Document oM6nx5dMY0aZnjbZj2rkY6p7w

FILE NAME: Kent (KNT) DATE: 1989 Nov 2 DOC#: KNT025 DOCUMENT DESCRIPTION: Journal Article - Asbestos-Associated Diseases in a Cohort of Cigarette-Filter Workers - New England Journal of Medicine U* *u&c L I B R A R Y !iiH I0 126680c New 1 ne K l ' rn iM P .i NC. I. Erigiam o , Journal of Me&me BaUbUabad la U U m Tke KKGLAKD JOlUDtAL OF 6UBOUY VOLUME 321 NOVEMBER 2, 1989 NUMBER 18 Original Articles Suicidal Ideation and Suicide Attempts in Panic Disorder and A ttacks.................... M yrka M. W eissman, G erald L. K lermas, J effrey S. M arkowitz. and Robert O lellette The Effect of Parity on the Later Develop* men! of Non-Insulin-Dependent Diabetes Mellitus or Impaired Glucose T oleran ce.................................... Donna K ritz-Silversteis, E lizabeth Barrett-Connor, --- Deborah L. W incard Asbestos-Associated Diseases in a Cohort of Cigarette-Filter W orkers.......................... J ames A. T alcott, Wendy A. T hurber, Arlene F. K antor, E dward A. Gaeksler, J ane F. Danahy, K aren H. Antman, and Frederick P. Li 1209 1214 1220 Mechanisms of Disease Hypercapnia....................................... Steven E. Weinberger, Richard M. Schwartzstein, andJ. Woodrow Weiss 1223 Medical Intelligence Drug Therapy -- Oral Hypoglycemic Agents J ohn L. Glrich Reversible Cardiac Dysfunction Associated with Interferon Alfa Therapy in AIDS Patients with Kaposi's Sarcoma.............. Lawrence R. Devton. Roblrt L. W ai.klk. JosrpH A. Koyacs. B irs E E jils riN . Margaret Parker. H enry M a sik . Anthony S. Facci. and H. C lifford Lane 1231 1246 Case Records of the Massachusetts General Hospital A 74-Year-Old Woman with Subxiphoid Pain and Narrowing of the E so p h ag u s...................................................... M ark B. O rringlr and Eicenf J . M ark 1249 Editorial Panic Attacks and the Risk o f S u ic id e ........ Peter Reich 1260 Sounding Board Health Care Tickets for the Uninsured: First Class, Coach, or Standby?........................ 1261 H. Gilbert Welch Correspondence Wider Use of Testing for HIV In fection?........... Mortality among 1862 HIV-Antibody-Positive Civilian Applicants for Military Service: Preliminary R esu lts....................................... Tuberculin Skin Reactivity in HIV-Seropositive Intravenous Drug A ddicts............................. Acyclovir to Prevent Cytomegalovirus Infection in Renal-Graft R ecipients............................. Permanently Decreased Renal Blood Flow and Hypertension after Lithotripsy..................... Cholesterol Embolization after Treatment with Tissue Plasminogen Activator....................... Treatment of Inadvertent Intrathecal Injection of V in c ristin e .......................... Increasing Prevalence of Excessive Erythrocytosis with Age among Healthy High-Altitude M iners........................................ More on Rhabdomyolvsis Associated with Cocaine Intoxication...................................................... A Proposal to Help New House O fficers............. Our Stubborn Quest for Diagnostic Certainty . . . 1265 1267 1268 1268 1269 1270 1270 1271 1271 1271 1272 Occasional Notes The Physiologic and Psychological Effects of the Redside Presentation.................... R ichardJ . S imons Robert G. Bails . Robert Zeus, and C lifford W. Zwiluch 1273 Book R e v ie w s ................................................. 1275 N o t ic e s ....................... 1278 Inform ation for Authors ............................ 1280 0*ord. Published, and f C opyrighted. 1989. by tbe Massachusetts Medical Society I mi Ni v IN--- 1 : k \ K i Of !Si 1>S`N i \ j: . p j: !,- r. wrri.h m.p rciin-ri.ii 0k bubscripiimt price IA` p* j \ra r. Sramd-clas? poMayr paid at Boston and ai additional maihnc ofhrcs " PLAINTIFF'S POSTM ASTER Send addre>* chance* it* R (). Bo* H03. Waltham, MA * EXHIBIT -5 CL , i:?' THE NEW ENGLAND J tH 'RVAl OF MEDICINE N o \ 'J | y;tu ASBESTOS-ASSOCIATED DISEASES IN A COHORT OF CIGARETTE-FILTER WORKERS J ames A. T alcoti, M.D., W endy A. T hurber, R.N., Arlene F. K antor, D r.P.H., Edward A. G aensler, M.D.. J ane F. D anahy, B.A., K aren H. Antman, M.D., and Frederick P. Li, M.I). A b s tra c t T o estimate the effects on health of occupa tional exposure to croddolite, a highly toxic form of asb es 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-eight of the men have died, as compared with 8.3 deaths expected. This increased mortality was attribut able to asbestos-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. W e condude that the extremely high morbidity and mor tality in these workers were caused by intense exposure to crocidolite asbestos fibers. (N Engl J Med; 32f :1220-3.) THE inhalation of asbestos may result in pulmo nary fibrosis (asbestosis),1lung cancer,7 or malig nant mesothelioma.3We recently observed three cases o f malignant mesothelioma among former employees o f a Massachusetts company that manufactured ciga rette filters containing crocidolite asbestos from 1951 to 1957.4 We now report a marked excess in mortality and morbidity from asbestos-related diseases in an independent cohort of 33 workers who made these filters. M ethods From 1951 to 1957, a subsidiar)' f Massachusetts company manufactured cigarette fillers according to a patented ``dry'' and dusty process in which asbestos, cotton, and acetate fibers were mechanically mixed, carded, and deposited on crepe paper-* The parent company produced other asbestos-contaming 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 asbestoais. lung cancer, and malignant mesothelioma,*'* presumably be cause of its unusual resistance to degradation in thr lung.' M easure ments at six production locations in thr factory on October 27. 1952. showed an average of 80 particles of asbestos dust per milliliter of air. which was within thr then-current Massachusetts standard of 173 panicles per milliliter. Thesr levels greatly exceed the current National Institute for Occupational Safety and Health standard of 0.1 asbestos fibers (not particles! per milliliter. A list o f all employees directly involved in manufacturing dgarr ttr filters at the factory on September 22. 1953. was obtained from th> records of the Massachusetts Division of Occupational Hy giene. The cohort included none of the faet n workers previously described bv us.* The median age of thrst 33 whue men on that date was 34 years (range, 21 to 67). T hr subjects were studied from that date until their death or until December 31,1988, thr closing date of Frote, the Division of Biosutisiics and Epidemiology. Daiu-Farher Cancer Institute (J.A.T., A.F.K.. K.H.A.. F.P.L 1. the Department of Medicine. Har vard Medical School (J.A.T.. K.H.A . F P L ), the Clinical Studies Section. Clnica.' Epidemiology Branch. National Cancer Institute (W A T.. A.F.K.. J.F.D . F.P.L ), and the Division of Thoracic Services. Booor University School cf Medicine IE. A G.). Boston Address reprint requests to Di. Talcon at die Dans-Farfcrr Cancer Instituir. AS Binnry St.. Boston. MA 02115 Supported in par, by a giant 11F32CA06242) from the National Cancer lnstirute and hy the Kellogg Foundation Program m Clinical Effectiveness Ms Thurber is the recipient of an Amy Pottct Research Nursing Fellowship, and D; has received a Research Carec Award tHL 1i73) from the National Heart. Lung, end Blood Institute th r study (thr mortality analysis), or until thr diagnosis of a first cancer (the morbidity analysis!. There were 773 and 76C personyears of follow-up in the mortality and morbidity analyses, respec tively. We attempted to contact each worker, or his next of kin if thr worker had died. We requested information about the worker's em ployment and health history and asked permission to review his medical records. For 18 workers, this information was supplement 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 thr iota) duration of employment by the company; for 23, the length of time spent manufacturing dgarettr filters was known. An experienced nosoiogist determined thr underlying cause of death from the death certificates of all deceased workers. Medical records establishing the cause of death independently were availa ble for 22 of thr 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 death-certificate diagnoses were obtained for six workers. All diagnoses of cancer were verified by a pathology report (18 workers) or radiographic and endoscopic studies (1 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 thr basis of a chest radiograph scored by one of us as 1/0 or more, according to thr Interna tional Labour Office's scheme for thr classification of pneumoco nioses.' Relative risks for mortality, or thr ratio of the numbers of deathobserved to the numbers expected, werr based on death rates specif ic to age and calendar time, according to cause, among the l .S male population* The numbers of newly diagnosed (incident) can cers observed, other than malignant mesothelioma, wetr rompa-erf with those expected on thr basis of incidence rates specific to ao and calendar time, according to site, from the Connecticut 1 unto: Registry."' More stable expected values fur malignant mesotiini,,ma, an uncommon tumor, were calculated with data from the Sur veillance, Epidemiology , and End Results program of the Nations1 Cancer Institute, which provided rates in approximately Id percent of the U.S. population for the time periods 1973 to !97<i and 1S77 u I980IUJ (and Connelly R; personal communication). In tin uiIcltalions of significance and confidence intervals, an underlying Pois son distribution was assum ed/' R esults Twenty-eight (85 percent) of the 33 worker. had died, and 5 're alive. The 28 deaths observed w e rr 3.4 times the num ber expected (8.3 deaths) on tinbasis of mortality rates for the I '.S. white malt t> -t.- -