HICNet Medical News Digest      Wed, 01 Jun 1994        Volume 07 : Issue 23

Today's Topics:

  [MMWR 27 May 94] Expanded Tuberculosis Surveillance/Morbidity
  [MMWR] Chlamydia Prevalence and Screening Practices
  [MMWR] Quality of Life as New Public Health Measure
  [MMWR] Public Health Leadership Institute
  Basic Forensic Pathology Course Offered
  Armed Forces Institute of Pathology Short Postgraduate Courses
  Study Links Smoking & Increased Risk of Fatal Breast Cancer
  National Cancer Institute CancerNet Update

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Date: Wed, 01 Jun 94 21:57:27 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR 27 May 94] Expanded Tuberculosis Surveillance/Morbidity
Message-ID: <gy10mc1w165w@stat.com>

                 Expanded Tuberculosis Surveillance
         and Tuberculosis Morbidity -- United States, 1993

     Because of the resurgence of tuberculosis (TB) in the United States,
in 1987 the Advisory Committee for the Elimination of Tuberculosis
recommended the strengthening of TB surveillance to improve monitoring and
to assist in targeting groups at risk for disease (1). In addition, because
of outbreaks of nosocomial multidrug-resistant TB (MDR-TB) in New York and
Florida during 1990-1992 (2), in 1992, the National MDR TB Task Force
recommended that drug-susceptibility testing be performed on all initial
and final Mycobacterium tuberculosis isolates from each TB patient and that
the results be reported to CDC (3). In January 1993, in conjunction with
state and local health departments, CDC implemented an expanded
surveillance system for TB. This report summarizes final TB surveillance
data for 1993, compares findings with previous years, and provides
information on expanded surveillance.
     In November 1992, following approval of the Report of a Verified Case
of TB (RVCT) form for reporting TB cases to CDC, TB programs in state and
local health departments were asked to use the new surveillance form
beginning January 1993. In July 1993, a new computer software package
(SURVS-TB) was distributed for data entry, analysis, and transfer of
records to CDC. Additional elements of the RVCT included results for human
immunodeficiency virus (HIV) testing, occupation, history of substance
abuse, homelessness, and residence in a correctional or long-term-care
facility. To evaluate the outcomes of antituberculous therapy, information
was collected about initial therapy, type of health-care provider, sputum
culture conversion, and use of directly observed therapy (DOT).
     In 1993, 25,313 cases of TB (9.8 cases per 100,000 population) were
reported to CDC from the 50 states, the District of Columbia, and New York
City (Figure 1), a 5.1% decrease from 1992 (26,673 [10.5 cases per
100,000]) (4) but a 14% increase over 1985 (22,201) (the year with the
lowest number of TB cases since national reporting began in 1953). During
1985-1993, there was an excess of approximately 64,000 reported cases,
compared with the number predicted based on the trend of decline from 1980
through 1984.
     During 1993, 33 states reported fewer TB cases than in 1992; in
comparison, during 1992, 27 states and the District of Columbia reported
fewer cases than in 1991. The states reporting fewer cases in 1993 included
those characterized by the greatest increases in cases since 1985
(California, New York, and Texas). Fifteen states and the District of
Columbia reported increases in TB cases (Table 1).
     Compared with 1992, the number of reported TB cases decreased for all
age groups except for persons aged less than 15 years. Decreases were
greatest for persons aged 15-24 (6.6%) and 25-44 years (7.8%). Among
persons aged less than 15 years, the number of cases increased 0.8%; of all
cases, the proportion accounted for by persons in this group increased from
6.4% in 1992 to 6.8% in 1993. During 1993, persons born outside the United
States and its territories (i.e., foreign-born) composed 29.6% of reported
cases, compared with 27.4% in 1992.
     Selected characteristics were analyzed for cases in states where
greater than or equal to 75% of records contained information requested for
the first time in 1993 (Table 2). Among these persons, injecting-drug use
was reported by 2.4%, noninjecting-drug use by 4.7%, excessive use of
alcohol during the preceding 12 months by 13.0%, and homelessness by 5.3%.
For patients aged 25-44 years, HIV test results were reported for 33%; 18
reporting areas reported HIV results for greater than or equal to 50% of
cases. These 18 reporting areas accounted for 63% of cases in persons aged
25-44 years with HIV results.
     From January 1, 1993, through May 25, 1994, antibiotic-susceptibility
results for M. tuberculosis isolates were reported for 10,941 (54%) of the
20,090 persons with culture-positive TB. For 26 reporting areas,
drug-susceptibility results were available for greater than or equal to
75%; however, these areas included only two of the 12 states in which
greater than or equal to 1% of cases had isoniazid and rifampin resistance
in the previous national survey (5).

Reported by: Div of Tuberculosis Elimination, National Center for
Prevention Svcs, CDC.

Editorial Note: The findings in this report document a substantial decrease
in the number of reported TB cases from 1992 to 1993 (5.1%; p less than
0.001*), probably reflecting the effectiveness of prevention and control
measures implemented during 1989-1993. However, a portion of this decrease
may be due to two other factors, including 1) delayed reporting caused by
use of the new TB surveillance reporting form and the change from paper
records to a computerized system; and 2) underreporting because of
modification of the acquired immunodeficiency syndrome (AIDS) surveillance
case definition in January 1993 (6).
     Following the resurgence of TB in 1985 and the recognition of
nosocomial outbreaks of MDR-TB in 1991 (2), the Public Health Service
increased funding to state and local health departments for TB-prevention
and TB-control activities, including DOT--which has been shown to reduce TB
case rates even in the presence of HIV infection -- and screening programs
for persons at high risk for TB infection (7-9). In addition, some
hospitals implemented recommendations to prevent nosocomial transmission of
M. tuberculosis (10). These measures may account for a substantial
proportion of the decrease in reported TB cases in 1993.
     Most states require that laboratories notify the health department
about patients with cultures positive for M. tuberculosis; during 1993, 79%
of all reported TB cases were culture-positive for M. tuberculosis. In
response to the initial report, local health departments conduct
investigations to verify the diagnosis of TB and to collect information
needed for completion of reporting. The addition of information needed for
the new TB surveillance form may have delayed investigation of suspected TB
cases and completion of case reports in 1993. Ongoing analysis is assessing
the impact of delayed reporting.
     The expansion of the TB surveillance system during 1993 coincided with
the revision of the AIDS surveillance case definition. The revised AIDS
case definition classifies as AIDS cases HIV-infection in persons who have
either pulmonary TB or extrapulmonary TB (6). As a consequence,
HIV-infected persons with pulmonary or extrapulmonary TB may have been
reported to the AIDS surveillance program at the local or state health
department but not to the TB program. This explanation may account for the
apparent decrease in the number of reported TB cases in states
characterized by a high incidence of AIDS (California, New York, and Texas)
and in persons aged 15-24 and 25-44 years.
     In the states with the largest TB/AIDS co-morbidity (i.e., California
and New York), laws to protect the confidentiality of persons with AIDS
have been interpreted to prohibit the disclosure of patients' names to
anyone outside the AIDS program, including other programs within the state
health department. Information on the HIV status of persons with TB in 1993
is incomplete (missing/unknown for 67% of TB patients in the 25-44-year age
group); thus, the impact of HIV on the TB epidemic in the United States can
only be indirectly measured in 1993. Collaboration between TB and HIV/AIDS
surveillance programs will be necessary to accurately measure the extent
of overlap between the TB and HIV epidemics.
     Maintaining the current decline in TB morbidity and reaching the goal
of eliminating TB in the United States will require sustaining prevention
and control activities. In particular, health-care providers should attempt
to identify all TB cases and report them to health departments and ensure
that persons with active TB successfully complete treatment (e.g., DOT).
In addition, TB skin-test screening programs that target persons at highest
risk (e.g., contacts of persons with active cases) can ensure appropriate
use of preventive therapy.

References
1. CDC. A strategic plan for the elimination of tuberculosis in the United
States. MMWR 1989;38(no. S-3).
2. CDC. Nosocomial transmission of multidrug-resistant tuberculosis among
HIV-infected persons--Florida and New York, 1988-1991. MMWR 1991;40:585-91.
3. CDC. National action plan to combat multidrug-resistant tuberculosis.
MMWR 1992;41 (no. RR-11):1-48.
4. CDC. Tuberculosis morbidity--United States, 1992. MMWR 1993;42:696-
7,703-4.
5. Bloch AB, Cauthen GM, Onorato IM, et al. Nationwide survey of
drug-resistant tuberculosis in the United States. JAMA 1994;271:665-71.
6. CDC. 1993 Revised classification system for HIV infection and expanded
surveillance case definition for AIDS among adolescents and adults. MMWR
1992;41(no. RR-17).
7. Weis SE, Slocum PC, Blais FX, et al. The effect of directly observed
therapy on the rates of drug resistance and relapse in tuberculosis. N Engl
J Med 1994;330:1179-84.
8. Chaulk CP, Chaisson RE, Lewis JN, Rizzo RT. Treating multidrug-resistant
tuberculosis: compliance and side effects [Letter]. JAMA 1994;271:103-4.
9. CDC. Tuberculosis prevention in drug-treatment centers and correctional
facilities--selected U.S. sites, 1990-1991. MMWR 1993;42:210-3.
10. Fridkin SK, Manangan LP, Mayhall CG, et al. A survey of the use and
efficacy of tuberculosis infection precautions. Proceedings of the Fourth
Annual Meeting of the Society for Hospital Epidemiology of America. West
Deptford, New Jersey: Society for Hospital Epidemiology of America, March
1994.

* Statistical significance assessed by Chi Square test for dispersion;
statistical tests for differences in surveillance data must be interpreted
in relation to epidemiologic and programmatic considerations.



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

Date: Wed, 01 Jun 94 21:58:16 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR] Chlamydia Prevalence and Screening Practices
Message-ID: <TZ10mc2w165w@stat.com>

               Chlamydia Prevalence and Screening Practices --
                   San Diego County, California, 1993

     Chlamydia trachomatis is the most common bacterial sexually
transmitted disease in the United States and causes an estimated 4 million
infections annually (1). Approximately 70% of infected women have few or
no symptoms (2), and asymptomatic infection in women can persist for up to
15 months (3). Infection can progress to involve the upper reproductive
tract and may result in serious complications. To identify women who may
have chlamydial infections, CDC has recommended routine testing based on
age, risk behavior, and clinical findings--especially in clinics and group
practices that provide reproductive health care to adolescent and young
women (4). This report describes the prevalence of chlamydial infections
among patients visiting the family-planning clinic service of the San Diego
County Department of Health Services from July 1989 through June 1993 and
summarizes the findings of a survey in May 1993 that assessed chlamydia
screening, reporting, and treatment practices for women who attended
primary-care community-based clinics and group practices in San Diego
County.

Prevalence of Chlamydial Infections
     The San Diego County Department of Health Services provides
family-planning services in San Diego County in six public health centers.
Each clinic follows a written protocol that requires screening of all
clients during their initial visit and recommends screening for clients
during annual visits--particularly for those whose sexual behavior
increases their risk for infection. From March 1989 through February 1991,
endocervical specimens were tested at the San Diego County Public Health
Laboratory using the Chlamydia Antigen ELISA (Ortho Diagnostic Systems,
Inc.*, Raritan, New Jersey); beginning March 1991, specimens were tested
using the MicroTrak EIA (Syva, San Jose, California). The proportion of
women screened was determined using data from annual family-planning
clinic-service utilization reports. Test results and demographic and
limited clinical information were obtained from the laboratory's
chlamydia-test database.
     During July 1989-June 1993, approximately 95% of family-planning
clients were tested for Chlamydia during their initial visit, and 70% were
tested during their annual visit. Of 11,044 specimens tested, 91% were
obtained during routine testing of clients without symptoms. The prevalence
of chlamydial infections decreased from 10.0% during July-December 1989 to
1.9% during January-June 1993, a decline of 81.0%.
     During July 1989-June 1993, the prevalence of chlamydia among black
women was 8.5%, more than 1.5 times that among Hispanic (5.3%) and white
(4.5%) women. During the 4-year period, the prevalence declined minimally
among black women and steadily among white and Hispanic women (Figure 1).
Prevalence was inversely related to age, with the highest prevalence among
women aged less than 20 years (8.4%); among women aged less than 20 years,
the prevalence decreased from 9.9% during July 1989-December 1990 to 4.8%
during January 1992-June 1993, a 51.5% decline.

Chlamydia-Screening Practices Survey
     The survey of chlamydia screening and related practices was mailed in
May 1993 to all 171 primary-care clinics and group practices in San Diego
County that provided women's health services. The survey requested
information about chlamydia screening, reporting, diagnosis and treatment
practices, types of clinical services, and other chlamydia-related issues.
Chlamydia-screening practices were classified as clinician-directed
screening (i.e., when testing was based on the clinician's assessment of
signs, symptoms, or risk behavior) or as protocol screening (i.e., when
clinics followed a policy to test all women of reproductive age or all
those aged less than 20 years at their initial or annual visit).
     Surveys were returned by 85 (50%) of the providers. All providers
reported conducting clinician-directed screening; 45 (53%) followed
protocol screening in at least one clinical service. Public providers were
more likely than private providers to follow protocol screening (60% versus
37%). Protocol screening was used commonly in prenatal services (79%),
compared with initial visits for adolescent services (39%), initial visits
for family-planning services (33%), and gynecologic services (20%) (Table
1). Among providers following protocol screening, written screening
policies had been established most commonly in prenatal services (75%),
followed by family-planning (58%) and gynecologic (46%) services.
     Almost all (greater than or equal to 92%) providers reported testing
and immediately treating (i.e., on the same day as their visit and before
test results were known) clients who had chlamydia-related syndromes (e.g.,
pelvic inflammatory disease [PID] or mucopurulent cervicitis) or who had
reported a sexual exposure to a Chlamydia-infected person. In California,
both PID and chlamydial infections are notifiable conditions; however, only
34 (54%) of the 63 providers who responded to this question routinely
reported PID cases, and 55 (75%) of 73 responding providers reported
positive chlamydia test results. Reporting practices were similar for
private and public providers. DNA probe testing was the most frequently
used chlamydia test (47 [58%] of 81).
     Almost all (74 [97%] of 76) providers who responded reported referring
male sex partners for examination and treatment. The most common approaches
were on-site examination with presumptive treatment (57%) and health
department referral (35%). However, only 14 (18%) of 80 providers reported
having a method of following up sex partners' treatment for chlamydia.

Reported by: M Mendes, MPH, C Spitters, MD, S Waterman, MD, C Peter, PhD,
R Ross, MD, San Diego County Dept of Health Svcs, San Diego; J Felten, MPA,
Sexually Transmitted Diseases Br, GW Rutherford, III, MD, State
Epidemiologist, California Dept of Health Svcs. Surveillance and
Information Systems Br, Div of Sexually Transmitted Diseases and HIV
Prevention, National Center for Prevention Svcs; Div of Field Epidemiology,
Epidemiology Program Office, CDC.

Editorial Note: The decline in the prevalence of chlamydial infections
among women receiving family-planning clinic services in San Diego County
during 1989-1993 was consistent with patterns in other areas. For example,
findings from a screening demonstration project in Public Health Service
Region X (Alaska, Idaho, Oregon, and Washington) indicated that, among the
approximately 70,000 women screened annually in public and private
family-planning clinics, the prevalence declined from 9.3% in 1988 to 4.2%
in 1993 (5). The prevalence also decreased among women attending
family-planning clinics in Wisconsin, where a statewide selective screening
program has been operated since 1986 (6).
     Although the low response rate in San Diego County precludes
generalization, the results of the screening practices survey suggest that
the use of protocol screening was limited. A policy implemented in
California in August 1993 by the California Office of Family Planning now
requires chlamydia screening for all women undergoing initial examinations
and for women at increased risk undergoing annual and limited examinations
who seek services at clinics funded by the California Office of Family
Planning. To assist health-care providers in developing protocols and
policies, CDC has recommended chlamydia screening for 1) all women with
mucopurulent cervicitis; 2) all sexually active women aged less than 20
years; and 3) women aged 20-24 years who meet either of two criteria or
women aged greater than 24 years who meet both criteria--a) inconsistent
use of barrier contraception or b) a new sex partner or more than one sex
partner during the previous 3 months (4).
     The Preventive Health Amendments of 1992 authorized CDC to develop a
national program to prevent infertility resulting from treatable sexually
transmitted diseases in women. Findings from San Diego County, Region X,
and Wisconsin also suggest that efforts to prevent chlamydia-associated
infertility through the delivery of early detection and treatment services-
-particularly for women with asymptomatic infections--may have been
effective in reducing the prevalence of chlamydial infections. A new
program to prevent infertility will expand services to approximately
800,000 women in the four Public Health Service regions in which
chlamydia-prevention projects have been established (Regions III, VII,
VIII, and X) and will evaluate critical issues in operational research.
     Ongoing analysis of surveillance data and other information
characterizing chlamydial infection can assist clinical programs in
modifying screening practices to ensure effectiveness. In San Diego County,
the prevalence of chlamydial infection was higher among black women than
women in other racial/ethnic groups; however, information was not obtained
about the social and economic status of patients. Therefore, in San Diego
County, race should be considered a risk marker rather than a screening
criterion for chlamydial infection.
     Health-care facilities that provide family-planning, adolescent
health, and routine gynecologic services to adolescent and young adult
women should consider the use of screening protocols for all clients at
risk for chlamydial infections. Important components of chlamydia-control
programs include treatment and risk-reduction counseling of sex partners
of infected persons. In San Diego County, only 18% of providers reported
having a method to ensure treatment of sex partners; this finding
underscores the need for facilities that provide health care for women to
offer examination and treatment services or arrange for appropriate
referral for their clients' male sex partners, and establish procedures for
follow-up of the status of referrals. Public health agencies may assist
health-care providers in developing such referral and follow-up procedures.

References
1. Washington A, Johnson RE, Sanders L Jr. Chlamydia trachomatis infections
in the United States: what are they costing us? JAMA 1987;257:2070-2.
2. Cates W, Wasserheit JN. Genital chlamydial infections: epidemiology and
reproductive sequelae. Am J Obstet Gynecol 1991;164:1771-81.
3. Lycke E, Lowhagen GB, Hallhagen G, Johannison G, Ramstedt K. The risk
of transmission of genital Chlamydia trachomatis infection is less than
that of Neisseria gonorrhoeae infection. Sex Transm Dis 1980;7:8-10.
4. CDC. Recommendations for the prevention and management of Chlamydia
trachomatis infections, 1993. MMWR 1993;42(no. RR-12):7-8.
5. DeLisle S, Fine D, Kaetz S, et al. A multi-state model for the
prevention and control of sexually transmitted chlamydia infections
[Abstract]. Sex Transm Dis 1994;21(suppl):S149.
6. Addiss DG, Vaughn ML, Ludka D, Pfister J, Davis JP. Decreased prevalence
of Chlamydia trachomatis infection associated with a selective screening
program in family-planning clinics in Wisconsin. Sex Transm Dis 1993;20:28-
35.

* Use of trade names and commercial sources is for identification only and
does not imply endorsement by the Public Health Service or the U.S.
Department of Health and Human Services.



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

Date: Wed, 01 Jun 94 21:59:06 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR] Quality of Life as New Public Health Measure
Message-ID: <8110mc3w165w@stat.com>

Quality of Life as a New Public Health Measure --
Behavioral Risk Factor Surveillance System, 1993

     A fundamental goal of the year 2000 national health objectives is to
increase the span of healthy life for all persons in the United States (1).
Public health programs, improved social conditions, and private medical
care have contributed to the prolongation of life expectancy of U.S.
residents at birth from 47 years in 1900 to 75 years in 1989. However, for
some persons, increased life expectancy includes periods of diminished
health and function (i.e., lowered health-related quality of life
[HR-QOL]). Because population-based surveillance of good health has been
limited, questions to assess HR-QOL were added to the 1993 Behavioral Risk
Factor Surveillance System (BRFSS). This report summarizes the preliminary
findings about HR-QOL from the 1993 BRFSS and describes an index used to
identify population subgroups with high and low HR-QOL.
     The BRFSS is a continuous, state-based, random-digit-dialed telephone
survey of the U.S. adult noninstitutionalized population. Data were
analyzed from 44,978 persons aged greater than or equal to 18 years who
resided in states in which 1993 data were available for analysis in early
March 1994 (i.e., 21 of 49 participating states and the District of
Columbia*). Although data were included for states from each region of the
United States, southern border and Gulf states were underrepresented.
     HR-QOL data were based on participants' responses to four questions:
respondents were asked 1) "Would you say that in general your health is
excellent, very good, good, fair, or poor?"; 2) "Now thinking about your
physical health, which includes physical illness and injury, for how many
days during the past 30 days was your physical health not good?"; 3) "Now
thinking about your mental health, which includes stress, depression, and
problems with emotions, for how many days during the past 30 days was your
mental health not good?"; and 4) "During the past 30 days, for about how
many days did poor physical or mental health keep you from doing your usual
activities, such as self-care, work, or recreation?" Response rates for
these questions ranged from 98.3% to 99.8%. The questions assessed
self-rated health (a previously validated item [2]), recent activity
limitation, recent physical health, and recent mental health. The latter
two items also were used to calculate a "good health days" (GHDs) index**
to estimate the number of days during the 30 days preceding the survey that
respondents' overall health was good. GHDs are obtained by subtracting the
sum of "not good" physical health days and "not good" mental health days
from 30 days, with the restriction that the number of GHDs cannot be less
than zero.
     Overall, in the 21 states, substantial limitations were reported in
1993 for each of the four measures of HR-QOL. Fifteen percent of
respondents reported "fair" or "poor" health; 32%, recent physical health
limitations; 31%, recent mental health limitations; and 19%, recent
activity limitations (Table 1).
     Of the characteristics studied, the mean number of GHDs during the 30
days preceding the survey was highest for persons with annual household
incomes of more than $50,000 (26.4 days), college graduates (26.2), and
Asians/Pacific Islanders (26.2) (Table 2). The mean number of GHDs was
lowest for persons who were aged greater than or equal to 75 years (23.0),
who smoked 20 or more cigarettes per day (22.9), who were told by a health
professional more than once they have high blood pressure (22.1), who were
unemployed (22.0), who were separated from their spouses (22.0), who had
less than a high school education (21.9), who had annual household incomes
of less than $10,000 (21.1), who were told by a physician they have
diabetes (19.9), and who were unable to work (10.7).
     Mean numbers of GHDs varied substantially when respondents were
grouped by annual household income, education, age group, and sex (Table
3). The mean number of GHDs was lowest (17.5 days) for men aged 35-49 years
who had annual household incomes of less than $10,000 and a high school
education or less (n=167). Each of the five groups with the lowest mean
number of GHDs (less than 20 days) comprised persons aged 35-64 years who
had an annual household income of less than $10,000 (combined n=362 men,
1140 women). The mean number of GHDs was highest (27.9 days) for men aged
50-64 years who had annual household incomes of more than $50,000 and at
least some college education (n=646). Each of the five groups with the
highest mean number of GHDs (27 or more days) comprised men aged greater
than or equal to 35 years who had annual household incomes of more than
$50,000 (combined n=2842).

Reported by the following BRFSS coordinators: P Owen, Alaska; J Senner,
PhD, Arkansas; M Leff, MSPH, Colorado; F Breukelman, PhD, Delaware; C
Mitchell, District of Columbia; E Pledger, MPA, Georgia; G Louis, MPA,
Idaho; B Steiner, MS, Illinois; K Bramblett, Kentucky; R Lederman, MPH,
Massachusetts; N Salem, Minnesota; P Smith, Montana; S Huffman, Nebraska;
N Hann, MPH, Oklahoma; C Becker, MPH, Pennsylvania; M Lane, MPH, South
Carolina; D Ridings, Tennessee; R Giles, Utah; P Brozicevic, Vermont; R
Schaeffer, MSEd, Virginia; T Jennings, MPA, Washington; F King, West
Virginia. Aging Studies Br, Div of Chronic Disease Control and Community
Intervention, Behavioral Surveillance Br, Office of Surveillance and
Analysis, National Center for Chronic Disease Prevention and Health
Promotion, CDC.

Editorial Note: The need to address and characterize HR-QOL has been
reflected by the national year 2000 objectives and the National Institutes
of Health (3). Health analysts have addressed key aspects of a definition
of HR-QOL (which includes functional status and individual health
perceptions) and approaches for distinguishing HR-QOL from overall quality
of life (which includes HR-QOL and satisfaction with one's life and
circumstances) (3-5). Because individual health perceptions reliably
predict loss of function, morbidity, and mortality (2,6,7), health agencies
are developing valid measures of such perceptions for use in surveys (8,9).
Comprehensive, yet brief, measures, such as those described in this report,
may be feasible for use in local surveys (10).
     The BRFSS findings suggest that a GHDs index can identify differences
in reported good health among population subgroups and in relation to other
key factors (e.g., annual household income and education). For some groups,
the calculation of fewer GHDs primarily was attributable to recent physical
health limitations (e.g., among persons with diabetes), to recent mental
health limitations (e.g., among cigarette smokers), or to both recent
physical and mental health limitations (e.g., among persons unable to work)
(Table 2). Refinement of this index in relation to other variables,
including location and season, may further differentiate subgroups.
     The findings in this report are subject to at least five limitations.
First, the data were not weighted to reflect the complex survey design of
the BRFSS. Second, less than half the states participating in the BRFSS
were included in this analysis, and some geographic regions were
underrepresented. Third, the GHDs group means were not adjusted for all
potential confounders (e.g., annual income adjusted for household size)
(Tables 2 and 3). Fourth, differences by racial/ethnic groups may reflect
cultural differences in how these measures are perceived (e.g., some groups
may stoically deny health problems or be reluctant to report problems to
strangers [2]). Finally, respondents were persons capable and willing to
participate in the household telephone survey; therefore, some groups with
lower levels of HR-QOL most likely were excluded.
     Future analyses of the weighted 1993 BRFSS data from all 49
participating states will 1) refine and validate the GHDs index, 2) examine
geographic and seasonal patterns of HR-QOL, and 3) assess the relation of
these HR-QOL data to behavioral risk factors and to other HR-QOL data
(e.g., National Health Interview Survey and other BRFSS data used to track
"years of healthy life" for the year 2000 national health objectives).
States can use their BRFSS data to identify population subgroups reporting
low levels of HR-QOL that may require additional health services and to
monitor temporal or secular changes in HR-QOL that may be associated with
major social and health events (e.g., implementation of health-care
reform).

References
1. Public Health Service. Healthy people 2000: national health promotion
and disease prevention objectives--full report, with commentary.
Washington, DC: US Department of Health and Human Services, Public Health
Service, 1991; DHHS publication no. (PHS)91-50212.
2. Schechter S, ed. Proceedings of the 1993 NCHS Cognitive Aspects of
Self-Reported Health Status Conference. Hyattsville, Maryland: US
Department of Health and Human Services, Public Health Service, CDC,
National Center for Health Statistics, 1994 (in press). (NCHS working
paper; series no. 10).
3. National Institutes of Health. Quality of life assessment: practice,
problems, and promise--proceedings of a workshop. Bethesda, Maryland: US
Department of Health and Human Services, Public Health Service, National
Institutes of Health, 1993.
4. Patrick DL, Bergner M. Measurement of health status in the 1990s. Annu
Rev Public Health 1990;11:165-83.
5. CDC. Workshop on quality of life/health status surveillance for states
and communities: meeting report. Atlanta: US Department of Health and Human
Services, Public Health Service, CDC, National Center for Chronic Disease
Prevention and Health Promotion, 1993.
6. Idler EE, Angel RJ. Self-rated health and mortality in the NHANES-I
epidemiologic follow-up study. Am J Public Health 1990;80:446-52.
7. Segovia J, Bartlett RF, Edwards AC. The association between
self-assessed health status and individual health practices. Can J Public
Health 1989;80:32-7.
8. CDC. Consultation on functional status surveillance for states and
communities: meeting report. Atlanta: US Department of Health and Human
Services, Public Health Service, CDC, National Center for Chronic Disease
Prevention and Health Promotion, 1993.
9. Hennessy CH, Moriarty DG, Zack MM, Scherr PA, Brackbill R. Measuring
health-related quality of life for public health surveillance. Public
Health Rep 1994 (in press).
10. Mosteller F. Implications of measures of quality of life for policy
development. J Chronic Dis 1987;40:645-50.

* Alaska, Arkansas, Colorado, Delaware, District of Columbia, Georgia,
Idaho, Illinois, Kentucky, Massachusetts, Minnesota, Montana, Nebraska,
Oklahoma, Pennsylvania, South Carolina, Tennessee, Utah, Vermont, Virginia,
Washington, and West Virginia.
** Computation of this index assumed minimal overlap of reported "not good"
health days (e.g., a respondent reporting five physical and three mental
not good health days would have 30-(5+3)=22 GHDs). An alternative index
that assumed maximal overlap (i.e., 30-5=25 GHDs for the same respondent)
added only 0.4 mean days to the 24.8 overall mean days of the minimal
overlap index.



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

Date: Wed, 01 Jun 94 22:02:47 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR] Public Health Leadership Institute
Message-ID: <c810mc4w165w@stat.com>

                Public Health Leadership Institute

     The CDC/University of California's Public Health Leadership Institute
(PHLI) is a 1-year scholars' program designed to strengthen the U.S. public
health system by enhancing the leadership capacities of senior city,
county, and state public health officials. The major themes of the program
curriculum are: challenges--current and future issues confronting public
health; leadership and vision; communication and information; and political
and social change. The fourth year of the PHLI will begin October 30, 1994,
and will include an intensive on-site session March 12-17, 1995. At least
50 officials will be selected to participate in the PHLI.
     Senior state and local health officials, including state deputy
directors nominated by health directors, are eligible to apply.
Applications will be available in June 1994 and are due August 5. Scholars
selected will be notified by September 15. Additional information and
applications are available from the PHLI office, telephone (916) 448-7891,
fax (916) 448-0753; or from CDC's Public Health Practice Program Office,
telephone (404) 639-1945.



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

Date: Wed, 01 Jun 94 22:04:33 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: Basic Forensic Pathology Course Offered
Message-ID: <aa20mc5w165w@stat.com>

     BASIC FORENSIC PATHOLOGY will be presented 3-7 October 1994 at the
     Holiday Inn Crowne Plaza, Rockville, Maryland, USA.

     SPONSORS: Armed Forces Institute of Pathology, the American Registry
     of Pathology, and the Office of the Armed Forces Medical Examiner.

     GENERAL INFORMATION: Education Dept. (INT), 14th & Alaska Avenue, NW,
     Washington, DC, USA; (301)427-5231; FAX (301)427-5001; or INTERNET:
     LOWTHER@email.afip.osd.mil

     CONTENT: This course provides a concise review of basic topics in
     forensic pathology.  The course is designed for pathologists,
     investigators, attorneys, and others who need to increase their
     understanding of the forensic sciences.  After completing this course,
     the registrant should have basic knowledge of the various aspects of
     multidisciplinary medicolegal death investigations.  The course
     faculty includes nationally renowned authorities in the forensic
     sciences.            (English)

     COURSE DIRECTORS:
      William T. Gormley, Colonel, USAF, MC
      Paul O. Vasallo, Colonel, MC, USA
      Steven C. Cogswell, Major, USAF, MC

     TUITION:  $475 Civilian.  Active duty military, DoD civilians,
     full-time permanent Department of Veterans Affairs employees (not
     residents or fellows), and commissioned officers of the Public Health
     Service with authorized approval have a registration fee of $250.



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

Date: Wed, 01 Jun 94 22:05:28 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: Armed Forces Institute of Pathology Short Postgraduate Courses
Message-ID: <TB20mc6w165w@stat.com>

                ARMED FORCES INSTITUTE OF PATHOLOGY
        POSTGRADUATE SHORT COURSES ON CONTINUING EDUCATION

                            SPRING 1994

      6-10 Jun  Exfoliative & Fine Needle       Hyatt Regency
                Aspiration Cytology             Bethesda, MD

      8-10 Jun  Methods & Advanced Techniques   USUHS
                in Human Identification         Bethesda, MD

     20-24 Jun  Forensic Anthropology           USUHS
                                                Bethesda, MD

     25-26 Jun  Hepatopathology 94'             Radisson Resort
                                                Vail, CO

     27-28 Jun  Gastrointestinal Surgical       Radisson Resort
                Pathology                       Vail, CO

                               FALL 1994

      3- 5 Aug  Histopathology                  AFIP
                                                Washington, DC

      8-12 Aug  Pathology of Laboratory         USUHS
                Animals                         Bethesda, MD

     19-21 Aug  Environmental Pathology         AFIP
                                                Washington, DC

     27-28 Aug  Anatomy, Histology & Electron   Georgetown University
                Microscopy of the Eye, Orbit    Conference Center
                and Ocular Adnexa               Washington, DC

     Aug29-2Sep Ophthalmic Pathology`for        Georgetown University
                Ophthalmologists                Conference Center
                                                Washington, DC

     12-16 Sep  Pathology of Congenital Heart   AFIP
                                                Washington, DC

     17-18 Sep  Pulmonary & Mediastinal         Menger Hotel
                Radiology                       San Antonio, TX

     19-22 Sep  Morphologic Findings in         Ramada Inn
                Renal Disease                   Bethesda, MD

     26-30 Sep  Advances in Diagnostic          Doubletree Hotel
                Pathology of Infectious         Park Terrace
                Diseases                        Washington, DC

      3- 7 Oct  Basic Forensic Pathology        Holiday Inn Crowne Plaza
                                                Rockville, MD

     10-14 Oct  4th Annual Radiologic           Disney Contemporary Hotel
                Pathologic Correlation          Lake Buena Vista, FL


     29-30 Oct  Hyperbaric Chamber Awareness    AFIP
                                                Washington, DC

      4- 5 Nov  DNA Databanks & Repositories    Sheraton Midway
                                                St. Paul, MN

     19-20 Nov  Interpretation of Prostatic     AFIP
                Biopsy                          Washington, DC

                                SPRING 1995

      4-8  Jan 95 Telemedicine I                Disney Contemporary Hotel
                  (Didactic)                    Lake Buena Vista, FL


     10-11 Jan 95 Telemedicine II               Disney Contemporary Hotel
                  (Interactive)                 Lake Buena Vista, FL

      9-13 Jan 95 Oral Pathology                Disney Contemporary Hotel
                                                Lake Buena Vista, FL

     22-27 Jan 95 Neuropathology Review         Hyatt Regency
                                                New Orleans, LA

     22-27 Jan 95 Uropathology                  Holiday Inn Crowne Plaza
                                                Rockville, MD

     13-17 Feb  Controversies & Recent          Contemporary Hotel
                Advances in Surgical            Lake Buena Vista, FL
                Pathology

     17-19 Feb  Respiratory Tract &             Marriott Rivercenter
                Mediastinum                     San Antonio, TX

     19-22 Feb  Pediatric Pathology             Grosvenor Resort
                                                Lake Buena Vista, FL

     25-26 Feb  Neuroradiology Review           Hyatt Regency
                                                Bethesda, MD

     13-17 Mar  Forensic Dentistry              Holiday Inn
                                                Crowne Plaza
                                                Rockville, MD

      1-2  Apr  Abdominal & Gastrointestinal    AFIP
                Imaging                         Washington, DC

      3-16 Apr  Problems in Anatomic            AFIP
                Pathology                       Washington, DC

     22-23 Apr  Uroradiology                    AFIP
                                                Washington, DC

     May 31-    Controversias y Adelantos       Caribe Hilton & Casino
        3  Jun  Nuevos en Patholgia             San Juan, PR
                Quirurgica

      5- 9 Jun  Comparative Pathology of        Woods Hole, MA
                Aquatic Animals

      5- 9 Jun  Diagnostic Exfoliative & Fine   Marriott Hotel
                Needle Aspiration Cytology      Washington, DC

      2- 5 Jul  Controversies & Recent          Snowmass Lodge & Club
                Advances in Surgical Pathology  Snowmass, CO

      3- 7 Jul  Forensic Anthropology           University of Bradford
                                                Bradford, England



     Schedules are published monthly.  Press announcements will be
     published as information becomes available. For additional
     information or clarification you may write: AFIP/ARP, Educ.
     Div.(INT), Washington, DC 20306-6000; Telephone 301/427-5231;
     Fax 301/427-5001; or INTERNET:  LOWTHER@email.afip.osd.mil



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

Date: Wed, 01 Jun 94 22:06:39 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: Study Links Smoking & Increased Risk of Fatal Breast Cancer
Message-ID: <sD20mc7w165w@stat.com>

Study Links Smoking and Increased Risk of Fatal Breast Cancer
American Cancer Society News Release

ATLANTA, May 15, 1994 -- A new study by the American Cancer Society
reports that a woman's risk of dying from breast cancer increases
by 25% if the woman is a smoker -- and rises in proportion to the
number of cigarettes smoked per day and the total number of years
smoked, culminating with a 75% increased risk in women who smoke
two packs per day or more.

The study, published in the May 15 issue of the American  Journal
of Epidemiology, found no association between former smoking
and risk of fatal breast cancer.

"Our results suggest that there is something different about
current smokers with breast cancer with regard to their risk of dying
from the disease," says Eugenia Calle, Ph.D., Director of Analytic
Epidemiology with the American Cancer Society, who is the lead
author  of the paper. "For example, smokers may have impaired
immune systems,  they may not obtain routine mammographic
screenings, or smoking may  cause a direct deleterious effect on
survival."

Women in this study were selected from the female  participants of
CPS II, a prospective mortality study of 1.2  million American men
and women begun by the Society in 1982. After  six years of follow-up,
880 cases of fatal breast cancer were  observed in a population of
604,412 women who were free of cancer  at enrollment.

Among the women who died of breast cancer, 53.2% had never
smoked, 16.4% were former smokers, 21.3% were current smokers,
and  9.2 could not be classified. Current smokers had about a 25%
increased risk of fatal breast cancer (rate ratio 1.26); this risk
increased to almost 75% (rate ratio 1.74) for women who smoked
40 or  more cigarettes per day.

"Interestingly, women who smoked and had a history of breast
cysts were not at increased risk of fatal breast cancer," says
Dr.  Calle. "These women may be more likely to get mammograms
on a regular  basis and to be diagnosed at an early stage of disease.

The authors offered the following hypotheses as to why smoking
created an increased risk of fatal breast cancer in this group of
women:

*       Poor survival experiences among current smokers with
        breast cancer. This could be due to conditions that are more
        common among smokers, such as respiratory and cardiovascular
        impairment. It would also occur if smoking accelerates the
        progression of the disease, or if smokers are diagnosed at a
        later stage.

*      Smoking may have deleterious effects on the immune system.
       Other studies have documented low natural killer cell activity
       and  immunoglobulin levels in smokers, findings which could
       contribute to  poorer prognosis among breast cancer patients
       who smoke.

*      Smokers may not seek screening services similar to
       nonsmokers. Data from the National Health Interview Survey
       Cancer  Control Supplement show that current smokers are
       less likely to  receive mammography screening than are never
       smokers or former  smokers and this screening disadvantage is
       greatest among heavy  smokers. Similar differences in
       screening behavior by smoking status  have been observed in
       other studies. Consequently, women who smoke  may be
       diagnosed at a later stage of disease.

"Our results suggest that current smokers may be at increased  risk
of fatal breast cancer, either because of poorer survival or delayed
diagnosis," says Dr. Calle. "They should be considered a  potentially
high-risk group for whom mammography education and early
detection may be particularly valuable."

Other authors of the study are Heidi L. Miracle McMahill,  BS,
Michael J. Thun, MD, and Clark W. Heath, Jr., MD, all with the
Society's department of Epidemiology and Statistics.

For further information, contact Eugenia Calle, PhD, at the
American Cancer Society, 404/329-5741.



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

Date: Wed, 01 Jun 94 22:08:17 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: National Cancer Institute CancerNet Update
Message-ID: <ig20mc8w165w@stat.com>

            *************************************************
            *       NATIONAL           INSTITUTE            *
            *               C A N C E R                     *
            *  INTERNATIONAL           INFORMATION          *
            *               C E N T E R                     *
            *************************************************
                   *   Cancernet@icicb.nci.nih.gov  *
                   **********************************




The National Cancer Institute has a new Information Associates Program
which provides one-stop, easy access to all of NCI's scientific
information resources, including online access to the PDQ database
via the Internet or by dialing toll-free to NCI using just a
modem and personal computer.  Request news article cn-400035
(U.S. Residents) or cn-400036 ( International) for details.


CancerNet has been updated for June.  The following statements
were modified.


Changed state-of-the-art physician statements:

Adult acute lymphocytic leukemia (cn-101024)
Adult Hodgkin's disease (cn-100003)
Adult non-Hodgkin's lymphoma (cn-100066)
Bladder cancer (cn-101206)
Breast cancer (cn-100013)
Cervical cancer (cn-100103)
Chronic lymphocytic leukemia (cn-101003)
Chronic myelogenous leukemia (cn-101031)
Colon cancer (cn-100008)
Gestational trophoblastic tumor (cn-101163)
Hypopharyngeal cancer (cn-101500)
Laryngeal cancer (cn-101519)
Lip and oral cavity cancer (cn-102840)
Myeloproliferative disorders (cn-101983)
Nasopharyngeal cancer (cn-101402)
Oropharyngeal cancer (cn-101521)
Ovarian epithelial cancer (cn-100950)
Pancreatic cancer (cn-100046)
Paranasal sinus and nasal cavity cancer (cn-102892)
Plasma cell neoplasm (cn-100281)
Prostate cancer (cn-101229)
Rectal cancer (cn-100076)
Small cell lung cancer (cn-100040)
Testicular cancer (cn-101121)
Thyroid cancer (cn-101252)



Changed patient statements:

Adult non-Hodgkin's lymphoma (cn-200066)
Adult soft-tissue sarcoma (cn-200921)
Bladder cancer (cn-201206)
Breast cancer (cn-200013)
Childhood acute lymphocytic leukemia (cn-200026)
Childhood acute myeloid leukemia (cn-201081)
Childhood Hodgkin's disease (cn-203043)
Chilchood liver cancer (cn-200963)
Childhood non-Hodgkin's lymphoma (cn-200915)
Childhood rhabdomyosarcoma (cn-200759)
Childhood soft tissue sarcoma (cn-203085)
Endometrial cancer (cn-201176)
Ewing's sarcoma (cn-200021)
Hypopharyngeal cancer (cn-201500)
Laryngeal cancer (cn-201519)
Lip and oral cavity cancer (cn-202840)
Myeloproliferative disorders (cn-201983)
Nasopharyngeal cancer (cn-201402)
Neuroblastoma (cn-200530)
Oropharyngeal cancer (cn-201521)
Paranasal sinus and nasal cavity cancer (cn-202892)
Prostate cancer (cn-201229)
Rectal cancer (cn-200076)
Renal cell carcinoma (cn-201070)
Retinoblastoma (cn-200993)
Skin cancer (cn-201228)
Testicular cancer (cn-201121)
Thyroid cancer (cn-201252)
Transitional cell cancer of the renal pelvis and ureter (cn-203364)
Uterine sarcoma (cn-203371)



Changed supportive care statements:

 No changes


Changed screening statements:

 No changes


Changed drug statements:

 No changes



The following news items were added:

*Addendum to Reanalysis of NSABP B06 (cn-400045)
*Letter Sent to Participants of the BCPT (cn-400046)
*Board of Scientific Counserlors Recommendations on BCPT (cn-400047)
AHCPR Quick Reference Guide: Management of Cancer Pain in Adults (cn-400032)
Letter to Investigators About Erwinia L-Asparaginase (cn-400048)

*Note:  This news item was added to CancerNet during May 1994 in advance of
the June update.

The following news items were deleted*:

NCI Statement on Falsified Data in NSABP Trials (cn-400018)
NCI Update on Falsified Data in NSABP Trials (cn-400026)
Results of First Phase of NSABP Chart Audit (cn-400037)
Suspension of LSU and Tulane from NSABP Studies (cn-400038)
NCI to Audit NSABP Center (cn-400043)
NCI Continues Audits; Will Re-examine Breast Cancer Studies (cn-400044)
NCI Considers Reopening some NSABP Studies ( cn-400049)

*The above items were removed from the news, but are available as fact sheets
below, with the numbers cn-600723, cn-600724, cn-600727, cn-600728, cn-600730,
and cn-600731, respectively.


The following news items were changed:

PDQ Distributors (cn-400003)
CANCERLIT Distributors (cn-400006)
PDQ User Guide (cn-400050, 400051, 400052, 400053, 400054)
Redistribution of CancerNet and CancerNet Availability (cn-400030)
PDQ Voluntary Submission Information (cn-400010)
Group C Protocol Information (cn-400014)
Reanalysis of NSABP Protocol B06 (cn-400027)  [Note: The reanalysis was
revised to incorporate the Addendum dated 4/27/94; the addendum alone is
available as item cn-400045.]

NCI Fact Sheets:
----------------

The following new fact sheets were added:

The National Cancer Institute's SEER Cancer Statistics Review (cn-600110)
Gene for Kidney Cancer Isolated (cn-600337)
NCI to Study Brain Tumors and Their Causes (cn-600338)
Q & A: Breast Cancer Prevention Trial (cn-600041)
Q & A: Adjuvant Therapy for Breast Cancer (cn-600720)
Suspension of LSU and Tulane from NSABP Studies (cn-600728)
Newly Cloned Gene Could Aid in Treating Melanoma (cn-600729)
NCI to Audit NSABP Center (cn-600730)
NCI Continues Audits; Will Re-examine Breast Cancer Studies (cn-600731)
NCI Considers Reopening Some NSABP Trials (cn-600732)
Q & A: NCI's Natural Products Branch (cn-600733)
Hospice (cn-600086)


The following fact sheets were changed:

Cancer Research Funding (cn-600011)
Q & A: Prostate Cancer (cn-600054)
Workshop on the Early Detection of Prostate Cancer (cn-600510)
NCI Seeks Answers on Prostate Cancer: Causes, Detection, Prevention, &
Treatment (cn-600066)

The following fact sheets were deleted:

Breast Cancer Research and Programs: An Overview (cn-600065)
NIH Researchers Attempt Gene Therapy in Blood Stem Cells (cn-600719)


NCI Publication Information:
-------------------------------------

The following item was added:

Down Home Healthy:  Family Recipes of Black American Chefs (cn-400055)


CANCERLIT Citations and Abstracts:
----------------------------------

The following new search topics were added:

Anal cancer (cn-7__030)
Bile duct and gallbladder cancer (cn-7__055)
Colorectal cancer (therapy) (cn-7__036)
Esophageal cancer (cn-7__045)
Diagnosis, histopathology, and pathogenesis of gastric cancer (cn-7__065)
Therapy of gastric cancer (cn-7__066)
Diagnosis, histopathology, and pathogenesis of primary liver cancer (cn-
7__080)
Therapy of primary liver cancer (cn-7__081)
Diagnosis, histopathology, and pathogenesis of pancreatic cancer (cn-7__095)
Therapy of pancreatic cancer (cn-7__096)
Small intestine cancer (cn-7__115)
Diagnosis, histopathology, and pathogenesis of primary brain tumors (cn-
7__550)
Therapy of primary brain tumors (cn-7__551)
Neuroblastoma (cn-7__560)

The CANCERLIT citations and abstracts for June will be available on June 15,
1994.


Request the Monthly PDQ Statement Changes ( cn-405001) for a description of
the changes in the statements listed above.

Request Changes to CancerNet ( cn-400000) for a complete listing of changes to
CancerNet content for the current month.

Instructions:

To request the CancerNet Instructions and Contents List, send a
mail message, and in the body of the message, enter HELP.
Address the mail message to:

          cancernet@icicb.nci.nih.gov

To request the modified statements, follow the above directions,
and in the body of the mail message, enter the statement code.
When requesting more than one statement, enter each code on a
separate line.

CancerNet statements are available in Spanish. To request the
Instructions and Contents List in Spanish, enter SPANISH in the
body of the mail message. If you would like to request the statements
in Spanish, substitute the prefix "cs-" in front of the number
e.g., cs-100022 to receive the statement on anal cancer in Spanish.
All of the physician and patient statements are available in Spanish.
Supportive care statements are now available in Spanish.
News items that are available in Spanish have a # next to the statement
title. Although both the English and Spanish are updated at the same
time each month, the Spanish statements do not reflect the changes made
in the English statements until the following month to allow time for
translation. If you are interested in requesting CancerNet statements
or news articles in Spanish, it is suggested that you request an updated
Contents List.

If you are redistributing the PDQ information you retrieve from
CancerNet to others at your location, or are interested in redistributing
the information from CancerNet, request the news article, Redistribution
of Cancernet ( cn-400030), to find out about conditions that apply when
redistributing the information.  This article also has information on
other sites providing access to CancerNet information.


Please send comments or questions to:

Cheryl Burg
NCI International Cancer Information Center
Internet: cheryl@icicb.nci.nih.gov



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

End of HICNet Medical News Digest V07 Issue #23
***********************************************


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

