A review of environmental and occupational exposure to asbestos in Israel.

The case for a total ban on manufacture and use of asbestos products is stated by the history of asbestos use, exposures, and risks in Israel. Manufacture and use of asbestos began in Israel in the 1950s, rising to a peak in the mid-1970s, and dropping gradually thereafter until reaching minimal levels in the 1990s. Following heightened public concern regarding the carcinogenic effects of asbestos products, there were reductions in use, manufacture, and persons exposed. Since the 1960s, asbestos-related diseases have been diagnosed in hundreds patients nationwide, including asbestos workers and users, as well as individuals living proximally to the manufacturing facilities. Exposures to asbestos in place remain, and patients with asbestos-related disease from environmental exposure are expected to appear for at least another 20-30 years. In the 1980s, an advisory committee appointed by the Ministry of Health of Israel outlined a comprehensive approach towards prevention, control, management, and compensation for health risks from asbestos exposures. As certain areas are still contaminated with asbestos waste and as environmental exposure persists, continued and improved medical monitoring and compensation programs are urgently needed in order to reduce the suffering of exposed individuals and their families. The ban on asbestos prevents risks from new exposures, but does not undo the damage from past manufacture, use, disposal, and dumping. In this paper, we review the history of Israel's import and use of asbestos, and the management of occupational and environmental exposures. We also address policy, practice, and the need to protect future victims of asbestos-related disease.

Rapid growth of a basilar aneurysm.

We describe a patient who developed, over a 22-month period, a giant aneurysm of his basilar artery. A prior MRI of the brain done for nonspecific symptoms showed a normal brainstem and basilar artery. At presentation, he had a repeat MRI scan for a 4-month history of a partial right oculomotor nerve palsy and left hemiparesis. The MRI revealed a giant aneurysm of the top of the basilar artery. This was treated by angiographic placement of Guglielmi detachable coils (GDC) after surgical intervention was deemed unfeasible. This case illustrates the acquired nature of intracranial aneurysms. All inoperable intracranial aneurysms should be closely monitored and MRI and MR angiography may currently be the best noninvasive methods for this purpose. Intra-arterial GDC embolization of aneurysms is an alternative treatment when surgery is not possible.

Cancer in radar technicians exposed to radiofrequency/microwave radiation: sentinel episodes.

Controversy exists concerning the health risks from exposures to radiofrequency/microwave irradiation (RF/MW). The authors report exposure-effect relationships in sentinel patients and their co-workers, who were technicians with high levels of exposure to RF/MW radiation. Information about exposures of patients with sentinel tumors was obtained from interviews, medical records, and technical sources. One patient was a member of a cohort of 25 workers with six tumors. The authors estimated relative risks for cancer in this group and latency periods for a larger group of self-reported individuals. Index patients with melanoma of the eye, testicular cancer, nasopharyngioma, non-Hodgkin's lymphoma, and breast cancer were in the 20-37-year age group. Information about work conditions suggested prolonged exposures to high levels of RF/MW radiation that produced risks for the entire body. Clusters involved many different types of tumors. Latency periods were extremely brief in index patients and a larger self-reported group. The findings suggest that young persons exposed to high levels of RF/MW radiation for long periods in settings where preventive measures were lax were at increased risk for cancer. Very short latency periods suggest high risks from high-level exposures. Calculations derived from a linear model of dose-response suggest the need to prevent exposures in the range of 10-100 microw/cm(2).

Cancer in thirty-nine nuclear industry workers: a preliminary report.

We constructed job-exposure profiles and assessed quality of health care in 39 of 47 current and former workers from a nuclear installation in the Negev whose files were referred to us for assessment of a possible work-related aspect of their tumors. The workers, all male except one, began employment at various times from the reactor construction and were engaged in different tasks in laboratory research, construction, maintenance, and service. Of those workers still living the average age was 57.9 years, with a range from 42 to 77 years of age. The average age at the time of death for the deceased workers was 57.3 years, with a range from 41 to 69 years of age, Information on past exposures to radiation and chemical agents came from employee records dosimetry, and interviews. Personal monitoring (urine assays) in 29 workers indicated the presence of various radionuclides, with higher levels found in persons with work histories in laboratory/research and development and technical/inspector job categories compared to those in administrative/service job categories. Among the 39 workers, latency between onset of exposure and first appearance of illness from tumor was 24.2 years, with a range of 5 to 34 years. Tumor distribution for these workers was as follows: hematolymphatic (n = 11 workers), gastrointestinal (n = 9), breast (n = 1 [male]), renal-urogenital (n = 8), skin (n = 1), and pulmonary (n = 8 [5 known smokers]). For all tumors except those of the respiratory tract, the first diagnosis was made more frequently in those patients under the age of 55. Observed/expected comparisons for tumor proportional incidence showed excess fractions of blood tumors in persons < 55 and > 55 years of age. Ratios were greater than unity for blood, breast (n = 1), gastrointestinal, and urogenital tumors in patients < 55 years of age and pulmonary tumors in persons > 55 years of age. The odds ratio for smoking history in patients with lung tumors compared to those with other tumors was 4.8. Nonmalignant conditions appeared at relatively younger ages. After the exposure episodes two children with major congenital anomalies were born to wives of the workers; one anomaly was fatal. Not all patients were first diagnosed for cancer following referral from the plant medical service, and delays between warning signs and symptoms and medical evaluation occurred in some. Although we lacked data on cancer incidence and population at risk, our findings suggest that earlier official assessments of risk should be reconsidered. There is a need for population-based monitoring of risk to nuclear industry workers, external quality control of their medical surveillance and care, and improvements in information delivery.

A scientific panel for determining health effects among radiation workers at Israel's nuclear research facilities.

The problem of compensation to employees of nuclear research facilities presents difficult issues to the practicing attorney. The major stumbling block to presenting a well-documented case in court is the worker's inability to discuss the full range of duties at his or her work station over the course of employment. In addition the worker is barred from discussing the types and concentrations of chemicals and radioactive substances to which he or she is exposed, thereby limiting the ability of a competent physician to prepare an opinion on the causation between effects of exposure and disease. This paper presents the dilemma faced by the authors, who represented over 40 workers with cancer at the nuclear research facility in Dimona, Israel. It shows how the authors extricated themselves from this difficult dilemma by creating a panel of scientific experts under the court's auspices and with the court's blessings, which obviated the need for heavy procedural rules of court that apply in torts litigation in Israel. The scheme as developed and approved by the court can serve as a model to other countries where security matters are as important as matters of environmental health.

Repeat CT or MRI in posttraumatic headache.

Repeat CT or MRI of the brain should be considered in posttraumatic headache. We describe two patients with posttraumatic headache who had negative CT scans on initial presentation. One patient later had bilateral subdural hematomas on CT, and the other had temporal lobe hemorrhage on MRI. We recommend considering repeat CT or MRI for persisting posttraumatic headache and mental status change.

False evidence of carotid stenosis on magnetic resonance angiography caused by surgical clips.

Patients with transient ischemic attacks are increasingly studied with magnetic resonance angiography, allowing noninvasive evaluation of both the intracranial and the extracranial vessels. Described here are 3 patients who after endarterectomies presented with transient ischemic attacks and in whom magnetic resonance angiography with a two-dimensional time-of-flight pulse sequence showed a false-positive arterial stenosis, as documented by transfemoral carotid angiography. The pseudostenosis was believed to be artifactually caused by operative clips. Results of magnetic resonance angiography should be interpreted with caution in patients with previous neck surgery.

Chrysotile and crocidolite asbestos in Israel: uses, exposures and risks.

Importation of raw asbestos (90% chrysotile; 10% crocidolite) for manufacture of cement products and other uses, including friction materials and spraying, had dropped to under 3000 tons by 1993 from a peak of 10,000 tons per annum in the late 1970s. Drops in use, manufacture, persons exposed in manufacture and measured exposure levels followed heightened public concern over the carcinogenic effects of asbestos products, despite a relatively high worker exposure standard of 400,000 f/m3. The atypically low ratio of reported deaths from lung cancer compared to mesothelioma in asbestos cement workers up to 1992 (1:2.5) is suggested to be a consequence of low baseline risks for lung cancer mortality in Israel and dropping smoking levels. Exposure to asbestos use and asbestos in place remain, but total risk should drop after 2010 if imports continue to drop. These projections may be altered by trade between Israel and its neighbors following peace agreements. Reductions in risk will have resulted from reduction in exposure brought about by reductions in manufacture and use.

The disposition and cerebrospinal fluid penetration of morphine and its two major glucuronidated metabolites in adults undergoing lumbar myelogram.

STUDY OBJECTIVE: To determine the pharmacokinetic disposition of morphine and its two major glucuronidated metabolites, morphine-6-glucuronide (M6G) and morphine-3-glucuronide (M3G), in serum and their penetration into cerebrospinal fluid (CSF). DESIGN: A single-dose, open-label pharmacokinetic study. SETTING: The Memphis Neurosciences Center at Methodist Hospital. PATIENTS: Twenty patients undergoing a diagnostic lumbar myelogram. INTERVENTIONS: All patients received morphine sulfate 10 mg intramuscularly approximately 1.5 hours before the procedure. MEASUREMENTS AND MAIN RESULTS: Three blood samples were drawn after the dose and a CSF sample was drawn immediately after lumbar puncture. The mean +/- standard deviation for the half-life of morphine was 2.8 +/- 1.4 hours. The apparent half-lives of M6G and M3G were 5.7 +/- 3.1 and 6.3 +/- 2.2 hours, respectively, and were inversely related to the estimated creatinine clearance (r = -0.61, p < 0.007 and r = -0.69, p < 0.002, respectively). The mean concentrations of morphine, M6G, and M3G in the CSF (collection time 1.5 +/- 0.32 hrs, n = 19) were 3.1 +/- 3.7, 12.5 +/- 17.6, and 19.6 +/- 16.1 nmol/L, respectively. CONCLUSIONS: Elderly patients and patients with renal dysfunction receiving morphine may experience prolonged analgesic and adverse effects secondary to a decrease in the clearance of M6G.

Assessment of MR angiography versus arteriography for evaluation of cervical carotid bifurcation disease.

PURPOSE: To assess the accuracy of MR angiography alone in screening for vascular stenosis of the common carotid bifurcation. METHODS: Two hundred two common carotid bifurcations in 101 patients were evaluated with MR angiography and selective contrast arteriography. A two-dimensional time-of-flight pulse sequence was used to obtain sequential transverse images through the common carotid bifurcations. These images were reprojected with a maximum intensity pixel ray-tracing algorithm. Both examinations were blindly graded as either normal or mildly stenotic (0%-29%), moderately stenotic (30%-69%), severely stenotic (70%-99%), or occluded. RESULTS: Of the 202 common carotid bifurcations, 119 were classified as normal-mild stenosis by contrast arteriography. In this category, MR angiography correctly identified 114 of these as normal to mild stenosis. Among 21 common carotid bifurcations graded as moderate stenosis by arteriography, 15 were correctly graded as moderate by MR angiography. Among 45 common carotid bifurcations graded as severe stenosis by arteriography, 41 of these were correctly graded as severe by MR angiography. There were 17 complete occlusions which were all correctly graded by MR angiography. CONCLUSION: MR angiography with its high rate of agreement with contrast arteriography can be regarded as an accurate screening method of the common carotid bifurcation.

Mesothelioma mortality among former asbestos-cement workers in Israel, 1953-90.

Asbestos workers have long been recognized as a high risk group for the development of mesothelioma and other cancers. In this study we collated from a variety of sources 26 mesothelioma deaths that occurred between 1978 and 1990 among a cohort of some 4,441 former workers from an asbestos-cement plant in northern Israel. Since the expected number of deaths for this number of Israeli males in this age-group over this period is 0.12 cases, the risk of this disease was more than 223 times the national rate, age and sex adjusted [standardized mortality ratio (SMR) = 22,351, P < 0.001]. The mean years of exposure of persons who died from mesothelioma was 16.2 (SE 2.5). The mean latency period for mesothelioma cases from onset of exposure to death was 25.6 years (SE 1.3). Additional follow-up systems are needed to ensure complete reporting of asbestos-related diseases, including epidemiologic follow-up of asbestos-exposed workers after cessation of their work, with regular analysis of death and cancer registry data for high risk groups. Asbestos-related cancer is an important element in cancer epidemiology that requires further development in Israel. Studies of former workers, their families and of persons who worked or attended school adjacent to the asbestos-cement factory, as well as follow-up of other former worker groups exposed to asbestos are recommended.

Medical findings in nickel-cadmium battery workers.

Thirty-eight workers from a factory producing nickel-cadmium and other types of batteries came to us for medical evaluation. They included 21 women and 17 men (seniority 2-20 years, age range 31-63 years), and represented a self-selected subset of 700-900 ever-employed and 200+ recently or currently employed workers in the factory. Thirty-four worked on the nickel-cadmium assembly line. Symptoms and signs included: headache in 34; weakness, fatigue and lassitude in 26; dizziness in 16; pruritus and skin eruptions in 37; gingivitis, teeth loss and caries in 34; nasal congestion, nosebleeds and anosmia in 30; cough, phlegm production, wheezing and shortness of breath in 26; "asthma" in 14; bone pain in 18; urinary frequency, beta 2 microglobulinuria and kidney stones in 17; and sterility or multiple abortions (33) in 8 of 21 women. One additional patient had died from an "amyotrophic lateral sclerosis-like syndrome", while CT scans in six workers revealed brain atrophy. One other worker had leukemia, and two had died from cancer (lung and pancreas). Those who had worked for more than 10 years had more symptoms and signs than shorter-term employees, especially neurological illness, bone pain and urinary tract problems, including beta 2 microglobulinuria. Past blood and urinary cadmium levels were in the range of 1.6-8.7 micrograms/dl and 8-306 micrograms/l, respectively. Our findings indicated that: a) health risks for workers were not confined to the nickel-cadmium assembly line or to older workers, b) hazardous exposures still existed and illness appeared in new workers after a clean-up and intervention program, and c) exposures involved increased risks for renal disease and cancers. Finally, there is a need to control exposures and determine health risks in the full cohort of those ever employed, in the workers' children, and in the surrounding environment (air, ground, water) due to the dumping of waste from the plant.

Exposure of workers to toxic substances and physical hazards: the law in theory and practice.

Israel has an enviable legal framework to protect the worker from exposure to dangerous substances at the workplace: a duty of the employer to inform the worker of exposure to dangerous substances; a duty of the employer and the occupational doctor to report exposure, disease and death to the factory inspectorate; and a comprehensive network of occupational doctors in place to find early symptoms of exposure in order to prevent disease. Unfortunately this framework has not been effective enough. In some instances--the Isabest factory in Naharia and the Tadiran factory in Ekron--the system has failed miserably.

Headaches due to spontaneous internal carotid artery dissection magnetic resonance imaging evaluation and follow up.

Spontaneous internal carotid artery (ICA) dissection is not an infrequent cause of headache and acute neurologic deficits in the younger population. Angiography has been the imaging modality of choice for both diagnosis and follow-up. The use of magnetic resonance imaging, (MRI), in conjunction with angiography, is described in three patients shown to have ICA dissection. Our clinical findings suggest that MRI may provide a less expensive, non-invasive, diagnostic and particularly a follow up modality in patients with headache and signs suggestive of ICA dissection.

Subacute pituitary apoplexy: MR and CT appearance.

We report three cases of subacute hemorrhage into a pituitary adenoma. Two patients each had visual disturbance and hypopituitarism treated with corticosteroids. No patient received bromocriptine. Because it is more exact than CT in displaying the metabolic products of hemorrhage, magnetic resonance is the preferred modality for radiographic investigation of subacute or chronic pituitary apoplexy in patients with prolonged headache and visual disturbance.