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FEB 11 1993

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Minnesota Medicine

A JOURNAL OF CLINICAL AND HEALTH AFFAIRS

COVER

The Less Than Equal Medical Treatment women receive has been called the Yentl syndrome. Not only do their health prob- lems receive less research attention than men’s, hut women also receive inequitable care, even when their complaints are similar to men’s, says this month’s feature story (page 16). That story and our interview with Doris Brooker, M.D., an ob/gyn pa- thologist specializing in women’s health (page 9), describe how women in Minne- sota and elsewhere are confronting this bias.

Illustration by Linda Frichtel.

JANUARY 1992 VOLUME 75 NUMBER 1 FACE TO FACE A Powerful Voice for Women’s Health

Minnesota Medicine intervieivs Doris C. Brooker, M.D. 9

MAURiei AND UURA FALK LIIRARY

Of the health SCleNCu

PERSPECTIVES UNIVEKilTY OF PITTSBURGH

Learning About Real Medicine and Real Life ^ ^ , /

BelhOke"

FEATURE

Less Than Equal Treatment: Women Battle Sex Bias. in, the Health Care Arena

Beryl Bynian t 16

SPECIAL REPORT

MINNESOTA MEDICINE Owner and Publisher Minnesota Medical Association Editor-in-Chief Edmund C. Burke, M.D. Managing Editor Meredith McNab Editorial Assistant Susan R. Rodsjo

Send manuscripts, subscriptions, and other material for consideration to Minnesota Medicine, 111 1 Universitv Avenue SE, Suite 400, Minneapolis, MN 55414, 612/378- 1 875. The editors reserve the right to reject editorial, scientific, or advertising material submitted for publication in Minnesota Medicine. The views expressed in this jour- nal do not necessarily represent those of the Minnesota Medical Association, its editors, or any of its constituents. Annual Subscrip- tion - $27.00. Single copies - $2.25. Cana- dian - $36.00. Foreign - $36.00.

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COPYRIGHT AND POST OFFICE ENTRY Minnesota Medicine (ISSN 0026-556X) is published on the fifth of each month by the .Minnesota .Vledical Association, 222 1 Uni- versity Avenue SE, Suite 400, Minneapolis, .MN 55414, copyright 1992. Permission to reproduce editorial material in this maga- zine must be obtained from Minnesota Medicine. Second-class postage paid at •Minneapolis, Minnesota. POST .MASTER, send address changes to; Minnesota Medi- cine, 111 I Universitv Avenue SE, Suite 400, .Minneapolis, .MN ,554 1 4. (USPS 35 1 900.)

Minnesota Medicine

MMA Grapples with Health Care Reform

Minnnesota Medical Association Legislative Staff 23

CLINICAL & HEALTH AFFAIRS

Complications and Mortality of the In-Situ Saphenous Vein

Bypass for Lower Extremity Ischemia

David S. Beebe, M.D., Kumar G. Belani, M.B.B.S., M.S.,

Ji-Chia Lao, M.D., Ph.D., and David Knighton, M.D. 27

MEDICINE LAW & POLICY Physician Malpractice and Managed Care Plans

James B. Platt, J.D.

t

31

ON THE BUSINESS

S 1

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Elexible-Benefit Plans Offer Savings for,,P^ health sciences Employees, Employers

Hilary O’Donnell and Walter Jones

FEBu 1993

35

DEPARTMENTS

Editor’s Notebook

5

NWs Clips .. '' ,,b .. ' .

41-

Instructions for Authors

26

CiME in Minnesota

45*"

President’s Letter

37 1

i (Classified Advertising

49

Book Review

39

Index to Advertisers

56

In Memoriam

40

January 1992/Volume 75

34 35PT XL -inr mII

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MINNESOTA MEDICAL ASSOCIATION

1990-91 Officers President

Thomas A. Stolee, M.IT.

President-Elect A. Stuart Hanson, M.D.

Chair, Board of Trustees Andrew]. K. Smith, M.D.

Vice President Barbara P. Yawn, .M.D.

Secretary

Thomas B. Dunkei, .M.D. Treasurer

Joseph A. Celia, Jr., .VI. D.

Speaker of the House J. Randolf Beahrs, .M.D.

Vice Speaker of the House Richard D. .Mulder, .M.D.

Past President

Richard B. Tompkins, .M.D.

Chief Executive Officer Paul S. Sanders, .VI. D.

Auxiliary

President Phyllis H. Ellis

Editor-in-Chief Edmund C. Burke, .M.D.

Advisory Committee Edmund C. Burke, .VI. D. Thomas W. Day, .VTD. Alice G. Harris, .Vi.D. Charles R. .Vleyer, .VI.D. Paul S. Sanders, .M.D. .Andrew]. K. Smith, .VI.D. Anne B. Warwick, .VI.D. .Meredith .VlcNab .Mark Vukelich

Editors Emeritus Richard L. Reece, .VI.D. 1975-1990

Reuben Berman, .VI.D. 1971-1974

Carl O. Rice, .VI.D. 1961-1970

Minnesota Medicine

Board of Trustees

N. W. District Erick Reeber, .VI. D.

N.E. District Thomas W. Day, .VI.D.

Jack B. Greene, .M.D.

N. Central District James]. Dehen, .VI.D.

David .VI. Van Nostrand, .VI. E).

West Metro

Roger W. Becklund, M.D. Andrew ]. K. Smith, .VI.D., Chr.

Richard E. Student, M.D. George V. Tangen, .VI.D. Ronald E. Villella, .VI.D.

East Metro

Joseph E. Rigatuso, .VI.D.

Kent S. Wilson, VI.D.

S. W. District

Theodore E. Eritsche, .M.D. Anthony C. Jaspers, .VI.D.

S.E. District

Gail E. Gamble, M.D.

J. Paul .Vlarcoux, .VI.D. Thomas E. Peyla, .VI.D.

Resident Member Cherie J. Hayostek, .M.D.

Medical Student Ty Dunn

Review Board Chester A. Anderson, .VI.D. Donald C. Bell, .VI.D. Dorothy Bernstein, .VI.D.

E. Blanton Bessinger, .VI.D. Jonathan H. Biebl, .VI.D. Paul J. Bilka, M.D.

Clyde E. Blackard, .VI.D.

R. J. Campaigne, .VI.D. Richard P. Carroll, .VI.D. Roger S. Colton, .VI.D. Gerald E. Cotton, .VI.D. Peter Dorsen, .VI.D.

Peter Eehr, .VI.D.

Paul Gannon, .VI.D.

James B. Gaviser, .VI.D.

H. W. Heupel, .VI.D.

Neil Hoffman, .VI.D.

James Janecek, .M.D.

.Miles J. Jones, .VI.D.

Carl .M. Kjellstrand, .VI.D. Arnold Kremen, .VI.D. Warren L. Kump, .VI.D.

Van S. Eawrencc, .VI.D.

(,. Patrick Eilja, .VI.D. .VIerle K. Eoken, .VI.D. .VIerle S. .Mark, .M.D.

John K. .Vleinert, .VI.D.

AM A T riistee

William E. Jacott, .VI.D.

AM A Delegates

Robert D. Christensen, .VI.D.

El. Duane Engstrom, .VI.D.

A. Stuart Hanson, .VI.D. James E. Knapp, .VI.D. Audrey .VI. Nelson, M.D.

Ben P. Owens, .VI.D.

Richard B. Tompkins, .M.D., Chr.

AM A Alternates Carolyn J. .VIcKay, .M.D. .Vlichael j. .Vlurrav, .M.D.

C:. Randall Nelms, Jr., .VI.D. Eawrence .VI. Poston, .VI.D. Thomas A. Stolee, .VI.D. James]. Tiede, M.D.

E. Ashley Whitesell, .VI.D.

Senior Staff

Director of Exonomics & Government Relations Roger K. Johnson

Chief Einancial Officer George C. Lohmer, Jr.

Director of Communications .Mark S. Vukelich

General Legal Counsel .Vlary E. Prentnieks, J.D.

James J. .Monge, .VI.D.

John S. Najarian, .VI.D.

Bruce C. Nydahl, .VI.D.

.Vlilton Orkin, .VI.D.

Richard R. Owen, .M.D. .Vlichael .VI. Paparella, .VI.D. James]. Pattee, .VI.D.

Willard Peterson, .VI.D.

John J. Regan, .M.D.

Krishna .VI. Saxena, .VI.D. William E. Schoenwetter, .M.D. Alvin E. Schultz, .VI.D.

Edward L. Seljeskog, .VI.D. John E. Smith, .VI.D.

Earrell S. Stiegler, .M.D.

George T. Tani, .VI.D.

Robert ten Bensel, .VI.D.

John V. Thomas, .VI.D.

John Verby, .VI.D.

Anne B. Warwick, .VI.D. Robert E. Woodburn, .VI.D.

Contributing

Organizations

.Minnesota Allergy Society .Vlinnesota Society of Anesthesiologists Minnesota Dermatologic Society

.Minnesota Association of E.VIS Physicians .Vlinnesota Chapter,

American College of Emergency Physicians .Minnesota Academy of Eamily Physicians .Minnesota Component, American Society of Internal .Medicine .Minnesota Chapter, American College of Physicians .Minnesota Society of Neurological Sciences Association of Neurologists of .Minnesota .Minnesota Neurological Society

.Minnesota Association of Nursing Home .Medical Directors

.Vlinnesota Obstetrical and Gynecological Society North Central Occupational .Vledical Association .Vlinnesota Academy of Ophthalmology .Vlinnesota Orthopaedic Society

.Minnesota Academy of Otolaryngology-Head dc Neck Surgery .Minnesota Society of Clinical Pathologists Northwestern Pediatric Society

.Vlinnesota Chapter, American Academy of Pediatrics .Vlinnesota Physiatric Society .Vlinnesota .Academy of Plastic Surgeons .Vlinnesota Psychiatric Society .Vlinnesota Radiological Society

.Minnesota Chapter, American College of Surgeons .Vlinnesota Surgical Society Minnesota Thoracic Society .Vlinnesota Urological Society

January 1992/Volume 75

Minnesota Medicine Advisers and Reviewers

3

HENNEPIN COUNTY MEDICAL CENTER / HENNEPIN FACULTY ASSOCIATES

1 992 Calendar of Medical Events

1 (Offered throughout the year)

CONTACT LASER LAPAROSCOPY CHOLECYSTECTOMY COURSE

Chairman: Richard Zera, MD

2 February 14, 1992

MINNESOTA DERMATOLOGICAL SOCIETY WINTER CONFERENCE

Chairman: Bruce Bart, MD

3 April 14, 1992

MINNESOTA REGIONAL SLEEP DISORDERS CENTER (MRSDC) ANNUAL DINNER LECTURE-DAVID DINGES, PHD

Sleep research related topic Chairman: Mark Mahowald, MD,

Minneapolis Athletic Club, Minneapolis

4 April 10, 1992

ANNUAL JOHN I. COE CONFERENCE "CURRENT CONCEPTS IN DERMATOPATHOLOGY”

Held in conjunction with MSCP April 11, 1991 annual meeting Chairman: Robert L. Strom, MD

5 April 24, 1992

ANNUAL PRACTICAL Gl CONFERENCE FOR PRIMARY CARE

Co-sponsored with St. Paul Ramsey Medical Center Co-Chairmen: Martin Freeman, MD/Robert Olson, MD

6 May 14-16, 1992

ACUPUNCTURE FOR PAIN CONTROL

Chairman: Miles Belgrade, MD

7 May 21-22, 1992

PRIMARY CA^E TREATMENT FOR PRESSURE SORES

Special afternoon tracks for physicians and nurses Chairman: George Peltier, MD

8 June 13, 1992

HCMC INTERN CLASS OF ‘61 MEDICAL REVIEW

Chairman: John Crosson, MD

9 June, 1992

CRISIS INTERVENTION PROGRAM

Chairman: Zigfrids Stelmachers, PhD

10 July 16-19, 1992

ADVANCES IN CLINICAL MANAGEMENT OF INFECTIOUS DISEASES

Co-Chairmen: Phillip Peterson, MD, HCMC/Dale Gerding, MD, VAMC Brainerd, Minnesota

1 1 Fall, 1992

NEUROLOGY CME AND ANNUAL A. B. BAKER DINNER LECTURE

Chairman: Milton Ettinger, MD; Location/Topics to be announced

12 Fall, 1992

PEDIATRIC HEAD INJURIES CONFERENCE

Co-Chairmen: David Fisher, MD/Thomas Rolewicz, MD

13 September, October, November, 1992

HEALTH CARE OBJECTIVES FOR THE YEAR 2000

A three part lecture series

Co-Chairmen: Charles Oberg, MD/Pam Thul-lmmler, RN

1 4 September 10-11, 1 992

APPLIED CLINICAL RESEARCH METHODS

Co-Chairmen: Nicole Lurie, MD/Alfred Pheley, PhD

1 5 September 1 8, 1 992

PAIN MANAGEMENT FOR THE PRIMARY CARE PHYSICIAN

Chairman: Miles Belgrade, MD

16 Seotember 18-20, 1992

ANNUAL AMBULANCE MEDICAL DIRECTOR RETREAT

Chairman: David Larson, MD; Brainerd, Minnesota

17 September 24-26, 1992

4TH INTERNATIONAL VAGINAL SURGERY PROGRAM

Chairman: Stephen Cruikshank, MD; Ritz Carlson, St. Louis, MO

1 8 September 24-25, 1 992

TRAUMA AND CRITICAL CARE CONFERENCE

Co-Chairmen: Brian Mahoney, MD/Arthur Ney, MD

19 October 1992 TEACHING THE MEDICAL INTERVIEW

Chairman: Gregory Silvis,MD

20 October 8-9, 1992 ANNUAL FORENSIC SCIENCE SEMINAR

Chairman: Garry Peterson, MD

21 October 9, 1992

ANNUAL CONTEMPORARY ISSUES IN DIALYSIS THERAPY

Chairman: Robert Berkseth, MD; Sheraton Midway Flotel, St. Paul

22 October 16, 1992

ANNUAL ADVANCES IN GERIATRIC CARE

Chairman: Patrick Irvine, MD

23 October 22-24, 1992

2nH ANNUAL ORTHOPAEDIC AND TRAUMA SEMINAR

Chairman: Ramon Gustilo, MD

24 November 5-6, 1992

MEDICAL INTENSIVE CARE CONFERENCE

Chairman: James Leatherman, MD

25 November 13-14, 1992 HUNTINGTON'S DISEASE:

PRACTICAL APPROACHES TO PATIENT AND FAMILY CARE

Chairman: Martha Nance, MD; Minneapolis Athletic Club

26 November 20-21, 1992

PRIMARY CARE UPDATE/SPORTS MEDICINE

Chairman: Patricia Cole, MD

27 Courses offered on a regular basis throughout the 1992 year by HCMC Emergency Medical Services. Call 612/347-5683 for more information

ACLS Provider Courses:

January 8, 9; April 8,10; July 8,10; October 7, 9 ATLS Provider Courses:

January 6,7; April 6,7; July 6,7; October 5, 6 Resuscitation Courses:

January 2-15; April 1-15; July 1-15; October 1-15

Courses are held at Hennepin County Medical Center unless otherwise noted

For more information regarding these courses contact

Hennepin County Medical Center

HCMC

Minnesota's Level X Trauma Center

HCMC/HFA Office of Academic Affairs 701 Park Avenue, Mail Code 867A Minneapolis, Minnesota 55415-1829 612/347-2075 facsimile 612/347-6155

P OFFICE OF ACADEMIC AFFAIRS

EDITOR'S NOTEBOOK

Confronting Bias in Health Care

Edmund C . Burke, M . D .

Undeniably, women have re- ceived inequitable medical care as compared with men. They have received inferior diagnoses and treatments, in large part, be- cause research on women’s health has been inadequate. The U.S. Public Health Service’s Task Force on Wom- en’s Health Issues reported in 1985 that a lack of research limits the understanding of women’s health needs. Similar conclusions have been appearing with increasing frequency in leading medical journals and the general media.

Still, in talking with some of my colleagues, I discovered that they are surprised by this bias. I believe their surprise may prove a point that we have historically assumed what is good for men is good for women. As a result, research on men is often mistakenly applied to women.

Researchers are reluctant to per- form studies on women of childbear- ing age for fear that the treatment or procedure might adversely affect re- productive capabilities or damage the fetus if the patient becomes preg- nant. Women have also been exclud- ed from research because of their hormonal cycles, which can affect therapeutic interventions. However, it is precisely because of these unpre- dictable hormonal effects that wom- en should be included in research.

Although biological factors ac- count for some differences in the provision of care for men and wom- en, studies indicate that nonbiologi- cal factors may also affect clinical decision making. In the July 25 Neiv England Journal of Medicine, two articles document evidence of sex bias in the management of coronary heart disease. In one study, women were half as likely as men to undergo cardiac catheterization. Is this bias due to stereotypes of men’s greater

“We have historically assumed what is good for men is good for women.”

societal value, as the AMA’s Council on Ethical and Judicial Affairs spec- ulates in the July 24 Journal of the American Medical Association} Whatever the factors, this health care gender gap is cause for concern. After studying the issue, the AMA council recommended that physicians examine their practices and attitudes for biases that might affect medical care; that research on women’s health be pursued; and that we work to increase the number of women phy- sicians in leadership roles, which would help to enhance the awareness of socio-cultural factors that lead to gender disparities.

In this month’s Face to Face in- terview (page 9), Doris Brooker, M.D., chair of the MMA’s Commit- tee on Women Physicians, shares her belief that organized medicine pro- vides a voice for women’s health issues. In fact, as our feature story (page 16) discusses, within medicine and without, women are becoming more politically active in efforts to ensure that their demand for equal medical treatment is heard.

Bernadine Healy, M.D., director of the National Institutes of Health, is another who believes it is time for a general awakening to the fact that women have unique medical prob- lems. In an editorial in the July 25 Neiu England Journal, she states that women have greater morbidity than men and are affected by more chron- ic debilitating illness. Although wom- en live longer, their quality of life may be burdened by breast cancer, lung and colon cancer, heart disease, stroke, osteoporosis, depression, and general frailty. She notes that the NIH has mounted a multi-disciplin- ary, multi-institute intervention study, called the Women’s Health Initiative, to address the major causes of death, disability, and frailty among middle- aged and older women. More than 140,000 women will participate in the $500 million study.

On a smaller scale, Minnesota has created a new task force to advise the commissioner of health on wom- en’s health issues. Dr. Brooker, who was instrumental in establishing the task force, describes its objectives more fully in her interview.

Individually, we can all work to improve health in our comiinunities. Internists I recently spoke with stressed the need for liealth care re- sponsibility. We should be very con- cerned, for example, that in spite of campaigns to eliminate smoking, a high percentage of young women still smoke, and we must strive to educate young people about the too-often deadly consequences down the road.

We must continually counsel against risk-taking activities. Drug and alcohol abuse, sexually trans- mitted diseases, and unwanted preg- nancy demand our utmost effort in teaching healthier lifestyles. mm

Minnesota Medicine

January 1992/Volume 75

5

ONiy ONE H, -ANTAGONIST HEALS REFLUX ESOPHAGITIS AT OUOOENAL ULCER DOSAGE. ONIY ONE.

Of all the H2-receptor antagonists, only Axid heals and relieves reflux esophagitis at its standard duodenal ulcer dosage Axid, 150 mg b.i.d., relieves heartburn in 86% of patients after one day and 93% after one week.

ACID lESlED. PATIENT PROVEN.

1. Data on file, Lilly Research Laboratories. See accompanying page for prescribing information. ei99i, ELI LILLY and company N2-2947-B-249304

Axm

nizatidine

150 mg b.i.d.

i

AXID’

nizatidine capsules

Brief Summary. Consult the package insert for complete prescribing information.

Indications and Usage: 1. Active duodenal ulcer - ' for up to 8 weeks of treatment at a dosage of 300 mg I h.s. or 150 mg b.i.d. Most patients heal within 4 weeks.

2. Maintenance therapy -tof healed duodenal ulcer I patients at a dosage of 150 mg h.s. at bedtime. The consequences of therapy with Axid for longer than 1

' year are not known.

3. Gastroesophageal reflux disease (GERD)-\oi up to 12 weeks of treatment of endoscopically diagnosed

I esophagitis, including erosive and ulcerative esophagitis, and associated heartburn at a dosage of 150 mg b.i.d.

Contraindication; Known hypersensitivity to the drug B^use cross sensitivity in this class of compounds has been observed. Hj-receptor antagonists, including Axid. should not be administered to patients with a history of hypersensitivity to other H^-receptor antagonists.

Precautions: General-^. Symptomatic response to nizatidine therapy does not preclude the presence of gastric malignancy.

2. Dosage should be reduced in patients with moderate to severe renal insufficiency

3. In patients with normal renal function and uncomplicated hepatic dysfunction, the disposition of nizatidine is similar to that in normal subjects.

Laboratory Tests-False-positive tests lor urobilinogen with Multistix' may occur during therapy

Drug Interactions-t^o Interactions have been observed with theophylline, chlordiazepoxide, lorazepam. Iidocaine, phenytoin, and warfarin. Axid does not inhibit the cytochrome P-450 enzyme system; therefore, drug interactions mediated by inhibition of hepatic metabolism are not expected to occur. In patients given very high doses (3.900 mg) of aspirin daily, increased serum salicylate levels were seen when nizatidine. 150 mg b.i.d.. was administered concurrently

Carcinogenesis. Mutagenesis. Impairment of Ferhlity-A 2-year oral carcinogenicity study in rats with doses as high as 500 mg/kg/day (about 80 times the recommended daily therapeutic dose) showed no evidence of a carcinogenic effect. There was a dose-related increase in the density of enterochromaffin-like (ECL) cells in the gastric oxyntic mucosa. In a 2-year study in mice, there was no evidence of a carcinogenic effect in male mice, although hyperplastic nodules of the liver were increased in the high-dose males as compared with placebo. Female mice given the high dose of Axid (2.000 mg/kg/day. about 330 times the human dose) showed marginally statistically significant increases in hepatic carcinoma and hepatic nodular hyperplasia with no numerical increase seen in any of the other dose groups.The rate of hepatic carcinoma in the high-dose animals was within the historical control limits seen for the strain of mice used. The female mice were given a dose larger than the maximum tolerated dose, as indicated by excessive (30%) weight decrement as compared with concurrent controls and evidence of mild liver injury (transaminase elevations). The occurrence of a marginal finding at high dose only in animats given an excessive and somewhat hepatotoxic dose, with no evidence of a carcinogenic effect in rats, male mice, and female mice (given up to 360 mg/kg/day. about 60 limes the human dose), and a negative mutagenicity battery are not considered evidence of a carcinogenic potential for Axid.

Axid was not mutagenic in a battery of tests performed to evaluate its potential genetic toxicity, including bacterial mutation tests, unscheduled DNA synthesis, sister chromatid exchange, mouse lymphoma assay, chromosome aberration tests, and a micronucleus test.

In a 2-generation. perinatal and postnatal fertility study in rats, doses of nizatidine up to 650 mg/kg/day produced no adverse effects on the reproductive performance of parental animals or their progeny.

Pregnancy-Teratogenic Effects -Pregnancy Category C-Oral reproduction studies in rats at doses up to 300 times the human dose and in Dutch Belted rabbits at doses up to 55 times the human dose revealed no evidence of impaired fertility or teratogenic effect; but. at a dose equivalent to 300 times the human dose, treated rabbits had abortions, decreased number of live fetuses, and depressed fetal weights. On intravenous administration to pregnant New Zealand White rabbits, nizatidine at 20 mg/kg produced cardiac enlargement, coarctation of the aortic arch, and cutaneous edema in 1 fetus, and at 50 mg/kg, it produced ventricular anomaly, distended abdomen, spina bifida, hydrocephaly, and enlarged heart in 1 fetus. There are. however, no adequate and well-controlled studies in pregnant women. It is also not known whether nizatidine can cause fetal harm when administered to a pregnant woman or can affect reproduction capacity. Nizatidine should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Nursing Mothers -S\.u6\es in lactating women have shown that 0.1% of an oral dose Is secreted in human milk in proportion to plasma concentrations. Because of growth depression in pups reared by treated lactating rats, a decision should be made whether to discontinue nursing or the drug, taking into account the importance of the drug to the mother.

Pediatric t/se-Safety and effectiveness in children have not been established.

Use in Elderly Patients -HeaUng rates in elderly patients were similar to those in younger age groups as were the rates of adverse events and laboratory lest abnormalities. Age alone may not be an important factor in the disposition of nizatidine. Elderly patients may have reduced renal function.

Adverse Reactions; Worldwide, controlled clinical trials included over 6.000 patients given nizatidine in studies of varying durations. Placebo- controlled trials in the United States and Canada included over 2,600 patients given nizatidine and over 1 ,700 given placebo. Among the adverse events in these placebo-controlled Inals, only anemia (0.2% vs 0%) and urticaria (0.5% vs 0.1%) were significantly more common in the nizatidine group. Of the adverse events that occurred at a frequency of 1% or more, there was no statistically significant difference between Axid and placebo in the incidence of any of these events (see package insert for complete information)

A variety of less common events were also reported, it was not possible to determine whether these were caused by nizatidine.

Wepaf/c-Hepatocellular injury (elevated liver enzyme tests or alkaline phosphatase) possibly or probably related to nizatidine occurred in some patients. In some cases, there was marked elevation (>500 lU/L) in SGOT or SGPT and. in a single instance, SGPT was >2.000 lU/L The incidence of elevated liver enzymes overall and elevations of up to 3 times the upper limit of normal, however, did not significantly differ from that in placebo patients. All abnormalities were reversible after discontinuation of Axid. Since market introduction, hepatitis and jaundice have been reported. Rare cases of cholestatic or mixed hepatocellular and cholestatic injury with jaundice have been reported with reversal of the abnormalities after discontinuation of Axid.

Cardiovascular-\n clinical pharmacology studies, short episodes of asymptomatic ventricular tachycardia occurred in 2 individuals administered Axid and in 3 untreated subjects.

C/VS- Rare cases of reversible mental confusion have been reported.

Endocrine-C\in\c2\ pharmacology studies and controlled clinical trials showed no evidence of anti- androgenic activity due to nizatidine. Impotence and decreased libido were reported with similar frequency by patients on nizatidine and those on placebo. Gynecomastia has been reported rarely.

Hemafo/og/c- Anemia was reported significantly more frequently in nizatidine than in placebo-treated patients. Fatal thrombocytopenia was reported in a patient treated with nizatidine and another H^-receptor antagonisl This patient had previously experienced thrombocytopenia while taking other drugs. Rare cases of thrombocytopenic purpura have been reported.

/nfegumenfa/- Urticaria was reported significantly more frequently in nizatidine- than in placebo-treated patients. Rash and exfoliative dermatitis were also reported.

Hypersensitivity- As with other H2-receptor antagonists, rare cases of anaphylaxis following nizatidine administration have been reported. Rare episodes of hypersensitivity reactions (eg, bronchospasm, laryngeal edema, rash, and eosinophilia) have been reported.

O/her- Hyperuricemia unassociated with gout or nephrolithiasis was reported. Eosinophilia. fever, and nausea related to nizatidine have been reported.

Overdosage: Overdoses of Axid have been reported rarely. If overdosage occurs, activated charcoal, emesis, or lavage should be considered along with clinical monitoring and supportive therapy. The ability of hemodialysis to remove nizatidine from the body has not been conclusively demonstrated: however, due to its large volume of distribution, nizatidine is not expected to be efficiently removed from the body by this method, PV 2093 AMP (1015911

Additional information available to the profession on reguest Eli Lilly and Company Indianapolis, Indiana 46285

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A Powerful Voice for Women’s Health

Minnesota Medicine interviews Doris C . B r o o k e r , M . D .

Women are increasingly demanding equal treat- ment in the doctor’s office. They are joining physicians, researchers, and others in calling attention to women ’s health issues and the need for more research on such illnesses as breast cancer and cardiovascular disease.

Recent studies document that not only is research on women’s health lagging behind that on men’s health, but, in some instances, women’s medical complaints are taken less seriously than men ’s, even when their symptoms are similar. Additionally, women tend to receive less intensive medical care than men do. For exam- ple, women are also half as likely as men to undergo cardiac catheteriza- tion and less likely to undergo bypass surgery or balloon angioplasty.

Doris Brooker, M.D., an obigyn pathologist specializing in women’s health at the University of Minneso- ta, is working to improve women’s health in the state. Dr. Brooker, the governor’s staff, and Commissioner of Health Marlene Marschall have created a women’s health task force to advise the health commissioner.

The goals of this bipartisan task force will be to consider women ’s health problems, set priorities, and recoinmend solutions for the state. Education and information dis- semination are key components of the initiative.

Dr. Brooker, who is also chair of the Minnesota Medical Association’s Committee on Women Physi- cians, believes that participation in organized medicine provides a powerful voice for women’s health issues. In this month ’s interview, she says the MM A led the way for the American Medical Association and other groups when it formed the Committee on Women Physicians in the early 1 980s. Women are now involved in organized medicine in all areas of the state and in every specialty, according to Dr. Brooker, who emphasizes the leader- ship role Minnesota women physicians have played in the AMA, as well as more locally.

Dr. Brooker believes we must strive for equality in women’s health care hut says we should avoid getting caught up in negative images of the past. Women ’s health has come a long way in recent years, and it’s important that we continue moving forward, she says.

Doris C. Brooker, M.D

‘Let’s move ahead and make things happen equally.”

Minnesota Medicine: Dr. Brooker, let’s start with your background. Where did you go to medical school, where did you do your residency training, and how did you end up in your current position?

Brooker: I am from Milwaukee, Wis- consin, and I went to the Marquette University School of Medicine. I did my residency training in pathology in a Harvard program, and I did a post- doctoral fellowship at Johns Hopkins University in the ob/gyn department. My last training was in clinical pathology here at the Univer- sity of Minnesota, where I accepted a position in 1 975 and now have a joint appointment in the Department of Laboratory Medicine and Pathology and the Department of Ob/Gyn. I am a pathologist specializing in women’s health. My research currently focuses on quality assurance in obstetrics and women’s cancer and on infectious disease in ob/gyn.

Organized Medicine’s Voice

Minnesota Medicine: You are chair of the Minnesota Medical Associa- tion’s Committee on Women Physicians. Tell us a little about the committee.

Brooker: I have been part of that committee intermit- tently for the past 1 0 years. The MMA led the way for the American Medical Association and other groups in allowing those of us who are interested in women’s issues to express ourselves through organized medicine. The committee was formed in the early 1980s. The Minneso- ta Medical Association is our voice on women’s issues in all areas of medicine, including such issues as pregnancy and maternity leave, violence and abuse, and research on women’s health. We’ve been lucky in Minnesota that we’ve had a voice and we’ve been listened to. I encourage women physicians to get involved. 1 realize young men’s and young women’s lives are very busy many women physicians have several different roles and a lot of time constraints but if they choose to get involved, there is ample opportunity in this medical association. It is critical that we all be involved, even in a limited role.

Minnesota Medicine: As a member of the American

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Academy of Pediatrics, I know that half of all pediatric residents are currently women. The AAP’s membership is now about one-third women, and the last president was a woman. How involved are women in Minnesota’s medical societies.^

Brooker: We now have four women physicians who are presidents of local medical societies in Minnesota and three or four who are officers. There are about 2,200 women physicians in .Minnesota, including about 1,200 in Hennepin and Ramsey counties, 100 in Twin Cities suburbs, 350 in Olmsted County, and 50 in St. Louis County. The other appro.ximately 450 are in Greater Minnesota, so women are represented in every area of the state and in every specialty. About half the state’s women physicians are involved in organized medicine. Women physicians are increasingly branching off into areas other than psychiatry, pediatrics, and oh/gyn the specialties that have traditionally attracted women phy- sicians. We are particularly proud of the contributions of Dr. Peggy Craig, the first woman president of the MMA and now a University of Minnesota regent, and Dr. Audrey Nelson, who is on the Mayo Clinic board and is a long-time AMA delegate.

Minnesota Medicine: Do you think greater numbers of women physicians will improve women’s health general- ly and increase the attention paid to women’s health issues?

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Brooker: I would like to believe that men and women physicians complement each other in their care of wom- en. Women’s health issues are nor exclusively the respon- sibility of women physicians. In Minnesota, some of the foremost women’s health advocates are men. A good example of women’s health advocacy is Gov. Arne Carlson’s public statement in August that violence against women is an issue society as a whole must address in attitude and dialogue.

New State Task Force on Women’s Health

Minnesota Medicine: You have been involved in a state effort to draw attention to women’s health issues. What can you tell us about this effort?

Brooker: As you know, health care reform has emerged as an important issue in Minnesota and elsewhere. I have joined many others in suggesting ways of making health care more accessible and cost effective. Last summer, the governor’s staff expressed a strong interest in forming a women’s health advisory task force. This is now a reality. An advisory task force to the commissioner of health will be created to consider women’s health issues and recommend solutions. The advisory group will be composed of physicians and other health professionals who daily listen to the problems of women. It will be a unique voice for women in Minnesota. The core group will be women in medicine, including physicians, nurses, technologists, physical therapists, psychologists, mid- wives, and nurse clinicians. Interest in, experience with, and knowledge of the issues and how to solve them will be the factors used to choose the task force members. We don’t want to make the group e.xclusive to health care providers; a great number of other women professionals will be part of this task force legislative, judicial, managed care, and business representatives, for exam- ple. In fact, the women’s health task force will include men. The National Women’s Political Gaucus has been successful, and it has many male advocates from Con- gress. Women exclusively providing women’s health is not the focus we want.

Improving access to health care and the quality of care for women patients is the priority of this group. Consumers women patients will have the most im- portant voice in this task force. I know of no better way to ensure success in this effort than to empower women with knowledge about health issues important to them. This is my bias as an educator and teacher.

An Assessment of Women’s Health As Compared with Men’s

Minnesota Medicine: Women’s health has been the fo- cus of many medical articles lately in such journals as I AMA and The Neti’ England Journal of Medicine. How has women’s health changed in recent years?

Brooker: In the past few decades, women’s health has changed dramatically. We’ve seen, for example, signifi- cant improvements in cancer survival, fertility, and

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survival rates of mothers and neonates since 1940. Hormone therapy is one example of how women’s health has changed in terms of medical treatment. Wom- en were taught 20 years ago that estrogen and hormone therapy might he dangerous and cancer producing, so use was limited. Today, we have more data showing that, in fact, cardiovascular disease is a much more likely cause of death for women than breast cancer or endome- trial cancer. We can now screen women’s risk status and watch for complications from hormonal therapy, which is absolutely necessary for preventing osteoporosis and maintaining cardiovascular health. Women deserve the physical and psychological benefits of hormone- replacement therapy.

Minnesota Medicine: A number of other recent articles have discussed gender disparities in health care. One in particular talks about differences in procedures used for women and men hospitalized for coronary artery dis- ease. I think it comes as a shock to a lot of physicians that they may not have taken care of women as well as they’ve taken care of men. How do you feel about this?

Brooker: Awareness of gender dis- parities in medicine started with the National Women’s Political Caucus about five or six years ago. That group generated significant interest in the issue. The National Cancer Institute, the National Institutes of Health, and the Institute of Medicine followed with important informa- tion about discrepancies in research and funding of women’s health con- cerns, such as breast cancer. It has also become clear that we need to include women in studies of cardio- vascular disease. We need more re- search on which hormonal medications and what combinations will help prevent cardiac disease in women while presenting the least risk of cancer. Men certainly have a preponderance of morbidity and mortality from this disease, but as women age and lose estrogen, they lose protection and their risk becomes greater.

Medicine evolves as issues evolve. I think it’s helpful to look at the past, but I don’t want to compromise our future by criticizing the past. What’s important is to develop a bank of information from credible research evaluations. There has already been a lot of progress in women’s health; however, I don’t want to de-emphasize the fact that there have been inequities in women’s health as compared with men’s. We must learn from the past, but let’s move ahead and make things happen and happen equally.

Women, Children, and AIDS

Minnesota Medicine: AIDS is another illness more typ- ically associated with men, but it’s becoming a signifi- cant issue for women. By the year 2000, the number of women with AIDS worldwide is expected to equal that

of men. Do you have any comments on this?

Brooker: By December 1, 1991, 1 63 women in Minneso- ta had been recognized as HIV seropositive; 40 of them actually had the disease. The university’s ob/gyn depart- ment has just organized a task force to address some of the problems faced by these women and develop a strategy to assist Minnesota physicians who are treating women with AIDS. These women have a greater risk for cancer, for pregnancy loss, and for many other problems, and it is our responsibility to provide quality care and education about prevention of this disease.

Minnesota Medicine: AIDS among teenagers is also a serious concern. What can physicians do about the problem?

Brooker: I believe young men and women are very open to information from physicians and other adults, as well as their peers. It’s important