Document 0JaVbRxrkBM8bYbN1oLkgEexb

! INTERNAL- a .V' CORRESPONDENCE AUG 1 7 1963 UNION CARBIDE CORPORATION old ridgesury road. DANBURj^g)|XJsltP*' todmwt*) t>vr LocrnXx*^ Atm Copy vo Medical Directors Contract Physicians Date no.nat^o Dept. Area Suoract August 8, 1983 Corporate Medical/HS&EA Danbury, P2594 Asbestos Related Diseases Because asbestos related diseases both with and without asbestosis are a cause of considerable concern and confusion, 1 have attached an execellent article written by D. Davies that appeared in the July 16, 1983 issue of the BRITISH MEDICAL JOURNAL. Davies has distilled a great deal of information into a succinct description of when compensability may be indicated. His comments on lung cancer are especially interesting. PLAINTIFF'S EXHIBIT UC-2634 The fact that only a small percentage of pleural plaques (15% reported by Hourihane) are detectable during a lifetime by usual chest radiographs gives one concern. If our chest x-ray examin ations are of poor quality and are poorly interpreted, we could be accused of exercising inadequate "reasonable" care in our detection efforts. Hilton has been working with you to try to up grade our chest x-ray examinations and interpretations. I appreciate that Dr. Hilton Lewinsohn called this article to my attention. Hilton is our resident expert on asbestosis and asbestos related diseases so if you have any questions or problems give him a call on extension 8-421-5214. Thomas A. ttncbln, M.D. Corporate Medical Director TAL:cms enclosure UCC 005047 164 value and importance? Once (he questions are identified it tnay be easier t. choose the forum in which to answer them. - -'I c* * Tony Smith Deputy Editor, BMJ 1 AnooymoOT. Does Britain oced in academy of medicine ? Bt Med J JP7pi:I611. 1 Godber G An institute of health > The Tima Health Supplement 1982 Feb 19:9 (ool 1-4). 1 British Medical Association. Tie medical effect: of msclear twtr. The report cf llu Britiek Medical Auodation't Board of Science and Education. Chichester: John Wiley and Sons, 1983. A~ Asbestos related diseases without asbestosis Asbestosis and mesothelioma are prescribed diseases under the Industrial Injuries Scheme and entitle the patient or his dependants to compensation. The term asbestosis should be used only to denote fibrosis within the lungs. The three othernnn-malignanr mmHiritms associated with exposure to asbestos are pleura! plaque, pleural effusion, and diffuse pleural thickening. The Industrial Injuries Council now recommends that, when h reaches a certain atcptaihe last of these should also be prescribed.' 7 Pleural plaques develop in the parietal pleura, seldom cause disability, and are not to be prescribed. Pleural effusions may tie transient but some art dironic and may recur.* No pre scription is proposed for these, but, under the new proposals, if they cause sufficient bilateral thickening of the pleura an application to a pneumoconiosis medical panel would lead to certification. Diffuse pleural thickening associated with exposure to asbestos has become increasingly recognised * 4 Both pleural layers are affected and restrict the expansion of the lung. Histological examination shows only non-specific fibrosis, and, as with effusions, the diagnosis depends on excluding other causes such as tuberculosis and other infections, collagen diseases, trauma, chronic uraemia, and drug induced fibrosis.* With such exclusions, the Industrial Injuries Council is satisfied that bilateral diffuse pleural thickening in asbestos workers is likely to be industrial and recommends that dis ablement benefit should be awarded when the thickening is bilateral, is over 5 mm thick, and extends over more than quarter of the chest wall. The prescription of this condition will be welcomed, though some may be dissatisfied that the disease has to be so extensive to allow certification. Nevertheless, the committee suggests that this requirement should be reviewed in the light of experience. The report also considers cancel of the lung in asbestos workers. At present this condition is not prescribed, but when it occurs in association with asbestosis it is considered to be a sequel and benefit is payable. Claims which have been rejected during life may be successful after death because necropsy may disclose previously undiagnosable mild asbestosis. The council now recommends prescription of lung cancer in patients with asbestosis and in certain other circumstances. In doing so h had to consider bow to take account of smoking habits and the amount of exposure which would justify cmifirarinn -The problem of the contribution of smoking rot lung cancei'jh asbestos workers has been disposed of neatly. Studies in the BRITISH MEDICAL JOURNAL SOLl'ME lCJULY United States in insulation workers hate shown that the relative risks of developing lung cancer are: non-exposed non-smokers 1; asbestos exposed non-smokers 5 ; non-exposed smokers 11, asbestos exposed smokers 53.* Because exposure \ increases the risk by a factor of five in both smokers and ' non-smokers the council recommends that smoking should be disregarded. Cancer of the Jung in asbestos workers may be divided into two broad types. Firstly, peripheral adenocarcinoma, which is unrelated to smoking and accepted as being due to asbestos exposure. The second is squamous, undifferentiated, and small-cell cancer arising in proximal airways, certainly related to smoking but only doubtfully related to asbestos. Perhaps wisely, the council makes no attempt to distinguish between these and recommends prescription irrespective of type. Most authorities accept that the risk of lung cancer is increased only when there has been heavy exposure to dust. Reasonable estimates of exposure may be made for people working in circumscribed places such as asbestos factories, but this may be impossible for, say, shipyard workers or engineers with intermittent exposure in various jobs, particularly in the distant past. Faced by this difficulty the council has made an ingenious proposal that the presence of other indicators of asbestos exposure should justify certification. It recommends prescrip tion when primary cancer of the lung is accompanied by one or more of the following features: asbestosis, bilateral diffuse pleural thickening, and bilateral pleural plaques. Asbestosis provides dear evidence of heavy exposure, but, though bilateral diffuse pleural thickening and bilateral pleural plaques are linked with exposure to asbestos, the relation is less definite and more capricious.1 Moreover, pleural disease and asbestosis! are also pooriv' correlated, for the former may appear in lig ttly exposed people such as the wives of asbestos workers aid residents in the vicinity of asbestos mines and factories. Given a minimum exposure to dust, the development of pletpa} calcification- which facilitates the diagnosis of plaques, is probably mainly determined byage, usually taking over 20 years from the first exposure.8 * "Only some 15% of plaques are detectable during life,10 but this proportion might be higher if oblique x ray views were used in addition to tW routine ones." Hence probably the people who are certified during life will not be alt those who have plaques but only the minority in whom they are demonstrable. The case for necropsies in people who have had industrial exposure to asbestos and die of lung cancer is dear. The council's aim has been to identify people with sufficient exposure to dust to justify certification if they develop lung cancer. Workable regulations are difficult to devise, but the~7 proposals favour those with pleural x ray shadows which may ' be the result of light exposure in the distant past and dis- . criminate against those with much heavier exposure who, for i unknown reasons, do not develop pleural lesions or have not ^ had time to do so. The council has derided against specifying a 1 duration and degree of exposure as a qualifying condition because it considers this to be arbitrary and lacking in scientific validity. Even so, the criteria of pleural lesions that it proposes are probably a less than satisfactory index and, though the extension of prescription will be welcomed--even if it requires legislation--probably many will find that the details of the proposals which are now before the Secretary of State for Health are unsatisfactory. D Davies Consultant Chest Physician, Gry Hospn*!, NottinghgfP NG5 1PB UCC 005048 BRITISH MEDICAL JOURNAL VOLUME 287 16 JCLY 1983 * Industrial Injuries Advisory Council. Asbtstos-relaial disease without -'-'dsbeuons. London: H*^SO-J982. (Cmnd 8750.) k Gaemler EA Kaplan Al. Asbestos pleural effusion. Amt lmrm Med 1972;74:178-91. * Sheers G. Asbestos*sesocisted disease is employees of Devooport dodc- yard. Am NY Acad Sd 1979430:281-7. HHlerda) G. Noc-malignant iibestot pleural disease. Thorax 198140: 969-75. 4 Albdda SM, Epstein DM, Gefier WB> Miller WT. Pleural thickening: its significance end relationship to asbestos dost exposure. Am Rev Rasper Du !982;m l-4 * Hemxoood EC, SeHkoff IJj_ Stidman H. Asbestos exposure, cigarette mnking and death rates. Amt NY Acad Sd 1979 436:475-90. 7 Gibbs GW. Etiology of pleural caldfication; a study of Quebec chrysotOe asbestos miners and mitkrs. Arch Environ Health 197940:76-82. * Rosaiter CE, Bristol LJ, Carrier FHtei al Radiographic changes in chryso- tOc asbestos mine and mill wotheis in Quebec. Arch Environ Health 197244 388-400- * Jones JSP, Sheers G. Pleural plaques. In: Bogoreki P, Timbrel) V, Gilson JC, Wagner JC, eds. Biological effects of asbestos. Lyon: IARC, 1973. (IARC Scientific Publication No 8.) 14 Hourihane DO'B, Lesaof L Richardson PC. Hyaline and calcified pleural plaques at an index of exposure to asbestos. A study of radiological and pathological features of 100 with a consideration of epidemiology. Br Med J 1966^.1069-74. u Fletcher DE, Edge JR. The early radiological changes is pulmooary ax>d pleural ubestotis. Clin Radiol 297041:355-65. Difficulties with knees Only a few years ago interna] derangement of the knee was an accepted diagnosis which led to arthrotomy on the Gainful side of the joint with, almost inevitably, the exrisiafl of the cartilage: "better to remove a normal meniscus thy miss the tom posterior horn." Those days have passed; thraicniscus is now preserved at all costs, and in some centres iwnay even be repaired. One of the main reasons for this ibangc is that successive reviews of the late results of memscectomy have shown that the operation is far from being banign--and that it is certainly not the cure for all problems oftm knees. Meniscec tomy may, indeed, increase the probleny in a knee which is unstable from damage to the ligaments. For the knee still remains an enigma Jcesprte a wealth of new tests and diagnostic aids such as arthrpeopy and arthrography. Among the most taxing of the problems within the knee are those of rupture .of the cruciate ligpnents. Rupture of the pos terior cruciate ligament is the casfr to manage. On examination the tibia is found to hang backjfiben the knee is flexed to 90 with the foot on the examinatiro couch. The anterior draw sign is positive--the tibia can he drawn forward when the leg is in the position described-bur in reality it is moved to the "normal" position only/re Lative to the femoral condyles. Radiographs may showft avulsed fragment from the posterior aspea of the tibia, 'rfeatxnent is conservative or operative. The fragment may bf screwed back into position, or the liga ment may be repaid directly or replaced by nearby tendons or muscles. This inftiry is frequently associated with major disruptions of trf knee in which serious neurovascular injuries may occur reapuing urgent attention. Longstanding injuries require caref* assessment before surgery, which should aim at controlling 4sy straight or rotatory instability. The exact nature of the sui^ry will depend on the instability and is likely to be compliczed. Surgery may not be needed, however; where pos sible tK management should consist of quadriceps and ham- fexerases to control the knee, with advice to the patient to cfduce his demands on the joint. Dandy and Pusey1 found in a group of 20 patients treated by this conservative ach the functional rrsuits bore no relation to die degree of 165 laxity of the ligament--and 18 of the patients eventually decided that their symptoms werjmot severe enough to justify surgical reconstruction. The greater problem is thyfnterior cruciate. After years of discussion authorities stillyKnnot agree. This difference of opinion was highlighted adun in theJournal of Bern and Joint Surgery in February of this year. Hughston and Barrett reported that rupture y the anterior cruciate did not in itself contribute to instabiU^ of the knee.' They believe that the instability which ocras in knees with this lesion is related to damage to the capsule, other ligaments and muscles, and the medial meniscus.^) their hands careful evaluation and repair of the damagedjftrucruies produced knees stable enough to withstand vigojeus sport, whether or not the anterior cruciate was rupturedyThey emphasised the prime importancethe media] menKus as a stabilising structure. By conmst, Noyes tt al described the disability in 103 patients wh chronic laxity of the anterior crudasp ligament uncomMcated by other major defidencies or previous reconstructijjC procedures.9 They showed that damadf to this Uga- menywas deteaed in only seven of the 103 orients initially, inching those examined by orthopaedic surgeons. They found . if untreated an isolated anterior audaty lesion would lead illy to a lower sporting achievement did later to reinjury, age to the meniscus, and eventuallyo osteoarthrosis. The average orthopaedic surgeon Mds such a wide diver gence of opinion difficult to understadG. He should have found comfort in the sensible editorial in tat same journal, though the author, Robert Larson, could ny reconcile the differences.4 He did, however, attempt to gjtysome guidelines on manage ment based on his beliefthat aljAne structures play a part in the stability of the joint; none is ft important, all depend on each other. Thus to re-establishstability all damaged structures should be identified, reputed, or augmented. Larson argues that repair should be iwiertaken urgently after injury, but acknowledges that this/tpproach requires accurate and early ^ diagnosis. The anteridf cruciate itself, be believes, should nq be repaired but aunented, for experience has shown pat repair is difficult apd produces poor results. He think^hat repair of the kne^vith chronic injuries should be appapached with caution, for judicious advice to the patient mfobviate surgery, espedglly if he is taught to develop his jfamstrings and quadricus and lower his athletic requiremras. In those patients whdfe knees are so unstable as to interfo^ with normal life--or who want to engage in sporting raivities at a high standard^the joint should be carefully ^Isessed and the approp^te repairs and augmentation unrataken. light of all this conflicting evidence, what is the key? PeThJbs the answer is a superspedamt service for the few who are crippled by the railage to their knee, or aps a better diagnostic servkyfor the acutely damaged knee, or perhaps both. C D R Lightowler Consultant Orthopaedic Surgeon, Essex Nuffield Hospital, Brentwood CM 15 6EH 1 Dandy DJ, Pusey RJ. long-term reiults of unrepaired tears of the posterior cruciate li^ment. J Bone Joint Surg 198244B -92-4. 1 Hughston JC, Bancdr GR. Acute anteromedial rotatory instability. Long-term roiuiyfof surgical repair. J Bone Joint Surg 1583,*65A?145- 53. Noyes FR,, PA, Matthews DS> Butler DL- The symptomatic anterior agnate-deficient knee. Pan I: the kmg-tens functional disabiliry^n athletically active individuals. J Bone Joint Surg 1983; 65A: 1 J_ L. The knee--the physiological joint. J Bom Joint Surg 1983; 68A:r143-4. UCC 005049 To: General Occupational Health Committee 25 \m J. B. Barrett - Solvents k Coatings Materials - Clear Lake City- Loc SIS 803 B. L. Barton - Carbon Products - Parma - Loc. 742 J. M. Cleverdon - Engineering Products Division - Danbury - Q1633 T. L. Collins - Engineering k Hydrocarbons - Clear Lake City - Loc 803 R. W. Cope - BS&EA - Danbury - P2608 J. S. Cornell - Silicone k Urethane Intermediates - So. Chas. - Loc. 511 T. A. Gagner - Home k Automotive - East Hartford - Loc. 746 N. W. Gaines - HS&EA - Danbury - P-2606 W. P. Gorham - Specialty Chemicals Division - Bound Brook - Bldg 200 J. P. 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