Document j49JRJpG9wp11enQN0GOLz7R

HOW TO USE THESE SEPARATORS Use one page fo r each sep aration . S elect appropriate ta b , add fu r th e r Id en tifica tio n i f d e s ir e d , and co v er it with scotch tape. Cut o f f and d is c a r d a ll tabs except the one covered by tape. TABBED SEPARATOR SHEET Fora HEN-696 (3 - 5 8 ) inhibition test was ncg -live for echinrco. rosis, cysticercosis, and toxoplasmosis. Hemagglutination inhibition and floccu lation tests for filariasis were done on the possibility that the hemoptysis and eosinophilia (Loffler syndrome) might be ex plained Positive results were reportedhemagglutination titer, 1:200-800; floccula tion, 1:5. The second (1.200) and third (1:800) hemagglutination titers were posi tive. Identification of microfilaremia in the patient's blood or in the blood of her pet dog was not made. A presumptive diag nosis of infestation with Dirofilaria imm itix was made. Comment Despite the absence of microfilaria in the blood or demonstration of a nematode, Adolph et al1- have indi cated that serologic tests for filariasis (hemagglutination and bentonite flocculation) were useful in arriving at a clinical diagnosis of filariasis. On the basis of presumptive diagnosis, a therapeutic trial was undertaken with the use of diethylcarbamazine citrate, (2 m g/kg/day for one week). The dose was increased over three weeks to 18 mg/kg/day. Follow-up examination after three weeks of therapy showed no un toward effects and no signs of menin geal irritation. Diethylcarbamazine citrate therapy was discontinued af ter two weeks at the dosage of 18 m^/kg/day (five weeks of treat ment). Chills, nausea, and malaise were complaints during the fina1, week of therapy. The patient had no further he moptysis. Chest x-ray film was nor mal four months after treatment. The peripheral blood no longer showed in creased eosinophils. There have been no recurrences of the patient's com plaints of hemoptysis. There has been no eosinophilia during the nine years of follow-up. The hemagglutination inhibition and floccula tion tests were performed at the Public Health Sendee Communicable Disease Center, Atlanta. 1. Phillips JH Studies of the transmission of Dirofilaria im m ths m Massachusetts. Am JH yg 29.121-129, 1939 2. Beaver PC, Orihel TO Human infection with filauae of animals m the United States Am J Trop Med Hug 14:1010-1029, 1965. 3. Harrison EG, Thompson JH* Dirofilariusis of human lung. Am J Chn Pathol 43 224-234, 1965. 4. TuarxiH 1U, Firestone F, Blaustein AU: Hu man ujlrnonarv diroiilariasis manifesting as a "coin'"' lesion. JAM A 199 45-46. 1967. 5. Spear HC, el al. Solitary pulmonary lesion References due to Dirofilaria. N Engl J Med 278.832-833, 1968. 6. Lewis JF, Williams RW, Tinsley E: Pulmo nary coin lesion due to Dirofilaria imnntis. Arch Surg 98:388-390, 1969 7. Goodman ML, Gore I: Pulmonary infarct secondary to DirofUa n a larvae. Arch Intern Med 113:702-705, 1964. 8. Donohugh DL Tropical eosinoplnlia An tiologie inquiry X Engl J Med 269.13t57-1364, 1963. ` 9. Pande RS: Filarial encephalitis. J Assoc Physicians India. 10 469-471, 1962. 10. Alajouanine T, et al Encphalite puir en docardite fibroblastique d'origine filarienne. Read before the Socit Franais de Neiimiogie, Nov 5, 1959. * 11. Harrison EG, Thompson JH ' Dirofla- n a sis in pathology of prott<znal and hehnirthic infection. Marcial-Rojas ted), Baltimore, Wil liams and Wilkins Co, 1971. 12 Adolph PE, Kagan JG. McQuay RM- Diag nosis and treatm ent of Acanthn-'kfdtnuma per stans filariasis. Am J Trap Mid Hyg 1176-i, 1962. Asbestos-Like Fibers in Duluth Water Supply Relation to Cancer Mortality Thomas J. Masson, PhD, Frank W McKay; Robert W. Miller, MD Asbestos-like fibers in industrial waste first entered the water supply of Duluth in 1955. In the next 14 years, no carcinogenic effect was apparent in the patterns of cancer mortality among persons of ali ages, nor among chil dren. The period of observation is short relative to the latent period for occu pationally induced carcinogenesis from asbestos. (,JAMA 228:1019-1020, 1974) HIGH concentrations of asbestos-like fibers have been reported recently in the drinking-water supplies of Du luth, Minn, and other communities on the shores of Lake Superior. Officials of the Environmental Protection Agency stated that these fibers prob ably came from mine-tailings or mill- From ihe Epidemiology Branch, National Can on: c-M iiu'e, B e ih e saa, Md Reprint requests to A-52I Landow Building, National C ancer Institute, Bethesda, MD 20014 (Dr Miller) waste from taconite ore, which has been emptied into Lake Superior since 1955.'J This pollution has caused concern because occupational expo sures to asbestos are known to induce mesothelioma of the pleura and peri toneum, as well as cancer of the lung, esophagus, and stomach, after a la tent period usually of 20 to 40 years.' Asbestos fed experimenta'ly to rats has passed through the gastric and intestinal mucosa into the blood stream. Fibers were lodged in gut wall, lungs, brain, omentum, and other organs.1 To determine if the fibers present in the drinking water of Duluth were related to cancer mortality, we have studied data abstracted from death certificates for all persons who died of cancer in the United States, from 1950 to 1969. Methods The data were made available to us by the National Center for Health. Statistics. We have tabulated the numbers of deaths ascribed to cancer among whites, according to age. sex, arid five-year inlet vt's. as veh as th-' age-adjusted cancel death, rates tor Duluth (1960 population, 105,759), for comparison with data for the stale JAMA, May 20, 1974 Vol 228, No 8 Asbestos in Water Supply- Mason et el 10 IP Sites With Risk Ratios S 'icantly Different From Unity in at Least 0. ,-ive-Year Interval White Men White Women Site (ICD)"* Esophagus (150) State Countyt Stomach (151) State County Large intestine, excluding rectum (153) State County Rectum (154) State County Total digestive tract (150-1541 State County Biliary passages and liver (155, 1S5A) State County Pancreas (157) State County Lung (162, 163) State County All malignant neoplasms (142-205) State County 1950 1955 1960 1965 1950 1955 1960 1965 1954 1959 1964 1969 1954 1959 1964 1969 1.42 2.26" 2.20 1.30 1.80 0.07'! 0.10 ' 0.16 1.04 1.79 1.58 1.05 1.79 0-06? 0.06 1 0.14 (16)5 (23) (25) (14) (6) (2) (3) (6) 1.14 1.58', 1 30 1.481 0.92 1 02 1.40 1.17 1.13 1.61 ! 1 37 1.5711 1.04 1.02 1.77" 1 41 (90) d o t) (70) (61) (38) (34) (43) (30) 1.04 0 98 (47) 1.29 1.31 (60) 0.95 0.87 (47) 0.83 0 73 (45) 0.59" 0.52'i (27) 1 06 0 98 (54) 1.04 1.02 (53) 1.18 1 10 (67) J.25 1.26 1 60" 1 60 0.86 1.17 1.20 1 97" 1.37 1.10 1.63'! 1.68l| 0 66 1.07 1.16 1 94' (31) (30) (40) (34) (13) (18) (17) (25) 1.10 1 11 (184) 1.48' 1 44" (214) 1.30 1 25' (182) 1.22 1 16 (154) 0 79 0.76 (84) 1.06 0.99 (108) 1.18 1.22 (116) 1.30 1 28' (128) 0.65 0 60 (91 1.12 1.08 (16) 1 45 1 19 (20) 1.14 1 11 (14) 0 84 0.94 (19) 1.62 1 94'! (32) 0.74 0.84 (15) 0.68 0 79 (12) 1.28 1 43 1.39- 1.40 0 96 1.9011 0.71 1.41 1.18 1.16 1 34 1 35 1.00 2 12'l 0 68 1.43 (35) (381 (44) (44) (16) (38) (17) (35) 1.15 1.58' 1.35 1.49' 0.76 0.90 1 18 1.14 1 25 0 69 169) (103) (109) HSU) 19J 1.76 1.63 123) 1 39 1 30 t22J 1.31 1 15 1.11 1 01 (5'91 1.38'' 1 26 ' (65 2) 1.18" 1 08 1594) 1.29" 0.93 1 18' 0 88 (648) (377) 1.26" 1.10 1 22 ' 1.10 (525) (465) 1 20" 1 17 (527) ` International C la s s ic a l,o n of D iseases for World Health Organization numbers. iS ta te of M innesota. Hennepin County, Minnesota. SNumber of deaths in Du'uth. i Risk ratio differs significantly from 1.0 (P < .0 1 ). of Minnesota and Hennepin County, which includes Minneapolis (1960 pop ulations, 3,371.60.3 and $25,986. re spectively). The number of deaths from cancer and the age-adjusted death rates were examined for each cancer site, as coded according to the International Classification of Dis eases. ' Results For 21 cancer sites, risk ratios were calculated from age-adjusted mortal ity rates for Hennepin County and the state, and tested for statistical significance, assuming an underlying Poisson distribution. The risk ratios (Duluth/comparison group) for eight individual sites that differed signifi cantly (/'C.01) from unity for either sex are given in the Table. If the as bestos fibers had induced cancer at a particular site, one would expect the mortality rates for that site to have increased in males and females over time, especially in the most recent five-year period studied (1.965 to 1969). As shown in the Table, the only site that fell into this category was cancer of the rectum. Comment The question arises, is the excess of rectal cancer attributable to the fi bers, or is it one observation among many, which by chance fits the pat tern sought? Other human experi ence, from occupational exposures, re vealed that among 17,800 asbestosinstallation workers in the United S' kes and Canada in the 1967 to 1971 i ,-d, there were 26 deaths from cancer of the colon or rectum as com pared with 17.5 expected, not a very large excess. An important feature of this study was that cancer of the upper gastrointestinal tract showed far greater excesses than were ob served for cancer of the colon or rec tum. There were 13 deaths from can cer of the esophagus vs 3.2 expected and 16 from cancer of the stomach vs 6.6 expected. Thus, in Duluth, one would expect a greater excess of can cer in the esophagus and stomach than in the rectum, but this did not occur. It appears that the high rate of cancer of the coion in the 1965 to 1969 period in Duluth was observed by chance. To determine if young people were especially susceptible to the carcino genicity of asbestos in the drinking water of Duluth, we examined cancer mortality data for persons who died before 20 years of age, during the pe riod of 1950 through 1969. Through the use of Hennepin County and state data, risk ratios were calculated for leukemia (ICD 204), cancer of the ner vous system (ICD 193), and all other cancers. No significant excesses were fcur.d. The delayed effects of asbestos in drinking water are unknown, and the extent to which asbestos has accumu lated in the water with the passage of time has not yet been reported. A longer period of follow-up than was possible in this study will be neces sary before one can conclude that there is no cancer hazard related to the drinking water supplies of Duluth and neighboring communities. References 1. Findings of Fact Conclusions of Laic and Order for Judgment Reserve Mining Company, Minnesota Pollution Control Agency, Dec 15, 1970, p 3. 2. Environmental News Environmental Pro tection Agency. June 15, 1973. 3. ARC Monographs on the Evaluation of Carcinogenic Risk of Chemicals9to Man, Lyons, France, International Agency for Research on Cancer, 1973, vol 2. pp 17-47. 4 Pontefract RD. Cunningham HM: Pene tration of asbestos through the digestive tract of rats. Nature 243:352-353, 1973. 5. Manual of the International Statistical Classification of Diseases. Injuries, and Causes of Death, ed 7. Geneva, World Health Organization, 1957 6 Hammond EC (ed)- Combined Clinical Sta*f Conference held at the Clinical Center, Na tion d Institutes of Health by the National Insti tute of Environmental Health Sciences, Bethei-da, Md. Ann Intern Med, to be published. 1020 JAMA, May 20. 1974 Vol 228, No 8 Asbestos In Water Supply--Mason et al