THE PHYSICIAN AND SPORTSMEDICINE - VOL 25 - NO. 8 - AUGUST 97
A record high for Lyme disease
The number of recognized Lyme disease cases is at an all-time high, according to the Centers for Disease Control and Prevention (CDC) in Atlanta (1). In 1996, 16,461 cases were reported, representing a 41% increase from the 1995 total.
Though Lyme disease was reported in 45 states and the District of Columbia, about 90% of the 1996 increase occurred in five states: Connecticut, New Jersey, New York, Pennsylvania, and Rhode Island. The CDC attributes the increase in cases to increased tick densities in certain regions, enhanced recognition of the disease, and improvements in laboratory surveillance.
Robert T. Schoen, MD, a rheumatologist and clinical professor at Yale University School of Medicine in New Haven, Connecticut, says the increase in Lyme disease cases is not surprising. "Lyme disease is both a new disease and a newly recognized disease, and the number of cases has risen almost every year," he says. Connecticut had the highest Lyme disease rate in the country in 1996: 94.8 cases per 100,000 population. Schoen says that he sees 200 to 300 patients a year who suspect they might have Lyme disease, and about a third of them have the illness.
The regional clustering of Lyme disease is helping physicians in affected areas improve their ability to recognize it, Schoen says. "Some physicians see a lot of patients with Lyme disease and are becoming very astute at recognizing it," he says. Also, physicians are now getting the clear message that the erythema migrans rash is a key diagnostic finding in Lyme disease. "It's been a pendulum. But most recent reports suggest that most patients with early Lyme disease have erythema migrans," he says.
A physician's index of suspicion for Lyme disease should be guided by the geographic location and the time of year, Schoen says. "In most areas, the Lyme disease season runs from mid April to mid July."
Diagnosis Still Imperfect
While understanding of the clinical manifestations of Lyme disease continues to grow, diagnosis and treatment remain imperfect, Schoen says. Researchers are currently working to develop a more defined role for polymerase chain reaction testing and establish clearer guidelines for the duration of drug treatment, he says. Prevention may someday include a vaccine against Lyme disease. "Two vaccines are in phase 3 clinical trials, and both have had promising results," says Schoen. The vaccines are being developed by SmithKline Beecham Biologicals, based in Rixensart, Belgium, and Pasteur Mérieux Connaught USA, in Swiftwater, Pennsylvania.
The most important prevention step for patients is periodic tick checks, Schoen says. The disease is spread by Ixodes scapularis, the black-legged or deer tick, in most of the United States and by the western black-legged tick along the West Coast. "The transmission from the tick to an individual is relatively ineffective, and studies show that the risk is related to duration of attachment," he says, adding that people who are outdoors in infested areas during Lyme disease season should check for ticks every few hours, or at least at the end of the day. In addition, the CDC recommends that people:
Pact may help stifle smokeless tobacco use
The proposed $368 billion settlement between the states and the tobacco industry could give a boost to the campaign to drive smokeless tobacco out of sports. The settlement comes as a national organization is working to curb use, starting with professional baseball players, who have long been role models for dipping and chewing.
The US Department of Health and Human Services (HHS) estimates that 1 million adolescent boys use "spit tobacco," as smokeless tobacco is now called by the National Cancer Institute and other antitobacco groups. (Smokeless tobacco includes chewing tobacco and dipping tobacco, or snuff.) Many athletes, particularly baseball players, use spit tobacco, and some believe that it improves their performance. Spit tobacco use in adolescents is associated with periodontal degeneration and lesions of the oral soft tissues (1). It is estimated that the risk of oral cancer is 50 times greater in long-term smokeless tobacco users than among nonusers.
The proposed settlement would make it harder for adolescents to buy smokeless tobacco and other tobacco products; provisions set a minimum age of 18 for buying tobacco products, require retailers to check the photo identification of anyone under age 27 buying tobacco products, and demand face-to-face transactions for all tobacco purchases. The proposal seeks to increase penalties for merchants who sell tobacco items to minors. The settlement is awaiting approval by Congress and President Clinton. Starting 90 days after the final agreement is signed, spit tobacco products would have to carry one of several rotating warnings that say:
Also under the settlement, spit tobacco and cigarettes would have to carry a statement from the US Food and Drug Administration that the product's intended use is nicotine delivery.
The American College of Sports Medicine (ACSM) in Indianapolis applauds the proposed tobacco agreement, but says more work is needed to address loopholes, define the authority of the FDA, and project the overall public health impact. Charlotte Tate, PhD, president of the ACSM, particularly supports the agreement's ban on tobacco company sponsorship of sports events. "Undoubtedly, tobacco sponsorship of sporting events is an effective way to persuade and reinforce tobacco use, but sporting venues just are not the appropriate place to sell poor health habits," Tate said in a news release.
One major effort to reduce the use of spit tobacco is the National Spit Tobacco Education Program (NSTEP), an initiative of Oral Health America, based in Chicago. Supported by Major League Baseball and the Major League Baseball Players Association, NSTEP is a 2-year-old program to establish smokeless tobacco cessation programs among major league teams. (Spit tobacco use in the dugout and on the field has been banned in minor league baseball since 1993, but is still permitted in the major leagues.) Joe Garagiola, chair of NSTEP, in an NSTEP news release, says every fan who watches or listens to a game during the 1997 major league baseball season will see its multimedia campaign against smokeless tobacco.
Meanwhile, a group from the University of Arkansas for Medical Sciences in Little Rock has developed a spit tobacco cessation program for high school boys and is conducting a clinical trial of its effectiveness. Each participant in the intervention group wears a nicotine patch, attends weekly hour-long classes, and receives phone counseling and newsletters.
Craig Stotts, RN, DrPH, says the Arkansas program has a "nine-inning game plan" and plenty of graphic pictures of diseased jaws and cancerous mouths. "Kids love gross pictures. They're horrified, yet fascinated by them," says Stotts, who is an associate professor in the University of Arkansas for Medical Sciences College of Nursing and the Arkansas Cancer Research Center.
Tools for Quitting
If a patient's history or oral examination reveals evidence of snuff or chewing tobacco use, physicians shouldn't hesitate to tell him or her to quit the practice, says Stotts. "Studies say patients want their physicians to tell them to quit," he says. "A physician's comment during the preparticipation exam can be a final cue for a player to take action."
The marketplace is responding to the crusade against chewing tobacco with nontobacco products to help people quit. Some products are made from mint (eg, Mint Snuff, Oregon Mint Snuff Co, Tillamook, Oregon), and others are made from dried apples (eg, Nature's Sport Chew, Markham & Reid, LLC, Asheboro, North Carolina). Their packaging mimics that of their tobacco counterparts.
In a list of quit tips for smokeless tobacco users, NSTEP suggests that athletes replace chewing tobacco or snuff with nontobacco chew, sunflower or pumpkin seeds, or gum. Other NSTEP quit tips that physicians can pass along to patients:
Exercise testing guidelines updated
New guidelines for the use of exercise testing for patients with known or suspected cardiovascular disease have been issued by the committee on exercise testing of the American College of Cardiology (ACC) and the American Heart Association (AHA). Among other features, the guidelines pay increased attention to special populations, underscore the validity of exercise testing, discourage its use in healthy people, and provide a scoring method to help physicians predict patient outcomes from exercise test data.
The guidelines (1), published in the July issue of the Journal of the American College of Cardiology, reflect advances in cardiology and exercise testing since the previous guidelines were issued in 1986. Gary J. Balady, MD, chair of the AHA's Committee on Exercise, said the current document offers new sections on ventilatory gas analysis and on the use of exercise testing among women, the elderly, revascularization patients, and cardiac rehabilitation patients. Balady is an associate professor of medicine at the Boston University School of Medicine.
Low-Tech but Worthwhile
Raymond J. Gibbons, MD, chair of the committee that wrote the guidelines, hopes that the document will "reassure primary care physicians that exercise testing, though low-tech and older, clearly has a role in the initial evaluation of patients." Gibbons, a professor of medicine at the Mayo School of Medicine in Rochester, Minnesota, believes that role has been strengthened because the guidelines include the Duke nomogram (2) that allows physicians to calculate a patient's 5-year cardiovascular survival probability based on his or her level of exercise-induced ischemia, ST-segment deviation, and angina. "If a patient has a low-risk test result," he says, "their risk of a cardiac event in the next 4 to 5 years is really very low. Therefore, the clinician and patient can be reassured, and additional, more expensive testing won't be required."
Exercise tests, however, can be overused. Victor F. Froelicher, MD, says the guidelines "make a strong statement on the inappropriateness of using exercise testing as a screening device for healthy people." The only asymptomatic patients for whom exercise testing may be useful are those who have multiple risk factors or men over 40 and women over 50 years old who are beginning vigorous exercise, whose jobs affect public safety, or who have other diseases predisposing them to coronary heart disease (2). Froelicher, a member of the guidelines committee, is a professor of medicine at Stanford University.
The guidelines also include a warning about overreliance on computer interpretation of exercise test data, Froelicher says. "Physicians need to know how to read raw electrocardiogram (ECG) data." According to the guidelines, "computer processing of the exercise ECG can be helpful, [but] it can result in a false-positive indication of ST depression. To avoid this problem, the physician should always be provided with ECG recordings of the raw unprocessed ECG data for comparison with any averages the exercise test monitor generates (1)."
Balady said the committee wanted to make the new exercise test guidelines as "user-friendly as possible. They were written to address the needs of all healthcare providers who might order an exercise test." The guidelines include data accumulated during more than 22 years of exercise-test studies (1). As a result, says Froelicher, "For physicians who want more expertise in exercise testing, there's one major source now that's very authoritative and evidence based."
The 12-member guidelines committee included representatives of the American Academy of Physicians, the American College of Sports Medicine (ACSM), and the American College of Physicians. The guidelines have been endorsed by the ACSM, the American Society of Echocardiography, and the American Society of Nuclear Cardiology.
Early warning about fen-phen
The US Food and Drug Administration (FDA) raised caution flags over the use of the popular diet drug combination fenfluramine and phentermine (fen-phen) after revelations in July that the pair may cause heart valve abnormalities. Mayo Clinic physicians in Rochester, Minnesota, reported that 24 women who had been taking the drugs had thickened valves, and 5 of them required surgery. The FDA had reports of 9 additional patients taking the drugs who had similar heart valve problems.
The unusual abnormalities involved the mitral, aortic, and tricuspid heart valves in women between the ages of 30 and 72 who had been taking the drug combination for 1 to 28 months, according to a US Department of Health and Human Services news release. No deaths have been reported to date.
Because of the possible risks to patients using fen-phen, The New England Journal of Medicine permitted release of the Mayo Clinic findings 7 weeks before the scheduled publication date. In an immediate response to the Mayo report, the FDA began sending letters to physicians July 8 warning them of the possible dangers of fen-phen.
Eileen R. Beran