Document mBXqZ95rjEeXgR76exv7VnoNg

/&>7 m -1* ; i r n r l ; m i ' i r o n h c d i J t 7 ( 1 9 8 ' ) 2 ! i 7-- 262 A c a : r -?- C d:sori.rJ: iolvcnu.Mr-Vii-i 7GJ U Curr -v J':.S'-*: ; Relationship between clinical and electrophys- luoiogical findings and indicators of heavy woio^^'eXposure to 2, 3, 7, 8 - tetrachiorodi- T'lvtfi'ijenzo-dioxin 0 > - o 3 - 0*/ 6) 2 2 2 ^*,*-^'- ^ Graziella Filippini. MD, B ia n c a Bordo, MD. Paolo Crenr.n. MD. oi 2,<---r-5'`uirnlella M assello, MD, M assim o M usicco. MD, R e n a to Boeri. MD 1 *. ^rri2 7 . & 1N.,CW | on their'd^; 2s- AixhY'I'S ` 7- ' : -Vii- * pcri.S5';ic 10 aa-rfijs-fj F I U I 'P I N I C. HOHDO D. CRF.NNA P. MAKSKTTO N. M C S H V O M. MtJKIM I; II,-I;,ionstiip betw een clinical an d clcclrophysiologicnl b o ilings anti iin lic a im s i.f Ihmvv exposure lo J.S.T.fl'tclrachlorodibonin-diiixin Srtmti } ...... c n rin tti lirnlili 7 il'Ullj 237--L't)!1. Jm llii.i Mnd.v th e |>rrv;ileim* rail* f |-i ]*1n.>I ni-u< <<n.<i My in :> Jation living in an a r e a p o llu ted with 2.2.7,l)-U'lr:ichlt>rinli)>rn/.M-ih<txiu Iillo xni-T l'IH l] 'c ' -mlo-]oe*V'*`-'*HrK3--f: n cifccu Scancl :`l i'kj-'H -! 69. ; :rs on tri.- p r ml5iitpaotjsvegd jj-wiagj.fi . 3r iuncM ifei 7S) 976--yi'i "' : h'!.! was d e term in ed . Of th e 723 su b jects inv llcd lo th e first .wrivniiu: in l!i77. 47n HiS *M attended. At t h e ' second s c reen in g in 1D7H, of ile 71tl invtivd su lijiv is. .'lip H.l attended. P re v a le n c e ro te ratio s for p e rip h e ra l n e m u p a t h v an d th e nssnci.-iOtl Pa */ confidence limits w e re c a lc u la te d for s u b g r o u p s rivii-rinmcd hy IIn* p re s e n c e uf ti) predisposing factors to n e u ro p a th y (alcoholism, riinbei rs. m r u p a iiim a l e x p u s iirr in ni*n- roloxic agents, etc) or fii) conditions th o u g h t to result fruin ex p o su re to diu x in -T C D D such as c h lo ra c n e o r a b n o r m a l s c r u m h ep atic enzym e levels. Tlu* p r e v a l e n c e rale n[ peripheral neuropathy among those subjects wiih predisposing factoi's and among those w ith chloracne or abnorm al scrum hepatic enzyme levels was n early lhr.ee limes greater th a n am o n g those w ith o u t these mariifcslnlintis. T h e resit Ms d e r i v e d from ihis study may be useful qualitative pointers for identifying subjects at risk in the neuro logical follow-up. K e y term s: chlurocne, dioxin, e n v ir o n m e n ta l p o llu ta n ts, liver dam age . p<-riplier.>t nei<. '11 rop alh v, raised s e r u m h e p a ti c enzym e levels. ; * of c a r j p S ij j'; : n . cait-jiJ'! TYg0bject5 occupational or accid en tal, lion of chlorocno w ith increased ;*GT, 71aco* 3s^U ,;elposure to 2,3,7,8-letrachlorodibenzo-di- GOT, and G PT activ.ilics and abnorm al slimaiio iiM- ;oxin (dioxih-TCDD) have been found lo lipid levels has also been rep o rted (19, -Pldcm ior^jr:evelop a wide v arie ty of lesions and 12mm0ssit9oo7rrE-yrj'*7;-I;^/f*??i -sr^P '.*d.uae loms' pn on llyv nn-Ner uuerruoornpoaallthhS. iii.eecssa.,l Endings may inlloo ww eerr ee xx ttrr ee mm iittyy ireskness, or sensorial im p airm en t (sight, essinait " : | faring, smell, taste), all of w hich hove ;2Ririea, Ma keen recorde* fr dioxin-exposed subjects -mg p r S ? in wi,om o lh er long-term effects such as spcc;jvf '-Jj Chloracne, raised levels of cholesterol, 12es* ^glyceride, gam m a-glutam yl iranspepti- :mus dase glutam ic oxalacelic trons- `seuISrcjj'if uninasc (GOT), and glulam ic pyruvic ^Sche:cj`_.;<`| transaminase (GPT) w ere m anifest (1, 3 - 5S">""r^t " ^ ,^7 IS). An associa- personal eommimieotion from M Muses). The rale of reported congenital anumnlies in men rnlhering at li*:ist one child a fte r service in Viet Nam was nearly twice as high among those with roeum -ni acne, skin rash with blisters, and skin color changes consistent with conditions thought lo result from exposure In dioxin-con tam inated substances as among those w ith out them (15). Knr men w ith these "in d i cators of exposure" g re a te r fro*ii;**:icie,s have also been ivporlrd for gastrointes tinal disturbances, swelling or num bness of joints, and sleep and psyehologieal dis .*;l| i Jsifluto .Vcurologico "C. S c stn ," M ilan. Italy. tu rb an c es (15). : Bcpdnt requests to; Dr C Filippini, Istiluio Ms yrurologico C. Bestn," Via CcJoria II .jDan, Italy. These previous findings prom pted us to com pare the prevalence ra le (PR) of p eri pheral neuropathy in exposed subjects *3 o;.ra-:i i-in i n <; _.*"-.:trev\'*St-iv'a?'c.";vfii.':U-s .*ri.-pt ..' w i!It i lil.ii.n ii- im mu i i .i.-fil f'i . t It)'I . ;i11ci of the study because t >l ` T ;i rl iv-jIm** u`il:: lh:il fniinri in vxpi'M'd jected the use of the needle, 'iibjiTi.*-' u*ilh.*iii Uu-m* m.itiifi-.sKiii>inv in a |*"|mi!:i1inn living in ; d m \ i n - 1il'-uud ;nv;i in Hu- S r \ c.mi i cl; ii*ii t>T 11:i)\- potentials were recorded elect rode (Disa 13 X 60) from171 lir minimum abductor and extensoirr *.-;-7 y'-/ i. ;J. sed enzyme act b re v is muscles at a surface 1 was a: SubjeclsTand methods above 27 *C. Minimum conduction was determined by the desynchro" . UP to ^6 vJ/1, Szasz 116]), G* ):i J u l y 1fi7G. :<n ;icfitleni ;il :i irichlurophi -nul-producing furiury in ,\U-d:i. 1laly, rc-sul led n the cun in mi n; 1lion of a large, densel y pupu):i led ;i rca. Seven hu ndred and thirty -t hroc residents were evacuated 15 lo 20 d after t he accident i r o m t he most pnlluied zone (:in :nva of 10S ho wi th an average* d ioxi n- TCDD level of 2-10 i/g "m". m a x i m u m I c e d of 5.-177 i<g n r . and an mu- val uabl e m i n i m u m level) (-l). These residents wen* inviled by leller and per method of Cosi et a] (5). Motor ^ range: up to ' latencies were corrected to z - A-- y * " o p t i m i z e d distance of 6 cm. A Disa 1500 ,above 50 U/l I myograph (Disa Elektronik, r f ' s . P^ > ^ determined Denmark) was used. -. . t^)]. A nonexposed population living -- ^ statistical analyse unpolluted area was used as a socrer ^"j ^ within the ex "norm al" reference values of the relationship betwee: physiological parameters. A total o. . : and indicators i (91.6 7t> of the randomized sample)^Y^j^Tdicxm_ being tested, jeets, representative of all ages. ^ sr,ce rale ratio (F sona! invilaliun d u r i n g visils al mine in cipalud. Seventy-five of these ^ ^ n ip a th y were caiculn ai: initial n eumlu^ieal scr eening in March were alcoholic, occupationally exposed : with chloracnc- 10.7 an d in a >eeu:id serei-iiing in April nvurotoxic agenLs, or had diseases Pr^ :* v ^ h i p a t k enzvrne levels v l!!<0. Al the first ser vening five s ubj ec ts posing to peripheral neuropathy and ^ had cited and five ha d moved front the thus excluded from the calculation o. c* .without *them . K rgr-y area. Of the 72.'l i n h a b i t a n t s inviled to reference v . l u c The noon,." LL p ar t ic i pa t e in the scr eening in Sevcsn. -i70 values obtained are given by age (fia " 0 atte nd ed , Dur ing the period March in table 1. Conduction velocity and di-Ct ^v;j: - (20) 1077 to April 197H. five died and nine latency were considered to be in *- moved from the ar ea . Of the 7(J!) i n h a pathological range when the former ^ ^ b i t an ts invited to the second sc r e n t in'*. lower than the mean - 2 SD and the Molotr " "S"*?*'?" 2 If) (-la **.) alt ended, 277 of w h o m had been ler was higher than the mean + 2 _________ ;______. e x a m i n e d at the first screenin' and -12 uf the reference population of the same whom were examined fur the first time. Of t he l a t t e r -!2. 1) c hi l dr en u n d e r iho age of 5 a r ef used lu p a rt i c i p a t e in t h e elccl r ophyxiological examination and were thus group. These two parameters were n-'* mally distributed. Amplitude and durs*^ of muscle action potential were consider^ abnormal when the former was below fci Humber oi referents Ape () Ur excluded from the prevalence calculation. No a c u t e p o l y n e u r o p a t h y wa s found d u r ing the study. haeh subject was examined according lo a standardized protocol requiring a med lower range limit and the latter was abo the upper range limit of the reference PF ulation of the same age group. peripheral neuropathy two or more ab- UUtiixlixlr*ls. w1 in7sa 15 Pwontil (.pliulum libultuUi) its 115 u 6-- 30--59 M fc--79 - 30--59 Cl 5i 59 5.* K4'. ical histor y q u e s t io n na i re , a clinical e x a normol param eters, among which cond*^ J . mination, and an electrophysinlngical in vestigation. The neurological symptoms specifically identified were paresthesia, lion velocity was obligatory, were coi^..^.-. side-red necessary, regardless of the volvcd nerve. All Scveso subjects Table 2. Prevalence rale roups-o! Seveso resident hypc sl hc si a, pain, and h y pu st he n ia . and investigated for the following factors pr*- \ llu* clinical signs wen- -"ipeifirial and deep disposing to neuropathy: alcoholism (mc.~i t sensory i m p a i r m e n t , m u s c u l a r weakness, than 1 ] of wine consumed daily), persor-il Yan d n. ndon h y po - or a ref) ex ia. T he elect ro- history of diabetes or fasting plasma glU' priysa nu^ical study included maximum and minimum motor conduction velocity along the ulnar (axilla-wrist) and peroneal (capiiulum fibulae-aiiklc) nerves and needle electromyography on the first in terosseous muscle. However, electnmiyo- cose ^2 100 g'llm, cancer, nutritional defici ency, infectious and inflammatory disease 1-. V (** Actual c a s e s of peripheral neuropalhv oslcuarlicular diseases, use of ncuroloxic 7clal num ber ot so! drugs, possible occupational exposure w ncurotox'ic agents [chemical workers, shoe' PR (7.) M PRR 65 V# c o n fid en ce limits makers, plastic workers, painters, cabinet p r a p h v w a s a b a n d o n e d d u r i n g t he course makers, printers, tanners, ceram ic work- 1 Evaluated versus emu subjects re- crs -- according to the International S ta n R esu lts usclc action dard. Classification of Occupations (9)]. a superficial *m ihe ;-cR CMoracnc was diagnosed by a aermnto- ficlufiuiis/iij brltcc'cn tin- <`tTitno'icc o/ laSist. pcrijilicrnf nein opir (hi; nmi u.diciitori or digi'orum Increased enzyme activities were re- n f hrttr;i e.rpoatrrc Jo (fin.iin temperature fC.-ded when ;*GT was above 50 U/l (not- lion velocity r.s! ronge: up to 30 U/!. as determ ined a f I' -. .11 .1iimi 1i177, 22 - with s-v/nptoms .ichronization Motor distal a standard 1500 electro- fording to Szas2 110]). COT was above- 50 U/l [normal range: up to 20 U/l, as d e te r i mined `he "optimized method" (2)), nnd C?T was above 50 U/l normal range: up nr clinical ant! electinpiiysiulugical signs of p erip iie r.il n e u r o p a t h y a n d 20 cases w ith electi ophysiologica! abnorm alities had been f o u n d a m o n g t h e i' 7l) M i b j e e t s e x a m i n e d , Skovlunde, yj 32 U/l. as determ ined by the "optimized f o r a to ta l PR of 8.9 ",> (9fi ``/u CL, 6.2--- method" (2)). M .(] A m o n g t h e 308 s u b j e c t s w h o u n d e r living in an 'I The statistical analysis of the data was w e n t a c o m p l e t e e x a m i n a t i o n . 2G c a s e s 3 a source for ^-formed within the exposed population, w i t h s y m p t o m s o r c l i n i c a l a n d e l e e i r o - )f the electro- jje relationship between peripheral neu phy x io lo g ieal s ig n s of p e r i p h e r a l n e u r o i total of 380 sample) sub- 1 ages, parti- these subjects ' lly exposed to! diseases prdis- 1 ,?:4 oath y and w ere ' - j culation of the -mal" reference -f-3 by age groups ocity and distal ropathy and indicators of heavy exposure to dioxin being tested. The PR and the prevalence rate ratio (PRR) of peripheral peuropathy were calculated for the Scvcso subjects with chloracne or raised serum hepatic enzyme levels versus Seveso su b jects without them. Ninely-five percent confidence limits (95 /o CL) were estim at ed according to the method described by tfoolf (20). p a t h y a n d 1G c a s e s w i t h e l e c t r o p h v s i o l u g i - cal a b n o r m a l i t i e s w e r e f o u n d b y 31 J u l y 1978. fo r a 'lo ta) PR of la.G u/v (95 B.:o CL. 9.5 - IT.li). Table 2 reports the PR and the PRR of peripheral neuropathy for subjects with predisposing factors (gruvip A) and for subjects with chloracne or raised serum hepatic enzyme levels [group 3) versus subjects without the sym ptom s of either to be in the* the former was SD and th e lal-Vt fatife L Motor co n d u c tio n velocity, distal latency, ampliiudr'. and duration ol m u scle action p o te n neap + 2 SD of ;u3 tial (surface elec tro d es) in the 305 relerents. af the same age eters w e re nor-f -fl jde and duration ***** were const dered:.y 2T was below the*AjJ NumOor ol rcfe'cnu A W Ujiimum conduction v e(ml o/cei)t y M e a n ;. so M e d ia n klinioun Cpnfliictinn voloc (m/i| M e a n t SD Meoion l.O'illsoin. icly Inis) Amolt.lmlo flTuorn!..1l1on M ean 1 SD M edian R jtne R ange latter was above, i f he referen ce p o p i:,j5 fV-irii 172 118 ^roup. 'J ii? fT7**i 15 fi&ntt1 1W gical diagnosis of pijtiutura 115 wo or m ore abl' j; j-.*t**- 12 s--rs so--ss > 60 ' 6-- 29 30-- 5? 1' 60 60.2 i 5.3 5 8 .2 i <.4 5 7 .8 5.0 52.7 i 5.0 5 0 .9 i 4.1 <9.8 r 3.7 60 58 57 52 51 50 65.5 t 6 1 54.3 53.4 Zt 44.43 40.9 t 4.9 47,9 z 3.7 47.3 1 * 1 55 55 5? 4P <7 47 25 *0n 2.5 0 5 *2 6 0.5 3 0 05 3 3 on 3 9 0 6 75 ?5 76 31 3? 34 4 r*-- 1J 4 5-- 15 4 5-- 15 2 -1 1 2-- 11 -- 11 11-- 13 11-- 18 --11 15 1 0 -- 17 1 0 -- 17 10-- 17 -ig which conduc- atory, Were conrdless of th e in- 1% tibte 2- Prevalence rale (PR) and prevalence rale mhos (PRRs) for peripheral neuropathy in sub- zso subjects Were !*.* ptnips ^ eveso resicienls in 7978. awing factors pre- - ........................................... ......... -- -*----------------------- : alcoholism (more ed daily), personal asting plasm a glu. With pred*isposing factors With indicators of exposure ~ Without A or B n u tritio n al oefici- jttuti cases of am m atory diseases,, peripheral neuropathy use of neuroloxic' loteJ number of subjects e).ion si exposure to deal workers, shoe- _ PRR/** confidence limits i. painters, cabinet 17 85 70 2.6 1.2-- 5.6 12 55 22 2.8 1.2 -G.5 13 168 7.7 1 .-rs, ceramic work- * E qualed versus group C. A in )i C). I'ul t h u Mibjt-L-lS nf g r m i p A ilit.- ! 'Kit u-.iv m j'.iu fn;:i nl !y g r i x i l c i ' 1n :in m u '. :i>. uni* w o u l d i* x p rcl. T h e J 'Ilit u'.i-; v i^ n irir.u illy g iv n tn lli;m unc :i!sii fur t h e s u b j i c l s of g r n u p li. T a b l e -i >In>ws llu- J'K ii of p e r i p h e r a l ;h.-u i oji.'i ih \ [ o r s u b j o i n w i l h i n c r e a s e d ;G T . G O T , ;oul C R T Hclivilics :ind for subjects wilh ehlm-acne versus subjects w ithout ;my of these muni festal iuns. The P n i\ wus significantly different fimn one for the subjects wilh abnorm al hepatic e n z y m e lev els ;nul w;is gre.'i ter lim n one for the subjects w ilh ch lo rarn r. even t h o u g h t h e l o w e r !Jo "V C L w a s e q u a l to one. in the upper and lower limbs) U'C; Neuropathy was ob significantly associated with periphery v-'ho showed indica' neuropathy in the three subgroups of to dioxin (12 out of expused population (table 4). Six subic'- rience was almost \x'iIh symptomatic neuropathy and six* than th a t of subje asymptomatic neuropathy anc six thest indicators. .1 clinical symptoms and signs only, with-- neuropathy found f clcctrophysiological evidence of periphery! ` _ *cne is interesting neuropathy, were found in the group v"'-t 2 good indicator i indicators ci heavy exposure to cioxtf- 7, Moreover, during The arms and legs were involved for s*^ t-\; cre w as found o polyncuropalhic subjects wilh chloracnecr igf; group (0 to 20 a) raised serum hepatic entym e levels, tr,! f-vtjuency of neuropal' legs of one and the arm s of five (the J:S' ' In fact, the FRR of : five subjects acne). were children with chlo-'* ir) jects u n d e r 20 a of : sus those without % -I CL, 1.2-- 18.1), a v i i e l o l i o n s h i p I i c li r c v n c iin ic o l si/ mij)Ioiiis e n d s ip ns. o i d p e r i p h e r a l n r u r t i j i n t h y Discussion one (2.6) observed jects oi all ages. I: mal hepatic enzyme- C lin ic a l s y m p t o m s ;iik I s ig n s ( p a r e s th e s ia , bypostheni:i. weakness, hypo- or areflexia It th is al a evid ver ent yh from igh p retvhaelenpcreeceodf inpgeriprhcseural--lI 12 iti:. mon in the adult a lion w ith peripher: be so unusual. It m ust be stress Table 3. P revalence role raiios for peripheral ab no rm al hepatic c n /y m c levels in 107(1 neuropathy in Seveso Abnormal hepatic enzyme levels B With Wiihoul subjects h&uropathy w?-^ v/ilh c h l o r a l 6 c` and the polym. * hoi severe. The cl*. Nosis oi periphera*. Chlorscne 1 ridered the most ivilh w hich to stut Wilh Wlfwrf F E lects of dtoxin-T Aciunl c a s e s of p eripheral neuropathy Total suojecls Prevalence rale raiio 95 % confidence limits 6 19 18 205 ` 3.6 1.3-- 10.2 6 12 24 125 2.6 1.0-- 7.2 peripheral nerves c At the follow-up Nonattendants was analysis was carr a Calculated only lor subjects without predisposing factors io peripheral neuropathy. whether the group amined in 1978 w-as regards the dise; Tabic 4. Rela'.ionshio betw een clinical sym ptom s and signs end peripheral n eu ro paih y in subgroup" ci Seveso residerus.a of the presence of signs which could 1 lecled subjects to SuDjocts With predisposing factors Wilh indicators of exposure V/ilhoul A or B .because of the pr disposing towards The frequency of Sym plom s Nlo sym ptom s nnd signs or signs Symploms No symploms and signs. or signs Symploms No sy: and signs or i pathy-related facto kv*. higher among* thoi Neuropathic Noi mal 11 (65) 130) 2G (361 [70J / - = 3.05 6 (35) 112] 42 (G2) l&SJ p < 0.05 D 6 (501 [50] 6 (14) |50J V - 7.15 6 (SO) n<i 37 (65) 1*6] p < 0.01 9 (69) 160) 6 (<) (40) z~ ~ 63.01 4 (31! i?i 149 (25) 13?) P< ;-* sp ed to those not \ mere subjects will ! mal scrum hepatic t reexamined in the `..t 1.hypothesis that :*p) Were positively sc The row p t i c e n i a g c s indicato ihc p e rc e n t a g e distribution of the sym ptom s an d sighs ol n e u ro p ath ic and normal sub jects lor e a c h su bg rou p, and the column p e r c e n t a g e s in diciti P* pcrconlngc: distribution ol the c a s e s ol neuropathy and normality tor the sym ptom s and *lpr i b Th;roi w as a significantly higher p rev alen ce of neuropathy for su b je c ts with sym ptom s and versu s subjects with no symptoms and signs in each subgroup. t'lV- * the disease (' r|*. fore confirmed*^j existent neuropath . subjects exposed t e vcre cr:>l i -neuropathy was observed arnunr. subjects j who showed indicators of heavy exposure .1:1 i m p o r t a n '. q u . i l i l . i l i v e f; rt 1t;' o r th c identifica',itn nf suhjrcis nt risk. the : ( to dioxin {12 out of 55, 22 D/cJ. This prev- A n e u r u l n g t c a l f o l l o w - u p uf llii*- v ' p u "1 zlcnce was almost three times ft renter la lio n is in p r o g r e s s . T h e p r i n c i p a l o b j e c - with ' * than that of subjects who did r.m show lix'Ot ;I c 1ni- 1 rn-.e Un i-n'.i mi na '. m r .n - v.-ith ' these indicators. The high frequency of lc*:i (Janee tu ai IcaM 95 ".* a n d tu i m p r u v e j-i0LJl | neuropathy found for subjects with chior-- lic I n f o r m a t i o n >n t h e " c x p o s u i e m c i - era) | ocne is interesting because chloracne is c a to r s ." with I a good indicator of exposure to dioxin, axin -4 Moreover, during the monitoring, chlorr six =VI acne was found only in the young age A ckn o w led g m en t ne or \ '0UP 10 20 a) (S), for which the frethe i quency of neuropathic signs was very low. This work was s uppor te d by a g r a n t from . t asl - Tn fact, the PER of neuropathy for the sub- Regione Lum barditi. hlor- : .1 jects under 20 a of age with chloracne ver- sus those without it reached -1.7 (95 "/w CL, 1.2-- 18.1). a value greater than the R e fe re n c e s t`:.| 0ne (2.6) observed in the chloracnc subjects of all ages. In contrast, since abnor- j ^jal hepatic enzyme levels were more com- esulls' i'l i.Bion in the. adult ago group, their nssucia- 1. B a u e r II. Kehnl/. K li. Npiegelberg U. Boruflichi- V crpifin nco n l>ei tier llefStcH ung von C h liT o i'h e in .1- V ri'h in ihm ce n. Areli GeU'i`i'1[ m 111 ( ieiVii Ih-)iyi i III lltilil; Mill --555. o b e r ^ 1'^ ! 1 ^on peripheral neuropathy may not '= ; - be so. unusual. ' li must be stressed that no acute polv- *'jH h f ': neuropathy was found during the study, 2. IJerp in oy rr IIU. Mu l i n e r II. Ilillin a n n G. K ren t 2 Kit. l - . n r H. l.a o e I). Kick W. S chin id l K. S chm id t KW. S ta m m l`J, S'/.asz ( 1. lii-i-imiiiii'nilalinns *<f tin* (o T m a ii S o ciety _fm (.`linieal Gliemisli'y: S latH lanfisa- cne o i `:J . nCj polyneuropalhic cases found were ij|a cot severe. The eleclrophysiologicol diug' Jig Dosis of peripheral neuropathy was conn e .-5-. jjdered the most appropriate procedure lion of ineihotls for the eslinialiun of enr.ynie aelieily in hinln^ical flniils. '/. K lin C hem Klin Miocliem K (IHTli) (iTiK--QWi. 3. BJeiberc J. W allen M. rirorikin R. A pp ieh a n m II. 1nrlnstrially ari|uir-il jnirp h y ria. --------- (rith-which to study the possible chronic A'ithout !jJ (fleets of dioxin-TCDD exposure on the periphernl nerves of a general population. 19 199 . At the follow-up examination the ra te of nonatte^dants was high, about 56 fl.V An 7.2 icalysis was carried out to determ ine ' :jiss chether the group of 277 subjects reex- A rch ilei inali'I HU 1 1JuMl 7!'.! 7U7: i. BoUelliiiii Uffieiale della Hecinne I.uiubai'- ilia. Kii)ijili-ini-nlii slram-ilinai-in .1! N.ga: IV ovvriliiiirnIi p'-r Xeeesn. M ilan" 1-1 l.ui;tio Ii'77. |.p Iltlftg 5. Cos: V. I'inelli I1. T n r r e l*L llaiiiie nf i-imdueliiin vi-lm-iiy nf m n iu r n'rvi* filnvs in a given nnisi-le: Method of cJesynehionisa^ lion and me!Inti of delay of the partial joined in 1978 was positively self-selected jj regards the disease under study because Jbgroups%iia.-cf'the presence of symptoms and clinical ' gas which could have encouraged the af- --------- -riiQl fected subjects to come to the clinic or .. huji2 because of the presence of factors pre- ,r B disposing towards peripheral neuropathy. ---------- Th< frequency of these possible ncuro- ;yntDloini'||^ pjihy-related factors was not significantly -'signs gher among those reexam ined with re- ."It! jpect to those not reexamined. "Moreover, 4 ^1 ore subjects with chloracne and abnor- 3 ` pal serum hepatic enzyme levels w ere not 9 iq6* examined in the second screening. The < 0 0ot tvpoihcsis that subjects who returned -----------: -f were positively self-selected with respect as ot jo the disease under study was not ihcre- Jicate/W -jjjl-jore confirmed by this analysis. The co- ^and xsistent neuropathy and chloracne among 1 5 exposed to dioxin may represent anlidronue Mock. Kh-elj-iK-neephalugr clin neoi*ophys<nl gl (HUUH .tl.'i. C. F ir e s to n e l). T h e TCDI) p r o b l e m : A review . In ; R a in rl C. *d. Chlorin:U eti p h e n o x y acids and their dioxin. Koval Swedish A c a d e m y nf Sciences. Ki'oekholin i:)7n. pp Hfl--53. (Kenl hall no NKK 371 7. G oldm an!) JM, Sell worst e akuti- I'lilu r a c n e . cine M:is.'eni:iifi.vikalio/t d o r e h 3..'l.ti.7 l e i r a - chliirodihen/.iuiiiixin. Ilaular/.l illtT.'ii Nil -- 153. 8. lA K C W n ikim ; t i r o n p on tin* Kvalwaliun of the Carvino^enie Kisk of Chemicals to M an. S o m e f o a a c a n l s . th e Iierhieitli-s 3.-1-IJ and 3,i.5-T. i-hlnrinaied diUeti/otlinxins ami nii>e**lIaiii-oO' iinlosSrial -ln-mie:*t' l i d e r - na Im nal Axuney fm Kesi-aieh osi ( 'ama-r. l.yon i;i77. p p 1 H'3, l l A K t ' 111* ut` 15). 1. Inletnalifiial !_iImii l Iftier lnlei-nalioual Standard et:o>.:firatiiin *! eeitpalinns. G e n e v a . Iin'.;: )0. J i r a s e k l.. K alm .^ky .1. K uIhv K. I'ay.de- ru v a J . I.n k as K. A r n e e h lo r m a . [orphyna cutanea tarda and oilier manifestaliiins of X eneral inl<vieaI ion darinj-. Hn* m a n n f a e - fi Jo 1 1 ti :i ; | 1 l * r j >-? !"*i - ^I I i .( 1f -*i ;.i - . 1 T; >- i- , t*1.S* r* ov* fi ! "C I j` ' I*, *1III f '-n i if Jii'i !n`ii h s iVl. itt-i ni.'i 11il - ;i (i'.i'-l) ii I I .l.i.i-.i I. I,. K . i U m n I; t .1. tsnliif K. ] *;i;*iliTt *v;i .1. I.ni;.i I! (.`Nini .H-in-, | hii |ihyi i;i cn:;iiir.i --* .......... 'I ili-li ni li i\i k;il in;u'M rim ili K- riii.iii. ji.mi.uA :rjn- I- I'.i.-il.*!. -t .i - Vi-|hij il.iiiM .1. Ni'iiiruVii M. I 'h ^ . iv.i .1. .lit .`nif1,; !.. I.uk:i> K T lir rii-tvl- ulim.-ii! ,1|||| |1! ill.-IS Ilf tliinliii' UltnMUi- Iinli l.t I]i .ifl ilii<if(Iii*li.-ii-I. tliti\in ill liici; Ai t i i-mi i li) !i*.ii:it ii i s i i -- i i . i:; r . i ! ; m d A J '. S m i t h 1). M i - I I . t C l. I ' u s . - i r k I '. A in .I: mu i cv nf w u t k i 'i s in ti ;tnci -`I.-'-T wlHi .<|tvi:il ;i l leni ion lo >`hlitr;iriic*. piirj ihyn;i cuhine.i l:trdn. nid jisyrliuln^ic )i.ir;inicU-i<. A rch environ h'.-alth 21 (I'.fTJl 3ir. --3^7- )! Srli;:!/ K li. /.ui klmit; uml til mlnpiv' (1er rJiinr.ifmi. AJ hi*:1 Mill'd Nti/.i:ihnrd ArUcilr- Iiyg ;i tihi iTi--"t, J l v o - n i i l fur j i n l i l i r ; i . ; i i i i i : 2 T M a y Iflffl i--- V * I.'. S lcllm an S. Su.-llm.in J. Hcaki work a in u n c Ml 5 V ietnam vctcrar.? .*" ex posed to toxic herbicide?. Arr. } r?" . . ! r j (1 fil'd!) --t- labsiracl). . -' Hi. Sr.asz C. Kinetic piiotomclrir r , " situiti ; -C T . Clin chc.*n 15 > ;` ; - - IT. Ti lhmu-ss aAMm .. LCioOllddmmaannn ?V. tFolnlo"w---a*; <* : , ^ 0 ^ ;;. liber d;is T ri ch )n rnph cno1-Dex':` t i Q g r H P* Jirsclu-Iu'n in der BASF AG VS,T;_'~ .O v . m b v r 1913. P resented ai `-hc tSfTi Q r i ^ . chcrn Konpress, Hntia. Septembre **'v , . t^ Lill1 !K Tnn 7k ha Tu ns. Pauogie "-"''T. i & g f i '. - J '' - ' an im a l de ]a dioxine, Rev rned f?*- V , *. If). (MITT) 653-- 657. V.a liter AE. M artin JV. Lipid _Oo In g e !* diox in-exposed workers. Lancet 30. Woolf B', On estim ating the iwcen blood group .me disease. genet 19 [1935) 251 -- 253. . ^tOLV/ under \ . . . *o l n o is t J" > b y a pi .used in : .' y to a pr- - Is a lie n * *uk?5--rJ- -'*" -ooldld iinn howevr -is coni hearing I itTpiki i *1yis.fVii'iiiii X -. f c ~ H t ' . : . - Key te leve ;'^ ^ fL i3reSSUre is ^ e^caring. Less f i t i n c r e a s i n g y i e n c e d by .unde -'K iitb e ..fact lh a t : j,regarded as ha p ro p e lle r nc ;'h,,^>-ir^Aa**n-' io u n ts to le \ * ` v;. relation to a ` '.i-j:-;the en e rg y b- - 3 5 eiretluency ran; of noisy p'.. cause oi con .. { y j .`fre q u e n t find)) ! ;-i;audiograms, w i.iin this field. ' ;; ;gation was to j f e ; irom the. non I '^ ^ r o c k drills an i;i';'iin d e r w a te r Norwegian t Norway. Eleclronlcs R w egtan" Insti' of T r o n d h e ir r h-,'. R e p r in t re 1= U n d c r a v a le r i p : Norway. r202 S':