Document Z4wVLQkbQNnBw1zYNwGmpJxod

R&S 110788 f BIO-MEDICAL RESEARCH DOCUMENT DESCRIPTION FORM 63 68 69 76 Duplicate in all cards:--> year as-1961- File number [Right justify [Numeric only] Author(s), as Last Name FS (No Punctuation) and coden for journal as JAMA preceeded by one blank space 1 20 21 Alonson . X?_ In _ xj /V\ AO 41 i lnhr\.on /H U 77______ 78 Sub-Index Code 60 61 62 Title of Report; end with space-hyphen-hyphen-space. Follow with Index Terms, separated from each other with comma-space. Avoid other punctuation; do not abbreviate. n n i -P/Z.Q pq/LT~/6/uA-L Mo/vf-fri-'/ ~tu ftfttonJGr. i hhuL-CU Loiii')r ^>------------------------------------------- 7--------------------------------------- (A)o j^ Lo'/'/'ds c//}_2 js-t 21 22 23 24 Source (Journal, Vol., Number, Pages, Date ) 12 Ane/'jLamclbT-- /--Au.gu%T /7~ ; IT * m"m--~/n7,*% 3?'f f-3f--~~ _ ....... _ 61 62 31 32 Brief Summary 12 10 SUMMARY: 61 62 61 62 63 64 the LANCET, AUGUST 17, 1974 lesions. Finally, radiology indicates only a possible and not the actual source of bleeding, and where two lesions arc seen endoscopy has the unique value of actually demonstrating the true site of bleeding. Thus radiology should be carried out only when endoscopy has proved negative. Endoscopy in Relation to Management The value of early endoscopy in management is that it tells the clinician the site of bleeding and the nature of the underlying lesion. Since acute mucosal lesions often heal rapidly and may Jbe difficult to deal with surgically, while chronic peptic ulcers tend to reblecd and to be amenable to surgery, endoscopic information could allow early decisions on manage ment. However, whether--or not this will reduce mortality remains to be evaluated. Other possible benefits from early endoscopy, such as reduction in blood-transfusion and reduced hospital stay, must also be evaluated, .. Emergency Endoscopy Services For the best possible results endoscopy should be carried out within 24 hours of the patient's admission, although there is still a good diagnostic yield up to 48 hours after admission. Early endoscopy involves the endoscopist in much time and effort, and, if adequate facilities with properly trained paramedical 0200231 397 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 foe acutely bleeding patients. Such hospitals planning to develop an endoscopy service should bear the manpower aspects 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. Requests for reprints should be addressed to J, A. H. F. REFERENCES 1. Memorandum on Future National Need* for Fibre-optic Endotcopy of the GascrointttuftAl Tract* British Society for DiftCitive Endoacopy, 1973. 2. Palmer. E. D. J. Am, mid. Att. 19M, 207. 1477. 3. Crook. J. N., Gray* J, W,, Nanco? F C., Cohn, I. Anm, Surf, J973. 175. 771. 4. Allen. H. M., Block. M. A.^S^humao, B. M. Artht Surg. 197X 104, 440, ., 5. Sugiw*, C Werner, M. H.. Hayes, D. F.t Luca*. C. E,t WaltJ A. J. ibid. 1973, 107, 133, |j 6. Katon, R. M,, Smith. F. W, Co4tro^nttndogyt 1973, AS, 728. * 7. Corton, P, B., Rosenberg, M. T*, Waldram, R, P. L., Axon. A. |T. R. Br. m*d, 7. 1973, ii, 505, jI 8. McGinn, F. P., Wilken. B. }.J. R-CotL Surg. Bdinb, 1974,15,112. 9. Forrest, f. A. H., FioUyson, N. D, C. Br. J. Hotp. Mid. (in the press). j, 10. Dvorakova, H., Jirasek, V., Setka, J. Urgent Endoacopy of Dilative and Abdominal Diseases; p, 48, Basel, 1972. ! 11. Allan, R, N. Dykes, P,W.,ToyevD. K. M. Br, mtJ. J. 1972, iv, 281. Public Health PROPORTIONAL MORTALITY AMONG VINYL-CHLORIDE WORKERS Richard R. Monson John M. Peters Deportments of Epidemiology and Physiology, Harvard School of Public Health, Boston, Massachusetts 02115, U.S.A. Maurice N. Johnson B. F. Goodrich Company, Akron, Ohio Summary In a proportional-mortality analysis of one hundred and sixty-one deceased wo.kcrs in two plants using vinyl chloride, a 50% excess of deaths due to all cancer was seen. Specific sites of cancer with the greatest excess included liver and biliary tract, lung, and brain. The excess in fatal cancer was seen mainly in men who died before age 60. Also, there was a trend in time in the ratio of observed to expected deaths: since 1970 over twice as many cancer deaths as expected have occurred. INTRODUCTION Os Feb. 15, 1974, four fatal cases of angiosarcoma of the liver among men who worked in a polyvinyl chloride polymerisation plant were reported.1 We present here a proportional-mortality analysis of all flXiths known among workers in that plant. Also v|Pcludcd are deaths in men who worked in a plant, in which vinyl chloride is produced. ,, methods j Vinyl-chloride monomer is produced at a plant in Calvert City, Kentucky, and is polymerised into pol)vinyl chloride at a plant in Louisville. These plants have been in operation since the late 1930s. Whenever an active or pensioned employee at these plants dies, a copy of the death certificate is obtained. An abstract of the certificate is made and the certificate is sent to the insurance company. Using these source*, one hundred and sixty-one deceased White males who were employed at one of the two plants were identified.' No information was available on workers who left cmplojment before retirement. For all but nineteen a copy of the death certificate was obtained. For the remainder the jrause of death as recorded in the company abstract was !used. Deaths from 1947 through 1973 were ascertained. Of these deaths, one hundred and thirty-five occurred among Louis ville workers and twenty-six were among Calvert City workers. j 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 White males. The observed deaths from all causes were stratified into 5-year age/time- specific groups, and age/fime/causc-specific proportional- mortality ratios were multiplied by these numbers to obtain the stratum-specific expected numbers.1 RESULTS The patterns of mortality among workers in the two plants were similar, so all men were grouped together. As seen in table t, a 50% excess of deaths due to cancer was observed (jc~5-7, p<0-02). in addition to the four deaths previously rcportcd,'| a fifth man who died of angiosarcoma of the fiver was identified. Also, there was one cancer of each of the following sites: gallbladder, common bile-duct, and R&S 110789 iI 398 / / THE LANCET, AUGUST 17, I9Tl ^ TABLE I--OBSERVED AND EXPECTED DEATHS IN VINYL-CHLORIDE WORKERS* An analysis using proportional-mortality ratios does not take into account the absolute risk of dyi>n4gl Hini I.C-D. no. f Cause of death Observed Expected Ob*./exp. 140-205 ISO-159 155 162, 163 193 200-205 330-334 400-458 800-998 960-969 - "' All All cancel .. ,. Digestive Liver and biliary tract .. Lung Brain Lymphatic and hematopoietic Other cancer! .. CN.J, vascular Circulatory External- .. Suicide . All other causes | .. 161 41 13 8 13 5 5 5 8 66 22 10 24 161 0 27*9 3-3 0-7 * 7*9 12 3-4 7*1 9-5 68-6 24*5 5-3 30*5 1*0 1*5 1-6 110 16 4-2 1*5 0-7 0-8 10 0*9 1*9 0*8 the population being studied. Thus, it is poss^ that the mortality-rate in the vinyl-chloride woirl ll is less than that of the United States populau? For example, the mortality in White steelworkers was 86% of that expected3 and in White cotton textile workers 79',*,, of that expected,' However, even if each of the observed/expected ratios in table II were multiplied by 0-8 (80%) an excess of cancer, especially of the liver and biliary tract and brain, would prevail. Further, the increase with time in the ratio for all cancers would still be observed, since each of the observed/expected ratios in tabic n would be multiplied by 0-8. I ^ * Expected numbers based on agc/time/causc~3pecific proportional* mortality ratio* for U.S* White males, f International Classification of Disease*, seventh revision, j Nasopharynx lf prostate 1. kidney 1. thyroid 1* Undetermined 1, | Includes 2 Cirrhosis (4-4 expected). Another theoretical objection to a proportionalmortality analysis i:> that a sigh ratio of observed to expected deaths jnay be c ue cither to an excess of one cause of death or a deficit of another cause liver (type unspecified). There were five brain tumours--three glioblastoma multiforme and two of unspecified type. There was a 60% excess of cancer of the lung, of the following cell types: bronchogenic of death.* Based ofi the data in table i, it seems most likely that the high ratio for cancer reflects an excess of cancer,! since the ratios for each of the four major categories other than cancer arc all in the range of 0-8-10. (one), anaplastic (one), adenocarcinoma (three), un specified (eight). There were two unusual other types of cancer--thyroid and nasopharynx. There was an excess of deaths due to suicide: ten observed and about five expected. The observed and expected numbers of all cancer according to age and year of death are presented in It will be several years before a final conclusion can be made with respect to the carcinogenic potential of vinyl chloride. Since ariy harmful effect in an individual may require many years of exposure, we believe that current exposure must be controlled. Requests for reprints should bejaddreued to R. R, M. table ii. Excess death due to cancer was seen REFERENCES primarily in men who died before age 60, There 1. Creech, J;. Johnson, M. N., Bloe't, D. Morbid. Mortal, vtkly was a trend in the observed/expected ratio with year 1974. 23. 49. , at death. Before 1965 no excess of deaths due to 2. Monson, It. K. Compmjri biomrd. !to. (in (he press), 3. Lloyd. J, W., Cioeco, r\. J, atcup Mtd, 1969, 11, 299. ii cancer was observed. However, since then there has been an increase in the proportion of death due to 4. Henderson, V., Enterline, l. C. ib J. 1973. 13. 717. 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. vital statistics data. Packaging f< r Safety Hospital admissions of chi dren with suspected acci TABLE n--OBSERVED AND EXPECTED DEATHS DUE TO ALL CANCER ACCORDING TO AGE AND YEAR 0? DEATH dental poisoning by medicines ; re 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 Characteristic Category Observed Expected Obs./cxp. of the treatment, and the worry to parents justify a hard look at any proposal to make medicines safer. A working-group Age at death (yr.) .. <50 50-59 60 +* ' 11 17 13 7-6 8-1 12-2 1-4 2*1 1*1 of the Medicines Commission has just reported on the packaging aspects of this question.* The working-group opposes the compulsory introduction of reclosable child Year of death < 1965 1965-69 1970 + 12 10 19 U4 7*3 9-2 1-1 1*4 2*1 proof containers and comes down in favour of a stepwise introduction ofnon-reclosabie containers, where potentially dangerous tablets and capsules are packed in individual units DISCUSSION in strip or blister packs. Among the objections to the reclos able containers comes one from the Department's lawyers; under the draft British Standard such containers would need 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 vinyl-chloride workers. It also appears that the relative frequency to be tested on children who would have to be taught how to open them to see if they were capable of repeating the operation. If a child so tutored poisoned himself the testers might be held liable. But the D.H.S.S, legal division adds a further objection: " the position in law is that no parent or guardian of a child of tender years is entitled to give consent to any procedure which is not for the benefit of the child." Medical research workers have long feared that this was so, but has the Department, now the commis of all cancers is increasing with time. While no pro sioner of much clinical research, stated this publicly before ? jection may be made with certainty, additional excess cancer among vinyl-chloride workers would seem likely. * Medicines Cnmmojion. Report on the Presentation of Medici in Relation to Clidd Safety. Obtainable from the D.H.S.S., 3r Fimbury Square, London EC2A 1PP. R&S 110790 848 THE LANCET, OCTOBER 5, 1974 cranial aneurysms during the time from initial haemorrhage until surgical treatment,1-21 * 4 5 6 A year ago we adopted a regimen of 4 g. b.a.c.A. 4-hourly in such patients, but it was our clinical impression that there was little change in the rcblccding-rate and several harmorrhages recurred on the night before operation. The e.a.c.a. blood level falls steadily over the 2 or 3 hours after intravenous administration, implying that there may be a " rebound phenomenon " by 4 hours.1 The dosage regimen of e.a.c.a. was therefore changed to 3 g. 2-hourly. Since using this higher dosage five patients out of nine have had a second subarachnoid haemorrhage before they could be treated surgically (see accompanying table). RESULTS OF HIGHER-DOSE REGIMEN OF E.A.C.A. IN PATIENTS WITH SUBARACHNOID HALMORRHAGE Age Sex (yr.) M 42 F 49 V F 49 F 41 M 50 M 37 F 48 F 66 F 36 Site of aneurysm Middle cerebral artery Anterior communicating artery Posterior communicating rtery Posterior communicating artery Posterior communicating artery Multiple Multiple Posterior communicating artery Multiple Spm Grade on admis sion --l Re bleed ? +1 + it 3 + l+ l l --l + + II -- -l - Final grade it Dead Dead III I I Dead II i Grade I -fully oriented and no signs. Grade II - confused or neurological signs. Grade m - chronic vegetative state. PROPORTIONAL MORTALITY AMONG VINYL-CHLORIDE WORKERS Sir,--As indicated by Purchase and Williamson (Sept. 7, p. 591) it is desirable in studies of mortality and propor tional mortality to compare disease-rates in a study group with those from a similar community. However, tabula tions of deaths in the United States are not available in sufficient detail by age, time, sex, race, and cause to permit county-specific or, for many diseases, State-specific comparisons. A recent publication is an invaluable aid in assessing the degree of bias likely to be introduced by using national data.1 Average annual age-adjusted cancer-mortality rates per 100,000 for White males in Jefferson County, Kentucky, where Louisville is situated, compared with rates for the United States (in parentheses) are: biliary passages and liver 5*5 (5*2), primary and secondary trachea, bronchus, and lung 43*9 (38 0), brain and other parts of central nervous system 4*5 (4*4), all malignant neoplasms 184-0 (174-0). Also, mortality in 1960 for all causes for Kentucky White males' is similar to that for United States White males *--973*6 (956*2). There is no indication in these data that use of proportional mortality for United States White males could account for the observed/expected ratios reported in our paper (Aug.-17, p. 397). Department of Epidemiology, Harvard School of Public Health, 677 Huntington Avenue, Boston, Massachuictti 02115, u.s.a. Richard R. Monson. 1. Mason, T. J., McKay, F. W. U.S. Cancer Mortality by County: 1950-69. Department of Health, Education and Welfare Publica tion no. (N.I.H.) 74-615. Washington, 1974. 2. Grove, K. D., Hcucl, A. M. Vital Statistics Rates in the United States; 1940-60. Public Health Service publication no. 1677. Washington, 1968. We have lately seen a case of extensive muscle necrosis in an obstetric patient on the lower-dose regimen. Throm boembolic complications during E.A.C.A. therapy have been reported, including peripheral gangrene; thrombosis in the coronary, gastrointestinal, and glomerular vessels; and pulmonary embolism from deep-vein thrombosis.1** Cerebral angiographic changes resembling arteritis or intravascular thrombosis have been reported in three of seven patients receiving e.a.c.a.* Although we realise that the number of patients involved is too small for statistical analysis, the benefits of E.A.C.A. therapy in subarachnoid hsemorrhage from ruptured intracranial aneurysm do not seem to justify the potential risks, and we feel deterred from proceeding with a thera peutic trial. We would, therefore, be interested to hear of the experiences of others. University Department of Institute oVNeurologica'l Sciences, M. D. M. SHAW Glasgow G51 4TF. J. DOUGLAS MtLLETt. 1. Mullen, 5., Dawley, I. J. Ntvrounz. 1968, 28, 21. 2, KamoholT, J., Goodgold, A., Benjamin, M, V. ibid. 1972, 36, 525. 3 Patterson, R. H.. Harper, P. ibid. 1971, 36, 365. 4. Charyton, C., Pantilo, D, New //. 7. Mid. 1969, 280, 1102. 5. Naeye, R. L. Blond, 1962, IS, 694. 6. Sonntag, V, K. H., Stein, B. M. J. Niuroniri. 1974, 40, 480. Obituary A ARTHUR HENRY DOUTHWAITE M.D.Lond., F.R.C.P. Dr A. H. Douthwaite, consulting physician emeritus to Guy's Hospital, London, died on Sept. 24 at the age of 78. He was born in China and educated at Bristol Grammar School, the University of Bris tol, University College Lon don, and Guy's Hospital. He was a civilian prisoner-of-war in Ruhlcbcn, Germany, from 19L4 to 1918, and he entered Guy's in 1919, qualifying in 1921. In 1922 he became M.R.c.P. and was appointed medical registrar at Guy's. Illhealth led him to leave London and work in general practice in Worthing for a few years, but he returned to Guy's as assistant physician in 1927. He remained at Guy's until his retirement as senior physician in 1965. His published work included