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Medical News for Week Ending November 26, 1989
Copyright 1989: USA TODAY/Gannett National Information Network
Reproduced with Permission
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Nov. 20, 1989
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FDA SEEKS DRUG RECALL:
The cooking.net">food and Drug Administration said Saturday it is seeking a nationwide
recall of all over-the-counter dietary supplements that contain L-tryptophan
as their sole or major component. Reason: Because of its possible link to
eosinophilia-myalgia syndrome, a rare {*filter*} disorder. (From the USA TODAY Life
section.)
PARENTS MISTAKE SYMPTOMS:
Parents aren't likely to notice "internalized" symptoms that indicate a
child is contemplating suicide, reports a study at the University of Missouri-
Columbia School of Medicine. Suggestions: Parents should talk frequently with
their children about things that bother them, perceptions about other people
and the world.
EXPOSURE DOESN'T INCREASE RISK:
{*filter*}-agers who are exposed to other {*filter*} suicides will be no more likely to
take their own lives, reports the Nov. 17 issue of the Journal of the American
Medical Association. A study of suicide clusters found that youths who killed
themselves didn't have increased direct or indirect exposure to previous {*filter*}-
age suicides.
DOCTORS RESEARCH {*filter*}HIV:
The National Institute of Dental Research has launched a epidemiologic
study on the {*filter*}effects of the human immunodeficiency virus (HIV). Why: To
document the prevalence and incidence of {*filter*}conditions that appear during
various stages of HIV infection and define risk factors associated with the
conditions.
GROUP ISSUES CPR GUIDELINES:
Because of the hepatitis B and human immunodeficiency virus scare, the
Emergency Cardiac Care Committee of the American Heart Association has revised
its guidelines, reports the Journal of the American Medical Association's Nov.
17 issue. Changes: CPR rescuers can begin chest compressions before
ventilating a victim.
DENTISTRY EXPECTED TO CHANGE:
The 1990s signals a new era in the dental industry, reports the American
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Volume 2, Number 44 November 29, 1989
Dental Association. Expectations: Breakthroughs in periodontal disease
control; dramatic gains in the control of decay around old fillings and on
tooth roots in {*filter*}s; popular use of dental implants to replace real teeth;
expanded use of lasers and computers in dental care.
DENTAL IMPLANTS COME OF AGE:
Dental implants are gaining in popularity, said Dr. Paul Kaufmann, an
associate professor or {*filter*}and maxillo{*filter*} surgery at both N.Y. State
University School of Dental Medicine and NYU School of Dentistry. Reason:
Recent advances in implant devices and techniques have led to a higher success
rate and significant increase in use.
PREVENTIVE CARE HAS CHANGED:
New methods of tooth decay prevention are being added to the regimen of
brushing, flossing and fluoride use and regular dental visits, reports the
American Dental Association. Development: Sealants that can offer 100 percent
protection against tooth decay on the chewing surfaces of children's back
teeth. Made of a clear or shaded plastic material, sealants coat against
plaque and acids.
SWALLOWING MEDICINE:
Taking medicine can be fun. At least that's what comic forces hope to teach
children. It's in the free D-C Comic book Super Heroes Good Health Activity
Book, starring Batman and Robin, Wonder Woman and Superman. The booklet, from
DuPont, in cooperation with the National Association of Retail Druggists. It
features puzzles with safety messages. Call (800) 341-4004
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Nov. 21, 1989
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HEALTH PREDICTIONS FOR 1990:
Major advances will be made in cancer and AIDS research in 1990, predicts
Maximilian de Clara, a well-known biotechnology venture capitalist and
president of Cel-Sci Corp., Alexandria, Va. Predictions: Researchers will
learn to mix anti-cancer "cocktails" of immune system modulators; AIDS vaccine
may appear sooner than expected.
SO FAR, NO LINK FOUND:
Since the recent outbreak of the rare {*filter*} disorder, eosinophilia-myalgia
syndrome, the U.S. Food and Drug Administration has been conducting tests to
find out if L-tryptophan products are linked to the disorder. Why: Because
many people with the illness have reported using the product. Findings: To
date, no medical evidence of a cause and effect association.
{*filter*} NOT GOOD FOR CHILD:
Yelling, yanking, slapping and verbally debasing a child in public are very
stressful to a child, said Kaoru Yamamoto, Ph.D., a University of Colorado at
Denver psychologist. Study: {*filter*} is considerably more painful for
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Volume 2, Number 44 November 29, 1989
children than other kinds of crises such as the arrival of a new sibling.
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Nov. 22, 1989
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ASTRONAUTS WILL SEE FLASHES:
Astronauts on the next few shuttle flights will see bright flashes, streaks
and pops with their eyes. Why: Subatomic particles from solar explosions will
penetrate the shuttle and finally, through the astronauts' eyes. The energized
particles travel at close to the speed of light, pass through the liquid of
the eyeball and convert to light energy.
X-RAY HOLOGRAMS ADVANCE:
Laser scientists at Lawrence Livermore National said they have achieved a
key advance toward developing an X-ray laser source suitable to eventually
produce three dimensional views of living cells. How: By achieving the
shortest X-ray laser wavelength ever - to 44.8 angstroms. Use: The holograms
would assist in learning about and fighting diseases.
BEWARE OLD PACEMAKERS:
Health officials are cautioning hospitals to dispose of old pacemakers
carefully. Presently, they are trying to locate a pacemaker containing
radioactive plutonium that was mistakenly left inside the body of an Iowa man
cremated last month. Why: It contains plutonium 238, a powerful radioactive
material that has been known to cause cancer.
CANCER STUDY AT A STALEMATE:
Despite advances in cell biology and related fields, finding a cure for
cancer is at a stalemate, experts in the field said. Facts: Overall incidence
of cancer and the cancer death rate still are rising. One in four Americans
still develops cancer and one in six dies of the disease. Results: Cancer
remains the leading cause of death in the U.S. after heart disease.
USAF TO STUDY CHOLESTEROL:
Wilford Hall Air Force Medical Center will launch a cholesterol study. Why:
As part of an effort to reduce heart disease. Study: Center will screen more
than 100,000 people in South Texas who are eligible for military medical care.
Those with symptoms or high cholesterol will be followed up with a program
that could include diet, exercise and medicine.
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Nov. 24-26, 1989
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FOLIC ACID HELPS UNBORN:
Pregnant women who take multivitamins containing folic acid during the
first weeks of pregnancy reduce the risk of having a baby born with a spinal
cord defect, a study shows. Results of study: In relation to other research,
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Volume 2, Number 44 November 29, 1989
it should end the multivitamin-neural tube defect controversy. (From the USA
TODAY Life section.)
CANCER DRUG SHOWS PROMISE:
Camptothecin, a compound derived from plants, is showing dramatic anti-
cancer potential in a laboratory study, reports Science's Nov. 24 issue.
Study: Genetically engineered mice were given human colon cancers and treated
with the drug. Results: Complete remissions in some cases and very little side
effects. (From the USA TODAY Life section.)
MANY AIDS CASES NOT REPORTED:
In South Carolina between 1986 and 1987, only 59 percent of AIDS cases were
reported, reports Journal of the American Medical Association's Nov. 24 issue.
Why: Cases among whites and Midwesterners are not reported probably because
doctors want to protect confidentiality, insurance coverage. Fear:
Underreporting could be across the U.S. (From the USA TODAY Life section.)
STUDY: FILTERED BREW HEALTHIER:
Filtered coffee, not boiled, may be the healthier for the heart, reports a
study in New England Journal of Medicine's Nov. 23 issue. Why: People who
drink percolated coffee risk a 10 percent rise in cholesterol levels over
those who drink filtered coffee. (From the USA TODAY Life section.)
{*filter*} TRANSMITS {*filter*} DISEASE:
Two new reports documented the first cases of Chagas disease to be
transmitted via {*filter*} transfusions in the U.S. and Canada. Facts: The
disease, caused by a parasite found mostly in Latin America, was contracted
from the {*filter*} of Bolivian and Paraguayan immigrants. Symptoms: Prolonged
fever and enlargement of the spleen, liver and lymph nodes.
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Volume 2, Number 44 November 29, 1989
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Center for Disease Control Reports
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Morbidity and Mortality Weekly Report
Wednesday November 22, 1989
Epidemiologic Notes and Reports
Eosinophilia-Myalgia Syndrome and L-Tryptophan-Containing Products --
New Mexico, Minnesota, Oregon, and New York, 1989
As of November 21, 360 cases of eosinophilia-myalgia syndrome (EMS) had
been reported by state health departments to CDC. Studies examining an
association of L-tryptophan-containing products (LTCPs) with the EMS epidemic
(1) have been completed in New Mexico, Minnesota, and Oregon. In addition, a
fatal case in New York has been reported.
New Mexico. In a New Mexico case-control study, EMS cases (N=12) were all
persons for whom an eosinophil count of greater than or equal to 2000
cells/mm3 was recorded from May 1 through November 11, 1989, in nine
laboratories in Albuquerque, Santa Fe, and Los Alamos and for whom
incapacitating myalgia was documented, either in the medical record or by
interview with the patient. Potential cases were excluded if eosinophilia
could have been caused by any of a predetermined list of approximately 20
infectious, neoplastic, allergic, or other chronic diseases. EMS cases were
compared with controls (two per case) who had been matched with case-patients
by age (plus or minus 5 years), sex, and neighborhood of residence.
Comparisons were made for factors such as the use of different vitamins, other
health foods or raw cooking.net">food products, medications, and different water sources.
All case-patients and two (8%) controls used LTCPs (odds ratio (OR) not
calculable) (X2=20; p=6.9 X 10-6). There were no statistically significant
differences between cases and controls on 32 other potential risk factors
studied.
Minnesota. In Minnesota, potential cases for an initial case-control study
of risk factors for EMS were identified by rheumatologists (who were asked by
the Minnesota Department of Health to report patients recently diagnosed with
eosinophilia and either severe myalgia or muscle weakness) and by clinical
pathologists and a pediatric neurologist (who were asked to identify patients
with muscle biopsies showing eosinophilic perimyositis or perivasculitis).
Criteria necessary for these patients to be considered as cases were
eosinophil count of greater than 1000 cells/mm3, myalgia or muscle weakness of
severity sufficient to affect normal daily activities, and a muscle biopsy (if
done) showing perimyositis, perivasculitis, or unspecified fasciitis. As in
the New Mexico study, potential cases were excluded if EMS could have been
caused by any of a predetermined list of diseases known to be associated with
eosinophilia. Investigators had no prior knowledge of patients' use of LTCPs.
Twelve cases were identified and compared with controls (one per case) matched
by age, sex, and telephone exchange. All case-patients and no controls used
LTCPs (OR not calculable) (p=8 X 10-4) during the month before onset of
illness for case-patients and during a similar time period for matched
controls. Nine (75%) case-patients and four (33%) controls were taking some
type of prescription medication (not statistically significant after
adjustment for use of LTCPs). Illness was not associated with consumption of
vitamins and health-food products, wild game, undercooked meat or fish
products, or nonprescription medications.
A follow-up study compared 30 EMS cases fitting the CDC surveillance case
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Volume 2, Number 44 November 29, 1989
definition of EMS (1) with 36 asymptomatic users of LTCPs who responded to a
public request and contacted the Minnesota Department of Health. Twenty (67%)
case-patients reported using brands of LTCPs from one particular tablet
manufacturer, compared with eight (22%) asymptomatic users (OR=7.0; 95%
confidence interval (CI)=1.5-24.6 (p less than 0.0002)). Asymptomatic LTCP
users were similar to case-patients for age, sex, and geographic areas of
residence; additional population-based studies of LTCP use continue in
Minnesota.
Oregon. The Oregon Health Division studied 29 EMS patients who conformed
with the CDC case definition. All had eosinophilia and myalgia; four also
reported respiratory signs or symptoms. These patients, all users of LTCPs,
were compared with users of LTCPs identified by a random telephone survey of
Oregon residents (control group A; N=32) and asymptomatic LT users who
contacted the Oregon Health Division (control group B; N=24). Four{*filter*} (48%)
case-patients were exposed to LTCPs from a single lot of 4500 bottles,
compared with two (6%) persons in control group A and two (8%) persons in
control group B (ORs=14.0 (95% CI=2.5-103.0) and 10.3 (95% CI=1.8-76.8),
respectively) who were so exposed. This association remains statistically
significant when controlled for age, sex, or average daily LTCP consumption.
New York. In New York, a 58-year-old woman with EMS died September 17,
1989. The patient, who had become ill in July 1989 with myalgia, fatigue, and
marked progressive weakness, had been taking 5-6 g of LT daily. She had
leukocytosis (19,800 cells/mm3) with 18% eosinophils. Electromyelographic and
nerve conduction studies were most consistent with axonal neuropathy. Studies
considered to be within normal limits included: cerebrospinal fluid glucose,
protein, and cell counts and celiac and renal arteriograms. Serologic tests
for a variety of autoimmune diseases were negative. The patient developed an
ascending polyneuropathy with near-total quadriplegia and a bi{*filter*}
hemiparesis. She failed to improve on corticosteroid and cyclophosphamide
treatment and died following cardiorespiratory arrest.
Reported by: M Eidson, DVM, R Voorhees, MD, M Tanuz, CM Sewell, DrPH, State
Epidemiologist, New Mexico Health and Environment Dept. SL Glickstein, MD, WE
Muth, MD, Park Nicollet Medical Center, Minneapolis; MT Osterholm, PhD, State
Epidemiologist, Minnesota Dept of Health. DW Fleming, MD, LR Foster, MD, State
Epidemiologist, Oregon Health Div, Oregon Dept of Human Resources. A Finn, Jr,
MD, Univ Medical Center, Stonybrook; J Melius, MD, DL Morse, MD, State
Epidemiologist, New York State Dept of Health. Div of Field Svcs, Epidemiology
Program Office; Health Studies Br and Surveillance and Programs Br, Div of
Environmental Hazards and Health Effects, Center for Environmental Health and
Injury Control, CDC.
Editorial Note: The case-control studies in New Mexico and Minnesota establish
a statistically significant association between use of LTCPs and development
of EMS. The strength of this association, the temp{*filter*}relationship, the
absence of apparent selection or data-ascertainment biases, and the failure of
different potential confounders to account for this association support the
potential causal relationship. In addition, of the 85 case-patients who
initially called CDC before the full implementation of the state-based
reporting system and for whom information on LTCP use was available, only one
(1%) did not use LTCPs. However, the biologic mechanism for the development
of EMS among LTCP users is unclear.
The report of an EMS-associated death in New York emphasizes the potential
severity of this condition, and confirmatory data are being sought on other
possible EMS-associated deaths. In the fatal case, the severe Guillain-Barre
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Volume 2, Number 44 November 29, 1989
syndrome-like ascending polyneuropathy resembles clinical manifestations in
patients with the intermediate and chronic phases of toxic-oil syndrome (TOS),
a disease similar to EMS that was epidemic in Spain in 1981 (2--5). Frank
vasculitis has been reported in some EMS cases. Physicians caring for patients
with EMS should be alert to the possibility that such patients may develop
clinical manifestations similar to those of chronic TOS, including peripheral
neuropathy (mononeuritis multiplex), thromboembolic phenomena, sclerodermiform
skin changes, joint contractures, and pulmonary hypertension (2-5). Case
reports received at CDC suggest that, as with TOS, the clinical manifestations
of EMS may not regress immediately on removal of LTCPs.
The findings of the lot and brand-name studies in Minnesota and Oregon,
suggest multiple interpretations: some LTCPs could contain a contaminant that
is causally associated with EMS; or host factors mediating the response to LT
may be unique to patients who use a particular brand or set of brands
associated with illness. Studies under way include identifying possible
chemical or microbial contaminants in LTCPs, tracing the sources of individual
brands and lots, identifying host factors related to clinical manifestations,
and determining factors associated with use and purchase of LTCPs.
On November 17, the cooking.net">food and Drug Administration (FDA) announced its
intention to seek a nationwide recall of all LTCPs in which LT is the sole or
major component; this reinforced a November 11 alert to the public to refrain
from using LTCPs. FDA is attempting to trace suspect lots of LTCPs and is
evaluating production procedures at the companies in Japan where LT is
produced for eventual sale and consumption in the United States.
CDC's initial surveillance case definition for EMS required specific
serologic testing or muscle biopsy to rule out trichinosis (1). It now appears
the clinical presentation of some EMS patients may be sufficiently distinct
from that of trichinosis patients that such specific laboratory tests are not
warranted. Accordingly, the CDC surveillance definition of EMS no longer
requires specific laboratory testing for trichinella. CDC now recommends
defining EMS as an illness characterized by 1) eosinophil count of greater
than or equal to 1000 cells per mm3, 2) generalized myalgia (at some point
during the course of illness) of severity sufficient to affect a patient's
ability to pursue his or her usual daily activities, and 3) absence of any
infection or neoplasm that could account for 1 or 2 above. This change has
been communicated to state health departments.
Epidemiologic investigations and research studies of EMS should be
directed toward further defining a causal association between LTCPs and EMS
and identifying specific etiologic factors and possible cofactors tha t may
modify risk. Additional questions relate to the existence of a possible dose-
response effect, the latent period between exposure and disease, establishment
of the beginning of the epidemic, determination of the full spectrum of
clinical manifestations, elucidation of pathogenetic mechanisms, and
determination of prognosis and the response to specific therapies.
References
1. CDC. Eosinophilia-myalgia syndrome--New Mexico. MMWR 1989;38:765-7.
2. Grandjean P, Tarkowski S, eds. Toxic oil syndrome: mass cooking.net">food poisoning in
Spain--report of a WHO meeting, Madrid 21-25 March 1983. Copenhagen: World
Health Organization Regional Office for Europe, 1984.
3. Toxic Epidemic Syndrome Study Group. Toxic epidemic syndrome, Spain, 1981.
Lancet 1982;2:697-702.
Health InfoCom Network News Page 7
Volume 2, Number 44 November 29, 1989
4. Kilbourne EM, Rigau-Perez JG, Heath CW JR, et al. Clinical epidemiology of
toxic-oil syndrome: manifestations of a new illness. N Engl J Med
1983;309:1408-14.
5. Martinez Tello FJ, Navas Palacios JJ, Ricoy JR, et al. Pathology of a new
toxic syndrome caused by ingestion of {*filter*}erated oil in Spain. Virchows Arch
(A) 1982;397:261-85.
*Includes persons reporting they currently had a cataract, had had surgery for
a cataract, or had had a lens implant for a cataract.
**Includes persons who reported they had ever had coronary heart disease,
angina pectoris, myocardial infarction, or any other "heart attack."
Health InfoCom Network News Page 8
Volume 2, Number 44 November 29, 1989
Current Trends
Comorbidity of Chronic Conditions and Disability among Older Persons --
United States, 1984
Although the coexistence of chronic conditions (i.e., comorbidity) is
considered common in the older population, there has been little systematic
evaluation of the prevalence, patterns, and impact of comorbidity in
representative populations (1). Data from the Supplement on Aging (SOA) to the
1984 National Health Interview Survey were analyzed to evaluate the prevalence
and impact of comorbidity.
The National Health Interview Survey, conducted by CDC's National Center
for Health Statistics, is a continuing survey of the civilian
noninstitutionalized population of the United States. In 1984, all respondents
aged greater than or equal to 65 years and a 50% sample of those aged 55-64
years were asked to also respond to questions on the SOA. The SOA was designed
to collect information about chronic conditions, physical limitations, and
other health-related and social information about middle-aged and older
persons (2). In total, 16,148 interviews were conducted. This report presents
results for the 13,807 persons aged greater than or equal to 60 years,
representing an estimated U.S. population of 37,256,000 in this age group in
1984.
Emphasis was placed on nine common chronic conditions in the population
aged greater than or equal to 60 years, including: arthritis, present in
49.0%; hypertension, 41.8%; cataracts,* 19.9%; heart disease,** 14.0%;
varicose veins, 9.9%; diabetes, 9.5%; cancer (except nonmelanoma skin cancer),
6.6%; osteoporosis/hip fracture, 5.5%; and stroke, 5.4%.
The proportion of the population greater than or equal to 60 years of age
with two or more of the nine chronic conditions increased with age and, for
each age group, was higher for women than for men (Table 1). For persons aged
greater than or equal to 80 years, 70% of women and 53% of men had two or more
of the nine conditions.
Prevalence of comorbidity is directly related to the prevalence of each of
the individual conditions. Hypertension and arthritis, the two conditions with
the highest prevalence, co-occurred in 24.1% of persons greater than or equal
to 60 years of age; cataract and arthritis were both reported by 11.7% (Figure
1). The remaining six pairs of the most common comorbid conditions had
coprevalences that ranged from 5.5% to 9.6%.
If the prevalences of two conditions are assumed to be independent, their
expected coprevalence is the product of their individual prevalence rates.
However, for each of the eight most common pairs of conditions, the observed
comorbidity exceeded the expected (Table 2). Except for the comorbidity of
cataract with hypertension in men, each of these increases was statistically
significant (p less than 0.001, adjusted for the complex sampling design).
Respondents were asked if they received assistance with six activities of
daily living: getting in and out of bed or chair, walking, using the toilet,
bathing or showering, dressing, and eating. The percentage of men and women
receiving assistance with one or more of these activities increased directly
with the number of chronic conditions (Table 3).
Reported by: JM Guralnik, MD, AZ LaCroix, PhD, DF Everett, MS, National
Institute on Aging, National Institutes of Health. Office of Vital and Health
Statistics Systems, National Center for Health Statistics; Office of the
Director, Center for Chronic Disease Prevention and Health Promotion, CDC.
Editorial Note: Analysis of the 1984 SOA data indicates that the prevalence of
Health InfoCom Network News Page 9
Volume 2, Number 44 November 29, 1989
comorbidity of chronic conditions in the noninstitutionalized older population
is substantial. Comorbidity prevalence rates for the nine chronic conditions
are highest for women, increasing from 45% in persons aged 60-69 years to 70%
in persons aged greater than or equal to 80 years.
For the most commonly reported pairs of conditions, the observed
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HICN244 News Part 1/2