Document xjbmJnRYJ1Od6Yw8w48mBerwG

E'fidWlJ* OCT 2 - Occupational AcroosfSolysis L An Epidemiological Study Bertram D. Dmmon, MD; Warren A. Coo/ Walter SI. Whitehoute UD, and Harold J. Magnoaon, SID. Aha Arbor, Mxk; and Theodore DUrkeek. SID, Phoenu, Aril A* s*tetoe*o*ic* sMy * psrtornsd coiiki *,*11 ^IBJII +> MJ1* run ex perience to nriM phases at Aft cSSortto ;VC) trd puli ito|< eStartor tPVC) steAa-iirV-g in U ptoati lmpvt the (MM Stotoe md Cev m nt M Ml! at Mm om at I......UinTnli (AOL) wet *; 1 eSwr *rs- cMrtf mecM *> toe M risestog to peh r"in Werksro wpgit to totoar ptee*. of VC *f PVC MNAMrin So ato WMf fetan itok ml Aivitoptog AOL The teportawos a< Me; I* i m`-J--J Sever* ftattotfcW sporescMil tor rapM i<al survey ere mguntoS- IcrwHofrWs appears It be eyHitolc (stow toss tool ear m port* of eatoy to know* w ITH THE emergence of a new clinical entity, occupational (K-oonteolysa (AOL),1 it became a manliest responsibility of the polyvinyl chloride (PVC) industry to define more dearly the character, extant, and pos sible causes of this disorder. Though indi vidual corporations might survey their em ployees, a statistically valid construction of the problem could not be developed without collation of the health experience of all PVC producers. To maintain the privacy of pro SutaiM b* pitolicatioo Fab f. 1PTO; a.eptiil Murk 14- Fran die Institute to Environmental and Into>tml Heellti (Or. Dinun), die Oepertnec at EwinunU ant tabeUal HnMc gttod at Pitot* Hutto iMl CM), the Darken at Re rlinksy, Scteto to Mifltoi (Dr Whinhnun), and toe Sttoaet to Mlt Hutto (Dr. Mmna). Utorartot; to MHIpa An Attar, ud dn Dtonrtnut to Radtotogy. Ceed femeritait Hcapatai, Pteeeii. Arto (Dt. Dtkteto). ReprtoC isqueala to toetitoto to Kuviranmentel and ladutotol Heeltfc. Ushwrwty to MirtifWk, An Ater 4S104 (Dr. Dinmul pririary in/ormation strode ted with detaito of manufacture, some cfimntereated group was needed to evaluate operating processes, is these might relate to the caunction id AOL Accordingly, the Manufacturing Che mists' Amodatkn requested the Institute of Industrial Health (Institute of Environmen tal and Industrial Health aa of Jan 1,1970) to conduct an epidemiological survey of tin PVC industry in the United States ai*l Canada to meet their roqwntobility to ttw workers and the public. The institute was requested to determine the extent of the problem among PVC work ers By establishing a specific Job suedatioo with AOL, it waa hoped to determine where the rid of incurring AOL arose within tfv PVC process. It was important to determiiw whether AOL was associated only with ttw synthesis stage or if those twndting tin finufeed polymer also might be aH-tmi The primacy of this consideration stem from the widespread use of the polymer in the fabrication of a multitude of mamtoacturad goods that oiter general auiu* While the number of wortm p|^ in the chemical synthesis of PVC la ralativety small, them are thousands of mull manufac turers engaged in the fabrication of products derived from this versatile plastic, Further, it was hoped that the qpldeoaolofjca] and industrial hygiene* inveWigation might define mom precisely how variation; in manufacturing prrinsms might rotate to variations in the prevalence of AOL among PVC producers. Medical and industrial hy giene studies might furnish some dues to the precise etiological agent(a) as wall as suggest preventive measures thst might be applied in the industry. In addition, it was planned that a aasIL Arrh Em-iron Health--Vol 12, Jan 1911 <3 OCCURATIOSA L ACROOSTEOLYSIS--DINMAN ET AL SAME FACE W I Other 14) upt. no. Soc. Sac. So. tshst ace_______szz r ' (i5=I&T (17) COMPANY SERVICE DATI Month Year ;20-21) (22-23) Da Not Write in Ibis Box Cora*__________________ (1=8) Pint. (3=4) ARE YOU (RIGHT) (LEFT) HANDED? (24) TO ER THE FOLLOWING QUESTIONS , PUT A CIRCLE AROUND YOUR ANSWER. FOR EXAMPLE! MONDAY IS THE DAY AFTER SUNDAY (YES) (NO) Have you noticed SUDDEN whiteness. blanching, or paleness of the f lagers of your RIGHT HAND LEFT HAND (YXS) (YES) (MO) (NO) 29 Hov du noticed a sudden redness or blueness of the i .ngers of your RIGHT HAND LEFT HAND (YES) (YES) (NO) 28 (MO) IF YOU HAVE NOTICED ANY OF THE ABOVE, are these chances brought on by cold (YES) (NO) (DON'T KNOW) 27 HAVE YOUR HANDS OR FINGERS BEEN BOTHERED WITH ANY OF THE FOLLOWING I Tingling or pins-aad>needles RIGHT HAND feeling LEFT HAND Wars feeling in hands or fingers RIGHT HAND LEFT HAND Cold feeling in hands or fingers RIGHT HAND LEFT HAND Munbness, fingers fall asleep RIGHT HAND LEFT HAND (YES) (YES) (YES) (YES) (YES) (YES) (YES) (YES) (MO) 38 (MO) (MO) (MO) 29 (MO) (MO) 30 (MO) (MO) 31 Stiffness, fullness, or tightness RIGHT HAND (YXS) (NO) of finfers _______________ LETT HAND (YES) (NO) 38 Prequant tenderness, soreness, or RIGHT HAND (YES) (NO) pain at fingertips LEFT HAND (YES) (NO) 33 A'e* fww Hrallh--Vol It, Jam 1971 ucc 020898 occvpatiosal acroosteolyhis--disuan et al Have you not lead any of the following changes of tho skin of your bands, wrists, or arms t Thickening of tho skin *(YIS) (10) 34 If 70s, is It on (HARDS) (WRISTS) (ARKS) White, raised patebos of skin *<YS) (WO) 35 If 70S, 13 It on (HARDS) (WRISTS) (ARKS) Whitish plaplos *(YIS) (WO) 36 If yes. Is it on (HAWDS) (WRISTS) (ARMS) Shiny skin patches *(Y1S) (WO) 37 If 70s, is it on (HARDS) (WRISTS) (ARKS) Snail, raised areas, orluaps loss than 1/3 inch around (WOT including warts) *(YIS) (WO) 36 If 70s, Is it on (HARDS) (WRISTS) (ARMS) Haws you boon bothered by base fingernail troubles 1 fits or sears of tho fingernails (YXS) (WO) Ridges or crocking of the fingernails (YZS) (WO) Have you used hand-held power tools or air-driven tools at work In tbo past six years: (DAILY) (0WCXAWX1X) (LXSS THAW OWCS A WUX) (WXVXR) 41 Hawa you ewer broken, fractured, or crushed a finger? (YIS) (WO) If yes, was it the (RIGHT) or (LUT) (Thunb) (Index) (Middle) (Ring) (Little) (Thunb) (Index) (Middle) (Ring) (Little) 42 43 Arth C,niw Hmlth--Vat ti. Jan 1971 ucc 020899 M OCCUPATIONAL ACROOSTEOLYSIS--DINUAN T AL elected sampli of worken directed with AOL he eodM in the dinial rraearch unit of the University of Midugan Medical Center * Pravtoualy. Rouuh end wwilei* performed an extensive Hinical evaluation of a groq> of such worker*, fttequeit * uninatianB here were designed to determine whether any new clinical feature* had de veloped ince thnae prior studies. Polyvinyl Chloride Manidacturing: AW Review A mote definitive description of the proc- ear whereby PVC k synthesised, finished, and compounded h wjwrted eleewhere in this ien*.` A brief review of the operation k appropriate to the prttniem under!yin* the epidemiological considerations. Vinyl chloride (VC), together with water, peroxide catalysts, and other additives, are placed in a reactor where pokmerixetian ie completed after ten to 10 hours. Unreacted VC is exhausted from the raartirai vemel and the aapanxton or emulsion of the plas tic transferred to equipment for dewatering and drying. Following ventilation of the re actor, one or two workers enter the wL'l to remove the residue from its surtaers. using putty knives or chisels J Sixteen plants, in addition to synthesis ing, also compound PVC while ftvs manta am engaged only in compounding the mein. flervey TMhalqwrw---Nineteen corporatioas knows to ho epfd la the polymerization f VC warn meemsd. The workao who wrrad as the study populations worn wnployd is S3 pleats io tbs United States and Canwta All dme whs eorkad at tea time of tbs snrvsy, ee is tlw past, in my rapacity to plants such ads wen sqnwyod. In multiple piudact plants, all workers having any pwestls osposum to <hs PVC procaw worn studied. This pspubttoa eretirwml tesdiral survey, work tostesj qiwarinnnalim. and hand x-ray liming. The aV-Muddto medical qurationaaira we* dsrigaad to probo for signs of Raynaud's phwusnsena or symptoms assodatsd with pe ripheral vssrsdar tes^rtsnej. la addition, quMtims wr posad to disrkao skta or dormal sprendaga abnormalities. iss of poser loots, and haad-takuy history. X-ray tlnss of both hantb warn roqussted frm tho coopersling plants: spocihe dirertiorw conremiag Sim typa. expeeura Isctsti, tsAaiqus, sad ktantiA-sticn ones wet to sadt plant The s-tay fitate, okas toreaniad to to iaotituta. worn codod and Irwismilliil sltosl identification to two tarfiotagtete for iadspswtostl interpretation. The fatap eem wwH on a sparideafly dwignsd *--vw which ee then retumod for stattatieal collation Hand iray ga that ssrvod as codtrail wera draws from 2,407 mb over apt 18: this rsprsaanted the entire male population of tlte tews sf Trmmsth Mick. Work history gusoHinuisiiss wots niplslril by sock individual saployse or by the potsoenet department at such plant or both. Those forme recorded wort assignments betas"i Jan 1, 1981. through Doc 91, 1999; each worker noted the first and test month of --tg----s fa* suck specific assignment during that period. At local jab doignatiooa to standard job titles. Them at* listed in to paper on the indoatrial hygiene aspects.1 Pilot Rms In order to determine the reliability of survey techniques and recording methodo logical patterns, a pilot run was carried out at one large plant Following this, minor modification of procedures and forma waa accomplished. Fpfriteaiiiingha] Dsriga Acroosteolyate appeared to consist of charaetertetic x-ray film abnormalities and Raynaud's phasmaim. non. Since the tetter would be --p--Hf to occur only infrequently in a population not at risk of developing AOL, it oould ba und as a prime indicator of the eriatanra of AOL. Thus, we hoped to eetafalish an initial dis tinction between two populations, fe, ona having AOL and die otiiar not having it Comparison of prevalence of defects with the Tacumaeh control population of 2,407 man wggested that all defects ocaared in the PVC population with a greater frequen cy than in the control population (TteMe 1). However, the significance of this finding re clouded by an unavoidabte bias which minimixed the value of the Teeumeeh population ae a control group, ie, identification marks which oould not be readily obliterated were praamt on these control ftbna. Furthermore, as is apparent from previous discussions of the x-ray film abnormalities, linear radkriucmt defects oould be ronfimul with old trauma, the absence of a tuft might ArcA Environ Health-- Vot tl. Jan 1971 ucc 020900 rnro OCCUPATIOXAL ACROOSTEOLYSIS~l)lNStAN ET AL follow amputation, or short ened jteiangra could be NC-oflWW. evHe -emu.wasn.oonmetent with a mufiital dried Defects such as ade- * tct Mq,mois of the tiwfte, widming TMMrotssrrangimHnmaiaM*srM(oWlto*cettafrtlrodui( Ho. %-S Ho. %ri the tufts, and aaft-timue dubbing were esdi euaeeptifafe to subjective reader w Whd error. Furthermore, eadi of tTTdnneShornwOarrtogurvtnMisnooaw/nn.WisparosSswO(hhWnawWntioctMSSntaithese defects could arte O(rid other bony ditoeee or roiaeclaSlcwifutuison e t ftinjury. Even multiple feiger invutvwnwd could be con i Itsistent with these etfcdogiml wWMwsinwinfeTvvt spcmibflitin- Became tbaae Soft umusdubbing * * 7problems did exist, aignif- icant d'nmpudm to x-i*y ToUl M ftfilm interpretations were * ef l-Aer Mw i iwc r 2.407 5 011 01 1 44 1 3 321 4.41 2 9 0.21 39 0.70 3 0.29 40 oao 4 21 0.43 9 2 0.00 o.ie 0-004 19 0.30 0.44 43 1.24 4 0.17 43 0.04 1 0.004 0.14 >0 2 ooa 40 0.00 7 3.14 994 11,17 found (TUfie 2). Because of these oocnpfexitiee. for the pur reported to occur in conjunction with AOL, poses of first appraisal. marginal defects of those x-ray film abnormalities unrelated to the phalangeal tuft (defect 1) were not con AOL were grouped as defect 11. sidered as indicative of AOL unless both Combining the x-ray film findings and roentgenologists independently concurred as Raynaud's, several diagnostic criteria wees to tha presence of thie abnormality. The et up (Table 3). The diagnostic criteria for existence of marginal defects with residual category 0 consisted of essentially normal fragment(s) (defect 2), transverse defects workers while category 1 induded individu (defect 3), transverse defect with distal fmg- als having x-ray film abnormalities which by mmtation (defect 4), and total resorption of history or radiographic evaluation or both distal portion of phalanx (defect 6) were were found to be consistent with old trauma, oontKMa if pofluqr ffliiwwc Of wm disease other than AOL, congenital or famil bony defect of AOL if found by only one ial defects, etc; Thehistory of persons in radiologist and if other causae for them diagnostic category 3 diedosed coU-induoed defects could not be eliminated Every man finger Mending imeeenrietad with x-ray with any of these five attentions was fol film abnormalities, dearly meeting our crite lowed up subsequent to the field airvey. If ria for AOL Category 4 consisted of persona there was a history of traums involving ths without Raynaud's phenomenon and sugges involved finger or if the appearance of then tive, though not diegnnsHr. x-ray film far x-ray film lariena was dearly consistent with AOL Category 8 induded time with domi trauma, thaae individuals wars eliminated cal AOL x-ray film defacta (2 to 8 and 1, fi. fromnamidon. and 7 without and with concurrence, reflec OOwr x-ray ftlm defects of an oven lew tively) and Raynaud's phenomenon. Cate specific nature an known to be emnrlilail gory 8 had typical AOL bone abnormalities with tha later ategee of AOL but ora not in (ae diagnosed in category 5) but rithout thwneelvee considered diagnostic Thaae x- Raynaud-poritive replies to the medical ray film findings induded ederoeis of the questionnaire. phalanges (defect 7), widening of the tuft Computational and Statistical Anttyria. (defect 8) or of the daft (defect 9), and ---Medical and work questionnaires and x- soft-timm dubbing (dried 101. Finally, wa ray film reports were checked for eompleto- looked with wepidan upon any bony defects nem. They were then coded, verified, involving multiple Angsts regardleoe of punched, and tend in an electronic com whether they won AOL-epedfic (ie, defects puter. Quality control checking of the putch 2 to 8). carde, uring a 38% movie, revealed an er In addition to thorn defects previously ror of 0.1% among throe cards Afrh Eminmi Health--Vol 11. Jan 1STI 1 JCUM ucc 020901 66 OCCUPATIONAL ACROOSTCOL YSIS--DINUAN ET AL rset* t aysiniat mm Mmmkm W Stepors Vmwtnt t-*sr nm Dm**? m ijtr AC Wmtmo Mo 1 F. rs NmInd MftfftAAl dttoct Otdci ft*. I a 3 4 7 * 9 10 Total 1 TN 30 3 0 1 0 0 0 - - -- 34 OiMgra* 237 JO II 4 3 1 t MW -- -- 2S7 TOUI 2S7 33 II ] 1 i " -w - 321 Morginsi dotaet. w*t\ rwdutf frogmonf 2 AgM 1--------*----- 7 Dl**^** 27 1 -- -- -- -- -- -- 2* t*m 33 2 TrtntaW'io dotect 3 *r* 90 2 0 0---- - 1 12 OtHSM 2* 1 -- 0 1 1 -4 * -- 0 2* Total 34 1 -- 2 1 1 " " " I 40 Trann*iM ootect. 4 Agra* 1-- xmOAtel Oteagro* t7-- IragmontebonTotalI* -- 1 -- -- ---------- 1 ---- -- -------- 1 -------------- 2 II 20 Total raapqrtion o< Wttel portion nataniTotal7 ScWTbtlt. wtth tocalcihcatian 5 Agra* 1 1 ------ ---------- j Oraagra* *1 -- -- -- -- -- -- -- _ * 2- -- -- -- - 4 Agra* 010 0 -- - a* 2 Dwgn 9 1 2 0-- 1 ---- IS Total 92 2 -- 1 -- -- - - 20 Shortening Short*mrtf Wtd*nmg of tvft WteMfHnf of fthott 7 tea 42 0- 1-- 0 12 Dft*^** 3* 4 1 l -- 1 -- 2 t S2 Total 4S s 2 1 " 2 -- 2 2 44 1 Agra* 2 1 0-- 1 1 0 12 Disagree 3* S 1 t -- 1 -- a 1 S2 Total AS s 2 1 -- 2 -- 3 2 44 4 tew 0 1 ---- - 0-- 0---- 1 Omgroo 33 3 -- -- -- 2 -- 2 -- -- 42 ToUf 35 4 -- -- -- 2 -- 2 -- -- 43 Agtoo 0 0-- 0 0 0 w-- -- thsagra* 3 1 -* 1 1 1 -- -- -- -- Total 3 1 - I 1 1 ----- 0 7 7 Soh tlSSU* chibbmg ToteM 10 tew 3 0 -a 0 0 0 0 -- i -- 5 Total 20 1 -- 2 2 1 2 -- 1 4W 2* 1 -- 2 7 1 2 -- 2 -- 35 40 Agra* 7 s 2 4 0 2 0 1 2 re DMagra* 423 41 IS s 7 * 3 4 2 > sir Total 4S0 >4 17 12 7 It 3 9 d 7 M ;% 0*ftcl arts *1 10.4 I.2S7 20.0 30.0 1.2*1 I.S 1,2*3 33.3 1.217 13.3 1.23* IS.* 1.23S its 1.2SS 2.3 1.2S* 2.3 U*S t-i Tha difforonc* batvton tnaaa two figwrai and the** in the datact 11 category. M. other detects. a not shown hare. Frequently, workers performed leversl different duties during a period spent on on* assignment Where this existed, an estimate was made at each plant of the fraction of time spent in aadi segment of the job amignmont Since the fraction 1/12 was used for aach month a worker vent full time in various jobs during the year, H was convenient to use this fraction of 12tha where his daily or weekly work was divided between two or more jobs. Thus, if a worker pent one half his time performing one vi atic pntTgwrwnt of his amigmnent, the value of 6/12 was assigned to our standard job title for that time period an assignment The remaining 50%, or 6/12. of his time was distributed over on* or more applicable job components during the period of assignment By this method, job ripen- enee on each of the standard jobs could be computed in terms of months or fractions thereof. The computer was utilised to perform col lation and statistical manipulations of data. CHafaal Evaluation of Ferities Caaaa.-- Four employers with active diaaaee wore admitted to the Clinical Research Unit of tha Univarsity of Michigan Medical Cwitar. Eitanoive clinical, laboratory, and physiologiml teats and radiographic, isotopic, nu tritional, and metabolic balance studtee war* performed. The findings are reported in detail.* Rawtte General Fopaletio* Suttetk^-Thr study population consisted of 5,011 workers, of Arrh Environ Hrolth--Vol IS, Jon It7l OCCUPATIONAL ACROOSTEOLYSIS--DINUAN ET AL which 96.4% m urn: 96.7% rrere whit*, 4.1% ____ flag Negro, and 03% other. The mean age waa 363 years, with the median and modal range being 35 to 39 yean. Hsne x-a*r Saacdit s ay Othct. Soynoud't OtIWIW. Conwsteflt CmnUM With AOL WSn SOL 1 I > ? a v to Thear workers were CTTV- ployed by 19 corporation at 32 plants in the United States and Canada; of the 32 plants, all but six were engaged in PVC synthesis. This number of plants tep- indicolot any the** Wtiont that may ba wwi Vi AOL (dotocts to 11 thou*1' Oto*noetic at AOL. * 9<nflo linsar nnMd. no concur,anca batwaan rood*?*. 1 No concurrtnea batwmn raador*. (reented 92% of the PVC synthesis indwtry in this country. The population at risk lepurerfiad a total of 21,510 man years. Population Analysis.--In order to oorwtruct several pnpulstion giogn for attri bute compariams, we ap plied our diagnostic criteria for AOL tie, x-ry film de fects 2 to 5 plus Raynaud's phenomenon). Using this approach, we found that the dmrly defined cans of AOL were limited to aval plants. Total PlAgnortlt Cotoeonot 7 pMnUwdh COttt ot AOL 3 ptAl with AOC 17 ptontt mthout AOL Posuloaon I.S73 S10 1.673 0-1 3* 41 9* 91 1.9M 4] 9 27 3 SV3 14 i 0 0 iasi 17 3 0 0 9 pMMt compound,ns only TOUI* 997 9.013 994 2 1 0 0 4,ess 74 16 27 3 * Soynoud't phaiwnanon only. OuotbonoM t-roy, no Soynoud't phonomonon. t X-royt ehofoetdfitue of AOL. *tth Stynaua't snonomonon. I X-roy choracwrtttK at AOL, without Soynoud't phonomonon at timo of wnoy. Using these same diagnostic criteria (Table 3), we detected another grog) but without Raynaud's phenomenon at time of 21 plants which had all renployee* in cate of surrev). We determined by follow-up that gory 0 and 1, or Ian than a total of two indi of these three workers, two had manifested viduals in diagnostic category 3 (Raynaud's Raynaud's phenomenon during tlw 1960's without bone change) or diagnoatic category prior to any preexpomire. The third subject 4 ("AOL questionable* x-ray film without waa re-x-nyed subsequent to the surrey ml Raynaud**) or both. TO determine whether demonstrated progressive changes diaracter- there was a riek of developing AOL among istic of AOL; however, he has never noted those working with the finfched polymer, we Raynaud's disorder. In view of this finding extracted for further analysis a third popu that 24 of 25 workers with severe AOL-type lation group, constituted by the fire plants x-ray film defects had associated Raynaud's whose employ-- worked exclusively with phenomenon, we believe it is appropriate to the finished PVC-produdng consumer prod link there two abfaerations in order de ucts. These three puginp left throe indi finitively to diagnose AOL. Thus, using re vidual plants In which there remained a our criteria Raynaud's phenomenon or question of AOL's existence. The distribu finger defects qualified as above or both, 25 tion of diegnostic categories among men were found to hare dearly established four populations sppsarx in Tsble 4. > of AOL. The reseon lor requiring the of x-ray film abnormality and Raynaud's phenomenon to eoUblieh the diagnosis of AOL becomes apparent upon consideration of the three individuals in diagnostic catego ry 5 i ie, x-ray films characteristic of AOL the number dete -mined of the four Arch Environ HroltA--Vat S2. Jon 1971 ucc 020903 J1 *i8 nca PATIOS AL ACROOSTEOLYSIS--01NMAN ET AL tm* i uamanag at Mtftmft i 4uoc>iM VW 401 (CwncM Mr Mats f 0"*) the Figure) was different in [npihii-- OaognootK Catogory 3 Um --------------- fcog'-oou. % mm* ciwim No. Popoirten 11 Total believed to be free at AOL ae mntnwtad with thorn jwhably hertog cams at AOL (sat above). This ob *nn cit tit AOt Mind witnout Itttl ol AOL PUrttk vrth QoftfttiOnjiM* Of AOi Plontl compoundinf only 41 2.40 1.4S2 1.4Z3 19 012 2.244 1,313 14 1.70 17 S3! 1 0-23 43S 439 TsH* a- t at Casas at fii'ssers Meat Waerrtsg Ja Varies* tns PVC-M*at m servation could be used to streen a group of workers at unknown risk at AOL devdopmsit by simply deter mining how many individu als reported only a single symptom. In order to deter mine whethre more intensive scrutiny of a group of 25 or more workers at unknown rfcfc of developing AOL k Popu'Otion RonfO Afrftormtl No- of SornooO't Pnonomonon warranted, one can me a tmt baaed upon the normal ap 4 491? S3-120 121 ISO IS]-220 22I-2S0 2SI 340 341 400 40] -400 461400 3 or mor*t 4 or IMN S or on 4 or moro 7 or fhort S or mor* 9 or moro 10 or moro 11 or moro 1Z or mof. 4-001. f llaynaud't. d*tir*d. eoM. oftHt fiftforo broufht cm by hand or body CMhtrtg Of t>0th. proximation of the binomial, with P - *: l2I \ I 3 'n where n is the rubber of employee* questioned, whwe n is 24 and p m the fraction at population fret of symp pUnt (roups havinc one, two, three, etc, tom*. Should the value obtained exceed 1.66, through no positive response* to questions further hrvmdgation of the populetim to concerning sign* snd symptoms. A graphical representation of the frequency with which respondents noted bilateral hand symptoms in those plants where AOL was believed to ccur and in those free of AOL is provided in the Figure. The one-tailed Kolmogorov-Smirnov (K- S) two-sample teat* was applied to the two distributions. The same analysis was direct- d to the compounding plant population AOL-free plant group fate above). The dis tribution of positive signs and symptoms were found similar in both groups Accord ingly, for the "AOL-free" population in the Figure, we have included the employees of the compounding plants. On the basis of affirmative responses concerning tfw pres ence of any symptoms, this test indicated that these two distributions did not stem fmm a oommon population pool < P < 0.001). This K-S test indicates that the frequency of occurrence of the asymptomatic state < ie, question should be considered. The foregoing analytes do not relate to any individual symptom sought fay our med ical questionnaire. These statistiwl ap proaches only considered the absence or preeence at any one symptom While these findings suggest the possibility of asking a single quwtkn to aoeen a population at risk of developing AOL, is there any one question that might be wed as a more partirent scrawling device? Pacing oner more upon Raynaud's phe nomenon, we found, by the we of factor analysis,* that this peripheral vascular disor der was significantly related to AOL That is, those questions which appear to be con tinently answered positively as a group con stitute a dueler of symptoms or a factor. In addition, each symptom is associated with factors by scores called "loadings," which weigh the associations! strength of tha fac tor to the question at hand, ie, the ocair- Arrh Enrirnn Hnlth--Vol 33. Jan 1971 ucc 020904 OCCUPATIONAL ACROOSTEOLYSIS--DINUAN ET AL XUM Cumulative % of Population i m ml reuse at AOL. The moat Uinttout of these clustering! at symptoms wee found to be, by fector analytic, gueoHnne 25, 20, and 27 (qwettaiiniie torn), ie, indicator* of Ray naud's phenonmon. Accordingly, this con stitutes one raaaon for examining the prcvaImee of this particular symptom TMyiTM among any group at risk of AOL develop ment This logicaliy back to an examination of the relative prevalence of Raynaud's phe nomenon bi our various piant-population subgroupinfft However, because Raynaud's ie more frequently amociatrd with women and since that as a relatively mall part of the total tiudy population, we Ant removed the (male repndnta front our dtia pool. Afpiyhg X* analyata, we famd that the prevalence of Raynaud's phenomenon woe dpiifartiy different fat the plants believed to be free of AOL (F<0l01) while in M ...... . ww famd betweser the "AOL-free" plants and the compounding locations (Thfala S). If indeed the "AOL-free" plant! repeeaent a population at no aignifleent titit at develop ing this disorder, one might inier that Ray naud'e phenomenon may occur among the Arrh Em-iron lirntth--Vni S, Jan 1971 ucc 020905 70 OCCUPATIONAL ACROOSTCOLYSJS--DINUAN T AL Tteter^h a* i8im Nm Orem ef avc me Qysst--fi rnm. 7 rw-- mtCrni sou *1471 <rf 17 PWntt w--iiCmh aol, a- tjrj iwCnn KML n- 1.97J s mm Cawpdunwne. *9*7 n + 2* 4 M4 29 4 JO 4- J1 4u- M 4U4 IS - -- -- - 4* - 4-- St 9- >7 4M-- n- 4 4-- -- 40 - 4- %NcM MmM. 9 < (LAI. * ml|nk. t M* 9l(flMcanl (Klwiiw. 9 > O.OI. * awUyV' I7PW-- WWwwtC-- 0 aol. - 1471 m 97Mi -997 -- 4- -- * -- -- - arwow was Cm* 8C7AOL. -10 V* 17 PUnt WWtCMM IA0L. a - 1.979 -- -- 4 - 4 4- 4 - 4 - 4 -- -- 4 1 TMl Mac-- rraot. a-010 17 ra*Na WHMut Caam arm. a - I47J -- -- -- -- -- -- 4 -- -- -- -- 4m -- -- -- general population in eight of 1,000 ml We tn imewere ot any epidemiological dots confirming tide ixnpraotion. Ertradlng our nw>bi| approach, could ora predict Ho TMtt f coom of Roy' nauf phenomenon whldi might btiktii the need for further mvmtigation? Sfcooe It appeere that the goraro] mole population inddmes of title circulatory dieorder ie Iw than 1% (Tehta 5), bp application of the cumulative probability dtotrtbution of the Urania] with P - 0.01. ora am 111..... . for vartoue dm of plant population, the minimi-- manfaar of poUtivo i^nram ktdioative of a pomibto AOL problem. Table 0 indfcatee the nmnbar of mam of Rigmaofl phanommn which would only rarely occtw by chaw (P < aoi) hi vartoue atoe popototiom. All rigne and eympiouw beltovad to be aaeodatad with AOL worn centered aa to their intergroup prevalence (Table 7). Them wem mnahtomble dtfemnom hi the prevalence of mat rtgno and eymptome be tween the planto with and without AOL while the compounding plants appeared not to bo dimimitor from the population be lieved to bo fra of AOL By contraat, the group about which dead* extoted ae to tte occurrence of AOL appeared to bo some what mom like the AOL-free group then the AOL-effacted population Week Htoiory Analyse A detailed review of the 2S dearly eetobliehad cmaa of AOL revealed that IS penora had worked In iwactoc deanlng at mme time during the etudy; additionally, rtx others, by hllHMp, were found to have worked at tide hd prior to the etudy. The ora man who Ing wa laboratory technician. However, QQBi Uttl JOD DCnKMO 1MDO MM| V nail reactor vemaie Tha, the amelation of hand ctoanlng of reortori and AOL dto- eaaa wee rtriUng. Beeeun of Job pmgiea- ion practiom, pinwiir aU pmmna mf- toring from AOL ted worked at otter PVC production Jobe at era time or another. Since the lowmt peying Jofaa, to. reactor rtoanlng and am ghwn to ml pioductiou wiw ghmt Item Jobs before programing igmwrd into tho Allied Jefce. The fact of tide igrwwrd progieteon to tmdortinad by work htotortoe Ank futw Health--W 8. Jm 1971 uoc 020906 OCCUPATIONAL ACROOSTEOLYSIS--DINMAN ET At 71 imt* i mihmh sot *p ww--t cmmn **tmr cm immu ima ir> portinf UtMlai Chtnlni Iipononta. 14411444 Mr >< Ckiim) tiMmw. py Wwmt Oafwutivo ttm (*. diagnostic eatagori** 9 and ) at AOL 29 Total work* at it**. reactor Mooning. 1 -047 Total man yuan. rooctar CkrisA4 1.M2 IS* 1 cat# po* 1.047 9S wofitfi IS* 1 caaa pa* 1 042 " 40 - workari *4 t caia so1*047 41 orh#** 74 t caio at* 1.042 ~ 49 ~ woria-y Oolimtmo oo4 potubtt UMI (i*a*noobe tIfrow 1. S. an* i). 41 Tata) aorton at riak. riKtgr ctaaron*. 1,047 Total man-ysar*. roador dWM|. 1.0*7 ne*4-10*)_ _ cam pat - r5aT~ 97 M~SMn-IsO*r) "> _ " Total WC vara lati. mala Mon at risk. 4.791 Total man-yoar* m eve population, 21.910 2 1 _ 4.791 " 170 " caaa pat mala ampiat'aaa w eve IH4) population 1 74S * caaa par man-yoa't In 7VC atuOy population (74*4'1 _ I 4.791 " 140 * caaa pa* maia mptaraaa m PVT ttuity populatm* 94 _ 71.910 *HJ* caaa po* * yw*' m C atuJy pooulation Py analyail of aunroy data, f Oaaad on poataurvay taiaa up. pi warKara in piatnottic catafaroa 9 and 4 aw'* ai raactat Mooning oiportanco: annOaf data net avoiabl* ta* diapnoabc catapory } populous* j Aaoumaa mat iia aor> a in dia*no*tK catafary ] Dai had no react* doom** **pari*i Qu*t<v ip o Mrtlary^ tKIOr c*i 1 1 047 1 QtA i*** ov* i on 'htd to bgea k7 of men with AOL; only experience M bagef-packer or reactor operator approached the frequency of experience of reactor dean- infReector deaninf has a stronf amodation with AOL. Ha prevaianca of AOL of reac tor deaninf wee one caae par 72 workers at riak (total population at rtak, 1,047) amonf all workers having a history of wch Job experience. For Job categories larger than S00 men. the prevalence rate of AOL by job was freetest for bagger-packets (one ease of AOL par H workare at riak out of a total population of 880) and reactor operators one owe par 88 at rwk out of a total population of 889). On the basis of manmonths at risk, the prevalence of deer-cut AOL wee even more strikingly aaenrieted with reector deaners; this job bed a preva lent! rate of one com per 721 man-months at risk * 12.964 total man-months at risk). Among those jobs reporting 5,000 or more men-monthe at riak, no other job category approached this prevalence rate. The question might hi asked whether plants with AOL differed him pianto free of this disorder in regard tone duration of duty tours in reactor riatnPg. Analysis dd not indicate that mm in thsDomur group of plants worked longer tours tha high-nak job. In addition to the 25 ch^-cut AOL, there remained individuals x-ray Alow might have minimal cases of this diaor the x-ray 81ma and medical of the 74 mm in diagnoetic cstoAry 3 ie. Raynaud's phenomenon) rwealeAl* nwn who might heve been menifeeting m oerty phase or minimal degree of AOL Britt of theae men had marginal defects, \fauut whose prince the radiolagisD coui\not agree, and two more had widening tuft and shaft. with eoft-tianw dubbing of the latter aubaequmtly developed mul pie osteolytic lesions). The other eight Arch Emvon Health--V'ot 22. Jan till fXOM ucc 020907 n <K< t PiTI<>\Al aCHDdsT/V V SIS-- DINMAS ET AL three, fire, Ul or eight other symptom* o< AOL on history but no tatv abnormality* Amonc three 1C indjvMkiak about whom iVre > of AOL. * found that bn ui them rr-ported npnrw* in reactor cleaning This reported rrpmrrwe m reactor rlramng war omrwhst similar to the wurfc og thorn nm with dear cut AOL ien^htoteiLJhr 25 oan It would br of irliild to { bilitv nt finding that among 1C at random from thr teudy population. ten i mom would mport ieh work expenreire .Among A.Olt individwls na-reveH 1.047. or 2lr0. reported ripniwar in this specific job^ i 'anatdrfing this entire aturtv the probability that within* uf 1C an we mail^dimbv rfcanre tan mom "only 0OOnW 'ie. .V chances at The drtrrminaUon a Smrd upon "application of thr cumulative probability 'U-tributmn, whrrr '! njl *h*rt- n If* It ia apparent that time alone will tell whether thaar laat eight Individuals will de velop AOL Sevrrtheleea. becauae we know that at laaat ana Individual in thla and- dona group atequntly haa devaloped clear-cut AOL we balirve that 25 mam underaatiniataa tha total ntanber of AOL caeca in the population teudy. Therefore, we have conaidated that to addition Id tha 2$ dearcut cases, theaa 1C might alao be categoriard in the AOL gmp for atetlatlcal purpoeea, providing a total timber of 41. On thia baak, tha pravalmee of cama in tha general plant population of AOL is calculated in Table S. Lteeng CnmgnmiiHag We*i of the reaaona for performing this atudy was to itatermlni whether fabricators handling PVC polymer risked development of AOL Nana of tha eaaet of dear-cut AOL occurred among thia group of 1JS7 employ ees despite than being 57.657 man-months experience. Among the 557 man working m compounded, there wm only one cme of Raynaud's phenomenon. The prevalence of Raynaud's ph--menon strong ere was one asa pm 6.408 man-monttw experience while in reactor deaner*. thia occurred with a prevalence of one ^721 man-months eqnam. Compar ing thr% plaate with caaes of AOL with piante by ,* snaJyte*. dgnif vs) occurred conaiderafaiy ntly in the piante with cama r Irm than in thnae oompomd- this group of compounders, o persons showing s-ray 61m a ipwtewnshle nature without pherwnenmt diagnostic categoMmaary, it would appear that on of the Aniahed PVC redn ia M --ooated with a risk of eoo- TV dtmaae aemcalrlLya appears to ha dearly awonated with halskcleaning of poly- tnerueni In (hoar pLnta l^ng high-prm> rore water lances or aolvreibiXr dramqi of polymeriaent there were pomi^r mam in only one. There appeared to far a mrebthm between the extent of defaming Jkior to entry into thr reactor * At this time, work prartirew. rather^ any one mwdfic ingredient or in the prociM, appear to determine ' thia direaae will occur. In view of tha prevalence, the probability of the occurrence^ of AOL ia corrrepondingly low in a nil plant Hoa nr, nailer piante without caam at the time of the survey texiuld not anted* themaehss Insnune to thto problem. Indeed, severs! piante with retathwly naQ populaticna do have this disaaM among their workers. An semination of ttw intimate detalla of aok ki-- might clarify them ambiguitiaa WUa piante with roam of AOL provided glovro for their reactor dsenrrs, we niamind in- reaaitemit wage. Furthermore, while the standard proceduree oaad to "air out" ttw reactor before entry are well deaigmd to ndrtentee expomre, these wars frequmtfy fot sd, tqmn worker inquiry, to have been "tewrt-eut." That boat charecteristtm may be dtitmi nant of the pathogensate of AOL ia sugarot- ed by the low prevalence of this condition, ie, idiosyncratic 'tomalUiatlon" or "amep- tibility" mute be aarimnly rmaklnwl It will hr recalled* that a timber of inade- Arrh Em-iron IInIlk--V'ol SS, Jan 1971 ucc 020908 0101 OCCVPATIOS'AL ACROOSTEOLYSIS--DINMAJi IT AL quateiy defined tow molrrtilar weight, par tially polymerized meleriele ere believed lo ratide to the reactor mrapinp. In thii connection, the areretizing proptnwtire of dextrenpotyvinyl pyrrolidine plana eztcnden timid be lacaDed.* While H to difficult to wee how a high mnienitor weight (MW IOjOOO) compoteirf cnuid be afaaorted peratUneoudy, the poaUHy of reapinrtoey tract t--and ytomlr distribution muat remain ope. In addition, became thto appean to be a qwtemic dtoeaae, we ere more iwrimart towaid the pulmonary portal of entry rather then the trenedennel route of etoorptim. The pamfcflity might be contodewd that thto dtonae to earned by aevernl agenta, each one producing a wwcific component of the picture. In thto oremaetton, there to ertotent e report of Plasterer and co-workerti which notee the occurrence of Raynaud's phenome non resulting from VC expoaure. Ia it poreibie that the Raynaud's component of AOL tame from retohwl, tmraacted VC amodted with the PVC remaining on the reactor welto? Contrariwise, the bone changes in animals produced by VC monomer by Viola* did not appear to t; earn dated with vasomotor lability. data an required. A more complete chemi cal characterization of the residual PVC whid> remains on tha reactur welto to aarenUaL Aetna! etpmure to thaaa various poreibie amportHda are dewreWe. Finally, medial aurrefltona for syngrtome of Raynaud's phretemrnen and period ic band i-rey Aha appear todknted for tha priaut. It may tranapire. a mote ore and .ttretthoa ' free of AOL among their rhare win, a time gore by. tee devetopnt of aorea aare. Thto aution particular ly applia to employees hi the PVC synthe sis area. It nut be --that tf limiUtiorw of ay letnMpective epwtemiotogical study make imporeibfe any definitive prediction at future consequereM of PVC manufacture. Knee mich atudtoa an only deacribe event* of the poet and up to inotant of tha survey, the reaanendatiaw a to work prnctioa and madiawi arveiDana be come specially pertinat for tha safety of three workers. to was msvlad by a gnat tre ___ UrreWn <iiiHr ky .-- t-ror-m oo4i?-oi Ina w Dnutml tt Hmhh, Eduatbm, ^ Wattira. Mary E. Pataa, PkD, red Leigh & Wtottoch, Ftft aided ta tbs diHbl aaaiyws. sad ftniaia J Dodsa, MXX pawkiad lbs toad i-iav Haw mat 1. Witom HE. McCormick WE. Tatum <. at at; Ompalbmel ansaaSaobtia. JAMA 177-Sei. 1MT. Z Ctok WA. Giavar PM. Dtomaa HD. at at: CkvupatfaM] armnalauljrdt: O- As todreUtal byfwoa atudy. Arch laadoa Hmtk MtH, tm. * Dntom VN, Dbi--m BD, Wlutaboa W1A at al: Ocrupatieaa] anwwuabaw: 1U. A rihdral studrArrh Emrirrm HteMM HSUL ten. 4. Haaatb O Jr. Patohieifa dha^ ClMqd Amerkre Aradamy oi Owpltod MdUa, Ctotmaali, W7U t fltaed & Waveaalnc gtotisrfo* Naw Yarh, MrCraw-Hifl Baak Cb lac, IMA re U7-UA A Harama HH: Factor --tyda to MdtoWW MatAoda for Mgitol Cbavadsaa. Naw Ywh, Wflay A 8nb toe, tMA atop IA 7. Ttinawm WL. Waltoa HP: Etoaattoa at piaa- "bwmaaal Em Ttm MtUl UA A lemar MN: (he Tr PrtJ 0H *| OM. A Vtoto PL. PMhafcgy tt vkyttkahfe to Ptonidtare of tto MO htawHiui Cbawwe aw Omeetiomt WaabA Tatoa, IMS. to to paMUwA J XUM Arek Fiuiro* Hmltk--Vol tt, Jem 1971 ucc 020909 74 Occupational Acroosteolysis II. An Industrial Hjfiac Study WatTrn A. Cook; Paul M. Ctrier. MPH; Bertram I) Dtnmon. MU. Sell: and Harold J. Magnuaon. SID. MPH. Ann Arbor. Mich Polyvinyl chloride < PVO ha> been in production end widespread use for nv ,e than 30 yean. An extensive account of the chemistry, methods of production, materials utilized, properties, and uses of the PVC resins was recently pubthhsd in a aeries of technical articles by Afcright.1 s Uses in clude such diverse products aa floor tiles, Aims for food wrappings, aheetinf for show er curtains, phonojpaphic records, and coat ings for cables. As an indication of the magnitude of the PVC industry, the average operating capaci ty in this country (or the year 1900 sms about 3 billion Bt* Much PVC is produced in other countries. Evan arith this extensive production involving thotuands of operators, the occurrence of occupational acroosteolysis (AOL) among them workers was not recog nised until about 1961.' MmilW tor prAlkslion Fife t, 1*70. m i siilwl April IS, 1*70 Fna tbs laatiSlto at ITS insimroUl sad lsdus trtol Hssltfa. Usivafrity at Michigan. Ana Arbor. Hwd tutors tbs Amru Infcwtiial Hygim* Caitoucs Dsw, May U, 1MB. Hsprint rsquasto to flthsal at thtoiir Health. L'nivermty at Michigan- Alto Altar. Midi UIM i Or. Oinanel. The dinknl and epidemiological aspects of this condition are diacuarart in separate papers in this issue of the aschiw.* * Industrial Hygiene Survey Surveys wet* ainrto of 32 plsnts by the authors at this paper, stoat of the plants faaiag visited by a team at one physician rad me industrial hygienist Twwnty-nx of that sura polymer production plants Vinyl chloride mon omer production plants and plants Mppd tat compounding and fabricating at the polymer ised rsrin were s part of the manufacturing complex nt a number of these locations Phi plants conducted compounding and fabricate operations only, and ana plant produced only the vinyl chloride monomer. TTwvs plants warn tomted throughout the United Stetm and me in Canada This survey was designed to obtain inforamlion on equipment mad. procedure* followed, materials involved, extent of exposure to (ham. and names and dneriptions of Jobs in order to compare practices in the plants where caam at AOL oorurtsd with Ihoee in plants experienc ing no cases. The oxtnit of exposures was estimated on the basis of ssneral observation, a knowledge at the physical, chemical, and physiological prop. An* Environ Health--Vat It. Jon 1971 OCCl'PATIOSAL ACROOSTEOLYS/S--COOK ET At 71 Fig 1. Flow dkagrtm ter productwn Ot FVC ten cities of the material*, and diaums* with technically informed ptiam at the plank. By actttnc up throe broad categorise of dumtkw and of ratativ* aavarity of thr sxpoeurv. samiquanhtativ* ertimatea wvrv made. Since materiala naponwhto for caudal AOL aught be abmrbod either through the mpiretory knot or through the akin or both, auch actiniatea were made for each of thane avonuaa of absorption. Production Operationa Vinyl Chloride Production^-'The two proccmea for production of vinyl chloride rlforrihrri fay Albright'* were found to in in currant uar. One of throe involves the renction of hydrogen chloride with acetylene in the preempt of a mercuric chloride catalyst In the other procem, 1, 2-dichloroethane to pyrolyied in the preaence of chlorine aa a cetalyet for the production of vinyl chloride and HCL In note plants, both methoda ana ueed, with the HCI produced in the latter of throe prooeros being urod in the former. Polyvtoyl Chloride Prodwcficm --Poly. vinyl chloride can he produced in Moordanee with four prncwroaa, each with many variations among different pianta. Tba final polymer may have a mnlarular weight vary* ing from 60,000 to 160,000, depending on oonditiona under which it la produced. The production pro tv-- are deaignatad as auapenaion, emukien, bulk (or nonaolvent), and solvent A typical procedure ia prancit- eri in the flow-ghaut (Fig 1). The iwrontlal stepa of throe operationa are outlined in thia paper. For more complete details, tvferanoe may be made to the papers by Albright14 ta the widely mi iaed water is fint iatioducad ills a hip i Have, usually glsm lined, followed by a variety of additives. Thaw indods agante such aa potyviay) alcohol, methyl leer, and gelatin, emuhitying agrota sock as aulfonated ab, aurfactaata act as sortstm moaotaurata, and bufiara such aa Hear boosts. TrichlorasAylawe may be arid la pro duce the lower molecular might polymer*. Cat alysts ara added ta initiate the polymerisation. These at* nearly all organic pefovidsa. with Ineroyl petuaida and diimprapylpereaydi- enrbonate (IPP) being uard at the greater number of plants The nweter is Oh dosed, evacuated to --ova oxygen, and vinyl chin- ride, normally a gas. piped in aa a liquid under pressure from the tank farm or Aa vinyl chloride plant In some plants, the cwtalyst ia added to a dtotfr tank (ram which it ia intro ducad into the rimed reactor fallowing addition of the vinyl chloride. The mixture is agitated with rotate propri- far bladm, and sterna initially fa directed Into the reactor jacket to tufas the tamparwlaiu to W or 55C. Sine* the polymerisation roarthw fa asotbarmic. cooling water must ha tun into the jacket after the reaction haa begun to avoid atrerove heating After ton to 1* heron, the pnlymarisatfan fa amantfaDy iaa|lite Mi Aa reactor fa brought dawn to atmrnpfaerir pron- urt. In mote plants. it pincod under vwrwam for raaroval of tmpriymariaad vinyl ridodd* mnarausr and bandar to As mntioroer recov ery ana The atwparwion of PVC fa Am dfa- charyad into a blowdown tank below Aa roar- tor. This tank ia placed under rorums tv of nnaiaiag vfayl Alarida to Aa ana In met pianta the hfaaduan ia riminatad. The gaoaral appearance of the charging Boor of a polymer riant fa abeam Arrh Environ Htultk--Val ft. /an 1*71 ucc 020911 76 I OCCUPATIONAL ACHO06TE0LY8IS-COOK gT At M- in Fig 2. The mctei itwd for ten feet or n WIWT'IBraif flUOliDa Tho polymer deny b (mH b Hnd tanka, than to cnMI^m lor wnotnl at mack at am wotor. Tho dinafii! pallor b pmod through rotary diyw abb haatod bir. tho tmpmiui of Ah pciyoH bb| bpt Wm 140 F to ovoid itopiabtlia Tho dried (XOMler polymer b paooBOttaOy wwirid Mo eyrim operator, with floor perildn botef ra iltor-typo tdkbr. Tito pd]rm perilriot on or riiippod la ML la oono pioato, flto polymer b otond la hiao prior to batap dilpptd proton b mowWally tot oano n in tho mrpaabon proem ap to the diyteg operation*, la order to produeo tho floor pdjaoi porifaln diarartorbtk of the mahrfaa pmeon, o arid* variety of omobifyiat ipah b mod Thom --lb addfcton to tho production of the tonmpolymer PVC, wbj <d ttn pin* aim tairafe. airfaetaab ad m nib of aapbthalam to all of thorn. Tho mpulyum vinyl ddorwlfaaic arid, or varioo* ryathotk ibliifiH Mo-vtayl acetate to to Mflhmt production rifri Eauroa Health--ViJ tl. Jba lt7t ucc 020912 OCCVPATIOSA L ACROOSTEOL *SIS--COOK FT AL T7 wrong thii group but it a minor product in an^arimm to thr tiomupotymrr. iMOue ftniwi tm Mai OotOH 10 Abookitc Protauro-Tane Vatuav rl IQ* Above Other oopotymma are vinyl chloride-vinylideno diloride and vinyl diloride lauryi- Maflt CaOo No. of NO Of Specter iiooctoe Ctoanart MX Cmi rum Coo* No. at No. ot ooctor tipocteo CWonor* AOI Cam vinyl ether. An example of a terpulyirrr vinyl chloride-n-butyl motootc-dibutyl malaata. ProoMMa. additives, and mtalyets centjelly identi rionti wen MX Cow* II 31 o.a B i F * nont* wen (mmo not co*# cc 32 0* TM 3 1.2 21* t.a IBS 4.S IS 0.4 1.1 43S u.a cal to thoae mad tor the homopolymer are employed in the production of the oopolymrea and terpotymwe with the addition to the re action mixture of the addi tional iiMManaw. Vtoyt Chhetde Baemeey.-- The unpolymeiised vinyl chloride removed from the F 0 V w Tatau DO Total* nM wan No aoi Co*o* 90 OJ 22 o. O H 1 2.1 L SO 1.4 S T 2 AA 1*3 9.3 22 2* 12 17 a 132 Plant* ftortoa hi Operation Hi INS or INt 21 o.e c SO J 13 21 a* S7 0.7 0.7 O.I AS 02 0.S 0.2 3.C l.S 0.4 l.S belch faDmrmg cnmplotkn of 2 < polymeriiitina ii conveyad to a vinyl chloride recovery area Tatotol-CtoaaMeataeaf: by the wctton pwp that ree Tew Coo* JOB Tftt* Com plaem the reactor and the tripping tank andar reduced praaaure. Hare the vtoyl chlo ride gm that ia removed la are In am- vapor to a Squid Tta watot and the vinyl thloride are hn- miii-ftli, premising thair aap- In inhibitor. mttaly L to to AcfJHIv* mokoup (othor l than eata**) **" *"d Umpphu oporotor 2 Cptalyel mMuo men 3 CUrkot, pPior office, otoff Cprepaantong on* tebraoOng 4 s Orjar aparatar Oonorol Merer. evtUCM loOwotwy wpwincr Libotalary taaFmteiaa * 7 a s Mcumnance, ctoctncoi 10 ttcliUcnomc, mechanical u Monomer moMtenenca operator 12 MaAa^Baf aparvtof 12 Uonomor recovery oporotor Monomer mpomow PWrtt (vorp. cacurtty officer Rooctor doenor Rooctar clconor. cefvent Reactor oporotor Okirry toanOor Tan* farm operate. UOROac orac operater (watar trvttmtnt ate) Warebouce cporotw Tranalar oporotor Other then PVC 14 19 1* 12 IB 10 20 71 22 22 24 2* 30 to prevmt wi Milan-- poly tta uaad iar ito puriSetotom Tba cMorhto. with tha dmon tta agitator bladm i ay require 1 far removal a ing in the atO. b r piaato urn wntor Jota with pc--mee af from 900 to 1000 lb/eq ia far tta rtaanlne operation. (toe af ttaao uoed ewtor )ato owly in one of twe production huildinge. aa tta etiut- reactor to aerated Thto to emompliriiad by dropping a laribta dwct oonnactod to a portoblo blower to the bottom af tha (vector, with die- rherga aormaDy through tha ipan maahofa at tha top of the reactor fato (ha ctargisw-loor area. Tha faeaa ml to i to wmhad ant with water, eftor which ena or twe mm mtor tha reactor to remove tta Ain af | ing on tta reactor nufacm lie i h by manual tciaping with putty knives lUri- tional faaturea interfered with movement of Ito portable Mgh-ptaawue --tor unit atant tta building. Three attar plant* have tom ariag animate far rear tor cleaning. Oua of (ton torted to are thto method tote to 1M4, a acend in 1001 and tta tUid from tta begfaning af plant oparmtioo fa lMtL Tta reactor to Ufad with tta aotvvnt which mat to taatod and egitalad far i PVC to dMculty aolohla. Are* JTaifron Hnttk--Vol It. den 1971 ucc 020913 7* OCCUPATIOSAL ACROOSTEOLY8IS--COOK FT AL manly/Oufrton Cipowr* Para M^fWtuda* r omaa eaM i 2 4 > Iftlyfaffdiiti 7 a e 10 ii 12 la The<v 1 nrfWaet Muirii tatanv Aaorartatm Aooncabu imvta i-a hr/Wwtfc Nana ***&* Nana Nona Nwgl^ibAt Moderate Moderate Mara Than ehr/Waah Nana Nano Nona Nona Nano Nana MdtfifIMff nm IMnk 12 toermehta Moderate 1* Sawstabta IS Aaoractaeta IS ApprtoMit 17 ia EipnM m ardaf o> mcraaiinf do*aft raeahwtf In I* ata (ununaban af lha thraa eatamna la tha It***t- t Smartly al aapaaura la aatmatad aa naoa, naflu aaaradaMt tar mamtaa tamain, Nano Modaraia Nana Moderate ApprPciMia , moderate. ar at a weekly, monthly, or other period. A damtfleathm of fa Job titieo far the v-i****1 purpome of fas etudy woe peopaiad (fable 1). Thme Job fa omn^ i fa til the group if typm of oipomam to production materiel*. Kvery Job in mdi of the planta waa ghmn ito faction of time related to the Job title aa defined lor the atudy. Detaile of tha manner fa which thie wa m the on apt of AOL* fab r the drat Job wigraniif of the new employee to that of pMdnf cnimata of --*'~f PVC with l multipbdty of pteatidaris. antioridanta. pigment*. mtlaUiri. aUfailiaara. and dhn apacial com pound* in ribbon bleeder* and miBa. Tha milturea am than paaaad through roO mflta or muera. aorb aa am and m ifca rubber Uiaby, ban lha tampanhu* any rim wittcianHy to vapor!e use al tha piaatiriiar and othar votet&a conatituonta. Tha compounded polynwi ta thou extruded through roil# or dim to form sheet*, Plan. or paQata. Than ar* mad in fabricating oparattom Many variables am introduced in the ptento surveyed and even in different tmlte of tha same plant in ragard to naeriy ovary phaaa of the opantfeoa. InvaeHgatfcm of wit Jobe fa the pianto diadoaad a wide nt of Job tttlaa. In fact, a fab title aa by the technical nfaervfcon often difI ben that bn the aane Job fa the i plant aa liatad by tha personnel da- a Job amigrunent fa one plant might fadude a different group of imit opantiana than fa another plant Atoo, tha proportion of time devoted to tha several unit operation often differed. To t-"1 the diflfeulttoa of dafafteatfen, worker* would frequently rotate through eevoral Jots eta many reactors, thie work dom not taqufa the mtiie time of the employee, fart of hie time may be part fa hogging or diippfag Inifud polymer or in the hndling of ctoniyeto and otto adrtirivva. Aa Job opottfaff arise and with aoaeticn of aeniority, (Me empioyae may peogiam to higher ebiBad Jobe audr ae ronctor,-- recovery or dryer operator, or any oonbfamtion of thaae at any ono time. In planta producing other producta fa ad dition to dqrt chloride polymers, employees may bander between fane prodnet aim either aa full tfam for a period of monthe or dividing thoir tfam within a given weak or am fay. Hit latter occurs partiafariy among maintenance poraonnaL Where productian of vinyl chloride is part of tha operation, operaton may rotate beiiein Jofaa fa tha production of lha monomar and thaae eaenrietnd with dm produc tion of tha polymer. Tha length of time pmt at varioae Jobe to a function of production recode. ----dcondBticwa. plant growth rates, and activity of other product line* of tha Arrk ffariraa Hralth--Vef . faa 1971 Ijcc 020914 XUM OCCUPATIONAL ACR0O6TB0LY818-COOK KT AL exposure to i both dumtk factors m ( from btd i bi Ited. The duration of i hour Since H' ak d rpiratory toast, through tfao *to, or both, the ntait of < themavaouss Por riatktkal purpoom, h m dariiafab into a to|b doee value. Although admittedly tha dbet of eipoart to mntariak vith diflariag pfayiologtoal grave of < He weralktodtol rkmiflwl to thme grouped i ignatad aa lhaae oonfatoationa aia IS values to Table Materiel*! teeterialr aai ties of PVC 1 estate, aad 4 incorporate* riayt elation, < nlvw aUshade aa chlorianted total f m difmat I la the farmer vinyl efaloride-vtnyi i fori n. tome*, re<- ef m l1i I* nteixn MKceteiw UWUM____ , M Vrifan VWiyl CNwrbds M Vhnyt n aa a4 tion pwlfal and < of vinyl i ridnhy of! The to the ako whan they wars toat faatog vontod toto tha dmrging room area. Air analyna rrewturtod by otfaan have dwwn viny! chloride oonoentoationa to the laoctor prior to ventilating to ha to tha ordar of 1000 ppn. Tha lower Itotit of detection of vinyl chloride by odor kaomfrtod aa 400 ppm. Except ndar the foregotng conditions, the odor of vinyl dUoride n not ohaorved to the general room air. a-- -- ft. a. tor die aatadtoi has reduced the rinyl chlor ide expooma to what k coneidered mtMwc- tory limits, normally 16 or SO minutes. Tlw toat k either by milling at tha *" opening or by uae of a vapor fadfaator. With tfao low* aiploaiva Hodt of vinyl ddoridr at 4%. It reqtdne 400 ppm far die taual type of flammable vapor indi <ator to give o paritive leading. Whata ak analyam have been nade to a wneB anfar of plank with aaae anflto toatrumank, andb aa the gaa dmanatograph, it baa bean fotmd that tlw vinyl ddorifc town ef AOL that ana net oyi chloride. temk to be below too boot 80 ppm. With the totno mpotymeriaod viMHMmto of thfa m e k carried mi. Ak mml- the rob of vtoyi ddoride aa a po^Ue to- flumoa to the ceumticn of AM* the mti- metm ri the extent of tlw ef fo- reviewed. State the autha enalyem, they had to Judge dw ware oak eoa of vinyl chloride to flw charging principally on tha faerie of tea wtlla- tfana dam to tha hand during therangeof note MXBppm. Although thk atudy provided no evidmee to eiggeri that vtoyi chloride par aa k tha edotogkal apart, Srn maaeuremant of vtoyi chloride conemtratfana may aarve m a uaeAil todan to the adhpmqr of leoetor ventflodim. tor, ueuaOy phenol, may be added to the Airk furiran HtmWi--Vol X>. Jm 1971 ucc 020915 80 OCCVPA TIOSAL ACROOSTSOLYSt3--COOK ST AJL HM iLHa ___ -_____ -- - FWnt After Ittry CM Pate* UM Tten [WfyCeV fidntt dfftft AOL eatH I CX FX AX (tATOMCA 1M4) RX 0 tvery 4 12 eytWe (tnnMinf A) (C X VUnU With pouWW MX cm** B (eery ''toyerer CUaivna by Wdter m From 1H) from 1M2 (buAtertf ) runic mtti no *01 cmm AX (o tc-ember 1M4) cX 0 HX ) Cmry 2*i eyelet l Ivory -8 My! NX f WM* throun 1**4. ' wry 2 mc'i 1MIW 0X SX T X t--ry IJ eyelot (emuttWn) tcmeciuiM) V Iwy lOcycUc i1 u Ivory 4 or mar* tystel 00 X M From I**2 From IMS rl chloride to prevent qwntanaoua polyatioo in etornga. An inhibitor may alao be added to the vinyl ddorida iicovered fron^he reactor. The phenol le removed by treatrnant with cauatie aoda prior to ite tranrttr to the reactor. The pmctiea over tfao yeera ooverad by the etudy ia praantod in TObi# A The we ot the inhibitor fa the virgin vinyl chloride at two of the poaitive pUrrtaand three of the negative pianta, with inhibitor being added fa the vinyl thloride recovery operetta fa two poritive pianta and low nagrtive ptafa tab to the atelution thet Wdfaitote profaebty ere not n factor in AOL roiwelliai Catajyrt TtfaWB film the catalyfto are all active compound, they < Cloomnf Cy faMM On guao bnotf. nUnMUcnOf hi IM*. entirely by Betamoor !W From loplombor acted cetalyrt 1ina fa the raairtut Twnfa-lwu of the 28 pints uaed lamjr! ] ide. Sight of with AOL tMi or AOL om, and 14 pianta witfaoid AOL The m organic the IPP, end it, too, wm to in in both the pnWwand the naptive plnh in hv of the fanner and in eight at the Utter. No catolyrt or group at catalyata wae uaed in ah perttive pianteand fa no mfative piarfa. at are cuwtiturnta at i iwawf fmn the during Thaaearabalicved to I aome partially pofynuriaed reacted catalyrta From atari ol them, vinyl chloride. Little wadf- ic adannatta h cwrentiy falttn thrtl with PVC Httia of the IPP fa the poiymv.* Purther faveatigetta at the from tfao reactor may bo mpertad to fumieh faformotta that may land to a batfar mdw- atandiag of tha Uctorn favtdvad fa onatta of AOL. A dfatalty hr auch Inviatliatimi fa that tiro comporitta of the aoepfap k continually dianghtg from the tima tfaay are removed fan the aurfam of the reactor. It to obvioua that comparatively maall mnl> culm at partially potymeriaed vinyl chloride fa rtae with r--n of time. and active ccntitanta axh aa laaidual cat- Ank fmiro* HrmJtA--Vol ft, Jm 1W7I OCCUPATIONAL ACROOSTEOLYStS--COOK ET AL 81 Mm*** Mtnual sensing sttsf M7 rssctm evsts Manual acra#*n *'*f 2 3 cfdaa Manual sc'sp-ng I*' 4-12 cyds* Water |at cwsivng Organ** uKlta t*M<wi| ftMU I o 2 2 1 Menu * I 4 2 2 alyst and vinyl dtloride monomer an de creasing or nay no longer be preranL Sinot all but one of the 28 operator* diagramed aa positive lor AOL had worked aa reactor cteanari and the one exception had '<--"*< laboratory Isadora,1 additional inquiry waa made of prooedurae that might affect the expaourra of thia group of atorkets. at men hour* required to dean the reactor* depended net only ea the Hbr of reecton but eleo on the frequency of rtsenmg la 18 of the 38 production pirate, reactor* were manual ly cleaned after eeary batch. His me tnw ef Mx of tha eevea podtive pirate rad one of two plants with pawible AOL eases. la only sine ef the 17 plants with an AOL came were reacted manually scraped after every hath The prooedurae followed in eodi of theee plante appears in Table 4 and an analydg of the types of procedure by podtive and raptive plante in Tabla ft. Prarntorm Paffewt^ CragliMia d My mu-t--ttoe Were viayt rhlnride aad otter velatjl* rrapwrate of tha letedue iwnaining aw the reactor snrteese Minwing rfiacharpe ef the belch might he (acted te AOL rmwatinri Womatiori eea ahtehmd otmoerateg the degree ef it and the length ef time that the reactor era unde* thia reduced pleasure The amount of velafcia materials lamainiug ia tha reelibis an tha reactor surfaces was considered te be roughly proportional te the absolute pramure and Inversely proportional to earns function at the time. Sines tha rale of removal ef volatile material would tend to decteaaa with lima, the toaarithm of this factor wee uaed in an absolute preaeure-time (AP-T) value It waa hvpnlheNted thnt the relative amount of vola tile materials remaining in the rm dm fallow ing application ef venwmn would appraterate a nofldimenmonal value obtained by dMdteg ttm sfaolute preaeure in inches of meitnry by the kqarithm of tha time fa adnutoa dnrfag which tha varan wee applied Thus, the loner the AP-T value, the lam is tha manual of vofatife materials remaining fa dm ramdot. Another factor affecting removal of vola tile materials is the temperature range over the period that die render it tmder vactun. The wiebiee in temperature control wore to diverse that thia factor (Wriad dei fication end eoirid not be incorporated fat the parameter tmder consideration. Actually, variations in dagrae of vacuum and timing of its appliestion were audi thnt tnenningful calculation of an AP-T salon could bn ac* oompliriwd only lor In of the raven posi tive plants, one of tha two with poarifals cases, and 14 of tho 17 negative plants. In the subsequent rftennriow of Aw val ues, the three plants thnt started fat opera tion ae recently an 198ft and 1968, all with no AOL caeca, are not indudad aa it la not known whethra euffldent time had dapnd foe caera to have developed by the terminal data of tha dndy period. Theae plante an listed separately fat Table & The AP-T values ranged front Oft to 2L The AP-T vshme were 10 or above (an entirely arbitrary divider line) lor lour ef the ftve podtive plante and for one of the two plante with poaeftla AOL caws. Fora of the negative plante give AP-T vahtea below 10, and raven gave valuer of 10 or above. Consideration is directed to the number of reactor deaners and tha mrwapnndlng num ber of aspacted AOL csaas fat tim two g*--im of poaitive plante ra compared with thaw fat the negative plante. 0 The total nranber of reactor deanan at rtek fat the podtive or pomfhfy poaitive plante with an AP-T value of law than 10 te 63; thnt fat audi plants with an AP-T value of 10 or more te 436. The relation of those two totals is to be compared with thet of tim negative plante in whidi 199 reactor deanera at risk art fat the four plante with an AP-T of fara than 10 and 132 are in the seven plante with an AP-T above that valur. The nranber of expected oeaw of AOL for eedi plant is also listed in Table & Thwr vahtea were obtained by dividing the mas her of tractor dmnevs at rtek by 38. Hite Arrk F.nvimti )Imilk--Vnl T2 Jan 1971 ucc 020917 OCCUPATIONAL ACBOOSTSOLY813-COOK ST At l|w dm* from the HV* UpidmdlokaJ ^eets of AOL* wfaidi reports fas pravatom of AOL or pnadhle AOL as one case par 37 motor (loonow at rii Of tfw iwgatlve ptanto with on AP-T val ue of 10 or more, none of thoae in operation earlier than IMS had enough motor dam an at riefc to expect an AOL caao, ufaanao two of the loir plants with an APT nine under 10 have enough worker* to export mat Caan would be eipaclad from the total population of reactor daanan in the entire group of the seven negative plants with APT values of 10 or more, but the total *-- would be Lt, as eengrarad with &3 exported mas from the entire gmp of bw negative plants with an APT value of leas than 1CL IMs oootmts with expected cases far tbs grmg> of podtivo plants with an APT value of lass than 10 as 1.7, compared with 1L8 far such plants with at. APT value of 10 or more The proportion of dm masher of reactor deanan m the negative plank with an AP-T value of Ini tim 10 to tha total matter in such plant* was 193 to 325. This propor tion far tbo podtive plants was 63 to 4M. A X1 test demonstrated that tha probability of thb diflermce talninn d negative and the positive plant* ocaartog by chance 1* lem than 0.001. In order to maks title oompariaon batwaen tha podtive and nagativa plants with APT value* below and above 10, K was noemauy to overdmplify a multiptidty of varying datalk of operational procedural from tin tins the pdymmfaatfan la completed to the time the daaner entam the mctor. Aooordindy. any interpretation of tha jmHnp that re duction of the APT value below 10 by reducing the absolute pranae or kaepii* the mctor at reduced premure far a longer time or both may reaulte in reduction in deuafapmnt of AOL am Mould be ap proached with gmt caution. The promt hnowfadge aa to AOL is swh that categoric etatenmnta aa to preventive meaeurm are ant Jiattid. However, on a are indicated that may bs ccnrfadve to AOL prevention: 1. Although some manual removal of rad- duo from reactor ashm nay ha required when solvate or Mgh-prmini water )ete are used far deanhifc tha mote aiterdve emptoynwot of those methote would gmtiy reduce the ti man hours requirad for conducting this operation by manual 2. Tha adequacy of ventilation of reactors prior to entry Mould bo ctected with Ssmmabie vapor indicator equipped with a cole of create amdtivity than 1% of the lower explosive bruit of vinyl ddoride or with other btenanente of such eemiUvity. 3. riirlhm hn atigeHnn nf tin mnoHtitei ey of the aaepiagt from the raecte urfaom should he considered, as such information might diarinaa the factor responsible for the causetian of the diseaea. t. AM*to LT: Vteyi gecTniteUA ncr. 1 AMd LT CtengnrNteS-1 A AWd IT: teb Cteai Cm MlSI-im t iAktelA Vtajrt ___ -._____> CP, at te: Oewteul iri nWinhjte Itapert f >1 wn JAMA *t*77-H. 1M7. SJteme , Cut WA. WVlWheaM^ WU, *t tel rteSy- Ardt Kmi um Hmhk S Dteas VK M--iia BP, WWlte-- WU. et OmpUrate inviilnbte m A riWel Mirty. Arrk gwim Hmhk SMS-tl. 1*71. Arch Kmnnm Hmltk--Vol K, Jan mi ucc 020918 Occupational Acroosteolysis m. A CMakil Stady Venom N. Mm. HD: Bertram D. Duiman. HD; Waiter U. Whitehame. HD; Ahmad N. H. Near, HD. BhD; md Harold J. Uaanamm. HD. HBH. Ana Arher. Hieh Each patient nee id--fund to fa (lldil Remaidi Ufat. Uahmity af Michigan H-- tel. for a two wash period where detailed medi cal faMn were ia i Minted and physical ossntaotfaas perfeneed Detaih at die noth rimd fa-- fa-plant spi I--t llogjnffataBn*earn riad ant fatally hy fee Irtaitats et Eavil----ntal and Ied--riol Health at fee Ufawoity at Mfalpi and fee Miadntwfa Ch--fats' Amociatfan. Tsfafa 1 Ifata fee khonfaty pat-- eten epptied Ia addition. cold-- and phaephone falonre atndfas were carried eat fating Occupational aaonteoiyafa caod omiefe primarily at Rigmnd'i phaxxnenon tod aeteolyfae ot the distal phafangn in the hands. 8uehi ft I ftrfa dtacrlhsd Rey naud** phenomenon fa polyvinyl worked in IMS.1 Otoatdytie Mow wed aborted fa other mM Other Moodefad dfalenl fae turee nh m hepatomegaly, the cuteneoge stigmata of edenfanna, hypothraid pernmfadt end nnenw Abnormal facntoy Hum-nhiwphenw fatake to which nth partit was an eat--ed Daily 34-hoar altar --cigrons were ceOeeted. and Woe) spa fawn wore pooled eery ferae days for tslrhn ad ptvwylioow JitsimlnUins Appropriate correct!nol c--- eelty, patients with AOL ad --odeted with the manrfacture of vinyl ddoride polymwe, non meciflrally with the hand rlaenlm of Tide paper reporte the reeulta of intaneive dfafael favestigetion <d four patients with AOL Than tour pntfanti wen edirled ft-- thoae employ-- of 83 plants mpeged fa the maddn of vinyl ddoride pdymen throughout the United States. Saltarill far ptattstin M % WTO; --od Maerh M. History Rhndting of the hands was the ft-- fee --tin fa anewH--I and Covhw--I Modkfas ata fee D--ri--at d lot--el Mfajdas^ftfe Mtata^fatlMMnta' flint sign of AOL In two of the awn, the onset wn gradual over a lew --oka, and fa two H was ehrvpt, n fax--i fa Table 1 fatarifatfafagf gctafafa*Pfafar Hatah (oTtfar Cold was the indting factor in ell cane. The WhHfaia--). V^mStfaTuiAHm!Anifae. It--fat rmmmeta h 1-- d bH--iahl nd fadmtrfaf Hast*. Ufa--tity fa MfaMess. An Aihar. Mkfc fatOt (Do. Dfa--a). Handling wee anodetad with either tingUng of the hands or tenderoam of the tngerdps. The polyvinyl work exposurw-toflnt-Mandiing ranged from one to S3 Arrk Emirem Health--Vat St. Jam 1971 ucc 020919 ef riprtMH Mbm Ptewow Cntm earn* own OMruM* Md/M Uree itmen* Cnnw Tm emw pnWn Beiiieemaiii mwi MWimln "1 a a y CnWim CMnnwn ohicm* otma) Meawwin Lena TflMwiiiM tennemw iwCMWI rnrtm ninrgtiw `rrnrmn tebwBvnnBmU[mM^n>eelaamru^nkBv maeceU. lace e hn>aiw>M eri * 'MuCMMM* kiMtA Mnew `Prttllra prw(ihn>inoe inwn Wi|ni"e ImiMlMlni Teen Vewneel Dt---- !eercw /Mimics teeter UOnenry a mb OVenCaimri UMi-ffcewneMM tacUr CMnMMe ta* an ao monlhe The bngth of the interval bene no relationahip to the mode of ooaet or the Mwity of the eymptoma. A aummary el die habile and dietary hiatoty althaea petianti ie detailed in Tafcfc X Three el the low m ware cferette nohan whh nn*mf hfaiorfca el (earn 1), 18 (cam 4). and 38 (<aae 2) pack-yeen. Half drank coflee (three or nine cupa par day). AH were aaoal tea drinker*. Three drank between three and 18 bottiaaoi bear each month. One (eaae 4) drank ISO cane a! beer par month but no nhhhay whfle the othen eornumd leae than tour ucc 020920 OCCUPATIONAL ACROOSTEOLYSI&-DOPSON JET AL otaweecf whbtagrpmmonth. Throe cJ At na rarely M dk, ad the attar feme 4) avenged two glamwdidir. Dietary Ntoorbe indicated mldmo btahae between tOOO n* and 1,300 mg/d|y wK fcr ora pa tient (aa 2) vine mual intake vae 516 mg/dqr. Thb petbnt'* normal dietary ki- take of phaphora enraged 2,400 mg/cby while da oth er* took ta latten 1,500 mid 1JN0 mg/dry. Nora had ii CkMte taMn Cm* 1 C*m 2 Cm* ) Cm* 4 il ii Tlnmn M #k* IkaiMk. MM Mto MM awikeie Ortotfutl OfMutl iuddan 4- 4OMn fetn + -- lov tack Hands Hand* Han* -- Knee* Kn*M m I Mp. 1 MM, 1 km, bane* lav back Vatra at -- -- f ip--im u >U iunin ndsntsi 1 mo |i4sim*UnlTir*in 4- rsipnrtwm rrri idfumi 4- mo 4* 4* 419 m* 4* 2J -a + -- Some detalb of bmfly hbtoty are recorded k> Table 4. TtfAs I*--MtiNi OHify Hktortm if l adeem talk 401 dm ae pnaent In either da tether or the mother in three v lour puttHt nd n hNIM CT*i n* M*nik (--o-ro Awarkpa eaKaa aataatnman (avpaMay) Cats 1 t Cm! X Cam 2 0 0 Cm 4 12 0 meDiha though nora pwoneOy evidenced da dbeea. Notably, the tatlan of a**r(lT ttflM) WM*k*y() M*k (MnJ*nl Catoum iMafca (tne/bay) ftkMhorv IMak* (mg/eay) 2 i tamy 1,042 l.l 12 4 l*My tie 1.207 0 lardy 1327 2.427 120 a 2 .0f* 1.727 all tour mm had hmrt db- Table 1 ttbneee to Pi towel Jedaw Wm AOt The Modeled eynyttm and dm* aI Joint involve- Bnnt am Httad to Itfab #. IntawdUmt famrimt criho- (amMy MhMc Cm# I Ftffror OmldM iNMut Ce 1________ Cat* t Maarten**** mdpn d^-g-d--d--g--g| Over** lung Cm* 4 Conga*o* Mart Un. rtatic thmitue aw mmtioned by three of da tour petimto. Thb occurred <an> rbtag from totting or recmienty. M*th*r IrOthor Cmp^yNmo HyOOflOhOtOh, Ofenfty ... Myparttnaien Hynrtkneiaii ObaaMy The one patient act hevtag thwWae (caw 3) had chronic poatnarel drip, mad etuiWnree. and a prior hbkvy of child hood bronchbl aathma. Hptaml Bsmdnattotaf--The major phyeical fading* ware leeUktad to the akin and Jofota, m dawn in Tdie 6. Synovial and Ain thfcfcarinf wen ntmmail by two or nan dtaidane independently. Dupuytron'a oontmctune were pnoent bilaterally in one patient (cam 1). Ha exteneor Ugamenta of the wriat were thickened in another (cam 2). Tha dbtal phalangea of da hanh of ora patient (erne 3) wan dartanad. laboratory ftnmlai The manerom dinical laboratory parameten depicted in Tebb 1 wan found to bo immHilly normal. All tour men vacillated between negative and poehlve ealdum halancea day-to-day during da two-week period. Except for one patient (caae 2). all averaged a poridve balance ranging from 33 to 246 mg/dey. Thb patient managed a deArit of 27 mg/ day. which wm pranarfly a function of renal excretion. All had poeitive phomhorue halancea except thb patient, whaae phomhoturia ahraye accounted for man than hb (tool Ioann. Flve-hydroxyindole acetic add determinettone wen performed on 24-hour urine pec- Arv* Fnrinm Hnlth--Vol Jan 1971 OCCUPATIONAL ACR006TB0LYSI&--DODSON XT At ntfiif ot Geo* 1 HoiKhtOf mthoutoM WOietfd MUs lncMfit*l _ 4- met art tun Duavytron'i contractor* f togor e 2 and ] IHMt M> Hagor*. ( PHrie*iM i fiaiat mnatoturpbfnto--rinoI Ml. kune whidt were nKim Com! Com J Com * partition*! in rix-hcw incns mm* (Table ). Om pa * 4* triot's third-period whe of 2J aeaared durrig cold _ 4* tmm while ptethywMfia. + phy wea being done (onl), mm _ ---- TlMctbSfiing awn llltltion Sherton. fcl0* Rn|ii b#S UM -- Another patriot*a tfawd value oiliridMthmtmfar rimihreoldrinB (awe 2). Plethyanograpfaie Madia revealed normal poke vd- (OHe 2). All patio* ex- cept one (one 3) Mowed di- maikhod puke vohanee with add etna typical of the Raynaud'* phanromon observed in oth* dio- in all oddeck a* riiown by harhan ftuoeospy and Silndtfo et at motility technique. RadMagknl TWtafk--The radiographic finding* of the four patknta aaabnd are amnariaed in the caae reports. Caan I--X-my Ik* made akewheie prior to the patriot** hospitalriotriu at tbo UaMnity i Michfoaa aiUarid aoeawl hawk aa Oet 90. IMS, aad, la 1907, ihowod auitatl bona dafort* of tlw right third and kit Mood, triid. aad fourth drital pharingaa aad drital ftogw*a tattaa o# the drital phalanx *i th* kit flat dig*. On Aw A 1907. trazwono dtfcrt* m aofod on the drital phaiaaca* oi the kit foam one to four aad right one to thru, with inarp trie i the drifol portrin o< tb* drital phafoaa oi tho right flflh tun. Tha appaanaee oi tho horik ou Oct I*. 19V7, when tha patknt n Int warn, k riwwa in Pig 1. Soot lupsrairie ehaagao uura aorid ia eaaipafrioa with tha peorioua fifaaa, with parriofoat tnaammo dafoeto in lagan ana to four on tha kit aad oaa to thiua ou tho right with a marginal dofori fo tha Matal portrin i tho drital ptnlaai oi tho right lith lager. further dwrit-up oxaninetria waa obtained ou Jaa 9. 1999. and Oct X 1999. the latter Mag den ia Pig A Itariag thri period oi time. them ha* booa further rmorptria ai bene, moulting la thorrinrig of tho terminal r*~~'~~irr of al *-|-- except tho rift fifth. which ha* mraahNd uaiavolmd. aad tho right fourth, which ha* mriataiaad it* length bat ha* devalopod a traamrm iM raciroa HfltA--Vol tt. Jm I9TI ucc 020922 OCCVPA TIO\AL ACHOOGTEOLYSIS--DODSON ET Al unwytanwt Fnt-itawr'ita M-ire ram-aare toi*hM Total (1) TatU (2) Total t taiaaa*TM* Com 1 4? UrVW Cr**t a* Vfcm art 4-12 IJO OW l-M M 4.0 7.% no 440 720 140 1.720 2.170 1.720 020 0-42 042 012 1.12 1.47 1.44 Cooo 2 UiH C/Ml Mg V^IWH Mm* Caaal UfNW Croat 1H aw* 2.0 204 aw >2 240 004 l-I 200 aw 1.0 210 a4g 7.0 1211 2.20 ... ... ... 22.0 Cm 4 UhM toaat- M 200 tjoa 410 420 2.444 020 007 022 024 1.04 ... ... (Ufcyt IV right tth tarr hre *0*1 addi tional inuiptioa ai IV phateapl tg Sait* tiM* ctabtog V aatad to Oia toeateaad phalaagre Sana ataoria V aaiad along tha margtoa ailanat to tha tiaaavtm daiacto 1Ua patiaat aba too aid artaaarea tmto aid mte- retic chaagre to tha wcre-Otoc jomta, aa aaaa to Fig 1 Aa treat** iarioa aw aho lemd to tha ptoator airfare al tha aa calda, aa dapietod to rig 4. Cub 1--Thte patiaat had m> aataaatoa akalatal Bitty aa Fab X IMS, with poaitiva Indian limited to tha haadt aad prfria. Aa rfrewa to Fig X <ha Wt hand------ *1 a matgiaal drfaet at tha tip of tha dtotal phataa* ai tha aaeaad to** wtoto ttm ttoid flw ahawad a toaiiti Mart to tha dtetf pla tens. At tha aaaaa Sma. tha right hand preaaat- ad tomant lytic Matte to tha diatal phateawa at tha mcood aad thud hmn mat mi Flgwre g aampaaaa a typical ao&aa tea rida "F ariatiacaa ai tha haatte aad tte cm tomteg iMBtgaaociaaaa. A rfight torrent to aodif teaorida F aptaka to naa to toa data) phatoagn ai tha tail thiid aad right aaeaad aad third team white tha aptaka to right Imuth aad ftfth lagan- GnataDy* to lakaa ovar tba remaining I-- ai tha teth art aaltnire tha toft, n khena to Fig X Cta X--Ertiaaiii ikatotrf aarewy aa tito U mm m Arm Entirm HtmHk--Vd tt. Jm H71 ucc 020924 1 020925 OCCUPATIONAL ACR0O8TSOLYSI8--D0D90N ET At right digits a* md tow mA a iMHiml MI|M tetert ddrhfl metmd digit (Pig 10). liNnWr at tha )* poi* d the right pririhvaiihiMhl Atint gtonea.lt appeared tint Aw* wua a ridi hhkqr of heart Ahm or hypartanrion or both hi the prate of than h. Connate* el dan with heatthr ah Raynaud** phawMon waa tha Int mantfoatattoe noted by than adbjacte and In tha Majority of 9m eaan repotted. Karri* and Adwnri wpihj ana can in which diatal digit Aortentag oounad teat, white WDaon at aH anted tfak fa tv* of hfa 31 eaan. Ihb augpate that tha vaaeuter krion todhrlduafa. Nona of than patlala ohUtad Raynaud** pfaanomanon of the teat, whidt oontena WIteon at al*a agartenca. All of than bdhdduala Ind boon "reactor deanan" b thay apart aome hen* ante weak darting A* polyvinyl chloride polymeria* tion hatUn Aortty prior to or at tha Ana of tha omot of their dtaana. No comfabnt lebttonridp wna fomd faotwmi tha occurranea of aavority of oithn Raynaud** pha* nomanon or A* oataoiytte farieua and thoaa habit pattaRM whkte have boon teowa to or tea, LOawiaa, aaitfan Aa bona Intern an Raynanfa phanonmon anand to oor- reteta wiA tha drily wwaanptliai of nUk n dietary tnlrium. Dull** and Norite1* have Acwn that white dietary Addenda* or cal- riun nay n nay not potarthte oatoopoa- tea of varioua typaa, an ffat-- tetahe of 18 mg/kg b pndactiva. Only one pattent (can 3) bad fan Aaa Ate mnt (SJ mg/kf). Stan nab dietary hfaterin <fate 1"SSS SfnbtiSX teat, uabg Yate*a eorractteu. Wbatfaw aud> an ohaervation augpate a hwaditefy MHy to etpUn tha auataptBdlity of Aon bdMduala drvetepfaf AOL te nacubth* Tin nianbar of ohaervatfana b too mall to amport aeriouriy ancfa a eontentlon at thia tin*. The ntot and dtanctor <d othar mmem lar akateta] ibxBnga ante n Mon wnl nnowial thfckaning eonten tha bd^ of W* at* abb to < orAoatatfc ttenttua by Ana of thaw am. Sucte at al deaertead Uvar afarpanant. varioua vague aathaoie gymptoma, and aaani- hatationa of hypothyroidfam. Such 1--ffn-- war* not praeat te than man or had they been te the past. Tha ndfalogteri te oocupattenal AOL have bean rattenad neatly cm Ao bn of tha apidaihdogtori tevnttgallun of ilui gPmWluyuV^HMHJbl CMOnBI MRJi WOMI other cmmtartoa have daacrifaad lytfe teriona te the diatal phalancn of the hanA, fayfald proeaana of A* ulna and radium and tha aaao-Qtec joint*.1-** te oeonuttenal AOL team A* aarifaat aw> final aaoriaa of A* dfatal phalam Aaough Artk fnrirm Htmttk--Val ft. da 1971 t mm OCCUPATIONAL ACPOOSTEOLYStS--DODSON KT At ceidum, inrihntinf active That the digits with margin*] defects pidid up low than the normal bone* hnpliee some type of uptake (dock or active damineralisaUon. If the latter is true, h ie all the more interesting thet different bone Won appear to be minamlinif and demineralising in the mme individual, even the eame bend. The etiological agent or afmts reeponaihle and the pathogwiical mechaniwna reoiein obacure. Medlcnl PiewauHna --The interval be tween the beginning of reactor cleaning end the meet of AOL appears highly variable, ie, one to 23 month* Accordingly, the few quency with which one examinm reactor deanm bee no rational basis By eonbaot, the occurrence of Raynaud** phenomenon should serve as a sUBdent warning for fur ther inquiry. This ie not to suggest thet prudent medi cal practice does not require periodic exami nation of reactor deanm end other groups of workers in whom AOL occur* These groups should be surveyed periodically by urn of hand roentgstogranw end medical questionnaire* Hie form the letter might take hes been diecumed in the epidemiologi cal segment in this eerie* But we would emphariie that prevention of AOL also re quire* the cooperation of a^Mrvirion. This group should be alerted as to the possible significance of Raynaud** phenomenon In relation to AOL Upon the dkuvery of any mm of AOL among workers at rfck, ouch individuals should be rsmuvd from the Job. X-ray films of the hand, back, and knees Would be obtained. A medical history questionnaire, similar to those used ki the epidemiological survey reported ham, Would also be pro cured. A medical evaluation for other cauam of Raynaud's phenomenon ia fat order. In view of the tmpredktable course of AOL, it would be wise to with Raynaud's with the pamepe of time, each endue prdbsbty would not return to thb Job. In view of the tow prcvahaoe of tfcis dtoeoee, we believe that permanent restric tion of them few workers from this )db does not pom any tmdue ertodnietiativw burden. UntQ more is known of the natonal btotory of this diooaae, prudence would dictate the 1th! I by PmMc Health 1 Swfal. Dr*j so t ValatoaL sf d to vtoyl AM /sms IMSTfT* 1083. * Gwdhr JM. fWCtitei YU, sc al: ts i Narlsta. CaA IM TMmil *14t* tea* * Ctohtala A, Mstilsa Ft A < Wstysh sf smowtfaattl wt*ta: Bmohs eat Maattosd to Pimra. J Radtel gift* 4*077-** J**7. * WUasw RE. MsCwatt WE. Tstam <T. M at: OsnwaMaaal irniiUslyili. JAMA MUn-in, I1S7. * Harris DC, Atoms WCF: ArisssSsstyto sefariai to wan swqsf to it pstywatowltaw M vteri sMsito* Bale Mod J W71S-TM, HV7 * BaasM fh AtrassCesbvdf sf mwchal srtis, Wash. Lwa, tom. 7_w EV. grkasldsr ftRaasb Q: Ototoal aa Rat tote too M^mSaMf gto Csausl > Cl, at si: . AmorJ'torMMMkl nb Ito rstslhw Amtr J CUm Nuir 11C 11. Straw sc totfk BP, Baeastos AM: Mftory fsrato VabAfarlfr A Jtfwifw, adaksl Mmrt Aaa Atoar. Mkh. tMvnWy sf MkWpsa. ImT* M7. XUM Arrk Eniiron ffraitk--VW tl, Jan 1971 ucc 020927