HICNet Medical News Digest Wed, 01 Jun 1994 Volume 07 : Issue 23 Today's Topics: [MMWR 27 May 94] Expanded Tuberculosis Surveillance/Morbidity [MMWR] Chlamydia Prevalence and Screening Practices [MMWR] Quality of Life as New Public Health Measure [MMWR] Public Health Leadership Institute Basic Forensic Pathology Course Offered Armed Forces Institute of Pathology Short Postgraduate Courses Study Links Smoking & Increased Risk of Fatal Breast Cancer National Cancer Institute CancerNet Update +------------------------------------------------+ ! ! ! 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 Subscription Requests = mednews@stat.com anonymous ftp = vm1.nodak.edu; directory HICNEWS FAX Delivery = Contact Editor for information ---------------------------------------------------------------------- Date: Wed, 01 Jun 94 21:57:27 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR 27 May 94] Expanded Tuberculosis Surveillance/Morbidity Message-ID: Expanded Tuberculosis Surveillance and Tuberculosis Morbidity -- United States, 1993 Because of the resurgence of tuberculosis (TB) in the United States, in 1987 the Advisory Committee for the Elimination of Tuberculosis recommended the strengthening of TB surveillance to improve monitoring and to assist in targeting groups at risk for disease (1). In addition, because of outbreaks of nosocomial multidrug-resistant TB (MDR-TB) in New York and Florida during 1990-1992 (2), in 1992, the National MDR TB Task Force recommended that drug-susceptibility testing be performed on all initial and final Mycobacterium tuberculosis isolates from each TB patient and that the results be reported to CDC (3). In January 1993, in conjunction with state and local health departments, CDC implemented an expanded surveillance system for TB. This report summarizes final TB surveillance data for 1993, compares findings with previous years, and provides information on expanded surveillance. In November 1992, following approval of the Report of a Verified Case of TB (RVCT) form for reporting TB cases to CDC, TB programs in state and local health departments were asked to use the new surveillance form beginning January 1993. In July 1993, a new computer software package (SURVS-TB) was distributed for data entry, analysis, and transfer of records to CDC. Additional elements of the RVCT included results for human immunodeficiency virus (HIV) testing, occupation, history of substance abuse, homelessness, and residence in a correctional or long-term-care facility. To evaluate the outcomes of antituberculous therapy, information was collected about initial therapy, type of health-care provider, sputum culture conversion, and use of directly observed therapy (DOT). In 1993, 25,313 cases of TB (9.8 cases per 100,000 population) were reported to CDC from the 50 states, the District of Columbia, and New York City (Figure 1), a 5.1% decrease from 1992 (26,673 [10.5 cases per 100,000]) (4) but a 14% increase over 1985 (22,201) (the year with the lowest number of TB cases since national reporting began in 1953). During 1985-1993, there was an excess of approximately 64,000 reported cases, compared with the number predicted based on the trend of decline from 1980 through 1984. During 1993, 33 states reported fewer TB cases than in 1992; in comparison, during 1992, 27 states and the District of Columbia reported fewer cases than in 1991. The states reporting fewer cases in 1993 included those characterized by the greatest increases in cases since 1985 (California, New York, and Texas). Fifteen states and the District of Columbia reported increases in TB cases (Table 1). Compared with 1992, the number of reported TB cases decreased for all age groups except for persons aged less than 15 years. Decreases were greatest for persons aged 15-24 (6.6%) and 25-44 years (7.8%). Among persons aged less than 15 years, the number of cases increased 0.8%; of all cases, the proportion accounted for by persons in this group increased from 6.4% in 1992 to 6.8% in 1993. During 1993, persons born outside the United States and its territories (i.e., foreign-born) composed 29.6% of reported cases, compared with 27.4% in 1992. Selected characteristics were analyzed for cases in states where greater than or equal to 75% of records contained information requested for the first time in 1993 (Table 2). Among these persons, injecting-drug use was reported by 2.4%, noninjecting-drug use by 4.7%, excessive use of alcohol during the preceding 12 months by 13.0%, and homelessness by 5.3%. For patients aged 25-44 years, HIV test results were reported for 33%; 18 reporting areas reported HIV results for greater than or equal to 50% of cases. These 18 reporting areas accounted for 63% of cases in persons aged 25-44 years with HIV results. From January 1, 1993, through May 25, 1994, antibiotic-susceptibility results for M. tuberculosis isolates were reported for 10,941 (54%) of the 20,090 persons with culture-positive TB. For 26 reporting areas, drug-susceptibility results were available for greater than or equal to 75%; however, these areas included only two of the 12 states in which greater than or equal to 1% of cases had isoniazid and rifampin resistance in the previous national survey (5). Reported by: Div of Tuberculosis Elimination, National Center for Prevention Svcs, CDC. Editorial Note: The findings in this report document a substantial decrease in the number of reported TB cases from 1992 to 1993 (5.1%; p less than 0.001*), probably reflecting the effectiveness of prevention and control measures implemented during 1989-1993. However, a portion of this decrease may be due to two other factors, including 1) delayed reporting caused by use of the new TB surveillance reporting form and the change from paper records to a computerized system; and 2) underreporting because of modification of the acquired immunodeficiency syndrome (AIDS) surveillance case definition in January 1993 (6). Following the resurgence of TB in 1985 and the recognition of nosocomial outbreaks of MDR-TB in 1991 (2), the Public Health Service increased funding to state and local health departments for TB-prevention and TB-control activities, including DOT--which has been shown to reduce TB case rates even in the presence of HIV infection -- and screening programs for persons at high risk for TB infection (7-9). In addition, some hospitals implemented recommendations to prevent nosocomial transmission of M. tuberculosis (10). These measures may account for a substantial proportion of the decrease in reported TB cases in 1993. Most states require that laboratories notify the health department about patients with cultures positive for M. tuberculosis; during 1993, 79% of all reported TB cases were culture-positive for M. tuberculosis. In response to the initial report, local health departments conduct investigations to verify the diagnosis of TB and to collect information needed for completion of reporting. The addition of information needed for the new TB surveillance form may have delayed investigation of suspected TB cases and completion of case reports in 1993. Ongoing analysis is assessing the impact of delayed reporting. The expansion of the TB surveillance system during 1993 coincided with the revision of the AIDS surveillance case definition. The revised AIDS case definition classifies as AIDS cases HIV-infection in persons who have either pulmonary TB or extrapulmonary TB (6). As a consequence, HIV-infected persons with pulmonary or extrapulmonary TB may have been reported to the AIDS surveillance program at the local or state health department but not to the TB program. This explanation may account for the apparent decrease in the number of reported TB cases in states characterized by a high incidence of AIDS (California, New York, and Texas) and in persons aged 15-24 and 25-44 years. In the states with the largest TB/AIDS co-morbidity (i.e., California and New York), laws to protect the confidentiality of persons with AIDS have been interpreted to prohibit the disclosure of patients' names to anyone outside the AIDS program, including other programs within the state health department. Information on the HIV status of persons with TB in 1993 is incomplete (missing/unknown for 67% of TB patients in the 25-44-year age group); thus, the impact of HIV on the TB epidemic in the United States can only be indirectly measured in 1993. Collaboration between TB and HIV/AIDS surveillance programs will be necessary to accurately measure the extent of overlap between the TB and HIV epidemics. Maintaining the current decline in TB morbidity and reaching the goal of eliminating TB in the United States will require sustaining prevention and control activities. In particular, health-care providers should attempt to identify all TB cases and report them to health departments and ensure that persons with active TB successfully complete treatment (e.g., DOT). In addition, TB skin-test screening programs that target persons at highest risk (e.g., contacts of persons with active cases) can ensure appropriate use of preventive therapy. References 1. CDC. A strategic plan for the elimination of tuberculosis in the United States. MMWR 1989;38(no. S-3). 2. CDC. Nosocomial transmission of multidrug-resistant tuberculosis among HIV-infected persons--Florida and New York, 1988-1991. MMWR 1991;40:585-91. 3. CDC. National action plan to combat multidrug-resistant tuberculosis. MMWR 1992;41 (no. RR-11):1-48. 4. CDC. Tuberculosis morbidity--United States, 1992. MMWR 1993;42:696- 7,703-4. 5. Bloch AB, Cauthen GM, Onorato IM, et al. Nationwide survey of drug-resistant tuberculosis in the United States. JAMA 1994;271:665-71. 6. CDC. 1993 Revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. MMWR 1992;41(no. RR-17). 7. Weis SE, Slocum PC, Blais FX, et al. The effect of directly observed therapy on the rates of drug resistance and relapse in tuberculosis. N Engl J Med 1994;330:1179-84. 8. Chaulk CP, Chaisson RE, Lewis JN, Rizzo RT. Treating multidrug-resistant tuberculosis: compliance and side effects [Letter]. JAMA 1994;271:103-4. 9. CDC. Tuberculosis prevention in drug-treatment centers and correctional facilities--selected U.S. sites, 1990-1991. MMWR 1993;42:210-3. 10. Fridkin SK, Manangan LP, Mayhall CG, et al. A survey of the use and efficacy of tuberculosis infection precautions. Proceedings of the Fourth Annual Meeting of the Society for Hospital Epidemiology of America. West Deptford, New Jersey: Society for Hospital Epidemiology of America, March 1994. * Statistical significance assessed by Chi Square test for dispersion; statistical tests for differences in surveillance data must be interpreted in relation to epidemiologic and programmatic considerations. ------------------------------ Date: Wed, 01 Jun 94 21:58:16 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR] Chlamydia Prevalence and Screening Practices Message-ID: Chlamydia Prevalence and Screening Practices -- San Diego County, California, 1993 Chlamydia trachomatis is the most common bacterial sexually transmitted disease in the United States and causes an estimated 4 million infections annually (1). Approximately 70% of infected women have few or no symptoms (2), and asymptomatic infection in women can persist for up to 15 months (3). Infection can progress to involve the upper reproductive tract and may result in serious complications. To identify women who may have chlamydial infections, CDC has recommended routine testing based on age, risk behavior, and clinical findings--especially in clinics and group practices that provide reproductive health care to adolescent and young women (4). This report describes the prevalence of chlamydial infections among patients visiting the family-planning clinic service of the San Diego County Department of Health Services from July 1989 through June 1993 and summarizes the findings of a survey in May 1993 that assessed chlamydia screening, reporting, and treatment practices for women who attended primary-care community-based clinics and group practices in San Diego County. Prevalence of Chlamydial Infections The San Diego County Department of Health Services provides family-planning services in San Diego County in six public health centers. Each clinic follows a written protocol that requires screening of all clients during their initial visit and recommends screening for clients during annual visits--particularly for those whose sexual behavior increases their risk for infection. From March 1989 through February 1991, endocervical specimens were tested at the San Diego County Public Health Laboratory using the Chlamydia Antigen ELISA (Ortho Diagnostic Systems, Inc.*, Raritan, New Jersey); beginning March 1991, specimens were tested using the MicroTrak EIA (Syva, San Jose, California). The proportion of women screened was determined using data from annual family-planning clinic-service utilization reports. Test results and demographic and limited clinical information were obtained from the laboratory's chlamydia-test database. During July 1989-June 1993, approximately 95% of family-planning clients were tested for Chlamydia during their initial visit, and 70% were tested during their annual visit. Of 11,044 specimens tested, 91% were obtained during routine testing of clients without symptoms. The prevalence of chlamydial infections decreased from 10.0% during July-December 1989 to 1.9% during January-June 1993, a decline of 81.0%. During July 1989-June 1993, the prevalence of chlamydia among black women was 8.5%, more than 1.5 times that among Hispanic (5.3%) and white (4.5%) women. During the 4-year period, the prevalence declined minimally among black women and steadily among white and Hispanic women (Figure 1). Prevalence was inversely related to age, with the highest prevalence among women aged less than 20 years (8.4%); among women aged less than 20 years, the prevalence decreased from 9.9% during July 1989-December 1990 to 4.8% during January 1992-June 1993, a 51.5% decline. Chlamydia-Screening Practices Survey The survey of chlamydia screening and related practices was mailed in May 1993 to all 171 primary-care clinics and group practices in San Diego County that provided women's health services. The survey requested information about chlamydia screening, reporting, diagnosis and treatment practices, types of clinical services, and other chlamydia-related issues. Chlamydia-screening practices were classified as clinician-directed screening (i.e., when testing was based on the clinician's assessment of signs, symptoms, or risk behavior) or as protocol screening (i.e., when clinics followed a policy to test all women of reproductive age or all those aged less than 20 years at their initial or annual visit). Surveys were returned by 85 (50%) of the providers. All providers reported conducting clinician-directed screening; 45 (53%) followed protocol screening in at least one clinical service. Public providers were more likely than private providers to follow protocol screening (60% versus 37%). Protocol screening was used commonly in prenatal services (79%), compared with initial visits for adolescent services (39%), initial visits for family-planning services (33%), and gynecologic services (20%) (Table 1). Among providers following protocol screening, written screening policies had been established most commonly in prenatal services (75%), followed by family-planning (58%) and gynecologic (46%) services. Almost all (greater than or equal to 92%) providers reported testing and immediately treating (i.e., on the same day as their visit and before test results were known) clients who had chlamydia-related syndromes (e.g., pelvic inflammatory disease [PID] or mucopurulent cervicitis) or who had reported a sexual exposure to a Chlamydia-infected person. In California, both PID and chlamydial infections are notifiable conditions; however, only 34 (54%) of the 63 providers who responded to this question routinely reported PID cases, and 55 (75%) of 73 responding providers reported positive chlamydia test results. Reporting practices were similar for private and public providers. DNA probe testing was the most frequently used chlamydia test (47 [58%] of 81). Almost all (74 [97%] of 76) providers who responded reported referring male sex partners for examination and treatment. The most common approaches were on-site examination with presumptive treatment (57%) and health department referral (35%). However, only 14 (18%) of 80 providers reported having a method of following up sex partners' treatment for chlamydia. Reported by: M Mendes, MPH, C Spitters, MD, S Waterman, MD, C Peter, PhD, R Ross, MD, San Diego County Dept of Health Svcs, San Diego; J Felten, MPA, Sexually Transmitted Diseases Br, GW Rutherford, III, MD, State Epidemiologist, California Dept of Health Svcs. Surveillance and Information Systems Br, Div of Sexually Transmitted Diseases and HIV Prevention, National Center for Prevention Svcs; Div of Field Epidemiology, Epidemiology Program Office, CDC. Editorial Note: The decline in the prevalence of chlamydial infections among women receiving family-planning clinic services in San Diego County during 1989-1993 was consistent with patterns in other areas. For example, findings from a screening demonstration project in Public Health Service Region X (Alaska, Idaho, Oregon, and Washington) indicated that, among the approximately 70,000 women screened annually in public and private family-planning clinics, the prevalence declined from 9.3% in 1988 to 4.2% in 1993 (5). The prevalence also decreased among women attending family-planning clinics in Wisconsin, where a statewide selective screening program has been operated since 1986 (6). Although the low response rate in San Diego County precludes generalization, the results of the screening practices survey suggest that the use of protocol screening was limited. A policy implemented in California in August 1993 by the California Office of Family Planning now requires chlamydia screening for all women undergoing initial examinations and for women at increased risk undergoing annual and limited examinations who seek services at clinics funded by the California Office of Family Planning. To assist health-care providers in developing protocols and policies, CDC has recommended chlamydia screening for 1) all women with mucopurulent cervicitis; 2) all sexually active women aged less than 20 years; and 3) women aged 20-24 years who meet either of two criteria or women aged greater than 24 years who meet both criteria--a) inconsistent use of barrier contraception or b) a new sex partner or more than one sex partner during the previous 3 months (4). The Preventive Health Amendments of 1992 authorized CDC to develop a national program to prevent infertility resulting from treatable sexually transmitted diseases in women. Findings from San Diego County, Region X, and Wisconsin also suggest that efforts to prevent chlamydia-associated infertility through the delivery of early detection and treatment services- -particularly for women with asymptomatic infections--may have been effective in reducing the prevalence of chlamydial infections. A new program to prevent infertility will expand services to approximately 800,000 women in the four Public Health Service regions in which chlamydia-prevention projects have been established (Regions III, VII, VIII, and X) and will evaluate critical issues in operational research. Ongoing analysis of surveillance data and other information characterizing chlamydial infection can assist clinical programs in modifying screening practices to ensure effectiveness. In San Diego County, the prevalence of chlamydial infection was higher among black women than women in other racial/ethnic groups; however, information was not obtained about the social and economic status of patients. Therefore, in San Diego County, race should be considered a risk marker rather than a screening criterion for chlamydial infection. Health-care facilities that provide family-planning, adolescent health, and routine gynecologic services to adolescent and young adult women should consider the use of screening protocols for all clients at risk for chlamydial infections. Important components of chlamydia-control programs include treatment and risk-reduction counseling of sex partners of infected persons. In San Diego County, only 18% of providers reported having a method to ensure treatment of sex partners; this finding underscores the need for facilities that provide health care for women to offer examination and treatment services or arrange for appropriate referral for their clients' male sex partners, and establish procedures for follow-up of the status of referrals. Public health agencies may assist health-care providers in developing such referral and follow-up procedures. References 1. Washington A, Johnson RE, Sanders L Jr. Chlamydia trachomatis infections in the United States: what are they costing us? JAMA 1987;257:2070-2. 2. Cates W, Wasserheit JN. Genital chlamydial infections: epidemiology and reproductive sequelae. Am J Obstet Gynecol 1991;164:1771-81. 3. Lycke E, Lowhagen GB, Hallhagen G, Johannison G, Ramstedt K. The risk of transmission of genital Chlamydia trachomatis infection is less than that of Neisseria gonorrhoeae infection. Sex Transm Dis 1980;7:8-10. 4. CDC. Recommendations for the prevention and management of Chlamydia trachomatis infections, 1993. MMWR 1993;42(no. RR-12):7-8. 5. DeLisle S, Fine D, Kaetz S, et al. A multi-state model for the prevention and control of sexually transmitted chlamydia infections [Abstract]. Sex Transm Dis 1994;21(suppl):S149. 6. Addiss DG, Vaughn ML, Ludka D, Pfister J, Davis JP. Decreased prevalence of Chlamydia trachomatis infection associated with a selective screening program in family-planning clinics in Wisconsin. Sex Transm Dis 1993;20:28- 35. * Use of trade names and commercial sources is for identification only and does not imply endorsement by the Public Health Service or the U.S. Department of Health and Human Services. ------------------------------ Date: Wed, 01 Jun 94 21:59:06 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR] Quality of Life as New Public Health Measure Message-ID: <8110mc3w165w@stat.com> Quality of Life as a New Public Health Measure -- Behavioral Risk Factor Surveillance System, 1993 A fundamental goal of the year 2000 national health objectives is to increase the span of healthy life for all persons in the United States (1). Public health programs, improved social conditions, and private medical care have contributed to the prolongation of life expectancy of U.S. residents at birth from 47 years in 1900 to 75 years in 1989. However, for some persons, increased life expectancy includes periods of diminished health and function (i.e., lowered health-related quality of life [HR-QOL]). Because population-based surveillance of good health has been limited, questions to assess HR-QOL were added to the 1993 Behavioral Risk Factor Surveillance System (BRFSS). This report summarizes the preliminary findings about HR-QOL from the 1993 BRFSS and describes an index used to identify population subgroups with high and low HR-QOL. The BRFSS is a continuous, state-based, random-digit-dialed telephone survey of the U.S. adult noninstitutionalized population. Data were analyzed from 44,978 persons aged greater than or equal to 18 years who resided in states in which 1993 data were available for analysis in early March 1994 (i.e., 21 of 49 participating states and the District of Columbia*). Although data were included for states from each region of the United States, southern border and Gulf states were underrepresented. HR-QOL data were based on participants' responses to four questions: respondents were asked 1) "Would you say that in general your health is excellent, very good, good, fair, or poor?"; 2) "Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?"; 3) "Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?"; and 4) "During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?" Response rates for these questions ranged from 98.3% to 99.8%. The questions assessed self-rated health (a previously validated item [2]), recent activity limitation, recent physical health, and recent mental health. The latter two items also were used to calculate a "good health days" (GHDs) index** to estimate the number of days during the 30 days preceding the survey that respondents' overall health was good. GHDs are obtained by subtracting the sum of "not good" physical health days and "not good" mental health days from 30 days, with the restriction that the number of GHDs cannot be less than zero. Overall, in the 21 states, substantial limitations were reported in 1993 for each of the four measures of HR-QOL. Fifteen percent of respondents reported "fair" or "poor" health; 32%, recent physical health limitations; 31%, recent mental health limitations; and 19%, recent activity limitations (Table 1). Of the characteristics studied, the mean number of GHDs during the 30 days preceding the survey was highest for persons with annual household incomes of more than $50,000 (26.4 days), college graduates (26.2), and Asians/Pacific Islanders (26.2) (Table 2). The mean number of GHDs was lowest for persons who were aged greater than or equal to 75 years (23.0), who smoked 20 or more cigarettes per day (22.9), who were told by a health professional more than once they have high blood pressure (22.1), who were unemployed (22.0), who were separated from their spouses (22.0), who had less than a high school education (21.9), who had annual household incomes of less than $10,000 (21.1), who were told by a physician they have diabetes (19.9), and who were unable to work (10.7). Mean numbers of GHDs varied substantially when respondents were grouped by annual household income, education, age group, and sex (Table 3). The mean number of GHDs was lowest (17.5 days) for men aged 35-49 years who had annual household incomes of less than $10,000 and a high school education or less (n=167). Each of the five groups with the lowest mean number of GHDs (less than 20 days) comprised persons aged 35-64 years who had an annual household income of less than $10,000 (combined n=362 men, 1140 women). The mean number of GHDs was highest (27.9 days) for men aged 50-64 years who had annual household incomes of more than $50,000 and at least some college education (n=646). Each of the five groups with the highest mean number of GHDs (27 or more days) comprised men aged greater than or equal to 35 years who had annual household incomes of more than $50,000 (combined n=2842). Reported by the following BRFSS coordinators: P Owen, Alaska; J Senner, PhD, Arkansas; M Leff, MSPH, Colorado; F Breukelman, PhD, Delaware; C Mitchell, District of Columbia; E Pledger, MPA, Georgia; G Louis, MPA, Idaho; B Steiner, MS, Illinois; K Bramblett, Kentucky; R Lederman, MPH, Massachusetts; N Salem, Minnesota; P Smith, Montana; S Huffman, Nebraska; N Hann, MPH, Oklahoma; C Becker, MPH, Pennsylvania; M Lane, MPH, South Carolina; D Ridings, Tennessee; R Giles, Utah; P Brozicevic, Vermont; R Schaeffer, MSEd, Virginia; T Jennings, MPA, Washington; F King, West Virginia. Aging Studies Br, Div of Chronic Disease Control and Community Intervention, Behavioral Surveillance Br, Office of Surveillance and Analysis, National Center for Chronic Disease Prevention and Health Promotion, CDC. Editorial Note: The need to address and characterize HR-QOL has been reflected by the national year 2000 objectives and the National Institutes of Health (3). Health analysts have addressed key aspects of a definition of HR-QOL (which includes functional status and individual health perceptions) and approaches for distinguishing HR-QOL from overall quality of life (which includes HR-QOL and satisfaction with one's life and circumstances) (3-5). Because individual health perceptions reliably predict loss of function, morbidity, and mortality (2,6,7), health agencies are developing valid measures of such perceptions for use in surveys (8,9). Comprehensive, yet brief, measures, such as those described in this report, may be feasible for use in local surveys (10). The BRFSS findings suggest that a GHDs index can identify differences in reported good health among population subgroups and in relation to other key factors (e.g., annual household income and education). For some groups, the calculation of fewer GHDs primarily was attributable to recent physical health limitations (e.g., among persons with diabetes), to recent mental health limitations (e.g., among cigarette smokers), or to both recent physical and mental health limitations (e.g., among persons unable to work) (Table 2). Refinement of this index in relation to other variables, including location and season, may further differentiate subgroups. The findings in this report are subject to at least five limitations. First, the data were not weighted to reflect the complex survey design of the BRFSS. Second, less than half the states participating in the BRFSS were included in this analysis, and some geographic regions were underrepresented. Third, the GHDs group means were not adjusted for all potential confounders (e.g., annual income adjusted for household size) (Tables 2 and 3). Fourth, differences by racial/ethnic groups may reflect cultural differences in how these measures are perceived (e.g., some groups may stoically deny health problems or be reluctant to report problems to strangers [2]). Finally, respondents were persons capable and willing to participate in the household telephone survey; therefore, some groups with lower levels of HR-QOL most likely were excluded. Future analyses of the weighted 1993 BRFSS data from all 49 participating states will 1) refine and validate the GHDs index, 2) examine geographic and seasonal patterns of HR-QOL, and 3) assess the relation of these HR-QOL data to behavioral risk factors and to other HR-QOL data (e.g., National Health Interview Survey and other BRFSS data used to track "years of healthy life" for the year 2000 national health objectives). States can use their BRFSS data to identify population subgroups reporting low levels of HR-QOL that may require additional health services and to monitor temporal or secular changes in HR-QOL that may be associated with major social and health events (e.g., implementation of health-care reform). References 1. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives--full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212. 2. Schechter S, ed. Proceedings of the 1993 NCHS Cognitive Aspects of Self-Reported Health Status Conference. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, National Center for Health Statistics, 1994 (in press). (NCHS working paper; series no. 10). 3. National Institutes of Health. Quality of life assessment: practice, problems, and promise--proceedings of a workshop. Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, National Institutes of Health, 1993. 4. Patrick DL, Bergner M. Measurement of health status in the 1990s. Annu Rev Public Health 1990;11:165-83. 5. CDC. Workshop on quality of life/health status surveillance for states and communities: meeting report. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, National Center for Chronic Disease Prevention and Health Promotion, 1993. 6. Idler EE, Angel RJ. Self-rated health and mortality in the NHANES-I epidemiologic follow-up study. Am J Public Health 1990;80:446-52. 7. Segovia J, Bartlett RF, Edwards AC. The association between self-assessed health status and individual health practices. Can J Public Health 1989;80:32-7. 8. CDC. Consultation on functional status surveillance for states and communities: meeting report. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, National Center for Chronic Disease Prevention and Health Promotion, 1993. 9. Hennessy CH, Moriarty DG, Zack MM, Scherr PA, Brackbill R. Measuring health-related quality of life for public health surveillance. Public Health Rep 1994 (in press). 10. Mosteller F. Implications of measures of quality of life for policy development. J Chronic Dis 1987;40:645-50. * Alaska, Arkansas, Colorado, Delaware, District of Columbia, Georgia, Idaho, Illinois, Kentucky, Massachusetts, Minnesota, Montana, Nebraska, Oklahoma, Pennsylvania, South Carolina, Tennessee, Utah, Vermont, Virginia, Washington, and West Virginia. ** Computation of this index assumed minimal overlap of reported "not good" health days (e.g., a respondent reporting five physical and three mental not good health days would have 30-(5+3)=22 GHDs). An alternative index that assumed maximal overlap (i.e., 30-5=25 GHDs for the same respondent) added only 0.4 mean days to the 24.8 overall mean days of the minimal overlap index. ------------------------------ Date: Wed, 01 Jun 94 22:02:47 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR] Public Health Leadership Institute Message-ID: Public Health Leadership Institute The CDC/University of California's Public Health Leadership Institute (PHLI) is a 1-year scholars' program designed to strengthen the U.S. public health system by enhancing the leadership capacities of senior city, county, and state public health officials. The major themes of the program curriculum are: challenges--current and future issues confronting public health; leadership and vision; communication and information; and political and social change. The fourth year of the PHLI will begin October 30, 1994, and will include an intensive on-site session March 12-17, 1995. At least 50 officials will be selected to participate in the PHLI. Senior state and local health officials, including state deputy directors nominated by health directors, are eligible to apply. Applications will be available in June 1994 and are due August 5. Scholars selected will be notified by September 15. Additional information and applications are available from the PHLI office, telephone (916) 448-7891, fax (916) 448-0753; or from CDC's Public Health Practice Program Office, telephone (404) 639-1945. ------------------------------ Date: Wed, 01 Jun 94 22:04:33 MST From: mednews (HICNet Medical News) To: hicnews Subject: Basic Forensic Pathology Course Offered Message-ID: BASIC FORENSIC PATHOLOGY will be presented 3-7 October 1994 at the Holiday Inn Crowne Plaza, Rockville, Maryland, USA. SPONSORS: Armed Forces Institute of Pathology, the American Registry of Pathology, and the Office of the Armed Forces Medical Examiner. GENERAL INFORMATION: Education Dept. (INT), 14th & Alaska Avenue, NW, Washington, DC, USA; (301)427-5231; FAX (301)427-5001; or INTERNET: LOWTHER@email.afip.osd.mil CONTENT: This course provides a concise review of basic topics in forensic pathology. The course is designed for pathologists, investigators, attorneys, and others who need to increase their understanding of the forensic sciences. After completing this course, the registrant should have basic knowledge of the various aspects of multidisciplinary medicolegal death investigations. The course faculty includes nationally renowned authorities in the forensic sciences. (English) COURSE DIRECTORS: William T. Gormley, Colonel, USAF, MC Paul O. Vasallo, Colonel, MC, USA Steven C. Cogswell, Major, USAF, MC TUITION: $475 Civilian. Active duty military, DoD civilians, full-time permanent 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 $250. ------------------------------ Date: Wed, 01 Jun 94 22:05:28 MST From: mednews (HICNet Medical News) To: hicnews Subject: Armed Forces Institute of Pathology Short Postgraduate Courses Message-ID: ARMED FORCES INSTITUTE OF PATHOLOGY POSTGRADUATE SHORT COURSES ON CONTINUING EDUCATION SPRING 1994 6-10 Jun Exfoliative & Fine Needle Hyatt Regency Aspiration Cytology Bethesda, MD 8-10 Jun Methods & Advanced Techniques USUHS in Human Identification Bethesda, MD 20-24 Jun Forensic Anthropology USUHS Bethesda, MD 25-26 Jun Hepatopathology 94' Radisson Resort Vail, CO 27-28 Jun Gastrointestinal Surgical Radisson Resort Pathology Vail, CO FALL 1994 3- 5 Aug Histopathology AFIP Washington, DC 8-12 Aug Pathology of Laboratory USUHS Animals Bethesda, MD 19-21 Aug Environmental Pathology AFIP Washington, DC 27-28 Aug Anatomy, Histology & Electron Georgetown University Microscopy of the Eye, Orbit Conference Center and Ocular Adnexa Washington, DC Aug29-2Sep Ophthalmic Pathology`for Georgetown University Ophthalmologists Conference Center Washington, DC 12-16 Sep Pathology of Congenital Heart AFIP Washington, DC 17-18 Sep Pulmonary & Mediastinal Menger Hotel Radiology San Antonio, TX 19-22 Sep Morphologic Findings in Ramada Inn Renal Disease Bethesda, MD 26-30 Sep Advances in Diagnostic Doubletree Hotel Pathology of Infectious Park Terrace Diseases Washington, DC 3- 7 Oct Basic Forensic Pathology Holiday Inn Crowne Plaza Rockville, MD 10-14 Oct 4th Annual Radiologic Disney Contemporary Hotel Pathologic Correlation Lake Buena Vista, FL 29-30 Oct Hyperbaric Chamber Awareness AFIP Washington, DC 4- 5 Nov DNA Databanks & Repositories Sheraton Midway St. Paul, MN 19-20 Nov Interpretation of Prostatic AFIP Biopsy Washington, DC SPRING 1995 4-8 Jan 95 Telemedicine I Disney Contemporary Hotel (Didactic) Lake Buena Vista, FL 10-11 Jan 95 Telemedicine II Disney Contemporary Hotel (Interactive) Lake Buena Vista, FL 9-13 Jan 95 Oral Pathology Disney Contemporary Hotel Lake Buena Vista, FL 22-27 Jan 95 Neuropathology Review Hyatt Regency New Orleans, LA 22-27 Jan 95 Uropathology Holiday Inn Crowne Plaza Rockville, MD 13-17 Feb Controversies & Recent Contemporary Hotel Advances in Surgical Lake Buena Vista, FL Pathology 17-19 Feb Respiratory Tract & Marriott Rivercenter Mediastinum San Antonio, TX 19-22 Feb Pediatric Pathology Grosvenor Resort Lake Buena Vista, FL 25-26 Feb Neuroradiology Review Hyatt Regency Bethesda, MD 13-17 Mar Forensic Dentistry Holiday Inn Crowne Plaza Rockville, MD 1-2 Apr Abdominal & Gastrointestinal AFIP Imaging Washington, DC 3-16 Apr Problems in Anatomic AFIP Pathology Washington, DC 22-23 Apr Uroradiology AFIP Washington, DC May 31- Controversias y Adelantos Caribe Hilton & Casino 3 Jun Nuevos en Patholgia San Juan, PR Quirurgica 5- 9 Jun Comparative Pathology of Woods Hole, MA Aquatic Animals 5- 9 Jun Diagnostic Exfoliative & Fine Marriott Hotel Needle Aspiration Cytology Washington, DC 2- 5 Jul Controversies & Recent Snowmass Lodge & Club Advances in Surgical Pathology Snowmass, CO 3- 7 Jul Forensic Anthropology University of Bradford Bradford, England Schedules are published monthly. Press announcements will be published as information becomes available. For additional information or clarification you may write: AFIP/ARP, Educ. Div.(INT), Washington, DC 20306-6000; Telephone 301/427-5231; Fax 301/427-5001; or INTERNET: LOWTHER@email.afip.osd.mil ------------------------------ Date: Wed, 01 Jun 94 22:06:39 MST From: mednews (HICNet Medical News) To: hicnews Subject: Study Links Smoking & Increased Risk of Fatal Breast Cancer Message-ID: Study Links Smoking and Increased Risk of Fatal Breast Cancer American Cancer Society News Release ATLANTA, May 15, 1994 -- A new study by the American Cancer Society reports that a woman's risk of dying from breast cancer increases by 25% if the woman is a smoker -- and rises in proportion to the number of cigarettes smoked per day and the total number of years smoked, culminating with a 75% increased risk in women who smoke two packs per day or more. The study, published in the May 15 issue of the American Journal of Epidemiology, found no association between former smoking and risk of fatal breast cancer. "Our results suggest that there is something different about current smokers with breast cancer with regard to their risk of dying from the disease," says Eugenia Calle, Ph.D., Director of Analytic Epidemiology with the American Cancer Society, who is the lead author of the paper. "For example, smokers may have impaired immune systems, they may not obtain routine mammographic screenings, or smoking may cause a direct deleterious effect on survival." Women in this study were selected from the female participants of CPS II, a prospective mortality study of 1.2 million American men and women begun by the Society in 1982. After six years of follow-up, 880 cases of fatal breast cancer were observed in a population of 604,412 women who were free of cancer at enrollment. Among the women who died of breast cancer, 53.2% had never smoked, 16.4% were former smokers, 21.3% were current smokers, and 9.2 could not be classified. Current smokers had about a 25% increased risk of fatal breast cancer (rate ratio 1.26); this risk increased to almost 75% (rate ratio 1.74) for women who smoked 40 or more cigarettes per day. "Interestingly, women who smoked and had a history of breast cysts were not at increased risk of fatal breast cancer," says Dr. Calle. "These women may be more likely to get mammograms on a regular basis and to be diagnosed at an early stage of disease. The authors offered the following hypotheses as to why smoking created an increased risk of fatal breast cancer in this group of women: * Poor survival experiences among current smokers with breast cancer. This could be due to conditions that are more common among smokers, such as respiratory and cardiovascular impairment. It would also occur if smoking accelerates the progression of the disease, or if smokers are diagnosed at a later stage. * Smoking may have deleterious effects on the immune system. Other studies have documented low natural killer cell activity and immunoglobulin levels in smokers, findings which could contribute to poorer prognosis among breast cancer patients who smoke. * Smokers may not seek screening services similar to nonsmokers. Data from the National Health Interview Survey Cancer Control Supplement show that current smokers are less likely to receive mammography screening than are never smokers or former smokers and this screening disadvantage is greatest among heavy smokers. Similar differences in screening behavior by smoking status have been observed in other studies. Consequently, women who smoke may be diagnosed at a later stage of disease. "Our results suggest that current smokers may be at increased risk of fatal breast cancer, either because of poorer survival or delayed diagnosis," says Dr. Calle. "They should be considered a potentially high-risk group for whom mammography education and early detection may be particularly valuable." Other authors of the study are Heidi L. Miracle McMahill, BS, Michael J. Thun, MD, and Clark W. Heath, Jr., MD, all with the Society's department of Epidemiology and Statistics. For further information, contact Eugenia Calle, PhD, at the American Cancer Society, 404/329-5741. ------------------------------ Date: Wed, 01 Jun 94 22:08:17 MST From: mednews (HICNet Medical News) To: hicnews Subject: National Cancer Institute CancerNet Update Message-ID: ************************************************* * NATIONAL INSTITUTE * * C A N C E R * * INTERNATIONAL INFORMATION * * C E N T E R * ************************************************* * Cancernet@icicb.nci.nih.gov * ********************************** The National Cancer Institute has a new Information Associates Program which provides one-stop, easy access to all of NCI's scientific information resources, including online access to the PDQ database via the Internet or by dialing toll-free to NCI using just a modem and personal computer. Request news article cn-400035 (U.S. Residents) or cn-400036 ( International) for details. CancerNet has been updated for June. The following statements were modified. Changed state-of-the-art physician statements: Adult acute lymphocytic leukemia (cn-101024) Adult Hodgkin's disease (cn-100003) Adult non-Hodgkin's lymphoma (cn-100066) Bladder cancer (cn-101206) Breast cancer (cn-100013) Cervical cancer (cn-100103) Chronic lymphocytic leukemia (cn-101003) Chronic myelogenous leukemia (cn-101031) Colon cancer (cn-100008) Gestational trophoblastic tumor (cn-101163) Hypopharyngeal cancer (cn-101500) Laryngeal cancer (cn-101519) Lip and oral cavity cancer (cn-102840) Myeloproliferative disorders (cn-101983) Nasopharyngeal cancer (cn-101402) Oropharyngeal cancer (cn-101521) Ovarian epithelial cancer (cn-100950) Pancreatic cancer (cn-100046) Paranasal sinus and nasal cavity cancer (cn-102892) Plasma cell neoplasm (cn-100281) Prostate cancer (cn-101229) Rectal cancer (cn-100076) Small cell lung cancer (cn-100040) Testicular cancer (cn-101121) Thyroid cancer (cn-101252) Changed patient statements: Adult non-Hodgkin's lymphoma (cn-200066) Adult soft-tissue sarcoma (cn-200921) Bladder cancer (cn-201206) Breast cancer (cn-200013) Childhood acute lymphocytic leukemia (cn-200026) Childhood acute myeloid leukemia (cn-201081) Childhood Hodgkin's disease (cn-203043) Chilchood liver cancer (cn-200963) Childhood non-Hodgkin's lymphoma (cn-200915) Childhood rhabdomyosarcoma (cn-200759) Childhood soft tissue sarcoma (cn-203085) Endometrial cancer (cn-201176) Ewing's sarcoma (cn-200021) Hypopharyngeal cancer (cn-201500) Laryngeal cancer (cn-201519) Lip and oral cavity cancer (cn-202840) Myeloproliferative disorders (cn-201983) Nasopharyngeal cancer (cn-201402) Neuroblastoma (cn-200530) Oropharyngeal cancer (cn-201521) Paranasal sinus and nasal cavity cancer (cn-202892) Prostate cancer (cn-201229) Rectal cancer (cn-200076) Renal cell carcinoma (cn-201070) Retinoblastoma (cn-200993) Skin cancer (cn-201228) Testicular cancer (cn-201121) Thyroid cancer (cn-201252) Transitional cell cancer of the renal pelvis and ureter (cn-203364) Uterine sarcoma (cn-203371) Changed supportive care statements: No changes Changed screening statements: No changes Changed drug statements: No changes The following news items were added: *Addendum to Reanalysis of NSABP B06 (cn-400045) *Letter Sent to Participants of the BCPT (cn-400046) *Board of Scientific Counserlors Recommendations on BCPT (cn-400047) AHCPR Quick Reference Guide: Management of Cancer Pain in Adults (cn-400032) Letter to Investigators About Erwinia L-Asparaginase (cn-400048) *Note: This news item was added to CancerNet during May 1994 in advance of the June update. The following news items were deleted*: NCI Statement on Falsified Data in NSABP Trials (cn-400018) NCI Update on Falsified Data in NSABP Trials (cn-400026) Results of First Phase of NSABP Chart Audit (cn-400037) Suspension of LSU and Tulane from NSABP Studies (cn-400038) NCI to Audit NSABP Center (cn-400043) NCI Continues Audits; Will Re-examine Breast Cancer Studies (cn-400044) NCI Considers Reopening some NSABP Studies ( cn-400049) *The above items were removed from the news, but are available as fact sheets below, with the numbers cn-600723, cn-600724, cn-600727, cn-600728, cn-600730, and cn-600731, respectively. The following news items were changed: PDQ Distributors (cn-400003) CANCERLIT Distributors (cn-400006) PDQ User Guide (cn-400050, 400051, 400052, 400053, 400054) Redistribution of CancerNet and CancerNet Availability (cn-400030) PDQ Voluntary Submission Information (cn-400010) Group C Protocol Information (cn-400014) Reanalysis of NSABP Protocol B06 (cn-400027) [Note: The reanalysis was revised to incorporate the Addendum dated 4/27/94; the addendum alone is available as item cn-400045.] NCI Fact Sheets: ---------------- The following new fact sheets were added: The National Cancer Institute's SEER Cancer Statistics Review (cn-600110) Gene for Kidney Cancer Isolated (cn-600337) NCI to Study Brain Tumors and Their Causes (cn-600338) Q & A: Breast Cancer Prevention Trial (cn-600041) Q & A: Adjuvant Therapy for Breast Cancer (cn-600720) Suspension of LSU and Tulane from NSABP Studies (cn-600728) Newly Cloned Gene Could Aid in Treating Melanoma (cn-600729) NCI to Audit NSABP Center (cn-600730) NCI Continues Audits; Will Re-examine Breast Cancer Studies (cn-600731) NCI Considers Reopening Some NSABP Trials (cn-600732) Q & A: NCI's Natural Products Branch (cn-600733) Hospice (cn-600086) The following fact sheets were changed: Cancer Research Funding (cn-600011) Q & A: Prostate Cancer (cn-600054) Workshop on the Early Detection of Prostate Cancer (cn-600510) NCI Seeks Answers on Prostate Cancer: Causes, Detection, Prevention, & Treatment (cn-600066) The following fact sheets were deleted: Breast Cancer Research and Programs: An Overview (cn-600065) NIH Researchers Attempt Gene Therapy in Blood Stem Cells (cn-600719) NCI Publication Information: ------------------------------------- The following item was added: Down Home Healthy: Family Recipes of Black American Chefs (cn-400055) CANCERLIT Citations and Abstracts: ---------------------------------- The following new search topics were added: Anal cancer (cn-7__030) Bile duct and gallbladder cancer (cn-7__055) Colorectal cancer (therapy) (cn-7__036) Esophageal cancer (cn-7__045) Diagnosis, histopathology, and pathogenesis of gastric cancer (cn-7__065) Therapy of gastric cancer (cn-7__066) Diagnosis, histopathology, and pathogenesis of primary liver cancer (cn- 7__080) Therapy of primary liver cancer (cn-7__081) Diagnosis, histopathology, and pathogenesis of pancreatic cancer (cn-7__095) Therapy of pancreatic cancer (cn-7__096) Small intestine cancer (cn-7__115) Diagnosis, histopathology, and pathogenesis of primary brain tumors (cn- 7__550) Therapy of primary brain tumors (cn-7__551) Neuroblastoma (cn-7__560) The CANCERLIT citations and abstracts for June will be available on June 15, 1994. Request the Monthly PDQ Statement Changes ( cn-405001) for a description of the changes in the statements listed above. Request Changes to CancerNet ( cn-400000) for a complete listing of changes to CancerNet content for the current month. Instructions: To request the CancerNet Instructions and Contents List, send a mail message, and in the body of the message, enter HELP. Address the mail message to: cancernet@icicb.nci.nih.gov To request the modified statements, follow the above directions, and in the body of the mail message, enter the statement code. When requesting more than one statement, enter each code on a separate line. CancerNet statements are available in Spanish. To request the Instructions and Contents List in Spanish, enter SPANISH in the body of the mail message. If you would like to request the statements in Spanish, substitute the prefix "cs-" in front of the number e.g., cs-100022 to receive the statement on anal cancer in Spanish. All of the physician and patient statements are available in Spanish. Supportive care statements are now available in Spanish. News items that are available in Spanish have a # next to the statement title. Although both the English and Spanish are updated at the same time each month, the Spanish statements do not reflect the changes made in the English statements until the following month to allow time for translation. If you are interested in requesting CancerNet statements or news articles in Spanish, it is suggested that you request an updated Contents List. If you are redistributing the PDQ information you retrieve from CancerNet to others at your location, or are interested in redistributing the information from CancerNet, request the news article, Redistribution of Cancernet ( cn-400030), to find out about conditions that apply when redistributing the information. This article also has information on other sites providing access to CancerNet information. Please send comments or questions to: Cheryl Burg NCI International Cancer Information Center Internet: cheryl@icicb.nci.nih.gov ------------------------------ End of HICNet Medical News Digest V07 Issue #23 *********************************************** --- Editor, HICNet Medical Newsletter Internet: david@stat.com FAX: +1 (602) 451-1165 Bitnet : ATW1H@ASUACAD