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Postmortem computed tomography (PMCT) is integrated into the evaluation of decedents in several American medical examiner offices and medicolegal death investigative centers in many other countries. We retrospectively investigated the value of PMCT in a series of firearm homicide cases from a statewide centralized medical examiner’s office that occurred during 2016. Autopsies were performed or supervised by board‐certified forensic pathologists who reviewed the PMCT scans prior to autopsy. PMCT scans were re‐evaluated by a forensic radiologist blinded to the autopsy findings and scored by body region (head–neck, thoracoabdominal, and extremities). Injury discrepancies were scored using a modified Goldman classification and analyzed with McNemar’s test. We included 60 males and 20 females (median age 31 years, range 3–73). Based on PMCT, 56 (79.1%) cases had injuries relevant to the cause of death in a single body region (24 head–neck region, 32 thoracoabdominal region). Out of these 56 cases, 9 had a missed major diagnosis by PMCT outside that region, including 6 extremity injuries visible during standard external examination. Yet all had evident lethal firearm injury. We showed that PMCT identifies major firearm injuries in homicide victims and excludes injuries related to the cause of death in other regions when a single body region is injured. Although PMCT has a known limited sensitivity for soft tissue and vascular pathology, it can be combined with external examination to potentially reduce or focus dissections in some of these cases depending on the circumstances and medicolegal needs.

Respiratory pathogens have been detected in forensic investigations using multiple techniques; however, no study has examined the use of automated, nested, multiplex polymerase chain reaction (ANM‐PCR), commonly used in living patients, in the forensic setting. This retrospective study assessed the utility of ANM‐PCR in detecting respiratory pathogens in the pediatric forensic setting. Respiratory samples from 35 cases were tested for up to 20 respiratory pathogens. 51.4% of these cases yielded a positive ANM‐PCR result, 20% of which were considered the cause of or contributory to death. The most commonly detected pathogens were rhinovirus/enterovirus and respiratory syncytial virus, and these were the only pathogens determined to play a significant role in cause of death. The sampled sites and postmortem intervals tested did not affect the likelihood of a positive or negative test. ANM‐PCR panels are effective, affordable, and rapid ancillary tools in evaluating cause of death in the forensic pediatric population.

Background Research suggests that women have higher mortality after acute myocardial infarction (AMI) than men. Potential factors to explain this disparity include delay to presentation, less aggressive interventional strategies, and more severe disease at coronary angiography in women. Methods Consecutive patients (n=663) presenting to coronary care between Jan 2002 and Jan 2005 with ischemic type chest pain and AMI (troponin T >0.09ng/ml) were recruited. Details of the presentation and management were obtained from the medical notes. The primary endpoint was three month all cause mortality. Results Of these patients 31% (205/663) were female. Mean age of women was 70 (SD 11) and 63 (SD 13) for men (p

Background: Stroke is a leading cause of death and disability in developing countries, afflicting individuals at a young age. The contribution of established vascular risk factors to ischaemic stroke in young adults has not been evaluated systematically in Indians. Methods: We conducted a case control study in 214 South Indian patients with first acute ischaemic stroke that occurred between the ages of 15 and 45 years, 99 age and sex matched hospital controls and 96 community controls. We compared the prevalence of the following risk factors: smoking, elevated blood pressure, high fasting blood glucose and abnormal lipids. Results: Compared with community controls, stroke patients had a higher prevalence of smoking (multivariable adjusted odds ratio (OR) 7.77, 95% CI 1.93 to 31.27), higher systolic blood pressure (OR per SD increment of 1.88, 95% CI 1.01 to 3.49) and fasting blood glucose (OR per SD increment of 4.55, 95% CI 1.63 to 12.67), but lower high density lipoprotein (HDL) cholesterol (OR per SD increment of 0.17, 95% CI 0.09 to 0.30). Compared with hospital controls, stroke patients had a higher prevalence of smoking (OR 3.95, 95% CI 1.61 to 9.71) and lower HDL cholesterol (OR per SD increment 0.27, 95% CI 0.17 to 0.44). The presence of ⩾3 metabolic syndrome components was associated strongly with stroke (OR 4.76, 95% CI 1.93 to 11.76; OR 2.09, 95% CI 1.06 to 4.13) compared with community and hospital controls. Conclusions: Key components of the metabolic syndrome and smoking are associated with ischaemic stroke in young South Indian adults. Our observations underscore the importance of targeting adolescents and young adults for screening and prevention to reduce the burden of ischaemic stroke in young adults.

Objectives: The objective of the present study was to investigate the risk of death from non-malignant diseases in female pulp and paper workers in Norway. Methods: A total of 3143 women first employed between 1920–93 were included in the study cohort. Information about each cohort member was obtained from personnel record files in the mills in order to identify employment periods and job categories. Data on cause and date of death were added by linkage to the Cause of Death Register using unique personal identification numbers. The follow up period was 1951–2000. Standardised mortality ratios (SMRs) with 95% confidence intervals (95% CIs) were calculated using the national female mortality rates as reference. Poisson regression analysis was used to examine internal relations between the duration of employment in paper departments and the risk of death from selected causes. Relative risks (RRs) and 95% CIs were calculated. Results: The study showed a significantly increased risk for total non-malignant mortality (SMR = 1.14, 95% CI 1.05 to 1.24), mainly due to increased mortality from ischaemic heart disease (SMR = 1.22, 95% CI 1.03 to 1.43) and cerebrovascular diseases (SMR = 1.16, 95% CI 0.94 to 1.42). Analysis by department showed the highest risk of death in paper department workers with short term employment. Internal analyses showed a 5% and 9% increase in risk of dying from ischaemic heart disease and respiratory diseases, respectively, among paper department workers exposed to paper dust. The risk decreased with increasing duration of employment. Conclusion: The increased risk of ischaemic heart diseases and respiratory diseases seen among employees of paper departments may be related to exposure to paper dust.

Objective: This study investigated the causes of death among patients with myasthenia gravis (MG), with emphasis on respiratory tract and cardiac disease. Methods: The Norwegian Cause of Death Register contains information on all deaths among Norwegian citizens. In total, 249 deceased patients with MG were identified (1951–2001). These were compared with 1245 controls deceased in the same period and matched for sex and year of birth. Results: The death certificates of patients with MG had a significantly higher occurrence of respiratory tract disease as cause of death than controls (28.1% v 20.9%, p = 0.012). The difference was most pronounced for male patients, for patients dying between 30 and 69 years of age, and for deaths occurring before 1996. For cardiac disease there was a significantly lower occurrence among patients with MG than among controls at 50–69 years of age, for both men (19.4% v 52.0%, p = 0.001) and women (14.6% v 29.6%, p = 0.036). Age and year of death were important determinants for the causes of death, but could not account for the differences between the patients with MG and controls. Conclusions: This study shows that patients with MG dying between 1951 and 1995 had a higher occurrence of respiratory tract disease listed as cause of death than had a matched control group. The lack of difference after 1995 probably reflects improved treatment of MG and its complications. The reduced occurrence of cardiac disease among patients with MG is probably explained by competing factors (respiratory tract disease) causing death.

To identify sociodemographic differences in the incidence of the subtypes of first ever stroke in a multiethnic population.A prospective community stroke register (1995-8) was developed using multiple notification sources and pathological and clinical classifications of stroke. Standardisation of rates was to European and World populations and adjusted for age, sex and socioeconomic status in multivariate analyses. A multiethnic population of 234 533 in south London, of whom 21% are black was studied.A total of 1254 cases were registered. The average age of stroke was 71.7 years with black patients being 11.3 years younger than white patients (p0.0001). The incidence rate/1000 population was 1.33 (crude) (95% CI 1.26 to 1.41), 1.28 (European adjusted) (95% CI 1.2 to 1.35) with a 2.18 (95% CI 1.86 to 2.56) (p0.0001) age and sex adjusted incidence rate ratio in the black population. Radiological diagnosis was confirmatory in 1107 (88.3%) with 862 (68.7%) infarction, 168 (13.4%) primary intracerebral haemorrhage, and 77 (6.2%) subarachnoid haemorrhage. Of the cerebral infarction cases 189 (21.9%) were total anterior circulatory, 250 (29%) partial anterior, 141 (16.4%) posterior (POCI) and 282 (32.7%) lacunar infarcts. The black group had a significantly higher incidence of all subtypes of stroke except for POCI and unclassified strokes. The incidence rate ratio (IRR) for men compared with women was 1.34 (95% confidence interval (95% CI) 1.19 to 1.50; p0.001). The IRR for manual versus non-manual occupations in those aged 35-64 years was 1.64 (95%CI 1.22 to 2.23; p0.0001). There was a borderline significant increase in adjusted survival at 6 months in the black group 95% (CI 0.61 to 1.03, p=0.078) with a hazard ratio of 0.79 after adjustment and stratification.Although the black population is at increased risk of stroke and most subtypes of stroke, this is not translated into significant differences in survival. Hence black/white differences in mortality are mainly driven by incidence of stroke. There are striking demographic inequalities in the risk of stroke in this multiethnic inner city population that need to be tackled through interagency working. Although the reasons for the increased risk in the black population are unclear, demographic factors such as socioeconomic status do seem to play a significant independent part.

The occurrence of deaths due to lung cancer was studied among 883 white male workers from a pulp and paper company in northern New Hampshire. All subjects had participated in a longitudinal study of respiratory morbidity, and data from interviews were used to construct lifetime cigarette smoking and occupational histories. Most of the subjects had entered follow-up in the 1960s and, at that time, their mean age was 51 years and they had worked for the pulp and paper company a mean of 25 years. By the end of follow-up in 1992, the 512 deceased subjects included 35 whose underlying cause of death had been lung cancer. With an internal comparison using the Cox proportional-hazards model, the hazard ratio for sulfite pulp mill work was 2.5 (95% CI 1.3-4.9), while controlling for the effects of age, cigarette smoking, and work in other parts of the pulping operation. In addition, the hazard ratio for the combination of35 pack-years of smoking and10 years sulfite mill work was greater than the product of the hazard ratios for each factor alone. While these findings are consistent with past asbestos exposure in the sulfite pulp mill environment, the absence of mesothelioma cases is inconsistent with this type of exposure.

In the context of a historical cohort study among workers in the pulp and paper industry, we examined the agreement between the underlying cause of death obtained from municipal mortality files and from the mortality register of Catalonia (n = 50 pairs). The percentage of simple agreement (P0) for major causes of death was 76%. The agreement and the Kappa index was higher for external causes (P0 = 98%; K = 0.87) and for cancer (P0 = 90%; K = 0.79). The agreement was moderate for mortality from circulatory diseases (K = 0.57). Agreement between 3 digit ICD codes was 48% but was higher for deaths from cancer (P0 = 67%). These results indicate that information on major causes of death and on specific causes of cancer retrieved from municipal mortality files may be used for the follow-up of historical cohort studies.

A physician's alert prompted us to investigate workers' cancer risk at a paperboard printing manufacturer. We conducted a retrospective cohort mortality study of all 2,050 persons who had worked at the facility for more than 1 day, calculated standardized incidence ratios (SIRs) for bladder and renal cell cancer, and conducted a nested case-control study for renal cell cancer. Standardized mortality ratios (SMRs) from all causes [SMR = 1.0, 95% confidence interval (CI) = 0.9-1.2] and all cancers (SMR = 0.6, 95% CI = 0.3-1.0) were not greater than expected. One bladder cancer and one renal cell cancer were included in the mortality analysis. Six incident renal cell cancers were observed, however, compared with less than two renal cell cancers expected (SIR = 3.7, 95% CI = 1.4-8.1). Based on a nested case-control analysis, the risk of renal cell cancer was associated with overall length of employment but was not limited to any single department or work process. Although pigments containing congeners of dichlorobenzidine and o-toluidine had been used at the plant, environmental sampling could not confirm any current exposure. Several limitations and a potential selection bias limit the inferences that can be drawn.

A review of autopsy reports in cases in which cocaine featured in the cause of death in Northern Ireland revealed that there were 18 deaths between 1(st) January 1999 and 31(st) December 2007. Analysis revealed an increasing incidence of these deaths during the study period and this is compared to national statistics and those published by local drug addiction services and police.

Three malignant pleural mesotheliomas occurred among workers of a small factory that manufactured drying machines for the textile and paper mill industries using asbestos cement (crocidolite, amosite and chrysotile) as insulating panels. The Occupational Medicine Unit of the Local Health Unit of Pistoia, Italy, carried out an intervention programme in the plant in order to 1) assess past asbestos exposure via analysis of the fibre content of samples from drying machines, and of dust samples collected in the factory. Information on the characteristics of occupational exposure was also collected; 2) investigate cancer mortality by means of a mortality study of the employees and, 3) carry out a health intervention programme in workers formally exposed to asbestos in the past.Samples from the drying machines and dust samples collected in the factory were analysed using X-ray diffractometric methods. Information on the characteristics of occupational exposure were collected by interviewing plant workers. Two-hundred and fifty employees who had worked in the factory between 1962 and 2000 were included in the mortality study. Follow-up was performed from 1962 to 2002. Health intervention in workers exposed to asbestos in the past involved general practitioners and occupational physicians (first level medical examinations); pneumologists and radiologists (second level medical examinations) of the local health unit.Asbestos fibres were found both in samples from drying machines and in dust samples collected in the factory. Interviews with workers showed that asbestos exposure varied considerably. The SMR for mesothelioma and lung cancer in 234 male workers were 37.0 (95%CI: 4.47-130.0), and 1.29 (95%CI: 0.26-3.78), respectively, based on mortality rates for Tuscany region. Sixty-two workers underwent first level medical examinations; 57 second level examinations. Chronic obstructive lung disease was found in 3 workers; restrictive lung disease was found in 3 employees, one of whom had pleural plaques.Further investigation is needed in order to identify unknown asbestos exposures in small metal engineering factories.

Objectives: To determine the long term survival and predictors of death in patients with primary intracerebral haemorrhage (ICH) in Central Finland. Methods: Data were collected retrospectively on all adult patients with first ever ICH in Central Finland county between September 1985 and December 1991. The survival of all patients at the end of December 2002 was investigated. Kaplan–Meier survival curves were constructed and factors associated with both early (⩽28 days) and late deaths determined. Long term survival was compared with the general Finnish population of the same age and sex distribution. The causes of death were compared with those of the population of Central Finland. Results: 411 patients with first ever ICH were identified, 199 men (mean age 64.9 years) and 212 women (mean age 69.5); 30 died before hospital admission, and 208 (50.6%) within the first 28 days. In Kaplan–Meier analysis, at 16 years the cumulative survival was 3.2% for men and 9.8% for women. The 28 day survivors had a 4.5-fold increased annual risk of dying during the first year after ICH, and 2.2-fold during years 2 to 6. On admission, significant independent predictors of death within the first four weeks were unconsciousness, lateral shift of cerebral midline structures, mean arterial pressure ⩾134 mm Hg, hyperglycaemia, anticoagulant treatment, and ventricular extrasystoles. Predictors of late death for the 28 day survivors were old age, male sex, and heart failure. Conclusions: Primary intracerebral haemorrhage has a poor short and long term outcome. The results emphasise the importance of primary and secondary prevention for ICH.

Background: The medical care of patients with acute stroke varies considerably between countries. This could lead to measurable differences in mortality and functional outcome. Objective: To compare case mix, clinical management, and functional outcome in stroke between 11 countries. Methods: All 1484 patients from 11 countries who were enrolled into the tinzaparin in acute ischaemic stroke trial (TAIST) were included in this substudy. Information collected prospectively on demographics, risk factors, clinical features, measures of service quality (for example, admission to a stroke unit), and outcome were assessed. Outcomes were adjusted for treatment assignment, case mix, and service relative to the British Isles. Results: Differences in case mix (mostly minor) and clinical service (many of prognostic relevance) were present between the countries. Significant differences in outcome were present between the countries. When assessed by geographical region, death or dependency were lower in North America (odds ratio (OR) adjusted for treatment group only = 0.52 (95% confidence interval, 0.39 to 0.71) and north west Europe (OR = 0.54 (0.37 to 0.78)) relative to the British Isles; similar reductions were found when adjustments were made for 11 case mix variables and five service quality measures. Similarly, case fatality rates were lower in North America (OR = 0.44 (0.30 to 0.66)) and Scandinavia (OR = 0.50 (0.33 to 0.74)) relative to the British Isles, whether crude or adjusted for case mix and service quality. Conclusions: Both functional outcome and case fatality vary considerably between countries, even when adjusted for prognostic case mix variables and measures of good stroke care. Differing health care systems and the management of patients with acute stroke may contribute to these findings.

Objectives: Cerebral vasospasm remains the leading cause of death and permanent disability after subarachnoid haemorrhage. This study determined whether the method of aneurysm treatment plays an important role in determining the incidence of cerebral vasospasm and its clinical consequences. Methods: Admission data, cranial computed tomography (CT), treatment details, transcranial Doppler (TCD) results, and clinical outcomes of patients who had surgical or endovascular management of their ruptured aneurysm were recorded and subject to multivariate analysis. Results: Between January 1995 and December 1999, 292 eligible patients (206 female, 86 male) had definitive aneurysm treatment at our unit. 212 patients were clipped, 80 coiled. There was no significant difference in patient age, pre-treatment neurological grade, Fisher grade, or timing of treatment in the two groups. 48.3% patients developed TCD detected cerebral vasospasm and 16.1% patients developed permanent ischaemic neurological deficit. At clinical follow up, 84.2% of patients were well (mGOS 1 and 2) with a cumulative death rate of 6.5% from all causes. The only significant predictor of TCD-detected cerebral vasospasm was patient age (inversely, p = 0.004). Increased patient age, vasospasm, poor pre-treatment WFNS, and higher CT Fisher grades correlated with a poor discharge GOS. However, only poor pre-treatment WFNS grade and patient age correlated with poor GOS at follow up (p Conclusion: The treatment method had no influence on the incidence or duration of TCD detected vasospasm and there was no significant difference in outcome at discharge or follow up between those patients who had surgery or endovascular management of their aneurysms.

Objectives: To predict the size of the vCJD epidemic it is important to know whether the description of cases of vCJD in 1996 represent the first cases of a new disease entity or whether detection was due to increased surveillance of CJD in humans. Detection of earlier cases would suggest a shorter incubation period and might lead to predictions of epidemic size being revised. Methods: All certified deaths (excluding external injury and poisoning) in residents of Wales aged 15–45, between 1985 and 1995, were reviewed to detect vCJD deaths that might have been overlooked. 12 091 deaths were reviewed. "Non-specific fatal disorders compatible with vCJD" were defined. Deaths recorded to diseases other than those defined were rejected from further analysis (8769). Remaining cases (3322) were subdivided. Group A comprised deaths recorded to suicide, transport accidents, and those that could not be ascertained (ICD9 rubrics E950–959, E800–848, and 7999), a total of 2698 cases. Group B comprised deaths due to neurological disease, psychiatric disease, or substance abuse (624). Results: For group A, remaining brain material was identified (n=218, 8.1%) and examined by routine histology and immunocytochemistry for prion protein. No cases of vCJD were detected. For group B, review of remaining clinical information was undertaken. Of 624 cases, information was available on 447 (72%). Brain tissue was examined by routine histology and immunocytochemistry in 47 (7.5%) cases. Sufficient clinical and pathological information was available to exclude all these as potential cases of vCJD. Conclusion: Variant CJD is a new disease entity and not simply the result of better case ascertainment.

A mortality cohort study was undertaken among Polish pulp and paper workers. This paper concentrates on neoplasms mortality among men and women employed continuously for at least one year in the factory producing sulphate pulp, paper board and paper products. A retrospective observation carried out till 31 December 1995 covered 10,460 workers employed during the years 1968-1990. The cohort accessibility was 99%. Cancer risk was evaluated on the basis of standardized mortality ratio (SMR) calculated according to the person-years method. The general population of Poland was the reference population. The results of a 23-year cohort observation, published earlier, showed a lowered overall mortality from all causes and from all malignant neoplasms, and a significant excess of death from peritoneum and prostate cancer among pulp mill male subcohort. The conclusion was drawn that a 'young' cohort and relatively short follow-up period might have affected the results. The results presented in this paper, obtained after further five years of observation showed in the male cohort an excess of deaths from cancer of respiratory tract and peritoneum (lung SMR = 122, nasal cavities SMR = 587, peritoneum SMR = 562). An approximate correction for smoking habits resulted in only 4 decreased risk estimates for lung cancer, indicating a small positive confounding effect of smoking in this material. In female cohort an excess of brain cancer was found (SMR = 355). Only the excess mortality from cancers of nose, lung and peritoneum was coherent with the exposure to higher concentrations of wood dust, pulp, paper and board dust. It may support a hypothesis that these factors as well as dust pollutants, not yet identified in this study, may be considered as one of the risk factors contributing to the incidence of neoplasms of these sites.

The objective was to describe a possible cancer mortality risk in relation with the occupational exposure within an International study co-ordinated by the International Agency for Research on Cancer.An epidemiological cohort study was set up to assess the mortality in four French pulp and paper companies. The four cohorts were followed up from January 1st 1968 to December 31st 1992. The causes of death were ascertained by matching with the national file of causes of death.The full cohort consisted in 5,529 men and 876 women. The total numbers of subjects deceased between 1968 and 1992 were respectively 708 and 34. Causes of death could be traced for 98%. The observed mortality was significantly lower than the expected for all causes of deaths (SMR = 0.86) as well for all deaths by cancer (SMR = 0.87). The analysis by departments showed an excess mortality by cancer of the pancreas in the wood preparation department (SMR = 3.14) as well as in the paper production department (SMR = 2.04).In absence of any prior hypothesis, it is difficult to assign an occupational origin to these observed excesses. The future results of the international study will enable us to interpret these results more precisely.

To assess possible health risks associated with the manufacture of paper, we carried out a retrospective analysis of mortality among 4,242 men and women employed at a Scottish paper mill between 1955 and 1992. During follow-up to 1994, 959 subjects had died giving an SMR of 0.85 (95% CI 0.80-0.90) in comparison with the national population. Mortality from all cancer (SMR 0.77, 95% CI 0.68-0.88) and particularly from lung cancer (SMR 0.64, 95% CI 0.50-0.81) was lower than expected. An excess of lymphatic and hematopoietic cancer (11 deaths, SMR 2.17) was observed in the making department. These findings do not support an occupational hazard of lung cancer as suggested by several earlier studies. The excess of lymphatic and hematopoietic cancer in the making department was unexpected, and may be a chance occurrence.

A cohort study was designed to evaluate the risk of death from malignant neoplasms among pulp and paper workers. This paper presents the evaluation of death risk among workers engaged only in the production of paper, paperboard and paper products. The cohort study covered 1,322 males and 1,914 females employed for, at least, one year in a big pulp and paper mill during the period 1968-90. The study of exposure to harmful factors revealed that concentrations of paper and paperboard dusts in this mill exceeded hygienic standards. The analysis of death risk by causes and gender of those under study was based on standardized mortality rate (SMR) calculated using the method of person-year observation. The general population of Poland was used as reference. The results do not confirm excess mortality from lung, stomach and hematopoietic cancers in paper mill workers reported by other authors. However, an elevated risk of bladder cancer in males (SMR = 491, two deaths) and brain cancer in females (SMR = 353, two deaths) was observed. Both SMR values were not statistically significant. Because of small number of deaths, risk according to exposure and latency was not evaluated.

The cohort consisted of 11,178 Mead Corporation employees (9,358 males and 1,820 females) who had worked for at least one year between January 1, 1975 and December 31, 1992 at seven pulp and/or paper mills in the United States. The vital status of the cohort was determined through a variety of sources over an observation period of 17 years (1976-1992). Mortality data were analyzed in terms of cause-specific standardized mortality ratios (SMRs), with expected deaths based on U.S. national mortality rates. Job categories with similar exposures were created based on an historical exposure assessment. Mortality analyses were performed separately for total female and male employees. Among female employees, overall mortality was less than expected, and no significant cause-specific mortality excesses were observed. The small number of deaths among female employees did not permit further detailed analyses. Among male employees, statistically significant deficits from overall mortality (SMR = 69.0) and from all cancers (SMR = 71.3) were reported. In addition, low mortality risks for many specific causes were also observed, including many specific cancer sites, various types of cardiovascular diseases, and different forms of nonmalignant respiratory diseases. In particular, there was no mortality excess from lung cancer (SMR = 77.5), digestive cancer (SMR = 69.4), stomach cancer (SMR = 46.7), laryngeal cancer (no observed death), rectal cancer (SMR = 82.8). Hodgkin's lymphoma (no observed death), non-Hodgkin's lymphoma (SMR = 103.6), leukemia (SMR = 72.2), diabetes mellitus (SMR = 110.4), ischemic heart disease (SMR = 80.0), and nonmalignant respiratory diseases (SMR = 36.7). Furthermore, detailed analyses by length of employment, interval since hire (latency), and job category demonstrated no occupationally related mortality increases from any of the diseases examined. Specifically, based on internal comparisons, no upward trends in cause-specific mortality risk were observed by duration of employment. In conclusion, the results of this epidemiologic investigation demonstrated a favorable mortality experience for employees at the seven pulp and/or paper mills.

Mortality among workers in the Polish pulp and paper industry was evaluated in retrospective cohort study of 10460 workers who had been employed continuously for at least one year between 1968 and 1990 in the factory producing sulphate pulp, paper, board and paper products. A standardized mortality ratio (SMR) analysis was used to compare death rates for the exposure group with Polish national rates. For all the subjects death due to all causes and all malignant neoplasms were lower than the number expected. The only significantly increased risks were those of malignant neoplasm of brain among women (4 cases, SMR = 318) and of retroperitoneum and peritoneum among men (2 cases, SMR = 659), exposed to high level of wood dust and irritant sulphur compounds. The authors could not find any etiological explanation of the excessive mortality from brain and peritoneum cancers.

The mortality pattern among Swedish pulp and paper mill workers was evaluated in a case-referent study encompassing 4,070 men decreased during the period 1950-1987. The subjects were identified from the register of deaths and burials in six parishes. A significantly increased mortality was seen for diabetes mellitus and for secondary tumors of the lung and liver among the pulp and paper mill workers. Indications of excess risks were also found for obstructive lung disorders, pulmonary emboli, accidents, and pneumonia, as well as for malignant lymphomas, leukemias, and cancer of the pancreas and stomach. In the only parish where a sulfite process was exclusively used, cancer of the digestive tract and especially of the rectum was found to be in excess. Except for this parish, the sulfate process predominated in the plants included. The mortality pattern found in this study is in reasonable agreement with findings in various studies from this type of industry.

A proportionate mortality ratio (PMR) analysis utilizing death certificates and work histories was performed on 201 white male decedents who had been employed in pulp and paper production plants and had died between 1970 and 1984. PMRs for all malignant neoplasms (PMR = 131) and lung cancer (PMR = 151) were significantly elevated, whereas PMRs for lymphopoietic system cancer (PMR = 190) and cancer of the large intestine (PMR = 147) showed nonsignificant excesses. Most of the excess cancers of the lung and large intestine were limited to those with greater than 30 years between initial employment in a pulp and paper plant and death. Excess lung and lymphopoietic system cancers have been found in other studies of paperworker mortality, although this study failed to support previous findings of excess stomach cancer. These results continue to raise concerns that paperworkers are at elevated risk for some occupational cancers.

Cause specific mortality was analysed among 883 white male workers from a paper company in Berlin, New Hampshire. Subjects were assigned to different exposure groups on the basis of their having worked in the pulp mill, the paper mill, or elsewhere in the paper company. A standardised mortality ratio (SMR) analysis was used to compare death rates for each of the exposure groups with United States national rates. For all the subjects, deaths due to all causes, all malignant neoplasms, and lung cancer were close to the number expected and excesses were noted for cancers of the digestive system and leukaemia. Among pulp mill workers, the number of cancers of the digestive system was raised and the SMR for pancreatic cancer was especially high (SMR = 305, 95% CI = 98-712). Among paper mill workers, more deaths were due to leukaemia and cancers of the digestive system than expected. These results are consistent with the findings from other studies that employment in pulp and paper mills is associated with excess mortality due to digestive and lymphopoietic cancers.

Mortality among workers in the Finnish pulp and paper industry was evaluated in a retrospective cohort study of 3520 workers who had been employed continuously for at least one year between 1945 and 1961. Six subcohorts were formed according to six work areas: sulphite, sulphate, paper, and board mills, maintenance department, and power plant. National mortality rates were used for comparison. The mortality of a cohort of 1290 sawmill workers was also studied in order to have a socially, geographically, and occupationally similar group without the exposures typical of the pulp and paper industry for comparison. Smoking habits were surveyed. Mortality was followed up until 31 December 1981. Overall mortality for the entire cohort did not differ from that expected (1044 obs, 1029.4 exp, SMR 101), but there was an excess of deaths from diseases of the circulatory system among the men (489 obs, 404.9 exp, SMR 121). This was due to the excess of deaths from ischaemic heart disease found among the men at the sulphite, sulphate, and paper mills, maintenance department, and power plant, but not at the sawmill. The existing smoking data did not explain this finding and it may therefore be associated with occupational exposures.

The International Agency for Research on Cancer (IARC) proposed this international historical cohort study trying to solve the controversy about the increased risk of cancer in the workers of the Pulp and Paper Industry. One of the most important aspects presented by this study in Brazil was the strategies used to overcome the methodological challenges, such as: data access, data accuracy, data availability, multiple data sources, and the large follow-up period. Through multiple strategies it was possible to build a Brazilian cohort of 3,622 workers, to follow them with a 93 percent success rate and to identify in 99 percent of the cases the cause of death. This paper, has evaluated the data access, data accuracy and the effectiveness of the strategies used and the different sources of data. A Agência Internacional para Pesquisa sobre Câncer (IARC) propôs uma coorte histórica internacional para tentar resolver a controvérsia sobre o risco aumentado de câncer em trabalhadores das indústrias de celulose e papel. Um dos aspectos mais relevantes deste estudo no Brasil refere-se às estratégias utilizadas para superar desafios metodológicos, tais como: acesso aos dados, acurácia e disponibilidade dos dados, múltiplas fontes de dados e longo período de acompanhamento. Através de múltiplas estratégias, foi possível construir uma coorte brasileira de 3.622 trabalhadores, acompanhar 93% dos casos e identificar a causa de 99% dos óbitos. Este artigo avalia o acesso aos dados, sua acurácia e a efetividade das estratégias utilizadas para o acompanhamento da coorte.