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MedWatch News


* Important Medical Product Safety Alert -- Aventis Pharmaceuticals has initiated a voluntary recall of Taxotere(r) (docetaxel) for Injection Concentrate 20-mg active and diluent vials. The lot numbers for this recall are: 0P273 (active) which was packaged together with diluent vials with the following lot numbers: 0T446 (diluent) or 0T449 (diluent). It has been determined that the Taxotere 20mg vial containing the active ingredient may have inadvertently been labeled as a "diluent" vial. Aventis has received one product complaint related to this mislabeling. The "Dear Healthcare Professional" and "Dear Wholesaler" letters published by Aventis can be seen on the MedWatch 2001 Safety Information page. Direct your web browser to: http://www.fda.gov/medwatch/safety/2001/safety01.htm#taxote

* Important Medical Product Safety Alert -- There is a potential for harmful lead exposure from dental films stored in containers lined with unpainted lead. We believe that there may be hundreds of these lead-lined boxes currently being used to store dental films. Some of them may have been in use for decades. Most of these boxes are the size and shape of shoe-boxes, made of wood, and lined with lead that has apparently not been painted or coated. Dental films stored in these boxes have been found to be coated with a whitish film that is about 80% lead. In many cases there are highly dangerous levels of lead on the films, enough to potentially cause serious adverse health effects in patients and health care professionals. These adverse health effects include anemia and serious neurological damage. The complete FDA Public Health Notification Letter may be seen at: http://www.fda.gov/cdrh/safety/leadcontainer.html.

* Important Medical Product Safety Alert -- Organon Inc. initiated a voluntary recall of Raplon(r) (rapacuronium bromide) for injection. Several serious adverse events, including bronchospasm and unexplained fatalities, were reported during postmarketing surveillance (in each of these cases the cause was unknown, as there were multiple drugs administered and other conditions present). The letter posted on the MedWatch site (http://www.fda.gov/medwatch/safety/2001/raplon_DDL.htm) is part of a package distributed by the manufacturer. 

* Important Medical Product Safety Alert - Health care professionals are notified of a shortage of Naloxone HCl injection, a narcotic antagonist. This appears to be a temporary situation of two to three months in length. FDA has identified a temporary alternate supplier of Naloxone Hydrochloride Injection, USP in 0.4 mg/mL ampoules (1mL) and vials (10mL), as well as 1 mg/mL vials (2mL) effective April 4, 2001. Physicians and hospitals will be able to obtain this product via overnight delivery. This temporary program will not cover the pediatric strength of product (0.02 mg/mL). Supplies of this strength are available, but limited. For further information, read the FDA Shortage Alert at http://www.fda.gov/medwatch/safety/2001/safety01.htm#naloxo




OSHA Affirms Need For Safer Devices To Prevent Needlesticks, Calls For Employee Involvement In Selection

As mandated by the Needlestick Safety and Prevention Act, OSHA has revised its bloodborne pathogens standard to clarify the need for employers to select safer needle devices as they become available and to involve employees in identifying and choosing the devices. The updated standard also requires employers to maintain a log of injuries from contaminated sharps.

According to the Needlestick Act, in March 2000, the Centers for Disease Control and Prevention estimated that selecting safer medical devices could prevent 62 to 88 percent of sharps injuries in hospital settings.

"Our revised bloodborne pathogen standard sets forth clearly the importance of reevaluating needle systems to identify safer devices every year. The new requirement to record all needlesticks will help employers determine the effectiveness of the devices they use and track how many needlesticks are occurring within their workplaces," said OSHA Administrator Charles N. Jeffress.

The revised OSHA bloodborne pathogens standard specifically mandates consideration of safer needle devices as part of the reevaluation of appropriate engineering controls during the annual review of the employer's exposure control plan. It calls for employers to solicit frontline employee input in choosing safer devices. New provisions require employers to establish a log to track needlesticks rather than only recording those cuts or sticks that actually lead to illness and to maintain the privacy of employees who have suffered these injuries.

Passed unanimously by Congress and signed by President Clinton on November 6, 2000, the Needlestick Safety and Prevention Act mandated specific revisions of OSHA's bloodborne pathogens standard within six months. The legislation exempted OSHA from certain standard rulemaking requirements so that the changes could be adopted quickly.

The revised bloodborne pathogens standard was published in the January 18 Federal Register. The updated rules became effective April 18, 2001.


New Tools For Health Care Providers And The Public To Combat Overweight And Obesity

A "practical guide" to help health care providers manage the treatment of their overweight and obese patients, an online interactive menu planner, and consumer tips on behavior change for weight management were some of the new tools unveiled by the National Heart, Lung, and Blood Institute (NHLBI) in March to help tackle America's battle of the bulge.

The need for these tools couldn't be more pressing. Recent statistics from the National Health and Nutrition Examination Survey (NHANES) show that between 1994 and 1999 the U.S. experienced a 5 percent increase in the number of adults who are overweight or obese.

To help these people and their health care team, NHLBI's Obesity Education Initiative in cooperation with the North American Association for the Study of Obesity convened a working group to prepare "The Practical Guide to the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults". Based on the clinical guidelines released by NHLBI in 1998, the practical guide is just that -- a practical manual with tools and tips for weight loss.

"This guide gives health care providers the fundamentals needed to evaluate and treat this important health problem and contains information which has not been provided elsewhere in their training," said Dr. Louis J. Aronne, chair of the committee that developed the guide and clinical associate professor of medicine at Weill-Cornell Medical College in New York City.

The guide's new features, which were not in the original obesity guidelines, include a 10-step plan and a quick reference tool to help physicians assess, classify, and treat overweight and obesity. The guide also includes detailed sections on dietary therapy, physical activity, and behavior therapy. In addition, the handbook discusses the appropriate use of weight loss drugs (with recommended doses of specific drugs) and indications for surgery as a treatment for obesity.

A key section of the guide is the appendices, which were written for patients and include practical information on diet, physical activity, and tools for behavior change. There is also a weight management chart, sample walking and jogging programs, and tips for dining out, shopping, and cooking.

Consumers -- and health care professionals -- can find all of these tools online on the NHLBI Web site (www.nhlbi.nih.gov). The Institute's Web site will also post a PalmOS (R) format version of the practical guide. In addition, the site already contains a body mass index (BMI) calculator for PalmOS (R) devices. The calculator accepts English or metric input and includes a BMI classification table for adults.

A new feature on the Institute's Web site is the ultimate "cyber" tool for devising low calorie meals -- an interactive menu planner. The menu planner allows the user to plan a single meal or a whole day's meals. To use the planner, you choose your total calories for the day, and select a meal. You then select foods from a list, according to the food groups included in the American Dietetic Association/American Diabetes Association exchange list. Finally, you choose the number of servings you want and the calories are calculated for you.

To order a printed version of the guide, call the NHLBI Health Information Center at 301-592-8573 or order online from the NHLBI catalog: http://emall.nhlbihin.net/. A single copy is $5.00. The consumer appendices in the guide have been compiled into a document called "Clinical Guidelines: Highlights for Patients". This document is $1.00 per copy.


FDA Approves Two New Intraocular Pressure Lowering Drugs For The Management Of Glaucoma

The FDA has announced the approval of two new drugs to treat the elevated intraocular pressure which is often associated with glaucoma - Lumigan (bimatoprost ophthalmic solution) 0.03% and Travatan (travoprost ophthalmic solution) 0.004%. They will provide additional alternatives for the reduction of intraocular pressure in patients who are intolerant of other intraocular lowering medications, or in patients who have had insufficient responses to other intraocular pressure lowering medications. 

In separate clinical trials, Lumigan and Travatan had similar effects in lowering intraocular pressure. Side effects associated with both drugs may include gradual darkening of eye color, darkening of eyelid skin, and increased thickness, number, and darkness of eyelashes.

Lumigan will be marketed by Allergan, Inc., of Irvine, California. Travatan will be marketed by Alcon Universal, Ltd., of Fort Worth, Texas. (FDA News release, 3-16-2001)

FDA Approves New Glucose Test For Adult Diabetics

The FDA on March 22 approved a wristwatch-like device that provides adult diabetics with more information for managing their disease. It is intended for use along with, not as a replacement for, finger-prick blood tests to monitor glucose.

The GlucoWatch Biographer, made by Cygnus Inc., of Redwood City, California, extracts fluid through the skin by sending out tiny electric currents. Glucose levels are measured using this fluid every 20 minutes for 12 hours - even during sleep. The device sounds an alarm if patient's glucose reaches dangerous levels, thus helping patients manage a potential problem.

The FDA approved the GlucoWatch, which is available only by prescription, to detect trends and track patterns in glucose levels in adults age 18 and older.

Clinical studies conducted by the manufacturer showed the GlucoWatch measurements generally were consistent with the results from traditional finger-prick blood tests. However, up to 25 percent of the time, the results differed by more than 30 percent. The GlucoWatch sometimes gave erroneous readings, was less effective at detecting very low glucose levels than very high levels, and would not measure it at all if a patient's arm was too sweaty. The GlucoWatch also caused mild to moderate skin irritation in at least 50 percent of patients. Because of the potential for error, physicians and patients should never use an individual GlucoWatch reading alone to make changes in insulin doses. Instead, the GlucoWatch results should be interpreted with several sequential readings over time and then confirmed with a finger prick test. (FDA news release, 3-22-2001)

The American College Of Physicians-American Society Of Internal Medicine Issued Guidelines On Antibiotics

The guidelines note that antibiotics are not needed for treatment of most upper respiratory infections, such as sore throats, bronchitis and most sinus infections, conditions usually caused not by bacteria but by viruses, against which antibiotics are ineffective. The guidelines, published in the Annals of Internal Medicine, indicate when an antibiotic is appropriate, such as for treatment of strep throat, whooping cough and pneumonia. (CNN.com, 3-19-2001)

One In Five Drugs Approved By The FDA Ends Up Undergoing A Change In Recommended Dosage After The Drug Hits The Market

An FDA report found that recommended doses were changed for 22 percent of drugs after approval, with dosage reductions accounting for 80 percent of the changes, while a drug approved between 1995 and 1999 was twice as likely to be changed as a drug approved between 1980 and 1984. The findings suggest that patients should pay attention to reactions to new drugs and keep their physicians informed. (Yahoo News, 3-9-2001)


Many Heart Disease Patients Are Not Receiving Surgical Procedures That Could Save Their Lives, According To A Study Published In The New England Journal Of Medicine

A study of more than 2,500 heart disease patients in the UK revealed that just over one third of those eligible for angioplasty had the procedure performed, and that patients who received drugs in lieu of angioplasty were almost twice as likely to have chest pain nearly three years later. Fifty-seven percent of patients who were eligible for coronary artery bypass surgery (CABG) underwent the procedure, and were less likely to die, suffer a nonfatal heart attack and experience severe chest pain than CABG-eligible patients who were treated with drugs. (New England Journal of Medicine, 3-1-2001; Yahoo News, 2-28-2001)


Only One Fourth Of U. S. Adults Meet Recommended Levels Of Physical Activity, According To An Analysis Of 1998 Data By The Centers For Disease Control And Prevention

Despite efforts made over the past 10 years to increase physical activity of Americans, the percentage of adults responding to the CDC's 1998 Behavioral Risk Factor Surveillance System survey who engaged in the recommended levels of activity only increased from 24.3 percent in 1990 to 25.4 percent in 1998. In 1998, the number reporting insufficient activity was 45.9 percent, and the number reporting no physical activity was 28.7 percent, also similar to the 1990 findings. (Morbidity and Mortality Weekly Report, 3-9-2001; Yahoo News, 3-8-2001)


Popular Pain Analgesics Found To Affect Central Nervous System

Widely prescribed pain killers that provide relief with minimal side effects may have more pain-relieving properties than previously identified. A new study funded by the National Institute of Neurological Disorders and Stroke (NINDS) shows that NSAIDs not only relieve pain at the local (peripheral) site of inflammation but in fact affect the entire central nervous system. Results of the study appear in the March 22, 2001, issue of "Nature".

NSAIDs reduce sensitivity of nerves in the central nervous system by inhibiting production of the Cox-2 enzyme responsible for pain and inflammation. Two prescription drugs introduced last year that target Cox-2 proved to be blockbuster pain relievers, but their mechanism of action was not understood until now.

A research team led by Clifford J. Woolf, M.D., Ph.D., at Massachusetts General Hospital in Boston used an animal model to study Cox-2's role in inflammatory pain. When inflammation occurred, researchers found Cox-2 throughout the central nervous system, as well as at the local site of inflammation. They also found that inhibiting Cox-2 production within the spinal cord and brain decreased pain and reduced hypersensitivity to normal sensations such as touch. Researchers now believe the widespread distribution of Cox-2 within the central nervous system may contribute to muscle and joint pain, depression, lethargy, and loss of appetite that often occur with inflammation and infection.

"The findings indicate new treatment options for arthritis and other inflammatory pain conditions," said Cheryl A. Kitt, Ph.D., program director for pain research at the NINDS. "Targeting the central nervous system when using NSAIDs, rather than the specific peripheral pain site, may result in more effective pain relief."

This release will be posted on EurekAlert! At http://www.eurekalert.org and on the NINDS Web site at http://ninds.nih.gov/news_and_events/index.htm


Free Health Information For Hispanic Seniors Offered By The National Institute On Aging

Reliable information on diabetes, high blood pressure, sleep problems, medication safety, and foot care is now available in Spanish from the National Institute on Aging. Five new "Age Pages" describe how to recognize and treat these conditions, which are common in older people, and provide up-to-date addresses and telephone numbers for further help. 

The free, science-based leaflets are written for older adults but also are useful to family members and health professionals who care for older adults. The "Age Page" on diabetes, for example, talks about how Hispanic Americans are at very high risk for type 2 diabetes. Symptoms of diabetes are then identified.

For single or bulk copies of the "Age Pages," call the NIA Information Center weekdays between 8:30 a.m. and 5:00 p.m., toll-free at 1-800-222-2225. An information specialist will be available to respond to queries in Spanish.

Colorectal Cancer Patients Treated In HMOs Receive The Same Level Of Care And Have Similar Survival Rates As Patients Treated Under Traditional Fee-for-Service Plans, According To A Study Published In The Journal Of The National Cancer Institute

A review of more than 50 studies found that characteristics of both colorectal patients and their doctors, rather than the type of health insurance the patients had, influenced the type of health care or survival times after treatment. The study noted that Black and Native Americans received less intensive therapy and had worse outcomes than white patients, but survival times were similar among blacks and whites who received comparable care. Women and men were equally likely to receive chemotherapy but older patients were less likely to receive chemotherapy than younger patients were. (Journal of the National Cancer Institute, 4-4-2001; Yahoo News, 4-3-2001)


International Guidelines Released On Chronic Obstructive Lung Disease

The first international guidelines for the diagnosis, management, and prevention of Chronic Obstructive Lung Disease (COPD) -- currently the fourth leading cause of death in the US and worldwide -- were released April 4th by an international team of scientists from the Global Initiative for Chronic Obstructive Lung Disease (GOLD). The "GOLD Workshop Report", which provides evidence-based recommendations for the clinical management of COPD, is the first step in an international effort to boost awareness of COPD and improve the way it is treated. GOLD was created by the National Heart, Lung, and Blood Institute (NHLBI) at the National Institutes of Health and the World Health Organization.

COPD has been on the increase in the US, and in 1996, an estimated 16 million Americans had COPD. The number of deaths attributed to COPD has also increased substantially in the past 40 years to approximately 100,000 men and women per year in the US alone. The highest rate of increase in deaths has been seen in white women. It is expected that by 2020, COPD will rank as the third leading cause of death, surpassing stroke. The annual cost of COPD to the US economy is estimated at nearly $30.4 billion.

The GOLD Report, which was reviewed extensively by medical societies in more than 100 countries throughout both the developed and developing world, emphasizes the need for clinicians and patients to recognize cough and sputum production as early signs of possible COPD and calls for the use of spirometry, a simple test of lung function, to confirm the diagnosis. It also provides a general scheme for classifying COPD by severity to help clinicians determine how best to manage the condition. Practical recommendations for reducing risk factors and for managing both stable COPD and exacerbations are also provided.

Copies of the GOLD Workshop Report and other information on COPD are available on the NHLBI Web Site at www.nhlbi.nih.gov.


TRICARE News and Related Military Issues

Beneficiaries Advised To Save Receipts For TRICARE Coverage Not Yet Implemented 

Given the significant number of new TRICARE benefits and competing requirements in the 2001 National Defense Authorization Act (NDAA), many programs that Congress authorized as being effective immediately when the NDAA was signed into law on Oct. 30, 2000, will be phased in over the next six to twelve months. Among these new programs that will be implemented over time are TRICARE coverage for school required physicals, reimbursement for certain travel expenses for TRICARE Prime beneficiaries, and reduction of retiree catastrophic caps.

In the meantime, TRICARE Management Activity (TMA) is advising beneficiaries to save receipts (as well as explanations of benefits and other claims-related information) for these covered services and benefits obtained from Oct. 1, 2000, for application to the fiscal year catastrophic cap, and from Oct. 30, 2000, for the other benefits until program implementation so they can later obtain reimbursement from the managed care support contractors in their regions. TMA will widely publish the date upon which beneficiaries may submit claims with the required receipts, and the managed care support contractors will adjudicate claims for dates of service retroactively to the effective date established by Congress. 

The new benefit covering school physical examinations applies to all TRICARE-eligible beneficiaries ages five through 11. It does not cover physical examinations for sports activities. 

TRICARE Prime beneficiaries referred to specialty care providers located more than 100 miles away from their primary care managers, will be reimbursed for their travel expenses, according to the provisions of the NDAA.

The existing catastrophic cap of $7,500 will be reduced to $3,000 for retirees, their family members and their survivors.

As soon as funding is secured for these initiatives, TMA officials will spread the word through all available communications channels.

The latest information about TRICARE benefits may be obtained through the Military Health System/TRICARE Web site at http://www.tricare.osd.mil. Beneficiaries may also contact the managed care support contractor in their region, the nearest TRICARE service center or TRICARE beneficiary counseling and assistance coordinators at a military treatment facility. 


DOD Implements TRICARE Senior Pharmacy Program

The new TRICARE Senior Pharmacy Program officially began operation on April 1 for an estimated 1.4 million potentially eligible uniformed Services beneficiaries age 65 years and older. The TRICARE Senior Pharmacy Program is a comprehensive drug benefit not provided under traditional Medicare.

"This new pharmacy benefit will greatly assist our beneficiaries by standardizing copayments and lowering the cost of generic medications. Our senior beneficiaries will benefit from this program by having access to medications with lower out-of-pocket expenses," said Acting Assistant Secretary of Defense for Health Affairs Dr. J. Jarrett Clinton.

By law, to use the TRICARE retail and mail order benefit, beneficiaries age 65 and over must be eligible for Medicare Part A and enrolled in Part B. (Exception: Those who turned 65 before April 1, 2001, are eligible for the benefit, even if they are not enrolled in Medicare Part B.) For more information on enrollment requirements for Medicare Part B, the toll-free number for Medicare is (800) MEDICARE or (800) 633-4227.

Beneficiaries also must be registered in the Defense Enrollment Eligibility Reporting System (DEERS). Beneficiaries who are unsure about their DEERS enrollment status or eligibility for this program may contact the toll-free Defense Manpower Data Center Support Office Beneficiary Line at (800) 538-9552 for assistance. The call center is open weekdays (Monday through Friday) from 6 a.m.-3:30 p.m. Pacific Time.

Pharmacy Copayments Simplified

At the same time, DoD is also simplifying the prescription copayments for all DoD beneficiaries, reducing the different copayment possibilities from about 30 to three.

The new TRICARE pharmacy benefit offers a straightforward co-payment structure and the following four dispensing options listed in order of cost/value to the beneficiary:

* Military Treatment Facility Pharmacy. Military treatment facility (MTF) pharmacies will continue to fill prescriptions written by either military or civilian prescribers for medications listed on the MTF's formulary. There is no co-payment or out-of-pocket expense for prescriptions filled at the MTF.

* National Mail Order Pharmacy (NMOP). Prescriptions filled through the NMOP will be $3 for up to a 90-day supply of most generic medications, or $9 for up to a 90-day supply of most non-generic medications.
NOTE: More NMOP information is available online at http://www.tricare.osd.mil/tricare/nmopp.html and 
http://www.tricare.osd.mil/pharmacy

* Retail Network Pharmacy. Prescriptions filled at a retail network pharmacy will be $3 for a 30-day supply of most generic medications or $9 for a 30-day supply of most non-generic medications.

* Retail Non-network Pharmacy. At non-network pharmacies, beneficiaries will pay either $9 or 20 percent of the total cost (whichever is greater), for a 30-day supply of a medication after they have met the TRICARE annual deductible ($150 per individual or $300 per family). Both deductibles and co-payments are applied toward the beneficiary's TRICARE catastrophic cap.

To use the retail pharmacy benefit beneficiaries should show the pharmacy a current Uniformed Services Identification (ID) card. To update an outdated ID card, beneficiaries may call toll-free (877) DOD-MEDS or (877) 363-6337 to locate the closest military ID card issuing activity. The call center is open weekdays (Monday through Friday) from 7 a.m.-11 p.m. Eastern Time.

In February and March, TRICARE's regional contractors sent a mailing to Medicare-eligible military beneficiaries worldwide. The mailing included a TRICARE Senior Pharmacy Program brochure, local pharmacy directories, NMOP brochures and NMOP registration forms. For more information on the TRICARE Senior Pharmacy Program, see the Military Health System/TRICARE Web site at http://www.tricare.osd.mil/pharmacy



Civilian Pharmacies That are Approved by TRICARE are Known as "Retail Network Pharmacies." 

To locate TRICARE retail network pharmacies in your area, directories are available online. Visit http://www.tricare.osd.mil/pharmacy/retail_network.htm and click on the applicable state to get to your TRICARE region and the location of the nearest retail network pharmacy.

To use a retail network pharmacy, you must present your written prescription, along with your military identification card.

If you have difficulties getting your prescriptions filled at a TRICARE retail network pharmacy, contact the nearest TRICARE service center or the Beneficiary Counseling Assistance and Coordinator (BCAC) assigned to your area. If you're not sure of the location of your nearest TRICARE service center, go to http://www.tricare.osd.mil/tricareservicecenters/default.cfm and click on your TRICARE region (if known) or select the applicable state from the map that's provided.

A BCAC directory is also available online at http://www.tricare.osd.mil/tricare/beneficiary/update_bcac_dir.doc

If you have questions about the new pharmacy program, please contact the toll-free Help Desk that's available at 1-877-363-6337. The Help Desk is available weekdays from 0700-2300 (EST).


D.O. Named VFW Surgeon General

Raymond W. Schlueter, D.O., of Indian Head, Illinois, was appointed the National Surgeon General of the Veterans of Foreign Wars of the United States.

A 1961 graduate of the Chicago College of Osteopathic Medicine, Dr. Schlueter served in the Army Medical Corps for 22 years, retiring as a colonel in the Army Medical Corps Reserves. 

He is presently a professor and chairman of the Department of Osteopathic Medicine at Midwestern University's College of Osteopathic Medicine in Chicago.

Dr. Schlueter founded the Osteopathic Orthopedic Training Program at CCOM.

(Newsletter of the Association of Military Osteopathic Physicians & Surgeons, Vol. 20, Issue 2, February 2001)


Two-year Extension of Medical and Dental Benefits for Survivors Provided

Under the provision of the National Defense Authorization Act (NDAA) passed last October, surviving family members of deceased active duty uniformed services personnel are authorized a two-year extension of their medical and dental benefits. The benefit extension is also authorized for survivors of deceased active duty Select Reserve and Individual Ready Reserve personnel. 

As a result of the legislation, survivors of active duty members who died on or after October 30, 1997, remain eligible for TRICARE medical benefits at the active-duty dependent rate for an additional two-year period. At the end of the three-year period, TRICARE eligibility for these survivors will continue, but at the retiree dependent rate.

Some survivors may be eligible to apply retroactively for the active duty dependent rate for medical benefits and are encouraged to contact their local TRICARE service center for assistance.

To be eligible for continued dental coverage under this provision, survivors must be enrolled in the TRICARE Dental Program (TDP) as of the date of the sponsor's death. Survivors who were within their original one-year period of eligibility for dental benefits as of January 31, 2001, will be authorized an additional two years of dental coverage, for a total of three years.

During the extended dental benefit period, the Department of Defense will continue to pay the survivor's dental insurance premiums. At the end of the three-year period, the eligibility status of the survivor will change to retiree status. As a retiree, surviving family members are no longer eligible for the TDP. However, surviving family members are eligible to enroll in the TRICARE Retiree Dental Program (TRDP): http://www.ddpdelta.org.

For up-to-date information on medical benefits, survivors are encouraged to contact their local TRICARE service center representatives, beneficiary counseling and assistance coordinators (BCACs), or the health benefits advisers (HBAs) at any military treatment facility. For additional information about TRICARE, visit the Military Health System/TRICARE Web site at: www.tricare.osd.mil.

For general information on the TRICARE Dental Program, eligible survivors may call United Concordia Companies, Inc. (UCCI), the TRICARE Dental Program administrator at 1-800-866-8499, or visit the UCCI Web site at www.ucci.com.



Guidelines for Comprehensive Risk Reduction for Patients with Coronary and Vascular Disease
By A.H. O-Yurvati, D.O., FACOS, FICS

Osteopathic physicians in the state of Texas have an opportunity to make a major impact on the health and welfare of Texas citizens. The majority of osteopathic physicians in Texas are primary care and reach out to thousands of patients within our state. The American Heart Association (AHA) has presented a goal, begun in the year 2000, to reduce disability from cardiovascular disease and stroke by 25 percent by the year 2010. This is a major project that will require the participation of every medical provider in the state of Texas, as well as patient education and management.

As a board member of the Texas affiliate for the AHA, I recently attended a board meeting in Austin. I was quite dismayed by the statistics that were presented, showing that there is a major lack of following the AHA guidelines for the management of risk reduction for cardiovascular disease. Of patients who have sustained a myocardial infarction, only about 85 percent were placed on aspirin. Only about one-third were placed on a beta blocker. As far as lipid-lowering therapy, one study showed that only 18 percent of physicians had started a patient on this type of an agent. I found these statistics quite staggering. In order to reach the impact goal we would need the assistance of every osteopathic physician in the state. 

As you recall, the University of North Texas Health Science Center participated in a cardiovascular reduction study under the direction of Dr. Michael Clearfield. Recommendations came out of the TexCAPS study that were quite encouraging, in that following these guidelines with lipid-lowering agents the reduction of a second cardiovascular event could be markedly impacted - in some patients by as much as 40 to 60 percent. Therefore, I wanted to bring to the attention of physicians some of the recommendations and guidelines from the AHA.

There have been two projects undertaken: one called "Get with the Guidelines" from the AHA. The other is a health partnership program developed by the TMA committee on cardiovascular disease and the Texas affiliate of the AHA, as well as Merck & Company. This healthcare partnership was started over a year or so ago, and the results are quite impressive as far as improvement. Recently, in the January 2001 issue of "Texas Medicine Rounds," a short article noted that there are a few facilities that showed marked recognition for improvement in following these guidelines. They included Baylor University Medical Center in Dallas, the Comprehensive Family Healthcare Center in San Antonio, and the Osteopathic Medical Center of Texas in Fort Worth. I think, as osteopathic physicians practicing in the state, we should be quite proud of this accomplishment, as we have taken on this initiative. Further information can be found on this partnership on the Web at www.texmed.org/has/prs/hcp/default.asp or by contacting Bridget Butler at 800-880-1300, ext. 1461, for those readers who are interested in obtaining more information on this program.

The guidelines program developed by the AHA is available on their Web site at www.americanheart.org and a PDF file can be downloaded showing these guidelines. The following chart shows the "Comprehensive Risk Reduction for Patients With Coronary and Other Vascular Disease." Major risk interventions should be undertaken to include smoking cessation, and recommendations are given for this, blood pressure control, lipid management and defining the current recommendations on lipid-lowering agents. The paper goes on to discuss physical activity and weight management. Further diabetes management with the management to reduce the hemoglobin A1c to less than 7, a second on antiplatelet agent and anticoagulation therapy as indicated, ACE inhibitor, and beta blockers, as well as estrogen management for women to reduce their risk of heart disease. 

The second document is a tracking form - "Primary and Secondary CVD Patient Tracking Form." This is a primary and secondary cardiovascular disease tracking form that could be placed in the patient's chart. It is an easy form that could be followed by the medical staff in the office to enter the data, and then it is a simple check-off list as far as patient education. This also would meet many of the requirements from managed care organizations for primary care physicians for following these cardiovascular guidelines.

In reviewing many of the statistics associated with cardiovascular disease, we find that in the state of Texas one in five deaths from cardiovascular disease is attributed to smoking. Therefore, a reduction of this factor would also improve the management of these patients. We find that 50 percent of patients have cholesterol levels that are over 200, and only 22 percent report any regular physical activity. In 1997, statistics from the AHA showed that cardiovascular disease remained the number one killer in America, with about 953,000 Americans dying of cardiovascular disease, so this accounts for about 41.2 percent of all deaths. Also, data has strongly supported a lack of physical activity as now clearly shown to be a risk factor for heart disease. Recently, there was a possible contributory link between the lack of regular exercise and stroke. Although there was not a direct link, there appeared to be some statistical increase in those patients. It may be related that these patients are also more at risk for other coronary events, and the stroke events are secondary, but we do not know that at this time.

An area that has only recently been studied is the risk of cardiovascular and stroke in women. We know that cardiovascular disease ranks first among all disease categories in hospital discharge for women, and 43.7 percent of all female deaths in America occur from cardiovascular disease. It is interesting to note that risk of dying from a cardiac event is substantially higher in African-American women than in Caucasian women. Cardiac disease claimed over 502,000 lives in 1997, as compared to 258,000 from cancer in women. This statistic also is quite staggering. Also, in patients who have had a primary event, 38 percent of these women, compared with 25 percent of men, will die within one year or after a coronary event. The stroke statistics are somewhat new, but they show that about 15 to 30 percent of stroke survivors are permanently disabled. We do not know the exact stroke incidence at this time in women; however, we know that stroke is a leading cause of serious, long-term disability.

I am encouraging every osteopathic physician in the state of Texas to help us on the American Heart Association to "Get with the Guidelines" so that we can impact on the health of the citizens of Texas. Our goal to reduce cardiovascular disease and stroke by 25 percent by the year 2010 cannot be done without the help of every osteopathic physician in the state of Texas.


References:

Texas Medicine Rounds. January 2001; page 29.

Preventing Heart Attack and Death in Patients with Coronary Disease. Circulation. 1995; Volume 92:pp 2-4.

Dr. O-Yurvati is an Associate Professor of Surgery at the University of North Texas Health Science Center, Fort Worth. 

10 Years Ago in the "Texas D.O."

* TOMA held its 92nd Annual Convention and Scientific Seminar May 1-5, in San Antonio. The new TOMA president was Donald F. Vedral, Ph. D., D.O. The new president-elect was Jerry E. Smola, D.O. Brian G. Knight, D.O., was elected vice president, and Robert L. Peters, Jr. D.O., became the immediate past president. Additionally, Mrs. Rita Baker assumed the ATOMA presidency, succeeding Mrs. Claudette Miller. 

* Robert B. Finch, D.O., was named the "General Practitioner of the Year" during the TOMA convention.

* Among the major actions of the TOMA House of Delegates was Resolution 7, pertaining to Thomas D. Hanstrom. It read, "The House of Delegates goes on record in support of dedicating the 46th annual meeting of the House of Delegates to the memory of Thomas D. Hanstrom." Mr. Hanstrom, TOMA executive director, passed away April 4. 

* Edward A. Luke, Jr. D.O., was re-elected to a second term as president of the TCOM Alumni Association. Alex Guevara, D.O., was elected president-elect; Dale Brancel, D.O., first vice president; and Ben Zemenick, D.O., second vice president.