Volume 3, Number 19 May 29, 1990
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Editor: David Dodell, D.M.D.
St. Joseph's Hospital and Medical Center
10250 North 92nd Street, Suite 210, Scottsdale, Arizona 85258-4599 USA
Telephone +1 (602) 860-1121
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Copyright 1990 - Distribution on Commercial/Pay Systems Prohibited without
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T A B L E O F C O N T E N T S
1. Medical News
Medical News for Week ending May 27, 1990 ............................. 1
2. Center for Disease Control Reports
[MMWR 5-24-90] Injuries Associated with Horseback Riding .............. 6
Alcohol Use and Aquatic Activities .................................... 9
Aeromonas Wound Infections Associated with Outdoor Activities ........ 11
Malignant Melanoma of the Skin ........................................ 13
Swimming-Associated Cryptosporidiosis ................................. 15
3. Food & Drug Administration News
BCG For Cancer ........................................................ 17
4. Columns
AIDS and Gerontology -- A Bibliography ................................ 18
5. Articles
Cancer Research In The 90's--The Gift Of The 80's ..................... 21
Common Air Pollutants and the Spread of Cancer ........................ 24
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Volume 3, Number 19 May 29, 1990
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Medical News
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Medical News for Week ending May 27, 1990
Copyright 1990: USA TODAY/Gannett National Information Network
Reproduced with Permission
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May 21, 1990
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TRAVELERS ON THE ROAD AND ILL:
Illness was right at home for people on the road last year. Nearly two-
thirds of U.S. travelers say they suffered some physical ailment while
traveling in the past year. A Procter and Gamble survey of 600 people found
upset stomach, heartburn, diarrhea and sunburn were illnesses cited most
often.
`JUST SAY NO' IS WORKING:
In Los Angeles, the "Just say no" program to fight drug abuse is working.
Undercover officers posing as students approached high school students about
drugs. The students advised the officers against drug use and told them they
would lose friends. Police Chief Daryl Gates to his knowledge this is the
first time in 17 years this has happened.
VACCINE APPEARS SAFE:
A vaccine that protects against meningitis and related childhood infections
caused by the Haemophilus influenzae type b bacteria appears to be safe and
effective in infants from two to 18 months of age, according to new data
reported at the Eighth Annual Meeting of the European Society for Paediatric
Infectious Diseases in Goteborg, Sweden.
VACCINE STUDY:
Drs. Steven Black, and Henry Shinefield, researchers from the Kaiser
Permanente Pediatric Vaccine Study Center in Northern California, will present
results of their vaccination study of 28,950 infants at the European Society's
meeting in Sweden. Their study supports recent findings of a Finnish study
with the HbOC conjugate vaccine, developed by Praxis Biologics of Rochester,
N.Y.
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May 22, 1990
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SEPARATE RULES FOR FOREIGN M.D.:
A new General Accounting Office study shows foreign medical graduates must
take a different and longer exam than U.S. graduates in most states. They
also must pass oral exams in many states, while U.S. graduates do not have to.
About 22 percent of the nation's 570,000 doctors are foreign medical
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Volume 3, Number 19 May 29, 1990
graduates; 29 percent were born in the USA. (From the USA TODAY Life section.)
BLADDER CANCER DRUG APPROVED:
The Food and Drug Administration Monday approved use of a drug, Bacillus
Calmette Guerin Live to treat a type of bladder cancer. The drug will sell
under the trade name Theracys. It goes directly into the bladder through a
tube, causing an inflammatory reaction that kills cancer cells. Studies
sponsored by the National Cancer Institute show 75 percent of patients
responded to the treatment.
SKIN DRUG PREVENTS CANCER:
The acne drug Accutane may block further growth of tumors in people being
treated for cancer of the mouth and throat. The drug, a synthetic form of
vitamin A, works by preventing pre-cancerous cells from changing into cancer
cells. A researcher at the M.D. Anderson Cancer Center in Houston says in
three years, only two of 49 Accutane patients developed second cancers.
LAB ANIMAL BAN OPPOSED:
Three out of four Californians oppose legislation banning the use of
laboratory animals in consumer safety testing of personal care products,
according to a poll of 1,006 adults conducted by the Public Policy Research
Group of Dallas. And two out of three believe we must rely on laboratory
animals to test product safety until there are valid alternatives.
RETT SYNDROME MEETING HELD:
The Sixth Annual Conference of the International Rett Syndrome Association
will be held May 25-27 in Arlington, Va. Rett Syndrome is a brain disorder
affecting only girls, who have normal development until between six- and 18-
months of life. A regression of skills leads to severe mental retardation and
physical disability by the age of three years. More info call: 703-920-3230.
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May 23, 1990
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CANCER RISKS HIGHER NOW:
Doctors believe people are more likely to develop cancer now than they were
10 years ago. They blame environmental pollutants, more women smoking and sun
exposure. The survey of 300 doctors was conducted by the Cytogen Corporation
at the annual meeting of the American Society of Clinical Oncology. (From the
USA TODAY Life section.)
SMOKERS QUITTING COLD TURKEY:
Most smokers who quit do it on their own, cold turkey. A study in
Wednesday's Journal of the American Medical Association shows of more than
13,000 adults, 85 percent made the attempt on their own. About 80 percent did
it cold turkey. Only 15 percent used a smoking-cessation program. Researchers
warn formal programs are important because they help prevent relapses.
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Volume 3, Number 19 May 29, 1990
STANDARD NUTRITION SCREENING:
A national coalition of health and medical organizations is launching a
project to begin elderly nutrition screening. The initiative will focus first
on senior citizens who face a disproportionate nutritional risk. Researcher
shows 30 percent to 40 percent of U.S. elderly in hospitals and nursing homes
suffer from malnutrition.
LESSONS FOR THE BEACH:
Skin cancer experts hope kids are learning sun-safety lessons to protect
themselves this summer. Studies show people get most of their sun exposure
before age 18 and cumulative lifetime exposure greatly contributes to skin
cancer. Experts say a couple of severe sunburns in childhood and teen years
can significantly increase chances of melanoma, the most deadly form of skin
cancer.
NEW TREATMENT FOR SHINGLES:
A new drug, Zovirax, is available for the treatment of herpes zoster,
commonly known as shingles. This drug offers effective treatment and shortens
the duration of the disease. A conference will be held in New York on May 24
to discuss this new treatment. For more information, call Cathy Pollini, 212-
951-5419.
TB AND THE HOMELESS:
The number of tuberculosis cases among Boston's homeless has increased from
two in 1983 to 20 in 1989, reports Dr. John Bernardo of Boston University
Schools of Medicine and Public Health and Boston City Hospital. Many of the TB
cases have involved patients who tested positive for HIV-1, the virus
responsible for AIDS, or were members of groups at high risk for HIV
infection.
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May 24, 1990
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NURSING HOME REPORT RELEASED:
Patients at 20 to 25 percent of nursing homes are denied basic hygiene and
protection from the spread of infection. The Health Care Financing
Administration found 24 percent administered drugs improperly; 36 percent did
not store food properly or prepare and serve food under sanitary conditions.
(From the USA TODAY News section.)
GENETICS AND WEIGHT GAIN:
Genes have more to do with whether a person's fat or thin than any other
factor, says a University of Pennsylvania researcher. He says genes determine
whether a person will have a high risk of becoming an obese adult. A high risk
person who exercises and diets regularly can avoid becoming obese. The
findings are in Thursday's New England Journal of Medicine.
POLICIES AID THE DISABLED:
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Volume 3, Number 19 May 29, 1990
Federal and state policies have improved life for people with developmental
disabilities, says a National Association of Developmental Disabilities
Council survey of 14,000 disabled people. The study also says the disabled
still face major barriers to becoming independent, productive members of
society. (From the USA TODAY Life section.)
DOCTORS BECOMING COST-CONSCIOUS:
Doctors who are aware of the costs of routine medical tests tend to order
fewer of them, says a report in Thursday's New England Journal of Medicine. A
study at an Indiana medical clinic found when costs were included on a
computer system doctors used, the number of tests ordered fell 15 percent.
Average savings: $7 per patient visit.
BLOOD PRESSURE AND EXERCISE:
Exercise can stack the odds in favor of high blood pressure sufferers
resulting in a longer life. Researchers at the Cooper Clinic in Dallas tested
18,000 men with high blood pressure over eight years. Men in the bottom 20
percent of fitness were three times more likely to die than men who exercised
the equivalent of a brisk 30-minute walk five days a week.
DRUG MAY HELP PREVENT PNEUMONIA:
Dr. Julio Montaner of the University of British Columbia reported evidence
that aerosolized pentamidine can be effective in preventing the recurrence of
pneumocystis carinii pneumonia, the most common infection that strikes AIDS
patients. Announced at the World Conference on Lung Health, the study was
conducted in 15 medical centers in Canada.
NEW DRUG APPEARS EFFECTIVE:
Dr. Bertrand Dautzenberg of Paris reported that a new drug, clarithromycin,
appears effective against Mycobacterium avium-intracellulare, a deadly AIDS
infection. To date, 16 patients receiving blood, urine and sputum tests showed
a decrease in MAIC levels in the period they received clarithromycin, and a
worsening or no change in the infection while they received the placebo.
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May 25-27, 1990
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HOPE FOR PATIENTS WITH MS:
Doctors have located two types of blood cells that react against nerve
tissue, which could become the first candidates for a possible treatment
against multiple sclerosis. The discoveries will not translate into a
treatment for several years, but researchers say they do represent one of the
most significant advances in the past 20 years. (From the USA TODAY Life
section.)
ACID AEROSOLS ARE THREAT:
According to experts at the American Lung Association's World Conference on
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Volume 3, Number 19 May 29, 1990
Lung Health, acid aerosols may cause excess respiratory illness. Doctors say
animal studies have shown that acid aerosols cause airway narrowing, changes
in the ability to clear particles from the lungs, changes in response to
inflammation and changes in some biochemical responses.
STUDY DONE ON COLORECTAL CANCER:
Researchers from Immunomedics Inc. have completed pilot
clinical studies of a new radioiodinated monoclonal antibody,
which reacts with colon specific antigen-P for imaging and
treating colon cancers. In mice lacking an immune system, human
colon cancers have been targeted and have regressed following
administration of fragments of this antibody labeled with
radioisotopes.
CANCER RESEARCH TOOL DEVELOPED:
Researchers at Lawrence Livermore National Laboratory have developed new
technique for studying the effects of small amounts of cancer causing
chemicals on DNA. An ultra-sensitive instrument, called an accelerator mass
spectrometer, allows scientists to monitor extremely small quantities of
carcinogens, labeled with radioactive carbon-14, as they interact with DNA.
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Volume 3, Number 19 May 29, 1990
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Center for Disease Control Reports
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Morbidity and Mortality Weekly Report
Thursday May 24, 1990
Current Trends
Injuries Associated with Horseback Riding --United States, 1987 and 1988
Each year in the United States, an estimated 30 million persons ride
horses (1). The rate of serious injury per number of riding hours is estimated
to be higher for horseback riders than for motorcyclists and automobile racers
(2). The following report uses data from the National Electronic Injury
Surveillance System (NEISS) to describe the epidemiology of horseback-riding-
associated injuries in the United States during 1987 and 1988.
NEISS is an emergency-room based active injury surveillance program of the
U.S. Consumer Products Safety Commission. NEISS records the most severe
diagnosis listed on the emergency room record. Reports from NEISS can be used
to develop national estimates of the number of persons with product-related
injuries treated in hospital emergency rooms.*
During 1987 and 1988, an estimated 92,763 emergency room visits were made
in the United States for injuries related to horseback riding. Although the
greatest number of injuries occurred in the 25-44-year age group, injury rates
were highest for 5-24-year-olds, especially for females (Table 1).
Nearly half the injuries occurred at home or on a farm (Table 2). Soft
tissue injury (e.g., laceration, contusion, or abrasion) was the most common
diagnosis, followed by fracture or dislocation, strain or sprain, and
concussion (Table 2). Most injuries to the extremities and trunk involved soft
tissue, fractures and dislocations, and strains and sprains. Head and neck
injuries were mainly soft tissue (56.9%), concussions (18.5%), and fractures
or dislocations (11.0%). The 14,120 fractures to upper extremities represented
the single most common site and type of injury.
Of the injured persons, 9.9% required hospitalization. More than two
thirds of hospitalized persons had head and neck (42.2%) or trunk injuries
(25.2%). The most common diagnoses for these patients were fractures or
dislocations (55.1%) and concussions (17.2%).
Reported by: DB Hammett, MD, American Medical Equestrian Association,
Waynesville, North Carolina. Unintentional Injuries Section, Epidemiology Br,
Div of Injury Control, Center for Environmental Health and Injury Control,
CDC.
Editorial Note: Estimates of the number of persons in the United States who
ride horses each year are broad, and demographic data are unavailable. The
lack of specific denominators for horseback riders requires the use of census
data to determine rates. However, the rates in this report may inaccurately
estimate the risks for injury. For example, one possible explanation for the
higher rates in 5-24-year-olds is that persons in this group are more likely
to ride horses.
The risks for severe injury to the head, trunk, abdomen, and pelvis
associated with horseback riding are well defined (3-5). Although no national
estimates exist for the number of fatal injuries associated with horseback
riding, a review of state medical examiner records from 27 states for 1976-
1987 identified 205 such deaths (6); head injuries were associated with more
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Volume 3, Number 19 May 29, 1990
than 60% of these deaths.
Although falls account for most horseback-riding-associated injuries
(4,6), in one study, fewer than 20% of riders had worn a helmet at the time of
the fall (3). Even when riders wear headgear, the headgear may be decorative
or improperly secured, thereby providing limited or no protection (2,5,7).
Because of the potentially severe sequelae of head injury (8,9), horseback
riders should wear a properly secured hard shell helmet lined with expanded
polystyrene or similar material. Helmet use has been endorsed by several
medical and trade organizations, and national performance standards for
helmets are available (10-13).
Horseback riders can also be injured when they collide with fixed objects;
are dragged along the ground with a foot caught in a stirrup; are crushed
between the horse and ground; or are trampled, kicked, or bitten (2).
Equipment problems associated with injuries include improper boot-stirrup fit;
broken reins, bridles, or stirrup straps; and malfunctions of the stirrup-
release mechanism (2,10).
To reduce injuries, riders should wear properly fitting heeled boots and
nonskid gloves, avoid loose-fitting clothing, regularly maintain and inspect
equipment, replace worn parts, and use appropriately sized stirrups (2,10).
Safety practices of horseback riders may improve when they are trained by
experienced instructors who have successfully completed a horse-safety course
from an accredited organization, who emphasize safe riding techniques, and who
themselves wear helmets while riding. In addition, riding safety may improve
for riders who use appropriate techniques to stop, start, and turn a horse and
to perform a rapid (emergency) dismount (14).
References
1. Bixby-Hammett DM. Accidents in equestrian sports. Am Fam Physician
1987;36:209-14.
2. Firth JL. Equestrian injuries. In: Schneider RC, Kennedy JC, Plant ML,
eds. Sports injuries: mechanism, prevention, and treatment. Baltimore:
Williams and Wilkins, 1985:431-9.
3. Grossman JA, Kulund DN, Miller CW, et al. Equestrian injuries: results of
a prospective study. JAMA 1978;240:1881-2.
4. Gierup J, Larsson M, Lennquist S. Incidence and nature of horse-riding
injuries: a one-year prospective study. Acta Chir Scand 1976;142:57-61.
5. Barber HM. Horseplay: survey of accidents and horses. Br J Med 1973;3:532-
4.
6. Bixby-Hammett D, Brooks WH. Common injuries in horseback riding. Sports
Med 1990;9:36-47.
7. Mahaley MS, Seabar AV. Accident and safety considerations of horseback
riding. In: Proceedings of 18th American Medical Association Conference on the
Medical Aspects of Sports. Chicago: American Medical Association, 1976:37-45.
8. Kraus JF. Epidemiology of head injury. In: Cooper PR, ed. Head injury. 2nd
ed. Baltimore: Williams and Wilkins, 1986:1-19.
9. Levin HS. Neurobehavioral sequelae of head injury. In: Cooper PR, ed. Head
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Volume 3, Number 19 May 29, 1990
injury. 2nd ed. Baltimore: Williams and Wilkins, 1986:442-63.
10. Brooks WH, Bixby-Hammett DM. Prevention of neurologic injuries in
equestrian sports. Physician Sports Med 1988;16:84-6,88,90,93-5.
11. Bixby-Hammett DM. Head injuries in the equestrian sports. Physician Sports
Med 1983;11:82-6.
12. National Highway Transportation Safety Administration. A report to
Congress on the effect of motorcycle helmet use law repeal: a case for helmet
use. Washington DC: US Department of Transportation, 1980; publication no. DOT
HS 805-312.
13. American Society for Testing and Materials. Standard specification for
headgear used in horse sports and horse-back riding (F1163-88). In: Annual
book of ASTM standards. Philadelphia: American Society for Testing and
Materials, 1988.
14. DeBenedette V. People and horses: the risks of riding. Physician Sports
Med 1989;17:250-4.
* Sixty-two hospitals with emergency rooms located throughout the United
States contributed to this data base each month in 1987, 61 contributed data
from January through March 1988, and 62 provided data from April through
December 1988. The NEISS code used for horseback riding injuries is product
code 1239, "Horseback riding (activity, apparel, or equipment)."
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Volume 3, Number 19 May 29, 1990
Alcohol Use and Aquatic Activities -- Massachusetts, 1988
More than 8000 drowning fatalities occur in the United States each year,
making drowning the third most common cause of death from unintentional injury
in the United States (1,2). Although 25%-50% of adult and adolescent drowning
victims had consumed alcohol near the time of death (3), information regarding
drinking behaviors during aquatic activities is limited. In September 1988,
the Boston University School of Public Health surveyed Massachusetts adults
aged greater than or equal to 20 years to determine in what settings and how
often they consumed alcoholic beverages on or near the water during their most
recent aquatic activity in August 1988.
A statewide probability sample was conducted through a random-digit-
dialing procedure (4). Of 306 adults called, 294 (96%) participated in the
survey. A total of 221 (75%; 107 (79%) men, 114 (72%) women) respondents
reported a mean of 13 days of aquatic activities during August 1988. The most
frequently reported aquatic activity was swimming (169 (76%)), followed by
boating (55 (25%)), and fishing from shore (31 (14%)). The most frequently
reported site of activity was the ocean (120 (54%)), followed by lakes or
ponds (57 (26%)), pools (38 (17%)), rivers (five (2%)), and other settings (1
( less than 1%)).
Of persons reporting aquatic activities, 38 (36%) men and 13 (11%) women
reported that they had consumed alcohol on the last occasion. Among alcohol
users, 15 (29%) reported having consumed greater than or equal to 4 drinks
from 2 hours before until completion of the activity. Men who drank reported
consuming more (mean: 3.5 drinks) than women (mean: 2.4 drinks) in an aquatic
setting. The proportion of drinking did not vary substantially by location or
activity. Respondents aged greater than or equal to 50 years were less likely
than younger respondents to report drinking on the last occasion on or near
the water (Table 1).
Reported by: J Howland, PhD, R Hingson, ScD, S Levenson, MPH, M Winter, Boston
Univ School of Public Health; T Mangione, PhD, Center for Survey Research,
Univ of Massachusetts at Boston. Unintentional Injuries Section, Epidemiology
Br, Div of Injury Control, Center for Environmental Health and Injury Control,
CDC.
Editorial Note: The relationship between alcohol use and water recreation
fatalities has been documented in a variety of settings (1,5,6). For example,
the National Transportation Safety Board estimated that alcohol use was
associated with 32%-64% of recreational boating deaths in 1983 (7,8). In a
North Carolina study of drownings from 1980 through 1984, 399 (46%) of 869
drowning victims greater than or equal to 15 years of age tested positive for
blood alcohol, and 286 (33%) had blood alcohol concentrations (BACs) of
greater than 0.1 g divided by L (1).
The ratio of male-to-female drowning rates in the United States is
approximately 12:1 for drownings associated with boating and approximately 5:1
for other drownings (9); the gender difference in drowning rates does not
change with age (10-12). The Massachusetts data suggest that differences by
sex in aquatic-activity-related morbidity and mortality may be associated with
differences in behaviors (e.g., use of alcohol, use of personal flotation
devices, and participation in different types of water activities (13)) rather
than exposure to aquatic environments. Men are more likely than women to drink
alcohol on or near the water.
In the United States, more than 50 million persons engage in various
recreational (noncommercial) boating activities on at least 8 days per year
Health InfoCom Network News Page 9
Volume 3, Number 19 May 29, 1990
(5,6), and 90% of all deaths from recreational boating result from drowning.
The prevalence of alcohol use during aquatic activities in Massachusetts was
high when compared with the estimated prevalence of alcohol exposure among
weekend nighttime drivers, who have the highest overall estimate known among
U.S. drivers (8.3% of a 1983 U.S. driver sample had BACs of greater than or
equal to 0.1 g divided by L) (2). This information suggests the need to 1)
strengthen education about the risks of drowning in all aquatic environments
and 2) clarify the relationship between alcohol use, drowning, and other water
recreation injuries.
References
1. Patetta MJ, Biddinger PW. Characteristics of drowning deaths in North
Carolina. Public Health Rep 1988;103:406-11.
2. Brooks JG. Near drowning. Pediatr Rev 1988;10:5-10.
3. Howland J, Hingson R. Alcohol as a risk factor for drowning: a review of
the literature (1950-1985). Accid Anal Prev 1988;20:19-25.
4. Waksberg J. Sampling methods for random digit dialing. J Am Stat Assoc
1978;73:40-6.
5. CDC. Recreational boating fatalities--Ohio, 1983-1986. MMWR 1987;36:321-4.
6. Smith GS, Kraus JF. Alcohol and residential, recreational and occupational
injuries: a review of the epidemiologic evidence. Annu Rev Public Health
1988;9:99-121.
7. Wright SJ. SOS: alcohol, drugs and boating. Alcohol Health and Research
World 1985;9:28-33.
8. National Transportation Safety Board. Safety study: recreational boating
safety and alcohol. Washington, DC: National Transportation Safety Board,
1983; publication no. NTSB no. SS-83-02.
9. Baker SP, O'Neill B, Karpf RS. The injury fact book. Lexington,
Massachusetts: DC Heath and Co, 1984:156.
10. O'Carroll PW, Alkon E, Weiss B. Drowning mortality in Los Angeles County,
1976 to 1984. JAMA 1988;260:380-3.
11. Quan L, Gore EJ, Wentz K, Allen J, Novack AH. Ten-year study of pediatric
drownings and near-drownings in King County, Washington: lessons in injury
prevention. Pediatrics 1989;83:1035-40.
12. Wintemute GJ, Kraus JF, Teret SP, Wright MA. The epidemiology of drownings
in adulthood: implications for prevention. Am J Prev Med 1988;4:343-8.
13. Gulaid JA, Sattin RW. Drownings in the United States, 1978-1984. In:
Public health surveillance of 1990 injury control objectives for the nation.
MMWR 1988;37(no. SS-1):27-33.
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Volume 3, Number 19 May 29, 1990
Aeromonas Wound Infections Associated with Outdoor Activities -- California
Aeromonas species are associated with gastroenteritis and with wound
infections, particularly wounds incurred in outdoor settings. On May 1, 1988,
isolates of Aeromonas became reportable in California, the first state to
mandate reporting of isolates of and infections with these organisms.
Surveillance data for 1988 and 1989 represent the first population-based
estimates of both the occurrence and public health impact of Aeromonas
infections in the United States and provide a basis for assessing the need for
further surveillance of these organisms.
From May 1, 1988, through April 30, 1989, clinicians and clinical
laboratories in California reported 225 Aeromonas isolates from 219 patients.
Cases were reported on Confidential Morbidity Report cards to local health
departments, which then conducted case investigations and forwarded their
reports to the California Department of Health Services. Of the 225 isolates,
178 (79.1%) were recovered from stool, 19 (8.4%) from wounds, 11 (4.9%) from
blood, and 17 (7.6%) from other sites. A. caviae was recovered from seven
stool cultures; A. sobria was recovered from two stool cultures and one
vaginal culture. All other cultures were reported as A. hydrophila or
Aeromonas unspecified.
Based on reported cases, the incidence of Aeromonas wound infections in
California was 0.7 per million population. Of the 19 patients with wound
infections, 13 were injured outdoors (Table 1). Six of these patients required
hospitalization for their injuries and/or infections. One patient had a mixed
infection including Aeromonas, Proteus, and Pseudomonas species. The number of
infections peaked in the summer months with three cases each in July and
August. The cases reported among persons aged 30-39 years represented the
highest incidence rate for all age groups (1.4 per million).
Reported by: SB Werner, MD, Infectious Disease Br, GW Rutherford, III, MD,
State Epidemiologist, California Dept of Health Svcs. Div of Field Svcs,
Epidemiology Program Office; Enteric Diseases Br, Div of Bacterial Diseases,
and Epidemiology Br, Hospital Infections Program, Center for Infectious
Diseases, CDC.
Editorial Note: Aeromonas species are gram-negative, facultatively anaerobic
bacteria found in soil and fresh and brackish water worldwide (1). Although
Aeromonas species were recognized in 1891 as colonizers and pathogens of cold-
blooded animals, especially fish (2), they were not identified as human
pathogens until 1968 (3). Since then, they have been associated with a wide
spectrum of human diseases (especially in immunocompromised patients), most
commonly gastroenteritis (4) and soft tissue infections (5).
The taxonomy of Aeromonas species requires further clarification. Three
species, A. hydrophila, A. sobria, and A. caviae, have been associated with
human disease (4), but DNA hybridization analyses support seven or more
distinct genotypes (6). Because many clinical laboratories are unable to
perform precise identification, many aeromonad isolates are reported as A.
hydrophila or A. hydrophila complex.
Although the California surveillance data provide limited information
about the morbidity of the wound infections reported, they suggest that the
public health impact of these soft tissue infections is low and may be
determined more by the nature of the underlying injury than by the presence of
Aeromonas organisms.
The California data do not provide information on case management.
However, one reported case series (7) suggests that surgical debridement is an
Health InfoCom Network News Page 11
Volume 3, Number 19 May 29, 1990
important component of treatment and has enabled resolution of the infection
when either no antibiotics or ineffective antibiotics (i.e., antibiotics to
which the organisms were resistant) were used. These findings, as well as the
occurrence of Aeromonas organisms in mixed infections, suggest that in some
cases Aeromonas species may be colonizers in wounds rather than pathogens.
References
1. Von Graevenitz A. Aeromonas and Plesiomonas. In: Lennette EH, Ballows A,
Hausler WJ, Shadomy HJ, ed. Manual of clinical microbiology. Washington, DC:
American Society for Microbiology, 1985:278-81.
2. Ewing WH, Hugh R, Johnson JG. Studies on the Aeromonas group. Atlanta,
Georgia: US Department of Health, Education, and Welfare, Public Health
Service, Communicable Disease Center, 1961.
3. Von Graevenitz A, Mensch AH. The genus Aeromonas in human bacteriology:
report of 30 cases and review of the literature. N Engl J Med 1968;278:245-9.
4. Holmberg SD, Schell WL, Fanning GR, et al. Aeromonas intestinal infections
in the United States. Ann Intern Med 1986;105:683-9.
5. Janda JM, Duffey PS. Mesophilic Aeromonads in human disease: current
taxonomy, labo ratory identification and infectious disease spectrum. Rev
Infect Dis 1988;10:980-97.
6. Popoff MY, Coynault C, Kiredjian M, Lemelin M. Polynucleotide sequence
relatedness among motile Aeromonas species. Curr Microbiol 1981;5:109-14.
7. Isaacs RD, Paviour SD, Bunker DE, Land SDR. Wound infection with aerogenic
Aeromonas strains: a review of twenty-seven cases. Eur J Clin Microbiol Infect
Dis 1988;7:355-60.
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Volume 3, Number 19 May 29, 1990
Progress in Chronic Disease Prevention
Malignant Melanoma of the Skin -- New Jersey, 1979-1985
Each year, several thousand New Jersey residents are diagnosed with skin
cancer. Although most types of skin cancer can be treated successfully, one--
malignant melanoma--has a high mortality rate. This report summarizes a study
by the New Jersey State Department of Health (NJSDH) that examined the
incidence and mortality rates for malignant melanoma in New Jersey residents
from 1979 through 1985 and compared those rates with U.S rates for the same
period (1).
Incidence data were obtained from the New Jersey State Cancer Registry
(NJSCR) and analyzed by the NJSDH's Data Applications Program. The melanoma
incidence data include all cases reported to the NJSCR from hospitals,
laboratories, and private practitioners and cases identified through New
Jersey death certificate matching. The mortality data were extracted from the
state's vital statistics mortality data tapes and included cases of malignant
melanoma of the skin (International Classification of Diseases, Ninth
Revision, rubrics 172.0-172.9) listed as the underlying cause of death.
Incidence and mortality rates were age-adjusted to the 1970 U.S. population.
National incidence rates were obtained from the Surveillance, Epidemiology,
and End Results (SEER) Program of the National Cancer Institute.* The
mortality rates include the entire United States, age-adjusted to the 1970
U.S. population. Because incidence and mortality rates for blacks in New
Jersey were low, they were not included in this analysis.
From 1979 through 1985, an average of 381 males and 324 females were
diagnosed annually in New Jersey with malignant melanoma, and an average of
111 males and 79 females died each year from the disease. White males had the
highest average incidence rate for the 7-year period (11.9 cases per 100,000,
compared with 10.9 per 100,000 from SEER data) (Figure 1). The incidence rate
for white females was 8.5 per 100,000 (compared with 8.8 per 100,000 from
SEER) (Figure 1). Mortality rates for whites were higher for males than for
females; the age-adjusted mortality rates for both sexes in New Jersey were
higher than the national rates. The mortality rate was 3.4 per 100,000 for New
Jersey males and 1.6 per 100,000 for New Jersey females; national mortality
rates were 3.0 per 100,000 for males and 1.6 per 100,000 for females (3). In
New Jersey, 73% of the melanomas were staged as local, compared with 78% in
the SEER Program. The most common site for melanoma of the skin in white males
was the trunk (47.9%), followed by the arm and shoulder (22.7%), face (12.3%),
leg and hip (10.4%), and scalp and neck (6.7%). For white females, the most
common site was the leg and hip (38.1%), followed by the arm and shoulder
(24.0%), trunk (23.5%), face (10.1%), and scalp and neck (4.3%).
In response to this study, the NJSDH and the Medical Society of New Jersey
are preparing a press release to the public and health-care community before
the summer season emphasizing the dangers of excessive sun exposure, which has
been linked to malignant melanoma (5). The NJSDH has advised all persons to
follow the guidelines set by the National Institutes of Health (NIH) to
prevent and reduce the risk for malignant melanoma and to take precautions
against excessive sun exposure (2).
Reported by: WE Parkin, DVM, ME Petrone, MD, DM Harlan, MS, BA Kohler, MPH, HC
Lewis, MPH, Div of Epidemiology and Disease Control, Cancer Registry and Data
Applications Programs, K Mertz, MD, K Spitalny, MD, State Epidemiologist, New
Jersey State Dept of Health.
Editorial Note: Since the 1970s, the incidence and mortality rates for
Health InfoCom Network News Page 13
Volume 3, Number 19 May 29, 1990
malignant melanoma of the skin have increased steadily in the United States.
From 1973 to 1985, the national mortality rate for melanoma of the skin rose
25.9%, a greater percentage increase for any neoplasm except lung cancer (3).
During the same period, the mortality rate for white males in the United
States increased 34.1%, the highest percentage increase of any cancer for this
population (3). In 1989, an estimated 27,000 new cases of malignant melanoma
will occur in the United States, and 6000 persons will die from the disease
(4).
Melanoma has been associated with intermittent exposure to high-intensity
ultraviolet radiation (5-7). The emphasis on suntanning and outdoor recreation
in the United States may account for the high rate of increase in melanoma
cases (4).
To minimize the risk for melanoma, persons should follow the NIH
guidelines (2), which recommend 1) minimizing exposure to the sun between 10
a.m. and 3 p.m., when the sun's rays are most intense; 2) wearing a hat that
protects the head and face and clothing that protects the back and shoulders
from sunburn; 3) using a waterproof sunscreen with a sun protection factor of
greater than or equal to 15 on exposed skin; and 4) consulting with a
physician about medications that can increase sensitivity to ultraviolet
light.
References
1. Mertz K, Lewis HC Jr, Meinert LA. Malignant melanoma of the skin. NJ Med
1990;87:401-7.
2. National Institutes of Health. Sunlight, ultraviolet radiation and the
skin: Consensus Development Conference statement. Bethesda, Maryland: National
Institutes of Health, 1989.
3. National Institutes of Health. 1987 Annual cancer statistics review.
Bethesda, Maryland: US Department of Health and Human Services, Public Health
Service, 1988; NIH publication no. 88-2789.
4. American Cancer Society. Cancer facts and figures--1989. Atlanta: American
Cancer Society, 1989.
5. Mackie RM. The role of sunlight in the etiology of cutaneous malignant
melanoma. Clin Exper Dermatol 1981;6:407-10.
6. Armstrong BK, Holman CD. Malignant melanoma of the skin. Bull WHO
1987;65:245-52.
7. Armstrong BK. Epidemiology of malignant melanoma: intermittent or total
accumulated exposure to the sun? J Dermatol Surg Oncol 1988;14:853-7.
---------
* The SEER Program comprises cases from nine population-based cancer
registries throughout the United States.
Health InfoCom Network News Page 14
Volume 3, Number 19 May 29, 1990
Epidemiologic Notes and Reports
Swimming-Associated Cryptosporidiosis -- Los Angeles County
From July 13 through August 14, 1988, 44 persons in five separate swimming
groups developed a gastrointestinal illness after using a swimming pool in Los
Angeles County. The outbreak began several days after an unintentional human
defecation in the pool during the first week of July. When the outbreak was
reported to the Los Angeles County Department of Health Services (LACDHS) in
early August, LACDHS initiated an epidemiologic investigation.
The affected groups had repeated pool contact in July and included a high
school water polo team, a SCUBA class, a "masters" group, an elementary school
group, and the pool lifeguards. Sixty (73%) of 82 persons from the five groups
were interviewed. A case was defined as any person with watery diarrhea or
diarrhea plus cramping and/or fever during July or August.
The overall attack rate was 73% (44/60) and ranged from 47% to 100% by
group (Table 1). Illness was characterized by watery diarrhea (88%), abdominal
cramps (86%), and fever (60%) and was often protracted (median duration: 5
days; range: 1-30 days). Two persons, both from the SCUBA class, were
hospitalized. Cryptosporidium was identified in stool specimens by modified
acid-fast staining from seven of 11 patients tested. Results of other
laboratory examinations, including bacterial culturing for Salmonella,
Shigella, and Campylobacter and testing for ova and parasites, were negative.
Assessment for viral agents was not performed.
For all persons with pool contact during the outbreak period, the attack
rate was highest among those with extensive (greater than 3 total hours) water
exposure (p less than 0.01, Fisher's exact test; relative risk=2.2; 95%
confidence interval=1.1-4.4). No other common exposures or risk factors were
identified. Review of surveillance data revealed no increase of
cryptosporidiosis or diarrheal illness during July or August in Los Angeles
County or the community affected by the outbreak. Pool water was not tested
for Cryptosporidium, and the person who fecally contaminated the pool was not
examined for Cryptosporidium infection.
The pool implicated in this outbreak is a 100,000-gallon pool at a school
in Los Angeles County. Inspection of the pool during the outbreak period
confirmed adequate chlorine levels (2 ppm) but detected a 30% diminished
filtration flow rate and established that one of three diatomaceous earth (DE)
filters was inoperative. The filtration system was repaired on August 3, and
no additional cases of diarrhea were subsequently identified among newly
exposed swimmers.
Reported by: FJ Sorvillo, MPH, K Fujioka, PhD, M Tormey, MPH, R Kebabjian, RS,
W Tokushige, L Mascola, MD, S Schweid, M Hillario, SH Waterman, MD, Los
Angeles County Dept of Health Svcs. Parasitic Diseases Br, Div of Parasitic
Diseases, Center for Infectious Diseases, CDC.
Editorial Note: Outbreaks of giardiasis, Norwalk gastroenteritis, and
adenovirus types 3 and 4 associated with swimming pool contact have been
reported (1-4). In each outbreak, inadequate pool maintenance was an important
contributing factor.
The clinical features and laboratory findings in this investigation are
consistent with an outbreak of cryptosporidiosis. Moreover, the investigation
suggests that Cryptosporidium may be acquired through recreational water
contact. Resistance of Cryptosporidium to chlorination (5), an inadequately
maintained filtration system, and repeated and prolonged exposure may have
contributed to the size and extent of this outbreak. Continued pool use and
Health InfoCom Network News Page 15
Volume 3, Number 19 May 29, 1990
possible ongoing contamination by infected persons, many of whom continued to
swim despite their illness, could also have sustained transmission.
Cryptosporidium oocysts are resistant to chlorine. Because Cryptosporidium
oocysts are small (4-6 u), rapid sand filters commonly used in swimming pools
may not be effective in filtering oocysts. However, evidence suggests that a
well-maintained, fine-grade DE filtration system may remove Cryptosporidium
(6). Further study is needed to assess the capability of different filtration
devices to remove Cryptosporidium oocysts from swimming pool water.
Recommendations for managing swimming pools that have been fecally
contaminated include prohibition of swimming until the chlorine level and
contact time are sufficient to kill Giardia cysts (1). Given the
ineffectiveness of chlorine against Cryptosporidium, greater consideration
should be given to control strategies that use effective filtration (e.g., DE
filters) or to draining the pool and replacing contaminated filter media in
filters not considered effective against Cryptosporidium. In systems that use
DE filters, one option may be to close contaminated pools until relatively
complete filtration has occurred (typically three turnovers or approximately 1
day).
References
1. Porter JD, Ragazzoni HP, Buchanon JD, Waskin HA, Juranek DD, Parkin WE.
Giardia trans mission in a swimming pool. Am J Public Health 1988;78:659-62.
2. Kappus KF, Marks JS, Holman RC, et al. An outbreak of Norwalk
gastroenteritis associated with swimming in a pool and secondary person-to-
person transmission. Am J Epidemiol 1982;116:834-9.
3. Martone WJ, Hierholzer JC, Keenlyside RA, Fraser DA, D'Angelo LJ, Winkler
WG. An outbreak of adenovirus type 3 disease at a private recreation center
swimming pool. Am J Epidemiol 1980;111:229-37.
4. D'Angelo LJ, Hierholzer JC, Keenlyside RA, Anderson LJ, Martone WJ.
Pharyngoconjunctival fever caused by adenovirus type 4: report of a swimming
pool-related outbreak with recovery of virus from pool water. J Infect Dis
1979;140:42-7.
5. Campbell I, Tzipori AS, Hutchison G, Angus KW. Effect of disinfectants on
survival of Cryptosporidium oocysts. Vet Rec 1982;11:414-5.
6. Lange KP, Bellamy WD, Hendricks DW, Logsdon GS. Diatomaceous earth
filtration of Giardia cysts and other substances. Journal of the American
Water Works Association 1986:76-84.
Health InfoCom Network News Page 16
Volume 3, Number 19 May 29, 1990
:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
Food & Drug Administration News
:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
BCG for Cancer
P90-32 Food and Drug Administration
FOR IMMEDIATE RELEASE Eva Kemper -- (301) 443-3285
May 21, 1990 (Home) -- (301) 972-9273
The Food and Drug Administration today approved the use of a live, but
weakened bacteria to treat a type of cancer involving the lining cells on the
inner surface of the urinary bladder.
More than 45,000 cases of bladder cancer are detected in the United States
each year. This type of bladder cancer -- "carcinoma in situ," the Latin for
"cancer in place" -- is found in 20 to 30 percent of the cases.
To treat the cancer, the live bacteria is administered at a high dosage
directly into the bladder through a catheter to cause an inflammatory reaction
that eliminates many of the cancer cells. The patient holds the product for
about two hours before urinating. The procedure is repeated once a week for
six weeks and then monthly for six to 12 months.
The treatment may be used alone or following surgical scraping to remove
visible tumor growth.
The product is called Bacillus Calmette Guerin Live (intravesical) or BCG
Live. Intravesical means that it is administered directly into the bladder
via a urethral catheter instead of being injected under the skin. BCG Live is
made by using live, but weakened, bacteria and is manufactured by Connaught
Laboratories Ltd. of Willowdale, Ontario. Although there are BCG vaccines
currently licensed in the United States, only BCG Live (intravesical) produced
by Connaught Laboratories has been approved for the treatment of CIS of the
bladder. The Connaught Laboratories' product is not approved for use as a
vaccine.
In controlled multicenter studies, sponsored by the National Cancer
Institute, 74 percent of patients with CIS of the bladder responded to the
treatment. Patients treated with BCG had a median time for recurrence of the
cancer of four years.
For persons who do not respond to treatment with BCG, other treatment such
as removal of the bladder may be recommended.
Flu-like symptoms such as fever, chills and nausea, and discomfort related
to inflammation of the bladder are the most common side effects following BCG
Live therapy. However, the FDA-approved labeling also warns physicians to
watch for and treat any spread of BCG organism throughout the body, which has
been associated with two deaths.
BCG Live (intravesical) will be distributed by Connaught Laboratories
Inc., of Swiftwater, Pa., under the trade name Theracys.
Health InfoCom Network News Page 17
Volume 3, Number 19 May 29, 1990
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Columns
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AIDS AND GERONTOLOGY
Prepared by Barbara R. Tysinger
A sampling of books on AIDS AND GERONTOLOGY
AIDS AND AGING. Bressler, J. Philadelphia: Leonard Davis
Institute of Health Economics, University of Pennsylvania; 1988.
AIDS IN AN AGING SOCIETY: WHAT WE NEED TO KNOW. Riley, M.W.;
et al. New York: Springer; 1989.
NURSING AND THE ELDERLY: A CARE PLAN APPROACH. Burggral, V.;
Stanley, M. Philadelphia: Lippincott; 1989.
See: "Medical diagnosis: acquired immune deficiency syndrome",
p.387.
Other books and audiovisual materials on AIDS AND GERONTOLOGY may be found by
searching medical sunject headings:
Searching by subject:
ACQUIRED IMMUNODEFICIENCY SYNDROME
ACQUIRED IMMUNODEFICIENCY SYNDROME--in old age
AGED--diseases
AIDS (DISEASE)
AIDS (DISEASE)--Age Factors
A sampling of journal articles on AIDS AND GERONTOLOGY
Age, rage, and the fear of AIDS. Myers, W.A. JOURNAL OF
GERIATRIC PSYCHIATRY. 1987; 20(2): 125-140.
AIDS and the geriatrician. Ross, R.J.; Miles, S.H. JOURNAL OF
THE AMERICAN GERIATRICS SOCIETY. 1987; 35(5): 460-464.
AIDS as a cause of dementia in the elderly. Ryan, F.M. MARYLAND
MEDICAL JOURNAL. 1989; 38(3): 251-254.
AIDS dementia. Moss, R.J.; Miles, S.H. CLINICS IN GERIATRIC
MEDICINE. 1988; 4(4): 889-895.
AIDS in the elderly: a case and its implications. Fillit, H.; et
al. GERIATRICS. 1989; 44(7): 65-68,70.
Allocation and the physician: the impact of aging and AIDS
[editorial]. Lynn, D.J. JOURNAL OF GENERAL INTERNAL MEDICINE.
1989; 4(2): 173-174.
Conversation with ... Philip G. Weiler, MD: Why AIDS is becoming
a geriatric problem. Weiler, P.G.; Peck, R.L. GERIATRICS. 1989;
44(7): 81-82.
Health InfoCom Network News Page 18
Volume 3, Number 19 May 29, 1990
Don't forget AIDS at any age [letter]. Schwartz, L.; Garay, S.
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY. 1989; 37(12):
1204-1205.
Family caregivers for non-Alzheimer's dementia patients.
Hepburn, K.W.; Gates, B.A. CLINICS IN GERIATRIC MEDICINE. 1988;
4(4): 925-940.
Geriatric AIDS is a growing concern [letter]. Butler, R.N.
GERIATRICS. 1989; 44(7): 21.
HIV and the older adult: taking the necessary precautions.
Whipple, B.; Scura, K.W. JOURNAL OF GERONTOLOGICAL NURSING.
1989; 15(9): 15-19.
Immunological impairment, infection, and AIDS in the aging
patient. Cohen, F.L. CRITICAL CARE NURSING QUARTERLY. 1989;
12(1): 38-45.
Normal aging and the subcortical encephalopathy of AIDS: a
neuropsychological comparison. Van Gorp, W.G.; et al.
NEUROPSYCHIATRY, NEUROPSYCHOLOGY, AND BEHAVIORAL NEUROLOGY.
1989; 2(1): 5-20.
Occult AIDS: pneumocystis carinii pneumonia in elderly people.
Hargreaves, M.R.; et al. BRITISH MEDICAL JOURNAL. 1988;
297(6650): 721-722.
Older adults need AIDS education. Seabrooks, P.A. FLORIDA
NURSE. 1989; 37(4): 1.
Older Americans and AIDS: transmission risks and primary
prevention research needs. Catania, J.A.; et al. GERONTOLOGIST.
1989; 29(3): 373-381.
Pancytopenia as a presenting manifestation of HIV infection in
the elderly. Boudes, P.; et al. JOURNAL OF THE AMERICAN
GERIATRICS SOCIETY. 1989; 37(12): 1151-1152.
Population projections for AIDS using an actuarial model.
Wilkes, A.D. PHILOSOPHICAL TRANSACTIONS OF THE ROYAL SOCIETY OF
LONDON. SERIES B, BIOLOGICAL SCIENCES. 1989; 325(1226): 99-112.
When a resident is diagnosed positive. Addenbrook, A.W.; et al.
PROVIDER. 1987; 13(9): 20, 23.
Other articles on AIDS AND GERONTOLOGY may be found in various indexes and
abstracts at medical libraries:
AIDS BIBLIOGRAPHY
ACQUIRED IMMUNODEFICIENCY SYNDROME
AGING
Health InfoCom Network News Page 19
Volume 3, Number 19 May 29, 1990
CUMULATIVE INDEX TO NURSING AND ALLIED HEALTH (CINAHL)
ACQUIRED IMMUNODEFICIENCY SYNDROME (1984+)
ACQUIRED IMMUNODEFICIENCY SYNDROME--in old age
AGED
EXCERPTA MEDICA.
SECTION 54. AIDS
SECTION 20. Gerontology and Geriatrics
Uses a permuted subject index.
INDEX MEDICUS
ACQUIRED IMMUNODEFICIENCY SYNDROME (1983+)
AGED--Diseases
AIDS-RELATED COMPLEX
HIV
HIV SEROPOSIVITY
A sampling of OTHER INFORMATION on AIDS AND GERONTOLOGY
Online databases
INDEX MEDICUS, EXCERPTA MEDICA, and CINAHL can also be
searched as computer databases where available.
You can also do your own search on AIDS and GERONTOLOGY using the
SilverPlatter MEDLINE and CINAHL databases where available.
AIDS KNOWLEDGE BASE is an electronic textbook on AIDS
available only online. Information is updated monthly.
Additional information on this topic may be found in other issues or updates
of the Health Sciences Library Information Series on AIDS.
WE WELCOME YOUR SUGGESTIONS AND COMMENTS
If you have comments on this bibliography or wish to suggest resources or
future topics please contact:
Health Sciences Library CB# 7585
University of North Carolina at Chapel Hill
Chapel Hill, NC 27599-7585
(919) 962-0700
e-mail address (School of Medicine): aids@med.unc.edu
or: pwatkins@med.unc.edu
Health InfoCom Network News Page 20
Volume 3, Number 19 May 29, 1990
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Articles
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CANCER RESEARCH IN THE 90's--THE GIFT OF THE 80's
by Samuel Broder, M.D.
American Cancer Society's
THIRTY-SECOND SCIENCE WRITERS' SEMINAR
Daytona Hilton
Daytona Beach, Florida
March 25 - 28, 1990
SAMUEL BRODER, M.D. (45), Director, National Cancer Institute, National
Institutes of Health, Bethesda, Maryland. Dr. Broder grew up in Detroit, and
received his B.S. and M.D. degrees from the University of Michigan. After
serving an internship and residency at Stanford University, Dr. Broder became
Clinical Associate in the Metabolism Branch of the NCI. He soon became an
investigator in the same branch, then senior investigator. In 1981, Dr. Broder
became the Associate Director of the Clinical Oncology Program, Division of
Cancer Treatment, NCI, and in 1989 became Director of the NCI. Dr. Broder's
interests include clinical lmmunology with special attention to the
relationship between immune abnormalities and neoplastic diseases.
The hallmark of the new decade of the 90's will be the applicatlon of research
results, of technology transfer. This is possible becauge the last decade has
been a period of significant accomplishment in cancer research. In a sense,
the 80's were marked by the achievements of molecular biologists with
important genetic discoveries and developing proficiency in genetic
englneerlng .
At the National Cancer Institute, many of the new diagnostic, prognostic or
treatment advances can be traced to recent findings from basic cancer
research. Our clinical trials and many of our projects are targeted to speed
new prevention, diagnosis, and treatment successes. Now while we are committed
to basic research, the time has come for an inspired application of the
findings of cancer research.
Ironically, as our ability to detect, diagnose, and treat improves, those with
access to the technology generated by NCI show better incidence and mortality
statistics than those who lack such access. So today, we require a unified
approach, an expeditious approach, an egalitarian approach, a humane approach-
in short, a committed and revitalized public health approach to cancer
research and application.
No one can reasonably dispute that enormous progress has been made against
cancer: one of the most formidable diseases yet known. In young children, in
adults under age 65, we have made advances. These advances came out of major
achievements in cancer research turing the past decade. Among these are:
o Significant development of the science and application of cancer prevention
and early detection: NCI is giving high priority to research on these areas
and their subsequent applications. ( o An understanding of the genetic and
Health InfoCom Network News Page 21
Volume 3, Number 19 May 29, 1990
molecular basis for cancer, including the identification of broad families of
genes that accelerate (so-called oncogenes) or retard (so-called suppressor
genes) the development of cancer.
o The characterization of physiologic growth factors and their receptors,
which when expressed in the wrong place and at the wrong time, contribute to
the development of cancer. During the past year, NCI-supported scientists took
advantage of this knowledge to develop a new treatment for wide-spread
prostate cancer using a drug called guramin. Thig drug specifically inhibits
a clags of growth factors that stimulate the development of prostate tumors.
(There are about 90,000 cases of prostate cancer each year in the United
States.) This approach is being expanded to treatment of other types of solid
tumors and leukemias.
o The elucidation of new families of viruses, such as the human retroviruses
involved in AIDS and some leukemias. The long-term commitment of NCI to the
study of such viruses has contributed to success in preventing and treating
AIDS. In addition, such viruges are involved in certain chronic liver and
neurologic diseages, so the value of this research extends beyond cancer.
o An understanding of the ways that cells evade the effects of cancer drugs
and consequent methods to reduce drug resistance and improve therapies.
o A better understanding of natural biological substances and their potential
applications. This has led, for instance, to using the patient's own host
defense cells, appropriately activated and multiplied, to shrink tumor cells.
o Increased expertise in using genetically engineered products to treat
patients with advanced cancer and AIDS.
o Improved adjuvant therapy. Successful adjuvant trials in breast cancer,
rectal cancer, osteosarcoma, pediatric sarcomas, and extremity soft tissue
sarcomas have extended the value of chemotherapy when added to surgery and
radiation.
o The use of the latest supercomputer technology, employing concepts from
physics and chemistry to understand how cancer cells and the AIDS virus
function and then to design new drugs to treat these diseases.
"As evidence of high momentum in our recent testimony before the Senate and
House appropriation~ committees, we listed a few of NCI's accomplishments of
the last year.
o Two NCI scientists working with colleagues from the National Heart, Lung,
and Blood Institute made medical history by inserting new genetic material
into human cells in the laboratory and then placing the cells back into a
patient.
o New insights into the role of tumor suppressor genes. Dr. John Minna's
laboratory has found that certain genetic abnormalities play an important role
in the genetic events that culminate in lung cancer. An NCI-grantee, Dr. Bert
Vogelstein, at Johns Hopkins, has shown that an accumulation of complex
genetic alterations is associated with the progression of colorectal tumors
from benign adenomatous polyps to frank carcinomas. This lays the groundwork
Health InfoCom Network News Page 22
Volume 3, Number 19 May 29, 1990
for new diagnostic, prognostic, and treatment of colorectal tumors.
o NCI scientists have discovered several proteins that may be involved in
positive and negative regulation of tumor invasion and metastasis. These
include the laminin receptor, autocrine motility factor, NM23 metastasis
suppressor protein, type IV collagenase, and the newest discovery TIMP-2
metalloproteinase inhibitor.
o Basic research leads to better diagnostic tests. Recent discoveries have
demonstrated that the N-myc oncogene is amplified in the neuroblastomas of
pediatric-patients and that the HER-2neu oncogene has been confirmed in both
breast cancer and ovarian cancer.
o New insights into the human papilloma virus and its attack on suppressor
cells in the development of cervical cancer--similar process at work in
squamous cell cancer of the oral cavity.
o It has been found that high testostrone levels may be related to prostate
cancer--as is a high-fat, inadequately nourishing diet.
o Scientists at NCI's Frederick Cancer Research Facility have completed
important steps in the development of a vaccine for AIDS.
o At NCI's Frederick Cancer Research Facility, using the supercomputer, the
crystallographic structure of the HIV-l protease has been discovered.
o NCI and FDA have embarked on joint programs, regular meetings, and other
actions designed to speed drug development in cancer and AIDS.
o Adjuvant therapy for advanced colon cancer and early breast cancer patients-
-also for patients with bladder, head, ant neck cancers.
o New diagnostic tests delineate subsets of breast cancer patients which
guides treatment decisions.
o Investigational New Drug applications were filed for 8 drugs and 11 new
biological response modifiers.
All in all, this past year has set a wonderful record of accomplishment, and
this accounting is only a partial list. NCI scientists , both extramural and
intramural, are achieving unparalleled levels of productivity--and new levels
of citation in the scientific literature, an indication of fundamental and
important findings. The future is exciting.
Health InfoCom Network News Page 23
Volume 3, Number 19 May 29, 1990
COMMON AIR POLLUTANTS AND THE SPREAD OF CANCER
by ARNIS RICHTERS, Ph.D
American Cancer Society's
THIRTY-SECOND SCIENCE WRITERS' SEMINAR
Daytona Hilton
Daytona Beach, Florida
March 25 - 28, 1990
ARNIS RICHTERS, Ph.D. (Experimental Pathology) (61), Associate Professor of
Pathology, USC School of Medicine. Dr. Richters was born in Sauka, Latvia, and
received his B.S. in zoology and his M.S. in biochemistry from the University
of Arizona. After receiving his Ph.D. from the University of Southern
California, Los Angeles, he became an instructor of pathology at USC, then an
Assistant Professor there. He is a member in many scientific societies, and
has acted as a consultant to many organizations, including the Society of
Experimental Biology and Medicine, and the Health Effects Institute.
Our recent studies with animals have indicated that inhalation of the common
air pollutant, nitrogen dioxide, facilitates blood-borne cancer cell spread to
the lungs. The animals develop a significantly larger number of cancer
colonies or metastases in their lungs, and die sooner than the animals
breathing clean air. This facilitation of cancer cell growth in lungs may be
due to several adverse nitrogen dioxide effects, in particular injury to blood
capillaries and cells of the immune system. Since most cancer patients have
circulating cancer cells at one time or another, there is the reasonable
concern that cancer patients subjected to air pollution may be at an increased
risk for seeding of cancer cells that otherwise would have been rejected by
the host. Adding to this concern are epidemiological studies indicating a
positive correlation of cancer mortality with air pollution indices.
It is now well recognized that one of the major obstacles to the eradication
of cancer is the failure to control cancer cell metastasis. Cancer metastasis
is a complex process, the final outcome being determined by interactions
between the biologic nature of the cancer cells, the general health of the
patient, and medical care. We have studied one phase of this complex process
in an animal model, that is the phase where cancer cells are circulating in
the blood stream. The major objective was to determine whether inhalation of a
common air pollutant (nitrogen dioxide) affects the spread of blood borne
cancer cells, and by what mechanisms. We have found that mice exposed to
nitrogen dioxide, at concentrations that occur in ambient Los Angeles air,
develop a greater number of cancer cell colonies (metastases) in their lungs
(4,5), and they die sooner than do control animals breathing clean air (6).
Moreover, we have found that the exposure of mice to ambient air in Los
Angeles facilitates the spread of blood-borne cancer cells to the lungs (7).
Other investigators have also reported an ozone-induced increase in lung
metastasis by blood-horne cancer cells (8), but these are the only studies
which have addressed this question.
Our ongoing studies suggest that the facilitation of metastasis may be due to
several kinds of adverse N02 effects. In particular, we have demonstrated that
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Volume 3, Number 19 May 29, 1990
the inhalation of an ambient level of N02 injures the endothelial cells of
lung capillaries (9), and also adversely affects specific cells of the
immunological defense system (10). Immunologic alterations are of special
concern since this complex system plays a significant role in preventing and
slowlng the progression of cancer. Our concern has been substantially
increased by our latest observations that inhalation of ozone adversely
affects cellular immunity. All of the foregoing, and recent progress in
pathobiology in general, strongly suggest that the mechanism through which air
pollution facilitates lung metastasis involves adverse effects on both blood
capillaries and the immune system. In the latter respect, x-ray and
chemotherapeutic treatment may under some circumstances enhance the spread of
cancer to the lungs (1,2,3) possibly by a similar mechanism.
In spite of the realization that a large number of people in the United States
are exposed daily to polluted air, relatively little attention has been paid
to experimental studies describing air pollutant effects on blood-borne cancer
cell dissemination (5,6,8,9), and epidemiological studies suggesting increased
cancer mortality among people living in a polluted environment ( 11,14).
Further, it has been reported that cigarette smoking appears to facilitate the
metastasis of melanoma (12). To date, there have been no reports where the
clinical course of the cancerous disease, particularly the development of
metastases, has been evaluated according to place of residence in general, or
air pollutant dosage specifically. Such studies could have significant a
impact on decisions concerning air quality standards. On the basis of
information to date, one decision that would appear prudent is the provision
of pollutant filtered air for the cancer patient during circumstances where
the level of cancer cells circulating in the blood stream is apt to be
unavoidably high, in particular during surgery and the immediate post-
operative period.
It should be emphasized that the facilitation of cancer metastasis by air
pollutants should not be confused with the causation of cancer but the issue
is no less critical. As stated by Professor Day, "even though the cause of
cancer is important, in the clinical case it is the spread, the phenomenon of
metastasis, that is of more immediate concern in the human situation" (13).
Thus, reasonable extra efforts are warranted to eliminate, or at least reduce,
the noxious agents present in the environment in general, and in the community
atmosphere in particular. The benefit can be a substantial improvement in the
general state of health and thereby an optimization of the natural resistance
of the host to the spread of the cancer. Two especially needed steps in this
direction are epidemiologic investigations specifically directed to the
metastasis question (e.g. breast cancer survival according to place of
residence) and the encouragement of basic research on the mechanisms of
metastasis.
References
1. Stjernsward, J. 1977. Radiotherapy, host immunity and cancer spread. In
Secondary Spread in Breast Cancer, vol. 3, New Aspects of Breast Cancer, ed.
B.A. Stoll, pp. 139-167. London Heinemann Medical Books.
2. Peters, L.J., Mason, K.A., and Withers, H.R. 1980. Effect of lung
irradiation on metastases: Radiobiological studies and clinical correlations.
In Radiation Biology in Cancer Research, eds. R.E. Meyn and H.R. Withers, pp.
515-529. New York: Raven Press.
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3. Milas, L. Effects of local thoracic irradiation, cyclophosphamide, and
misonidazole on the formation of lung metastases. Cancer Bull:209-214,1982.
4. Richters, A. and Kuraitis, K.V. Inhalation of N02 and blood-borne cancer
cell spread to the lungs. Arch. Environ. Health 36:36-39,1981.
5.Richters, A. Effects of nitrogen dioxide and ozone on blood-borne cancer
cell colonization of the lungs. J. Toxicol. Environ. Health 25:379-387,1988.
6. Richters, A., Richters, V. and Alley, W.P. The Mortality Rate from Lung
Metastases in Animals Inhaling Nitrogen Dioxide (NOl). J. Su~p. Oncolo~ ~:63-
66, 1985.
7. Richters, A. and Richters, V. A new relationship between air pollutant
inhalation and cancer. Arch. Environ. Heath 38:69-75,1983.
8. Kobayashi, T., Todoroki, T., and Sato, H. Enhancement of pulmonary
metastasis of murine fibrosarcoma NR-FS by ozone exposure. J. Toxicol.
Environ. Health 20:135-145, 1987.
9. Richters, A. and Richters, V. Nitrogen dioxide (N02) inhalation, formation
of microthrombi in lungs and cancer metastasis. J. Environ. Path. Tox.
Oncolology 9:45-51, 1989.
10. Richters, A. and Damji, K.S. Changes in T-Lymphocyte Subpopulations and
Natural Killer Cells Following Exposure to Ambient Levels of Nitrogen Dioxide.
J. Toxicol. and Environ. Health 25:247-256, 1988.
11. Jacobson, B.S. The role of air pollution and other factors in local
variations in general mortality and cancer mortality. Arch. Environ. Health
39:306-313,1984.
12. Shaw, H.M., and Morton, G.W. Smoking and the development of metastases
from malignantmelanoma. Int.J.Cancer 28:153-156,1981.
13. Day, S.B. (1977): Preface. In: Progress in CancerResearch and Therapy.
Vol. 5. Day, SB, Meyers, P., Stansly, S., Garattini, S., and Lewis, M.G.,
Eds. p ix, Raven Press, New York.
14. Ford, A.B., and Bialik, 0. Air pollution and urban factors in relation to
cancer mortality. Arch. Environ. Health 35:350-359,1980.
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