Document QkZrYKQ9w35rqmxnd6q6vLExv

1 ,>; ^ .#< i /j 19/4 397 _ Finally, rdiology indicates only a possible J^hhe sexual source of bleeding, and where two seen endoscopy has the unique value of ty detnonsmiiag the true site of bleeding. Thus ary should be earned oui only when endoscopy :ovcd negative. copy in Relation ic Managcmei:; : value of tarly" endoscopy in management is : tells the clinician the site of bleeding and the : of the underlying lesion. Since acute mucosal ; often heal rapidly and may be difficult to deal . surgically, while chronic peptic ulcers tend to i zrid to be amenable to surgery, endoscopic nation could allow early decisions on manage* However, whether or not this w-ill reduce ;;::y remains to be evaluated. Other possible v.s from early endoscopy, such as reduction in -transfusion and reduced hospital stay, must also titrated. -y Endoscopy Services : the best possible results endoscopy should be ;t rt: within 24 hours of the patient's admission, -ih there is still a good diagnostic yield up to .trues after admission. Early endoscopy involves tr.doscopis; in much time and effort, and, if ttttt facilities with properly trained paramedical staff are not easily available, it is prohibitively time consuming. It is inconceivable that a district general hospital with one gastrointestinal consultant trained in endo scopy could provide an adequate service for acutely bleeding patients. Such hospitals planning to develop an endoscopy service should bear the manpower aspens carefully in mind when doing so. Ideally two consultants with the help of middle-grade medical staff trained in endoscopy should be employed in each hospital. Rcqucsii tor Jcpnnu should be addressed ie ]. A. K. T. HtTtttSCtS I. MtaennOum on Future Xaueiu! Needs (w Fibre-optic Endoscopy of the Gastrointestinal Tract. Bruise Sooti> (or Dijrtuvr EnOoitopy, 1071 C. Patmci, . D. J die. mtC. An. 1965, COT, JtTt. J, Crook, 3. X., Gray, J V., Nance, F. C., Cohn, 1. Aar.. Sms 1*72, ITS, "1. <. Allen, H. M.. Block, V.. A.. Sehumat., E. M. Archi Sort- 1ST;. JOS. 44*. S. 5urr*i, C.. V7t.-nt;,M. K., Hayes, D. F., Lucas, C. ., Wall, A. ) aid. 1073. JOT, 153 t. Knon, R, M., Sm-3., ?. W. Caiirani1*75, *S, T2S. 7. Cottor., F. E., Keren berg, Si. T.. Waldrarr., R. P. L-, Ateon, A. T. R. Bi. mec'. 1*73, It, SOi. E. McGmr., F. P., RTUtn, S. ).J. R. Cel!. Svrs. Semi. 1*7*. IS, lit. S. Fbtrcit, 3. A. K., Ftaisitor., N. D. C. r.J. Help. Met. (in the pteit;. 1C, Dvortsovs, H,, 3irssck, V., Sttki, 3. Urfen: Endoscopy of Ditesuvc and Abdominal Diseases; p. 4t. Betel, 1573 JL Allan, R, N., Dykct, P. V., Toyc, D. K. M. r. nci.}.) *72, iv, 3*1. Public Health I3.0P0RTI0NAL MORTALITY AMONG VINYL-CHLORIDE WORKERS ?-*chasp R. Monson John M. Peters icnmcr.ls of Epidemiology er.d Physiology, Hervad ei Public Kealik, Bosior., Massachusetts 02115, U.SmL. Maurice N. Johnson S. F. Goodrich Comport}, Akror., Ohio rniar- a F^P^iioftal-mortality analysis of one hundred and sixty-one deceased r.'i in two plants using vinyl chloride, a 50% c. deaths due to all cancer was seen. Specific cancer with the greatest excess included ^rtc biliary tract, lung, and brain. The excess cancer was seen mainly in men who died age 60. Also, there was a trend in time in 7:io of observed to expected deaths: since 1970 t'-ice as many cancer deaths as expected have METHODS Vinyl-chloride monomer ij produced at a plant is Calvert City, Kentucky, and is polymerised into polyvinyl chloride at a plant is Louisville. These plastj have bets in operation since the hit 3930$. Whenever ar. active or pensioned employee at these plants dies, a copy of the death certificate is obtained. An absirae: of the certificate is made aac the certificate is sent to the insurance company. Using these sources, one hundred and sixty-one deceased White malts who were employed a: one of the two plants were identified. No information was available-tr. workers who left employment before retirement. For all but nineteen a copy of the death certificate was obtained. For the remaader the cause of death as recorded in the company abstract was used. Deaths from 1947 through 1975 were ascertained. Of these deaths, one hundred and thirty-five occurred among Louis ville workers and twenty-six were among Calvert City workers. The distribution of causes-of-death was tabulated using the code on the death certificate. The expected distribution was calculated on the basis of proportional-mortality ratios for United States Vhite males. The observed deaths from all causes were stratified into 5-year age/timespeeific groups, and age/iime/cause-sptcific proportionalmortality ratios were multiplied by these numbers to obtain the itraium-spccific expected numbers.5 INTRODUCTION to. 15, 1974, four fata! cases of angiosarcoma ktt: among men who worked in a polyvinyl: polymerisation plant were reported.1 \Ve here a proportional-mortality analysis of all known among workers in that plant. Also = ve deaths in men who worked in a plant vinyl chloride is produced. RESULTS The patterns of mortality among workers in the two plants were similar, so all men were grouped together. As seen in tabic l, a 50% excess of deaths due to cancer was observed (x:=5'7, p<0-02). In addition to the four deaths previously reported,' a fifth man who died of angiosarcoma of the liver was identified. Also., there was one cancer of each of the following sites: gallbladder, common bileduct, and sL*>&r /f>/ VC5902 396 THE LANCET, AUGUST 17, ^ lanct, august tAAU l---aKCUVCP AVD XrtC7XP fiUTW W yiH*X*05LOIUt WOKlW 1.C.C.IW.1 Ciuu ef dc*lh aj: )4o-aw AU nnrrr .. J50-S59 Dsruvt MS Liver vc; it:, lei - Lunt m * fimr, 200-305 L>7nphuc nd #, J Oiht; Ufice:; .. JJ0-SJ< c.s\i 400-461 Drcvlatorj SO0-M6 Lxtcrnai eo-6p Suicide Ati other e>ue*| .. Obtervcd J61 4) IS 6 U S } i i 26?6 10 24 Zxpatt* U1<0 224 S3 0? 24 12 >4 VI 9i 61 *6 34 -5 53 } 06i./cxp. 1*0 l-S )-6 11*0 ) *6 42 3-5 02 Dl 1-0 04 14 ot * EipeetcC number? b**tC or, *f e*iimciei*te*f>ri6c proportibnal* tnorulny rinet for U.S. V*hiu tr.aiet. 1 Inictnationa} OmiAouon of Dutam, trvcnih rrviiior.. ! Nasopharynx 1, proiutc 1, kioney 1, thyroid 1, undetermined 1. } Include* 2 tirrhom (4-4 cjtpenrd). liver (type unspecified). There were five brain rumours--three glioblastoma multi/orme and rwo of unspecified type. There was a 60% excess of cancer of rhe lung, of :he following cell Types: bronchogenic (one), anaplasiic (one), adenocarcinoma (lhree), unspecified (eight). There were two unusual other types of cancer--thyroid and nasopharynx. There was an excess of deaths due io suicide: ten observed and about five expected. The observed and expected numbers of all eancer according to age and year of death are presented in table u. Excess death due to cancer was seen primarily in men who died before age 60. There was a trend in the observed/expected ratio with year at death. Before 1965 no excess of deaths due to cancer was observed. However, since then there has been an increase in the proportion of death due to cancer, so that since Jan. 1, 1970, death from cancer has occurred twice as frequently as would be expected on the basis of U.S. vita) statistics data. table it--osserved and expected deaths dui to all cancer ACCORDING TO AGE AND YEAR OF DEATH Chr*eieritit Ai ii dtitn (v:.) .. Veil d tittir. Caiefory < 50 50-59 60- < 3965 1965-69 1970- Obtervtd 11 17 35 12 10 19 Expected 7*6 E1 3:: 31*4 3 92 Obi./exp. 1*4 2J M 3-3 1*4 2-1 DISCUSSION These data include the original four vinyl-chloride workers who were known to have died with angio sarcoma of the liver. Four other workers with fatal cancer of the liver and biliary system have been identified. In addition, there is a suggestion that at least two other types of cancer--lung and brain-- appear with excess frequency in vjnyl-chloridc workers. J: also appears that the relative frequency of all cancers is increasing with time. \Thi)e no pro tection may be made with certainty, additional excess cancer among vinyl-chloride workers would seem likeiy. As analysis using proportional-monaliry ratios do om take into account the absolute risk of byi^ ^ the population being studied. Thus, it is possib that the mortality-rate in the vinyl-chloride worktn is less than that of the United States population For example, the mortality in White steelworkers 86% of that expected1 and in White cotton textii. workers 79% of that expected.' However, even j> each of the observed/expected ratios in table n were multiplied by OS (80%) an excess of cancet, especially of the liver and biliary tract and brain, would prevail. Further, the increase with time a the ratio for all cancers would still be observe*, since each of the observed/expected ratios in table n would be multiplied by 0-S. Another theoretical objection to a proportional, mortality analysis is that a high ratio of observed to expected deaths may be due either to an execu of one eause of death or a deficit of another caust of death. Based on the data in table :, it seems most likely that the high ratio for cancer refiects an excess of cancer, since the ratios for each of trie four major categories other than cancer are all in the range of 0-8-1-0. It will be several years before a final conclusion can be made with respect to the carcinogenic potential of vinyl chloride. Since any harmful effect in an individual may require many years of exposure, wr believe that current exposure must be controlled. Rrqucsts to: reprints should be addressee to R. R. M. REFERENCES J* Otcch, Johnior., M, S., Block, B. Moreic, Mattel. tpkiy Ac 1974,23, 49. 2. Mon*o."., R. JL Cpuipvtrrt iipmtd. Ac. (in the prctil. 3. Lloyd, ). Dottt>. A.,?, ntufi. Mt. 3969, 11, 299. 4. Hcndcrior., V.f Enurlme, P. C. Vd. 1975, IS, 717. Packaging for Safety Hospital admissions of children with suspected acci dental poisoning by medicines are not on the increase, and death of the child is a very unlikely result of such incidents. All the same, the work-load involved, the unpleasant nature of the treatment, and the worry to parents justify a hard look at any proposal to make medicines safe:. A working-group of the Medicines Commission has just reported on ihr packaging aspects of this question." The working-group opposes the compulsory introduction of reclosatle child proof containers and eomes down in favour of a introduction of non-redosable containers, where potentially dangerous tablets and capsules are packed in individual units in strip or blister packs. Among the objections to the reclosable containers comes one from the Department's lawyers; under the draft British Standard such containers would nceto be tested on children who would have to be taught ho*' to open them to sec if they were capable of repealing thf operation. If a child so tutored poisoned himself the tester* might be held liable. But the D.H.S.S. legal division add* a further objection: " the position in law is that no pare"' or guardian of a child of tender years is entitled to g"' consent to any procedure which is not for the benefit 0; the child." Medical research workers have long searee that this was sc, but has the Department, now the cer.'.mtsj sioner of much clinical research, stated this publicly before * .Mejiciaei Cerunrinen. Perwt on :hr P.-r>rr.:r,-i cf V,cwi.'1^" in Relation to Chile Site:'1. OOtair.iblt 5,or-, the D.H.S-d" IF Fimbvtj Squirt, LenCrn CM IPP. Letter ACRODERMATI LETHAL ISH1 DEF7CL Six.--Last year we , child under Err nrian: of acrodcrrr.it: ,! which requires a tyr. -ji either glucose or fr 3 addition to *rDiodoouin *).* Sms. talphate daily) led to restoration of n: tnrbborsly resisted a \ icrapy. Review of t: t,c; revealed that it hi sooths md it appeart tetponsible for delay ir. .best rapidly returnee tootrnued, as did the were promptly and c -stored to the diet.* It was then ippreei: to the pathogenesis of At ekmcal improver status, as shown by : which accompanied t) ttmm of normal be then tested clinically of the remaining eight pithica under my ear Karnes, and a: the restpietely from she : A!) of the children terns and are thrivin; tcrthtrmoie they en.ic Xipiri increase in the all the children (ext soon as zinc was add-, tpicuous when diodor hit patients has had the last patient in indicates that quite physiological limits c line sulphate daily) v. complete relief of sy: daily intake seems to doses, in order to dea tnc the like, in whir the element. Pubt require increased a cope with the growth that Prasad and ht: thuline phosphatase Plasma of ainc-defie: *bd hypogonadism j High doses of a: 'ell tolerated by ch he known toxic lire. J- AtuyiuMn, E. J.. E .. Meyn.Iwr,, E. C. k P. .V... S'.,-; C. MeyniEie., . J. L'. - hint, A. S.. jiilv si. * Pliuc. A. .. VJllr At(ki t. ,MrJ VC5903