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FILE NAME Kent KNT DATE 1989 Nov 2 DOC KNT025 DOCUMENT DESCRIPTION Journal Article - Associated Diseases in a Cohort of Cigarette Workers - New England Journal of Medicine a: . = MUSC LIBRARY \ The The HOVEHUSARA HOVEHUSARA . c i. - . a340 126680c E % New > | . oEfngland Medicine Journal Medicine MUSC Established in 1813 as The NEW ENGLAND JOURNAL OF LIBRARY SURGERY ! = } : = VOLUME 321 NOVEMBER 2 1989 NUMBER 18 Original Articles Suicidal Ideation and Suicide Attempts in Panic Disorder and Attacks MYRKA M. Weissman Gerald L. KlermaN JEF REY JEFFREY S. MARkowitz and Robert OuelletTE The Effect of Parity on the Later Develop- ment of Dependent Diabetes Mellitus or Impaired Glucose Tolerance .......-2cseeeerees DONNA Silverstein Elizabeth BaRRETT and Deborah L. Wingard ; Associated Diseases in in a Cobort of Asbestos Associated Workers Filter Workers ....6sscsceees Cigarette Thurber JAMES A. TALCOtt Wendy A. ARLENE F. Kantor Edward A. Gaensler Jane F. Danahy Karen H. AntmAS and Frederick P. Li 1209 1234 1220 1220 Disease Mechanism of Disease Mechanisms Hypercapnia .. STEVEN E. Weinberger Richard M. Schwartzstein J. and Woodrow Weiss Intel igence Medical Medical Intelligence Hypoglycemic Drug Therapy - Oral Hypoglycemic Agents JOHN E. GERICH Reversible Cardiac Dysfunction Associated with Interferon Alfa Therapy in AIDS Patients with Kaposi's Sarcoma LAWRENCE R. Dlyton Robert E. WalkeK Joseph A. Kovacs Brisey Brisey HeRPIN - MARGARET Parker Henry Masuk ANTHONY S. Fauci and H. Clifford Lase 1223 1231 1246 Editorial Panic Attacks and the Risk of Suicide PETER REICH ..... 1260 Sounding Sounding Board First Uninsured Health Care Tickets Tickets for the Uninsured First Coach Class or Standby H. Gilbert Welch 1261 Correspondence Wider Use of Testing for HIV Infection ..---- Mortality among 1862 Antibody Civilian Applicants for Military Service seropositive Preliminary Results .....-+--+++> success Tuberculin Skin Reactivity in Intravenous Drug Addicts .....-- vecceeee Acyclovir to Prevent Cytomegalovirus Infection in Renal Recipients .-.ss+--s+e+20 Permanently Decreased Renal Blood Flow and Hypertension after Lithotripsy .---+---++- Cholesterol Embolization after Treatment with Altitude Tissue Plasminogen Activator . see Treatment of Inadvertent Intrathecal Injection of Vincristine Excessive ers at Erythrocytosis Increasing Prevalence of Excessive Erythrocytosis with Age among Healthy Miners Cocaine More on Rhabdomyolysis Associated with Cocaine Intoxication ...-- paves pene ceeerereeees A Proposal to Help New House Officers .------ Our Stubborn Quest for Diagnostic Certainty 1265 1267 1268 1268 1269 1270 1270 1271 3271 1271 1272 Occasional Occasional Notes Psychological The Physiologic Physiologic Physiologic and Psychological Effects of the Bedside Presentation ......----: Richard J. Simons Robert G. Bails Robert Zelis and Clifford W. Zwilligh 1273 Case Records of the Massachusetts General Hospital Reviews Book Reviews seveeenes ca eeceaeee deneees . A Year Woman with Subxiphoid Notices Notices ....--+-- sen ceecececceenseeseeees Pain and Narrowoifnthge Esophagus Mark B. Okringer and Eugene J. Mark tees 1249 Information for Authors ..- .-----+-++ 1275 1212778 8 1280 Copyrighted offres J. Tai Nay Inuman Owned Published and 1989 by the tikka 09 Ma asMa as ISSN Subscription prici 74 Wiper PUZZLETEK PUZZLETEK przblutoon przblutoon servich iron Second Wiper yrat postage paid Massachusetts Medical Society editonal values at Stablize Stablize SP Boston and additional mailing bows PLAINTIF'S EXHIBIT 5898.0 5898.0 1770 THE NEW ENGLAND JOURNAL OF MEDICINE Nov 2 198U ASSOCIATED DISEASES IN A COHORT OF CIGARETTE WORKERS M.D. James A. Talcoti M.D. Wendy A. Thurber R.N. Arlene F. Kantor Dr.P.H. EDWARD A. GAENSIER JANE F. DANAHY B.A. KAREN H. ANTMAN M.D. AND FREDERICK P. Li M.D. Abstract To estimate the effects on health of occupa- tional exposure to crucidolite a highly toxic form of asbes- tos we studied a cohort of 33 men who worked in 1953 in a Massachusetts factory that manufactured cigarette fil- ters containing crocidolite fibers from 1951 to 1957 Twenty of the men have died as compared with 8.3 deaths expected This increased mortality was attributable to associated diseases Fifteen deaths were caused by cancer as compared with 1.8 expected relative risk 8.2 95 percent confidence interval 4.6 to 13.4 including eight from lung cancer five from malig- nant mesothelioma and two from other types of cancer There were seven deaths from nonmalignant respiratory disease as compared with 0.5 expected relative risk 14.7 95 percent confidence interval 5.9 to 30.3 of which five were due primarily to asbestosis In contrast the mortality rates from cardiovascular diseases and all other causes were not increased Four of the five living workers have pulmonary asbestosis three of them have recently diagnosed cancers including two additional lung cancers We conclude that the extremely high morbidity and mor tality in these workers were caused by intense exposure to crocidolite asbestos fibers N Engl J Med 1220-3 HE inhalation of asbestos may result in pulmonary fibrosis asbestosis lung cancer or malig- the study the mortality analysis or until the diagnosis of a first cancer the morbidity analysis There were 773 and 766 person- years of follow in the mortality and morbidity analyses respec- nant mesothelioma We recently observed three cases of malignant mesothelioma among former employees of a Massachusetts company that manufactured cigarette filters containing crocidolite asbestos from 1951 tively We attempted to contact each worker or his next of kin if the worker had died We requested information about the worker's employment and health history and asked permission to review his medical records For 18 workers this information was supplement- ~fl to 1957. We now report a marked excess in mortality and morbidity from asbestos diseases in an independent cohort of 33 workers who made these ed with data gathered in an ongoing health survey of company employees begun by one of us in 1971. For 29 workers we were able to determine the total duration of employment by the company for 23 the length of time spent manufacturing cigarette filters was filters known METHODS An experienced nosologist determined the underlying cause of death from the death certificates of all deceased workers Medical From 1951 to 1957 a subsidiary of a Massachusetts company manufactured cigarette filters according to a patented dry and on Crepe paper dusty process in which asbestos cotton and acetate fibers were mechanically mixed carded and deposited on The parent company produced other containing products be- tween 1942 and 1971 by the conventional wet papermaking proc- ess in which asbestos was added to a pulp Crocidolite a member of the amphibole family of long straight asbestos fibers was the primary type of asbestos used It is strongly associated with asbesto sis lung cancer and malignant mesothelioma presumably because of its unusual resistance to degradation in the lung Measure- ments at six production locations in the factory on October 27 showed an average of 80 particles of asbestos dust p^rmilliliter of air which was within the current Massachusetts standard of 173 particles per milliliter These levels greatly exceed the current National Institute for Occupational Safety and Health standard of 0.1 asbestos fibers not particles per milliliter A list of all employees directly involved in manufacturing eiga- rette fillers at the factory on September 22. 1953. was obtained from the records of the Massachusetts Division of Occupationa Hy- the previously giene The cohort included none of factorworkers described by us The median age of these 33 white men on that date was 34 years range 21 to 67 The subjects were studied from that date until their death or until December 31 1988 the closing date of records establishing the cause of death independently were available for 22 of the 28 deceased workers including all those whose death was possibly related to asbestos These included the results of a postmortem examination in 8 workers other pathology reports for 10 and other medical records for 4. Only certificate diagnoses were obtained for six workers All diagnoses of cancer were verified by a pathology report 18 workers or radiographic and endoscopic studies I worker Asbestosis was diagnosed in deceased workers on the basis of the presence of pulmonary fibrosis and asbestos bodies in 12 workers or clinical studies in 3 workers In living workers asbestosis was diagnosed on the basis of a chest radiograph scored by one of us as 1/0 or more according to the Interna- tional Labour Office's scheme for the classification of pneumoco Dioses Relative risks for mortality or the ratio of the numbers of death observed to the numbers expected were based on death rates specif ie to age and calendar time according to cause among the U.S. male population The numbers of newly diagnosed incident cancers observed other than malignant mesothelioma were compared with those expected on the basis of incidence rates specih~ to ag~- and calendar ume according to site from the Connecticut Tunn Registry More stable expected values for malignant mesothelive ma an uncommon tumor were calculated with data from the Sur- veillance Epidemiology and End Results program of the National Cancer Institute which provided rates in approximately 100 percent . From the Division of Biostatistics and Epidemiology Farber Cancer Institute 1.A.T. A.F.K. K.H.A. F.P.L. the Department of Medicine Har- vard Medical School J.A.T. K.H.A. F.P.L. the Clinical Studies Section Clinica Epidemiology Branch National Cancer Institute W.A.T. A.F.K J.F.D. F.P.L. and the Division of Thoracic Services Boston University to School of Medicine E.A.G. Boston Address reprint requests Dr. Talcon al the Farber Cancer Institui~ 44 Bmney St Boston MA 02115 11F32CA08242 from the in part by a grant 11F32CA08242 National Canzer Insunjie Ms Thurber is and by the Kellogg Foundation Program in Clinical Effectiveness the resipient of an Amy Poner Reszarot Kursing Fellowship and Dr. Caught has received a Research Career Award HL1173 HL1173 from the National Heart Lung of the U.S. population for the time periods 1973 to 1976 and 1977 to 1980'1.12 and Connelly R personal communication In the calcu lations of significance and confidence intervals an underlying Pois- son distribution was assumed RESULTS Twenty 85 percent of the 33 workers had diedand 5 were alive The 28 deaths observed were 3.4 times the number expected 8.3 deaths on the basis of mortality rates for the U.S. white male pomas and Blond Institute