Health bulletin

              UNC-CH HEALTH SCIENCES LIBRARY
H00338139R
HEALTH SCIENCES LIBRARY
OF THE
UNIVERSITY OF NORTH CAROLINA
AT CHAPEL HILL
January, 1973 NXO>
The
Health Bulletin
The Official Publication of The North Carolina State Board of Health
N. C. STATE BOARD OF HEALTH
BOARD MEMBERS
James S. Raper, M.D., President
Asheville
Paul F. Maness, M.D., Vice President
Burlington
Ernest A. Randleman, Jr., B.S.Ph.
Mount Airy
Jesse H. Meredith, M.D.
Winston-Salem
Joseph S. Hiatt, Jr., M.D.
Southern Pines
Charles T. Barker, D.D.S.
New Bern
Lenox D. Baker, M.D.
Durham
Donald W. Lackey, D.V.M.
Lenoir
Robert B. Nichols, Jr., B.S.
Hillsborough
CHIEF EXECUTIVE OFFICER
Jacob Koomen, M.D., M.P.H.
State Health Director
EXECUTIVE STAFF
W. Burns Jones, M.D., M.P.H.
Asst. State Health Director
Marshall Staton, B.C.E., M.S.S.E.
Sanitary Engineering
Martin P. Hines, D.V.M., M.P.H.
Epidemiology
Ronald H. Levine, M.D., M.P.H.
Community Health
E. A. Pearson, D.D.S., M.P.H.
Dental Health
Lynn G. Maddry, Ph.D., M.S.P.H.
Laboratory
Ben Eaton, Jr., A.B., LL.B.
Administrative Services
Theodore D. Scurletis, M.D., M.P.H.
Personal Health
R. Page Hudson, M.D.
Medical Examiner
EDITORIAL BOARD
W. Burns Jones, M.D.
Ben Eaton, A.B., LL.B.
J. N. MacCormack, M.D.
THE HEALTH BULLETIN
Editor
Clay Williams
Associate Editor
Mary W. Cunningham
Volume 88 January, 1973 Number!
First Published — April 1886
The official publication of the North Carolina
State Board of Health, 106 Cooper Memorial
Health Building, 225 North McDowell Street,
Raleigh, N. C. Mailing address: Post Office
Box 2091, Raleigh, N. C. 27602. Published
monthly. Second Class Postage paid at Ra-leigh,
N. C. Sent free upon request.
IN THIS ISSUE
Shot Follow-up Stressed 3
Strange Pain . . . UNC
Establishes Clinic 4
Public Health in North
Carolina 8
Gallstones: New Method of
Treatment 10
On the Cover
Dr. John Gregg examines sen-sory
nerves of a patient with
facial pain. The examination is
part of an in-depth neurologic
examination that each patient
is given upon entering the pain
clinic. Purpose is to determine
if there are neurologic disorders
that might be contributing to
the pain problem. Other tests
include electromyography
,
nerve conduction studies and
electroencephalography.
THE HEALTH BULLETIN January, 1973
COMMENT
Shot Follow-up Stressed
By
John Irvin
Coordinator
Immunization Program
Irvin
DATA from a recent immunization level survey indicate that only
38 percent of North Carolina's two-year olds have completed a
minimal basic immunization series, i.e. three or more doses of
DTP and oral polio vaccines and vaccination against measles and
rubella. One-fifth of the two-year olds had less than three DTP shots,
and one-third had less than three doses of oral polio vaccine. One-third
were unvaccinated against measles; one-half had not had rubella
vaccine. Private medicine and local health departments provided im-munizations
to an almost equal number of children, and only five per-cent
of the surveyed population had had no immunizations of any
kind. Why did 95 percent of the two-year olds begin immunizations
while only 38 percent completed a relaxed basic immunization series?
I believe it was largely attributed to the lack of a systematic and
flexible approach to serving the patients. First, the child must be
kept in the immunization system. Keeping him there requires record
keeping and appropriate follow-through at the local health department
and private physician level. Secondly, private and public medicine
must be flexible and take advantage of every immunization oppor-tunity.
New immunization recommendations now permit the simul-taneous
use of DTP, oral polio, measles and rubella vaccines in children
over 12 months of age. Proper utilization of this new option should in
itself greatly reduce the number of underimmunized children.
January, 1973 THE HEALTH BULLETIN 3
Strange Pain . . . UNC Establishes Clinic
FOR over a year the 62-year-old
woman had suffered periodic
episodes of tortuous pain in
her lower jaw. The episodes,
which lasted as long as 20 minutes
at a time, left her exhausted, and
more than a little confused as to
the reason for such excruciating
pain.
The pain began as something
resembling a dull toothache. Later,
it progressed to sharp, stabbing
pain that could be induced by the
slightest touch. A gentle breeze,
even the touch of food on the lips
would cause intense pain. Finally,
she was referred to the newly or-ganized
pain clinic at the Dental
Research Center, a part of the
UNC Medical Complex, Chapel
Hill. The clinic is made up of a
group of doctors who are examin-ing,
studying, discussing and
treating patients with pain prob-lems
on a team basis.
A physical examination reveal-ed
diabetes and high blood pres-sure.
In fact, according to Dr.
John M. Gregg, an investigator at
the Dental Research Center, who
sparked development of the pain
clinic, the patient's physical con-dition
had deteriorated to the
point where surgery had to be rul-ed
out as a means of providing re-lief.
Next, an attempt was made to
locate the actual source that was
triggering the pain, which gener-ally
appeared on a two-week cycle.
After a complete physical exami-nation,
findings were presented to
members of the clinic staff
—
which includes specialists from
the departments of neurosurgery,
anesthesiology, psychiatry, inter-nal
medicine, pharmacology, phy-siology,
occupational and physical
therapy, as well as the School of
Dentistry. The diagnosis was tic
douloureux, a syndrome which
causes acute pain of the facial
nerves.
The patient was placed on an
anti-convulsive drug which had
the effect of dampening the stab-bing
pain. Dr. Gregg pointed out
that it took a while for the patient
to adjust to the drug, but she has
now been comfortable for nearly
three months. "She is receiving
supportive psychological care be-cause
of the emotional trauma she
has experienced. The corps of doc-tors
will reevaluate her case in the
near future to determine if the
prescribed treatment is good for
THE HEALTH BULLETIN January, 1973
the long run," he said.
Dr. Gregg explained that al-though
pain is a phenomenon that
occurs in all parts of the body,
many kinds of bizarre and chronic
pains appear in the jaw and face
region. The incidence of pain in
the jaw and face may be higher
than for any other region of the
body of comparable size. "Perhaps
the reason why is because there is
periodically so much disease: in
the jaw associated with teeth, the
throat associated with tonsils and
face associated with sinus tissues,"
he said.
Many authorities feel that pain
or the anxiety concerning pain is
the greatest single deterrent to
proper oral health care. Dr. Gregg
contends that because of painful
experiences early in life, patients
often avoid seeking the kinds of
routine treatment, such as dental
infection control, that ironically
could prevent the more severely
painful conditions that result from
neglect. "The actual performance
of even routine treatment activi-ties
such as dental extractions,
dental restorations and periodont-al
therapy can be made more dif-ficult
or in some cases impossible
when the dentist is unable to con-trol
the pain or the pain-anxiety of
his patients.
"Chronic pain of the jaw and
face that results from disease of
nerve tissues is another aspect of
the health problem," Dr. Gregg
continued. "These disease condi-tions
do not appear as one uni-form,
recognizable type of pain.
Symptoms may be mild and of a
burning or itching quality that is
felt at the skin or membrane sur-faces,
or pain may be felt deep
within muscles or within the bony
tissue.
"Patients may find the pain
strange in sensation such as a
crawling, drawing or buzzing feel-ing.
The pain may be constant and
appear without warning, or at the
other extreme it may appear in
instantaneous stabbing and shock-ing
spasms that are brought on by
simply touching the face. These
last types of symptoms are char-acteristic
of a form of trigeminal
neuralgia (tic douloureux) which
is known to be one of the most
severe forms of pain known to
mankind," he said.
The oral surgeon ventured that
pain cannot be removed from emo-tion.
"In the susceptible personal-ity,
the person who is dependent
and somewhat depressed, a chron-ic
pain is more likely to have a
negative effect. Because of the
very basic nature of pain itself
with its obnoxious and fear-pro-ducing
qualities, there are gradual
rises in the anxiety levels of pa-tients
as the pain persists. As a
matter of fact, this psychiatric
component may eventually come
to outweigh in importance the un-derlying
basic pain sensation."
What are the causes of pain in
the facial region? "Acute neuritis
(inflammation of nerves) may
arise from a great variety of les-ions
in the area including infec-tion,
tumors, direct injuries, and
other visible reactions. In other
cases chronic facial pain may re-
January, 1973 THE HEALTH BULLETIN
DR. JOSE GHIA . . . anesthesiologist, performs a nerve block on a patient with a pain
problem. The procedure is used both to aid in diagnosis of the specific problem and
also to bring immediate relief of severe pain problems that might arise from sources
such as pinching of nerve roots and from poorly controlled cancer in various body
regions.
suit from systemic disease condi-tions.
For example, a number of
the metabolic diseases states such
as diabetes mellitus or pernicious
anemia may cause chronic and
often bizarre burning sensations
in the facial tissues. Disease and
aging processes in the blood ves-sels
themselves can starve the tis-sues
of oxygen and cause pain on
this basis alone. Temporal arter-itis
(inflammation of the arteries
in the temple) is an example of a
condition in which the entire side
of the face may be exquisitely
painful because of thickening and
inelasticity in the blood vessel
walls.
"Perhaps the greatest source of
persisting pain conditions in the
facial region is trauma or injury
itself. When the sensory nerves
are damaged either due to acci-dental
facial fractures, through
cutting during necessary surgery,
the nerve tissue may react by de-generating.
Unfortunately, nerves
have the least ability to repair
themselves of all the body tissue.
The regenerated nerves often do
not function as they once did. Most
of the post-traumatic pains are
only mildly aggravating and of a
burning or itching character.
"New patient services and treat-ments,
research and education are
the general areas in which pain
problems are being attacked," Dr.
THE HEALTH BULLETIN January, 1973
Gregg stated. "A number of new
drug therapies are available. Acute
types of pain associated with med-ical
or dental care are beginning
to be controlled by new combina-tions
of systemic drugs that can
simultaneously sedate and calm
the anxietous patient, raise the
pain threshold to give pain relief,
permit necessary uncomfortable
treatments, and at the same time
provide better safety for the vital
functions of the heart, lungs and
brain.
"These treatments are opening
up new avenues for the manage-ment
of extremely anxietous or
psychotic individuals as well as
the unmanageable pediatric or
mentally retarded patients. Many
of the newer techniques involve
the use of 'dissociative' drug tech-niques,
where the patient remains
semi-conscious but has been plac-ed
in a detached or 'trance-like'
state by the drug."
Dr. Gregg noted that another
type of drug therapy that has now
gained wide acceptance is the use
of anti-convulsive drugs to control
the severe stabbing pains of trige-minal
neuralgia. "Although anti-convulsive
drugs are giving en-couraging
results with most kinds
of facial pain, ironically, there ap-pears
to be little effectiveness for
the milder forms of pain that are
seen more frequently in the facial
region.
"Surgical approaches are being
combined with physiological tech-niques
for inhibiting the transmis-sion
of pain. Hypnosis is being
used as an effective technique for
controlling milder and chronic
forms of pain. Acupuncture has
also proven effective in relieving
patient pain, although the basis
for its effectiveness is not yet
clear."
Perhaps the most promising in-novation
in patient services in the
treatment of pain is the develop-ment
of the team approach. Dr.
Gregg, acting as spokesman for the
UNC team of specialists, cited re-lieving
pain as the team's primary
objective. "We hope to do this by
serving as a source of information
to physicians and dentists over
the state who have to care for dif-ficult
pain problems. The day may
come when computer assistance
might help to transfer knowledge
and assistance about pain prob-lems
to dentists and physicians in
outlying areas that are not acces-sible
to the major treatment cen-ters.
Too, through the team ap-proach
it is probable that research
projects will come forward that
will make clear the mechanisms
behind pain problems, along with
logical solutions to these prob-lems,"
he said.
The research program relating
to pain at the Dental Research
Center at UNC is part of a nation-al
effort sponsored by the National
Institute of Dental Research.
Facial pain has also been singled
out as a principal area for research
by Dr. Seymour Kreshover, direc-tor
of NIDR, for the 1970's. Be-ginning
with the 1972 school year,
the subject of pain is now taught
all four years at the UNC School
of Dentistry.
January, 1973 THE HEALTH BULLETIN
Public Health
In
North Carolina
The completion of the North
Carolina nutrition survey and en-suing
recommendations from a
nutrition task force have been
cited as one of the major public
health accomplishments of recent
years by Dr. Jacob Koomen, State
Health Director.
The nutrition survey revealed
that 43 percent of preschool chil-dren
in North Carolina have in-adequate
diets, a factor which is
frequently related to impaired
growth and brain development,
according to Dr. Koomen. Based
on survey findings, one of the
State Board of Health's primary
budget requests for the coming
biennium will be for funds to ex-pand
nutrition education.
With the coming of a new year,
Dr. Koomen recapped public
health highlights of the past year
and spoke optimistically about
objectives which the agency has
set for itself as it begins its 96th
year of service to citizens of the
state.
In the area of dental health,
Dr. Koomen pointed out that the
agency's Dental Health Division
has gained national attention for
its program of plaque control, a
technique involving flossing the
teeth which research has shown
can prevent dental disease.
Through an innovative education-al
approach, dentists and dental
technicians across the state have
been taught the flossing technique.
The plaque control program is be-ing
brought to all age groups
(adults and school children). Un-til
this program was begun, pre-ventive
dentistry efforts were pri-marily
aimed at school children.
Additional funding has been re-quested
in this area also for con-tinuation
and expansion of the
program.
Other accomplishments of 1972
include:
• Development of a kidney di-alysis
and transplant program.
• The state laboratory handled
over a million specimens, an all-time
high.
• Training of approximately 1,-
800 ambulance attendants.
• The State Board of Health as-sisted
each of the state's 100 coun-ties
in developing a county-wide
solid waste management program.
• Last year, 125 open trash
dumps were closed and 56 sanitary
landfills became operational in
compliance with State Board of
Health rules and regulations.
• Appropriate arrangements are
being made for dispersal of $70
million in state funds to local gov-ernments
for development of safe
water systems under the water
supply grants program.
• Approximately a half-million
doses each of measles vaccine and
rubella (German measles) vaccine
have been supplied and/or ad-ministered
by the immunization
program.
8 THE HEALTH BULLETIN January, 1973
Ben Eaton, Director of Administrative Services of the N. C. State Board of Health,
Dr. Jacob Koomen, State Health Director, and Dr. Burns Jones, Assistant State Health
Director, discuss programs and activities for the State Board of Health for 1973.
• A statewide gonorrhea pro-gram
has been launched to find
and treat people with gonorrhea
and their contacts.
The accomplishments of 1972
are already history, Dr. Koomen
observed. "Health challenges of
1973 promise to be equally excit-ing.
With the General Assembly
in session this year, we anticipate
adoption of new public health leg-islation
which we are currently
preparing in conjunction with the
Department of Human Resources.
We are looking forward to reports
of several health-related legisla-tive
study commissions, in par-ticular
the ones on delivery of
local public health services and
emergency medical care. We will
also be seeing the impact of con-siderable
federal legislation cover-ing
the entire health field, but
most intensively related to the
state's function in Medicare and
Medicaid," he said.
"Some of our plans for the com-ing
year depend on how the legis-lature
apportions funds. Our most
pressing needs budget-wise for the
coming biennium are funds to in-crease
the number of ambulance
attendants being trained, funds to
expand the services of the Medical
Examiner System, and to improve
certain elements of sanitation. We
have also requested additional
money to strengthen county health
departments. We are hopeful that
the General Assembly will grant
funds for these much needed pro-gram
increases," Dr. Koomen
said.
"The coming year should indeed
be an exciting one for public
health as the State Board of
Health continues its efforts to pro-vide
innovative and high quality
public health services to North
Carolinians," he concluded.
January, 1973 THE HEALTH BULLETIN
GALLSTONES: New Method of Treatment
EACH year the gallbladder, one
of the body's smallest organs
and one which the body does
not even need to survive, is re-sponsible
for the expenditure of
approximately one billion dollars
for medical and surgical treatment
of gallstones. Health statistics re-veal
that close to 500,000 Amer-icans
have their gallstones remov-ed
each year, with the illness and
recovery period causing each of
them to be out of work up to a
month or longer.
Although the number of deaths
caused by gallstones is relatively
low (only 35 in North Carolina in
1971), the large number of peo-ple
affected and the resulting high
costs in terms of medical expenses
and temporary disability, merit
the interest and concern of med-ical
professionals and the consum-ers
of medical services.
Gallbladder diseases are not
selective in their victims. Even
presidents are not exempt. Lyndon
Baines Johnson ha«^ his gallblad-der
removed during his stay in the
White House. Just as a person is
susceptible to an acute appendi-citis,
anyone can have acute chole-cystitis
(inflamed gallbladder).
Any human being can develop
gallstones, although the incidence
of gallstones appears to be higher
in females and Indians.
The gallbladder is about the
size of a small lemon. It is located
on the right side of the body, on
the undersurface of the liver. Its
function is to store bile which is
produced by the liver. Bile (made
up primarily of bile salts and
cholesterol) is a bitter fluid, vary-ing
in color from golden brown to
greenish yellow. When food enters
the upper part of the digestive
tract, the gallbladder contracts
and empties bile into the first part
of the small intestine under the in-fluence
of the hormone cholecys-tokinin.
Bile combines with fatty
foods and the fat soluble vitamins
(A, D, K, and E) so that the in-testine
can absorb their nutrients
and refuel the body's energy sup-ply-
The most prevalent gallbaldder
disorder is gallstones (cholelithi-
10 THE HEALTH BULLETIN January, 1973
ADMISSION 5 DAYS OF HEPARIN
AT THE UNC SCHOOL OF MEDICINE, research is currently being conducted to deter-mine
the possibilities of dissolving gallstones in the hepatic and common bile ducts by
using the anti-clotting drug heparin. These X-rays show results of the heparin-drip
technique on a patient who had three stones in the common bile duct. On admission,
three stones were visible. Five days after being treated with heparin, one stone was
dissolved. Eight days later only one stone remained. Treatment was continued for 11
days when X-rays revealed all three stones had disappeared. (See p. 13 for final results.)
asis), according to Dr. Eugene
Bozymski, gastroenterologist at
the University of North Carolina
School of Medicine. He estimated
that as many as 16 million Amer-icans
have gallstones.
Dr. Bozymski said that the exact
cause of gallstones is not known.
"However, one of the main theo-ries
is that there is a chemically
abnormal bile excreted by the
liver which is then stored in the
gallbladder. In some people, the
concentration of bile salts decreas-es
relatively to the increasing con-centration
of cholesterol. This
causes cholesterol seed crystals to
form. Around these crystals,
stones develop and grow. Most
gallstones are cholesterol stones.
The role of infection in the de-velopment
of gallstones remains
to be clarified."
The size of gallstones varies
from patient to patient, he said,
with some stones as big as the
gallbladder itself and others just
barely visible. The number of
January, 1973 THE HEALTH BULLETIN 11
stones found in a gallbladder also
varies from one to dozens.
Gallstones primarily occur in
middle-aged people, in the 40's and
50's. Approximately three times as
many women as men have gall-stones,
although medical science
has not yet been able to answer
why. It is not known whether gall-stone
formation is due to constitu-tional
makeup or genetic factors.
For many years medical students
were taught to suspect gallstones
among women who were "fair, fat,
forty, and fertile;" or in other
words, women who were light-skinned,
obese, middle-aged and
the mother of several children. Dr.
Bozymski indicated, however, that
in light of recent findings, the
"four F's" are no longer depend-able
in diagnosing gallstones. He
explained that research among the
Pima Indians in Arizona revealed
that 70 percent of the females of
the dark skinned tribe had gall-stones
by their 30th birthday and
the same percentage of Pima In-dian
males developed gallstones,
but later in life. Research findings
also discounted the relationship of
motherhood and obesity to the for-mation
of gallstones. To date, re-search
has not established any re-lationship
between diet and for-mation
of gallstones.
Of the 16 million Americans
who have gallstones, probably
two-thirds are not aware that they
have them, Dr. Bozymski noted.
"These people have what we call
silent gallstones, with no pain or
discomfort caused by the presence
of stones in the gallbladder. Gall-stones
cause symptoms and be-come
a health hazard when they
get firmly lodged into a position
at the neck of the gallbladder or
in the common bile duct, blocking
the duct and often causing the
gallbladder to become inflamed.
The liver continues to produce
bile, but with the ducts blocked,
the bile has no place to go *but
back into the liver and then into
the blood. With this type of ob-struction,
a person's skin often
takes on a yellowish, or jaundiced,
appearance."
Dr. Bozysmki said that other
symptoms of gallbladder obstruc-tion
include cramping pain in the
right upper side, fever and chills,
nausea and vomiting. Itching may
occur in long-standing obstruction
because of increased concentration
of bile salts in the skin.
Dr. Bozymski said many victims
of gallbladder obstruction think
they are having a heart attack. Be-fore
making a diagnosis of gall-bladder
disease, the physician
must rule out the possibility of
heart disease, peptic ulcer disease,
pancreatitis (inflamed pancreas)
and small bowel obstruction, all of
which may cause similar symp-toms.
In making the diagnosis, the
physician takes a complete clinical
history, gives the patient a thor-ough
physical examination along
with a battery of chemical tests
for liver function as well as X-rays
of the gallbladder. Dr. Bozym-ski
said the physical examination
often reveals extreme tenderness
in the patient's right side.
12 THE HEALTH BULLETIN January, 1973
8 DAYS OF HEPARIN II DAYS OF HEPARIN
Surgical removal of the gall-bladder
is the primary means of
treating gallstones with associated
inflammation, according to Dr.
Bozymski. Once the diagnosis of
inflammation of the gallbladder is
established, the surgeon may
choose to remove the gallbladder,
or as Dr. Bozymski prefers, treat
the immediate problem by decom-pressing
the gastrointestinal tract.
This is done by giving the patient
no nourishment by mouth and
suctioning the stomach. Antibiot-ics
are often given along with
pain medication. Then, he usually
recommends that the patient have
elective surgery after a few
months.
Dr. Bozymski points out that
after the pain is relieved and the
acute attack subsides, this does
not mean that the patient is well
and can forget his gallstones. It is
merely temporary relief. The
stones are still there and attacks
will probably continue, with each
attack compounding the problem
and possibly leading to permanent
liver damage. Also, Dr. Bozymski
stressed, if the patient continues
putting off the operation, another
attack may come at a time when
increased age or another health
problem may make surgery a
much more serious risk.
Because of modern anesthetics
and operative procedures, the mor-tality
risk in an elective (non-acute)
gallbladder removal opera-
January, 1973 THE HEALTH BULLETIN 13
tion is very low, Dr. Bozymski
said. After a week or so of recov-ery
in the hospital, the patient is
discharged. Then after one or two
week's rest at home, he is usually
allowed to return to work, as long
as physical strain is kept to a
minimum. Dr. Bozymski explained
that because the gallbladder is not
essential, the body does not miss
it when it is removed. The bile
which the liver secretes into the
hepatic ducts is adequate for prop-er
absorption of fat and fat-relat-ed
foods.
Because of the high rate of suc-cess
of surgical treatment of gall-stones
and due to a lack of trained
manpower and resources in this
area, the lowly gallbladder has
failed to receive equal research
time with the major killer diseases
such as cancer and heart disease.
However, within the last five
years, medical researchers at UNC
School of Medicine and across the
nation have shown renewed in-terest
in the gallbladder and are
now attempting to find answers
to questions that could unlock the
mysteries surrounding gallstones.
How are gallstones formed? Why
are some people susceptible and
others are not? Is there a medicine
that could provide an alternative
to treating the patient by surgical-ly
removing the gallbladder? And,
ultimately, can gallstones be pre-vented?
At UNC, a surgeon, Dr. Hubert
C. Patterson is looking into the
possibilities of using heparin (a
drug that prevents the clotting of
blood) to eliminate existing gall-stones
in the hepatic and common
bile ducts by dissolving them. In-itial
experiments conducted by a
Dr. Gardner in New York indicat-ed
that heparin was capable of
dissolving stones when it was
steadily dripped into the common
bile duct, allowing the stone to be
constantly bathed in the solution.
In the past six months, Dr. Patter-son
has tried the heparin-drip
technique on two patients. In one
patient, his only stone disappear-ed
in four days. In the other pa-tient,
who had three stones, they
disappeared in 11 days.
Perhaps the most exciting de-velopment
in gallbladder research
deals with oral administration of
bile salts to patients with gall-stones,
reported from the Mayo
Clinic. Evidence so far indicates
that patients who have taken bile
salts have had their gallstones
either reduced in size or in some
instances have had them disap-pear
altogether. Currently, the
U.S. Public Health Service is in
the process of setting up a center
for coordinating a national re-search
effort to determine the ef-fectiveness
and safety of the bile
salt treatment of gallstones. Once
the center is operational, contracts
will be awarded to universities and
institutions to conduct controlled
clinical trials. Results of this ef-fort
may revolutionize gallstone
treatment.
After years of neglect, there at
last appears to be hope for a solu-tion
to gallstones that will not in-volve
surgery and the ensuing
man-hours lost from work.
14 THE HEALTH BULLETIN January, 1973
State Of North Carolina Vital Statistics Summary
Births
Deaths
Infant Deaths (under 1 year)
Fetal Deaths (stillbirths)
Marriages
Divorces and Annulments
Deaths from Selected Causes
Diseases of the heart (all forms)
Cancer (total)
Cancer of trachea, bronchus and lung
Cerebrovascular disease (includes stroke)
Accidents
Motor vehicle
All other
Diseases of early infancy
Influenza and pneumonia
Bronchitis, emphysema and asthma
Arteriosclerosis (hardening of arteries)
Hypertension (high blood pressure)
Diabetes
Suicide
Homicide
Cirrhosis of liver
Tuberculosis, all forms
Nephritis and nephrosis (certain kidney diseases)
Infections of kidney
Enteritis and other diarrheal diseases
(stomach and bowel inflammations)
Ulcer of stomach and duodenum
Complications of pregnancy and childbirth
Congenital malformations
Infectious hepatitis
All other causes
Marriages, divorces and annulments are by place of occurrence,
data are by place of residence.
October
-%\iA^n
"I'm glad we're re-entering the community of nations.
I'm up to here with acupuncture."
THE HEALTH BULLETIN
P. O. Box 2091
Raleigh, N. C. 27602
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CHAPEL r* Oo 27514
PRINTED BY THE GRAPHIC PRESS, INC., RALEIGH, N. C.
February, 1973 /\
The
Health Bulletin
The Official Publication of The North Carolina State Board of Health
David T. Flaherty
Secretary
Department of Human Resources
Jacob Koomen, M.D., M.P.H.
Director
State Board of Health
N. C. STATE BOARD OF HEALTH
BOARD MEMBERS
James S. Raper, M.D., President
Asheville
Paul F. Maness, M.D., Vice President
Burlington
Ernest A. Randleman, Jr., B.S.Ph.
Mount Airy
Jesse H. Meredith, M.D.
Winston-Salem
Joseph S. Hiatt, Jr., M.D.
Southern Pines
Charles T. Barker, D.D.S.
New Bern
Lenox D. Baker, M.D.
Durham
Donald W. Lackey, D.V.M.
Lenoir
Robert B. Nichols, Jr., B.S.
Hillsborough
EXECUTIVE STAFF
W. Burns Jones, M.D., M.P.H.
Asst. State Health Director
Marshall Staton, B.C.E., M.S.S.E.
Sanitary Engineering
Martin P. Hines, D.V.M., M.P.H.
Epidemiology
Ronald H. Levine, M.D., M.P.H.
Community Health
E. A. Pearson, D.D.S., M.P.H.
Dental Health
Lynn G. Maddry, Ph.D., M.S.P.H.
Laboratory
Ben Eaton, Jr., A.B., LL.B.
Administrative Services
Theodore D. Scurletis, M.D., M.P.H.
Personal Health
R. Page Hudson, M.D.
Medical Examiner
THE HEALTH BULLETIN
Editor
Clay Williams
Associate Editor
Mary W. Cunningham
Volume 88 February, 1973 Number 2
First Published — April 1886
The official publication of the North Carolina
State Board of Health, 106 Cooper Memorial
Health Building, 225 North McDowell Street,
Raleigh. N. C. Mailing address: Post Office
Box 2091, Raleigh, N. C. 27602. Published
monthly. Second Class Postage paid at Ra-leigh,
N. C. Sent free upon request.
IN THIS ISSUE
Medieare-Medieaid Benefits
Boosted 3
Radiation Lifts Cancer
Cure Rate 4
Flaherty Gets Human
Resources Post 9
The Kidney Program . . .
A Second Chance at Life 10
On the Cover
The biggest advantage in us-ing
cobalt in the treatment of
cancer is that the equipment
can be positioned at any angle
to deliver therapy to any part of
the body. The source of energy
for this type of treatment is
radioactive cobalt-60, an ele-ment
that has been activated in
a nuclear reactor. Cobalt radia-tion
therapy also affords more
protection for the skin, it is
more economical, it is simple
mechanically, and cobalt can be
used to treat a wide spectrum
of tumors.
THE HEALTH BULLETIN February, 1973
COMMENT
Medicare-Medicaid Benefits Boosted
By
Ernest Phillips
Chief
Medicare-Medicaid Section i%L Phillips
A:.FTER more than three years of debate and public hearings by
Congress, the 1972 Social Security Amendments were enacted into law.
Not only do the amendments affect the payment of monthly retirement
benefits but they make many significant changes in delivery of health
care under the Medicare and Medicaid programs. Passage of the amend-ments
is indicative of the priority placed by our legislators and health
professionals on the improvement in the health delivery system. Medi-care
and Medicaid are relatively new programs. Yet, amendments were
passed in 1970 and again in 1972 with the aim of improving and
strengthening both Medicare and Medicaid. Such frequent revision of
a federal program is not typical and underscores the national commit-ment
to seek solutions to one of our most pressing problems. The 1972
amendments do not fully meet the needs of those under Medicare.
Drugs and dental services are still not covered to the extent that is
needed. There is little in the amendments that speaks to the problem
of the upward spiral of health care costs. Yet the fact remains that
Medicare is a far better program in 1972 than it was in 1966. It can
safely be anticipated that future years will bring further improvements.
However, improvements in our delivery of health care cannot come
about solely through laws. Health professionals must constantly seek
ways of providing the highest level of care at the best possible price.
We must seek ways of more appropriately using our health facilities
and our health personnel.
February, 1973 THE HEALTH BULLETIN 3
Radiation Lifts Cancer Cure Rate
ALTHOUGH the best chance
for cure of cancer is still ear-ly
detection, more successes
are being achieved as a result of
improvements in the delivery of
radiation therapy, increased use of
anti-cancer drugs and surgery
—
or combinations of all three.
Cancer is the second leading
cause of death in the United
States. Statistics indicate that
about 350,000 people will die of
cancer in the United States this
year. It is estimated that one out
of four people will develop cancer
sometime during their lifetime.
In 1930 one out of five victims
was cured of cancer. In 1970 the
survival rate had increased to two
out of six. Today, if all methods
available for the treatment of can-cer
were made available to every
patient who develops a malignant
disease, it is believed that three
out of six could be cured.
Objectives of radiation therapy
fall into two main categories
radiation therapy with curative
intent and radiation therapy with
palliative intent (treatment given
to relieve symptoms or to improve
the quality of survival)
.
Why is radiation effective in
the treatment of cancer? Abnorm-al
cells (tumor cells) are more
susceptible to the effects of radia-tion,
according to Dr. John Cella,
associate radiologist at Rex Hos-pital
in Raleigh. He explained,
however, that normal cells are
certainly affected by radiation
but, being normal cells, they have
the ability to survive whereas ab-normal
cells lose their ability to
multiply and grow. Dr. Cella point-ed
out that normal cells can be
destroyed or adversely affected by
radiation given too fast, for too
long a period of time or going to
a dose that surpasses the tolerance
of normal tissue.
Certain types of cancer lend
themselves to radiation therapy
more so than others. Results are
now being achieved radiograph-ically
with some types of tumors
that would not have been consid-ered
for treatment a few years ago.
The linear accelerator, a 25 mil-lion
volt X-ray unit at the UNC
Medical Center and the more ad-vanced
cobalt units give flexibility
to the treatment of a variety of
cancers.
Dr. Norman Abramson, radiol-ogist
at the Duke Medical Center,
notes that cancer of the pancreas,
the gland that manufactures insu-
THE HEALTH BULLETIN February, 1973
Before treatment begins the patient is fluoroscoped and X-rayed to define the exact
dimensions of the tumor. This is necessary in order to confine treatment to the affected
area. The area is then outlined on the patient's skin. Lead shielding blocks are shaped
to protect healthy tissue adjacent to the tumor.
lin, and other types of gastrointest-inal
malignancies have not been
treated with radiation in the past
because of technical limitations.
Now, according to Dr. Abramson,
these diseases are being treated
with encouraging results. Another
type of tumor that lends itself to
treatment by radiation is early
cancer of the vocal cord.
The treatment of another dis-ease
with radiation has undergone
radical change during the last five
years. Dr. Gustavo S. Montana,
professor of radiology at UNC,
looks upon Hodgkin's Disease as
one of the most interesting be-cause
it is potentially curable.
"It used to be a disease that
was thought to be incurable," Dr.
Montana said. "Now we look upon
Hodgkin's Disease as curable in
many cases. We have learned how
to prescribe adequate doses of
radiation and with the equipment
available to us we can deliver
these doses which some years ago
we were not able to do.
"We know that Hodgkin's Dis-ease
is a disease that most likely
starts in lymph nodes and that it
spreads in a predictable pattern in
that it goes to adjacent lymph
nodes and ultimately to the larger
February, 1973 THE HEALTH BULLETIN
organs and the stomach. Using
more refined diagnostic radiologic
procedures we can map out the ex-tent
of the disease much better
now."
The South American radiologist
explained that an exploratory lap-arotomy
is sometimes indicated in
the treatment of Hodgkin's Dis-ease.
"The abdomen is opened and
the lymph nodes are biopsied, a-long
with the spleen and liver. In
this way we get a more accurate
assessment of the disease which
enables us to make a better judg-ment
in the selection of patients
for radiation treatment who are
potentially curable. At the same
time we can outline the disease
more accurately for administra-tion
of radiation.
"The course of radiation that
patients with Hodgkin's Disease
undergo can vary depending upon
the extent of the disease—the
prognosis also varies accordingly.
But it is safe to say that in excess
of 50 percent of these patients will
survive five years if given the
proper treatment. A few years ago
their chances for survival were not
anywhere as good. In addition, we
have found that there are combi-nations
of chemotherapeutic
(chemical) agents that can be used
to fight the disease effectively,
particularly for patients beyond
the scope of radiation or for those
who have suffered a relapse of the
disease in spite of radiation treat-ments,"
Dr. Montana said.
Radiologists have known for
some time that a number of dis-eases
could be cured with radia-tion.
The refinement of techniques
and equipment have made treat-ment
easier and more applicable
for the patients. Dr. Montana
pointed out that many women fall
victim to cancer of the cervix. "We
can provide them with much bet-ter
treatment than we could have
only a few years ago," he said.
"Head and neck tumors, when de-tected
early, can be readily cured
with radiation. Another area of
interest to us is radiation in con-junction
with chemotherapy. Chil-dren
with acute leukemia can be
successfully managed and perhaps
cured with chemical agents. It has
been demonstrated, however, that
some of these agents do not pene-trate
to leukemia cells that may be
in the brain. As an adjunct to
chemotherapy we now give these
children brain radiation and in
this way have attained more sus-tained
remissions of the disease.
"Radiation in conjunction with
surgery has been used, as was
mentioned earlier, but the poten-tial
of this approach has not been
fully explored," Dr. Montana said.
In some instances radiation is used
prior to an operation to enhance
the likelihood of success with the
surgery. The objective of preopera-tive
surgery is to shrink the tumor
in order to make it resectable.
Sometimes tumors are attached to
vital structures and cannot be re-moved.
In some cases the tumor
cannot be expected to be control-led
exclusively with radiation, but
when surgery and radiation are
combined, better results can be
expected.
THE HEALTH BULLETIN February, 1973
The 25 million volt betatron X-ray unit is used mostly to treat deep-seated tumors. It
is the only unit of its type in North Carolina. The patient wears ear pieces to protect
against noise generated by the unit.
The area of postoperative radia-tion
is also being explored in depth
now. "Although it is generally be-lieved
that postoperative radiation
is not as effective as preoperative
radiation, there are instances
when it may improve the chances
of a patient's having a successful
treatment," Dr. Montana said.
"For instance, carcinoma of the
breast is a very common disease
and the treatment of choice, at the
present time, is surgery. Postoper-tive
radiation is sometimes given
to decrease the possibility that the
tumor may return in the area
where the operation is perform-ed."
Cobalt and electricity (X-ray)
are the sources of energy for thera-peutic
radiation. Cobalt is con-sidered
by most to be a dramatic
breakthrough, a new and power-ful
source of radiation—used
mainly as a last resort for cancer
patients. Cobalt is not new (it has
been in use about 20 years) and
about the only advantage it has
over X-ray is that the design of the
February, 1973 THE HEALTH BULLETIN
##•
The treatment procedure is controlled from a panel connected to X-ray and cobalt
units in other rooms. From this point the technologist can control the exact amount
of radiation prescribed by the radio-therapist. The patient is monitored continually by
closed circuit television in order to observe any movement or other indication of a
problem.
unit in which the cobalt is encased
is smaller and more flexible be-cause
the radioactive source is
very small. As a result the unit can
be positioned in many different
angles. The treatment can be aim-ed
from any direction in the body
because the unit can be rotated.
The main advantage of X-ray
over cobalt is that the different X-ray
units can produce X-rays of
varying energies which, in some
instances, allows underlying tis-sues
to be given higher doses with
less damage to surrounding tis-sues.
The more powerful X-ray
units can deliver higher doses at
a greater depth.
Dr. Montana reasoned that there
is need for better understanding of
the time-dose factors in radio-therapy.
"We can give a course of
treatment in a short period of
time, but we sometimes employ
longer periods thinking we will
get better results," he said. "I
think that this very simple factor
of radiation has not been explored
in sufficient depth. As we gain
more experience with the differ-ent
schemes of radiation therapy,
we may find that entirely differ-ent
schemes of treatment apply to
different tumors."
8 THE HEALTH BULLETIN February, 1973
Flaherty Gets Human Resources Post
David T. Flaherty, former legis-lator
and businessman, took office
last month as Secretary of the De-partment
of Human Resources.
Human Resources, the largest
of the 21 newly reorganized state
government departments, spends
nearly one-fourth of the state
budget, is comprised of some 30
agencies, commissions, commit-tees,
boards and councils, and em-ploys
over 20,000 people.
Flaherty listed as his primary
objective the streamlining of the
agencies so that they will provide
more service and "do it at a more
economical price."
Only the second to head the
sprawling department, Flaherty
pointed out that "We want to
bring good management into this
department and this means that
first we will be reviewing all the
programs with the idea of drop-ping
those that are not performing
as they should and, secondly,
pushing for those programs that
we've needed but haven't been
able to afford."
The biggest need in the public
health field, Flaherty said, is pro-viding
more assistance to county
health programs. "Right now the
counties carry the burden. We
must also improve the quality of
our health departments in many
of the poorer counties where they
are not able to do the job that
needs to be done."
Flaherty said the state should
effect a savings of between $50 to
$75 million in the next biennium
with the governor's efficiency
study task force and reorganiza-tion.
February, 1973 THE HEALTH BULLETIN
The Kidney Program ... a second chance at life
UNTIL recent years, a person
who developed chronic renal
(kidney) failure was doomed
to almost certain death unless he
could afford to pay $20,000 a year
to be kept alive by dialysis. Even
so, the mystery and the ever-present
possibility of rejection of
a kidney transplant gave little
hope of viewing the future with
optimism.
Now, however, thanks to the
kidney program implemented last
year by the N. C. State Board of
Health, a second chance at life
has been put within reach of al-most
every North Carolinian suf-fering
from kidney failure.
About 200 victims of chronic
kidney disease in the state are
now being kept alive through
means of an artificial kidney (di-alysis).
The state program spon-sors
50 of them.
The kidney program grew out of
a joint effort by the State Board
of Health, Duke Medical Center
and the UNC School of Medicine
to make dialysis available to peo-ple
who could not afford the cost.
After being denied federal funds,
the committee wrote legislation
spelling out specifics of the prob-lem
and presented it to the 1971
General Assembly. The legislature
passed the measure and awarded
the State Board of Health $500,000
for the biennium to establish and
continue the program.
Dialysis is a procedure which
involves circulating the blood
through a machine to cleanse it of
impurities. The six-hour proced-ure,
done twice weekly for mosl
patients, replaces the cleansing
function of kidneys that no long-er
work.
While serious kidney disease
does not strike as frequently as
heart disease or cancer, its vic-tims
are faced with three alter-natives—
dialysis, transplant or
death. It has been estimated that
over 1,000 North Carolinians died
from kidney or kidney-related dis-eases
before dialysis became avail-
10 THE HEALTH BULLETIN February, 1973
Ernest Howard, a native of Watha, N. C, watches as Lottie, his wife, takes his blood
pressure. It's only one of the procedures she learned to do during a six-week course in
home dialysis at the Hemodialysis Home Training Center at the Duke Medical Center.
Howard, 53, is the victim of polycystic kidney disease, a congenital problem. The disease
first appeared over 10 years ago. Both kidneys finally gave out and he was dialyzed for
the first time last October. Mrs. Howard will have to be in attendance twice each week
to manipulate the home dialysis unit — a process she has become quite proficient at.
able to all the state's citizens. Of
these, 25 percent could have been
saved through dialysis or trans-plantation.
The State Board of Health kid-ney
program has made notable
progress in a year. According to
William G. Gainey, program man-ager,
the program has filled a gap
in services available to kidney dis-ease
sufferers. "Before the 1971
General Assembly funded the pro-gram,
only the rich, persons with
insurance coverage, or those eli-gible
for Medicaid could benefit
from dialysis. Our program helps
people who would be unable to
pay the high costs of dialysis."
The kidney program provides
financial assistance for dialysis in
six medical centers located around
the state—Duke, in Durham; UNC,
Chapel Hill; Bowman Gray, Win-ston-
Salem; Pitt Memorial Hos-
February, 1973 THE HEALTH BULLETIN 11
pital, Greenville; Memorial Mis-sion,
Asheville; and Charlotte Me-morial.
If a patient has insurance
covering a portion of the cost, the
program will provide the remain-der.
Certain financial requirements
must be met to enroll in the pro-gram
but, according to Gainey,
they are usually interpreted liber-ally.
For example, a family of four
with a net income of as much as
$11,000 a year would be eligible.
About five years ago a more
compact version of the dialysis
machine used in hospitals was de-veloped
for home use. For the first
time, dialysis would cost consider-ably
less than that received at hos-pitals
(approximately $5,000 a
year, machine excluded). Patients
who meet the State Board of
Health kidney program require-ments
are usually eligible to re-ceive
a dialysis machine from N.
C. Vocational Rehabilitation. The
cost of the machine itself is about
$3,000.
If a kidney patient is consider-ed
able for home dialysis, the kid-ney
program provides financial as-sistance
for training him and a
partner (usually the husband or
wife). Training, which lasts about
five weeks, is offered at the six
medical centers listed above. In
addition to training, the program
provides home disposable supplies
necessary to the operation of the
machine, such as filters, blood sets
and needles.
Half of the 200 North Carolin-ians
currently on dialysis are on
home units. The state program
consists of 25 patients on home di-alysis
and 25 who receive dialysis
at a medical center.
In addition to lower cost for
home dialysis, Gainey indicated
another advantage is that the pa-tient
can use the machine at his
convenience. Also, the psycholog-ical
factor of being away from a
hospital atmosphere lends itself to
more rapid rehabilitation.
However, a serious deficiency
has developed in the health care
system between the patient at
home on dialysis and the center
—
there is no place nearby where a
home dialysis patient can go for
help if he runs into a problem.
Most medical people do not wish
to assume responsibility for a pa-tient
on dialysis since most are
not experienced in the new tech-nique.
In an effort to deal with this
problem, the kidney program re-cently
sponsored a day-long semi-nar
at Duke for 40 public health
nurses who have dialysis patients
in their areas. The nurses received
instruction in kidney function,
proper diet and health mainten-ance
for dialysis patients and fol-lowup
care for transplant patients.
While dialysis is the best avail-able
means of maintaining life, it
is not considered a permanent so-lution
to kidney failure. Dialysis
is a supportive measure until a
donor can be found and a trans-plant
performed. In North Caro-lina,
approximately 50 former vic-tims
of chronic renal disease now
live relatively normal lives due to
transplanted kidneys.
12 THE HEALTH BULLETIN February, 1973
Howard looks with affection toward his saving gTace . . . his mechanical companion.
The kidney transplant proced-ure
is only 19 years old. The first
successful kidney transplant was
performed on identical twins in
Boston in 1954. Identical twins
were used because their blood and
tissue type are alike. Since then,
over 8,000 kidney transplants
have been performed throughout
the world.
While the operative technique
for kidney transplants has been
perfected, the body's constant at-tempt
to reject foreign tissue con-tinues
to hamper efforts to make
transplants the ultimate cure for
chronic renal disease. However,
according to Dr. Stanley R. Man-del,
assistant professor of surgery
and head of transplantation at the
UNC School of Medicine, develop-ment
of anti-rejection drugs in the
1960's spurred progress in the
field. "While science has not been
able to find a drug that totally pre-vents
rejection, the current suc-cess
rate for transplants is ap-proximately
80 percent for trans-plants
from live related donors
and 50 percent for deceased, non-related
donors. These figures are
based on transplanted kidneys
that are functioning five years
after the operation," Dr. Mandel
February, 1973 THE HEALTH BULLETIN 13
said.
In the early days of kidney
transplants, the donor was usual-ly
the patient's mother, father,
sister or brother because of great-er
compatibility of tissue and
blood type. However, the success
of anti-rejection drugs has led to
more frequent use of organs from
deceased donors. Dr. Mandel pre-dicts
that as tissue typing becomes
more sophisticated and accurate,
the success rate for deceased-donor
kidneys will go even higher
than 50 percent.
Kidneys from deceased donors
are usually obtained from accident
victims who die as a result of
brain injury. A person who died
from a brain tumor would not be
an acceptable kidney donor for
obvious reasons.
Transplant candidates in North
Carolina may have to wait a
month or as long as two years for
a kidney, Dr. Mandel said. "The
waiting period varies depending
on the patient's blood type and
how many kidneys become avail-able
for transplanting. Patients
with a common blood type, "0"
positive for example, must usual-ly
wait the longest. There are 15
candidates currently awaiting
transplants from UNC."
Kidney transplants are most
often performed on people be-tween
the ages of 15 and 50, Dr.
Mandel said. "We place no age
limit on transplant candidates, but
the risks of such major surgery
are always greater in the very old
and very young.
"After a kidney transplant, pa-tients
usually return to leading a
normal and satisfying life. The
only restrictions are that the pa-tient
must always take anti-rejec-tion
drugs and use common sense
to avoid infection and injury to
the kidney. The drugs fool the
body into accepting the foreign
kidney, but at the same time they
lower the body's resistance to in-fection,
the most common cause
of death in transplant patients,"
Dr. Mandel said.
Dr. Mandel expressed optimism
for those patients whose trans-planted
kidneys were rejected or
failed after several years. "Unlike
a heart transplant, when the kid-ney
stops functioning the patient
does not automatically die. He can
go back on dialysis and await an-other
transplant," he said.
The kidney program provides
an evaluation of a patient's living
relatives for a possible donor.
Funds are provided for a kidney
from a deceased, non-related donor
if the patient belongs to the kid-ney
program.
Changes in the Social Security
Act will eventually result in
broadening the scope of the N. C.
kidney program. For the first
time, beginning July 1, 1973, work-ers
paying Social Security tax and
their dependents will be eligible
for Medicare payments to cover
costs of care for chronic renal dis-ease
after the first three months
of dialysis. Relieved of the long
term responsibility for patient
care, the kidney program will be
able to offer the service to a great-er
number of people.
14 THE HEALTH BULLETIN February, 1973
State Of North Carolina Vital Statistics Summary
Births
Deaths
Infant Deaths (under 1 year)
Fetal Deaths (stillbirths)
Marriages
Divorces and Annulments
Deaths from Selected Causes
Diseases of the heart (all forms)
Cancer (total)
Cancer of trachea, bronchus and lung
Cerebrovascular disease (includes stroke)
Accidents
Motor vehicle
All other
Diseases of early infancy
Influenza and pneumonia
Bronchitis, emphysema and asthma
Arteriosclerosis (hardening of arteries)
Hypertension (high blood pressure)
Diabetes
Suicide
Homicide
Cirrhosis of liver
Tuberculosis, all forms
Nephritis and nephrosis (certain kidney diseases)
Infections of kidney
Enteritis and other diarrheal diseases
(stomach and bowel inflammations)
Ulcer of stomach and duodenum
Complications of pregnancy and childbirth
Congenital malformations
Infectious hepatitis
All other causes
Marriages, divorces and annulments are by place
data are by place of residence.
February, 1973 THE HEALTH BULLETIN
November
"Abstain from all media."
THE HEALTH BULLETIN
P. O. Box 2091
Raleigh, N. C. 27602
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