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Although farmers experience lower overall cancer rates than the U.S. population, they are at increased risk for cancers of certain sites, such as brain, stomach, lymphatic and hematopoietic, lip, prostate, and skin. Little research has been done to determine the extent to which farmers and their families use cancer control services or how their utilization behaviors and cancer survival rates compare to those of nonfarmers in the United States. In 1989, recognizing the occupational uniqueness of farm populations and the limited cancer-related information about them, Congress mandated that the National Institute for Occupational Safety and Health (NIOSH) develop a program to promote cancer control among farming populations. Eight institutions were funded through cooperative agreements to collaborate with NIOSH and each other to develop the demonstration research and intervention projects. The projects are aimed at identifying barriers that prevent farmers, farmworkers, and their families from accessing the full range of cancer control services, and then implementing interventions to mitigate those barriers. This paper illustrates some of the conceptual and methodological issues NIOSH researchers and their collaborators faced while developing the cancer control program.

Study Objective. To investigate the occurrence of tramadol-associated seizures. Design. Retrospective cohort and case-control studies. Setting. UnitedHealth Group-affiliated independent practice model health plans, from different regions of the United States, contracting with large networks of physicians. Intervention. Analysis of administrative data from a large U.S. managed care population. Patients. A cohort of 9218 adult tramadol users and 37,232 concurrent nonusers. Measurements and Main Results. Fewer than 1% of users (80) had a presumed incident seizure claim after the first tramadol prescription. Risk of seizure claim was increased 2- to 6-fold among users adjusted for selected comorbidities and concomitant drugs. Risk was highest among those aged 25–54 years, those with more than four tramadol prescriptions, and those with history of alcohol abuse, stroke, or head injury. A case-control study among users was conducted to validate incident seizure outcomes from medical records. Only eight cases were confirmed, and all had cofactors associated with increased seizure risk. Conclusion. In a general population, risk of seizure may be associated with long-term therapy with tramadol or the presence of cofactors, or confined to a small sensitive population subset.

To the Editor. —Tramadol hydrochloride (Ultram, McNeil Pharmaceutical, Spring House, Pa) is a centrally acting, synthetic, opioid analgesic that was approved for marketing in the United States in March 1995 for the treatment of moderate to moderately severe pain. The recommended adult dosage is 50 mg to 100 mg every 4 to 6 hours, not to exceed 400 mg/d.1 Within the first year after marketing approval in the United States, the Food and Drug Administration (FDA) received 83 reports of seizures among patients using tramadol. This led to labeling changes and issuance of a "Dear Doctor" letter.2During tramadol's second year on the market, the FDA received more than 200 reports of seizures. We describe the clinical features of seizure cases reported for tramadol. From the FDA's database of adverse drug events,3we retrieved all domestic US reports for tramadol coded for seizures that the FDA had