Henry Falk

Clinical epidemiology of toxic-oil syndrome. Manifestations of a New Illness.

An epidemic of a new illness involving multiple organ systems began in Spain in May 1981, with 19,828 cases and 315 deaths reported by June 1, 1982. An epidemiologic investigation has linked the occurrence of illness with ingestion of an unlabeled, illegally marketed cooking oil. To elucidate the natural history of this illness, we reviewed the medical records of 121 patients in one severely affected town 100 km northwest of Madrid. The findings during the first week after onset were those of a febrile, pneumonia-like illness. Gastrointestinal findings and striking eosinophilia became prominent later in the first month. Although the disease followed a self-limited course in many patients, severe neuromuscular manifestations (myalgia severe enough to restrict movement, motor deficits, atrophy of major muscle groups, and contractures of the jaw and extremities) occurred late in the course of the illness (an average of 96 days after onset) in 23 per cent of the patients. The onset of disease early in the epidemic and particularly severe initial systemic findings were associated with progression to neuromuscular illness.

Global approach to reducing lead exposure and poisoning

Lead poisoning is an important environmental disease that can have life-long adverse health effects. Most susceptible are children, and most commonly exposed are those who are poor and live in developing countries. Studies of childrens blood-lead levels (BLLs) are showing cognitive impairment at increasingly lower BLLs. Lead is dangerous at all levels in children. The sources of lead exposure vary among and within countries depending on past and current uses. Sources of lead may be from historic contamination, recycling old lead products, or from manufacturing new products. In all countries that have banned leaded gasoline, average population BLLs have declined rapidly. In many developing countries where leaded gasoline is no longer used, many children and workers are exposed to fugitive emissions and mining wastes. Unexpected lead threats, such as improper disposal of electronics and childrens toys contaminated with lead, continue to emerge. The only medical treatment available is chelation, which can save lives of persons with very high BLLs. However, chelating drugs are not always available in developing countries and have limited value in reducing the sequelae of chronic low dose lead exposure. Therefore, the best approach is to prevent exposure to lead. Because a key strategy for preventing lead poisoning is to identify and control or eliminate lead sources, this article highlights several major sources of lead poisoning worldwide. In addition, we recommend three primary prevention strategies for lead poisoning: identify sources, eliminate or control sources, and monitor environmental exposures and hazards.

Vinyl-Chloride-Induced Liver Disease from Idiopathic Portal Hypertension (Banti's Syndrome) to Angiosarcomas

Histologic examination of liver tissue (eight autopsy and 18 biopsy specimens) and five spleens from 20 workers with vinyl chloride polymerization showed hepatic angiosarcomas in 15. In addition, a peculiar pattern of progressive portal-tract, inconspicuous intralobular and conspicuous capsular fibrosis was observed in the five workers without angiosarconma, in all the seven patients with angiosarcoma from whom tumor-free portions of the liver were available, and in two tumor-free biopsies from patients subsequently found to have angiosarcoma. The fibrosis was accompanied by splenomegaly. Hypertrophy and hyperplasia of both hepatocytes and hepatic and splenic mesenchymal cells were also seen. The histologic similarity to chronic inorganic arsenical poisoning, in which angiosarcomas also occur, and to idiopathic portal hypertension (Bantis syndrome) suggests that the latter syndrome at times results from unknown toxic, possible environmental, chemicals.

Ultraviolet light: A hazard to children

BACKGROUND Sunlight is subdivided into visible light, ranging from 400 nm (violet) to 700 nm (red); longer infrared, “above red” or .700 nm, also called heat; and shorter ultraviolet radiation (UVR), “below violet” or ,400 nm. UVR is further subdivided into UV-A (320–400 nm), also called black (invisible) light; UV-B (290–320 nm), which is more skin-penetrating; and UV-C (,290 nm). UV-B constitutes ,0.5% of sunlight reaching the earth’s surface, but is responsible for most of the acute and chronic sunrelated damage to normal skin.1 Most UVR is absorbed by stratospheric ozone. UV-B has greater intensity in summer than in winter, at midday than in morning or late afternoon, in places closer to the equator, and at high altitudes. Sand, snow, concrete, and water can reflect up to 85% of sunlight, thus intensifying exposure.1

Inhalation Exposure to Formaldehyde: An Overview of Its Toxicology, Epidemiology, Monitoring, and Control

Increasing production and use of formaldehyde in consumer products have resulted in widespread recognition of its acute irritant effects at exposure levels below the current occupational health standard [3 parts per million parts of air (ppm)]. Formaldehyde is an allergic (immunologically mediated) skin sensitizer which may also cause or exacerbate respiratory distress in individuals with preexisting or formaldehyde-induced bronchial hyperreactivity. Formaldehyde gas is a very reactive alkylating agent which is mutagenic in several in vitro test systems. At exposure levels less than one order of magnitude greater than those often found in human occupational and nonoccupational environments, it induces squamous cell carcinomas in the nasal cavity of rats. Recent reviews suggest that formaldehyde exposure should be treated as though it poses a carcinogenic risk to humans and should be reduced to the lowest feasible level. This report reviews information on the epidemiologic evaluation of health effects which may result from hazardous levels of exposure to formaldehyde. Methods for monitoring exposure are discussed in detail because of considerable diversity in the methods used by state health departments for recognition, evaluation and control of nonoccupational exposures. Current guidelines for the evaluation and control of exposures to formaldehyde gas are suggested.

Interim Guidance on the Eosinophilia-Myalgia Syndrome

Excerpt The Centers for Disease Control (CDC) has recently received a large volume of calls from physicians caring for patients with either clear-cut or suspected cases of the eosinophilia-myalgia ...

Review of four cases of childhood hepatic angiosarcoma--elevated environmental arsenic exposure in one case.

Four cases of childhood hepatic angiosarcoma (HAS), representing the malignant form of infantile hemangioendothelioma, are described. The morphologic appearance of childhood HAS differs from the adult form in the following features: the associated presence of benign infantile hemangioendothelioma; the presence of dysontogenetic features; and an altered appearance of the angiosarcoma itself. It is postulated for these cases that the benign infantile hemangioendothelioma progressed to the malignant angiosarcoma. One of the four cases had exposure to elevated levels of arsenic in the environment that may have contributed to this progression. This latter case adds to published reports associating arsenic exposure with increased risk for hepatic angiosarcoma.

CHARACTERISTICS OF CASES OF ANGIOSARCOMA OF THE LIVER AMONG VINYL CHLORIDE WORKERS IN THE UNITED STATES

A total of 13 cases of ASL have been documented to date among VC workers in four different plants in the United States. In this particular industrial population, this number of cases represents at least a 400-fold increase over expected incidence for this extremely rare tumor. The first case occurred in 1961. Average age at diagnosis is 48.2 years. Average length of time between initial VC work and diagnosis has been 20.3 years. A detailed review of 7 cases associated with one plant revealed that clinical features varied from little or no overt illness prior to diagnosis to advanced liver disease with portal hypertension and marked splenomegaly. Portal fibrosis was present in all 7 of these ASL cases as well as in 4 additional cases with non-malignant liver disease among VC workers at the same plant. These findings suggest that exposure to VCM in industrial settings can produce hepatic fibrosis with angiosarcoma as a late manifestation. Conventional liver function tests may not be sensitive indicators of such liver impairment, at least in its early stages.

Mount St. Helens Eruptions: The Acute Respiratory Effects of Volcanic Ash in a North American Community

After the May 18, 1980 volcanic eruption of Mount St. Helens, increases were observed in the number of patients who, because of asthma or bronchitis, sought medical care at emergency rooms of major hospitals in areas of ashfall. An interview study of 39 asthma and 44 bronchitis patients who became sick during the 4 wk following the eruption and who attended the emergency rooms of two major hospitals in Yakima, Washington, and of healthy matched controls indicated that a history of asthma, and possibly of bronchitis, were risk factors for contracting respiratory problems. The interview study also indicated that the main exacerbating factor was the elevated level of airborne total suspended particulates (in excess of 30,000 micrograms/m3) after the eruption. An interview study of 97 patients who had chronic lung disease and who lived in the same area as the above-mentioned patients, but who did not go to a hospital, showed that the ashfall exacerbated the condition in about one-third of these. Emergency planners and their geologist advisers should be aware that special preventive measures are justified for people with a history of asthma or chronic lung disease who live in communities at risk to volcanic ashfalls.

Cancer and Birth Defects Near the Drake Superfund Site, Pennsylvania

The Drake Superfund site in Clinton County, Pennsylvania, has been contaminated with the carcinogens beta-naphthylamine, benzidene, and benzene. The authors reviewed county-wide, age-adjusted, sex-, race-, and site-specific cancer mortality rates for the years 1950-1959, 1960-1969, and 1970-1979, and type-specific birth defects incidence rates for 1973-1978. During the 1970s, a significantly increased number of bladder cancer deaths occurred among white males in Clinton County, and a significantly increased number of other cancer deaths occurred in the general population of Clinton and three surrounding counties. There were no statistically significant clusters of any specific birth defect or of all birth defects. County-wide data on cancer and birth defects can be used for initially screening counties with Superfund sites, but more definitive studies are needed to assess the actual health effects caused by these sites.