Studies, 1993. ------------------------------ Date: Thu, 30 Jun 94 21:31:09 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR] Viral Gastroenteritis Associated with Raw Oysters Message-ID: Viral Gastroenteritis Associated with Consumption of Raw Oysters -- Florida, 1993 During November 20-30, 1993, four county public health units (CPHUs) of the Florida Department of Health and Rehabilitative Services (HRS) in northwestern Florida conducted preliminary investigations of seven separate outbreaks of foodborne illness following consumption of raw oysters. On December 1, the HRS State Health Office initiated an investigation to characterize the illness, examine risk factors for oyster-associated gastroenteritis, and quantify the dose-response relation. This report presents the findings of these two investigations. Preliminary Investigations by the HRS CPHUs In November 1993, private physicians notified the CPHUs of 20 persons with possible foodborne illness. These 20 ill persons identified seven well meal companions. Raw oysters were the only common food item eaten by all ill persons; no well meal companions had eaten oysters. At the request of the HRS State Health Office, CPHUs initiated active surveillance for cases of raw oyster-associated gastroenteritis among patients of hospital emergency departments, urgent-care centers, and private physicians in northwestern Florida. A case was defined as sudden onset of nausea, vomiting, diarrhea, or abdominal cramps within 72 hours of eating raw oysters. Twenty-five additional cases of gastroenteritis associated with eating raw oysters were detected. Traceback of implicated oysters by the CPHUs and the Florida Department of Environmental Quality indicated the oysters had been harvested from Apalachicola Bay in northwestern Florida during November 15-23. Epidemiologic Investigation by the HRS State Health Office The 45 persons with raw oyster-associated gastroenteritis reported by the CPHUs identified 26 well meal companions who had eaten oysters during the same meal as ill persons, but did not become ill. Of 44 ill persons for whom data were available, 36 (82%) had developed diarrhea; 34 (77%), nausea; 33 (75%), abdominal cramps; 25 (57%), vomiting; 17 (39%), fever; 15 (34%), headache; and 14 (32%), myalgia. The attack rate was 63%. Of the 45 ill persons, 10 were hospitalized for 24 hours or longer. For 30 persons for whom data were available, the median incubation period was 31 hours (range: 2-69 hours). For 26 persons for whom data were available, the median duration of illness was 48 hours (range: 10 hours-7 days); for 13 persons, duration of illness was more than 3 days. No household contacts of ill persons developed gastroenteritis. No differences were identified between persons who became ill and well meal companions in preexisting medical conditions or medications. Consumption of alcohol or food (e.g., crackers and hot sauce) with the oysters was not associated with risk for illness. Based on the 33 cases for which data were available, a dose-response relation was observed between illness and number of raw oysters eaten (chi square for trend=3.98; p=0.05). The attack rate was highest among raw-oyster eaters who had consumed more than 5 dozen oysters (91%) and lowest among those who had consumed less than 1 dozen oysters (46%). Paired serum specimens from 10 patients were tested for antibody to Norwalk-like virus by enzyme immunoassay (1); three pairs demonstrated a fourfold or greater rise in titer. Seven stool specimens were examined by electron microscopy (EM) and reverse transcription-polymerase chain reaction (RT-PCR). In four specimens, small round-structured viruses were detected by EM; in one specimen, a Norwalk-like genome was confirmed by RT-PCR (2,3). This Norwalk-like virus strain had a nucleotide sequence distinct from similar viruses in nearly simultaneous outbreaks associated with consumption of oysters harvested along the Louisiana coast (4). No confirmed evidence of improper handling (e.g., inadequate refrigeration time or temperature) of the implicated oysters was detected. However, three ill persons had purchased oysters from retail establishments that were not licensed seafood dealers. The National Shellfish Sanitation Program (NSSP) requires fecal coliform testing at least once each month. Fecal coliform testing of water drawn from 39 monitoring sites in Apalachicola Bay on October 3, November 21, and November 24 indicated that water quality in the bay met the criteria of the NSSP (5). No environmental source of pollution was identified. Sanitation procedures at the oyster-processing facilities where seafood dealers purchased oysters met standards set by the Florida Department of Environmental Protection (FDEP). However, based on the epidemiologic evidence of illness associated with oysters harvested from those waters, FDEP temporarily closed the shellfish-harvesting area of Apalachicola Bay during December 1-7. No cases of gastroenteritis related to consumption of oysters harvested after December 7 have been reported. Reported by: C Davis, A Smith, MD, R Walden, Bay County Public Health Unit, Panama City; G Bower, K Cummings, B Dean, J Rigsby, Jackson County Public Health Unit, Marianna; P Justice, C Anderson, N Brown, J Minor, Washington County Public Health Unit, Chipley; EF Geiger, MD, V Laxton, District 1 Health Office, Pensacola; L Crockett, MD, W McDougal, District 2 Health Office, Tallahassee; WG Hlady, MD, RS Hopkins, MD, State Epidemiologist, State Health Office, Florida Dept of Health and Rehabilitative Svcs. Food and Drug Administration. Viral Gastroenteritis Section, Respiratory and Enterovirus Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases; Div of Field Epidemiology, Epidemiology Program Office, CDC. Editorial Note: This report documents outbreaks of viral gastroenteritis in Florida linked to consumption of raw oysters from waters that apparently met the standards for shellfish sanitation. Clinical and epidemiologic features of the outbreaks are similar to recently reported multistate outbreaks of viral gastroenteritis associated with eating oysters harvested in Louisiana (4). RT-PCR with sequencing identified different strains of the virus in the multistate outbreak and the Florida outbreak, suggesting independent sources of oyster contamination. Although infection with the oysterborne Norwalk-like virus caused no fatalities in this outbreak, raw oyster consumption has been linked in Florida to 30 fatal cases of infection with Vibrio vulnificus during 1981-1992 among persons with preexisting liver disease (6). V. vulnificus is a ubiquitous organism found in seawater. In Florida, consumer information statements (required as labels on bags of oysters and in restaurants) emphasize the risk for Vibrio infection among persons with underlying liver disease and other preexisting illnesses (6). In addition, these statements suggest that such persons eat oysters fully cooked and consult with their physician if uncertain about whether they are at risk. States conduct monitoring programs to assure clean oyster beds, legal harvesting, and proper handling of oysters. However, at both the Louisiana and Florida oyster harvest sites, routine fecal coliform water-quality monitoring conducted once each month did not detect oyster-bed contamination. Furthermore, the outbreak reported in Florida was identified in part because of publicity about the larger outbreaks associated with oysters harvested in Louisiana. These findings suggest that monitoring waters for fecal coliforms may be insufficient to indicate the presence of viruses (e.g., Norwalk-like virus). Continued surveillance for outbreaks of gastroenteritis associated with consumption of raw oysters is needed to assess efficacy of the NSSP in preventing human illness. Public health officials should consider raw oyster consumption as a possible source of infection during the evaluation of gastroenteritis outbreaks. References 1. Monroe SS, Stine SE, Jiang XI, Estes MK, Glass RI. Detection of antibody to recombinant Norwalk virus antigen in specimens from outbreaks of gastroenteritis. J Clin Microbiol 1993; 31:2866-72. 2. Moe CL, Gentsch J, Ando T, et al. Application of PCR to detect Norwalk virus in fecal specimens from outbreaks of gastroenteritis. J Clin Microbiol 1994;32:642-8. 3. Ando T, Mulders MN, Lewis DC, Estes MK, Monroe SS, Glass RI. Comparison of the polymerase region of small round structured virus strains previously classified in three antigenic types by solid-phase immune electron microscopy. Arch Virol 1994;135:217-26. 4. CDC. Multistate outbreak of viral gastroenteritis related to consumption of oysters--Louisiana, Maryland, Mississippi, and North Carolina, 1993. MMWR 1993;42:945-8. 5. Office of Seafood, Shellfish Sanitation Branch, Food and Drug Administration. Sanitation of shellfish growing areas, part 1. [Section C.3.c]. In: National Shellfish Sanitation Program manual of operations. Washington, DC: US Department of Health and Human Services, Public Health Service, 1992:C8-C9. 6. Hlady WG, Mullen RC, Hopkins RS. Vibrio vulnificus from raw oysters: leading cause of reported deaths from foodborne illness in Florida. J Fla ------------------------------ Date: Thu, 30 Jun 94 21:32:04 MST From: mednews (HICNet Medical News) To: hicnews Subject: Oral Pathology Course Message-ID: <64oRoc4w165w@stat.com> ORAL PATHOLOGY will be presented 9-13 January 1995 at Disney's Contemporary Resort, Lake Buena Vista, FL, USA. SPONSORS: Armed Forces Institute of Pathology and the American Registry of Pathology, The formal continuing medical education program of the AFIP is accepted by the Academy of General Dentistry for Fellowship, Mastership, and membership maintence credit. GENERAL INFO: AFIP Education Dept.,NW, Washington, DC 20306-6000 USA; 301/427-5231; FAX 301/427-5001; INTERNET: LOWTHER@email.afip.osd.mil (Brochure is available upon request) CONTENT: This course is designed to provide dentists and all dental specialists, including trainees in oral pathology with a fundamental knowledge of various aspects of oral diseases. General pathologists, general residents, and other physicians with an interest in diseases of the head and neck area would also find the course beneficial in brining them up to date on recent developments in this field. Developmental disturbances of the head, neck, and oral regions, inflammatory diseases of the oral mucosa and jaws, oral manifestations of certain systemic diseases, and neoplasms of the oral cavity and related structures will be discussed in detail. Information detailing the oral manifestations of HIV infection and AIDS will be included. The primary emphasis of the course will be on clinical and radiographic characteristics of disease. Treatment aspects and a brief discussion of the histopathologic features of each disease will be provided. Lectures and case presentations will be complemented by clinical problem-solving exercises and elective microscopic slide laboratories. The course will be presented by oral pathologists from the staff of the AFIP and other civilian and military institutions. The focus will be primarily on the clinical and radiographic aspects of oral disease. Anticipated learning outcomes include enhancing skills in developing a meaningful clinical differential diagnosis and establishing effective communication between clinician and pathologists. The course will provide the dentist and physician with the understanding of the diseases affecting the oral and paraoral regions that facilitate the early detection, diagnosis, and proper treatment of such disorders. (27 hours with labs/ 22.75 w/o labs, CAT 1, AMA) (Brochure is available upon request) COURSE DIRECTOR: Robert B. Brannon, Col, USAF, DC TUITION: Early-Bird tuition is $475. After 11 November 1994 it is $495. Active duty military, DoD civilians, full-time permanant Department of Veterans Affairs employees (not residents or fellows), and commissioned officers of the Public Health Service with authorized approval have a registration fee of $175. After 11 November this fee will be $195. ------------------------------ Date: Thu, 30 Jun 94 21:32:47 MST From: mednews (HICNet Medical News) To: hicnews Subject: Parkinson's Disease Conference Message-ID: PARKINSON'S DISEASE CONFERENCE Communication in Europe: A multi-professional approach to management and care. Organized by the European Parkinson's Disease Association (EPDA), 21-23 September 1994, The Hospitality Inn, Glasgow, Scotland. The aim of the conference is: To enhance the quality of life of people in Europe with Parkinson's disease and their familie by encouraging good communication, mutual awareness and respect, and a sharing of knowledge and experience amongst a wide range of professionals involved in management and care. Objectives of the conference: Conference participants will: * exchange knowledge and understanding of the care of Parkinson's disease with members of their own profession and members of the multi-professional team * develop knowledge and awareness of the medical, social and personal needs of people living with Parkinson's disease * consider ways of overcoming the barriers to good communication with patients, their families and between professionals * develop strategies for multi-professional care in the management of Parkinson's disease from the time of diagnosis * to share models of good practice throughout Europe. Scientific Programme Committee: * Professor Yves Agid * Dr. Alfredo Berardelli * Dr. Paul Delwaide * Dr. Erik Dupont * Professor J.P.W.F. Lakke * Dr. Jan Peter Larsen * Professor Dr. Werner Poewe * Dr. Jan Presthus * Professor U.K. Rinne * Professor Dr. R.A.C. Roos * Professor Goran Steg * Professor Eduardo Tolosa * Dr. Steinar Vilming. CALL FOR PAPERS: Delegates are invited to submit abstracts for poster presentation. Anyone interested in presenting a poster should send in an abstract of not more than 250 words to the: Conference Administrator, Macmillan Magazines Ltd., 4 Little Essex Street, London, WC2R 3LF, U.K. Conferences Department Tel: 071-836 6633 Ext: 2593 Fax: 071-379 5417 Closing date for receipt of abstracts is June 30th, 1994. The conference is supported by a wide-range of professional organisations: * the World Health Organization * Commission of European Communities - Helios II Programme * the British Geriatrics Society * Association of British Neurologists * the Royal College of Nursing * the Chartered Society of Physiotherapy * the College of Occupational Therapists * the College of Speech and Language Therapists * Care of the Eldery * Nursing Times * Community Outlook * Therapy Weekly * the Parkinson's Disease Society of the UK. ========================================================================= At the beginning of August 1994 I will forward the final programme of the conference. Regards, Gerard van Rossum Gerard.G.J.vanRossum@MTA6.KEMA.NL ========================================================================== ------------------------------ Date: Thu, 30 Jun 94 21:33:43 MST From: mednews (HICNet Medical News) To: hicnews Subject: Obstructive Sleep Apnea Syndrome Message-ID: Obstructive Sleep Apnea Syndrome St Joseph's Medical Letter, Vol 2, Issue 1, 1994 Reproduced with Permission Most clinicians have cared for patients with complaints of "lack of energy" and fatigue-symptoms which frequently may be more precisely defined as "sleepiness" after further questioning. With more than 1/3 of the population suffering from moderate or severe insomnia, and other sleep disorders being as common a disorder as diabetes, a-sleep-disorders evaluation is often in order. Sleep-related abnormalities of respiration have been recognized since at least the mid 1800's, but standardized definitions of these nocturnal respiratory events awaited more systematic study in the last 30 years: Apnea is defined as cessation of airflow at the nose and mouth lasting at least 10 seconds. Hypopnea is a reduction in airflow without complete cessation of breathing, resulting in oxyhemoglobin desaturation or arousal. Patients may experience either one of these events through two distinct mechanisms: central, in which respiratory effort declines, and obstructive, in which respiratory effort is maintained while the upper airway narrows or occludes entirely. Furthermore, a distinction has emerged between asymptolllatic sleep disordered breathing-now called simply sleep apnea, and symptomatic sleep-disordered breathing, now termed sleep apnea syndrome. It is now recognized that obstructive sleep apnea syndrome (OSAS) is a relatively common disorder, while the central variety occurs rarely. A much-publicized recent study found an unexpectedly high prevalence of sleep disordered breathing in a random sample of 602 working adults. A respiratory disturbance index (RDI=the number of apneas+hypopneas per hour of sleep) greater than 5 is considered abnormal, and 9% of the women and 24% of the men had this finding. Frank sleep apnea syndrome was present in 2% of the women and 4% of the men, a prevalence similar to that of diabetes mellitus. Obstruction in OSAS occurs in the region of the oropharynx and hypopharynx. Fiberoptic airway examination during apneic events reveals that the tongue prolapses backward while the posterior and lateral pharyngeal walls collapse inward, obstructing inspiratory airflow. The underlying pathogenesis of these alterations in airway caliber has remained elusive. Although many patients exhibit a reduction in upper airway caliber while awake (eg, from obesity), many subjects with similar degrees of daytime airway narrowing do not exhibit sleep disordered breathing. Electromyographic studies of the upper airway muscles demonstrate that a reduction in the tone of these muscles also occurs during the apneas. Thus, OSAS results from both an anatomic lesion and a poorly understood abnormality of the control of upper airway muscle tone. When the patient suffers nocturnal airway obstruction and consequent asphyxia, arousal from sleep occurs which terminates each obstructive event. The patient then falls back to sleep, only to repeat the cycle frequently throughout the night. The repeated interruptions of sleep lead to sleep deprivation and complaints of daytime sleepiness. Most patients do not recollect these arousals because Off their very brief nature, although occasionally a patient will complain of insomnia or frequent nocturnal awakenings. The increase in upper airway resistance coupled with deep, resuscitative breaths in between apneas results in loud snoring, which is characteristically intermittent. Morning headaches or nausea may occur, related to recurrent nocturnal hypercapnia and cerebral vasodilatation. Cognitive impairment has been recognized, and correlates best with the degree of nocturnal oxyhemoglobin desaturation during the obstructive events'. No physical findings are pathognomonic of OSAS. Obesity is common, and collections of adipose tissue surrounding the upper airway are thought to contribute to the pathogenesis of the disease. Obesity, however, only doubles the odds ratio for deep disordered breathing, and cannot be used to predict the presence of the disorder Frank anatomic abnormalities of the upper airway are not common (eg, macroglossia micrognathia) except in the pediatric age group, where adenotonsillar hypertrophy is a frequent finding. The "gold-standard" for diagnosing OS AS consists polysomnographic which continuous]y Records multiple physiologic parameters during deep Airflow, respiratory effort, and pulse oximetry signals are used to detect respiratory events, and an ECC is recorded in case respiratory events are accompanied by arrhythmias. The most common indications for polysomnography include excessive daytime sleepiness; loud, intermittent ("resuscitative') snoring; or apneas witnessed by a bed partner Testing is also indicated for patients with unexplained corpulmonale or polycythemia Because the recordings of "home screening" devices are often poor, there usualness remains questionable Treatment for OSAS is generally recommended for patients who are symptomatic or who have an RDI>20 An apnea index>20 has been associated with increased mortality, and hypopneas which result in oxyhemoglobin desaturation or arousal are thought to be equally as important as apneas The mainstay of treatment currently is nasal continuous positive airway pressure (C-PAP), administered using a nasal mask or prongs ("pillows") which lit within and seal the nares Nasal CPAP pressurizes the upper and acts as a pneumatic "splint", preventing oropharyngeal and hypopharyngeal collapse. Nasal C-PAP is capable of suprressing obstructive apneas and hypopneas in virtually every patient, although long-term complainance with the therapy has been a signifcant problems. A variety of surgical treatments have also been advocated. Uvulopalatopharyngoplasty (excision of the uvula and resection of reduntant orophyaryngeal tissue) will usually eliminate snoring, but lowers in OSAS the RDI to < 20 in only about 50% of patients. Laser tongue reduction (midline glossectomy) is not as well studied and carries the danger of damage to ncurovascular structures. Excellent results have ken obtained by some workers using maxillary and mandibular advancement by ostotomy'. Several adjunctive measures can also be of benefit. Weights loss of surprisingly small degree can result in significant improvement Patients who have positional apneas (when supine) can be treated with mechanical devices (i.e., tennis balls) sewn into the backs of their pajama tops that make sleeping in the supine position uncomfortable. Oral prostheses may have some utility in mild disease but are more useful in benign snoring. The anti-depressants protriptyline and fluxetine have shown to increase upper airway muscle tone and reduce the amount of time spent in REM (dreaming) sleep, when the most severe apneas characteristically occur. There agents may be useful in mild disease. When any treatment is employed, repeat polysomnography should in general be used to demonstate efficacy. Considering the high prevalence and potential health risks of OSAS, symptoms of sleep-disorder breathing deserve careful attention and a full patient evaluation. Most often, patients benefits from an overnight study at a sleep disorders center to define the breathing disorder and determine the most effective form of therapy. WHen chronic "fatique" is really "sleepiness", it's time to consider a sleep center referral. ------------------------------ Date: Thu, 30 Jun 94 21:36:22 MST From: mednews (HICNet Medical News) To: hicnews Subject: Cardiology: Today and Tommorrow - Conference Message-ID: Cardiology: Today and Tomorrow Mayo Educational Satellite Teleconferences Course Director: Bijoy K. Khandheria, M.D. Presented by: Division of Cardiovascular Diseases, Mayo Clinic Continuing Medical Education, Mayo Clinic Video Communications, Mayo Clinic #012#Discover a new way of learning Offer your staff solid cardiovascular instruction from one of the world's leading heart centers through the video conference, Cardiology: Today and Tomorrow. Mayo's premiere video education conference is based upon 70 years of experience conducting continuing medical education for physicians. Study with Mayo's experts Taught by Mayo cardiologists and cardiovascular surgeons, Cardiology: Today and Tomorrow covers relevant, timely topics and gives your staff clinical "pearls" for managing their practice and improving the care they give to patients. Provide cost-effective education Becoming a video conference host gives you a cost-effective way to offer education at your site to staff and other community physicians. For $200 per program, participants will receive up-to-date cardiovascular information and participate in an interactive question-and-answer session while earning continuing medical education credits. Review and discuss clinically relevant topics Cardiology: Today and Tomorrow is designed to benefit cardiologists, internists, family practitioners, nurse practitioners and physician's assistants from both urban and rural settings throughout the United States and Canada. Each four-hour program contains a series of four didactic lectures presented by Mayo physicians and will provide ample time for "live" questions and answers. The series will be broadcast quarterly beginning the first quarter of 1995. Mayo Foundation is accredited by the ACCME to sponsor Continuing Medical Education for physicians. Mayo Foundation designates this Continuing Medical Education activity (each session) for 4 hours of Category 1 of the Physicians Recognition Award of the American Medical Association. Mayo Foundation adheres to all ACCME standards regarding industry support of Continuing Medical Education. 1995-96 video conference topics o Coronary artery disease: state-of the-art Medical therapy, catheter interventions, and bypass surgery in the modern management of coronary artery disease. o Women and heart disease Information for practicing physicians on management of women with heart disease. #012#o Atrial fibrillation: management strategies for 1995 Newer drugs; role of transesophageal echocardiography, ablation and maze procedure. o Vascular medicine and hyperlipidemia for the practitioner A concise, practical overview of how to manage commonly encountered problems in vascular medicine and hyperlipidemia. o Current review of cardiac arrhythmias, pacemakers and implantable defibrillators o Newer concepts and treatment of congestive heart failure and cardiomyopathies o Update on cardiac imaging: MRI, Echo, Nuclear, Cine CT o Valvular heart disease: new quantitative techniques and management strategies Register your site for Cardiology: Today and Tomorrow Please complete the attached postage-paid card to register your hospital or clinic for this exciting educational experience. You will receive a confirmation letter and additional details about the program in the coming months. This Mayo CME course is supported in part by unrestricted educational grants from the following firms: Major contributors: Acuson, Advanced Technology Laboratories, Hewlett-Packard, Mallinckrodt Medical Inc., Marion Merrell Dow, Merck Sharp & Dohme, and Pfizer. Contributors: Bristol Myers Squibb, DuPont Pharmaceuticals, Intermedics Inc., Interspec Inc., Key Pharmaceuticals (Schering Sales Corporation), SCIMED Life Systems, Searle, and Wyeth-Robins. (Postcard information) Cardiology: Today and Tomorrow If you wish to register your hospital or clinic as a host site, please complete and return this postage-paid card. Name Hospital/Clinic Address City State Zip Code Phone number FAX number #012#Please indicate the type of video receiving facilities your clinic/hospital has. KU band Fixed dish C band Steerable dish KU and C band Please check the day and time you prefer for this conference. Monday Morning Tuesday Afternoon Wednesday Thursday Friday Saturday Sunday Who: Mayo cardiologists and cardiovascular surgeons What: Offer premiere educational video conference Cardiology: Today and Tomorrow Where: At your hospital or clinic When: Beginning the first quarter of 1995 Cost: $200 per session (no limit on number of attendees) ------------------------------ Date: Thu, 30 Jun 94 21:37:34 MST From: mednews (HICNet Medical News) To: hicnews Subject: New Vaccine May Prevent Tooth Loss Message-ID: New Vaccine May Prevent Tooth Loss by Kathleen Canavan NIDR Research Digest, April 1994 Researchers at the National Center for Research Resources (NCRR) Washington Regional Primate Research Center in Seattle recently found that immunization significantly slows the progression of periodontal disease in monkeys. This offers hope for a human vaccine that could help thousands of Americans plagued by tooth loss caused by periodontal bone and tissue damage. The study-headed by Dr. Roy C. Page, director of the Research Center in Oral Biology at the University of Washington School of Dentistry, and funded by the National Institute of Dental Research-is the first to show vaccination as a possible treatment for periodontitis, an infectious disease that destroys tooth-supporting tissue and bone. The University of Washington researchers, in collaboration with investigators at the University of Texas in San Antonio and the Bristol Myers Squibb Pharmaceutical Research Institute in Seattle, developed the vaccine using killed Porphyromonds gingivalis bacteria, a major cause of periodontitis. The Washington scientists used 20 cynomolgus monkeys in the study, inoculating half with the vaccine and half with a placebo. The monkeys were vaccinated again at three-, six-, and sixteen-week intervals. After four months, the researchers wrapped silk thread around each monkey's teeth below the gumline to induce bacterial growth and periodontal disease. Both groups had similar levels of bacterial buildup and gum inflammation, indicating that the vaccine had not cured the monkeys of bacterial infection. However, additional tests and x-rays showed that the control monkeys had lost twice as much tooth-supporting bone as the vaccinated monkeys. 'We know enough already to say that a human periodontitis vaccine seems feasible, but it may be a decade before we see full-fledged clinical trials of such a vaccine' says Dr. Page. In later tests, the scientists applied live P. gingivalis bacteria directly to the gums of three control and three test monkeys. The control monkeys displayed dramatic bone loss after this application, while the test monkeys remained protected from disease. "It appears that immunization may in fact block bacterially induced bone loss," says Dr. Page. 'Over the next five years we're going to study why the vaccine works, how it works, and whether we will be able to produce a vaccine that effectively reduces the level of bacteria in gum tissue." Production of such a vaccine would not only reduce patient suffering, but would also lessen the costs of treating periodontitis. ------------------------------ End of HICNet Medical News Digest V07 Issue #29 *********************************************** --- Editor, HICNet Medical Newsletter Internet: david@stat.com FAX: +1 (602) 451-1165 Bitnet : ATW1H@ASUACAD