HICNet Medical News Digest      Thu, 30 Jun 1994        Volume 07 : Issue 29

Today's Topics:

  [MMWR 24 June 94] Arthritis Prevalence and Activity Limitations
  [MMWR] Injecting-Drug Users and Bleach Use for Disinfection
  [MMWR] Viral Gastroenteritis Associated with Raw Oysters
  Oral Pathology Course
  Parkinson's Disease Conference
  Obstructive Sleep Apnea Syndrome
  Cardiology: Today and Tommorrow - Conference
  New Vaccine May Prevent Tooth Loss

             +------------------------------------------------+
             !                                                !
             !              Health Info-Com Network           !
             !                Medical Newsletter              !
             +------------------------------------------------+
                        Editor: David Dodell, D.M.D.
   10250 North 92nd Street, Suite 210, Scottsdale, Arizona 85258-4599 USA
                        Telephone +1 (602) 860-1121
                           FAX +1 (602) 451-1165
                         Internet: mednews@stat.com
                           Bitnet: ATW1H@ASUACAD

Compilation Copyright 1994 by David Dodell,  D.M.D.  All  rights  Reserved.
License  is  hereby  granted  to republish on electronic media for which no
fees are charged,  so long as the text of this copyright notice and license
are attached intact to any and all republished portion or portions.

The Health Info-Com Network Newsletter is  distributed  biweekly.  Articles
on  a medical nature are welcomed.  If you have an article,  please contact
the editor for information on how to submit it.  If you are  interested  in
joining the automated distribution system, please contact the editor.

                             Associate Editors:

E. Loren Buhle, Jr. Ph.D. Dept. of Radiation Oncology, Univ of Pennsylvania

       Tom Whalen, M.D., Robert Wood Johnson Medical School at Camden

        Douglas B. Hanson, Ph.D., Forsyth Dental Center, Boston, MA

             Lawrence Lee Miller, B.S. Biological Sciences, UCI

            Dr K C Lun, National University Hospital, Singapore

             W. Scott Erdley, MS, RN, SUNY@UB School of Nursing

      Jack E. Cross, B.S Health Care Admin, 882 Medical Trng Grp, USAF

  Albert Shar, Ph.D. CIO, Associate Prof, Univ of Penn School of Medicine

  Martin I. Herman, M.D., LeBonheur Children's Medical Center, Memphis TN

   Stephen Cristol, M.D., Dept of Ophthalmology, Emory Univ, Atlanta, GA

                  Subscription Requests = mednews@stat.com
              anonymous ftp = vm1.nodak.edu; directory HICNEWS
               FAX Delivery = Contact Editor for information


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

Date: Thu, 30 Jun 94 21:28:05 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR 24 June 94] Arthritis Prevalence and Activity Limitations
Message-ID: <iXoRoc1w165w@stat.com>

        Arthritis Prevalence and Activity Limitations --
                       United States, 1990

     Arthritis is a leading cause of work-related disability and the
leading cause of disability among persons aged greater than or equal to 65
years in the United States (1). However, there are few national or
state-specific estimates and no projections of arthritis prevalence or its
impact (2). To develop national and state estimates of arthritis prevalence
and physical activity limitation for 1990 and to project these measures
through 2020, rates derived from household interview data from the
1989-1991 National Health Interview Survey (NHIS) were applied to the 1990
census population and to census population projections. This report
presents the results of that analysis.
     The NHIS is a probability sample of the civilian, noninstitutionalized
population of the United States (3). Estimates of arthritis prevalence were
derived by using a random sample of one sixth (n=59,289) of survey
respondents, who were asked about the presence of any of a variety of
musculoskeletal conditions during the preceding 12 months and for details
of these conditions. Each condition was assigned an International
Classification of Diseases, Ninth Revision, Clinical Modification
(ICD-9-CM), code. Arthritis was classified as a condition that matched
ICD-9-CM codes* selected by the National Arthritis Data Workgroup. A total
of 8963 (15.1%) persons were classified as having arthritis. Estimates of
activity limitation attributable to arthritis were derived by using all
356,592 NHIS respondents, who were asked whether they were limited in or
prevented from working, housekeeping, or performing other activities as a
result of a health condition(s) and, if so, what specific condition(s)
caused the limitation; 10,084 (2.8%) persons reported arthritis as a major
or contributing cause of activity limitation.
     Synthetic state estimates** for 1990 were developed by applying
respective regional arthritis rates, stratified by age, sex, race, and
ethnicity, to the stratum-specific populations of each state as reported by
the 1990 census. National projections through 2020 were determined by
applying national arthritis prevalence rates, stratified by age, sex, and
race, to the total U.S. population projected by the U.S. Bureau of the
Census (4).
     In 1990, an estimated 15.0% (37.9 million persons) of the U.S.
population had arthritis. Estimated prevalence rates were 49.4% for persons
aged greater than or equal to 65 years, 5.1% for persons aged less than or
equal to 44 years, and 0.5% for children aged less than or equal to 16
years. Arthritis rates age-adjusted to the 1989-1991 population were higher
for women (17.1%) than men (12.5%) and for non-Hispanics (15.3%) than
Hispanics (11.3%) (Table 1). Rates were similar for blacks and whites. Of
persons reporting arthritis, 83.6% had consulted a physician for the
problem.
     In 1990, an estimated 2.8% (7.0 million persons) of the U.S.
population had arthritis as a major or contributing cause of activity
limitation. Arthritis limited activities in 11.6% of persons aged greater
than or equal to 65 years, 0.5% of persons aged less than or equal to 44
years, and 0.1% of persons aged less than or equal to 16 years. Rates of
activity limitation, adjusted for age, were higher for women (3.4%) than
men (2.0%) and for blacks (4.0%) than whites (2.6%) (Table 1). Age-adjusted
rates of activity limitation were twofold higher for persons with 8 or
fewer years of education than for persons with a college degree and were
threefold higher for persons earning $10,000 or less per year than for
persons earning $35,000 or more.
     Based on region-specific rates and state-specific age, sex, race, and
ethnicity distributions, estimated synthetic prevalence rates for
self-reported arthritis were lowest in Alaska (10.0%) and highest in
Florida (19.1%) (Table 2). Similarly derived rates of arthritis-limited
activity were lowest in Alaska (1.5%) and highest in Florida and the
District of Columbia (3.8% each).
     The prevalence rate of self-reported arthritis in the United States is
projected to increase from 15.0% of the 1990 population to 18.2% (59.4
million) of the estimated population for 2020. Activity limitation
associated with arthritis is projected to increase from 2.8% of the 1990
population to 3.6% (11.6 million) of the 2020 population.

Reported by: National Arthritis Data Workgroup. Statistics Br and Aging
Studies Br, Div of Chronic Disease Control and Community Intervention,
National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note: The findings in this report indicate that both the
estimated number of persons with arthritis and the prevalence rate of
arthritis have increased since 1985, when 35 million (14.5%) persons had
arthritis (5). By 2020, the estimated number of persons with arthritis is
projected to increase by 57% and activity limitation associated with
arthritis by 66%. These projected increases are largely attributable to the
high prevalence of arthritis among older persons and the increasing average
age of the U.S. population.
     The reasons for higher rates of arthritis among women and higher rates
of activity limitation among women and persons with low education and low
income are not clear. Race and ethnicity are probably risk markers and not
risk factors for arthritis. Risk markers may be useful for identifying
groups at greatest risk for arthritis and targeting intervention efforts.
     Although arthritis is more prevalent and a more frequent cause of
activity limitation than heart disease, cancer, or diabetes (6),
epidemiologic data about this condition are limited. To address this
limitation, federal and private groups are collaborating to provide better
information about the frequency and impact of arthritis. In addition, some
states are gathering data through the Behavioral Risk Factor Surveillance
System (7) and making diagnostic, treatment, educational, and
rehabilitative services more accessible to all persons with arthritis (8).
     The findings in this report are subject to at least three limitations.
First, the estimates are based on self-reported data that were not
validated by a health-care provider. However, because many persons with
arthritis do not seek medical care, self-reported data may provide a better
indicator of symptomatic arthritis (9). Second, synthetic estimates are not
based on direct measurements of state data. Third, synthetic state
estimates were not adjusted for income, education, and metropolitan
statistical area. In addition, the definition for arthritis used in this
report was more comprehensive than that used in the 1985 study and includes
additional conditions (e.g., lupus, infectious arthritis, and carpal tunnel
syndrome) that persons would identify as arthritis.
     Further studies are needed to define the frequency of the specific
types of arthritis, determine the characteristics of persons who do not
seek medical care, and better assess the financial and societal impact of
arthritis. In addition, data are needed to better characterize differences
in the prevalence and impact of arthritis in demographic subgroups and to
provide more direct measures of arthritis for individual states. These data
will assist in efforts to reduce the projected impact of arthritis and to
direct interventions and services to groups disproportionately affected by
arthritis.
     States can use these synthetic estimates to set priorities and target
resources until more direct measures of arthritis prevalence and impact are
available. To lessen the projected impact of arthritis, health-care
providers should 1) promote primary prevention of arthritis through
prevention of obesity and sports-associated or occupational-associated
joint injury, and 2) encourage early detection and appropriate management
of persons with arthritis, including exercise and educational programs
(e.g., the Arthritis Self-Help Course, which has been shown to reduce pain
and physician visits [10]).

References
1. Pope AM, Tarlow AR, eds. Disability in America: toward a national agenda
for prevention. Washington, DC: National Academy Press, 1991.
2. CDC. Prevalence of arthritic conditions--United States, 1987. MMWR
1990;39:99- 102.
3. Massey JT, Moore TF, Parsons VL, Tadros W. Design and estimation for the
National Health Interview Survey, 1985-94. Vital Health Stat 1989;2:1-4.
4. Day JC. Population projections of the United States, by age, sex, race,
and Hispanic origin: 1993 to 2050. Washington, DC: US Department of
Commerce, Bureau of the Census, 1993. (Current population reports; series
P25, no. 1104).
5. Lawrence RC, Hochberg MC, Kelsey JL, et al. Estimates of the prevalence
of selected arthritic and musculoskeletal diseases in the United States. J
Rheumatol 1989;16:427-41.
6. LaPlante MP. Data on disability from the National Health Interview
Survey, 1983-1985. Washington, DC: US Department of Education, National
Institute on Disability and Rehabilitation Research, 1988.
7. CDC. Prevalence of arthritis--Arizona, Missouri, and Ohio, 1991-1992.
MMWR 1994;43:305-9.
8. CDC. Arthritis program--Missouri. MMWR 1988;37:85-7.
9. Edwards S. Evaluation of the National Health Survey diagnostic
reporting. Rockville, Maryland: Westat, Inc., December 21, 1992, (report to
NCHS).
10. Lorig KR, Mazonson PD, Holman HR. Evidence suggesting that health
education for self-management in patients with chronic arthritis has
sustained health benefits while reducing health care costs. Arthritis Rheum
1993;36:439-46.

*ICD-9-CM codes 95.6, 95.7, 98.5, 99.3, 136.1, 274, 277.2, 287.0, 344.6,
353.0, 354.0, 355.5, 357.1, 390, 391, 437.4, 443.0, 446, 447.6, 696.0,
710-716, 719.0, 719.2-719.9, 720-721, 725-727, 728.0-728.3, 728.6-728.9,
729.0-729.1, and 729.4. **Synthetic estimation obtains state estimates of
characteristics by combining regional estimates of the characteristics
specific to demographic subgroups with estimates of the proportional
distribution of the local population in those subgroups.



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

Date: Thu, 30 Jun 94 21:29:51 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR] Injecting-Drug Users and Bleach Use for Disinfection
Message-ID: <g1oRoc2w165w@stat.com>

       Knowledge and Practices Among Injecting-Drug Users
           of Bleach Use for Equipment Disinfection --
                       New York City, 1993

     Sharing (i.e., multiperson use) of drug-injection equipment among
injecting-drug users (IDUs) is a major risk factor in the transmission of
human immunodeficiency virus (HIV) and other bloodborne pathogens.
Abstaining from injection of drugs eliminates this risk; disinfection of
needles and syringes with household bleach can reduce this risk. Because
studies suggest the effectiveness of bleach disinfection may be limited,
the March 1993 National Institute on Drug Abuse (NIDA) Community Alert
Bulletin included recommendations that IDUs who do not stop injecting and
sharing injection equipment use full-strength household bleach and keep the
bleach in contact with the equipment for at least 30 seconds (1). To
determine whether these new recommendations had been disseminated
effectively to IDUs, the knowledge of bleach use for disinfection of
drug-injection equipment among IDUs participating in a NIDA-sponsored New
York City cohort study was assessed during August-December 1993. This
report presents data about knowledge of bleach use for disinfection among
persons who reported injecting drugs at least once during the 3-6 months
preceding the interview.
     During September 1991-December 1993, cohort members were recruited
originally from methadone-maintenance treatment programs (MMTPs) in
Manhattan and through flyers and word-of-mouth in Manhattan communities
with large numbers of out-of-treatment IDUs. During August-December 1993,
696 cohort members were interviewed during scheduled study visits; 367
(53%) who stated they had not injected drugs during that period and 39 (6%)
who were not asked about bleach were excluded from this analysis. At the
time of the interview, 304 (83%) of those excluded because they had not
injected drugs were enrolled in MMTPs, and eight (2%) were in other types
of drug treatment. Respondents were asked, "Should bleach be mixed with
water to clean works?" "If yes, how much water are you supposed to mix in
with the bleach?"; and "How long do you need to leave the bleach in the
syringe in order to kill the AIDS virus?" Respondents also were asked
whether they had "injected [drugs] with used needles or shared needles with
anyone."
     Of the 290 active IDU respondents, 232 (80%) were male; the mean age
of all persons interviewed was 40 years (range: 22-66 years). Most (230
[79%]) respondents were enrolled in MMTPs at the time of interview; five
(2%) were in other types of drug treatment; and 55 (19%) were not in
treatment. Overall, 150 (52%) reported average injection frequency of at
least once per week during the 3-6 months preceding the interview. The
primary drugs injected were heroin, cocaine, or a combination of heroin and
cocaine. Needle-exchange programs were reported as the primary source of
injection equipment for 118 (41%) during the 3-6 months preceding the
interview.
     Of the 290 respondents, 173 (60%) knew that full-strength bleach
should be used to clean used needles, compared with 90 (31%) who thought
bleach should be mixed with water; 27 (9%) did not know what strength
bleach should be used. One hundred seventy-one (59%) respondents knew that
needles and syringes must be in contact with bleach for at least 30
seconds. Approximately one third (102 [35%]) responded correctly to both of
these questions.
     Of 60 persons who reported sharing injection equipment during the
preceding 3-6 months, 38 (63%) did not answer both questions correctly.
Forty-five (75%) reported either not using bleach or using bleach
inconsistently. Four (7%) of those who reported sharing injection equipment
responded correctly to both questions and reported always using
full-strength bleach.
     Correct bleach use knowledge did not differ substantially for sex;
age; methadone-treatment status; educational level; and recent needle
exchange, needle sharing, and bleach use.

Reported by: M Marmor, PhD, H Wolfe, MS, S Titus, MPH, New York Univ
Medical Center, Dept of Environmental Medicine; DC Des Jarlais, PhD, Beth
Israel Medical Center, New York. Behavioral and Prevention Research Br, Div
of Sexually Transmitted Diseases and HIV Prevention, National Center for
Prevention Svcs; Office of the Associate Director (HIV/AIDS), Office of the
Director, CDC.

Editorial Note: The findings in this report indicate that only one fifth of
the active IDUs reported sharing injection equipment. However, of those who
did share, only one fourth used bleach consistently and, of all the active
IDUs, only one third knew both recommendations for correct bleach use,
regardless of whether they shared injection equipment or used bleach.
Because of inconsistent use and incomplete knowledge, active IDUs who reuse
syringes that have been used by other
IDUs are at high risk for HIV infection.
     The findings of this study are subject to at least three limitations.
First, these findings may not be generalizable to other IDUs in New York
City or in other U.S. cities. Second, because the data were gathered 5-9
months after the NIDA bulletin was issued in March 1993, knowledge levels
of IDUs since then may have increased. Finally, the sample size was
adequate to detect only large effects of many characteristics on knowledge
of correct bleach use for disinfection.
     Because IDUs do not always use sterile equipment, since the mid-1980s
HIV-prevention programs for IDUs in the United States have recommended
using bleach for disinfection of drug-injection equipment previously used
by another person to reduce the possibility of HIV transmission. Bleach was
recommended based on its widespread availability, low cost, and ability to
inactivate HIV (2).
     Recent findings have indicated three limitations in the effectiveness
of using bleach: 1) the presence of blood or other organic material in the
equipment can reduce the effectiveness of bleach (3); 2) there appears to
be a minimum contact time needed for bleach to inactivate HIV (4); and 3)
many IDUs do not follow recommendations for bleach use for disinfection
(5). As a result of these limitations, two national bulletins were issued
in early 1993 (1,6) describing disinfection procedures that would increase
the likelihood of disinfection. The provisional recommendations included
prebleach washing of the syringe to remove organic material, use of
full-strength bleach, and presence of bleach in the syringe for at least 30
seconds.
     HIV-prevention programs that target drug users should inform IDUs 1)
not to inject drugs; 2) if they do inject, to use new, sterile needles and
syringes for every injection; and 3) if they cannot use sterile equipment,
to disinfect the equipment following the recommendations for bleach
disinfection. The availability of effective drug-treatment programs and
sterile injection equipment are HIV-prevention priorities to assist IDUs
who will not or cannot stop injecting drugs (7).

References
1. Millstein R. Community alert bulletin. Rockville, Maryland: US
Department of Health and Human Services, Public Health Service, Alcohol,
Drug Abuse, and Mental Health Administration, National Institute on Drug
Abuse, March 25, 1993.
2. Martin LS, McDougal JS, Loskoski SL. Disinfection and inactivation of
human T lymphotrophic virus type III/lymphadenopathy-associated virus. J
Infect Dis 1985;152:400-3.
3. Flynn N, Jain S, Keddie E, et al. Bleach is not enough: giving IV drug
users a choice of disinfectants when they share needles and syringes
[Abstract]. Vol 3. VI International Conference on AIDS, San Francisco, June
20-24, 1990:279.
4. Shapshak P, McCoy CB, Rivers JE, et al. Inactivation of human
immunodeficiency virus-1 at short time intervals using undiluted bleach
[Letter]. J Acquir Immune Defic Syndr 1993;6:218-9.
5. Gleghorn AA, Doherty MC, Vlahov D, et al. Insufficient bleach contact
time during syringe cleaning among injecting-drug users (IDUs) [Abstract].
Vol 2. IX International Conference on AIDS/IV STD World Congress, Berlin,
June 6-10, 1993:872.
6. CDC/Center for Substance Abuse Treatment/National Institute on Drug
Abuse. HIV AIDS prevention bulletin. Atlanta: US Department of Health and
Human Services, Public Health Service, CDC, April 19, 1993.
7. Lurie P, Reingold A. The public health impact of needle exchange
programs in the United States and abroad. Vol 1. San Francisco: Institute
for Public Health Studies, 1993.



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

Date: Thu, 30 Jun 94 21:31:09 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR] Viral Gastroenteritis Associated with Raw Oysters
Message-ID: <m3oRoc3w165w@stat.com>

                      Viral Gastroenteritis
   Associated with Consumption of Raw Oysters -- Florida, 1993

     During November 20-30, 1993, four county public health units (CPHUs)
of the Florida Department of Health and Rehabilitative Services (HRS) in
northwestern Florida conducted preliminary investigations of seven separate
outbreaks of foodborne illness following consumption of raw oysters. On
December 1, the HRS State Health Office initiated an investigation to
characterize the illness, examine risk factors for oyster-associated
gastroenteritis, and quantify the dose-response relation. This report
presents the findings of these two investigations.

Preliminary Investigations by the HRS CPHUs
     In November 1993, private physicians notified the CPHUs of 20 persons
with possible foodborne illness. These 20 ill persons identified seven well
meal companions. Raw oysters were the only common food item eaten by all
ill persons; no well meal companions had eaten oysters. At the request of
the HRS State Health Office, CPHUs initiated active surveillance for cases
of raw oyster-associated gastroenteritis among patients of hospital
emergency departments, urgent-care centers, and private physicians in
northwestern Florida. A case was defined as sudden onset of nausea,
vomiting, diarrhea, or abdominal cramps within 72 hours of eating raw
oysters. Twenty-five additional cases of gastroenteritis associated with
eating raw oysters were detected.
     Traceback of implicated oysters by the CPHUs and the Florida
Department of Environmental Quality indicated the oysters had been
harvested from Apalachicola Bay in northwestern Florida during November
15-23.

Epidemiologic Investigation by the HRS State Health Office
     The 45 persons with raw oyster-associated gastroenteritis reported by
the CPHUs identified 26 well meal companions who had eaten oysters during
the same meal as ill persons, but did not become ill. Of 44 ill persons for
whom data were available, 36 (82%) had developed diarrhea; 34 (77%),
nausea; 33 (75%), abdominal cramps; 25 (57%), vomiting; 17 (39%), fever; 15
(34%), headache; and 14 (32%), myalgia. The attack rate was 63%. Of the 45
ill persons, 10 were hospitalized for 24 hours or longer. For 30 persons
for whom data were available, the median incubation period was 31 hours
(range: 2-69 hours). For 26 persons for whom data were available, the
median duration of illness was 48 hours (range: 10 hours-7 days); for 13
persons, duration of illness was more than 3 days. No household contacts of
ill persons developed gastroenteritis.
     No differences were identified between persons who became ill and well
meal companions in preexisting medical conditions or medications.
Consumption of alcohol or food (e.g., crackers and hot sauce) with the
oysters was not associated with risk for illness. Based on the 33 cases for
which data were available, a dose-response relation was observed between
illness and number of raw oysters eaten (chi square for trend=3.98;
p=0.05). The attack rate was highest among raw-oyster eaters who had
consumed more than 5 dozen oysters (91%) and lowest among those who had
consumed less than 1 dozen oysters (46%).
     Paired serum specimens from 10 patients were tested for antibody to
Norwalk-like virus by enzyme immunoassay (1); three pairs demonstrated a
fourfold or greater rise in titer. Seven stool specimens were examined by
electron microscopy (EM) and reverse transcription-polymerase chain
reaction (RT-PCR). In four specimens, small round-structured viruses were
detected by EM; in one specimen, a Norwalk-like genome was confirmed by
RT-PCR (2,3). This Norwalk-like virus strain had a nucleotide sequence
distinct from similar viruses in nearly simultaneous outbreaks associated
with consumption of oysters harvested along the Louisiana coast (4).
     No confirmed evidence of improper handling (e.g., inadequate
refrigeration time or temperature) of the implicated oysters was detected.
However, three ill persons had purchased oysters from retail establishments
that were not licensed seafood dealers.
     The National Shellfish Sanitation Program (NSSP) requires fecal
coliform testing at least once each month. Fecal coliform testing of water
drawn from 39 monitoring sites in Apalachicola Bay on October 3, November
21, and November 24 indicated that water quality in the bay met the
criteria of the NSSP (5). No environmental source of pollution was
identified. Sanitation procedures at the oyster-processing facilities where
seafood dealers purchased oysters met standards set by the Florida
Department of Environmental Protection (FDEP). However, based on the
epidemiologic evidence of illness associated with oysters harvested from
those waters, FDEP temporarily closed the shellfish-harvesting area of
Apalachicola Bay during December 1-7. No cases of gastroenteritis related
to consumption of oysters harvested after December 7 have been reported.

Reported by: C Davis, A Smith, MD, R Walden, Bay County Public Health Unit,
Panama City; G Bower, K Cummings, B Dean, J Rigsby, Jackson County Public
Health Unit, Marianna; P Justice, C Anderson, N Brown, J Minor, Washington
County Public Health Unit, Chipley; EF Geiger, MD, V Laxton, District 1
Health Office, Pensacola; L Crockett, MD, W McDougal, District 2 Health
Office, Tallahassee; WG Hlady, MD, RS Hopkins, MD, State Epidemiologist,
State Health Office, Florida Dept of Health and Rehabilitative Svcs. Food
and Drug Administration. Viral Gastroenteritis Section, Respiratory and
Enterovirus Br, Div of Viral and Rickettsial Diseases, National Center for
Infectious Diseases; Div of Field Epidemiology, Epidemiology Program
Office, CDC.

Editorial Note: This report documents outbreaks of viral gastroenteritis in
Florida linked to consumption of raw oysters from waters that apparently
met the standards for shellfish sanitation. Clinical and epidemiologic
features of the outbreaks are similar to recently reported multistate
outbreaks of viral gastroenteritis associated with eating oysters harvested
in Louisiana (4). RT-PCR with sequencing identified different strains of
the virus in the multistate outbreak and the Florida outbreak, suggesting
independent sources of oyster contamination.
     Although infection with the oysterborne Norwalk-like virus caused no
fatalities in this outbreak, raw oyster consumption has been linked in
Florida to 30 fatal cases of infection with Vibrio vulnificus during
1981-1992 among persons with preexisting liver disease (6). V. vulnificus
is a ubiquitous organism found in seawater. In Florida, consumer
information statements (required as labels on bags of oysters and in
restaurants) emphasize the risk for Vibrio infection among persons with
underlying liver disease and other preexisting illnesses (6). In addition,
these statements suggest that such persons eat oysters fully cooked and
consult with their physician if uncertain about whether they are at risk.
     States conduct monitoring programs to assure clean oyster beds, legal
harvesting, and proper handling of oysters. However, at both the Louisiana
and Florida oyster harvest sites, routine fecal coliform water-quality
monitoring conducted once each month did not detect oyster-bed
contamination. Furthermore, the outbreak reported in Florida was identified
in part because of publicity about the larger outbreaks associated with
oysters harvested in Louisiana. These findings suggest that monitoring
waters for fecal coliforms may be insufficient to indicate the presence of
viruses (e.g., Norwalk-like virus). Continued surveillance for outbreaks of
gastroenteritis associated with consumption of raw oysters is needed to
assess efficacy of the NSSP in preventing human illness. Public health
officials should consider raw oyster consumption as a possible source of
infection during the evaluation of gastroenteritis outbreaks.

References
1. Monroe SS, Stine SE, Jiang XI, Estes MK, Glass RI. Detection of antibody
to recombinant Norwalk virus antigen in specimens from outbreaks of
gastroenteritis. J Clin Microbiol 1993; 31:2866-72.
2. Moe CL, Gentsch J, Ando T, et al. Application of PCR to detect Norwalk
virus in fecal specimens from outbreaks of gastroenteritis. J Clin
Microbiol 1994;32:642-8.
3. Ando T, Mulders MN, Lewis DC, Estes MK, Monroe SS, Glass RI. Comparison
of the polymerase region of small round structured virus strains previously
classified in three antigenic types by solid-phase immune electron
microscopy. Arch Virol 1994;135:217-26.
4. CDC. Multistate outbreak of viral gastroenteritis related to consumption
of oysters--Louisiana, Maryland, Mississippi, and North Carolina, 1993.
MMWR 1993;42:945-8.
5. Office of Seafood, Shellfish Sanitation Branch, Food and Drug
Administration. Sanitation of shellfish growing areas, part 1. [Section
C.3.c]. In: National Shellfish Sanitation Program manual of operations.
Washington, DC: US Department of Health and Human Services, Public Health
Service, 1992:C8-C9.
6. Hlady WG, Mullen RC, Hopkins RS. Vibrio vulnificus from raw oysters:
leading cause of reported deaths from foodborne illness in Florida. J Fla



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

Date: Thu, 30 Jun 94 21:32:04 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: Oral Pathology Course
Message-ID: <64oRoc4w165w@stat.com>

     ORAL PATHOLOGY will be presented 9-13 January 1995 at Disney's
     Contemporary Resort, Lake Buena Vista, FL, USA.

     SPONSORS: Armed Forces Institute of Pathology and the American
     Registry of Pathology,  The formal continuing medical education
     program of the AFIP is accepted by the Academy of General Dentistry
     for Fellowship, Mastership, and membership maintence credit.

     GENERAL INFO:  AFIP Education Dept.,NW, Washington, DC 20306-6000 USA;
     301/427-5231;  FAX 301/427-5001;  INTERNET: LOWTHER@email.afip.osd.mil
     (Brochure is available upon request)

     CONTENT: This course is designed to provide dentists and all dental
     specialists, including trainees in oral pathology with a fundamental
     knowledge of various aspects of oral diseases.  General pathologists,
     general residents, and other physicians with an interest in diseases
     of the head and neck area would also find the course beneficial in
     brining them up to date on recent developments in this field.
     Developmental disturbances of the head, neck, and oral regions,
     inflammatory diseases of the oral mucosa and jaws, oral
     manifestations of certain systemic diseases, and neoplasms of the
     oral cavity and related structures will be discussed in detail.
     Information detailing the oral manifestations of HIV infection and
     AIDS will be included.  The primary emphasis of the course will be on
     clinical and radiographic characteristics of disease.  Treatment
     aspects and a brief discussion of the histopathologic features of
     each disease will be provided.  Lectures and case presentations will
     be complemented by clinical problem-solving exercises and elective
     microscopic slide laboratories.  The course will be presented by oral
     pathologists from the staff of the AFIP and other civilian and
     military institutions.
        The focus will be primarily on the clinical and radiographic
     aspects of oral disease.  Anticipated learning outcomes include
     enhancing skills in developing a meaningful clinical differential
     diagnosis and establishing effective communication between clinician
     and pathologists.  The course will provide the dentist and physician
     with the understanding of the diseases affecting the oral and
     paraoral regions that facilitate the early detection, diagnosis, and
     proper treatment of such disorders.  (27 hours with labs/ 22.75 w/o
     labs, CAT 1, AMA)   (Brochure is available upon request)

     COURSE DIRECTOR:
     Robert B. Brannon, Col, USAF, DC

     TUITION: Early-Bird tuition is $475. After 11 November 1994 it is
     $495.  Active duty military, DoD civilians, full-time permanant
     Department of Veterans Affairs employees (not residents or fellows),
     and commissioned officers of the Public Health Service with authorized
     approval have a registration fee of $175. After 11 November this fee
     will be $195.



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

Date: Thu, 30 Jun 94 21:32:47 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: Parkinson's Disease Conference
Message-ID: <c6oRoc5w165w@stat.com>

PARKINSON'S DISEASE CONFERENCE
Communication in Europe: A multi-professional approach to management and
care.
Organized by the European Parkinson's Disease Association (EPDA),
21-23 September 1994, The Hospitality Inn, Glasgow, Scotland.

The aim of the conference is:
To enhance the quality of life of people in Europe with Parkinson's disease
and their familie by encouraging good communication, mutual awareness and
respect, and a sharing of knowledge and experience amongst a wide range of
professionals involved in management and care.

Objectives of the conference:
Conference participants will:
* exchange knowledge and understanding of the care of Parkinson's disease
with members of their own profession and members of the multi-professional
team
* develop knowledge and awareness of the medical, social and personal needs
of people living with Parkinson's disease
* consider ways of overcoming the barriers to good communication with
patients, their families and between professionals
* develop strategies for multi-professional care in the management of
Parkinson's disease from the time of diagnosis
* to share models of good practice throughout Europe.

Scientific Programme Committee:
* Professor Yves Agid
* Dr. Alfredo Berardelli
* Dr. Paul Delwaide
* Dr. Erik Dupont
* Professor J.P.W.F. Lakke
* Dr. Jan Peter Larsen
* Professor Dr. Werner Poewe
* Dr. Jan Presthus
* Professor U.K. Rinne
* Professor Dr. R.A.C. Roos
* Professor Goran Steg
* Professor Eduardo Tolosa
* Dr. Steinar Vilming.

CALL FOR PAPERS:
Delegates are invited to submit abstracts for poster presentation.
Anyone interested in presenting a poster should send in an abstract of not
more than 250 words to the:
Conference Administrator,
Macmillan Magazines Ltd.,
4 Little Essex Street,
London, WC2R  3LF,
U.K.
Conferences Department Tel: 071-836 6633 Ext: 2593 Fax: 071-379 5417
Closing date for receipt of abstracts is June 30th, 1994.

The conference is supported by a wide-range of professional organisations:
* the World Health Organization
* Commission of European Communities - Helios II Programme
* the British Geriatrics Society
* Association of British Neurologists
* the Royal College of Nursing
* the Chartered Society of Physiotherapy
* the College of Occupational Therapists
* the College of Speech and Language Therapists
* Care of the Eldery
* Nursing Times
* Community Outlook
* Therapy Weekly
* the Parkinson's Disease Society of the UK.

=========================================================================

At the beginning of August 1994 I will forward the final programme of the
conference.
Regards,

Gerard van Rossum       Gerard.G.J.vanRossum@MTA6.KEMA.NL

==========================================================================



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

Date: Thu, 30 Jun 94 21:33:43 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: Obstructive Sleep Apnea Syndrome
Message-ID: <w7oRoc6w165w@stat.com>

                    Obstructive Sleep Apnea Syndrome
            St Joseph's Medical Letter, Vol 2, Issue 1, 1994
                      Reproduced with Permission

        Most clinicians have cared for patients with complaints of "lack
of energy" and fatigue-symptoms which frequently may be more precisely
defined as "sleepiness" after further questioning.  With more than 1/3 of
the population suffering from moderate or severe insomnia, and other sleep
disorders being as common a disorder as diabetes,
a-sleep-disorders evaluation is often in order.
        Sleep-related abnormalities of respiration have been recognized
since at least the mid 1800's, but standardized definitions of these
nocturnal respiratory events awaited more systematic study in the last 30
years: Apnea is defined as cessation of airflow at the nose and mouth
lasting at least 10 seconds. Hypopnea is a reduction in airflow without
complete cessation of breathing, resulting in oxyhemoglobin desaturation
or arousal. Patients may experience either one of these events through two
distinct mechanisms: central, in which respiratory effort declines, and
obstructive, in which respiratory effort is maintained while the upper
airway narrows or occludes entirely. Furthermore, a distinction has
emerged between asymptolllatic sleep disordered breathing-now called
simply sleep apnea, and symptomatic sleep-disordered breathing, now termed
sleep apnea syndrome.
        It is now recognized that obstructive sleep apnea syndrome (OSAS)
is a relatively common disorder, while the central variety occurs rarely.
A much-publicized recent study found an unexpectedly high prevalence of
sleep disordered breathing in a random sample of 602 working adults. A
respiratory disturbance index (RDI=the number of apneas+hypopneas per hour
of sleep) greater than 5 is considered abnormal, and 9% of the women and
24% of the men had this finding. Frank sleep apnea syndrome was present in
2% of the women and 4% of the men, a prevalence similar to that of
diabetes mellitus.
        Obstruction in OSAS occurs in the region of the oropharynx and
hypopharynx. Fiberoptic airway examination during apneic events reveals
that the tongue prolapses backward while the posterior and lateral
pharyngeal walls collapse inward, obstructing inspiratory airflow. The
underlying pathogenesis of these alterations in airway caliber has
remained elusive. Although many patients exhibit a reduction in upper
airway caliber while awake (eg, from obesity), many subjects with similar
degrees of daytime airway narrowing do not exhibit sleep disordered
breathing. Electromyographic studies of the upper airway
muscles demonstrate that a reduction in the tone of these muscles also
occurs during the apneas. Thus, OSAS results from both an anatomic lesion
and a poorly understood abnormality of the control of upper airway muscle
tone.
        When the patient suffers nocturnal airway obstruction and
consequent asphyxia, arousal from sleep occurs which terminates each
obstructive event. The patient then falls back to sleep, only to repeat
the cycle frequently throughout the night. The repeated interruptions
of sleep lead to sleep deprivation and complaints of daytime sleepiness.
Most patients do not recollect these arousals because Off their very brief
nature, although occasionally a patient will complain of insomnia or
frequent nocturnal awakenings. The increase in upper airway resistance
coupled with deep, resuscitative breaths in between apneas results in loud
snoring, which is characteristically intermittent. Morning headaches or
nausea may occur, related to recurrent nocturnal hypercapnia and cerebral
vasodilatation. Cognitive impairment has been recognized, and correlates
best with the degree of nocturnal oxyhemoglobin desaturation during the
obstructive events'.
        No physical findings are pathognomonic of OSAS. Obesity is common,
and collections of adipose tissue surrounding the upper airway are thought
to contribute to the pathogenesis of the disease. Obesity, however, only
doubles the odds ratio for deep disordered breathing, and cannot be used
to predict the presence of the disorder Frank anatomic abnormalities of
the upper airway are not common (eg, macroglossia micrognathia) except in
the pediatric age group, where adenotonsillar hypertrophy is a frequent
finding.
        The "gold-standard" for diagnosing OS AS consists polysomnographic
which continuous]y Records multiple physiologic parameters during deep
Airflow, respiratory effort, and pulse oximetry signals are used to detect
respiratory events, and an ECC is recorded in case respiratory events are
accompanied by arrhythmias. The most common indications for
polysomnography include excessive daytime sleepiness; loud, intermittent
("resuscitative') snoring; or apneas witnessed by a bed partner Testing is
also indicated for patients with unexplained corpulmonale or polycythemia
Because the recordings of "home screening" devices are often poor, there
usualness remains questionable
        Treatment for OSAS is generally recommended for patients who are
symptomatic or who have an RDI>20 An apnea index>20 has been associated
with increased mortality, and hypopneas which result in oxyhemoglobin
desaturation or arousal are thought to be equally as important as apneas
The mainstay of treatment currently is nasal continuous positive airway
pressure (C-PAP), administered using a nasal mask or prongs ("pillows")
which lit within and seal the nares Nasal CPAP pressurizes the upper and
acts as a pneumatic "splint", preventing oropharyngeal and hypopharyngeal
collapse.  Nasal C-PAP is capable of suprressing obstructive apneas and
hypopneas in virtually every patient, although long-term complainance with
the therapy has been a signifcant problems.
        A variety of surgical treatments have also been advocated.
Uvulopalatopharyngoplasty (excision of the uvula and resection of
reduntant orophyaryngeal tissue) will usually eliminate snoring, but
lowers in OSAS the RDI to < 20 in only about 50% of patients. Laser tongue
reduction (midline glossectomy) is not as well studied and carries the
danger of damage to ncurovascular structures. Excellent results have ken
obtained by some workers using maxillary and mandibular advancement by
ostotomy'.
        Several adjunctive measures  can also be of benefit. Weights loss
of surprisingly small degree can result in significant improvement
Patients who have positional apneas (when supine) can be treated with
mechanical devices (i.e., tennis balls) sewn into the backs of their
pajama tops that make sleeping in the supine position uncomfortable.  Oral
prostheses may have some utility in mild disease but are more useful in
benign snoring. The anti-depressants protriptyline and fluxetine have
shown to increase upper airway muscle tone and reduce the amount of time
spent in REM (dreaming) sleep, when the most severe apneas
characteristically occur.  There agents may be useful in mild disease.
When any treatment is employed, repeat polysomnography should in general
be used to demonstate efficacy.

Considering the high prevalence and potential health risks of OSAS,
symptoms of sleep-disorder breathing deserve careful attention and a full
patient evaluation.  Most often, patients benefits from an overnight study
at a sleep disorders center to define the breathing disorder and determine
the most effective form of therapy.  WHen chronic "fatique" is really
"sleepiness", it's time to consider a sleep center referral.



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

Date: Thu, 30 Jun 94 21:36:22 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: Cardiology: Today and Tommorrow - Conference
Message-ID: <BBPRoc7w165w@stat.com>

Cardiology: Today and Tomorrow
Mayo Educational Satellite Teleconferences
Course Director: Bijoy K. Khandheria, M.D.

Presented by:
Division of Cardiovascular Diseases, Mayo Clinic
Continuing Medical Education, Mayo Clinic
Video Communications, Mayo Clinic
#012#Discover a new way of learning
Offer your staff solid cardiovascular instruction from one of the world's
leading heart centers through the video conference, Cardiology: Today and
Tomorrow.  Mayo's premiere video education conference is based upon 70 years
of experience conducting continuing medical education for physicians.

Study with Mayo's experts
Taught by Mayo cardiologists and cardiovascular surgeons, Cardiology: Today
and Tomorrow covers relevant, timely topics and gives your staff clinical
"pearls" for managing their practice and improving the care they give to
patients.

Provide cost-effective education
Becoming a video conference host gives you a cost-effective way to offer
education at your site to staff and other community physicians. For $200 per
program, participants will receive up-to-date cardiovascular information and
participate in an interactive question-and-answer session while earning
continuing medical education credits.

Review and discuss clinically relevant topics
Cardiology: Today and Tomorrow is designed to benefit cardiologists,
internists, family practitioners, nurse practitioners and physician's
assistants from both urban and rural settings throughout the United States
and Canada. Each four-hour program contains a series of four didactic
lectures presented by Mayo physicians and will provide ample time for  "live"
questions and answers. The series will be broadcast quarterly beginning the
first quarter of 1995.

Mayo Foundation is accredited by the ACCME to sponsor Continuing Medical
Education for physicians. Mayo Foundation designates this Continuing Medical
Education activity (each session) for 4 hours of Category 1 of the Physicians
Recognition Award of the American Medical Association. Mayo Foundation
adheres to all ACCME standards regarding industry support of Continuing
Medical Education.

1995-96 video conference topics
o Coronary artery disease: state-of the-art
Medical therapy, catheter interventions, and bypass surgery in the modern
management of coronary artery disease.

o Women and heart disease
Information for practicing physicians on management of women with heart
disease.


#012#o Atrial fibrillation: management strategies for 1995
Newer drugs; role of transesophageal echocardiography, ablation and maze
procedure.

o Vascular medicine and hyperlipidemia for the practitioner
A concise, practical overview of how to manage commonly encountered problems
in vascular medicine and hyperlipidemia.

o Current review of cardiac arrhythmias, pacemakers and implantable
defibrillators

o Newer concepts and treatment of congestive heart failure and
cardiomyopathies

o Update on cardiac imaging: MRI, Echo, Nuclear, Cine CT

o Valvular heart disease: new quantitative techniques and management
strategies


Register your site for Cardiology: Today and Tomorrow
Please complete the attached postage-paid card to register your hospital or
clinic for this exciting educational experience. You will receive a
confirmation letter and additional details about the program in the coming
months.

This Mayo CME course is supported in part by unrestricted educational grants
from the following firms:
Major contributors: Acuson, Advanced Technology Laboratories,
Hewlett-Packard, Mallinckrodt Medical Inc., Marion Merrell Dow, Merck Sharp &
Dohme, and Pfizer.
Contributors: Bristol Myers Squibb, DuPont Pharmaceuticals, Intermedics Inc.,
Interspec Inc., Key Pharmaceuticals (Schering Sales Corporation), SCIMED Life
Systems, Searle, and Wyeth-Robins.

(Postcard information)
Cardiology: Today and Tomorrow

If you wish to register your hospital or clinic as a host site, please
complete and return this postage-paid card.

Name
Hospital/Clinic
Address
City                     State           Zip Code
Phone number                     FAX number

#012#Please indicate the type of video receiving facilities your
clinic/hospital
has.

        KU band                                 Fixed dish
        C band                                  Steerable dish
        KU and C band

Please check the day and time you prefer for this conference.

Monday                          Morning
Tuesday                         Afternoon
Wednesday
Thursday
Friday
Saturday
Sunday




Who:    Mayo cardiologists and cardiovascular surgeons
What:   Offer premiere educational video conference Cardiology: Today
        and
Tomorrow
Where:  At your hospital or clinic
When:   Beginning the first quarter of 1995
Cost:           $200 per session (no limit on number of attendees)



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

Date: Thu, 30 Jun 94 21:37:34 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: New Vaccine May Prevent Tooth Loss
Message-ID: <BDPRoc8w165w@stat.com>

New Vaccine May Prevent Tooth Loss
by Kathleen Canavan
NIDR Research Digest, April 1994

Researchers at the National Center for Research
Resources (NCRR) Washington Regional Primate Research
Center in Seattle recently found that immunization
significantly slows the progression of periodontal disease
in monkeys. This offers hope for a human vaccine that could
help thousands of Americans plagued by tooth loss caused by
periodontal bone and tissue damage.

The study-headed by Dr. Roy C. Page, director of the
Research Center in Oral Biology at the University of
Washington School of Dentistry, and funded by the National
Institute of Dental Research-is the first to show vaccination
as a possible treatment for periodontitis, an infectious disease
that destroys tooth-supporting tissue and bone.

The University of Washington researchers, in collaboration
with investigators at the University of Texas in San Antonio
and the Bristol Myers Squibb Pharmaceutical Research
Institute in Seattle, developed the vaccine using killed
Porphyromonds gingivalis bacteria, a major cause of
periodontitis.

The Washington scientists used 20 cynomolgus monkeys in
the study, inoculating half with the vaccine and half with a
placebo. The monkeys were vaccinated again at three-,
six-, and sixteen-week intervals.  After four months, the
researchers wrapped silk thread around each monkey's teeth
below the gumline to induce bacterial growth and periodontal
disease.

Both groups had similar levels of bacterial buildup and gum
inflammation, indicating that the vaccine had not cured the
monkeys of bacterial infection.

However, additional tests and x-rays showed that the control
monkeys had lost twice as much tooth-supporting bone as the
vaccinated monkeys.

'We know enough already to say that a human periodontitis
vaccine seems feasible, but it may be a decade before we
see full-fledged clinical trials of such a vaccine' says Dr. Page.

In later tests, the scientists applied live P. gingivalis bacteria
directly to the gums of three control and three test monkeys.
The control monkeys displayed dramatic bone loss after this
application, while the test monkeys remained protected from
disease.

"It appears that immunization may in fact block bacterially
induced bone loss," says Dr. Page. 'Over the next five years
we're going to study why the vaccine works, how it works,
and whether we will be able to produce a vaccine that
effectively reduces the level of bacteria in gum tissue."

Production of such a vaccine would not only reduce patient
suffering, but would also lessen the costs of treating
periodontitis.



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

End of HICNet Medical News Digest V07 Issue #29
***********************************************


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

