HICNet Medical News Digest      Sun, 24 Apr 1994        Volume 07 : Issue 13

Today's Topics:

  [MMWR 8 April 94] Water Hemlock Poisoning
  [MMWR] Health-Risk Behaviors Among Persons Aged 12-21 Years
  [MMWR] Fatalities Associated with Harvesting of Sea Urchins
  [MMWR] Human Plague
  [MMWR] Adult Blood Lead Epidemiology and Surveillance
  FDA Approves Tacrolimus for Liver Transplant Patients
  FDA Warnings on "Sensor Pad"
  Tamoxifen Warning Increased Risk Cancer of the Uterus
  Antioxidants and Cancer Study

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----------------------------------------------------------------------

Date: Sat, 23 Apr 94 15:33:15 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR 8 April 94] Water Hemlock Poisoning
Message-ID: <56a0kc1w165w@stat.com>

                  Water Hemlock Poisoning -- Maine, 1992

     On October 5, 1992, a 23-year-old man and his 39-year-old brother were
foraging for wild ginseng in the midcoastal Maine woods. The younger man
collected several plants growing in a swampy area and took three bites from
the
root of one plant. His brother took one bite of the same root. Within 30
minutes, the younger man vomited and began to have convulsions; they walked
out
of the woods, and approximately 30 minutes after the younger man became ill,
they were able to telephone for emergency rescue services.
     Within 15 minutes of the call, emergency medical personnel arrived and
found the younger man unresponsive and cyanotic with mild tachycardia, dilated
pupils, and profuse salivation. Severe tonic-clonic seizures occurred and were
followed by periods of apnea. He was intubated and transported to a local
emergency department. Physicians performed gastric lavage and administered
activated charcoal. His cardiac rhythm changed to ventricular fibrillation,
and
four resuscitative attempts were unsuccessful. He died approximately 3 hours
after ingesting the root.
     Although the older brother was asymptomatic when he arrived at the
emergency department, he was treated prophylactically with gastric lavage and
administered activated charcoal. He began to have seizures and exhibit
delirium
2 hours after eating the root; he was stabilized and transferred to a
tertiary-care center for observation. No additional adverse effects were
reported.
     The root ingested by the two brothers was identified as water hemlock
(Cicuta maculata). In October 1993, postmortem samples of frozen liver tissue,
blood, and gastric contents from the man were analyzed by high-pressure liquid
chromatography for cicutoxin, a poisonous substance in water hemlock.
Cicutoxin, a neurotoxin, was not detected; however, the toxin is labile and
may
have degraded during storage.

Reported by: K Sweeney, MD, Office of the Chief Medical Examiner; KF
Gensheimer, MD, State Epidemiologist, Maine Dept of Human Svcs; J
Knowlton-Field, Damariscotta, Maine. RA Smith, Livestock Disease Diagnostic
Center, Dept of Veterinary Science, Univ of Kentucky, Lexington. Health
Studies
Br, Div of Environmental Hazards and Health Effects, National Center for
Environmental Health, CDC.

Editorial Note: Based on mortality data files maintained by CDC's National
Center for Health Statistics, from 1979 through 1988 (the most recent national
data available) at least 58 persons in the United States died after ingesting
a
poisonous plant that was misidentified as an edible fruit or vegetable;
inadvertent ingestion of water hemlock, as in the two cases in this report,
caused at least five of these deaths. During 1989-1992, the American
Association of Poison Control Centers recorded four deaths attributed to
ingestion of poisonous plants (1-4). Water hemlock--also known as beaver
poison, children's bane, death-of-man, poison parsnip, and false parsley--is
in
the same family as parsley, parsnips, celery, and carrots. It is similar in
appearance to parsnips, smells like fresh turnips, and tastes sweet, but it is
the most toxic indigenous plant in North America (5).
     Although cicutoxin is present in all parts of the water hemlock plant,
the
root contains the highest concentration. Ingestion of a 2-3-cm portion of the
root can be fatal in adults (6), and use of toy whistles made from the water
hemlock stem has been associated with deaths in children (7). The plant is
poisonous at all stages of development and is most toxic in the spring.
Poisonings typically result from ingestions; however, cicutoxin also may be
absorbed through the skin.
     Mild toxicity from water hemlock produces nausea, abdominal pain, and
epigastric distress within 15-90 minutes. The early gastrointestinal response
of vomiting may be somewhat protective as many persons regurgitate the
undigested root. Diaphoresis, flushing, and dizziness also have been reported.
In severe intoxications, profuse salivation, perspiration, bronchial
secretion,
and respiratory distress leading to cyanosis develop soon after ingestion. In
fatal poisonings, severe seizures occur after the initial symptoms, and death
results usually from status epilepticus. The case-fatality rate for poisonings
reported from 1900 through 1975 was 30% (8). The last fatality attributed to
ingestion of water hemlock in Maine occurred in the early 1970s. No antidotes
exist, and treatment is supportive. Complications associated with serious
poisonings include rhabdomyolysis with renal failure (transient hematuria,
glycosuria, and proteinuria), severe metabolic acidosis, bradycardia, and
hypotension (9).
     This report underscores the need for persons who forage for edible wild
plants to be aware of and able to recognize poisonous plants in their area.
Water hemlock causes most of the fatalities attributed to misidentification of
poisonous plants because the plant is lethal in small quantities, resembles
edible plants, and is found throughout North America. Health-care providers
who
know that their patients eat wild plants should caution them about the
potential adverse health effects.

References
1. Litovitz TL, Holm KC, Clancy C, Schmitz BF, Clark LR, Oderda GM. 1992
Annual report of the American Association of Poison Control Centers National
Data Collection System. Am J Emerg Med 1993;11:494-555.
2. Litovitz TL, Holm KC, Bailey KM, Schmitz BF. 1991 Annual report of the
American Association of Poison Control Centers National Data Collection
System. Am J Emerg Med 1992;10:452-505.
3. Litovitz TL, Bailey KM, Schmitz BF, Holm KC, Klein-Schwartz W. 1990 Annual
report of the American Association of Poison Control Centers National Data
Collection System. Am J Emerg Med 1991;9:461-509.
4. Litovitz TL, Schmitz BF, Bailey KM. 1989 Annual report of the American
Association of Poison Control Centers National Data Collection System. Am J
Emerg Med 1990;8:394-442.
5. Kingsbury JM. Poisonous plants of the United States and Canada. Englewood
Cliffs, New Jersey: Prentice Hall, 1964:372.
6. Dreisbach R. Handbook of poisoning. 8th ed. Los Altos, California: Lange
Medical Publications, 1974:433.
7. Miller MM. Water hemlock poisoning. JAMA 1933;101:852-3.
8. Starreveld E, Hope MB. Cicutoxin poisoning (water hemlock). Neurology
1975;25:730-4.
9. Carlton BE, Tufts E, Girard DE. Water hemlock poisoning complicated by
rhabdomyolysis and renal failure. Clin Toxicol 1979;14:87-92.



------------------------------

Date: Sat, 23 Apr 94 15:34:04 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR] Health-Risk Behaviors Among Persons Aged 12-21 Years
Message-ID: <H8a0kc2w165w@stat.com>

                     Health-Risk Behaviors Among Persons
                   Aged 12-21 Years -- United States, 1992

     Health-risk behaviors among youth may result in immediate health problems
(e.g., injuries and sexually transmitted diseases) or extend into adulthood
and
increase risk for chronic diseases (e.g., heart disease and cancer) (1). This
report uses national data from the Youth Risk Behavior Survey (YRBS),
conducted
as part of the 1992 National Health Interview Survey (NHIS), to examine the
prevalence of selected self-reported health-risk behaviors among persons aged
12-21 years.
     The YRBS is a component of CDC's Youth Risk Behavior Surveillance System,
which periodically measures the prevalence of priority health-risk behaviors
among adolescents (1). The 1992 NHIS was conducted among a representative
sample of the civilian noninstitutionalized U.S. population using a multistage
cluster-area probability design of approximately 120,000 persons representing
49,000 households. The YRBS was conducted as a follow-back survey to the NHIS
among a representative sample of persons aged 12-21 years in the sampled
households. Adolescents who did not attend school were oversampled. During
April 1992-March 1993, respondents listened to a tape recording of the
questionnaire and recorded their responses on a standardized answer sheet.
Questionnaires were completed by 10,645 (77.2%) eligible respondents.
Respondents were categorized into three age groups that generally corresponded
to three schooling levels: middle/junior high school (12-13 years; n=2195),
senior high school (14-17 years; n=4126), and postsecondary school (18-21
years; n=4324). SUDAAN was used to compute all standard errors for the
estimates and for differences between the estimates (2). All estimates were
based on weighted data.
     Persons aged 12-13 years were significantly less likely than those aged
18-21 years to have reported "always" using safety belts when riding as a
passenger in a car or truck (31.6% versus 36.1%) (Table 1). The percentage of
persons who reported that, during the 30 days preceding the survey, they had
ridden with a driver who had been drinking alcohol increased significantly
with
age group (12-13-year-olds, 11.3%; 14-17-year-olds, 21.7%; and
18-21-year-olds,
34.5%); in comparison, the percentage who reported physical fighting during
the
12 months preceding the survey decreased significantly with age group
(12-13-year-olds, 49.0%; 14-17-year-olds, 43.8%; and 18-21-year-olds, 29.4%).
Adolescents aged 14-17 years were significantly more likely than those aged
12-13 years and aged 18-21 years to have reported carrying a weapon (e.g.,
gun,
knife, or club) during the 30 days preceding the survey (17.1% versus 12.6%
and
13.6%, respectively). Reported use of motorcycle helmets did not vary by age
group.
     Lifetime and current* cigarette use increased significantly with age
group, and current* use of smokeless tobacco was significantly higher among
the
older age groups (Table 1). Compared with persons aged 12-13 years, those aged
18-21 years were three times more likely to have reported using alcohol during
their lifetimes (28.0% versus 86.7%), nine times more likely to report current
episodic heavy drinking** (4.3% versus 39.7%), 13 times more likely to have
used marijuana during their lifetimes (3.4% versus 45.8%), and 28 times more
likely to have used cocaine during their lifetimes (0.4% versus 11.4%).
Reported injecting-drug use was significantly higher among persons aged 14-17
years (0.9%) and aged 18-21 years (1.2%) than among those aged 12- 13 years
(0.1%).
     Persons aged 18-21 years were significantly more likely to report having
had sexual intercourse (81.7%) and to have had four or more sex partners
during
their lifetimes (41.3%) than 14-17-year-olds (43.4% and 13.3%, respectively)
(Table 1).*** Among adolescents who reported having had sexual intercourse
during the 3 months preceding the survey, 14-17-year-olds were significantly
more likely than 18-21-year-olds to have used a condom (58.5% versus 36.9%)
and
significantly less likely to have used birth control pills (18.2% versus
34.8%)
during last sexual intercourse.
     Reported consumption of five or more servings of fruits and vegetables
during the day preceding the survey decreased significantly by age group (12-
13-year-olds, 17.0%; 14-17-year-olds, 13.4%; and 18-21-year-olds, 10.9%)
(Table
1). Consumption of two or more servings of foods typically high in fat during
the day preceding the survey was significantly less common among 18-
21-year-olds (27.7%) than among 12-13-year-olds (32.9%) or 14-17-year-olds
(34.2%). Participation in moderate physical activity**** decreased
significantly by age group (12-13-year-olds, 34.8%; 14-17-year-olds, 27.4%;
and
18-21-year-olds, 21.2%).

Reported by: Div of Adolescent and School Health, National Center for Chronic
Disease Prevention and Health Promotion; Div of Health Interview Statistics,
National Center for Health Statistics, CDC.

Editorial Note: The findings in this report document age group comparisons of
the most important health-risk behaviors among a nationally representative
sample of 12-21-year-olds. These findings extend previous analyses, which
documented how health-risk behaviors differ between young persons who were and
were not enrolled in school (3).
     Public health and education officials can use these findings to target
interventions to the most appropriate age groups. For example, although
reported sexual activity was higher among 18-21-year-olds than among 14-
17-year-olds, condom use was lower and birth control pill use was higher among
members of the older group. These findings suggest that although persons in
the
older group were better protected against unintended pregnancy, they were less
protected against human immunodeficiency virus infection and other sexually
transmitted diseases. The finding that levels of reported physical activity
were inversely proportionate to age suggests the need for increased efforts to
motivate adolescents to sustain at least moderate levels of physical activity
throughout their lives.
     Based on the survey, at least one fourth of all 12-13-year-olds engage in
at least one health-risk behavior (e.g., failure to always wear safety belts,
physical fighting, tobacco use, or alcohol use), underscoring the importance
of
initiating prevention measures early--ideally during elementary school (4).
However, because the prevalence of health-risk behaviors generally increases
with age, such measures must be reinforced in middle/junior high school and
senior high school. For example, comprehensive school health education should
be provided from kindergarten through 12th grade and should focus on assisting
students to develop skills to avoid or reduce the most important health-risk
behaviors (4). Additional interventions that focus on skills to promote
healthy
behavior should be made available to young persons in the workplace and in
postsecondary institutions.

References
1. Kolbe LJ, Kann L, Collins J. Overview of the Youth Risk Behavior
Surveillance System. Public Health Rep 1993;108(suppl):2-10.
2. Shah BV, Barnwell BG, Hunt PN, LaVange LM. SUDAAN user's manual, release
5.50. Research Triangle Park, North Carolina: Research Triangle Institute,
1991.
3. CDC. Health risk behaviors among adolescents who do and do not attend
school--United States, 1992. MMWR 1994;43:129-32.
4. 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.

* On 1 or more of the 30 days preceding the survey.
** Drinking five or more drinks of alcohol on at least one occasion during
the 30 days preceding the survey.
*** Respondents aged 12-13 years were not asked the sexual behavior
questions.
**** Walked or rode a bicycle at least 30 minutes at a time on 5 or more of
the 7 days preceding the survey.



------------------------------

Date: Sat, 23 Apr 94 15:35:01 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR] Fatalities Associated with Harvesting of Sea Urchins
Message-ID: <39a0kc3w165w@stat.com>

                       Fatalities Associated with Harvesting
                            of Sea Urchins -- Maine, 1993

     During 1992-1993, six persons died while diving for sea urchins in Maine
waters--two during 1992 and four during August-November 1993. The four 1993
deaths were investigated by the Maine Department of Marine Resources, the U.S.
Coast Guard, the Office of the Chief Medical Examiner in Maine, and the
Occupational Safety and Health Administration (OSHA); each of the deaths was
attributed to drowning. This report describes the results of the
investigations
of these cases.

     Case 1. On August 19, an experienced 52-year-old diver was harvesting sea
urchins from a vessel anchored in heavy fog. He exhausted his air supply after
1 hour and, while still in the water, requested another air tank from a
support
person (i.e., tender) in a small inflatable boat. The tender and another diver
in a larger boat could not locate the diver in the reduced visibility. He was
found submerged approximately 30 minutes later, and cardiopulmonary
resuscitation (CPR) was unsuccessful.

     Case 2. On August 31, an experienced 22-year-old diver was attempting
on-board repairs to his urchin-harvesting vessel, which was moored in harbor
during a rainstorm. During the repairs, his skiff broke loose from the
harvesting vessel and began to drift in rough waters. He drowned while
swimming
to recover the skiff. His body was recovered 3 weeks later.

     Case 3. On September 7, a 24-year-old college student, who had recently
completed a basic scuba diving certification course, was attempting his first
saltwater dive in fair sea and weather conditions. He was harvesting sea
urchins in 30 feet of water when the tender lost sight of his bubbles within
minutes of starting the dive. A diver onboard the boat and another diver in
the
water were not in visual contact with the distressed diver. He was found
submerged approximately 20 minutes later, and CPR was unsuccessful. OSHA
subsequently cited the boat owner for violations of commercial diving
standards.

     Case 4. On November 3, a 25-year-old man with less than 2 weeks of diving
experience was harvesting sea urchins in open seas with powerful surf. The
diver surfaced and was attempting to untangle his catch-bag recovery line when
he became caught in breaking surf along a nearby rock formation. The person in
the tending vessel was unable to assist him because the vessel was too large
to
maneuver in shallow waters. Another diver in the water was unaware of the
situation. The man was found submerged approximately 20 minutes later, and CPR
was not attempted. OSHA subsequently cited the boat owner for violations of
commercial diving standards.

Reported by: SC Shannon, DO, Occupational Health Program, Div of Disease
Control; KF Gensheimer, MD, State Epidemiologist, Div of Disease Control, Bur
of Health, Maine Dept of Human Svcs; RH LeHay, Maine Dept of Marine Resources;
J Ciampa, US Coast Guard Marine Safety Office, Portland. Alaska Activity, Div
of Safety Research, National Institute for Occupational Safety and Health; Div
of Field Epidemiology, Epidemiology Program Office, CDC.

Editorial Note: The commercial fishing industry has one of the highest
occupational fatality rates in the United States (1). In Alaska, during 1991
and 1992, the average annual occupational fatality rate for the fishing
industry was 200 per 100,000 workers, and the fatality rate for the shellfish
fishery was 530 per 100,000 (1). In comparison, during 1993 in Maine, the
fatality rate for the sea urchin-harvesting industry was 278 per 100,000
workers. During 1980-1989, the average annual rate of traumatic occupational
fatalities in Maine was 7.6 per 100,000 (2). Although sea urchin-harvesting
vessels constitute approximately 10% of commercial fishing vessels, they
account for 25% of all commercial fishing vessels lost in northern New England
(U.S. Coast Guard Marine Safety Office, Portland, Maine, unpublished data,
1994).      Commercial harvesting of sea urchins in Maine began in 1987, and
the harvest doubled during 1992-1993, primarily because of increased demand
for
yellow roe. In 1993, 1439 divers were licensed to harvest sea urchins in Maine
waters, and approximately 30-40 million pounds of roe were harvested.      In
general, sea urchins are harvested by hand by divers using scuba equipment.
The
most marketable sea urchins are present in the subtidal zone along rock ledges
in less than 30 feet of water. The highest quality roe is harvested during the
winter. Shallow water over ledges and the often adverse Maine weather require
divers and vessels to operate in waters with strong currents and powerful
surf.
These conditions pose substantial hazards for the sea urchin industry in
Maine--especially for inexperienced divers and persons unfamiliar with
operating vessels in adverse sea and weather conditions (U.S. Coast Guard
Marine Safety Office, Portland, Maine, unpublished data, 1994).
      In addition to the four deaths reported in 1993, the U.S. Coast Guard
reported an estimated five incidents in which deaths were averted only after
extensive search-and-rescue efforts by state and federal agencies. For
example,
in one incident, aircraft were used to locate a sea urchin diver who became
separated from the harvesting operation. Many divers work alone, and one
harvest vessel may support several divers in multiple locations along a
productive ledge. Thus, divers may be unable to summon assistance from the
supporting vessel or from other divers.
      Basic recreational scuba diving certification may not adequately train
new divers for commercial activities such as sea urchin harvesting.
Legislation
has been introduced in Maine that would impose stricter training and
certification requirements for sea urchin divers. The proposal would require
persons to obtain a certificate of commercial diving competency before being
issued a license to hand-harvest sea urchins. OSHA regulations require that
each boat that tends sea urchin divers must have a diver stand by to provide
assistance when another diver is in the water, and support personnel must be
trained in CPR. In addition, each diver must be line-tended from the surface
or
in visual contact with another diver. Two of the cases described in this
report
(cases 3 and 4) prompted OSHA to apply work-safety standards for commercial
diving to the sea urchin fishery for the first time by issuing citations to
the
owners of both boats.

References
1. CDC. Commercial fishing fatalities--Alaska, 1991-1992. MMWR 1993;42:350-
1,357-9.
2. NIOSH. Fatal injuries to workers in the United States, 1980-89: a decade
of surveillance. Cincinnati: US Department of Health and Human Services,
Public Health Sevice, CDC, 1993.



------------------------------

Date: Sat, 23 Apr 94 15:35:36 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR] Human Plague
Message-ID: <20a0kc4w165w@stat.com>

                         Emerging Infectious Diseases
                   Human Plague -- United States, 1993-1994

     From 1944 through 1993, 362 cases of human plague were reported in the
United States; approximately 90% of these occurred in four western states with
endemic disease (Arizona, California, Colorado, and New Mexico) (1). During
each successive decade of this period, the number of states reporting cases
increased from three during 1944-1953 to 13 during 1984-1993 (Figure 1),
indicating the spread of human plague infection eastward to areas where cases
previously had not been reported. In 1993, health departments in four states
reported 10 confirmed cases* of human plague to CDC; one case has been
confirmed during 1994**. This report summarizes information about the 11 cases
of human plague reported during 1993-1994 and describes epidemiologic and
epizootic trends of plague in the United States.
     In 1993, the 10 confirmed cases of human plague were reported from New
Mexico (six cases), Colorado (two), Texas (one), and Utah (one) (Table 1).
Persons with plague infection were aged 22-96 years (median: 55.5 years); five
were aged greater than or equal to 67 years. Six cases occurred among men.
Five
cases occurred during June-August, three during March-May, and two during
September-November. Seven persons were exposed at their homesites, and one (a
veterinarian) was exposed at work; exposure sites could not be determined for
two cases. Seven cases were bubonic plague; two, primary septicemic; and one,
primary pneumonic. Nine of the 10 patients recovered with antibiotic therapy;
one patient died (Table 1).
     For three patients, the probable mode of transmission was flea bite
(based
on the presence of an inguinal bubo or a recollection of flea bites). Two
patients (including the veterinarian) were infected by domestic cats with
visible signs of plague infection (i.e., oral lesions and a swollen tongue).
For five cases (including the fatal case), the probable mode of transmission
could not be determined; however, evidence of plague infection in local animal
populations was detected in association with three of these cases (Table 1).
     In 1994, plague infection has been confirmed in a 56-year-old resident of
Inyo County, California, who had onset of illness on January 1 (the first
report in California of a human plague case during winter since 1928) (Table
1). The patient lived in a county where plague was known to be endemic. In
addition, he had recently worked in a subterranean gold mine and slept in a
cabin at the minesite; signs of rodent activity were found in the mine shaft
and the cabin outbuildings.

Reported by: SB Werner, MD, R Murray, DrPH, K Reilly, DVM, M Madon, MS, M Jay,
DVM, C Smith, MS, B Wilson, MS, J Wang, MS, RJ Jackson, MD, California Dept of
Health Svcs; R Hurd, J Levesque, MD, Inyo County Health Dept, Independence,
California. J Pape, MS, T Davis, MS, RE Hoffman, MD, State Epidemiologist,
Colorado Dept of Health. R Stoneberg, Montana Dept of Fish, Wildlife, and
Parks; TA Damrow, PhD, State Epidemiologist, Montana State Dept of Health and
Environmental Sciences. C Montman, Albuquerque Environmental Health Dept; T
Brown, MS, P Reynolds, M Tanuz, New Mexico Environment Dept; M Eidson, DVM, CM
Sewell, DrPH, State Epidemiologist, New Mexico Dept of Health. S Lanser, MPH,
R
Tanner, MPA, CR Nichols, MPA, State Epidemiologist, Utah Dept of Health. W
Kramer, Nebraska State Dept of Health. TG Murnane, DVM, BN Hicks, PV Thomas,
DVM, J Buck, J Taylor, MPH, GM Moore, MS, Texas Dept of Health; J Wood, City
of
Dallas, C Vaughn, MS, C Haley, MD, R Farris, MD, Dallas County Health Dept,
Dallas. DR Akin, P Bohan, MS, R Enscore, MS, J Sarisky, MPH, L Courtois,
Office
of Environmental Health, Indian Health Svc. L Handegard, MT Billings, D
Virchow, NE Scottsbluff, Animal and Plant Health Inspection Svc, Animal Damage
Control, US Dept of Agriculture. RJ Andrascik, Theodore Roosevelt National
Park, National Park Svc, North Dakota. Div of Field Epidemiology, Epidemiology
Program Office; Bacterial Zoonoses Br, Div of Vector-Borne Infectious
Diseases,
National Center for Infectious Diseases, CDC.

Editorial Note: The findings in this report emphasize the increasing
importance
of two related trends in the epidemiology of human plague in the United
States:
1) increased peridomestic transmission and 2) the role of domestic cats as
sources of human infection. Peridomestic transmission is especially important
in the most highly plague-endemic states of Arizona, Colorado, and New Mexico,
where rapid suburbanization has resulted in increasing numbers of persons
living in or near active plague foci. Domestic cats that are permitted to roam
freely in areas where plague occurs in rodents are at increased risk for
infection and, therefore, increase the risk for peridomestic transmission to
humans. Before 1977, domestic cats were not reported as sources of human
plague
infection; however, since 1977, cats have been identified as the source of
infection for 15 human plague cases. In addition, the proportion of human
plague cases with primary pneumonic plague has been substantially higher among
cat-associated cases (four of 15 cases) than among cases for which cats were
not sources of infection (one of 236 cases). Persons working in veterinary
practices should be warned of the risks associated with handling
plague-infected cats. Four of the 15 cat-associated cases occurred in
veterinarians or their assistants. In addition, CDC recommends that veterinary
personnel wear gloves and eye protection and take appropriate respiratory
precautions (2) when examining sick cats in or from plague-endemic areas,
especially cats with lymphadenopathy, oral lesions, or pneumonia.
     Surveillance for plague in rodent and rodent-consuming carnivore
populations during the 1990s indicates that plague has spread eastward to
counties in areas (e.g., eastern Montana, western Nebraska, western North
Dakota, and eastern Texas) believed to be free of this disease since
widespread
animal surveillance began in the 1930s (3-5). For example, the potential for
human plague cases in eastern Texas was demonstrated in 1993 when an infected
roof rat (Rattus rattus) and two infected fox squirrels (Sciurus niger) were
identified in Dallas. Animal surveillance was initiated in the Dallas
metropolitan area to monitor plague in local rodent and carnivore populations
as a sentinel of increased risk for plague among humans. The continued
expansion of human plague in the United States (Figure 1) underscores the need
to enhance plague surveillance and to increase efforts to prevent, detect, and
control human plague.
     Epizootic plague activity usually peaks during or immediately after years
with cooler temperatures and more rain than usual. Such conditions occurred
during 1991-1993 in the highly plague-endemic areas of Arizona, Colorado, and
New Mexico, as well as in the western Great Plains region,*** and resulted in
large populations of many plague-susceptible rodent species-- including deer
mice, the principal reservoir of hantavirus in the western United States (6).
     Nearly all fatal plague cases in the United States result from delays in
seeking treatment and in making the proper diagnosis. The person with fatal
plague in 1993 received medical care 6 days after onset of illness and died
within 4-6 hours of seeking care at a hospital. Because of similarities in
clinical features of plague and the recently discovered hantavirus pulmonary
syndrome (HPS) (7), diagnosis of plague may be further complicated. In 1993,
HPS was suspected in a person with secondary pneumonic plague; as a result,
the
patient was transported to a regional medical center in another state for
specialized care. At this facility, plague was diagnosed, and the patient
recovered with antibiotic treatment. Increasing public and physician awareness
about plague can assist in prompt diagnosis and treatment.
     Efforts to prevent plague should include public education about risk
factors for exposure, methods to prevent plague, and the signs and symptoms of
infection; surveillance of rodent populations; and use of insecticides, and
occasionally rodenticides, to control populations of fleas and rodents,
respectively. Control measures should be undertaken when surveillance
indicates
epizootic activity among rodent populations.

References
1. Craven RB, Maupin GO, Beard ML, Quan TJ, Barnes AM. Reported cases of human
plague infections in the United States, 1970-1991. J Med Entomol
1993;30:758-61.
2. CDC. Draft guidelines for preventing the transmission of tuberculosis in
health-care facilities, 2nd edition; notice of comment period. Federal
Register
1993;58:52843-54.
3. Eskey CR, Haas VH. Plague in the western part of the United States. Public
Health Bulletin 1940;254.
4. Caten JL, Kartman L. Human plague in the United States, 1900-1966. JAMA
1968;205:81-4.
5. Barnes AM. Surveillance and control of bubonic plague in the United
States. In: Edwards MA, McDonnel U, eds. Animal disease in relation to
conservation. New York: Academy Press, 1982:237-70.
6. CDC. Hantavirus infection--southwestern United States: interim
recommendations for risk reduction. MMWR 1993;42(no. RR-11).
7. CDC. Update: outbreak of hantavirus infection--southwestern United States,
1993. MMWR 1993;42:495-6.

* A case of human plague is considered to be confirmed when 1) a bacterial
culture is identified as Yersinia pestis by biochemical testing and
bacteriophage typing or 2) there is a fourfold rise in antibody titers to the
F-1 antigen of Y. pestis.
** Provisional data.
*** West North Central, West South Central, and Mountain regions.



------------------------------

Date: Sat, 23 Apr 94 15:36:32 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR] Adult Blood Lead Epidemiology and Surveillance
Message-ID: <LBB0kc5w165w@stat.com>

                            Current Trends
           Adult Blood Lead Epidemiology and Surveillance --
                 United States, Fourth Quarter, 1993

     CDC's National Institute for Occupational Safety and Health (NIOSH) Adult
Blood Lead Epidemiology and Surveillance (ABLES) program monitors elevated
blood lead levels (BLLs) in adults. Blood lead data from laboratory reports
are
transmitted to state-based lead surveillance programs and are compiled by
NIOSH
for quarterly reporting (1). Data for 1993 from the 20 states currently
reporting results to NIOSH are complete (Table 1). Efforts to expand the
number
of states participating in the surveillance system continue as states increase
their capacity to monitor BLLs in both adults and children.

Reported by: NH Chowdhury, MBBS, Alabama Dept of Public Health. C Fowler, MS,
Arizona Dept of Health Svcs. FJ Mycroft, PhD, Occupational Health Br,
California Dept of Health Svcs. BC Jung, MPH, Connecticut Dept of Public
Health
and Addiction Svcs. M Lehnherr, Occupational Disease Registry, Div of
Epidemiologic Studies, Illinois Dept of Public Health. R Gergely, Iowa Dept of
Public Health. E Keyvan-Larijani, MD, Lead Poisoning Prevention Program,
Maryland Dept of the Environment. R Rabin, MSPH, Div of Occupational Hygiene,
Massachusetts Dept of Labor and Industries. A Carr, MBA, Bur of Child and
Family Svcs, Michigan Dept of Public Health. D Solet, PhD, Div of Public
Health
Svcs, New Hampshire State Dept of Health and Human Svcs. B Gerwel, MD,
Occupational Disease Prevention Project, New Jersey State Dept of Health. R
Stone, PhD, New York State Dept of Health. M Barnett, MS, State Health Div,
Oregon Dept of Human Resources. J Gostin, MS, Occupational Health Program, Div
of Environmental Health, Pennsylvania Dept of Health. R Marino, MD, Div of
Health Hazard Evaluations, South Carolina Dept of Health and Environmental
Control. DM Perrotta, PhD, Environmental Epidemiologist, Texas Dept of Health.
D Beaudoin, MD, Bur of Epidemiology, Utah Dept of Health. L Toof, Div of
Epidemiology and Health Promotion, Vermont Dept of Health. J Kaufman, MD,
Washington State Dept of Labor and Industries. D Higgins, Wisconsin Dept of
Health and Social Svcs. Div of Surveillance, Hazard Evaluations, and Field
Studies, National Institute for Occupational Safety and Health, CDC.

Reference
1. CDC. Surveillance of elevated blood lead levels among adults--United
States, 1992. MMWR 1992;41:285-8.



------------------------------

Date: Sat, 23 Apr 94 15:38:21 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: FDA Approves Tacrolimus for Liver Transplant Patients
Message-ID: <meB0kc7w165w@stat.com>

      FDA APPROVES TACROLIMUS FOR LIVER TRANSPLANT PATIENTS
      =====================================================

     FDA is receiving inquiries about its April 8, 1994, approval
of the drug tacrolimus (FK-506) for preventing graft rejection in
liver transplant patients.  The following may be used to answer
questions.
     Tacrolimus is the third immunosuppressant drug to receive FDA
approval for use in organ transplants.  Reports from early clinical
trials had suggested that it might be safer and better tolerated
than the two older transplant drugs--cyclosporine, used for heart,
liver and kidney transplants, and azathioprine, approved only for
kidney transplants.
     On Nov. 22, 1993, an FDA advisory committee agreed unanimously
that later clinical trials have not shown tacrolimus to be safer or
more effective than cyclosporine-based treatments.  However, the
committee recommended approval of tacrolimus because it would
provide another alternative for preventing rejection of
transplanted livers.
     These conclusions were based on two multicenter clinical
trials, each with more than 500 patients, that compared tacrolimus-
and cyclosporine-based treatments for liver transplants.  One study
was conducted in the United States and the other in Europe.  In
both trials, patient and graft survival rates were very similar for
the tacrolimus and cyclosporine groups.
     Although adverse effects were somewhat different for the two
drugs, both were associated with neurological problems (headaches,
insomnia, tremors), metabolic disturbances (high blood sugar),
kidney disorders, high blood pressure, nausea and vomiting.  These
problems, which occur early in treatment, tend to subside with
time.
     In the tacrolimus/cyclosporine clinical trials, 75 to 88
percent of patients were still alive one year after surgery.
Nationally, the one-year survival rate for all first-time liver
transplant patients is about 75 percent.  Approximately 3,000 liver
transplants are performed annually in the United States.
     Tacrolimus is manufactured by Fujisawa USA of Deerfield, Ill.,
and will be sold under the name Prograf.



------------------------------

Date: Sat, 23 Apr 94 15:39:03 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: FDA Warnings on "Sensor Pad"
Message-ID: <sFB0kc8w165w@stat.com>

=========================================================================
       Food And Drug Administration Recalls, News, And Warnings
=========================================================================

                           SENSOR PAD
                           ==========

     FDA is receiving inquiries about Sensor Pad, a thin plastic
pad filled with liquid silicone designed to aid in breast self
examination.
     This product is not currently approved as safe and effective
by FDA.  The agency has informed the manufacturer, Inventive
Products Inc. of Decatur, Ill., that it must conduct clinical
studies on the product's safety and effectiveness and obtain pre-
market approval from FDA in order to legally market it.
     FDA is requiring the firm to conduct clinical trials because
the agency has not seen valid scientific evidence that the product
will actually help women detect lumps and aid in the detection of
breast cancer.
     FDA is concerned that rather than aid in detection, the
product might actually miss lumps or mask their presence.
Detection of lumps has important health implications for American
women.  If a product making this claim does not perform as
intended, women who depend on it are put at grave risk.
     Inventive Products submitted a pre-market notification (510k)
for Sensor Pad in 1985, saying the device was substantially
equivalent to a legally marketed product.  Upon review, FDA
concluded that the device and its use were different from other
devices.  The firm was told that it would need to submit a full
premarket approval application (PMA).
     Despite the denial of its application, in 1987 the firm began
illegally marketing Sensor Pad to hospitals.   This led to a series
of seizures of the product by FDA.  When the firm contested the
original seizure, a federal court ruled in favor of FDA, concluding
that the pad was an adulterated medical device.  The firm appealed
the ruling, contending that the product was not a medical device.
     In 1991, a federal appeals court affirmed the original ruling
that the pad was a medical device and that an approved PMA would be
required before the device could be marketed.  Following the
initial seizure and throughout the legal process, the firm
continued to distribute the device, and FDA continued to seize it.
     In 1989, following the initial seizure, the firm submitted a
PMA to the agency.  This application contained little information
and it was inadequate as a basis for determining safety and
effectiveness.
     FDA has been working with Inventive Products for the past nine
years to assist in its attempt to bring its product to market.  The
agency is continuing to work with the firm to help it identify what
is necessary to show the product is safe and effective.  FDA has
met numerous times with the manufacturer to discuss the type and
quality of data that are needed and the ways clinical trials can be
conducted so as to be the least burdensome on the firm yet still
provide the necessary information on safety and effectiveness.



------------------------------

Date: Sat, 23 Apr 94 15:39:52 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: Tamoxifen Warning Increased Risk Cancer of the Uterus
Message-ID: <6gB0kc9w165w@stat.com>

                          TAMOXIFEN WARNING
               INCREASED RISK OF CANCER OF THE UTERUS
               ======================================

     The Food and Drug Administration announced today a stronger
warning to women and doctors that tamoxifen, an anti-cancer drug
used in treatment of breast cancer, poses an increased risk of
cancer of the uterus.
     Despite the increased risks, however, the latest study
results have reaffirmed that tamoxifen can delay or prevent
relapse in patients who have undergone surgery for breast cancer.
Therefore, tamoxifen continues to be indicated for the treatment
of breast cancer.
     The updated warning is based on the drug's package insert
that has been revised to reflect the most recent data from large
randomized trials.  The manufacturer of tamoxifen, Zeneca
Pharmaceuticals, is sending the updated labeling information in a
"Dear Doctor" letter to 380,000 oncologists and health care
professionals.
     "Tamoxifen is a valuable treatment for breast cancer, but it
is important for women to recognize that there are side effects
including an increased risk of cancer of the uterus," said FDA
Commissioner David A. Kessler, M.D.  "Women must also be advised
that if they have used the drug, they need to get regular
gynecologic exams and report to their doctor any abnormal vaginal
bleeding or discharge."
     A study in Sweden, which has now followed participants for
about nine years, showed that breast cancer patients who take
tamoxifen have a higher risk of uterine cancer than had been
suggested on the basis of earlier research.  In the latest
results of this study, 23 of the 1,372 patients randomized to
take tamoxifen developed the disease, compared with 4 of the
1,357 patients in the control group.  The ongoing B-14 trial of
the National Surgical Adjuvant Breast and Bowel Project produced
similar results after 6.8 years of follow-up.
     These data taken together show that women taking tamoxifen
face a risk of uterine cancer about two to three times higher
than the risk for women without breast cancer in the general
population.   Additional studies are under way to more clearly
define the role of other risk factors, such as prior hormone use.
     Recent unpublished data suggest a possible increase in
cancers in the gastrointestinal tract among women receiving
tamoxifen.  These results are at odds with other trials, and the
potential risk is being evaluated.  In addition, animal studies
continue to support long-held concerns that use of tamoxifen in
pregnancy might cause fetal harm, and raised the possibility of
causing DES-like syndrome.
     The FDA-revised package insert and the manufacturer's letter
to the health care professionals provide information on the new
findings and suggest steps that should be taken by women who are
using or have used tamoxifen.  FDA has also taken steps to ensure
that the new findings are reflected in the informed consent
document for women participating in NCI-sponsored studies using
tamoxifen, and that all women taking tamoxifen for treatment are
informed about updated risk information.
     The NCI emphasizes that the benefits of tamoxifen as a
treatment for breast cancer far outweigh the potential risks of
other cancers.  NCI's current clinical trial to study tamoxifen
as a preventive agent is based on evidence that the drug reduces
the risk of a new cancer in the other breast.  Data also suggest
that tamoxifen may decrease cardiovascular disease and stabilize
postmenopausal bone loss.
     NCI emphasizes, however, that tamoxifen should not be used
as a preventive agent outside of a clinical trial.
     Tamoxifen is marketed under the trade name Nolvadex by
Zeneca Pharmaceuticals, Wilmington, Del.



------------------------------

Date: Sat, 23 Apr 94 15:40:37 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: Antioxidants and Cancer Study
Message-ID: <eiB0kc10w165w@stat.com>

                  ANTIOXIDANTS AND CANCER STUDY
                  =============================

     FDA has been receiving inquiries concerning a Finnish study
on whether certain antioxidant vitamins protect against lung
cancer.  In the study, conducted jointly by the U.S. National
Cancer Institute and the National Public Health Institute of
Finland, vitamin E and beta-carotene supplements, when taken by
male smokers age 49 and older, did not protect against lung
cancer.  Incidence of certain other cancers was also examined.
     This study is important because it is the largest controlled
study of antioxidant vitamins and cancer to date.  It is also the
first study of this type in a well-nourished population.
     The following may be used to respond to questions:
     This study, published in the April 14, 1994, issue of the
New England Journal of Medicine, evaluated effects of the use of
beta-carotene and vitamin E dietary supplements on cancer.  The
study was designed to investigate whether the ingestion of higher
levels of antioxidant-containing vitamins can reduce the
incidence of lung cancer among smokers.
     A secondary objective of the study was to determine the
effects of the supplements on the incidence of other cancers.
Illnesses and deaths due to causes unrelated to cancer, such as
heart disease and strokes, were also monitored.
     Some evidence of a role for antioxidants in prevention of
cancer -- particularly lung cancer -- has been accruing from
animal studies and human observational studies.  However, there
have been no controlled, prospective trials in humans with normal
diets to evaluate the benefits and risks of antioxidants.  The
Finnish study, because it is a large and well-designed randomized
trial, provides a better chance of being able to identify a
genuine beneficial effect of antioxidant vitamins on incidence of
cancer.   The study was conducted over the course of
approximately six years in Finland and involved more than 29,000
male smokers above the age of 49 years.  This was a double-blind,
placebo-controlled trial.  Patients received either 50 mg of
vitamin E (50 I.U. of vitamin E as alpha-tocopherol -- more than
three times the Recommended Dietary Allowance), 20 mg of beta-
carotene (about 33,000 I.U. or more than three times the RDA for
vitamin A, the active form of beta-carotene), both vitamin E and
beta-carotene, or neither (a placebo).
     The primary conclusion of this study is that there was no
evidence of a beneficial effect of supplemental vitamin E or
beta-carotene in prevention of lung cancer over the six years of
the trial.  Rather, the group consuming the beta-carotene had a
significantly higher (18 percent) incidence of lung cancer than
those participants who did not take it.  Participants who took
beta-carotene also had higher rates of cancers of the prostate
and stomach.  The overall death rate was 8 percent higher in
beta-carotene supplement users than in the placebo group.
     Overall mortality did not significantly differ for vitamin E
users and nonusers.  Vitamin E was associated with a lower rate
of prostate cancer and perhaps colorectal cancer, but was
associated with increased risk of bladder, stomach and other
cancers.  While vitamin E was also associated with decreased
deaths from heart disease and related strokes, it was associated
with increased deaths from hemorrhagic strokes.
     While FDA believes this study is important and its results
significant, it does not settle the antioxidant question.
Confirmation in other studies is important to clarify the
results.  So far, data do not allow a determination of whether
the results would apply to non-smokers, women and younger people.
Nevertheless, FDA agrees with the study's authors that the
results "raise the possibility that these substances may have
harmful as well as beneficial effects.  Longer observation of the
participants in this trial and data from other studies of people
at normal risk or high risk for cancer will be required to
determine the full spectrum of effects of these agents."
     The results of the Finnish trial are consistent with FDA's
health claim policy for foods rich in antioxidant-containing
vitamins.  FDA shares the view in the New England Journal of
Medicine's editorial, which accompanies the study report, that
many issues need to be resolved before the agency could authorize
specific health claims for supplements (as opposed to diets)
containing beta-carotene and vitamin E.
     While the study did not show that the tested supplemental
beta-carotene and vitamin E were beneficial, baseline diets rich
in foods containing these nutrients were predictive of lower lung
cancer risk.  FDA has authorized a health claim linking reduced
cancer risk with consumption of low fat diets rich in fruits and
vegetables that are sources of beta-carotene and vitamin E but
has not authorized a health claim for beta-carotene or vitamin E
in supplement form.  This conclusion was based on the available
data and significant scientific agreement among qualified experts
that diets rich in fruits and vegetables are associated with
decreased cancer risk.  The agency did not find sufficient
scientific agreement to attribute the effect to specific
substances -- such as beta-carotene and vitamin E -- in these
foods.
     Recommendations in the U.S. Dietary Guidelines and NCI's
"Five-a-Day" program, which emphasize low fat diets rich in
fruits and vegetables, remain sound advice for consumers wishing
to reduce their risk of cancers and chronic diseases.

     FDA continues to believe that the majority of vitamin and
mineral supplements consumed today -- particularly
multivitamin/multi-mineral products containing nutrients at
levels consistent with recommended daily amounts -- do not raise
safety concerns.  FDA also agrees with the conclusions of the New
England Journal of Medicine's editorial: "The results of the
Finnish trial do not disprove the potential benefits of
antioxidant vitamins, but they do provide timely support for
heightened skepticism ...".



------------------------------

End of HICNet Medical News Digest V07 Issue #13
***********************************************


---
Editor, HICNet Medical Newsletter
Internet: david@stat.com                 FAX: +1 (602) 451-1165
Bitnet  : ATW1H@ASUACAD


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