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HICNet Medical News Digest Tue, 21 Mar 1995 Volume 08 : 
Issue 08

Today's Topics:

 [MMWR] Occupational Lead Surveillance -- Taiwan, July-December 1993
 [MMWR] Update: Dracunculiasis Eradication -- Ghana and Nigeria, 1994
 Moderate physical activity confers CVD benefits on men and women
 FDA Approval of AIDS Virus Test on Oral Fluid Samples
 FDA Saline-Filled Breast Implant Update
 National Cancer Institute's CancerNet Update March 1995
 FDA Approves New Diabetes Drug
 Armed Forces Institute of Pathology CE Course Schedule
 Latin-American Congress on Organ/Tissue Transplantation

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 Jack E. Cross, B.S Health Care Admin, 882 Medical Trng Grp, USAF

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

To: hicnews
1993

 Occupational Lead Surveillance -- Taiwan, July-December 1993

 Lead poisoning has been recognized as an occupational disease for
centuries and has been linked with both severe and subtle health damage 
(1-
3). In July 1993, the government of Taiwan initiated a compulsory 
system*
for surveillance of elevated blood lead levels (BLLs) among workers in 
that
country (4). All lead-exposed workers in lead-using factories** are
identified and included in the lead surveillance system. This report
summarizes findings from this program for July-December 1993.
 A total of 18 categories of production processes (e.g., battery
recycling or manufacturing, lead smelting, plastic stabilizer additive
processing, and lead-based paint production) or occupation/job 
categories
constitute the high-lead exposure group. Lead-exposed workers in these
settings are required to have their BLLs monitored annually by one of 22
specified, certified hospital laboratories. Based on job titles and an
occupation register published by the Labor Council of Taiwan, a minimum 
of
4500 workers in Taiwan were directly exposed to lead-contaminated work
environments (at exposure levels ranging from 0.002 mg per cubic meter 
to
3.051 mg per cubic meter***), and 10-fold more workers were indirectly
exposed (e.g., secretaries who work at the same factories but in jobs 
that
do not entail direct lead exposure).
 Employers are required by law to report at least annually to local
health bureaus and labor inspection offices the BLLs and results of 
health
examinations (specifically designed for lead-exposed workers and 
performed
at one of the specified hospitals). Labor Council factory inspectors are
responsible for enforcing this law. To ensure employer and worker
participation, employers are subject to fines equivalent to $1200-$2400
U.S. for delayed reporting (i.e., beyond 3 months) or failure to report.
To encourage continued reporting by local health officials, the Ministry
of Health publishes a quarterly report that contains county-specific BLL
results and complete rates of follow-up.
 During July-December 1993, BLLs were tested in 2905 lead-exposed
workers. The mean BLL in males (n=1941) was 15.0 ug/dL (standard 
deviation
[sd]= plus or minus 15.1 ug/dL) and in females (n=964), 12.5 ug/dL (sd=
plus or minus 12.2 ug/dL). Mean BLLs were significantly (p less than 
0.05,
Z test) higher than BLLs for the total population aged greater than or
equal to 15 years in Taiwan (9.6 ug/dL for males; 7.4 ug/dL for females)
(5). In addition, BLLs in 287 (9.9%) workers exceeded the applicable
regulatory level (40 ug/dL for males; 30 ug/dL for females).
 Most monitored workers were employed in soldering/cable stripping
(452) and in battery recycling/manufacturing (364) (Table 1). Mean BLLs
were highest among battery workers (34.6 ug/dL) and plastic 
manufacturers
(27.5 ug/dL), and BLLs were elevated for approximately 25% of workers in
plastic-manufacturing factories and 50% in battery-producing factories.
Mean BLLs and proportions of workers with elevated BLLs were lowest in 
the
following exposure categories: electric plating and painting, railroad
workers, traffic police, and soldering/cable stripping.
 The surveillance system in Taiwan also provides for an intervention
team (including epidemiologists, industrial hygienists, and physicians) 
to
evaluate the workplaces of workers with elevated BLLs. This response
includes monitoring ambient lead exposure levels, evaluating the 
company's
health and safety procedures, providing technical assistance to reduce 
lead
exposure, and improving high-risk work practices and worker behaviors
(including prevention of inadvertent transport of lead from the 
workplace
to the worker's home). Through February 1995, the intervention teams had
investigated the workplaces of 201 (70%) of the 287 workers with 
elevated
BLLs. Priorities for follow-up are based on the BLLs of the workers
involved.

Reported by: TN Wu, PhD, CY Shen, PhD, GY Yang, MD, SH Liou, MD, KN Ko,
MPH, SL Chao, MPH, CC Hsu, MPH, JS Lai, PhD, PY Chang, MD, Disease
Surveillance and Quarantine Svc, Ministry of Health, Taiwan, Republic of
China. Div of Surveillance, Hazard Evaluations, and Field Studies, 
National
Institute for Occupational Safety and Health, CDC.

Editorial Note: The establishment of the compulsory occupational lead
surveillance system described in this report is an important step in
industrial hygiene and occupational disease prevention in Taiwan, and
similar systems may be used in other countries and settings. In 
particular,
the surveillance system in Taiwan indicates the usefulness of exposure
information to target monitoring activities and using that information 
to
target intervention efforts. This system should facilitate improvements 
in
the industrial hygiene of the work environment, assist in evaluating the
effects of intervention, and reduce both primary and secondary (e.g.,
take-home) exposures to lead.
 Since the mid-1980s, occupational lead surveillance programs have 
been
developed in both Taiwan and the United States. In both countries, these
systems are laboratory-based and legally mandated; however, each system
also has distinguishing features (Table 2). In particular, in Taiwan,
companies subject to surveillance are predetermined based on predicted
potential for exposure and are required to report to the government. In
comparison, in the United States, companies are required to self-
identify
the existence of lead exposures and then to comply with the requirements
of the Occupational Safety and Health Administration (OSHA) General
Industry (6) and/or Construction Standards (7), which include provisions
for environmental and medical monitoring. In Taiwan, 70% of the workers 
in
workplaces where elevated BLLs were detected received follow-up
interventions. In the United States, follow-up interventions vary 
according
to state resources and BLLs. Seven of the 14 CDC-funded state-based
surveillance programs have formal or informal agreements with OSHA for
referral and follow-up of cases. However, the apparent exclusion of the
nonman-ufacturing sector (e.g., construction) is an important potential
limitation in Taiwan and may preclude identification of new hazards or
sources of lead poisoning, as well as reflect an underestimate of the
magnitude of the problem outside of the manufacturing sector. Finally, 
the
reported compliance with monitoring was relatively high in Taiwan (2950
[66%] workers monitored of an estimated 4500 exposed); in comparison, 
based
on an assessment in California in 1986, the requirements of the OSHA
standard for air and blood lead monitoring have been adhered to by only 
a
small proportion of facilities**** (8). Despite this apparently low
compliance with biologic monitoring provisions of the standard, state-
based
surveillance programs have succeeded in identifying industries and
occupations where lead hazards remain (9).
 Although the systems in Taiwan and the United States differ, the
beneficial public health effects of surveillance in each country are
substantial--large numbers of workers with exposure and/or elevated BLLs
have been identified (10), monitored, and trained to prevent future lead
poisoning. The surveillance system in Taiwan reflects efforts to 
establish
improved occupational health surveillance in conjunction with rapid 
growth
in industrial capacity. The legal mandate in Taiwan enables the
incorporation of surveillance requirements as integral parts of standard
business operations, rather than only as reactive responses to a public
health problem, and emphasizes that occupational health concerns are an
important part of industrialization.

References
1. La Dou J. Occupational medicine. Englewood Cliffs, New Jersey: 
Prentice
Hall, 1990:297.
2. Rempel D. The lead-exposed worker. JAMA 1989;262:532.
3. Hamilton A. Exploring the dangerous trades. Boston: Little Brown, 
1943.
4. Wu TN, Shen CY, Yang GY, et al. Establishment of an occupational
diseases surveillance system to monitor blood lead levels in Taiwan. 
Prev
Med 1995 (in press).
5. Liou SH, Wu TN, Chiang HC. A nation-wide survey of blood lead level 
in
Taiwan. Taipei, Taiwan: Taiwan Department of Health, 1992.
6. Office of the Federal Register. Code of federal regulations:
occupational safety and health standards. Subpart Z: Toxic and hazardous
substances--lead. Washington, DC: Office of the Federal Register, 
National
Archives and Records Administration, 1985. (29 CFR ***1910.1025).
7. Occupational Safety and Health Administration, US Department of 
Labor.
Lead exposure in construction: interim final rule. Federal Register
1993;58:26590-649. (29 CFR ***1926).
8. Rudolph L, Sharp D, Samuels S, Perkins C, Rosenberg J. Environmental 
and
biological monitoring for lead exposure in California workplaces. Am J
Public Health 1990;80:921-5.
9. Rabin R, Brooks D, Davis L. Elevated blood lead levels among
construction workers in the Massachusetts Occupational Lead Registry. Am
J Public Health 1994;84:1483-5.
10. CDC. Adult blood lead epidemiology and surveillance--United States,
fourth quarter, 1993. MMWR 1994;43:246-7.

* Based on the Labor Safety and Health Law (enacted in 1974 by the Labor
Council of Taiwan).
** Defined according to the worker's occupation/job category and the
company's production process, which is registered on the license of 
every
factory in Taiwan.
*** Data from a Labor Council survey of working environments of
lead-related workers; in the United States, the maximum allowable 
exposure
to lead in air is 50 ug per cubic meter (0.050 mg per cubic meter).
**** In 1986, an estimated 2.6% of facilities using lead had ever done 
any
environmental monitoring, and 1.4% of facilities (employing 2.6% of
potentially lead-exposed workers) had routine biologic monitoring 
programs.

-------------------------------------------------------------------------
-
NOTE: In this report, ug/dL represents micrograms per deciliter. --LBW
-------------------------------------------------------------------------
-



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

To: hicnews
1994

 Update: Dracunculiasis Eradication -- Ghana and Nigeria, 1994

 The plan for the global eradication of dracunculiasis (i.e., Guinea
worm disease) was developed in October 1980 (1). Since 1987-1988, Global
2000, Inc., the United Nations Children's Fund (UNICEF), and the U.S.
Agency for International Development have assisted the Guinea Worm
Eradication Programs in Ghana and Nigeria, countries in west Africa. In
1989, Ghana and Nigeria ranked first and second in the number of 
reported
cases of dracunculiasis with 179,556 and 640,008 cases, respectively 
(2).
This report summarizes data for the two countries during 1994 and 
describes
efforts toward eradication of dracunculiasis.

Ghana
 In 1994, Ghana (1991 population: 16 million) reported to the World
Health Organization (WHO) 8432 cases of dracunculiasis in 1347 villages
with known endemic disease, representing substantial declines in the
numbers of cases (53%) and villages with known endemic disease (42%) 
from
1993. Since initiation of active surveillance in 1989, the numbers of 
cases
and villages with known endemic disease have been reduced by 95% (Figure
1) and 79%, respectively.
 In 1994, an average of 74% of villages with known endemic disease
submitted surveillance reports on time each month; the rate of timely
reporting increased from 30%-45% during January-March (when ethnic
disturbances occurred in parts of the northern region, which has high 
rates
of dracunculiasis) to 98% during October- December. During 1994, the
northern region reported 69% of all cases in the country. Five of the 10
regions reported no indigenous cases for greater than or equal to 3
consecutive months. Overall, 65% of the reported cases were fully 
contained
(i.e., the case was detected within 24 hours of worm emergence, the worm
extracted surgically and/or the lesions bandaged, and the affected 
person
prevented from entering sources of drinking water to prevent 
transmission);
the percentage of contained cases increased steadily during the year, 
from
30% in January to 93% in December.

Nigeria
 In 1994, Nigeria (1992 population: 90 million) reported to WHO 
35,749
cases of dracunculiasis in 2571 villages with known endemic disease,
representing substantial declines in the numbers of cases (53%) and
villages with known endemic disease (29%) from 1993 (3). From July 1988
through December 1994, the annual numbers of cases and villages with 
known
endemic disease declined 95% (Figure 2) and 56%, respectively.
 In 1994, an average of 75% of villages with known endemic disease
submitted surveillance reports on time. Five of the 30 states and the
Federal Capital Territory reported 66% of the total number of cases; 
seven
states reported no cases. By December 31, approximately 72% of the
remaining villages with known endemic disease had begun case-containment
measures designed to prevent further transmission.

Reported by: S Bugri, MD, Ghana Guinea Worm Eradication Program, 
Ministry
of Health, Ghana. AA Adeyemi, MD, Nigeria Guinea Worm Eradication 
Program,
Federal Ministry of Health and Social Svcs, Nigeria. Global 2000, Inc, 
The
Carter Center, Atlanta. World Health Organization Collaborating Center 
for
Research, Training, and Eradication of Dracunculiasis, Div of Parasitic
Diseases, National Center for Infectious Diseases, CDC.

Editorial Note: This report documents continued progress in Ghana's and
Nigeria's efforts to eradicate dracunculiasis. However, the civil
disturbances in Nigeria and ethnic fighting in Ghana during 1994 may 
slow
this progress. For example, during January 1995 in Ghana, 1971 cases of
dracunculiasis were reported, a 136% increase over the 834 cases 
reported
in January 1994. However, concerted efforts to rapidly reinstitute
eradication efforts in Ghana as the ethnic strife subsided resulted in
rapid detection and full containment of 97% of the cases. Improvements 
in
surveillance and case containment in Ghana and Nigeria indicate that the
two countries may reach the goal of eradicating dracunculiasis by the 
end
of 1995.

References
1. Hopkins DR, Foege WH. Guinea worm disease [Letter]. Science
1981;212:495.
2. World Health Organization. Dracunculiasis: global surveillance 
summary,
1993. Wkly Epidemiol Rec 1994;17:121-8.
3. CDC. Update: dracunculiasis eradication--Ghana and Nigeria, 1993. 
MMWR
1994;43:293-5.


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

To: hicnews
women
0100000@orichalc.acsu.buffalo.edu>

 National Center American Heart

 Moderate physical activity confers CVD benefits on men and 
women

 SAN ANTONIO, March 10 -- Even moderate physical activity offers 
women
and men protection against heart attack and stroke, according to a trio
of studies reported today at the American Heart Association's 35th 
Annual
Conference on Cardiovascular Disease Epidemiology and Prevention. Two 
of
the three studies show activity's link to reduced cardiovascular risk in
women.
To date most studies on the benefits of physical activity have focused 
on men.
 Boston researchers reported a reduced risk of heart attack and 
stroke
in physically active women. The findings emerged from the Nurses' Health
Study, a collection of data on 73,029 female nurses, who were 40 to 65


 

(Continued from last message)
years old when they were originally surveyed in 1986 regarding physical
activity and other lifestyle practices.
 The nurses were divided into five equal groups (quintiles) 
according
to
estimated level of physical activity. The researchers expressed physical
activity in terms of energy expenditure, which takes into account
duration and intensity.
 In the four years after the survey, 168 heart attacks and 139 
strokes
occurred among the nurses. Nurses in the highest activity group (the
fifth quintile) had a 44 percent lower risk of heart attack and a 42
percent lower risk of stroke compared to nurses in the lowest group 
(first
quintile). The impact of physical activity was not substantially 
affected by
cardiovascular risk factors, such as high blood pressure, smoking and
diabetes.
 For heart attack, the risk decreased progressively with 
increasing
physical activity, says JoAnn E. Manson, M.D., Dr.P.H., co-director of
women's health at Brigham and Women's Hospital and Harvard Medical
School. For example, women in the second quintile had an 11 percent 
lower
risk compared to the least active women.
 The risk of ischemic (markedly decreased blood flow) stroke was
especially reduced and was 56 percent lower among women in the highest
quintile of physical activity compared to the lowest. The risk of a
hemorrhagic (bleeding) stroke was only modestly and insignificantly
lower among exercisers.
 "The greatest reduction in risk of heart attack and stroke was 
in
those
women who exercised most frequently," says Manson. "It's difficult to
tease out individual activities, because we have combined intensity and
duration, but it appears that even more moderate forms of exercise, such
as walking, were associated with lower risk."
 "The benefits compare favorably with other risk-reducing 
behaviors,"
she adds, "and they are consistent with findings in men. The bottom line
of this report is that physical activity seems to confer similar
cardiovascular benefits in women and men."
 Seattle investigators estimated that physical activity may 
reduce the
risk of heart attack by 50-60 percent in postmenopausal women. Even
modest levels of activity appeared to offer substantial benefits.
 The study involved 268 women (cases) who had had a myocardial
infarction, or heart attack, and 925 women who had not had heart attacks
(controls). The average age of all the women was about 67. All the women
completed a survey that included a number of questions related to
leisure-time physical activity.
 Using the type of activity, frequency and duration, the 
investigators
estimated the energy expenditure of each woman. The women were then
divided into four equal groups (quartiles) based on physical activity
levels. The risk of heart attack was estimated for each activity group
by comparing the number of cases and controls in the group.
 Women in the three quartiles with the highest levels of physical
activity had a 48 to 60 percent lower risk of heart attack, compared to
women in the lowest quartile. The reductions persisted after controlling
for the effects of such other heart disease risk factors and 
contributing
factors as age, cigarette smoking, high blood pressure, diabetes, family
history of heart disease, blood cholesterol, aspirin use and estrogen
therapy.
 Overall, the scientists say, the risk of heart attack among
post-menopausal women decreases by 50 percent with modest leisure-time
energy expenditures, equivalent to 30 to 45 minutes of walking for
exercise three times a week.
 "Numerous studies have looked at the influence of physical 
activity on
coronary risk, but most did not include women," says Rozenn N. Lemaitre,
Ph.D.,
M.P.H., a research scientist in the Cardiovascular Health Research Unit 
at the
University of Washington, Seattle. "Many studies also have not been 
adjusted
for other risk factors. So, while our findings may not be entirely 
new,they
definitely contribute new knowledge about physical activity and women's
health."
 Rhode Island investigators found that even "light activity on 
less
than a daily basis" not only lowers the risk of coronary death and but 
also
lowers mortality from all causes. These findings emerged from the long-
term
follow-up of the Israeli Ischemic Heart Disease Study, involving 8,463 
Israeli
men who were followed for 21 years. The men were all government 
employees who
were at least 40 years old and had no evidence of coronary disease when 
they
were surveyed in 1963 and 1965.
 Men who reported any leisure-time physical activity in the 
baseline
surveys had a 21 percent lower risk of coronary mortality and a 16 
percent
lower all-cause mortality. Light activity on a daily basis was 
associated with
27 percent and 19 percent reductions in coronary and all-cause 
mortality,
respectively. Men who reported moderate or heavy physical leisure-time
activity
had a 29 percent lower risk of coronary mortality while all-cause 
mortality
was
reduced by 16 percent.
 The mortality reductions emerged after the investigators took 
into
account other factors that can contribute to the development of heart 
disease
such as age, systolic blood pressure (the first reading in a blood 
pressure
measurement), cigarette smoking, total and HDL cholesterol levels, body 
mass
index (a measure of obesity) and psychosocial factors.
 "The take-home message from this study was the finding that most 
of
the
benefit occurred with light activity, not even on a daily basis," says
Charles B. Eaton, M.D., assistant professor of family medicine at Brown
University and director of the heart disease prevention center at 
Memorial
Hospital of Rhode Island in Pawtucket.
 "The second important message is that the benefits of physical
activity
appear to be independent of weight or HDL-cholesterol [the "good"
cholesterol]."
 The association between physical activity and all-cause 
mortality is a
third noteworthy aspect of the study.
 "Most studies have focused on the effect of physical activity on
coronary mortality," he says. "To my knowledge, this is one of the few
prospective studies to suggest an effect on mortality from any cause."
 Manson's co-investigators were: Meir J. Stampfer, M.D., Dr.P.H.;
Walter C. Willett, M.D., Dr.P.H.; Graham A. Colditz, M.D., Dr.P.H.; 
Frank
E. Speizer, M.D.; and Charles C. Hennekens, M.D., Dr.P.H.
 Lemaitre's colleagues were: Susan R. Heckbert, M.D., Ph.D.; 
Bruce M.
Psaty, M.D., Ph.D.; and David S. Siscovick, M.D., M.P.H.
 Eaton's associates were: Jack H. Medalie, M.D.; Susan A. Flocke, 
M.S.;
Steve Zyzanski, Ph.D.; Shlomit Yari; and Uri Goldbourt, Ph.D.



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

To: hicnews

 Statement on FDA Approval
 of AIDS Virus Test System Based on Oral Fluid Samples
 December 23, 1994

The Food and Drug Administration today announced that it has
approved the first U.S. HIV test system using oral fluid samples.
Until now, all approved HIV tests have used blood samples.

In approving this new HIV test system, FDA approved both a product
for collecting specimens of oral fluid and a specific test used to
analyze the specimens for the presence of antibodies to HIV, the
virus that causes AIDS. The test system is intended for use in
subjects 13 years of age or older. Use of the specimen collection
product is subject to several restrictions.

This new HIV test system is not as accurate as the approved HIV-
antibody tests used on blood. Studies show that for every 100
people infected with HIV, the oral-fluid-based test will miss one
or two. For every 100 people who are not infected, test results
will be incorrectly positive for approximately two people.

The test system includes a specially treated cotton pad on a stick
and a preservative solution in a plastic container. A trained
collector instructs the subject to place the pad between the lower
gum and cheek to obtain a sample of oral fluid. The pad is then
stored in the preservative until the sample is processed and
analyzed by a qualified laboratory using an ELISA test specifically
licensed for testing oral fluid samples.

FDA approved this HIV test system with the following restrictions:

o The test system is available for purchase and distribution
 only through physicians.

o The test system may be administered only by individuals
 properly trained in its use.

o The test system must not be provided to subjects for home use.

o Testing of the oral fluid samples for HIV antibodies may be
 carried out only with the Oral Fluid Vironostika HIV-1
 Microelisa System.

o The test system may be used for diagnosis only and must not be
 used to screen blood donors.

o Before the oral fluid specimen is collected, subjects must be
 given a "Subject Information" sheet.

The information sheet provides information about the reduced
accuracy of testing oral fluid compared with testing blood and
about the alternative of testing blood. Because there is currently
no confirmatory test for use with oral fluid samples, the sheet
informs subjects that if their oral fluid samples are found to be
positive for HIV antibodies they should have blood samples drawn
and tested with a licensed blood-based test to verify their HIV
status. It also gives subjects information on how to reduce the
risks of HIV infection.

The oral fluid sample collection kit for HIV testing is
manufactured by Epitope Corporation of Beaverton, Ore., and is
marketed under the name "OraSure HIV-1 Oral Specimen Collection
Device." The Oral Fluid Vironostika HIV-1 Microelisa System
approved to test specimens is manufactured by Organon Teknika
Corporation of Durham, N.C.



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

To: hicnews

 SALINE-FILLED BREAST IMPLANT UPDATE

 FDA is receiving inquiries about its decision to require
manufacturers of saline-filled breast implants to proceed in
conducting studies to demonstrate the safety and effectiveness of
these devices. The companies will be required to enroll patients
promptly in clinical trials, report the data in stages and
disseminate revised patient information. The saline implants may
remain on the market while these studies are conducted.
 The following may be used to respond to inquiries.
 Saline-filled breast implants are silicone envelopes filled
with salt water. These devices were on the market prior to the
Medical Device Amendments of l976, which gave FDA regulatory
authority over these products. Like many other pre-amendment
devices, saline-filled implants have been allowed, under the law,
to remain on the market until FDA systematically requires
manufacturers to demonstrate their safety and effectiveness.
 Saline implants currently are the only product generally
available to women who seek breast implants. Although they have
silicone rubber envelopes like silicone gel-filled implants, FDA
believes that saline implants present a lower degree of risk than
gel-filled implants because leakage or rupture would release only
salt water into the body. Since 1992, gel-filled implants for
breast reconstruction have been available only for women who could
not use saline-filled implants, and who agreed to participate in
clinical studies.
 The two manufacturers of the saline-filled implants -- McGhan
Medical Inc. and Mentor Corp, both of Santa Barbara, Calif. -- have
agreed to conduct studies and submit data, as follows:

 TYPE OF STUDY STUDY COMPLETED

Preclinical testing (short-term) 1995

10-year retrospective epidemiological study 1996
 -- rupture/failure rate

1-year large, simple clinical trial 1997
 -- short-term complications
 -- peri-operative infections, deflation and
 capsular contracture

3-year prospective clinical study 1998
 -- augmentation and reconstruction patients
 -- full clinical profile
 -- quality of life


 FDA is also requiring the companies to submit a complete
battery of preclinical data. The first set of these data will be
submitted in the first quarter of l995.
 The agency will review the new studies as they become
available, and will make public any significant new health
information derived from these studies. Manufacturers will use the
information to update labeling as appropriate.
 The agency plans to issue a final rule calling for the
submission of premarket approval applications in 1998. By that
time the manufacturers will have submitted all preclinical data, as
well as the results of both the epidemiology study on rupture rates
and the large simple trial on complication rates. The remaining
three-year clinical data and quality of life assessment will be
required as part of the marketing application.
 FDA has called on the American Society of Plastic and
Reconstructive Surgeons to assist the manufacturers in recruiting
the clinical investigators and patients needed to conduct these
studies in a timely manner.
 The manufacturers have also agreed to disseminate, through
surgeons, updated patient information to prospective patients. FDA
is in the process of updating the patient information sheet, with
the assistance of health professional groups, consumer groups and
the manufacturers.
 Women considering implants should carefully read these patient
information sheets, as well as the informed consent form, and
discuss the risks with their doctors before undergoing implant
surgery. Known risks include rupture, capsular contracture and
infection. Saline implants are also known to interfere with
mammography. Special radiographic techniques need to be used on
women with implants in order to minimize interference.



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

To: hicnews

 +----------------------------------------------+
 | NATIONAL INSTITUTE |
 | C A N C E R |
 | INTERNATIONAL INFORMATION |
 | C E N T E R |
 +----------------------------------------------+
 | CancerNet@icicb.nci.nih.gov |
 +-------------------------------+



Changes to CancerNet, March 1995


CancerNet was updated on March 1, 1995.

PDQ Statements
--------------

The following PDQ statements were added or updated in CancerNet with the 
March
update (see the file Monthly PDQ Changes -- cn-405001 for detailed 
information
on the changes in each statement).


New Statements:
None


Changed Statements:

Changed treatment statements for physicians:

Adult Acute Lymphocytic Leukemia (cn-101024)
Adult Hodgkin's Disease (cn-100003)
Anal Cancer (cn-100022)
Bladder Cancer (cn-101206)
Breast Cancer (cn-100013)
Carcinoma of Unknown Primary (cn-103331)
Childhood Acute Lymphocytic Leukemia (cn-100026)
Childhood Hodgkin's Disease (cn-103043)
Chronic Lymphocytic Leukemia (cn-101003)
Colon Cancer (cn-100008)
Cutaneous T-cell Lymphoma (cn-100098)
Hypopharyngeal Cancer (cn-101500)
Laryngeal Cancer (cn-101519)
Lip and Oral Cavity Cancer (cn-102840)
Liver metastases (cn-103856)
Lung metastases (cn-103855)
Malignant pericardial effusion (cn-103860)
Malignant pleural effusion (cn-103861)
Neuroblastoma (cn-100530)
Oropharyngeal Cancer (cn-101521)
Osteosarcoma (cn-100049)
Pancreatic Cancer (exocrine) (cn-100046)
Pituitary Tumors (cn-101273)
Primary Central Nervous System Lymphoma (cn-104272)
Prostate Cancer (cn-101229)
Rectal Cancer (cn-100076)
Skin Cancer (Non-Melanoma) (cn-101228)
Testicular Cancer (cn-101121)
Thyroid Cancer (cn-101252)
Wilms' Tumor (cn-100719)


Changed treatment statements for patients:

Anal Cancer (cn-200022)
Bladder Cancer (cn-201206)
Chronic Lymphocytic Leukemia (cn-201003)
Neuroblastoma (cn-200530)
Osteosarcoma (cn-200049)
Pancreatic Cancer (exocrine) (cn-200046)
Pituitary Tumors (cn-201273)
Thyroid Cancer (cn-201252)
Wilms' Tumor (cn-200719)


Changed supportive care statements:

Fatigue (cn-304461)


Changed cancer screening and prevention statements:

Screening for Cervical Cancer (cn-304728)
Cancer Prevention Overview (cn-304750)
Prevention of Colorectal Cancer (cn-304731)


Changed drug information statements:
None.


Changed other PDQ information:
None.


Changed CancerNet News and NCI Publication Information:
-------------------------------------------------------
The following news bulletin was added:

Breast Reconstruction Trials using Saline-Filled Implants (cn-400077)

The following news bulletins were changed:

Institutional Protocol Submission Checklist (cn-400011)
How to Access NCI Information Resources -- U.S. Residents (cn-400035)
How to Access NCI Information Resources -- International (cn-400036)
NIH Consensus Development Conference on Ovarian Cancer (cn-400041) [This
 bulletin was changed in a Special Update on February 10, 1995.]
FDA's Mammography Quality Standards Act Takes Effect (cn-400075)

The following news bulletin was deleted:

Selected NSABP Trials Reopened (cn-400060)



 

(Continued from last message)
No NCI publications were changed:


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

The following fact sheets were added:

Increased Cancer Incidence Due Mainly to Screening and Smoking (cn-
600343)
Results of Community Effort to Enhance Cigarette Smokers Quit Rates 
Reported
 (cn-600344)
Q&A on COMMIT (cn-600345)

The following fact sheets were changed:

Cancer Research Funding (cn-600011)
The National Cancer Institute Cancer Centers Program (cn-600012)
Community Clinical Oncology Program (cn-600013)
Synovial Sarcoma (cn-600061)
Mycosis Fungoides and Sezary Syndrome (cn-600063)
Breast Cancer Deaths Decline Nearly 5 Percent (cn-600613)


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

No new CANCERLIT citation and abstract topics were added.

The CANCERLIT citations and abstracts for March will be available on 
March 8,
1995.


Instructions:

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

 cancernet@icicb.nci.nih.gov

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

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

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

Please send comments or questions to:

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



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

To: hicnews

 FDA APPROVES NEW DIABETES DRUG

 We have been receiving inquiries about the approval of
metformin, a new drug for treatment of adult onset non-insulin
dependent, or type II, diabetes, a serious disorder of blood
sugar control. Type II diabetes afflicts 12 million Americans
and can cause damage to the eyes, kidneys, heart and peripheral
circulation. The following may be useful in answering questions.
 Patients with type II diabetes are generally advised to lose
weight and maintain a strict diet. If these measures fail to
control blood sugar levels, they are generally prescribed oral
drugs and, if these fail, insulin injections.
 Metformin is an oral medication for controlling elevated
blood sugar levels in type II diabetes. It differs from other
currently approved antidiabetic drugs chemically and in how it
works. It can be used together with currently available
oral antidiabetic drugs.
 In March 1994, an FDA advisory committee voted unanimously
to recommend that FDA approve metformin for people with diabetes
who cannot achieve adequate blood sugar control with diet alone.
At this meeting the president of the American Diabetes
Association urged approval of metformin as a safe and effective
drug that controls blood glucose by mechanisms different from
currently available drugs.
 In people with diabetes, the pancreas does not produce enough
insulin to control blood sugar, which then rises to harmful
levels. Metformin and other oral anti-diabetic drugs lower these
elevated blood sugar levels. Currently approved and marketed
anti-diabetic drugs work by stimulating the pancreas to secrete
more insulin. Metformin increases the body's response to its own
insulin. Unlike the other drugs, metformin rarely causes
hypoglycemia and generally does not cause weight gain. It may
cause temporary anorexia (loss of appetite), abdominal discomfort
or nausea.
 One concern with oral antidiabetic drugs -- including
metformin -- is the potential risk of cardiovascular death. A
warning to this effect is contained in the labeling for these
drugs. Studies are under way to gain more information about this
and other complications.
 Safety concerns about a related drug -- phenformin --
resulted in its being removed from the market in 1977.
Phenformin was found to promote the development of lactic
acidosis, a life-threatening buildup of lactic acid in the blood
that was fatal in about one patient in one thousand treated for a
year. Numerous studies with metformin and marketing experience
in other countries have shown that, although it can cause lactic
acidosis, the risk is much less than that of phenformin.
 Patients given metformin should be made aware of lactic
acidosis symptoms -- malaise, rapid breathing, shortness of
breath and severe weakness -- and be advised to contact their
doctors immediately if they experience any of these. Lactic
acidosis can be diagnosed with laboratory tests and requires that
metformin therapy be stopped immediately and proper supportive
care initiated.
 During worldwide marketing, patients on metformin have
developed lactic acidosis at about one tenth the rate of those on
phenformin. Metformin has been approved in about 80 countries
and has never been withdrawn for safety reasons. The
manufacturer, Lipha Pharmaceuticals Co. of New York, N.Y.,
submitted an application for marketing to FDA in September l993.
 A patient package insert will be included with metformin.
Lipha will conduct an educational campaign to inform health
professionals and patients about the drug's risks and benefits
and appropriate precautions. The company will also conduct a
postmarketing study in 10,000 patients to increase knowledge
about potential safety problems.
 Metformin will be sold under the trade name Glucophage.
The product will be distributed in the United States by Bristol-
Myers Squibb of Princeton, N.J.



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

To: hicnews

 ARMED FORCES INSTITUTE OF PATHOLOGY
 POSTGRADUATE SHORT COURSES ON CONTINUING EDUCATION


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

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

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

 25-26 Feb Neuroradiology Review Hyatt Regency
 Bethesda, MD

 6-9 Mar Pediatric Radiology AFIP
 Washington, DC

 6-31 Mar Otolaryngology: Head & Neck AFIP
 Washington, DC

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

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

 2-7 Apr Orthopedic Pathology Wyndham Hotel
 Annapolis, MD

 3-14 Apr Update & Review of AFIP
 Anatomic Pathology Washington, DC

 22-23 Apr Uroradiology AFIP
 Washington, DC

 24-28 Apr Advanced Forensic Pathology FBI Academy
 Quantico, VA

 2-5 May 17th Annual Hematopathology Bethesda Marriott
 Bethesda, MD

 20-21 May Musculoskeletal Imaging AFIP
 Washington, DC

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

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

 6- 9 Jun Descriptive Veterinary AFIP
 Pathology Washington, DC

 10 Jun Endoscopic Biopsy of the AFIP
 Gastrointestinal Tract Washington, DC

 21-23 Jun Histopathology AFIP
 Washington, DC

 Jun 27- Forensic Anthropology University of Bradford
 1 Jul Bradford, England

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

 17-21 Jul Musculoskeletal Radiology AFIP
 Washington, DC

 22-28 Jul Uroradiology AFIP
 Washington, DC

 7-10 Aug Pathology of Laboratory USUHS
 Animals Bethesda, MD

 14-18 Aug 5th Annual Radiologic Westin Bayshore
 Pathologic Correlation Vancouver, BC, CANADA

 18-20 Aug Analytical & Molecular AFIP
 Techniques in Environmental Washington, DC
 Toxicology & Pathology

 20-30 Aug Healing Arts: Voyage of Greece/Turkey
 Discovery Sea Cruise

 Aug 26 - Ophthalmic Pathology for Georgetown University
 1 Sept Ophthalmologists Conference Center
 Washington, DC

 11-12 Sept Gastrointestinal Surgical Washington Marriott
 Pathology Washington, DC

 13-17 Sept Hepatic '95 Washington Marriott
 Washington, DC

 16-17 Sept Pulmonary & Mediastinal AFIP
 Radiology Washington, DC

 18-22 Sept Neuroradiology AFIP
 Washington, DC

 Sept 30 - Pulmonary & Mediastinal Marriott Riverwalk
 1 Oct Radiology San Antonio, TX

 23-26 Oct Difficult Diagnosis in Omni Hotel
 Surgical Pathology Charleston, SC

 18-19 Nov Interpretation of Prostatic AFIP
 Biopsy Washington, DC

 1- 3 Dec Respiratory Tract Disney Contemporary
 & Mediastinum Hotel Resort
 Lake Buena Vista, FL

 4- 8 Dec Oral Pathology Grosvenor Resort
 Lake Buena Vista, FL


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



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

To: hicnews

8th LATIN-AMERICAN CONGRESS ON ORGAN AND TISSUE TRANSPLANTATION


1st IBERO-AMERICAN SYMPOSIUM ON ORGAN PROCUREMENT

1st LATIN- AMERICAN SEMINAR ON BRAIN DEATH

1st IBERO-AMERICAN SEMINAR ON THE TEACHING OF HEALTH BIOETHICS

3rd INTERNATIONAL WORKSHOP ON CARE TO PATIENTS WITH CHRONIC RENAL
FAILURE IN DEVELOPING COUNTRIES


Havana, Cuba
April 24-28, 1995



Dear colleague:

The Latin-American Society of Transplantation and the Council of
Scientific Societies of the Ministry of Public Health of Cuba are
honored in inviting you to participate in the 8th Latin-American
Congress on Organ and Tissue Transplantation, the 1st
Ibero-American Symposium on Organ Procurement, the 1st
Latin-American Seminar on Brain Death, the 1st Ibero-American
Seminar on the Teaching of Health Bioethics and the 3rd
International Workshop on Care to Patients with Chronic Renal
Failure in Developing Countries, which will be held on April 24-
28, 1995, at the International Conference Center Havana, Cuba.

The central subject of the Congress will be problems related
to: ORGAN AND TISSUE TRANSPLANTATION, ORGAN PROCUREMENT, BRAIN
DEATH AND CHRONIC RENAL FAILURE IN DEVELOPING COUNTRIES.

The main purpose of simultaneously holding these conferences, is
to gather specialist in organ transplantation of the
Ibero-Latin-American region to discuss relevant topics related to
our work and allow them to share their experiences and exchange
points of view on a broad scope of topics related to the subject.

To this end we are developing a scientific and cultural
program that we hope will please the participants. Additionally, you
will have the opportunity of enjoying the friendship, warn climate
and traditional Cuban hospitality.

Looking forward to meeting you personally in Havana


Dr. Ra.l Herrera ValdThetas
Chairman of the Organizing Committee


SPONSOR
- Latin-American Transplantation Society

CO-SPONSORS
- Latin-American Society of Nephrology
- Pan-American Society of Dialysis and Transplantation
- Pan-American Health Organization-World Health Organization
- National Organization of Transplantation of Spain
- Ministry of Public Health of Cuba
- Council of Scientific Societies of the Ministry of Public Health
 of Cuba


LATIN-AMERICAN TRANSPLANTATION SOCIETY
President :
Hugo Valencia Guzman (Peru)

vice-president :
Raul Herrera Valdes (Cuba)

Secretary :
Armando Vidalon Fernandez (Peru)

Alternate Secretary :
Adolfo Delgado Rodriguez (Cuba)

Treasurer :
Walter Chaname Delgado (Peru)

Alternate Treasure :
Jorge P. Alfonzo Guerra (Cuba)

HONORARY CHAIRMEN

Dr. Julio Teja Perez
Minister of Public Health of Cuba


Dr. Noel Gonzalez Jimenez
Chairman National Commission of Organ Transplantation

Dr. Rodrigo Alvarez Cambras
Director, Frank Pais Hospital

Dr. Raul Gomez Cabrera
Director, Hermanos Ameijeiras Hospital



 

(Continued from last message)
Dr. Miguel A. Marquez
PAHO/WHO Representative in Cuba

ORGANIZING COMMITTEE

Chairman :
Dr.Raul Herrera Valdes

Secretary :
Dr. Adolfo Delgado Rodriguez

Treasurer :
Dr. Jorge P. Alfonzo Guerra

MEMBERS :

Renal Transplant :
Dr. Charles Magrans Buch
Dr. Reynaldo Manalich Comas

Heart Transplant :
Dr. Noel Gonzalez Jimenez
Dr. Felix Duarte Castaneda

Liver Transplant :
Dr. Lazaro Quevedo Guanche
Dr. Leonel Gonzalez Rapado

Bone Marrow Transplant :
Dr. Jose M. Ballester Santovenia
Dr. Jose Carnot Uria



Neural Transplant :
Dr. Raul Macias Gonzalez
Dr. Carlos Suarez Monteagudo

Cornea Transplant :
Dr. Jaime Alemany Martorell
Dr. Marcelino Rios Torres

Bone Transplant :
Dr. Rodrigo Alvarez Cambra
Dr. Eddy Sanchez Noda

Pediatric Transplant :
Dr. Santiago Valdes Martin
Dra. Lourdes Lopez Agramonte

Immunology :
Dr. Sergio Arce Bustabad
Dr. Catalino Ustariz Garcia

Organ Procurement :
Dr. Rene Ruiz Armas
Dr. Arnaldo Vall Martin

Brain Death :
Dr. Calixto Machado Curbelo
Dr. Orlando Garcia Garcia

Medical Ethics :
Dr. Jose Jordan Rodriguez
Dr. Jorge Gonzalez Perez

Nursing :
Lic. Maria Teresa Trincado Agudo
Lic. Raquel Perez Campo



PCO, International Conference Center :
Lic. Alicia Garcia Gonzalez

TOPICS
- Ethical, social, legal and economic aspects
- Brain death
- Procurement and preservation of organs and tissues
- Immuno-biology
- Management of the recipient with chronic organ failure
- Clinical and surgical aspects
- Immunosuppression, cyclosporines, mono- and poly-clonal
 antibodies, new agents

- Long-term prognosis
- Transplantation in pediatric patients
- Xenotransplantation
- Record and statistics
- Nursing services in organ transplantation

PROGRAM

The Scientific Program will include pre-Congress courses,
lectures, symposia and free communication in the modalities of
oral, posters and video presentations.


PRE-CONGRESS COURSES

They will held on the 24th and will delivered by highly qualified
professors on the respective subjects. Participants will receive a
certificate.

LECTURES

Lectures about the latest developments on the above mentioned
topics will be offered by specialists of renowned international
prestige

SYMPOSIA

Updated knowledge and the experiences achieved in the field of
transplantation in different countries will be presented

FREE-PAPER PRESENTATION They will be presented in the modalities
of oral presentations, posters and videos Oral presentations may
be accompanied by graphic support such as slides and overhead
projections.

Posters shall be presented in a format of 0.95 m wide and up to 2 m
high. They shall include introduction, materials, methods,
results, debates and conclusions.

Video requirement: Only Betamax and VHS (NTSC 3.58 standard)
videocassettes will be accepted.

ABSTRACT PRESENTATION

Format
- two-hundred and fifty words maximum
- Title in capital letters at the top the page
- Author(s)
- Name, address, and country to which your institution belongs
- P.O. box. fax, telex and telephone number
- Name of speaker if other than main author

Confirmation of accepted papers by the Organizing Committee will

be sent no
later than January 31st, 1995.

WORKING LANGUAGES English and Spanish; simultaneous interpretation
will be provided for the main activities of the Congress

AUDIOVISUAL Audiovisual aids must meet the following requirements :
Slides 35mm
Video-cassettes Betamax or VHS
(NTCS 3.58) Films 16-,
35- mm and super 8

TECHNOLOGICAL EXHIBITION

The 7th International Fair of Medical Techniques "Health for All"
will take place parallel to the Congress at Pabexpo, the
International

Conference

Center's Exhibition Hall. More than 300 companies from 25
countries will display a wide variety of cutting edge technology and
pharmacology

SOCIAL PROGRAM

All participants and guest registered in the Congress will
participate in official activities.

Speakers and accompanying persons will be able to choose from a
specially designed program of optional tours organized before,
during and after the Congress.

REGISTRATION FEES
Physicians: US $200.00
Residents and other professionals: US $150.00
Nurses: US $
125.00
Accompanying persons US $
75.00

Participants who register through the International Conference
Center's representative travel agencies listed in this brochure
will take advantage of the following services:

-TECHNICAL AND SCIENTIFIC ACTIVITIES
Information and consulting on the program
Confirmation of guest status
Reception and acceptance of contributed papers

-TOURISTIC ACTIVITIES
Granting of visas, ticket reservation, hotel bookings, optional
tours,etc.

PRE REGISTRATION

Please send us the enclosed registration form as soon as
possible. The Organizing Committee will kindly appreciate any
information you could give to your colleagues about this Congress.


IMPORTANT DATES
December 31st, 1994
Deadline for the reception of papers abstracts

January 31st, 1995
Confirmation of acceptance of papers by the Organizing Committee

April 24th, 1995
Pre-Congress courses/Opening of the Congress

April 25 to 28, 1995
8th Latin-American Congress on Organ and Tissue Transplantation

2do IBERO-AMERICAN COURSE ON NEPHROLOGY
This course will take place immediatly before the Congress, from
April 20 to
22, 1995 and will be held in the city of Santiago de Cuba.

Course Coordinator : Dr. Carlos Valle Santana

TOPICS
- Molecular biology of renal damage
- Chronic renal failure
- Up-date of dialytic methods
- Post-transplantation acute renal failure
- Hypertension in renal transplantation

Registration fee: US $150.00

For more information, please contact:
8th Latin-American Congress on Organ Transplantation
Palacio de las Convenciones
Calle 146 e/ 11 y 13, Playa
Apartado Postal 16046 , La Habana, Cuba
Tels : (537) 22-5511 to 19 ext. 1514
 (537) 81-2413 / (537) 81-3968
Telex: 511609 palco cu
Fax (537) 33-1657 or 22-8382

NOTICE
We would be specially grateful if you communicate with Committee
via
FAX

_________________________________________________________________
_____


 8th LATIN-AMERICAN CONGRESS ON ORGAN TRANSPLANTATION
 April 24-28, 1995, Havana, Cuba


 REGISTRATION FORM

Please fill in block letters:

Name:____________________________________________________________
_____

Surname:_________________________________________________________
_____

Address:_________________________________________________________
_____

Postal
Code:____________________________________________________________
_____

City:______________________________
Country:_______________________________

Fax No.____________________________ Telex
No.______________________________

Telephone________________________________________________________
_____

Speciality_______________________________________________________
_____

Institution:_____________________________________________________
_____


___ I kindly request further information

___ I will participate alone

___ I will be accompained __ persons(s)

I will attend the 2nd Ibero-American Course on Nephrology Yes__

No__

I will attend pre-congress courses Yes__

No__

I will present paper Yes__

No__

Title:___________________________________________________________
_____
_________________________________________________________________
_____

Modality

 __Oral presentation __Posters ___Video

_________________________________________________________________
_____


OTHER COOPERATING AGENCIES

BAHAMAS: Havanatur Bahamas
 - Tel. 322-2606
 - Telex (809) 322-2606
 - Fax 1191-809-3265785
BARBADOS: Bim International Travel Inc.
 - Tels. (809) 4310127 / 4310123
 - Fax (809) 431-0123
BENELUX: Havanatur Benelux
 - Tel. 32-2502.0700
 - Telex 23614
 - Fax 32-2502.34.75
CANADA: Cubanacan-Canada
 - Tel. 4166010343
 - Telex. (21) 6524017
 - Fax 416 6010346,Toronto
CHILE: Cosmo Service
 - Tel. 633224 / 6399320
 - Telex 241309 cosmo cl
 - Fax 6392331
FRANCE: Havanatur Paris
 - Tel. (1) 4742.58.58
 - Telex 215 891F
 - Fax (1) 4265.1801
GERMANY: IT Reisen. Internationale Touristik GmbH
 - Telex 8881 425
 - Fax 0221 / 253220
Tropicana Touristik
 - Tels. 030-8537041 / 7042
 - Telex 186760 tropi d
 - Fax 030 / 583.40.70
HAITI: Citadelle S.A.
 - Tel. 225900
 - Telex 20141
 - Fax 22-1792
IRLANDA: Cubatravel
 - Tel. (01) 713422
 - Telex 31594.g.e.t
 - Fax (01) 798006
JAMAICA: Caribic Vacations
 - Tels. (809) 952-5013 / 4469
 - Telex 2001/5374 caribic
 - Fax (809) 952-0981/8288
JAPON: Co-your Tours Co. Ltda
 - Tel. 03-3574-1594
 - Telex 36372 coyou
 - Fax 03-3574-0018
Kyoei Havanatur Ltd.
 - Tel (03) 3581-7451
 - Telex J 27349 kyoeitok
 - Fax 03-3581-4725
NICARAGUA: Soltours
 - Tel. 663913 / 663914
 - Fax 661591
PANAMA: Atlantis Tours
 - Tel. 64-4466 / 64-4471
 - Fax (507) 64.8370
PARAGUAY: Intertours
 - Tel. 211747 / 624-212229
 - Telex 22142 Py
 - ITR Fax (595-21) 211870 Asuncion
SWEDEN: Columbus Resor ab
 - Tel. + 46 8 33 88 80
 - Telex 10186 colum s
 - Fax +46 8 34 09 50, Estocolmo



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

End of HICNet Medical News Digest V08 Issue #08
***********************************************


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