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MEDICAL STATUS OF MARSHALLESE ACCIDENTALLY EXPOSEDI TO 1954 BRAVO FALLOUT RADIATION:J

JANUARY 1985 THROUGH DECEMBER 1987 ‘

William H. Adams, M.D., Peter M. Heotis,and William A. Scott

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MEDICAL STATUS OF MARSHALLESE ACCIDENTALLY EXPOSEDTO 1954 BRAVO FALLOUT RADIATION:

JANUARY 1985 THROUGHDECEMBER 1987

William H. Adams, M.D., Peter M. Heotis,and William A. Scott

MEDICALDEPARTMENT

BROOK HAVEN NATIONAL LABORATORY

UPTON, LONG IS AL ND, NEW YORK 11973

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DEDICATION

This report is dedicated to the captain and crew of the M.V.Liktanur. For ten years the Liktanurs11and III have ser~red as home and workplace for much of each medical mission to the MarshallIslands. Throughout this time it has been the good fortune of the medicaI program to have theexcellent support of the ship’s crew. More impotzantly, that good fortune was extended to thepopulation served by the medical team: the emergency rigging of oxygen tanks to treat hypoxicpatients, lighting of a small airstrip at night to facilitate an emergency air evacuation. radio liaison.transportof patients between the atolls and to and from shore. and the emergency repair of medicaiequipment are just some of the non nautical activities that benefited the medical missions. Now. a newsupport vessel for work in the~arshall Islands has come under contract to the Department of Energy.Therefore, on the departure of the Liktanur, we would like to acknowledge our debt to Capt. KeithCoberly Monroe Wlghtman. engineen Jim Whitney and Jan Kocian, first mates Cisco Peru, cook LesNunes, boatswain; Tony Ned and Mathan Almen, seamen: and other crew members who, for shomerperiods, also contributed to the effectiveness of the missions. We thank them for a job well done.

IN MEMORIAM

Two former members of the Brookhaven medical team who participated in several surveys diedduring the past year. Colonel Austin Lowrey, Jr., died at the age of eighty-six. He was a well-knownophthalmologist with a long career in the army. He was a most kind and generous person andcontributed a great deal to the evaluation of possible radiation effects on eyes. Dr. Leo Meyer, who diedat age eighty-two, was a well-known hematologist and was Director of the Sickle Cell Anemia Programof the Veterans’ Administration. He made outstanding contributions to the program in evaluatinghematological radiation effects. Leo will be remembered for his joviality, for always having a joke ready[o cheer us. Both of these men were well liked by medical teams and the Marshallese people. and weshall truly miss them.

Robert A. Conard. .M.D.January ’23, 1989

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CONTENTS

Page

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ””””-””

Exposure Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .The .Marshall Islands Medical Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...”. “.”””Procedures . . . . . . . . . . . . . . . ..- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Medical Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Overall Sufival . . . . . . . . . . . . . . . . . . . . . . . .. - . . . . . . . . . . . . .. OO.O.0Causes ofRecent Modality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

,Rongelap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Utirik . . . . . . . . . . . . . . . . . . . . . . . . . . .........................Comparison population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Laboratory Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Neopiasms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Thyroid nodules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Nonthyroidal tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Autoimmune Thyroldlnjury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Noncancerous Thyroid Morbidity in Exposed MarshaUese . . . . . . . . . . .Review ofCancers in the Comparison Population . . . . . . . . . . . . . . . . . . .References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..+ppendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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INTRODUCTION

This report updates. through 1987, the medi-cal findings on a population of .Marshalleseaccidentally exposed to radioactive fallout in1954. The Marshall Islands Medicai Program ofthe Medical Department, Brookhaven NationalLaboraco~, issues these summaries for distri-bution to institutions and individuals world-wide who are concerned about the adverse med-ical consequences of radiation exposure ingeneral or, in particular. the plight of theradiation-exposed Marshallese.

The exposed Marshallese population origi-nally comprised 64 persons on Rongelap Atollwho received an estimated 190 rads of whole-body external gamma radiation. 18 on AilingnaeAtoll who received 110 rads. and 159 on UtirikAtoll who received 11 rads. In addition. therewere 3 fetuses on Rongelap, 1 on Ailingnae. and8 on Utirik. each of which received equivalentwhole-body doses. Because of radioiodines inthe fallout, the thyroid gland received an addi-tional exposure that was much greater than thewhole-body dose, although its magnitude wss.in part, a function of age at the time of exposure(Lessard et al.. 1985).

The content of this repon is restricted to themore recent medical findings, some aspects ofwhich bear on late effects of radiation exposure.Those feat u res of the Marshall Islands MedicalProgram by which medical diagnosis and treat-ment are prowded are discussed. For detailedinformation on the nature of the 1954 falloutand the acute effects suffered by the population.the reader is referred to several earlier publica-tions [Bond, et al., 1955; Cronkite et al.. 1955:Cronkite et al.. 1956: Conard et al., 1957).Otherreports provide reviews of delayed effects of theexposure (Conard et al., 1980 Conard, 1984:Robbins and Adams, 1989).

EXPOSURE GROUPS

The medical program examines and treatsabout 800 persons annually. However, the popu-lations on which this report is based includeonly the exposed persons and a selected groupof unexposed individuals. In December i 987.the number of exposed persons was: Rongelap -50, Ailingnae - 12, and Utirik - 112. For mostpurposes in (his report the Rongelap and

.%lin gnae groups are combined and referred toas the Rongelap group, for those personsexposed on Ailingnae atoll were \’isiting fromnearby Rongelap at the time of the fallout. .Usoexammea was the Comparison group that datesfrom 1957 when 86 unexposed people fromRongelap were selected so that the Comparisongroup approximated. in age and sex distribu-tion.the exposed Rongelap group (Conard et al.,1958). Sixty persons remain in this group,against which the overall survival of the exposedpopulation is compared (Figure 1). However, alarger unexposed group is also followed. Cur-rently numbering 135, the age and sex distribu-tions of its members were statistically similar tothose of the Rongelap and Utirik groups in 1982(Adams et al,, 1983). Included among the 135are most of the remaining 60 individuals selectedin 1957. It is this expanded unexposed popula-tion that is used for statistical comparisons ofyear-to-year medical events: this provides thebaseline prevalence from which any unex-pected consequences of the radiation exposure .can be identified.

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Fig. 1: Percent survivors of the different exposuregroups since 1964. The number of persons m eachgroup are given in the parentheses.

THE MARSHALL ISLANDSMEDICAL PROGRAM

Policies:The Marshall Islands Medical Program pro-

vides medical care twice yearly to the exposedpopulation by visiting the islands where mostnow reside, namely Rongelap (and, temporarily,Mejato ), Utirik. Ebeye, and Majuro. In addition,the medical team provides health care to a con-

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siderable number of unexposed persons. AHtheinhabitants of Rongelap. Me.jato. and Utirik areeligible for medical attention at the time of theteam \isits to those islands. Team physiciansneed not be aware of the status of radiationexposure of the individual patient becausehealth care delivery is the same for everyone.The only difference allotted to the exposed pop-ulation ISa U.S. Department of Energy-sponsoredreferral system to the Marshallese health caresystem or to tertiary care facilities m the UnitedStates for diseases that can reasonably be con-sidered to be radiation-related or for diagnosisof such diseases. Unexposed persons aredirected into the referral channels of the HealthSenlces of the Republic of the Marshall Islandswhereby referrais are assigned on the basis ofpriorities set by a medical committee in Majuro.

.Any exposed person who has, or who mu?hthave. a malignant neoplasm. IS referred tosecondary or tertiary medical facdities for adefinitive evaluation and for therapy if a lesion Efound. The usual hospitals to which patients arereferred are in Honolulu and Cleveiand. the lat-ter because of the presence there of a preemi-nent thyroid surgeon who has long beeninvolved with the exposed and Comparisongroups of Marshallese.

The medical program also dispenses prima~medical care and preventive medical services,such as immunizations, during \mits to theexposed population. In bringing modern facili-ties for diagnosis and treatment of disease to theexposed Marshallese, the physicians of the med-icai program come into contact wxh childrenand other family members of the exposed. aswell as other inhabitants of the Aands. It hasbeen the policy of the Department of Ener~ tosupport the medical program in its efforts toprovide primary medical care to these individu-als on the basis of humanitarian need and asresources permit.

The medical direction of the Marshall IslandsMedical Program and the orgatuzation of themedical missions to the Marshall Islands arecentered at Brookhaven National Laboratory.The staff of the program includes a physician-director. an administrator. and a technical spe-cialist at the Laboratory, and a .Marshalleselaboratory technician on Ebeye. .+t the time ofthe missions a variety of physicians are chosenfor the medical team. They are skilled volun-

teers. primarily faculty from medical schools,often \vith past exp,.rience with the program.Logistical support is provided by the Depart-ment of Energy, capably facilitated by Holmesand Xarver. Inc.. Honolulu. HI. The MarshallIslands government. as requested. temporarilyassigns nurses. transistors. and other healthcare workers to each mission.

Although there are two medical missions eachyear. in the interim the exposed population hasaccess to the MarshaUese health care system. Toexpedite exchange of medical information,copies of all examination and laboratory datafrom the Marshall Islands Medical Program areforwarded to the Marshall Islands Health Ser-vice hospitals on Ebeye and Majuro and to thespecial programs set up for persons from theradiation-affected atolls, currently the 177Health Care Plan \vith administrative offices atthe Majuro hospital. In addition. copies of theexaminations and laboratory data are given tothe examinees.

A computer program with data base wasdeveloped for portable (lap-cop) computers.Computerization of the clinical data permitsrapid access while in the field to all findingsobtained during the preceding five years ofexaminations and to selected data collectedover more than thirty years. Itis hoped that inthe near future the development of compatibleprograms by the Marshallese 177 Health CarePlan wdl permit sharing of up-to-date problemlists and other medical record items that areimportant to effective continuity of care.

The Marshall Islands Medical Program. as asateilite clinic of the Clinical Research Center,Brookhaven National Laborato~, is accreditedby the Joint Commission on Accreditation ofHealthcare Organizations. a nationwide organi-

zation that sets standards of performance forinstitutions dispensing medical care and moni-tors compliance with those standards, By volun-tary participation in the accreditation process,the Marshall Islands Medical Program receives avaluable and impanial external review of itspolicies and procedures, ss well as an assess-ment of the adequacy of the services it provides.Laboratory and radiological services, medicalrecords, patient satisfaction. pharmaceuticalset-vices, and clinical competence of physiciansare among the many items reviewed by the JointCommission,

Much medical data unreiated to radiationexposure is acquired during each medical mls-+ion. Some of this information. from exposedand unexposed indi~tiduals. is relevant to healthcare throughout the Marshall Islands. Conse-quently, public health reports. based on medicalteam observations unrelated to radiation. havebeen submitted periodically to the Health Servi-ces of the Republic of the .Marshall Islands. Thetopics during this reporting period have includedthe following

1) Serum lipids in Marshallese2} Pediatric growth and development (ananalysis prompted by observations of med-ical team physicians that Rongelap child-ren, following their transfer to Mejato,were not maintaining their positions oncharted growth curves )3) Pediatric audiometry4) DentaI conditions on Rongelap andUtirik5) Chlamydia infections in Marshallesewomen6) Large optic disks (a relatively frequentfinding by medical team ophthalmologists)

Some signifkant observations in these andearlier public health reports were published inmedical journals. Moderately elevated serumuric acid levels were noted in many Marshalleseand the frequency of this finding and that ofgout were analyzed (Adams et al.. 1984).Toxo-plasmosis was identified as a serious healthhazard in the Marshall Islands. with an esti-mated 200 persons being visuaily impaired andan inc]dence of chorioretmitis of 273 caseslyearl 100,000 seropositive persons (.Adams etal., 1987). Hepatitis B, the subject of a serologicalsurvey described in a previous BrookhavenNational Laboratory report (Adams et al.,1985), constituted another serious public healthproblem (Adams et al-, 1986). The prevalence ofanemia in children was described. and normalranges for hemoglobin level and erythrocfiemean corpuscular volume for ,Marshallesechildren were derived (Duntzy et al.. 1987). Thelatter were found to be identical to those ofchildren in the United States. Because of thedevastating effects of diabetes mellitus amongthe Marshallese, an effort was made to deter-mine if a dietary deficiency of chromium, a traceelement that is relevant to glucose tolerance.contributed to the problem. The analytic proce-

dure used was too insensitive to quantitateblood levels of chromium, but during the analv-sis it Ivas found that bromine levels were higherthan those reported for any other population(Wielopoiski et al.. 1986). The reason for this isunknown: further, the levels of bromine thatwere detected fall far short of its known toxiclevels. The observation by team ophthalmolo-gists of large optic disks in many personsprompted another report to the MarshaUeseHealth Services because the associated increasein disk cupping could be misconstrued by physi-cians as representing glaucoma. The high pre-valence of the condition indicates Marshalleseare unique among all populations in whom suchmeasurements have been obtained (Maisel et al.,1989).

Procedures:The exposed population. which now numbers

163, must be considered at increased risk formalignant disease as a late complication ofradiation injury. Therefore. the medical pro-gram has in place a cancer-oriented annualhealth evaluation. The examination follows the‘guidelines of the Anerican Cancer Society andincludes a medical history, complete physicalexamination, advice on decreasing risk factorsfor cancer, advice on self-detection of lesions,annual pelvic examinations and Papanicolaousmears, stool testing for blood, blood count, andurinalysis. Several new diagnostic procedureswere incorporated into the medical missions inthe past three years. Because of the develop-ment of x-ray fdms and cassettes that signX]-cantly decrease radiation exposure, annualmammography is offered to all exposed womenand to alI unexposed women forty years of ageor older. For persons over the age of ffiy years,flexible sigmoidoscopy is offered every threeyears or whenever clinically indicated. An tdtra-sound machine has been acquired that greatlyincreases the diagnostic capabilities of the med-ical team, especially in managing acute prob-lems seen at the time of team visits. For thyroiddiagnosis, needIe biopsy of selected thyroidnodules has been instituted in an effort to avoidsurgery and the subsequent loss of normal thy-roid tissue in patients with benign nodularlesions. Because of earlier medical programobservations it is known that the exposed are atgreater risk for certain endocrine problems andfor this reason they receive annual thyroid-

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func[lon blooa tests and thyroid examinationsby a specialist in endocrinology or thyro]dsun?ery. Other tests are performed on a regularhas~ m an attempt at early detection of malig-nant nonthyToldal les]ons. There is also ongoingmonitoring for clinical evidence of immunecompetence. for exposed persons may be atincreased risk for unusual manifestations ofinfecuous diseases.

Nedical examinations and services performedduring this three-year reporting period wereconducted primarily aboard the Liktanur 11andthe Liktanur 111, vessels chartered from U.S.Oceanography Exceptions, as in the past.included the use of Brookhaven National Labor-atory facilities on Ebeye and, when necessary,.Marshallese medical dispensaries on Rongelap,Llink. and Mejato. Laboratory support duringthe medical missions is provided by severaltechnicians. Routine blood counts are performedon a J.T. Baker 5000 electronic particle counterand sizer. Leukocyte differentials and phasecontrast platelet counts are part of each hemo-gram. A variety of nonhematological testing ser-\Ices is provided. including bacteriology, stoolexamination. and urine testing. In the past abattery of manual clinicai chemistry tests wasearned out using commercial spectrophoto-metric kits. Recently, however, Eastman-KodaksDT-60 and D’13C analyzers were added toincrease the ~ariety of chemistry tests availablein the field and to improve the turn-around timefor results: this has significantly improvedlaboratory operation. Fortunately, there havebeen few problems associated with transpon.operation, and handling of the new” equipmenton board ship, even during bad weather. ABeckman Electrolyte 2 analyzer is used to mea-sure sodium and potassium in serum and urine.Roentgenographic services are performed witha Bennett standard x-ray unit and mammo-graphy unit. both of which are contained in aseparate module on the deck of the ship. Serumis usually collected from most exarninees andfrozen for subsequent testing. Referral laborato-ries have included Bio-Science Laboratories andAccupath in Honolulu for special chemistriesand serologies: Pathologists’ Laboratories, Inc..Honolulu, for Papanicolaou smears and othercytology; Brookhaven National Laborato@clinical laboratory for general chemistv andalpha fetoprotein analysis: Hazelton Biotech-

noiogies Co.. ~lenna, V.% for hormone assays:\lichael Reese Hospitai and Medicai Center (Dr..+. B. Schneider. Department of Endocrinologyand Metabolism ], Chicago, for thyroglobuiinanalysis: Medical Microbiology Division. Univer-sity of California. Ifine. for chlamydia ctdtureand serolo~, and the Eugene L. Saenger Radio-isotope Laboratory, University of Cincinnati. forantimicrosomal and antithyroglobuiin antibodytesting (Dr. Harry Maxon).

The .Marshall Islands Medical Program isdeepiy indebted to the many outstanding physi-cians who, despite the inevitable personalinconvenience. participated in the medical team\isits of 1985-1987. It is fair to say that they arethe heart of the program. Drawn from excellentmedical centers throughout the United Statesand from private practices, these physiciansprovide the program with a wide range of up-to-date clinical experience and perspective thatcontribute to better patient,care. The physiciansinvolved in the 1985-1987 missions are listed inAppendix A, and represent the following medi-cal specialties:

Internal MedicinePediatricsInfectious DiseaseCardiologyObstetrics/ GynecologyOphthalmologyEndocrinologySurgeryGastroenterologyFamdy PracticeGeriatricsAllergy/immunologyDermatologyNeurologyPediatric Dentistry

The participation of many excellent medicalspecialists undoubtedly has been a major factorin the acceptance of the Marshall Isiands Medi-cal Program by the population it serves. Thepercent of persons in the exposed and Compari-son groups who appear for the voiuntary exam-inations remains high. For the current reportingperiod the annual acceptance rates were:

1985 1986 1987Rongelap 82X 93!Z 95XUtirik 92% 92X 90’X}Comparison 76% 66%8 72%

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The percent ot’ the eligible population exam-]ned on at least one occas]on during the threeyear period \vas:

Rongelap ‘47”%,Utirik : 00:!

Comparison 94’:,

These figures do not include several personsresiding outside the Jlarshall Islands. \fostexposed persons in this category have medicalexaminations arranged through a local physi-cian by the Department of Ener~ or the Mar-shall Islands Medical Program. The acceptancerate for mammography among eligible womenwas 100:{,.For sigmoldoscopy, about 50’YIof age-eligible persons elect to undergo this procedureon a regular basis.

MEDICAL FINDINGS

Overall Survival:After thirty-three years there continues to be

no significant difference in the sunival curves ofthe high-exposure Rongelap group, the low-exposure Lkirik group, and the unexposed Ron-gelap population followed for the purpose ofcomparison (Fig. 1). Estimates of the sum’ivaldistribution by the actuarial life table method\vere analyzed by Mantel-Cox and Breslow sta-tistics for testing the equality of the survivalcurves. The “p” values were 0.68 by both tech-niques. In the Brookhaven National Laboratoryreport covering January 1983 through Decem-ber 1984, it was noted that Okajimaet al. (1985)suggested that medical programs providinghealth screening might lead to an underestima-tion of the effect of radiation on mortality. Inparticular, it was postulated that this couidexpiain the iower agespecflc death rates fromail causes among Nag=aki A-bomb survivors,compared to a controi population. The effect ofmedicai examinations on the survivai of theexposed Marshaliese is unknown. On the onehand about 15 percent of the Comparison groupseiected in 1957 is no ionger seen because thoseindividuals have voluntarily foregone examina-tion. In addition, BNL referrais for the Compari-son group are channeied into the MarshaiieseHeaith Services system. whereas seiected medi-cal probiems in the exposed groups can bereferred directiy to tertiary care facilities in theUnited States. On the other hand. the exposedpopulations of Rongeiap and Utirik have received

equivalent medical attention Irom the BNL pro-gram since 1972. and yet. despite the far higherradiation dose received by the Rongeiap group,the su nivai tunes are similar.

.Inother factor that contributes to the diffi-culty in interpreting differences in the groupsurvivais in Fig. 1 is that the population used toconstruct the “’Rongelap unexposed” curve wasseiected in 1957. and it is in that year that theirsuntivai is graphed as one-hundred percetm i.e..data from three years of observation, duringwhich some deaths occurred. had aiready beenacquired from the two exposed populations.

Causes of Recent MortalitwThe number of deaths occurring in the iast

three years are as foiiows: Rongeiap exposed - 2;Cltirik exposed -9: Comparison group -10. Thespecific ciinicai situations are described beiow.

RongelapSubject No. 1. The causes of death iisted on

the death certificate of this” 8 I-year-oid womanin June 1985 were ““Inanition” and “Senility.”When seen in March 1985. she had a normalbiood pressure and cardiac examination reveal-ed “premature beats.” In 1984 she was noted tohave cataracts, atriai fibrillation. and complaintsof urinary incontinence, some cough, constipa-tion, and joint pains. Her hemoglobin was 12.7g(di. the mean corpuscular voiume was 92 fl,and the white biood ceii count was 6,600 per U1with a normai differenciai.

Subject No. 11. This 81-year-oid man died in1987 of unknown cause. Diagnoses made duringthe preceding four years inciuded severe osteo-arthritis, chronic obstructive pulmonary dis-ease with builous emphysema. macrocWic ane-mia that was being t mated with vitamin B12injections, cataracts, and ‘organic brain syn-drome.” He had declined a medicai examinationwhen visited at his home in September 1986. butdid not appear acuteiy iii at that time.

UtirikSubject No. 2123. This 47-year-oid man died

in December 1986 from biopsy-proven hepato-ceiiuiar carcinoma. His alpha fetoprotein ieveiwas elevated and the serum contained hepatitisB surface antigen but no deita antibody. No evi-dence of tumor was found at his March 1986examination. Symptoms related to the tumordeveioped in June of that year.

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Subject No. 2125. This patlem died in 1987from carcinoma of the lung ff~th brain metas-tasis at age 70. He had been referred to a Hono-lulu hospital for el’aluatlon of guaiac-poslti~’e~toois in October 1986. A chest x-ray was nega-twe at the time of referral. Xo seIYous problems\vere detected during his Honolulu exammation.

but respirato~s~ptoms from the tumor deve-loped in January 1987. He had been a cigarettesmoker, and was felt to have severe chronicobstructive pulmonary disease with recurrentbronchitis.

Subject No. 2128. This 39-year-old womanhad diabetes mellitus complicawd by chronicrenal failure. severe diabetic retinopathy andneuropathy, and anemia Ihemoglobin 9.4 gjdl inOctober, 1984). She died in a Honoiulu hospitalafter emergency air evacuation from Utirik.Diagnoses made at the hospltai rncluded hypo-glycemic and hypoxemlc brain damage. diabetesmellitus treated with insulin. anemia secondanto renal failure. and sepsis.

Subject No. 2164. “Postpartum hemorrhage”’and ‘“uterine inertia” were listed on the deathcertificate of this 42-year-old woman in Febru-aty 1985. Previous problems included obesityand possible gout. A blood count m .March 1984was normal.

Subject No. 2189. This 59-year-old womandied in 1987 from chronic renai failure due todiabetes mellitus. Her serum creatinine in\larch 1986 was 10.9 mgidl and the hemoglobinlevel was 7.7 g:dl.

Subject No. 2200. “Inanmon- and “senditv”’were the death certificate diagnoses for this 72-year-old woman who died in December 1985. Athyroid nodule had been noted at least since1977 but the patient “appeared to be a poorsurgical risk.” Her hemoglobin Icvei was 11.6 gl dland the white blood cell count w= 6.200 per u1..%left breast mass had been notd since 1966.but the patient had declined biop~ and surgery.She said the mass had been present since youth.

Subject No. 2212. This 66-year-old womandied in 1987 from chronic renal failure due todiabetes mellitus. She was evaluated at Kwaja-Iein hospital in 1985 and noted to have renalfailure. hypertension. and anemia. When evalu-ated by physicians of the 4-Atoll Healthcare

Program she was not felt to be a candidate fordiaiysls. and her family agreed to supportivemanagement.

Subject No. 2218. The death certificate diag-noms on this 34-year-old woman in September1985 was “congestive heart failure.” When exa-mined in March 1985. the only significantabnormality had been a urinary tract infectionfor \vhich she was giveh an antibiotic. althoughasthma had been noted in the past. The patientwas late in pregnancy at the time of her demiseand was, on the basis of history obtained fromthe 4-Atoll program physicians. probably ec-Iamptic.

Subject No. 2249. This woman died at age 57in February 1986 from complications directlyarising from local extension of a “’malignantmenmgioma.’”.% description of this patient andthe tumor was presented in a previous BNLrepon (Adams et al.. 1983) following the o’rigi-nal diagnosis in 1982.

Comparison groupSubject No. 814. The death certificate diag-

nosis in June 1985 for this 33-year-old man waspneumococcal meningitis confirmed by culture.He \vorked on Kwajalein and died in Kwajaleinhospital after being transferred from Ebeyehospital. His most recent BNL medical examina-tion had been in April 1983. when problems ofsmoking and heavy alcohol consumption werenoted. His blood count was normal at that time.

Subject No. 821. This 38-vear-old woman diedin 1986 from complication of childbirth. herdeath certificate diagnoms being ‘postpartumhemorrhage.” When seen in April 1986 she was22 weeks into her thirteenth pregnancy. No sig-nificant abnormalities were noted at that time.

Snbject No. 842. The death certificate diag-nosis on this 6 l-year-old man in March 1986 was“liver failure due to hepatoma.” The only activeproblem noted in his last BNL medical examina-tion in March 1985 was chronic low back pain. ArouIme sigmoidoscopic examination was nor-mal except for the presence of hemorrhoids.Hepatitis B surface antigen was not detected inhis serum. but antibody to the surface antigenwas present.

Subject No. 846. This 63-year-old womanunderwent a bone marrow aspiration in March

SO ON(N

19bn (or cwaluatlon of anemia and leukopema.The f.]]agnosls ot’ refractov anemia wmh excesshl~l.; NXMmade and subsequently confirmed inIIonolulu at the Straub Clinic (“mvelodyspiastic>>narome !t”ith an evolving acute nonlympno-c}~]c ieukem]a”). She died in 1986.

Subject No. 928. The cause of death in 1987 ofIhis 73-year-old woman is unknown. When lastseen by the BNL medical team in Majuro inMarch 1986. no serious medical illnesses. werenoted. She had been moderately anemic for sev-eral years ( hemoglobin level between 10.5 and11.5 g all). and a flexible sigmoidoscopic exami-nation in 1985 was normal. NO gastrointestinalblood loss was documented in recent years.

Subject No. 950. This 40-year-old woman diedin Kwajalein hospital in August 1985. The deathcertlticate diagnoses were essentiai hyperten-sion and intracerebral hemorrhage. She hadbeen known to be h~ertensive for 13 years and\vas followed in the hypertension program ofrheTrust Terrnories.

Subject No. 969. The clinical diagnosis in this69-year-old man was either metastic tumor tothe lung or puImonary tuberculosis. However.the 1987 death certificate diagnoses were ““con-gestive heart failure”’ and “pneumonia.”.SPutumcuh ures for .!4 tuberculosis were negative and[here $vas no clinicai response to antitubercu -ious therapy.

Subject No. 975. When splenomegaly and[hromboc>lopenia were detected in March 1984.[his ti~-year-oid man was referred for furthere~aiuat]on. .% lymph node biopsy in October1984 showed “atypical lymphoepithelioid cellproliferation of uncertain etiolo~,” possibly al}mphoma. He died in 1985 and details of theterminal illness could not be obtained.

Subject No. 991. This 78-year-oid woman diedin January 1986. Death certificate diagnosesInciuded “septicemia. diabetes meilitus. andchronic renal failure from diabetic nephro-pathv.” She had a mid-calf amputation of theright ieg some six years eariier and was beingfoliowed at the Ebeye hospital. Her most recentBSL medical examination was m 1981.

This diagnosis W= made after she W= referredto Majuro for e~”aJuation of a possible abdominalmass detected in June of 1984.

Laboratory Findings:

A review of average blood cell counts of thedifferent exposure groups during the three-yearreporting period does not reveai any systematicdifferences among groups. Figure 2 is a contin-uation graph in which the exposed groups areportrayed in relation to the Comparison group.Table 1 gives the actual mean counts of formedblood elements of the different groups and iden-tifies counts which differed significantly fromthose of the Comparison group.

Biochemical test results are iisted by individ-ual identification number in Appendix B.

Neopiasms:

Thyroid nodulesSurgery for palpable th~oid nodules was per-

formed on five persons in 1985 and one personin 1986. No new iesions were detected in 1987.The specific diagnoses, determined by an expert “panel of pathologists, are listed -in Table Z, andTable 3 gives a summary of all nodules diag-nosed throughout the medical program. Thebenign thyroid nodules include adenomak. ade-nomatous nodules, and occult papillary carci-nomas. The adenomatous nodules are includedin the tabulation even though it is highly debat-able that they are true neopiasms. The occultpapillary carcinomas are. \vith rare exceptions,“harmless tumors” (Sampson. 1976). A recentlyreported autopsy series from the FederalRepublic of Germany found occult papihrycarcinomas in 6.2% of 10’20 thyroid glands.Almost half of the tumors were multicentric and14’,%had regional lymph node metastasis (Langet al., 1988). Since there was no predilection forage it was concluded, as in earlier studies, thatoccult papillary carcinomas have no propensityto cause clinically apparent thyroid ,disease.However. controversy continues on how the clin-ical diagnosis of occult papillary carcinoma is tobe made (Schneider et al.. 1980), and someauthorities would accept that diagnosis only ifthe tumor were an incidental finding at surgery.Since some of the purported occult papihrycarcinomas removed from the Marshallese

Subject No. 1050. Colon carcinoma with patients presumably were palpable beforehepatic metastasis is the death certificate diag- surgety, there may by differing opinions on theirnoslsin March 1985 for this 50-year-oid woman. clinical. if not histologic, classification.

Sootlm

‘4EuTROPHILS

.— .-. . -

LYMPHOCYTES

QONGELAP ,31 -—

-_l L- rb - -;~L--_J

-., J-

iaILINGNAE

UTIRIK rP-r

7 _.-’ :1 11#-

901 ,,, ,,z 4 6 a IO IZ141618202224262 E30 32

YEARSPOST-EXFOSURE

PLATELETS-MALES! ,, 1

RONGELAP (c) -

AILINGNAE nf

Eo~, t I

z 4 6 0 1012 14 16 1820222426283032YEARS POST- EXPOSURE

120k ?ONGELAP (b) -

lfl - n

00- ~+- -_l-I d I_l 1’

b

L1 -J -80r-

1201- AILINGNAE

-look n

8o1- b

y

f

120!-UTIRIK

n .1001 mn

uLlu ~

80 ‘,,,

2 4 6 8 IO 12 1416 18 202224262 S3032YEARS POST-EXPOSURE

?LATELETS”-FEMALESr 1

IOOF

801-

RONGELAP (d]1

AILINGNAE f

u

uTIRIK %

80’I

z 4 6 81012 14161820222426283032YEARS POST- EXFk3SURE

Fig. 2: Annual mean blood cell counts of the different exposure groups (age 5 years or more) expressed =percent of controL beginning two years after exposure. VahIes for both sexes are grouped for neutrophiia andIymphocnes. Detailed annual observations. including blood cell counts, on the Utirik population did not be@nuntil 1973. Iakoqne differentmls and Platelet counts were not obtained for six and five of the examinations,respectively, but for graphing purposes the 100% line has not been broken at those years.

TABLE 1:

Comparison Rongelap Exposed Utiri.k Exposed

LEUKOCYTES1985 7392 z 1955 {n=%)1986 7438 z 2102 (n=7811987 7690 z 1843 (n=781

NEUTROPHILS1985 :3948 z 14331986 3786 z 13961987 :3998 z 1427

LYMPHOCYTES1985 ?739 z 8831986 2785 z 11311987 ‘2972 z 950

MONOCYTES1985 :309 z 1681986 294 z 1891987 323 z 240

BASOPHIIS1985 12 f 35

1986 40 k 571987 53 * TO

EOSINOPHIXS1985 261 z 2161986 365 z 4261987 310 t 267

PMTELETS,MEN1985 261 t 75(n=:3811986 ’252 z 541987 266 z 76

PLATELE’T%WOMEN1985 271 t 611986 276 t 71

n=:]a)

n=35)

n=56)n=44)

1987 273 * 67(n=47)

HEMOGLOBIN,MEN1985 14.5 3 1.41986 14.9 f 1.61987 14.4 t 1.1

HEMOGLOBIN, WOMEN1985 13.0 t 1.21986 13.0 f 1.61987 13.1 t 1.3

6731 z 1775 (n=48)7231 z 2060 (n=.54)7418 z 16~5(n=49)

3716 z 15243771 z 16483825 ~ 1434

2345 z 860”2811 z 981‘2915 z 863

229 z 127”301 z 169307 = 203

18 & ~~

47 * 5953 ~ 58

2fM * 207297 t 310293 * 326

’242 5 57(n=20)240 ? 43(n=24)240 c 54(n=20)

277 * 66(n=28)291 + 84(n=30)261 & 51(n=28)

14.8 & 0.814.7 t 1.014.6 t 1.1

12.9 t 1.213.1 & 1.413.3 * 0.8

7985 z 1957” (n=100)7684 z 2023 (n=98)8$34 = :3195 (n=90)

4606 z 3948*4188 z 15704926 * 2984-

2607 * 9152691 z 9272749 * 1054

:321 2 177:361 =251429 =311”

12 * 32ijo * ‘j~63 & 71

273 & 238343 ~ 322?38 t 239

271 z 51 (n—=15)289 z 66” (n=-13)266 z 55(n=41)

~~ * 72S (n=~5)

328 & 81’(n=55)308 & 73”(n=19)

14.9 t 1.215.3 & 1.315.2 f 1.3”

12.6 k 1.2*12.8 & 1.613.0 t 1.2

“Signiflcarttly different, by t-test analysw, from equwalent values of the Comparison group. The only level ofs]gniticance tested was p <005.

.

9

---

TABLE 2: THYROID SURGERIES, 1985-1987

Identification Age at Year of

Xumber & Group Diagnosis Sex Surgery Consensus Diagnosis-

ti~ - Rongelap 45 F 1985 Papillary follicuiar carcinomapius occult papillary carcinoma

S22 - Comparison 41 \l [ 985 Normal

2172 - t’tirik 45 F 1985 Follicular adenoma

2172 - Utirik :34 F 1985 Occult papillary carcinoma

2225 - Utirik 39 F 1985 Adenomatous nodule

2251 - ~tirik :37 F 1986 Follicular adenoma plus occultpapillary carcinoma

“ !4ajorltv diagnoses. based on interpretations by Dr. L.\’. Ackerman. HeaIth Sciences Center. SUNY. StonyBrook. NY: Dr. W.A. ,Meissner. formerly with New England Deaconess Hospital. Boston. k~ Dr. -~.l-- J’ickery,Massachusetts GeneraI Hospual. Boston. MA: Dr. LB Woolner. .Mavo Clime. Rochester. MN.

TABLE 3: THYROID NODULES DIAGNOSED ATSURGERY THROUGH 1987

Adenomatous Papillary Follictdar occultnodules Adenomas cartcers cancem cancers

Rongelap (67)” 17 .1 .5 1

.%ilingnae ( 19)” 4 1

l-’tink ( 167)- 11 -1 4 1. . . 5

C_omparlson (227)” ● 4 1 2 .>.0=.

NOT INCLUDED are the following unoperated (and therefore unconfirmed) nodules: Rongelap — 1; Ailingttae— 1: Utirik — 1; Comparison — 5.INCLUDED are alf consensus diagnoses of a panel of consultant patholog~ts two different lesions were detectedin one person from Rongelap, one from A.i3ingnae. and two from Utirik.- ?Jumber of persons (including those in utmo) who were originally exposed.

“” This number includes all persons who have been in the Comparison group since 1957 (see page 18). Some

have not been seen for many years others were added as recently as 1976.“”- Equally divided opinion in one case: follicular carcinoma vs. atwcal adenoma.“-”- Majority opinion in one cw+e: occult papdlary carcinoma Js. follicular carcinoma. The same paclent hadlyrnphocytlc thyrolditis.

10

Sooullo

.

The cumulacm’e experience of ben]gn plusmalignant nodule detreiopment as a funct]on ofage at exposure shows clearly the increased

~usceptlbiiity of the }’oun~er population [o

nodule indurtion i Fig. 3 L Jlost benw!n nodules

and all the th>Toid carcinomas have occurred infemales. It was noted (Robbins and Adams.1989) that the prevalence of rh}_roid carcinomascompared to benign nodules ( 15(\,) WZMlowerthan that reported follotvmg medical x-raytherapy (about 30.1,).

AGERONCiELAP - SIFO % JTIRIK

* 954

-. --. :!OYR —

fi”

.5 — ‘./= =LPILLARY r ‘.., CER

. . . ‘3 LLIC-L.. ~ :ANCER-.-.__ *

“2%}1

J“_/

;J. :0-18YR.? 37%}!

Y. ‘..: {.5— l–

~ >18 YR—

‘- W“-” /f “o”:,fEARS A~Eq ‘;54

Fig. 3: The amrual of cases w?h thyroid nodules and

thyroid cancer in the exposed Rongelap populationas a function of age at the time of exposure in 1954.The <10 yeargroup includes exposure in urero. ‘Mocases of thyrod atrophy wnhout nodule formation (2Rongelap bo~ <10 years of age ) are excluded. (Fig-ure taken from Robbins and Adams. 1989).

It appears that there is an reverse correlation

between the radiation dose absorbed by the thy-

roid and the time after exposure for develop-ment of the benign adenomatous nodules (Fig.-1). However. since the thyro]d-absorbed radia-tion dose w-as determined primarily by ageatexposure I children receiving greater doses than

adults I. another interpretation of Fig. 4 is thatthe time for development of adenomatousnodules following radiation exposure variesdirectly wmh age at exposure.

Nonthyroidal tumors

During the period 1985 through 1987, deathsattributable to cancer occurred in three exposedpersons. all from Utirik. The types of tumorswere: lung cancer, hepatoma. and meningiomaDuring the same period there were three cancer-related deaths in the unexposed population, thetumor t}~es being: colon carcinoma. hepatom~and myeiodysplastic syndrome.

Additional tumor diagnoses resulted fromclinical investigation initiated at the time ofmedical team \lsits. These included a case ofbreast carcinoma (detected by mammography)and a cas-e of colon carcinoma. both diagnosedin exposed LTtirikwomen. Both lesions weresur-gicallyresectedand have a high probability ofbeing cured. In addition, an epithelioma wasremoved from the skin of an exposed Rongelapwoman. the site of the lesion being in theapproximate area of a beta burn that developedsoon after the 1954 exposure. This type of lesion,

also termed basal cell carcinoma. is very com-mon in the United States and is not included inthe detailed cancer statistics published by theAmerican Cancer Society (Silverberg and Lub-era. 19871. However. its frequency in ,Makshal-lese is unknown.

The development of two cases of hepatomaamong the population served by the medicalteam requires comment. Two persons. one eachfrom the Utirik and the Comparison groups,died from this tumor during the period coveredby this report.To this number should be addedthe death of another Utirik man who died in1984 from complications of cirrhosis (Adams etal., 1985), for he, like one of the hepatomapatients. had hepatitis B surface antigendetected in his serum. Studies have demon-strated an association between hepatitis B sur-face antigenemia and hepatoma, cirrhosis, andchronic active hepatitis (Beasley et al., 1981).Early BNL observations revealed that infectionwith hepatitis B virus is nearly universal amongMarshallese, as it is among many tropical popu-lations, and that serological evidence of theinfection is common in childhood. In view of the

500WI

-— ------- -

ttvo (atalicies [hat m]ght be causally linked tohepatitis B \-irus. infect]on with this orgamsmmust he considered a public health problem of

grea[ concern. The JIarshail Islands \ledical

f’rogram annually [esrs all persons previously

>ho\vn [o be hepatitis B surface antigen -posititiefor the presence of alpha-fetoprotein. a tumormarker for hepatoma. Should an elevated levelbe detected the affected subject would bepromptly referred for e~’aluation in the hope[hat early detection might permit curativeresection of a localized Ie.won [ He.yward et al..1984).

The question arises as to whether the exposedMarshallese are at increased risk for the latecomplications of hepatitis B. This problem was

5

1

0

discussed previously (~dams er al.. 1986). and itwas noted that the prevalence of hepatitis Bsurface antitzenemia ws 3.3’’I’Iin the Rongeiap~roup. 1S.8’:’,in the Utirik group. and 10.5% in theComparison group. There is evidence suggestingan association between radiation dose and pre-valence of cirrhosis. but not hepatoma. in SUI+-

t“ors of the atomic bombings in Japan Ifiano etal.. 1982). .%suming that two of the three deathsfrom hepatoma and cirrhosis in Marshalleseresulted from chronic hepatitis B infection, thefrequency of hepatitis B-related deaths. as per-cent of hepatitis B surface antigen-positive per-sons is: exposed Rongelap - (W, (O 2): exposedVtiril.i - 9.5% (~~~11; Comparison group - O’X

(0’ 10).

ADENOMATOUS NODULESAS FUNCTION OF RADIATION DOSE AND TIME

9

o 10 14 18 22 26 30 34

YEARS POST-EXPOSURE

Fig. 4: The time required to develop adenomatous nodules foilowmg radiation exposure appears. m this graph, to

be dose-related. However. the thyroid-absorbed radiation dose was highly dependent on the age at exposure.

12

500W2

●

Autoimrnune thyroid iqjuw

Radiation-induced thyro]a hypofunction.

diagnosed in four[een exposed Rongelap indi-\lduais. was not found to be increased among

.Japanese .4-bomb survivors-. This difference

reflects the larger dose absorbed by thyroids of

the Marshallese. a consequence of ingestion of

radioiodines. The question arises as to whether

thyroid hypofunction in the exposed Marshal-]ese is a consequence not only of direct radiationinjury, but also of immunologic damage. Immu-

nologic studies by the Radiat]on Effects ResearchFoundation found that Japanese A-bomb survi-vors greater than fifteen years of age at expo-sure had a significant decreme in mixed lyre-phoc}le culture response that was inverselyrelated to radiation dose (Akiyama et al.. 19871,and lymphocyte responses to phytohemagglu-tinin decreased more rapldlv with age m per-sons who received more than 200 rad. However.the immunological responses of aging JapaneseA-bomb survivors do not appear to have beenaffected by radiation exposure (Bloom et al.,1988), nor does there appear to be an increase indiseases associated with autoimmunity in theexposed Japanese population.

Immunologic damage to the thyroid ismediated, in part, by circulating autoantibodiesthat are apparently cytotoxic. Antimicrosornalantibodies are important in the diagnosis ofautoimmune thyroid itis. a disease processcommonly progressing to hmothyroidism (Frey,19871. Antithyroglobulin anubodies are far lessspecific an indicaLor of thy~old autolmmune

disease. but are useful as a screening test. Hypo-thyroidism ISoften quite subtle and difficult todiagnose. and any marker that might identi~ apopulation at risk for subsequent hypothyroi-dism would be clinically useful. Therefore 231Marsh allese sera collected in March 1987 were

tested for the presence of antithyroglobulin andant]microsomal antibodies in the laboratory ofDr. Harry Maxon. Fifty-five sera were from theRongelap-exposed. 94 were from Utirik-,exposed,and 82 were from the Comparison group. Two

persons had data consistent with the diagnosis

of autoimmune thyroid disease (Table 4), and

both were in the Comparison group. One was a38-year-old woman who had Grave’s diseasewith hyperthyroidism diagnosed in 1980 thatwas treated with 131 I. Her serum containedboth types of antibodies in 1980 as well as in1987.The other person. a 32-year-old woman,had an antithyroglobulin antibody level of 35U/l. She has Sheehan’s syndrome, present since1975 following postpartum hemorrhage. In .addition, six persons had nondiagnostic butslightly elevated levels of a“ntithyroglobulinantibodies, two from Rongelap and four fromLTtirik. None have clinical evidence of aut~im.

mune thyroid disease, although three have hadthyroid lobectomies for benign nodules. The lackof evidence for an increase in autoimmune thy-roid disease among the exposed Marshallese isconsistent with the findings of Radiation EffectsResearch Foundation studies. In a 30-year fol-10WUPof persons less than 20 years of age at thetime of exposure to the atomic bomings inJapan, no difference was detected in the preval-

TABLE 4: ANTITHYROID ANTIBODIES IN THE DIFFERENTRADIATION EXPOSURE GROUPS.

Elevated antithyroglobulin

Exposure group(n) antibodies” Percent elevated

Rongelap (551 2 42’!

Utirik (94) 4 4’/%’!Comparison (82) Z** 2%

“ The levels ranged between 6 and 11 WI1, with normal levels being= 5 U/1.“” One subject had elevated antlmicrosomal antibodies (35 U/1) and a history of Grave’s dise=e withhyperthyroldism.

500411313

. . ....

ence of antlthyrogiobulin antibodies In unex-posed versus exposed groups {Morlmoto et al..1987). In addition. no difference in the preval-ence of chrome th.yroiditis was found in childrenconsidered exposed or unexposed to radioac-tive fallout in Utah and Nevada [Ralhson et al..1974), Notably, in that study the pre~’alence ofelevated titers of antithyroglobuIin antibodies inchildren with ‘“normal” thyroids was 4.8!’{,.Hypo-th}Toldism is common in aging populations. andm the Framingham Heart Study a clearly ele-vated thyrotropin (TSH) level was found in 4.4’X,of persons older than 60 years (Sawin et al..1985a). The prevalence of antimicrosomal anti-bodies also increases with age: two-thirds ofelderly persons with evidence of thyroid hypo-function had sign~]cant levels of antimicrosomalantibodies (Sawin et al.. 1985b). The .Marshal-Iese data suggest that autoimmune thyroid dis-ease is not common in that population. regard-less of a history of radiation exposure.

NONCANCEROUS THYROIDMORBIDITY IN EXPOSED

MARSHALLESE

Thelatesomaticeffectsofexposureto ioniz-ing radiation have been equated with cancerinduction, the ultimate measure of those effectsbeing expressed in mortality. Since cancer mor-

TABLE 5: I-ATE THYROID

tality from radiation exposure is low whencompared to naturally occurring cancer mortal-lty it is not surprising that there is no observedincrease in mortality among the radiation-exposed Marshallese. Nevertheless. much at-tention has been addressed to their cancer riskOn the other hand, limited attention has been “given to morbidity from nonmalignant disease,principally of the thyroid. as a late consequenceof radiation exposure, and yet these lesionshave been of great clinical importance (Table 5).

.& Thyroid surgeryTwenty-six (30 %) of the Rongelap group and

eighteen ( 1l%) of the Utirik group have hadsurgery for thyroid nodules that were ultimatelyfound to be benign. The types of thyroid nodulesfound in the exposed population since 1963 canbe grouped into cancers, adenomas. and ade-nomatous nodules. Cancers and adenomas areneoplasms. Adenomatous nodules, which, likeadenomas, are benign, are not propedy catego-rized as neoplasms. HistologicaUy, they’ arehyperplastic lesions. In the exposed populationboth benign nodules and thyroid hypofunctiondisplay a similar correlation with radiation doset Fig. 5), and, in contrast to thyroid cancer, ade-nomatous nodules have been very common (seeTable 3). Adenomatous nodules are rarely ofclinical significance, because they do not evolveinto carcinoma. Surgery is necessan only to

MORBIDITY UNREL4TED TODIAGNOSIS AND TREATMENT OF THYROID CANCER IN

253 RADIATION-EXPOSED MARSHALLESE.

Morbid event Number of cases

Thyroid surgery for benign lesions 44

Hypothyroidism. radiogenlc 15

Hypothyroidism. posts urglcal 21

Hypoparathyroldism. postsurgtcal ~

Recurrent laryngeal nerve palsy 1

Pitunary tumor” ~

Total morbid events 85

‘ Possible association (Adams et al.. 1984).

14

Sooulu

exclude that diagnosis. Nevertheless. the clinicalevaluation required to establish a diagnosis isassociated with its own morbidity. Prominent inthis morbidity is thyroid surgery itself, a proce-dure that requmes general anesthesia andresults in a cosmetic defect and the unavoidableremoval of some normal thyroid tissue.

B. Thyroid hypofunction, radiation-induced:Overt hypothyroidism was diagnosed in two

Rongelap boys who were infants at the time ofexposure (Sutow et al., 1965). In addition. sub-clinical hypothyroidism unrelated to thyroidsurgery was confirmed in twelve other Rongelappersons [Larsen et al., 1982). In 1987 a Utirikman was diagnosed as biochemically hypothy-roid. He was two years of age at the time ofexposure. and he is the first exposed personfrom Utirik to have this diagnosis.

C, Hypothyroidism, postsurgical:In 1972 to 1974 it was noted that 11 of 20

exposed persons from Rongelap who under-tvent surgenfor removal of thyroid nodules hadelevated levels of thyroid-stimulating hormonetTSH). Because this evidence of postsurgicalhypofunction was more frequent than expectedit was surmised that thyroid insufficiency mightbe developing in the exposed Rongelap popula-tion as a whole, rather than being limited to thetwo hypothyroid children diagnosed some tenyears earlier (Sutow et al., 1965). Such an eventwas likely to be clinically inapparent because allof that group had been placed on suppressivedoses of thyroxin since 1965 to prevent thyroidneoplasia. Therefore, after temporarily discon-tinuing thyroxin. a survey of thyroid functionwas undertaken. and twelve persons were found

LOhave biochemical evidence of thyroid insuffl-

THYROID DISEASE VS. RADIATION DOSE

100

zz 50=

-0

o

r m BENIGN NODULES 1

1-250 251-500 501-1000 1001-2000 2001-3000 3001-4000 4001-5000

REM

Fig. 5: Thyroid-absorbed radiation dose VS.benign thyroid nodules. carcinoma. and hypofunction.

5004115 15

(,]ency. Retrospectwe testing of six persons \vho

had th\Toid h}~ofunction a&er th}Toid surgeryreveaied the h>_pofunctlon had been presentearlier fLarsen et al., 1982).

The development of thyroid hypofunction m[he exposed indi~lduals continues to be a causefor concern. R’bile the routine use of suppressivedoses of thyroxm should render [his concernmoot. it was noted that. based on medical his-to~ or results of annual TSH testing, somewhatmore than forty percent of exposed personswho are supposed to be taking thyroxin haveevidence of irregular or noncompliance withthe prescribed medication regimen (Adams etal., 1983). It is desirable to minimtze 10SSof thy-roid tissue at surgery insofar as It is deemedclinically safe to do so: in fact. this has been thepractice of the thwoid surgery consultant to the\larshall Islands Medical Program for almost[wentv years.

Desp]te efforts to mitigate loss of thyroidtissue. however. there continues to be evidenceof an inordinantly high frequency of postsurgi-cal thyroid hypofunction among the exposedpopulation. Table 6 shows data obtained through1987 illustrating this point. An increase in fre-quency of postsurgical thyToid hypofunctionw]th increase in the 1954 thyroid radiation doseis apparent, even though all thyroid surgerypatients were advised to take thyroxin. How-ever. the data in Table 6 must represent a min-imum estimate of the prevalence of postsurgicalthyroid h-ypofunction. In contrast to the studyby Larsen et al. ( 19821, thyroxm was not pur-

poseiy discontinued before testing. Therefore.except for those relatively few instances in;vhich seiected individuals were asked not totake thyroxin for four to six weeks prior to thy-roglobulin testing or thyroid scanning, eievated

TSH levels were apparent only because of non-compliance. Some persons may have had nor-mal TSH Ieveis after surgery oniy because theyare adhering satisfactorily to the prescribed[hyroxin regimen.

It is unlikely that the differences in prevalenceof postsurgical thyroid hypofunction among thegroups resuit from different degrees of com-pliance in taking thyroxin after surgery, Furth-ermore, it is iikeiy that. on the average, theextent of resecIion of thyroid tissue was greater]n the unexposed persons undergoing thyroidsurgery than in exposed individuals because ofconcern that the iatter were more iikeiy to haveImpaired thyroid reserve. As Table 6 shows, thisconcern was weii-founded. “Mthough presentdata are without doubt quantitatively inaccu-rate, they are iikeiy to be qualitatively adequate.

The distinction between these data and thoseof Larsen et ai. ( 1982) is that. whereas thyroidhypofunction was found by the latter group toantedate thyroid surgery (as documented byretrospective analysis of stored sera collectedbefore institution of thyroxin suppression in theexposed Rongeiap group), the present datareveai an inordinantly high frequency of post-surgicai thyroid hypofunction in exposed per-sons with previously normal TSH Ieveis. TheImportance of this finding is that there appears

TABLE 6: MARSHALLESE WITH PREVIOUSLY NORMAL TSHLEVELS WHO HAVE DEVELOPED ELEVATED LEVELS

FOLLOWING THYROID SURGERY.

Exposure Adult thyroid Number with Number withgroup dose (rad)” surgery hypothyroidism*” Pement

Rongelap” ● ” 1200 23 14 61

Utirtk 160 25 7 28

Comparison none 11 1 8

“ Average estimated dose for an adult male.- ● Biochemical ewdence of thyroid hypofunction ss indicated by at least two determinations of thyroid stimulat-ing hormone >7.0 uU/ 1. .Norrnal values are less than 6.0 uU/ 1.“•” Routine th~oxin suppression prescribed.

501NHb 16

TObe slgnlficantlv dimmlshea th}’roid reser~’e mmany exposed persons. and. although this dim-inution ]s not apparent from routine TSH test-ing, it frequently may be made clinically signifi-

cant by thyroid surgery. The extent of theproblem cannot be accurately assessed with thedata at hand because ot’ the variability in com-pliance with the taking of the prescribed thy-roxin suppression, and because no clinicalbene!it would accrue to the exposed populationfrom discontinuing thyroxm for the purpose ofproving the point. Nevertheless. a 61!7, preval-ence of postsurgical thyroid hypofunction isreason for great concern in tiew of the highfrequency of benign thyroid nodules in theexposed population.D. Postsurgical hypopsrathyroidism:

In two thyroid surgery patients transientpostsu rgical hypocaicemia was observed. How-ever. two other Rongelap women developedchronic hypoparath.moidism requiring replace-ment therapy since undergoing thyroid surgery.In one the deficiency was diagnosed postopera-tively and has not resolved. In the other thediagnosis was first made. twenty years followingsurgexy. Both surgeries were performed onGuam during the early years of the medical pro-gram. Postsurgical hypoparathyroldism is notan unusual complication of extensive thyroidsurgery, occurring in up to 20Xof patients. How-ever, in experienced hands the frequency ofpostsurglcal hypoparath.yroidism is much lower.

E. Laryngeal neme iqjuwOne Rongelap man has a mild but definite

impairment in speech resulting from recurrentlaryngeal nerve injury, a well-known complica-tion of thyroid surgety. This is not a commoncomplication, occurring in perhaps l!% ofpatients. i% with postsurgical hypoparathyroi-dism, its frequency depends greatly on the expe-rience of the surgeon and the extent of thesurgery.F. Pituit.my tumor formation:

Two women exposed as young children, onefrom Rongelap and one from Utirik. have deve-loped pituitary tumors. These tumors are usu-ally benign, causing disease. in part, because oftheir expansion inside a rigid structure. There isno known direct association between radiationexposure and development of pituitary tumor,but there are reasons to suspect that pituitawtumor formation may be a consequence of thy-roid injury (Adams et al.. 1984).

In summary. hypothyroidism and subclinicalthyroid hypothnction. benign thyroid noduleformation. thWoid surgew with its attendantrisks and complications. an excessive preva-lence of thyroid hypofunction after thyroidsurgery, and possibly pituitary tumors can beconsidered adverse delayed consequences ofradiation inju~ in the exposed Marshallese. Thetally comes to 85 morbid events in 253 persons.In contrast. the only evidence for a “stochastic”effect of radiation exposure has been anincrease in thyroid cancers in the Rongelappopulation, none of whom yet have evidence ofresidual disease. While several nonthyroidalcancers known to be inducible in humans “byexternal ionizing radiation have been docu-mented in the exposed population, similarcancers have occurred in the unexposed Com-parison population of Marshallese. Therefore,one may conclude that in the Marsh allese expe-rience the delayed expression of nonmalignantmorbidity due to irradiation has indeed beengreat and far exceeds that of malignant disease.

REVIEW OF CANCER IN THECOMPARISON POPULATIONIn earlier BNL publications neoplasms of the

exposed population were compared to those ofan unexposed “Comparison” population with asimilar age and sex distribution. However, since,the last report. which brought the period ofmedical coverageup to December 3 lst, 1984,concerns have been voiced about present-daysafety of habitation on Rongelap island. Ananalysis of the current radiation risk of Ron-gelap habitation is not a function of the MarshallIslands Medical Program. which is a clinical pro-gram devoted to aspects of health care for per-sons acutely exposed to radioactive fallout in1954. Nevertheless, medical information col-lected over many years concerning the unex-posed Rongelap people has been requested bydifferent groups who are involved in assessingthat risk. To assist them and others who maywish to review the medical experience of theComparison population, a summary of diag-noses of neoplastic disease is presented here. Itis essential to realize that whatever radiationrisk exists today on Rongelap is quite distinctfrom that incurred by 86 Rongelap inhabitantsand 167 Utirik inhabitants during the two-dayexposure to Bravo fallout in 1954. The reasonsfor this statement are given below.

5004111 17

The selection of the Comparison woup beganin1957at Majuro when the group was initiated~rlth .96 individuals matched approximately forsex and age with the exposed group of 86 indl-\~duals, }Iembers of the Comparison group wereexammed periodically thereafter at Rongelap orelsewhere along with members of the exposedRongeiap population. During 1958-59, after thereturn to Rongelap island. the number of per-sons actively enrolled in the Comparison groupwas increased to about 150. During the followingyears up to 1974, another 31 persons wereadded. In 1974-76, to make up for more personslost to followup or deceased. another 32 personswere added. No additions to the roster havebeen made since that time. When all enrolleesare tallied, including those who have discon-

tinued their participation in the annuai medicalexammations, 227 persons have been exammed

at one time or another as part of the Compari-

son group. Although some of the group were lost

to followup, there were 63 deaths recorded

through 1987. Some deaths may have occurred

In those lost to followup that were not brought

to the attention of the Marshall Islands Medical

Program. Furthermore, the death rate in subse-quently added subgroups may not be the sameas that for persons in 1957. There IS no way todetermine if there is any bias introduced intomonality statistics as a consequence of theseevents which were beyond the control of theprogram. However. two points can be made.First. since it is cancer mortality which is specif-ically in question. cancer deaths can be expres-sed in terms of total known deaths. thereby con-trolling to some extent for uncertainties in thedetermination of total deaths. Therefore, on thebasis of information made available to the Mar-shall Islands Medical Program. 8 of the 63known deaths ( 13!7,) may have been due tomalignant disease. In the United States cancermortality accounts for 22’% of total mortality(Silverberg and Lubera, 1987), and in theexposed Rongeiap group it accounts for 19X,oftotal mortality (5 of 26 deaths). Second, cancerdeaths can be expressed in personl years ofobsenation, thereby controlling somewhat forpersons lost to followup. When this is done thecancer death rate for the 33-year observationperiod is 171/100,000(8 possible cancer deathsin 4669 person lyears) for the Comparisongroup overali and 187/ 100,000 (4 possiblecancer deaths in 2136 personl years) for the 86

persons in the original 1957 Comparison group.The slmilarityof these numbers does not suggestthe introduction of bias in death rates in subse-quent additions in the Comparison population.For the Rongelap exposed population. \vhichwas statistically similar in age and sex distribu-tion to the Comparison group when evaluated in1982 (Adams et al.. 1983), this number is234/ 100.000 ( 5 possible cancer deaths in 2139personi years). The confirmed or presumptivecancer diagnoses in the Comparison group aregiven in Table 7, along with cancer deaths in theexposed Rongelap population.

Table 8 contrasts the distribution of possiblecancer deaths in the Comparison group accord-ing to years of residence on Rongelap with thatoft he exposed population. One of the eight per-sons dying of possible cancer in the Comparison

grouP WaS never known to be present on theisland. Furthermore, six of the eight spent only ashort time on Rongelap. However. for those sixthat short time lay between 1958 and 1961, aperiod when residual radioactivity would havebeen higher than in subsequent years. Onehundred fifty-one persons in the Comparisonpopulation were known to be on Rongelap atsome time between 1958 and 1961. Of the sixthat ultimately died of possible cancer, fourwere among forty-two who were not on Ron-gelap after 1961, whereas two were among theone hundred-and-nine that were seen on Ron-geiap at a later date (Table 9). It is a statisticaloddity that even the latter two individuals werefound on Rongelap only once after 1961.

There are several points that are relevant forthose who would apply an epidem]olog]c analy-sis to these data

1. Since the Marshall Islands Medical Programhas not maintained a year-round medical pres-ence on the different atoUs where examineesmay be found. causes of death were obtained inmany instances from records and verbalaccounts of health aides and family membersliving on those atolls and from records anddeath certflcates at the Ebeye and Majuro hos-pitals. Autopsies are rarely performed in theMarshall Islands.

2. Of the eight deaths that clinically may havebeen cancer-related. confirmation by tissuediagnosis is available in only four. In the exposedRongelap population only three of the fivedeaths attributed to cancer were confirmed.

500411818

Table 7 presents Iimlted information relevant to

[he diagnosis of the cancers m the Compatuson

group+ but all 8 cases have been desmbed in:reater detali in this or earlier B!NLreports.

3. The mosr frequent lethal cancers m the Uni-ted States are lung, breast. colon and leukemia. -Iymphoma.

4. Areas where health care is limited often haveincreased mortality from noncancerous disease.and an increase in cancer incidence has been\tiewed as e]~dence of improved overall health ofsome populations because it reflects improve-ments in longevity.

5. Table 7 lists only cieaths that might have beenrelated to cancer. There have been two cases ofthyroid cancer that have been diagnosed. Thethyroid cancers, discussed elsewhere In thisreport, have not been a cause of death. and at

[he present time there is noevidenceof residuaidisease in either of the thyroid cancer patients.

6. In attempting to determine whether therehas been an increase in cancer deaths in eitherthe exposed or Comparison poptdation oneshould note a Radiation Effects Research Foun-dation report on the Japanese exposed to atom]cbombing. From 1950 to 1985. there had been.5936 cancer deaths among 75991 persons in theLSS (Life Span Study) cohort. Three hundredand forty of the cancer deaths ( 6’Lof the totalcancer deaths) are thought to be attributable tothe 1945 radiation exposure (Preston andPierce. 1988). The small size of the exposed andComparison Marshallese groups, the smallernumber of cancer deaths, and naturally occur-ring fluctuations in disease incidence will makestatistical detection of any excess cancer mor-tality Impossible in these populations.

TABLE 7: POSSIBLE CANCER DEATHS IN THE RONGIXA.PEXPOSED AND COMPARISON (UNEXPOSED) POPULATION

Yeu of Age at Yeara on CancerIDU Death Death Rongelap” Type Confirmation

A COMPARISON GROUP842 1986 61 ~ ? Hepatoma Not avadable

S46 1986 63 4 Leukem:a Yes

861 1960 68 ~ Cervix No. Normal pelvic exam in3/59.

S89 :980 55 ,> Breast yes

975 1985 65 > ‘? Lymphoma “~typical Iymphoeplthelioid

proliferation”

1005 19s4 51 2 Lung Yes (Smoker)

1050 1985 50 2Q*. ? Colon No

1571 1982 28 ()*.. Astrocytoma Yes

B. RONGELAP EXPOSED62 1959 60 2 Yea

30 1962 60 5 Cervix 30

13 1966 71 9 Uterus !VO

54 ~972 19 7 Leukemia Yes

68 1974 64 16 Stomach Yes

“ Years of remdence on Rongelap after rehabitation of RongeIap isiand in 1957, u recorded in the medicalrecords of the .Marshall Island Medical Program or from personal history.“” .4dded to Compar~on group m 1964: did not live on Rongelap between 1957 and 1964“““ Added to Comparison group m 1976: res]dence prior to 1976 is not recorded.

19

500 UIVJ-.

TABLE 8: DISTRIBUTION OF POSSIBLE CANCER DEATHSACCORDING TO YEARS OF RESIDENCE ON RONGEIAP

Years on Number of Possible Cancer

Rongelap Persons Deaths

.+. COMPARISON GROUP1).~ 135 75-9 -$0 ()10-14 20 ()15-19 13 ()20-24 10 125-28 9 0

Total ~~7 8 ( 13”,, of recorded deaths)

B. RONGELAP EXPOSED()-4 9 1)

.5-9 10 1)

10-14 12 1

1.5-19 1:3 020-24 :30 3‘25-28 10 1

Total 83 5 ( 19{, of recorded deaths)

TABLE 9: COMPARISON AND EXPOSED GROUP– CANCER DEATHS

No. in Total Cancer Age atGroup Group Deaths Deaths Death

.-!. Comparison ~~7 6:3” 8 ‘28-68

.+.1 Resident on Ron~elap on@

during “57-’61 42 12 4 55-68

.A.2 Resident in ‘57-’61 and forsome time thereafter 109 32 ~ 51.63

A.3 Resident oniy am “57-”61 47 5 1 50

A.4 Ne\@r on Rongelap 29 13 1 28

B. Exposed in 1954 86 ~~.. 5

B.1 Like .4.1 8 3 1 60

B.2 Like .+.2 73 ’20 4 19-71

B.3 Like A.3 1 0 0

B.4 Like .+.4 1 0 0

- One death occurred five months after return to Rongelap.-” Three deaths occurred prior COreturn to Rongelap in 1957.

REFERENCES

Adams. U’H.. Harper. J.A.. Rittmaster. R.S.. and Grim--on. R.S. 1984. Pitu]tarvtumors follow]nz fallout radiatlon exposure. J. Amer. .Ved. ASSIX. 252:664-6.

.-ldams. \V H.. Harper. J. A.. Rittmaster. R.S.. Heous.PM.. and Scott. W.A. 1983. Sfedical Status of ’,tfarshal-lese Aco”den taliy Exposed to 1954 BRAVO FalloutRadiation: January 1980 Through December 1982.BNL 51761.

Adams. W.H.. Fields. H.A., Engle. J. R., Hadler. S.C. 1986.Serologic markers for hepatlcls B among Marshalleseaccidentally exposed to fallout radlatlon In 1954.Radiat. Res. 108:74-9.

.Idams. W’.H..Harper. J.A.. fieOLIS. P.M.. and Jamner.

.\,H. 1984. Hyperuricemla in the inhabnants of the\larshali Islands. Arthritis Rheum.. 27:713-6.

.Idams. W’.H..Engle, JR.. Harper. J..%..Heotls. P.M..andScott, IV.A. 1985. Medical Status Vi Marshailese

.-lccidentally Exposed to 1954 BRA VOFallout Radia-tion: January 198S through December 1984. BSL.51958.

.\dams. tV.H.. Kindermann. W’.R.. \Valis. K.~V..Heotls.P.M. 1987. Toxoplasma annbodles and retmochoroi-ditis in the !larshall Islands and their associationwith exposure to radioactive fallout. Am. J, Trop..Ifed. H,yg, 36:315-20.

Akiyama. \f.. Zhou. O-L.. Kusunoki, Y.. Kyoizuml. S..Kohno. X.. Akiba. S.. and Delongchamp. R.R. 1987..~ge- and dose-related alteration of in ~ltro mixedlymphocyte culture response of blood I}mphocytesfrom A-bomb survivors. Radiation Effects ResearchFoundation Tech. Rept. TR-19-87.

.\sano. \l.. Kate. H.. Yoshimoto, K.. I:akma. S.. Ham-~da. T, and [ijima. S. 1982. Pr]mary Itver carcinomaand liver cmrhosts in atomic bomb surwvors, Hiro-shima and Nagasaki, 1961-1975, wnh special refer-ence to hepatit:s B surface antigen. J. .Vatl. CancerInst. 69:1221-1227.

BerAey, R.P.. Hwang, L.-Y.. Lin. C.-C., and Chien, C.-S.1981. Hepatocel]ular carcntoma and hepatitis B virus.L.ancet 1:1129-32.

Bloom ET.. Akiyama. M.. Kern. E.L. Kusunoki. Y..Makmodan. T. 1988. ImmunologIcal responses ofaging Japanese A-bomb survivors. Radiat. Res.116:343-55.

Bond. \’.P.. Conrad. R.A.. Robertson. J.S. and Weden.E.A.. Jr.. .Ifedical Examination of Rongelap PeapLeSiz .tfonths A@?r Exposure at Fallout. WT.-937.Operation Castle Addendum Report 41.A. April 1955.

Conard. R,A, 1984[slanders exposed

50041

Late radiation effects m Marshallto fallout twenty-eight years ago.

In: Radiation Carfl”nogtmesis. Epidemiology andBioicgic Significance. PP 57-71.1301ce..f.D..Jr. andFraumem. J.F. (Editors ~.Raven Press inc.. Sew York.

Conard. R.A.. Paglia. D.E.. Larsen. P.R.. f?L al. 1980.Review oJ”.\fedical Findings in a Marsha tlesei%pula-

tion T&tq-Six Years After Accidental Exposure toRadioactive Fallout. f3NL 51261.

Conard. R.&Cannon. B.. Huggins. C.E.. Richards. J. B..and Lowrey, A. 1957. Medical survey of MarshalleseLWOyears tier exposure to fallOIJt radiation. ~. Amer.Med. Assoc. 164:1192-7.

Conard. R..+.. .Meyer, LX. RalL J.E.. Lowery, A.. Bach,S.A., Cannon. B., Carter. E.L.. Either, M.. and Hechter,H. 1958. .tfa rch 1957 Medical Survey oJ-Rangelap andLlin”k Peopie Three Years After Eqasure to Radioa.c-(itv Fa/lou~ BNL 501 (T-1 19).

Cronkite. E.P.. Bond. \’.P., Conard. R.A.. Shulman. N.R..Farr. R.S.. Cohn, S.H.. Dunham. C.L, and Browning,L.E. 1955. Response of human beings accidentallyexposed to signitlcant falfout radiation. ~. Amer. MA.-lssoc. 159:430-4.

Cronkite. E.P., Bond. VP.. and Dunham, C.L 1956.Some Efy=ts of Ionizing Radiation on HumanBeings. AEC-TID 5358.

DunKv, C.I.. Morgan. B.C.. Heotis. P..M..Branson. H.E..Adams. \V.H. 1987. Normal hematologic values andprevalence of anemia in children living on selectedPacific atolls. Acts Haematol. 77:95-100.

Frey, H. 1987. Circulating autoantibodies in thyroiddisease. Actu Med. Stand. 222:289-91.

He~ard. iV L.. Lanier. A.P.. Cartter. M.L.. McMahon.B.J.. and Bender. T.R. In: Wh-ai Hepatitis and LiverDisease. \“yas. G.X.. Dienstag, J.1+ and Hoofnagei. J. H..eds. Orlando. Florlda. Grune and Stratton. Inc.. p.663-4.1984.

Lang W.. Borrusch, H.. and Bauer. L 1988. Occultcarcinomas of the thyroid: Evaluation of 1020sequentmi autopsies. Aw. J. Clin. Pat.hd 9072-6.

Larsen. P.R. Conard. R.& Knudsen. K., Robbins, J.,Wolff. J.. WI, J. E.. ?Jicoioff. J.T., and Dobyns. B.M.1982. Thyroid hypofunction after exposure to faUoutfrom a hydrogen bomb explosion. J. Amer. Med...kWC.247:1571-5,

Lessard. E.. .Miltenberger, R.. Conard. R.. .Musoiino. S.,Naidu. J.. Moor-thy, A.. and schopfer, C. 1985. l?L@-Absorbed Dose for Pev@ at Rart.geiap, Llink. andSifo on March 1, 1954. BNL 51882.

Maisei. J.Jf.. Pearlstein, C.S.. Adams, W,H.. and Heotia,P.M. Large optic disks m the MarshaUese population.Am. J. Oph.#tnlmoL 107:145-1.50.

!!lonmoto. 1.. Yoshimoto. Y.. Sate. K.. Hamilton. H.B..‘Kawamoto. S.. Izuml. M.. and Sagataki. S. 1987. Serum~H, thyroglobulin. and [hWold disorders in atomicbomb sunwors exposed in vouch: 30-vear follow-upstudy. J. .Vucl. Med. 28:1115-22.

IIkajima. S.. Mine. M,. and Nakamura. T. 1985. Nortal-,ty of registered A-bomb surwvors m Nagasaki. Japan.1970-1984. Radiat. Res. 103:419-31.

Preston, D.L and Pierce. D.A. 1988. The effect ofchanges in dosimetry on cancer monality risk esti-matesin the atomic bomb surwvors. Rad. Reseamh114:437-66.

Rallison. M.L, Dobyns, B.M., Keating. F.R.. Rafl. J. E.,and ~ler. F.H. 1974. Thyroid disease m children: Asurvey of subjects potentially exposed to fallout radi-ation. Aw. J. Med. 56:457-63.

Robbins. J.. and Adams, W.H. 1989. Radiation effectsm the Marshafl Islands. Elsemer Publishing Co.. mpress.

Sampson. R.J. !detastatic occult follicular thyroidcarctttomz 1976. J. Aw. .!fed. Assoc. 236:1693.

Sawm-t. CT.. Bigos. S.T.. Land. S,. and Bacharach. P.1985a. The aging thyroid: Relauonship between ele-vated serum thy’rotropin level and thyroid antibodiesin elderly patients. Amer. J. Jfed. 79:591-5.

Sawm. CT.. Casteili. W.P.. Hershman. J.!d.. McNamara.P.. and Bacharach. P. 1985b. The aging thyroid: ??Ly-rmd def&iency in the fiamlngham Study. 145:1386-8.

Schneider. AIL, Favus. M.J.. and Frohman, LA. 1980.Nodules in irradiated thyroids. .V. Engl. J. Med.

302:1148-9.

Silverberg, E., and Lubera. J. 1987. Cancer ,statiatics.1987. Ca-A Cancer JoumalJor Clinicians. 372-19.

Sutow, W.W.. Conard. R.A.. and Griffith. K.M. 1965.Growth status of children exposed to fallout radia-tion on Marshall Islands. Pediatrics 36:721-31.

Wlelopolski. L.. Adams. W.H.. and Heous. P.M. 1986.Blood bromine levels in a Pacific atoll population.Envtron. Rx+. 41:91-8.

.>.9

.-

5004122

APPENDIX APROFESSION& STAFF PARTICIPATING IN THE

1985-87 MARSHALL ISLANDS SURVEYS

PARTICIPATINGNAME SURVEY SPECL4LTY AFPHJATION

Adams. \V.H.

.+nderson. J.

Arelong, T.

Barclay, P.

Benes. S

%evcioun. S

Bliss, M.

(’heatham. if”

Dec. W’

[)obvns. R

Engle. J

Ferguson. F.

Giorglo. R

Giorg]o. L.

Greene. G.

3,85. 985. 3 869/86. 587. 987

5/87

3,’85, 9’85. 387

5i87

3/’86

:3T85, 9’87

3 86

:1 86

.1 85

3/85. 9{85, 3 86

9’85

:) 85, .5 67

3.’85

9/85

Internal Medicine(Hematolo~J

Internal Medicine(Geriatrics)

Nurse

Internal Medicine(AIlergylmmun. I

Ophthalmolow

Obstetrics; G:n.

Internal Med]cme(Gastroenteroiogy)

Internal !dedlcme(Endocrlnolow )

Internal \ledlc]ne(Cardiology )

Surgery

Famdy Pracuce

Pediatr]c Dentistry

G-yn. Surge~

Nurse

Pediatrics

23

500$123

Brookhaven Natl. Lab.Upton. NY 11973

NY Bellevue Div. ofGeriatric MedicineNY. NY 11016

Armer Ishoda MemorialHosp., Majuro. Ml 96960

Central General Hosp.Plainvtew. NY 11803LDirector, EmergencyPhysicians)

Ohio State UniversityMedical SchoolColumbus, OH 43210

Univ. of MiamiSchool of MedicineMiarnLFL 33101

Boston City HospitalBoston. ,MA02118

Walter Reed ArmyMedical CenterWashington, D.C. 20012

Harvard Medical SchoolMass. Gen. HospitalBoston. MA 0211-1

Case \Vestern Resene L_nw.Cleveland Gen. HospitalCleveland. OH 44109

Vet. Adm. Med. CenterMartinsburg, W’ 25401. .(tormeriy BNL ResidentPhysician stationed atKwajalein )

School of Dental MedicineState Univ. of Sew }“ork atStony Brook. NY 11791

Private PracticePearl City, H] 96782

Peari City, HI 96782

Univ. of CaliforniaIrvine .Medical CenterOrange, CA 92668

NAMEPARTICIPATING

st.m7zY SPECLALTY AFFILIATION

Harper. J.

Jacobs. D.

Jensen. L.P.

Kabua. J.

iiehne. S.

Kindermann. R.

Lakshmanan. M.

Landsberger, E.

Langrme, H..

MacKay, D.

WiseL J.

!4axon. H.

McClintock. C.

.Melkonlan, R.

MelIan. M.

Pacifico, A.

Panebianco. R.

Rittmaster, R.

9 66

3 86

:3 85

3, 85. 985. 3)’869/86. 5 87. 986

:3 85. :3 86

:3 85

3/ 86. 5 87

386

3,85. 985. 3)’86

5/87

3/85

5/87

3,85

5/87

5/87

5i87

3/’85

3/’85

Famliv Pracr[ce

Surse

Obstetrics/Gyn.

Yurse

Internal Medicine(Pediatric Neurolo~)

Ophthalmology

Internal Medicine

Obstetrics/Gyn.

Nurse

Internal Medicine(Infectious Diseases)

Ophthalmology

Internal Medicine(Nuclear MedicineThyroldology)

Internal Medicine(Gastroenteroiogy)

Obstetrics/Gym.

Nurse

Internal Medicine(Cardiology)

Internal Medicine

Internal Medicine(Endocrinology)

Private Pract]cePortland. XIE 04103(formerly BNL ResidentPhysician sratloned atKwajalein }

.\rmer Ishoda ,Mem.Hospital. Xlajuro, MI 96960

University of MiamiSchool of Medicine%liami,FL33101

Ebeye.Marshall Islands, 96960

Boston City HospitalBoston, MA 02118 -

Private Pratt iceCherry Hill. NJ 08003

Natl. Institutes of HealthBethesda MD 20892

Albert Einstein College ofMedicine, Bronx, NY 10461

Armer Ishoda Mere.Hospital, Majuro. MI 96960

Dartmouth-HitchcockMedical CenterHanover, NH 03756

State Univ. of New York atStony Brook NY 11791

University of CincinnatiMedical CenterCincinnati. OH 45267

Boston City HospitalBoston, MA 02118

Stony Brook Univ. HospitalSUNY at Stony BrookNY 11791

Armer Ishoda Mere. Hosp.Majuro, Mashall 1s.,96960

Baylor College of MedicineHouston. TX 77030

.Private PracticeSouthampton, NY 11968

Natl. Institutes of HealthBethesda MD 20892

.

(Formerly BNL ResidentPhysician stationed atKwajalein)

,-

500!/24

PARTICIPATINGSAME SURVEY SPECIALTY AFFILIATION

$[e\vart, D. 9 8.5 Pediatrics Univers]tv of California[r\ine Medical CenterOrange, CA 92668

Symes, D. .5 87 Ophthalmology Pritate Pratt iceTucson. AZ 85718

1“golini. 1“ .5 87 Internal Medicine University of Texas(Cardiology) - !%uthwestern Medical Ctr.

Dallas. TX 75235

\Verth. \’. 3 86 Internal Medicine New York Uni\w-sity(Dermatology) Dept. of Dermatology

NY. NY 10017

UWams. K. 3’86 [nternal .Medicine Cornell LTniversnyDepartment of MedicineNY. NY 10032

.

500! 125

SAME

TECHNICAL SPECIALISTS PARTICIPATING IN THE1985-87 MM?SHALL ISLANDS SURVEYS

P.4RTICIPATIXGSURVEY AFFILIATION

.Idams. Diana

Anklen. Risong

Boyd. Lindora

Bulbs. James Jr.

defhum. Reynoid

Duhaime, Susan

Emos. Helmer

Gideon. Kalman

Heotis. Peter

Heinrlchs. John

Jacob, Stanley’

Lehman. l!’i]li~

Saul. Joe

Scott, Wiiiam

Shonlber. Sebio

Stra%lno. Michaei

Tommy. Morris

:1 85 Medical DepartmentBrookhaven National LaboratoryUpton. .NY 11973

.1 85. 5 87

9 85

.1 86

.1 85. 9 85. 3 S69 86. 5 87, 9 87

5 87

3 85. 985. 3 86986. 5’87, 987

.1 86

.3 85. 9 85, 3 869 86. 5 87. 9 87

5 87

1 85. 3 86

9/86, 5:87, 9/87

3;85, 9/85. 3’86

3/85, 9/85. 3;86.5,’87. 9187

1 85 9 85, 587

:3 85. 9 85, 3 86

5 87. 9 87

Armer Ishoda Memorial HospitalMajuro. Marshall Islands 96960

Medicai DepartmentBrookhaven Nationai LaboratoryUpton. NY 11973

Medical DepartmentBrookhaven National LaboratoryUpton. NY 11973

U.S. Depanment of EnergyMajuro. Marshall Islands 96960

Stony Brook University HospitalState University of Sew York atStony Brook, NY 11791

Medical DepartmentBrookhaven National LaboratoryStationed at Ebeye, Marshall Islands

Armer Ishoda Memorial HospitalMajuro. Marshall Islands 96960

Medical DepartmentBrookhaven National LaboratonUpton. NY 11973

Medical DepartmentBrookhaven ?Jatlonal LaboratoryL’pton. XY 11973

Ebeye HospitalEbeye, Marshall Islands 96960

Medical DepartmentBrookhaven National LaboratoryUpton, NY 11973

Armer Ishoda Memorial Hospital!’vlajuro. ,Marshall Islands 96960

Medical DepartmentBrookhaven National LaboratoryUpton. NY 11973

Armer Ishoda Memorial HospitalMajuro. Marshall Islands 96960

Medical Department (Retired)Brookhaven National LaboratoryUpton. NY 11973

Armer [shoda Memor]al HospitalMajuro. Marshall Islands 96960

APPENDIX B

lndii~dual Marsnallese Iaboratorvdata collected durm~ the 1985.1986. and 1987 medical surveys. ( Idenuficatlon

numbers i to bti belong to exposed persons 01 Roneelap and Ailingnae. numbers begmnmc at 21(P belong to the1“[irlk exposed

.+bbreviations:

[’ID =

sEX =

.-lGE =

W13C =

PMN =

BAND =

L134PH =

MONO =

EOS =

BASO =

f’LT =

Ha =

RBC =

)1(X’ =

HGB =

TSH =

PRL =

T4 =

TPR =

.4LB =

GLOB =

.4/G =

CAL =

FBS =

HBAIC =

numbers t’rom 805 through 1.578 belong to the Comparison group).

EWookhaven National Laboratory Identllicatlon number

1 - Male: 2- Female

years

leukocyte countl PI

neutrophii countt PI

band formsj p]

Iymphocvesjul

monocytesl PI

eosinophiis/ pl

basophils/ PI

platelet count x 1(Y MI

percent

e~hrocytes x 10~‘d

mean corpuscular volume In fl

hemoglobin level in g d]

thyroid stimulating hormone level m ~U I

serum prolactin m ng: ml

thyroxine in ~g/ dl

total protein in g d]

albumin in g) dl

globulin in g~dl

albumin jglobuiin ratio

calcium in mg/dl

fasting blood sugar In me dl

glycosylated hemoglobin A 1C in percent

27

Cn

m

a

l---. .-

PID

24

:9

::141610

::

::aiaa2324273436373040414a

::0183080007717a?476707?’7870838688

846

%al84

2ioa2103alo4aloe2100

SEX AGE

; %I 33I 001 6a1 66a 40a 60a 391 712 36a 931 37I 38a 34a 471 36a 48

: %1 301 8a: .4:

1 73a 341 36a 4aa 40a 07a 33a 61a 4Sa 88a 3@a 47a 43I 4aI 60a e71 71I aa1 31a 31a 33a 03a 30a 48a 411 30I 4a1 75a.B51 ?71 30.

COtiPUTER LISTING OF 1986 ltAW DATA‘r4

10.4

6.2

3.97.9

B.(I

14.29.44.3

11.()

13.818.80.96.1

0.6

12.112.40.2

NBC PnN BANDLYMPH HONO E08 IIASOPLT HCT RBC MCV IIGB TSH Pul.

7000 4808 168 21339800 emo 90 aeeo6100 2Bea O 2989

0000 3033 2001 828

70 224 42.9 4.4595 11344f3.1 6.a6

O 201 42.7 4.6\

96 15.088 14.996 14.1

16.600.206.006.803.202.006.100.30

36.0017.00a.600.90

t)8.008.202600.30

452.223

11.9

3.0a.7a.e

21.70.3

18.115.012.94.8

17 213.0

3.11.3

11 1

316870a44

13862Baaa2043B63aa38428B:::

I 72i2a

200aa6I 60372

3::08

130308100320148

i 9:ao4

7s38038034Ba28

310190308

270aio304308

8940

la8399438

04304a7

618Bae1BO03

410I 8049

0aoa31

60448

01186338a721604s0304207114aeo

842343903a4

862808604B013210sI ae670

01@4

a 30370

—

r-a

CDO 246 43.6 4.460 270 48.4 8.300 410 40.3 4.a7o aae 34.3 3.490 300 4a.1 4.400 320 43.8 8.88

(I4 190 40.0 6.040 313 30.6 4.310 202 48.1 6.980 292 B1.1 B.78oaao 41.1 B.04O 2t31 4~.6 6.80

98 15.284 14.894 13.2ee 11.704 13.874 13.993 la.992 la.776 14.3aa 16.48a 13.790 12..9

10BOO7600610000004000840067007300aaoo43000100

7a4B3408a8603@lea4843770307846a06088a0a32748

1067081

013826617173aa43

12a

2416W&

4s391010179a1707ao442a96]03a2f104

2.903.10

10.60

740078007800Oaoo4100eaoo4000eBoo7700600004007400680040000800700070007eoo0900

114006000B40078007900640000007000

1 I 0004800000036004aoo480004000700

3700362B40803600aoeo33481ma37704488a700a40e3330333a2406346841e7aaoo6016a7eoaaoa18003684312046aaa60a404460408010a34033062a7B2004200446308402

02a639018041

040

00

10004

0ao4

48ao4316

00

8934a

olea

7:00

36033013B

:4a

] oao

a91

aalaaQaD2416198414702294a84aao80a096ao60307239aaao40la80a86a300 I330019003460a608a70016084368a44t3ao6a36a611901210130Ba904

980I 3oa1776327024a6

$’4202 38.7 4.2476 a43 43a 4.s6

o a39 34.3 3.48

91 13.899 14.898 11.7

0 27a 47.3 4.69 101 16.6 6.008a aoo 39.3 4.10 90 13.8 6.70

Iae 3ao 40.4 4.a7 93 la.4 6.000 208 42.4 4.63 94 13.9 3.900 186 44.0 4.01 9B 13.9 e.ooo a31 4e.7 6.11 91 16.a 3.100 280 46.8 B.40 86 14.8 0.200 a44 43.8 4.81 91 13.4 0.000 388 41.2 4.68 90 13.7 3B.00o am 39.0 4.a4 94 13.1 4.00

43

6,04.61.03.2

N3.8

30.3396,06.3

2a.3

:::

4.94.74.94.3

[ACD

48 200 33.6 i.’?3o a41 38.7 4.aoo aon 41.1 4.aoo lee 38.7 4.}9O 396 39.7 4.39

W 304 47.6 6.300 a48 41.9 4.60

60 1B6 43.6 4.410 334 40.3 4,a4o 3ao 40.0 4.030 148 47.8 B.14O 206 46.7 4.78

90 10.89a ia.798 13.3@a 13,090 13.0,90 16.193 i3.a99 14.895 13.a09 13.393 16.898 10.B

108.0010.30

3,ao8.603.803.40

13.103.304.003.004.00a.80

aoo

::3QB3a4344140

0a26198140I ae1oa604388

346768

0 346 48.0 6.14 96 14.80 a3a 31.1 3.3a 9a 10.8 4.000 ale 31.B 3.82 87 10.0 l:.?: 69.9

4B a98 34.7 3.0’7 06 Ia.1 6.a

o 300 43.4 4.01 04 14.3 9:800 all 36.0 4.a4 86 la.3 3.BO 6.70 400 38.7 4.31 90 13.0 6,30 10.4

0 199 60.0 6.28 96 16.0 3.00

84 380 48.6 4.92 00 16.8 1.60

0 281 43.7 4.48 98 13.8 3.906.40

0 310 41.a 4.68 90 13.1 3.900 313 49.8 6.79 M 16.9

i 1600Iaeoo

73606790

028a

a9906410

PID

alo721082110all]at13al14aile9117a]iealasala4alaoalaeala9a]302134almai37a13eai39ai40a14aa143a146a147

.a148a]49aleoaiaa2183aieealoea188aleoaleoaleaaieealeealtna}71a17aa174a17eal?ealaaa188aleoa193alcma]eea197aaooaaoeaao8aao7

6EX !

a1

:a

ImII

:aaa1

:a

:aaaaa111

WBC

Iaeoo7aoo78008QO0eaoo84000600,Cmo8400eooo88000700eaoo800001008700aaoo0000

1080088006400

I I aoo040001008300@BOOB800930086004000eaoo0400700081008000?400780078007800080071008800080081004000880084006900070008000300eaooeaoo0200

Ioloo

PMN

7aee403a46800340ea40a77a

49903948aaoo4ee43a833834::~

1740418a3300001633804090710833a8aeaa1aoaeaa6aoltl608030803470awm30044830s4a7Baoo401430003060374460166041033031a8;;::

4400ema41303484aaeo3160

478446086069

COMPUTER LISTINGBAND LYNPII MONO

78a144I Be

o0

aee

80

%88

e:

::87

000

860

Ila

1a:83

380

18:6849

000

a43aao148

78

3::4a814a

0:00

178108a06

076603

1::404

3008a808aaeaacwoaa14S040

ao?eaefiwa)eo33443149ao4ea3aoIaal8608a64aaa80aaooa408179a347aa304aaol318034aoa430a88318801078310aao481810aloe1440aaao3888af3e43198aalo”1633le7a3400ae7s.a67eaaie

76e1475a747318Sa487

3e803t38e3a3a

3B4o

3ia440410laa

4a@4aoI aoeleI 3437a6eoa443483aaI aoaloaeo3aoIIa384a44189ama90I ae33014737a3ao4ao3a4480aoe31a4e84ee17014a440ao4408I 3eeao33e

oao 13a6aaa

4eoa7e303

OF 1S85 RAW DATAEOfi BASO PLT ilCT RBC MCV tlGB

384ale390448aaelea

Saaa8a

o

I::ea

8801aaeiaa40a300

1470300

03se384a441oe1Qo88

4e0aao147:;:

140el

6eoaaa1ue64e

78595I 4aae4

I ei@a

440804

0e7ea

318

164I 04Iol

o aoa 4a.e 4.770 333 43.3 4.810 a44 30.9 3.070 ael 30.8 4.870 34s 38.9 4.90

:::: ~j:~ p]

o a38 40:4 4.6eo ao4 47.1 4.880 a84 48.8 e.3eo aao 47.1 4.eJ4o aeo 41.a 4.610 4al 40.7 6.000 ao4 34.8 3.8eo 308 39.3 3.00

8a a36 4e.4 4.800 a3e 48.9 6.110 4e8 40.4 4.elo 304 37.0 4.010 a14 40.1 4.170 aoe 61,0 3.aoo 408 41.0 4.770 a87 41.8 4.300 358 41.7 4.e9o a44 4a.a 4.400 aee 38,a 4.330 aoe 40.8 e.114

50 aee 43.8 4.eeo aee 4e,4 6.810 ae4 48.? 6.780 a7a 48.4 4,0eo a70 3e.e 4.alo 304 43.1 4.e7o a9e 46.0 4.700 399 36.e 4.oaO aaQ 43.6 4.94

78 aea 4e.6 4.740 all 4e.9 6.3a

06 abo 41.a 4.eoO 330 37.4 4.06

88 a80 61.6 6.760 a33 44.0 4.eeo aazi t51.o e.aao 37a 34.e 3.74

80 1S1 64.7 6,91e4 ale 31.7 3.4e

o 300 40.1 4.300 388 40.0 4.800 ao4 41.6 4.70

63 171, 33.1 3.7336.8 3.7e

o a9i 43.7 4.Oeea a40 4?.0 6.13

101 30Q 47.e 6.eo

00 13.790 16.IIol ia.8

ma 13.179 13.6MI a.e

14.6

# .008 13.497 16.e01 le.o97 18.191 13.Ial 13.aee 11.490 la.3oe 14.390 14.488 la.a96 ta.aee la.8e7 le.480 la.e01 la.7se 14.796 13.788 11.480 Ie.a93 14.7e4 13.a84 ie.1ea 14.eea 13.09a 13.894 14.089 11.48S 14.6,98 13.988 16.390 la:oea la.6ee 16.9ee 14.eel Ie.e93 11.e93 lee9a 10.393 13.Oea 13.4ea 13.a89 10.994 11.e06 13.79a 14.686 14.9

TSU PRL T’1

1.301.306.403.004.00a.oo

a.803.ao3.ao4.103.104.10e.oo3.404.303.803.ao6.ao6.604.ao7.406.40a.404.704.404.60a.oo

3.eo3.004.104.70e.ooe.303.406.603.aoa.eo3.304.404.803.004.eo4.303.704.804.70

a7. 004.70

3.90a,403.30

izAan.

20 Ooooooooomoeoooo 000000000000:00 00000;0000;;00 Oocaago:ooovQ2

mmm

n aaaaaaaaaaaa aaaaaa-----a -a-aa-aaaa-a ----maa-a-m- -aa-a.-

:

:31

500UNI

cm

CD

C3

-1=

--

bJ

—

wto

PID

83a03383403003883984084184284304484e848881ee480588780887988088188a89001191’7019OaoOaaDasQaa03103a034038041e4a043044060068086909000Oea90600000007097107?08090199(I

10011007

881 AGE

a 4a

I 81a em1 84a M1 00a 631 ela 07a 071 06a 83a ?01 60a eaa s’?1 eaa So1 831 031 aaa 40a 331 es) 381 04a ma wa 731 ma 01a 61a 83a ma 711 Be1 61a 30a wa 77a wa 341 ma 4a) 84) 00a 731 43a 40a 33I aaa 888 em1 78

VBC

060041007eoct

I oeoo88007800

100008400etmo6eooT4000700370001007eoo0300

1080044008800

1aoooeaooe400eeoo88008000830083008!?00wooeaoo8eooe400eioo

1000080007eoooaoo9100

i ) 80010400

eeoo8000

11800800083008800

I aooo8600aeoo670074007400800076006000

PMU

3316

M6ela4T6aaaea46704068aoa4aaao4688ao4a

ema86ea344474s48eo808061867800S740s77e33e44ooa6aoo8366ao14aaa369a63036481639e8ae64660064404040467e4660e138e8e43380a8eo886031a74731a80683764846a6aeaeo?4e0a4aeaaa404104a744

COMPUTER L18TING OF 1986 RAW DATA— ..BAND LTMPH IIONO

o

108170

78ale

I::1 la

74

14:61

a7;43a

eo;ea

oa3a174

80

1%67

a86310

a

1::Too

40:184a73600aoa

oaao118118ee4

o600

00

6700

18:60

a730

M4a40334447886460aia434e8aeaoa3e8308aa4001e3a37a43tea48eo1760aeooaveoa684a3e8107a1460a400a438a644aeo7ao90I eaa336417a8aoasa800a6601000a300aela4484aeooa340ao361888ala4a168ao36a76031464at4a337aa04aoeo1000S040a3aa

130

0$304a438a64e6404aoI 3eIlaaaa4e0Ill387aae668ale

80340eoo408

0a3a

66a40alaala171ee6a48344

1::eoo17046073ee373648ao466a78600a0633a110600426sleae6aoe148

304lea

E08 BA60 PLT JiCT RBC WCV I(GB

3a8

4b10017016610976eI 3e336146aol

37ao4a2a668432

8088

a40

aeg

11:80

ala37134a4’?6eaa

aee7e1aaaoo340aaaeao16aamaoe3a6110364aim33a496600

3::114146

I e:

ae~

:“o

o0000000000000

40000000000000000

aooo

7e184

:0n

a61le4alwaooa403a 13eea6a1443a3a41ai7n3aalo227a79336a16306allaaaa44a61aeoaa4;;:

aooaoa1ee4383a7a46179a44ao6410aae333aa4a84

30.7

1::!4a.663.347.146.043.144.330.0S7.64a.o34.630.443a43.e44.843.04e.e48.34e.e47.440.7aa.a3e.636.746.043.338.e3a.446.338.84a.o40.137.440.743.?4e.646.330.83e.6

4.Ba

1::;4.4e6.464.ee6.6a4.4@4.el4.034.044.e63.e44.024.814.476.004.6e6.474.478.140.704.673.364.a74.194.074.eo4.403.316.11a.7e4.884.644.oa4.aa4.376.4a6.a44.aea,ae

la.a18.4Ia.1114.6le.114.a14.913.a13.9la.7Ia.o13.ail.e12.1ia.914!016.214.elao613.s14.714.e13.611.011.7la.o14.0ia.4la.6lo.a16.711.8la.a14.DIa.ela.914..616.016.1Ia.711.6

ii 3ai 41,a 4.eeo aea a6.a a.8eo a4e 41.8 4.60

83 366 3?,7 4.a666 a4t3 43.4 4.37

0 41a 37.0 a.eao a84 a4.e a,eao a91 41.4 4.7ao 197 a9.7 4.490 a48 4].e 4.eaO a48 64.7 6.890 106 a7,6 4.190 a7a 41.0 4.900 101 4].0 4.08

as la.691 11.4ea ]a.169 ta.109 la.607 10.404 lo,ee7 14.188 Ia.o

.:: ~:.;

89 taleea la.e89 Ia.e

TSH PRI, T4

6.90a.80

e.ao

3.30

a.oo

a.ao

2.eo

Cn

C2

C3

-r=

LIJ

I-.3

PID

103010431800I 60810181820163018411843104018481849166a1863168016601068106918001601180318t3416001670167a18731B771878

SEX AGE

a 34a 00; ::

1 43a sea Wa 68a 331 ?aa 441 aa1 M1 34a 43a 41a sea asa eaa 001 80a 37a ii Ia 06I aa1 30a 36a 81

WBC

8000e 3006700

77007aoo3000680084006800

I afroo0800710064008100Baooeooo8000oaoo07007000000008008800eaoo8800Oeoo9300

PUN

4000

3819

431a430aaoe7aooo3oa4318574eaaoea4970ae70

ae404080a440aaaoa7473’780348037403996ame47ea48@e0046

BAND LYMPH MONO

80 3440

134 aall

154 atwo144 aa3a117 loea

o aaeaa8a 448a

8s 3a80aol 3ea7

08 aleo71 1’7’?884 law

3s 18a4480 amo

o a870184 8000

0 ao8ao aOOoo aloeo a618o a8as

ea alaa88 38a000 a840

a79 a3a6

480

4oa

4ea360

783484ao

ad470a84ale

JJ

1::4aoa7e408;;:

88480858

OF 1980 RAW DATAEOS BASO PLT XCT RBC MCV tlGB TSII PRL T4

o

I 34

77?a

540aooaea

o636

080

64

114I eo774044070140

1::170I 8038aa88

@a

o 4ae 4a.7 4.74180 44.8 tI.a3

o 280 30.3 a.08

o aae ea.a 6.490 L3a4 44.0 0.110 140 40.8 4.880 17a ae.a 4.a7o a86 40.0 6.800 lea 01.1 0.410 3a8 a8.1 4.]0o ae4 44.0 4.880 300 43.1 4.770 208 46.0 4.ve

41.8 6.860 ai3 44.8 4.340 a61 36.0 4.3ao aea 4a.4 e.aao aoe 44.0 4.01

07 300 ao.1 4.010 a84 45.8 4.?3o aa7 41.a 4.070 aoe 38.0 4.aeo aaa 4a.o 4.880 a14 49.8 8.400 40.0 6.a3o 307 a8.7 4.alo aea 4e.a 6.a9

00 14.800 11.091 11.7

3.2090 ie.aBe 14.089 1S.8ea 13.180 16.8es 10.8ea Ia.a91 14.790 14.3:; ;:.:

09 la:8aa ia.a 4.2081 la.897 14.898 13.090 14.888 13.4 a.7091 Isa08 14.391 )0.398 10.6 3.00ea la.a80 14.6

PID

67’71727374787077?879868e0i!

46486370

SEX AGE

1I ::I 71I 341 e’?1 631 80a 4Qa 67a 40I 7aa 30a 641 38I 30a 38a 48a 48

: ::a 771 461 40

: %I aaI 74a 381 37I 41a 49a 41a 082 83a 34a eaa 40a 80a 40

61; 49a 441 43

87: 08I1 Ha 3a1 34a 34a ena 38a 40a 49

VBC

040011700

760089004300000007008aoo6LIO0

113008300840074004800

137000000e8006100

10800880083004600770084000000000083008aoo680000006800aaoo70004700470070007aoo8000@7008900aloo

I31OO00007800‘?4000300800086006900aaoo6400040004006400

PMII

a6eoeem3116a419116033814aal49ao30B68703a78etwaa34?831ao

116083033318638193888431aa304a7eo4158aeeaae40aaaoS60148103000ae40)488309030104ooa3431aa4030003070oeaea419340a7860ao40478837004410490a3oa83a493620aae83778461aa430

COMPUTER LISTING OF 198(3 RAW DATAMONO E08 BA80 PLT llCT RBC 14CV MGB TSH PRLBAND LYMPU

64 3204a34 3510’

0 38760 an37o 18490 3030

67 18700 a870o aea6

113 44070 aoe7

84 18480 3330

11040 la33o aeelo atiea

81 11730 e160

88 3784340a

o 13600 3080

84 a37eo ae70o aaaoO 96730 31080 10600 a6aoo 36760 377ao 3430

a41e840

0 39900 31080 4300

07 aelo89 300Qal 3078

131 31443a40

o iaa4o 3404

‘o 1440a838

o ao90o a301

8a 3864Ion a3aa

64 ao48o 43a4o 1990

128468304364a68ao7336104J06791371ao2aaaa40.tlml

00aeo250648sea318180a31

o3@ea40

83a48466180110164aao

a%alo604

803884134086a4a4070014a316616a202301643a43ao4aoa70

38481930447aa6a138

07a4eaeo113

83588am338a74

09300102I 08ae41ae180

043a

e:83

a40

3:a76674alo414

4%14434468a

o11341834

480aaa

7463

3441101184oa3a4

04

(34:

O sell 46.0 4.00 00 14.8 0.000 236 40.7 8.10 90 16.0 a44.00 30.40 300 48.8 4,90 02 10.6 4.ao

IIa a70 iw.a 4.2aa6a aoo 40.3 4.40130 183 46.0 4.78134 ale 4a.a 6.08

0 a70 38.0 4.a8en aao 37.4 3.87

113 400 43.3 4.70e3 a48 4a.8 6.70

0 186 43.0 4.8974 418 40.8 4.83

240 48.6 6.070 a68 40.0 6.740 a83 36.7 4.8ao 3a6 30.6 4.040 aao 44a 4.7so a88 49.1 4.910 338 40.8 4.ae

ao3 38.0 3.880 aao 44.3 4.400 a43 40.7 4.040 ao8 4a.3 4.aao 6a8 30.1 4.01

00 308 43a 4.840 a70 37.9 3.860 ao3 43.3 4.3a

]30 aio 40.0 6.00ea 103 46.0 4.4886 300 41.4 4.74

0 a43 43a 4.ea70 103 40.9 4.30

1s7 33.0 3.4394 ii3 aa.i i.4e70 a3e 38.7 4.17

144 306 39.4 4.340 a13 3e.a 4.03

97 380 37.6 3.910 a38 46.8 4.960 310 46.9 6.aa

131 aee 40.6 4.430 180 46.1 4.040 a6a 47.0 6.aeO 406 40.0 3.90

03 178 49.4 6.aoa38 40.6 4.96

66 a76 33.7 4.100 333 4a.o 4.41

aa a80 40.0 4.400 316 30.0 3.88

Iao ale 41.1 4.1704 8’73 43.9 4.8864 a30 ae.a 4.61

’93 13.39a 13.090 14.783 14.390 13.497 la,aaa 13.379 13.093 13.3B9 14.078 ]4.a80 16.881 la.396 13.093 14.4

100 17.0Be 13.403 II.(I01 10!101 14.700 13.6e4 13.3w 1s.090 Ia.e:: ;:.:

oa 16:687 13.804 14.808 13.790 11.3ea03010690@3

::07

1%0604aa9693Q3990087

1:::13.013.s11.814.7]e.a13.014.816.113.918.616.610.914.313.6la.a13.314.913.0

3a. 10. ao

a.700.003.004.ao

.30

4.400.803.40

3.BO4.80

.0001.00

6.ao0.004.00a.oo0.603.60’3.40

a.ao3.60a.eo

Ia.eo1.30

.7046.80

0.60

4.0010.00

.40

11.004.404.600.40a.70a.oo3.003.40

.10

3.80e.ao

1.6

18.3

14.9

4.6

1.6

4.0

3.3

T4 TPR AI.B GLOB AfG CAL

a.a 4.20 4.0 1.0 10.20.8 8.3 4.00 4.3 ,007

8.1 4.10 4.0 1.0 880.0 7.2 3.00 3.3 1.27.6 8.1 3.30 4.8 .7 0.5

7.6 4.10 3.4 1.2 10.07.7 3.00 3.8 1.0 10.07.6 3.00 3.0 1.1 0.47<6 3.00 3.0 1.0 9aa,l 3.80 4.3 .9 9.3

7.0 3.80 3.a 1.0 8.67.4 7.0 4.20 3.0 I.a 9.B

8.] 4.ao 3.9 1.0 10.2la.7 7.3 4.00 3.6 1.1 6.7

7.(? 3.60 4.3 .8 0.S6.0 3.00 4.4 .0 o.a:.: ;.;: :.: .8 9.8

.8 9.47:8 3:40 4:4 .8 0.07.6 4.00 3.4 l.a 9.3

1.87.6 7.a 3.ao 3.4 .1.1 0 7

a.a 3.00 4.0 .8 0.5e,l 3.40 3.a 1.1 0.a

e,e a.a 3.60 4.7 .7 0.08.0 3.00 4.a .9 9.7

ta.a v.7 3.70 4.0 .0 0.28.0 4.10 4.6 .9 10.1

0.4 8.8 4.10 4.7 .07.1 3.00 3.6 1.0 967.3 3,70 3.0 I.O lo.]

10.0 7.6 3.00 4.a .B 9.67.7 7.3 3.ao 4.1 .8 8.60.0 7,0 3.00 4.0 .9 9.1

7.6 3.60 3.7 1.0 9.48.a 3.70 4.6 .8 9.17.8 3,ao 4.0 10.1

4.a 16.3 7.7 4.00 3.7 1.1 9.47.9 3.80 4.4 .a 9.I8.3 3.80 4.8 .8 9.5

3.38.0 3.40 4.(3 ‘r 10.()8.1 4.00 4.1 1:0

0.8 7.4 3.80 3.0 1.0 8.9

7.0 3.90 3.7 1.18.a 4.403.6 “1.1 9.4

a4.6 7.6 3.80 4.0 .9 9.87.7 3.60 4.a .0 0.9;.; ~.;; ~.; I.o 9.a

lea .0 0.88:3 4:00 4:3 .9 9.8

u-l

C3

c)

-“

PID BEX BAND LYHPECOMPUTER LISTING OF 1988 RAU DATAMono E08 BA80 PLT EC’? RBC MCV IIGB TSH PRL T4 TPR ALE GLOB AIG CAL

7.3 4.00 3.3 1.27.0 3.00 4.0 .98.0 4.00 3.4 1.40.1 4.10 4.0 1.1

wBc Pun

6900 me?0100 317a

2102

aio3alo4aloealoe21072110aliial132114ali7alioala3alaaalaaala9a130a13aai34alwa137a138a130a140a14aa14sai44a14ea147a14aa140aieoalaaaieealoe2108aimaleoaleaa)eaabtteaie7a171al?aai742170alaa2188alwa)malesall)ea197aaoe

0306

0

a02alf+naa400a78141784808188838801800I waaelaat4aIala17a8Soee3010a883lalea4eoa89a1709ae78maaao793379l18aaela1488aae3SrlsoWleoa8aaI 378a?eoyltl:

a064a4e4414039s01344aollaa14a6831848a884a8t3alw&

1024aa7aa310aiee4780

4833003307a IIooaI008

3%

1%801870aoot!a4300aee9373?8meaaleaea804

aa3a300ma3003001031 la308a18114

0lea73

a434oaI ee408a70

o80

300080

1104

3:;a84saaao70]0ao4

eat108aa4aeo79a

7ao

em ttao 60.8 5.aoo aao 41.7 4.aa

48 a@8 38.1 3.Q3103 4fM 40.0 4.BQ

o aoo 40.1 8.08144 a40 44.1 4.80

10: !% 1::s ;:::00 383 41.9 O.la

o aee 40.0 8.300 310 49.0 0.10

03 a08 43.8 4.840 aa3 46.0 4.ea

108 aee 46.0 4.7a73 318 3Q.9 4.44

0 3etI 40.0 s.00o ao8 30.7 4.000 a73 4a.4 4.940 S18 41.6 4.040 308 47.4 4.8@o aa8 40.8 6.380 438 37.8 4.160 348 43.6 3.88

S08 188 30.0 3.38aia aea 47.3 4.oa

87 305 44.6 8.100 180 8a.7 8.47

04 300 4a.e 4.330 313 40,7 4.80

at aa3 39.3 4.17134 aeo 30.0 4.14

0 a18 4?.1 8.430 300 40.0 s.oeo 380 4Q.a e.eao a30 66.7 0.70

60 310 3Q.8 4,400 410 4a.0 4.000 370 40.4 6.040 376 40.8 4.68

104 33a 44.4 8.000 aa3 41.I 4.38

71 313 43.8 4.810 a78 4a.3 4.08

00 403 44.9 4.0ao 370 40.3 6.300 360 4?.9 4.870 aos 37.8 4.oa

114 aoo 00.3 8.800 330 al.9 a.34

a83 31.8 3.3406 343 41.a 4.00

0 a18 40.0 4.40i44 aee 30.8 4.40

0 330 47.9 6.48

97 le.o09 )3.697 la.388 14.387 10.401 13.7

104 Iaoa:: ::.!

87 14:400 14.700 14.199 14.490 16.a00 i3.a80 13.400 ia.180 13.380 13.797 10.091 16.091 13.09B 13.89a 10.0:: ;:.:

08 17:108 la.O8S 1S.704 Isa

4800 10aO8000 eeoa0700 108864400 77700900 33030800 01840000 34800400 38400100 81870300 34087aoo alla8400 a7e4.7300 37a30700 ai440300 30344800 a7466300 eaao7aoo 38100100 30000300 01800400 18197aoo 47740000 08076700 3s0111400 43000400 3a047300 407aaloo 41310700 aei38300 6003IJaoo aais0300 01308aoo 30306000 aa407000 sa7e

e.40

I e7

:918

00I ae

o000

0!o

4688

0

10:0

0.8 4.70 4.1 1.17.8 3.90 3.0 1.09.4 4.60 4.~7.6 3.90 3.0 I:!8.3 4.00 4.3 .O8.8 4.ao 4.3 1.08.1 4.10 1.08,a4.10 4.1 I .0

384t oee

a403ao304aaasee00414e07000 I130I 0043a308309448a311004804ao43aaoa010aota40a76

03410tee3 Bo

3.007.e 4.20 3.4 1.2

aaaa1I

:a1111a1

363333374e

%7@3e3e

::377741

8.44. 104.3 1.0

7.e 3.70 3.97.0 3.90 3.i8.7 4.00 4.18.8 4.20 4.37.6 4.00 3.87.a 3.eo ,3.e7.a 3.70 3.87.7 4.00 3.77.9 4.40 3.67.9 4.00 3.97.7 4.00 3.777 4.00 3.77.7 3.00 3.8

8.6 4.40 4.17.9 4.00 3.s7.0 4.10 a.o8.4 4.10 4.37.8 4.ao 3.08.a 4.10 4.18.9 3.00 8.38.3 4.30 4.07.a 3.00 3.07.4 4.00 3.47.e a.eo 4.07.0 3.00 4.08.0 4.40 3.89.0 8.80 4.a8.8 4.60 4.3

.9I.a1.11.01.11.01.01.11.31.0II1.11.0

8.eo

8;o000

uu!

a.oo

3 00

1.0004 ia.8e7 14.800 18.0ee Ie.e

% !!::83 14.390 14.909 11.eeta i4.eee 13.091 16.591 13.401 13.7ea 10.6ee 14.e94 la.191 10.394 7.794 10.4ee 13.890 13.489 ta.een 13.7

461.11.41.4

.0l.a1.0

I ::1,0i.a

.9I.ai.a1.0

eo

1040

8ih0oaooeaoo80007100eaoo0900eeooeeoo63008700e4008000

aaea3ee4344430403470e41a3804eaeo3004a173aeoe0300308030403300ml:

agoo

874a80a84a4eao7

e.io4.10

3.10

.80a.30

aa1

:1a

4e3343e8306604e77134ea

1080470aea084840

60I 30I oeaeeaee

l.aoa.tlo

7.2 3,30 3.07.3 3,80 3.6 l:;7.6 4.20 3.3 1.38.3 4.40 3.9 1.17.9 4.20 3.7 1.17.4 3.70 3.7 1.0

a.eoa.lo

10.004.00

1300

7ao

eBoo00007aoo@800

u-l

CD

C3

r-. . .

--

LJJPID

u-laaoeaao’?aaoaa aoeaaioaalaaa13aatasaleaa17aaaoaaalaaa4aaaeaaaeaaa~aaa8aaaeaa30aas Iaaaaaawaa38aa3eaa37

m0 aaw

aa4aaa44aa4eaa47aa48aaeoaaolaaa4aaeeaawaae7aaeoawlaaeoaa71aa73aa74aa7t3

80681a810sal8a38a6eaaaae830831

681 AGE

I 061 88a 70a 30a 33a 07a 34a wa e7a 84a eaa 88a 04a sea 34a 37a 41a eta 46a a4I asI a3i 401 44I aoa aeI aaa 77I asa 41a 48I 4aa a8a a7a aaa 381 40a 331 “68I aaI aaI aa1 sa1 3aa a3a 3aa 37a ae1 43a 48a 80a 491 481 40

Vnc

8800

l%%930008000100830070009000eeoo07W87W71WWooe9w

Ioaoo1~::

7aw8700Woo88000700oaw83006awS7W

:%%oaoosewWw

I oaooBow74W0400Wweaoosaw

I aaoo79W71W7800

1oaoo78008800oaoo

070070004400Woo080093W

Pull

4070aoloeae4wee:;;:

308aaaooea)o3300aloealoa401seooeawaeaao::::

4mae800saaoa480883s0a4aea77aa70aaawa400awe4610ao]e3784e4at3ao74waaao444ee8a48eaaa4oa?aaeaaa414aaea387045a4eaeoa704

4a88aeeoaaooa48840043834

COMPUTER LISTING OF 1986 RAV DATABAND LTUPII MONO E08 BA80 PLT IICT R8C MCV UGB

o

(4o000

1J!67

alg180

B@o0

1::07

8:0

:00

8000

a078aeooaa40alsoI eaoa7a4aw4a73eaaooa840alw19901917

070Ioaaa448aeaeaot)oI a7a1740aa7aa48saa14aeeeaoe Iao14leaaaoaoaaeoa70ea8483870aaea1740aaaeaaaalaao39841404aoaeaoaoaeoe37a40010aloe

4a819a4

19434000laao3000

8844807

8100

ale@a

478leaa40aao90

I aa

daeo

Warnela080074

a%79a

::

37:100aw

80847738440aeoaoe174aQe

oawwa410600711ex)3801oa31a340104

ao IaBoweao4ao4668

t704ao8e4eao08007418084a803s0a4a114

I0:118408090a40070

0440a404oa

:;477aee400a31a4e

1:;:

510890

74

13:aza

I%aleI 4a

78408ea4

86410

ao 1

30:0

e44a7a

170 a40 40.3 4.08 ea 14.470 aeo 44,.a 0.16 a7 13.e

ale 360 40.9 4.47 91 13.0a79 488 36a 4.07 se ta.e

o a7a 30.0 4.aa 05 la.4al a93 ao.o a.oo 90 8.9

0 a7a 30.0 4.40 89 Ia.eo 34a 47.I5 6,83 84 14.7

w 440 ae.s 4.a9 00 Ia.oIaa a63 44.1 4.49 00 14.a

o a7a 4a.8 4.t3a w 14.60 a7a aa.v 4.01 97 la.3o aoe a4.o a.se 06 Ii.a

130 asa ae.i 3.)a 90 0.4tie aee ae.a 4.17 86 la.1loa 476 a7.e a.7a 74 9.1110 460 4a.o 4.7a 09 13.a

o a40 41.1 4.46 oa ta.7o aoa 4a.a e.oe 84 14.4

ael 008 44.4 6.a6 84 14.788 aaa 61.4 e.aa 97 16.7

0 aw sI.o 6.44 04 17.367 aee 40.8 e.aa faa 14.7ea a3e 4a.a 4.97 00 14.9

lae aas 4a.8 4.s0 oa 14aa7v aa.o a.7a 88 It.a

87 a4a ala 6.01 oa la.9o a70 40.8 4.00 *W la.a

77 300 00.1 8.1s 07 10.10 310 ae.e 4.ao ea la.7

178 a40 46.0 0.46 aa la.7w aos 47.1 ooaa 88 Ie.o

]oa aw a7.6 4.00 70 Ia.slie 410 a4.a 4.00 74 10.7aaa lea 4a.o 4.ea 09 la.a

o aoo a8.4 4.aa 91 Ia.aw aaa 46.0 sea aa IS.8

o 408 4a.a 4.46 98 14.ao a18”4a.a o.la 04 la.a

13a aea 48.7 6.00 07 16.80 aw 48.6 e.ae 00 15.90 aio 40.7 s,89 84 17.1

716 47a 47.8 9.41 87 10.4ao4 aoa 83.0 5.78 oa 18.I

o 34a a8.4 4.00 80 11.30 aw ao,7 3,30 ea Io.e

8a 14a aa.a 3.03 aa 11.1

e7 186 4a.6 4.48 96 14.40 a80 30.7 4.61 08 Ia.eo ale 30.6 4.ao oa la.3

68 4ao w.o a.ae w ta.eo aos 4a.7 4.30 07 Ie.o

a70 aaa 46.6 4.87 oa 1s.6

TSH

a.ao

4.10

0.00a.oo

1.00

8.80

ii.ao

a.eol.ao

PRL T4 TPR ALB GLOB

7.7 3.60 3.08.0 3.80 4.a8.1 3.60 4.87.9 3.70 4.a7.a a.ao 4.08.0 a.30 3.78.1 3.80 4.38.1 3.70 4.48.6 3.30 6.38.0 3.70 4.98.8 4.60 4.07.7 3.30 4.47.0 4.30 3.87.8 3.30 4.37.0 3.30 3.77.4 3.20 4.ao<a 6.00 4.a7.1 a.eo 3.08.0 4.40 3.e8.0 4.40 4.a7.4 4.10 3.3a.? 4.80 3.97.8 4.aoa.e8.0 4.60 4.aS.o 4.40 3.0

A/G

10.9.8.9.8.6.0.8.e.7

1.17

1“2

,:

i:1.0I.a1.0i.aI.aI.a1.1I.a

8.0 4.80 3.88.1 3.70 4.47.8 4.50 3.37.7 3.QO 3.88.1 4.ao a.a7.7 4.80 a.ga.a 4.00 4.ao.a 3.00 4.e7.1 3.80 3.87.3 3.BO a.77.9 4.40 3.8‘?.6 4.10 3.88.0 4.30 3.77.6 4.40 a.a8,6 8.00 3.88.8 4.00 3.ea.1 4.80 a.e0.8 8.00 4.00.7 3.ao 3.8

0.7 3.70 3.00.6 3.30 3.37.0 4,00 3.00.0 3.70 4.ae.a 4.00 6.a8.7 3.60 4.07.a 3.70 3.88.3 3.70 4.5

1.3

l::1.01.11.61.0.0

1.01.01.4I.a1.11.41!41.3I.a1.4

.9

la1.01.4

.9

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l::

CAI,

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w

o-

COHPUTER LI&ZTINGoF 1080 RAW VATABAND LYUPII MONO E08 BASO PLT MCT NBC MCV HGtiLiEX AGE

a 491 841 63a 63i 96a 04a ua 681 8?a 83a ?71 301 00a eaa 881 64I 041 70a 87a 38a 47a 34a ea: ::

1 asa V41 33a eaa eaa r141 41a ‘?91 asI eaa 36a 771 86a 3va 36a 431 861 44a 40a 341 33a wa 831 70I 66i 44a 60I 44a 43

PID

83a833634830840841843844046040eel86380486686708)eea68388a891f)90911914017

Wnc PUN TSM PUL ‘I-4 TPH ALLIGLOB A/G CA!.

1.01.1

\ ::.8.8.Q

1.0

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I.a

::.8

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1.01.11.0

.0.8.?

1.3.8.0.8

1.0.9

1.41.11.11.21.2I.o1.01.21.6

.81.1

6400e 000630003008800wooSeoo8aoo91001800S4008000640000007300840080007000

LOOOO80003000eeoowoo70000100Oaooclaw

1saoo7000610084008s004000040000000400:;::

6700)3100

780060007aoo8100

114004400030007006100610089006100

10IOO0900

a69a108042al32664084a43aae40aaoa4460

308a7e4S056$044aea4a77447044000

0 atlmo i$oaeo 17e4o 63940 a376

w SO1Oo 19800 aoaao 8aaao 1386

84 aloeo 80080 saleo 3a04

73 41010 34440 aaao

I ea330189I 867048733803847aa

10;aeoI ea408148108

80

)08110I ae37a1086380440

Q:

l::66

440ao4

7s

104:

0 3ae 37,8 4.63Oe 346 44.e 6.16

ala 4e.7 e.ri3m ao3 43.6 4.840 198 46.4 e.82o a83 3e.3 3.9055 a3e 40.6 4.aeo alo 38.0 3.900 ago 4a.e 4.630 164 al.o 1.060 ao3 30.8 3.8?

es aeo s4.o 9.490 aaa 40.1 0.060 aao 44a 4.04

73 843 46a 8.0604 a63 4a.4 4.70

0 a78 ::3: 8.s0

8a la.e88 14.680 16.096 16.180 lea03 la.a96 Ia.a06 ]a.?oa 13.8

loa 6.407 la.7w 17.080 14.3Oa 14.301 10.780 14.083 le.o

7.f3 3.00 3.77.8 3.90 3.e

?,8 3.60 4.0:.: :,;; :.:

7:3 3:30 4:08.0 4.00 4.07.3 S.TO 3.0

7.8 3.00 4.a?.0 3.70 4.1

a.40 7.8 4.20 3.67.@ 3.00 4.s7.8 S.eo 4.37.0 3.00 4.0

~i:o

ee 383 40.7 4.93117

68 306 3B.O 4.3008 lao 34.1 3.01

0 a38 30.6 4.40\oa ass 4a.4 4.03

0 170 46.9 4.040 a70 30.7 a.7ao a3e 00.6 8.90

aea 37.6 4.000 308 48a 8.40

e4 lee 41.a 4.03170 aao 43.B 4.70

0 ala 30,1 4.04

afmoa80aa76a4a144aoo814aaa@44aa 198864070aaoa4aa43668aaoa

o 306830 680

0 la3ao 4010

70 aaeoo alo3o 8e7e

+4: ::::

a8e4et a370

o 16040 4aeoo a64a

130a73lea3ea

70010188aea7ea148

e:

aeo70

ma107s

es t4.8 7.6 3.60 4.0

7.6 3.80 3.77.3 3.80 3.6

3.00 e.o S.40 3.08.3 3.70 4.08.8 3.QO 4.90.0 3.70 6.37.4” 4.10 3.38.1 3.70 4.47.0 3.70 4.aa.1 S.’lo 4.47.’7 3.90 3.87.4 3.00 3.8

‘al 13.1ae tl.a80 la.4se 13.796 16.e08 10.e

103 19.0ea la.784 14.389 13.1ea 14.884 tame

a80163744I aame8181833844a8147

919eaoQaa031t33a034930030e4a0439449s09869s896900000s08607107798098 If)ea

1001I 007I 6001519i6ao]52418a8

CJ-4

14:ao3

lao aoo eo.a 8.6684 303 38.8 4.la

o 313 36.0 3.80eo aee 3e.7 4.01

0 aso 40.6 4.680 403 38.1 4.380 396 40.1 4.e7o 103 40.0 4.aeo 37s 48.7 e.aa

81 a73 46.1 6.19114 a83 40.3 e.la

o 19s 43.7 4,,770 108 39.8 4.390 aa3 44.0 e.aeO a98 39.9 4.380 a43 34.5 4.oa

89 a66 4G.8 6.0461 a66 41.1 4.87

101 aaO 47.6 6.alo 313 30.7 4.a7

89 18.404 la.a04 11.89a la.4“88 13.66S Ia.s8(J 12’.690 13.0:: ~:.:

90 14:09a 16.0el 13.484 14.4:; ;:.:

01 16:884 14.391 16.103 13.0

7.0 4.40 s.a7.8 4.00 3.07.4 3.00 3.67.@ 4.30 3.07.a 3.00 3.37.@ 4.00 3.Q7.@ 3.90 4.07.8 4.ao 3.38,7 6.aO 3.68.0 4.20 4.49?.7 4.00 3.?

4140371a300036a7301673364768aeoo33643046718aaaaa696a3149a7643843338119eaa8283033

0 i3ao64 17a874 a900

178 373867 ao77

131 497atea ie7a

60 1660:; yltl:

O S420o 189a

93 a7f30o 98140 aoeto 18010 ae22O 36990 8888

8tl 8663

180aoe148366ae6aea304100486a43460I 3a37a630163a44483300aoaaov

;;;

aaa7~a

1139393e84400390

1134aa8

::ao II oa1a2346laa101i38

7,a 4.30 a.e 1.6?.2 .34 3.s .98.2 4.40 3.8 l.a7.6 3.6 1.17.7 3.80 3.0 1.07.6 4.ao 3.4 1.37.3 3.00 3.4 I.a?.8 4.40 3.4 1.37.a 4.00 3.a I.a

1.40

u-i

C2

c)

4=

—

t_JJ

J

ww

PID

I eaeI eae1841le4a1840164aIoea10631000Illet)I!lael108918031804i 006I 87018721673I 077

AGS

00aeaa

a83030

WocCOUPUTBR LISTING OF 1906 RAW DATA

PMII BAND LYMPH MONO COa BAaO PLT UCT RBC MCV llGB

810011000

08000100oeoo

Jaooo6800

10000830041006aoo90000000eaoowoo080074007800

10400

4eee8004aaaaBowa3ee4000a87e6300mea9000aaee40B0memo3930

eo7aaeea36a88816

an

10:80

0

aeila784soloaae7B4489880a6363700ae8e10s8a7a84410a9403I1O

aaooawoasoo3744

a4aa3a174040

4%10s800410mooeeaa70

80a46

ae4660eae410

oe7484aoo

ea?aiao

1Deaoo168a4037a

)::eoa

ae4146100416

81 30s ao.e 4.080 183 40.1 e.87o aaa 40.6 4.01

91 aoa 41.7 8.1700 810 47a 4.76

]ao a93 41.I 4.600 aao 40.4 6.10

moo aaa ae.4 4.030 moo 48.8 0.040 moo 40.a 4.07

ea a40 44.0 4.e6o a7s 40.a 4.000 aw 47.0 s.16o saa ;;.; 4.4a

o 418 40:4 4.9014s ate 00.7 e.al

o eo.a e.aeo 300 4e.s 4.BO

filaao

ia.710.3la.e14.31s.0Isa14.813.9ls.eia.o14.0ia.418!113,8

91 14.307 Io.a00 17.497 Ia.o

TSH

1.00

e.30a.40

PRL T4 TPR ALB G1.OS

7.6 3.803 87.4 4.30 3.17.8 4.20 3.e7.1 3.00 a.a7.a 4.00 a.a7.s 3.704.1

10.4 8.QO 4.8e.a 4.To 3.0?.8 4.20 3.07.4 4.00 3.47.4 3.00 3.e7.0 3.00 a.o8.0 4.40 3.e8.0 3.00 4.1

13.a 0.30 8.97 6 4.ao s.a

~.e 4.20 4.4

PID

234

:0

10la14Is18171819aoalaaa3a4a733

%!373940

::4447:;

8364000807‘?17a7374767077?8708380

08

46485370

SEX AGE

11 ::1 711 34) 07I 631 86a 49a 87a 401 7aa 30a 641 381 30a 30a 401 3ea 401 60a 34a 771 401 83: :;

1 74a 3e; :;

a 40a 41a 08a 03a 34a eaa 40a 80; ::

a 49a 441 431 67a 081 7a1 3aa 3a1 34a 34a e6a 3sa 40a 49

COt4PUTER LISTING OF 1!$87RAW DATAPRL T4 FBS HBAIC

14.8

a20.o 15.7

18.3

8.3 131.O 8.8

U-I

(Z3

a

.!

—

kJ

cc)

WBC PMM

8200 4692

e mm 197a8400 19446100 16268800 eaao0000 48806900 aooe7100 8063

llaoo aa7a0100 aotn8100 4af330600 34009100 89169000 4800eaoo 38308300 a70a7aoo 80000000 a3io9000 3861eeoo 343a8eoo 83sae300 am46600 19ao7100 447seloo aIIo7e700 4ae8

11OOO 71608400 aeee8300 a40a

7eoo 4484emo ae40

7100 4e157100 aoeaeeoo aeoe7400 4514e700 aaeleeoo a8e4

Ioeoo seen10400 8408

8aoo a3a4

8600 4080

8s00 1600euoo 41eo6700 a7t23

Ilaoo 79107400 4elo6aoo aeoe

4800 a400

BANO LYMPH MONO E08 BASO PLT HCT RBC MCV HGB TSH

)04

aooe48849ae4a7a1?7ala784308

aiiae4400104ale

J:60413aamaao

H3a4sae110aea408

i 9:

e3faae44ea

74aaaae464541e249

eeo

I aoaauWro1132aaI oe

4a

o a842 820

0aa41eaae4

o

%

:aa4ela

o0301041oeI 44

I 3%ee

o

a%

6:~a4

100:lee

eoe106

0aa4190a70

1D:84BmeI ee

340

715390

87330618

83

43a

ea 226 43.9 4.64 97 t6.a44.90

1.6081.40

68

:00

11800

elo

:000000000

:00

aaoo0

6s a70 43.1 6.020 190 44.3 4.71

e~ ae6 3ta.a 4.~e88 176 43.9 4.60

lae a86 4e.o 6.a4o aeo 36.1 a.ato a30 ae.e a.7a

lla 3a6 41.0 4.a4O 196 41.1 6.680 290 40.8 4.630 ae6 a8.3 4.la

EI1 aee 4i.5 0.6700 a76 48.4 6.44

0 a60 3a.4 a.olioe aoo ~;.; a.87

o

se 16.694 14,094 i3.1:: ::.?

9a la:a00 ]a.e94 Ia.a74 la.489 14.093 13.a?4 14.489 Ie.1B6 la.1ee ]3.a

16.0

34alaaaaa7aaaoo41aae304037e3alaaa8e7s40aa88417at33330146ealaoa38436e44060awoa838aalaao80a34a3888le76a41041104oe7

1.00. ao

i.eoa.40a.40

. ao

a.lo3oa. 00

1.10

14.292.0

10.2

100.0.607.eo

06 340 4;:8 4.68 8Bo 140 43.4 4.3a 1000 3a0 38.8 4.60 84ee a40 38.4 a.ee 104

0 aao 37.1 a.ee 046s aoa 4a.a 4.a6 97

ala 338 38.7 4.00 060 a80 39.6 4.16 960 a06 40.6 4.27 06

110 le6 38.8 a.aa 08lee a48 4a.1 4.93 08

oa

ia.8leeIa.1la.e::.:

ia:e::.!

la:e14.416.6

.ao106.0 9.8

3a. 8010.00

e.eoa.loa.aoa.loa.40a.706.10

.60i.eo

,30

8.7

349.0103.0 3.8

e.a

lee aao 44.4 4.aa

O a96 46.3 6.00oa80 ae.a 4.)a

14a a70 3e.o 3.8771 a4e 38.0 4.14ee aeo ae.e 4.11

0 a30 ae.4 4.080 a76 ao.o 4.4eO a06 46.0 4.81

109 a7e 4a.e 4.oao a06 40.8 4.3e

ea aao 46.0 4.?6

o aa6 40.e 4.a6

90 16.6ea la.8

o0

2888aa76

1704a3a7a17ea3e818a4aa444oaa3040S478

eo.0010.80a.oo

. eoa.80

ial.oo.10

e3 It.(?oa Is.o94 la.e:: ;;.?

e4 16:a89 16.at3a la.a96 16.0

071

07467

0000

10.80a.eo1.90

d:4.70a.40a.eo

1.80.80

ee la.6o

0000

7483

3400

40001495aaasaQ3819a4a173

137.0

0 176 46.1 4.77 101 16.8lao a40 a7.a 4.68 ea Ia.a

87 a96 41.7 4.44 94 ~4.eo aoe 4a.3 4.31 98 14.e

74 109 ae.a 3.7e e8 ia.7loe a80 a7.7 a.a3 98 la.3

o 176 37.I 4.44 84 la.ao I 9ao

A0

PID

81atoaato3a]04aloeato7aloe$a; ly

al13a114a1172119alaealaoa130a134alwa137a138a139a140a14aa143a14ea148a140aleoalea2153a106aloealoealoea160aleaaleea167a]70al?la]7aa174a17ealeaaloea193alo6a19ea197aaonaaoeaao7aaoaaaota

SEX AGE

a 411 431 70a 001 ?8a 801 431 80a aea a71 73a 87a 01a 41a soa 30a a31 37I 46a 38a 88a 70I aa1 ae1 081 7Va 411 481 001 341 aa1 48a oaa 38a a7a 081 701 471 74a asa 4Bt aa1 4aa 891 30a (34a 67a 71a 341 eaI ee1 38a 70a aa

VBC PMM

eloo 30408100 a(llla

10800 laeoo8000 a4aa

10800 8804maw

09007aoo

a1700moosaw

Iiaoo8000700074000100

710066007600

6700oaoo

1;;W&

6UO076008400elmS800

it%6400?4000600

111001080010WO

aaoo0400

%%6600

I 08008700870071000700800000008000

101008400

Sam4aotia7a3ea?e418asaaaetea4810elea4884aeeo

aoli8440e400aoeoa70s44aaeaaaaaeoao88a800::::

messaoa8aloea7ea4aoaa44870s0Sooesasa

s31aalaa04.00aeeilaleo787s3s19aeo741s934844a403000ao40777?4sae

COMPUTER LISTXIIG oF 1987 RAW DATABAND LTMPU MONO E08 BASO PLT EC? RBC UCV llGB

o 31890 aeie

e7a aeaoo lsaoo mooo oeoe

aov aaoso a701o 30380 4a7a

sa ]e40o S040o a3e4o 1s00

74 1ss4o 19sa

o 38900 aeooo 1s7so ]eao: ::::

0 e174o 17eso a7aoo alleo a43eo 14e4o aaooo aseoo 3s90o a044

aaa aaaoo a340o a331

ale 47sao 41ao

o as73o a0a4o a430o a903o aa6so 1s90o 1s39o a394o a7e0o aesoo aoeoo alooo 37000 17170 a444

1ea881804

:: A4s0138aes

1aoaae7a4ea3e17a

oa70I aa

38sI asaoo300ass0s4

oaeoago

Ttlsiloa44440as4a44a84seaeso88sale8a4

33a4487aoaes

o73s

o114

IuSeo000400101S4

1093a43

1::8a*1383es

loss178le444s

37;aee

as410s100am171le4147aos1004se1:3

I es11s

3a~74es

111aa4103

: a;1so

730

aaiaaa

71aefia40a40Tao404338

81 218 40.0 4.34lea 30s 44.9 4.86108 a7s ss.e 3.0s

1Wm :;1

M 4ao tltt .080 a7s 43.1 4.s3

73 a3s 3s.1 a.37a17 1s8 47.0 6.03

0 a40 44.0 0,41a4e aao 41.e 4.71

0 a9s 43.7 4.800 19s 43,0 4,71

7s 340 3s.4 4.aa14s aoe 33a 4.la

O 940 3S.0 3.87

0 aao 46.0 4.7480 aeo 40.4 4.38

0 300 3a.4 3.470 4as 3a.a 3.sso aeo as.o 3.1so a30 4a.3 4.47

92 13.4%6 10.69s 13.a9s 13.000 14.906 18.480 le.3

104 la.3S3 1s.ssa 14.0Ss 14.493 14.791 13.791 la.s81 la.o90 Ia.o

147 33s 44.4 S.oe104 a7s ae.7 a.va130 aas 37.0 a.04Isa aao 30.s 4,03

0 3ao 47.@ s.elo aao 41.s 4.a8

IIO aos 41.a S.OSo als 4a.s s.11

el a70 so.a s.a4o ae3 43.4 4.s7o 4Q0 4a.7 4.seo aos 4a.a 4.7a

III aoo 36.s 4.tao aas 4e.a s.ooo als 44.s s.os

97 16.103 )3.e93 11.a04 la.491 9.900 14.s

83 a36 40.a 4.4864 440 40.e 4.s7

100 aso 4e.6 s.16o ase 43.7 4.ea

ss aso 34a 3.060 als so,7 6,as

114 aa6 30.9 3.36s? 37s 37.8 4,49

0 310 3e.4 4.ao134 a38 34,7 3.74

0 3ss 4s.0 s.3ao a40 40.4 4.49

so aao 44.7 s.33loI aes ae.a 3.0s

o a7s a7.1 4.1s

81 )s.090 Ia.s04 la.ebe la.ass leas04 14.esa 14.0Ss 14.9ee 17,400 la.aSs 14.000 14.486 Ia.a9a 1s.4Ss 1s,s

90 13.4scI laoe90 10.09s 1s.194 la.194 lea6ia 10.s84 la.a87 la.793 la.oSs 14.790 14.aS4 1s.0:: ;:.?

TSH

.001.40].aoBoo

.30m.noa.loa.lo3.001.901.00a.40).s0

,70a.eo1.001.401.s01.001.304.00S.401.90a.40a.oo4.30

1.701.30a.so1.00

.901.701.90e.so4.30a.so1.10

PRL

ia.1

.401.s01.40y% 19.9

3:70].ao

.301.301,00

.001.s06.001.s0

T4 FBS HBAIC

07.0Se.o

8.4 lal.o 0.4

164.006.0

a74.0 10.0a80,0 10.0aat.o

363.0 I(J.O

oa.o 0.7

am.o la.a70,0

100.0 9.480.0 7.9

a33.0 10.0

10.3aoe. o

0.4167.0 Ii.a

87.09.4

la4.o 8.0

207.0 10.1

151.0 10.3a8e.o 13.0

COMPUTER LISTING OF 1987 RAV DATAu-l

C2

C.2

+=

-!=

C2

4-

PID

aaloaalaaatssale2210aa17aaaoaaaiaaa4aaasaaaeaaa7aaaeaaaaaa30aaslaa3aaa34aamaawaawaa4aaa44aa46aa47aa48aaeoaaelaa84aa6saaeeaa67aatloaaelaaoaaawaa7 Iaa73aa74aa?eaa77

0088118188108188aa8a3eaeaaeaae830a31tua

SEX AGE

a 33a 07a 84a eea 87a 64a 88a Bea 84a 30a 34a 37a 41a 81a 46a 341 w1 401 401 44a 30i 33a 77I aaa 41a 481 43a 38a 37a 33a 381 40a 331 68I 3aI 3a1 3a1 a31 3a1 33a 33a asa a31 37a a71 aei 41

.1 43a 46a 60a 49] 4e1 4ea 40

VBC

iaiooa8aoo

moomoo97007400eeooeeoo08008800eeoovaoo

} 08009200emowrooaaoo84004000eaoo80004900

13400:;g

eeooewoeoooeeoo7800740081008800?1007800eloo97007000

loaoo

aioo00008700e9007aooeloo7aoo

4eooe4000600eeoo

PUN

0689a4e48

4e48409e80444614::::

377:

ae33a4al

89806080a8e4tiaaaaeeo46ae17e4oeue4eeolelie8ee46504848a48e4e80aleoa740aa8aa774a807::;:

444e4aeaBaae:;;:

ao40aa40aaeo::::

aaaa4899eeeaaT801e3a441eaeo4eeee

BAND LTMPU

121 al?ao0 30770 a13eo aeeeo ao7ao a17ao 14ea: m:

ee aomo aoee

o 4aooo aaaao aeaa

104 a4ea]e4 aaaeo aeo4o ae4eo lae4o a480o a460o saaeo 3ooao aa80o aeeBo leloo a400o aeaeo aoa8o a7aao 37aeo 1s06o aaoio aeeao afmo ae)eo 41aoo 3670

0 amoo 64000 a337o a416o a877o aa67o 19710 a403o 14000 a300o leooo a004o aaoo

Mono EOS “BASO PLT “IICT RBC”WCV IIG8

a4a

I8:a9aamaee4ea14eaBe

eaea7e5B4

10:Iao77e7a8

1000aea410aao490

Laoea7a4a6510aaoaeoB1Oaa4eeeaa4eaaeea4e848e

14664ao610

ao4

at:eua14e1aaalfa634aoo~aalaaa30ae4

ao:a3a

ia74e7e

o108

1%ae4

14:

aleo

aovo

1%

e$a40

oaea

~lsa6eu4ao

ee

1::1 Be

1:;a48I 4aI eea4aae I

1::

3oe160171

0aea4a7438

ee;aaoaae4ea440

0 a06 30.80 aoe

Ba m a3.eo aee 40.40 366 S7.0

aaa aeo 37.0taa aeo ae.eaBa aoo a8.4

o a7e 30,80 aau 34.1

4.41I.~e3.834.Oe4.414.134.oe4.00a,aea.ee

ee aa4 a7.e 4.e47a a70 3e.e 4.68

0 aee 40.0 4.4711B4 aae 41.1 4.94

0 a7e 4a.7 0.010 aeo el.8 B.40o aao 48,a 8.040 aeo 4a.7 4.e4

ee aee 4a.e 4.e7ea a46 a4,1 sea

o aae 47a 6.034e moo a4+e a.e7

la4 aeo 44.e 4.eoe] a70 a7.4 a.04

a68 aae 4a.t) 8.0688 aao 48.e B.4eee 406 aa.e 4.41

a7.4 4.8417: tee 4a.e 4.84

0 4ao ao.a 4.ae74 aau 48.3 a.alal 3eo 40.0 4.86

0 ]eo eo.e 8.4eo 176 4a.e a.ea

7e aea 4e.o 4.7881 aeo 4e.5 e.~ee7 3ae e~.e e.0470 aae 46.s 6.36

~oa aoo 47.0 6.81

0 aae ae.o 4.34eo a7e a8.6 a.ae

o moo 4e.a e.oeee aao,40.a 4.67

0 a70 acme 4.a6el :eo 4a.e 4.7473 aao 4a.e 4.a4

o 300 41.8 6.070 a40 ae.e 4.080 a80 3e.8 3.970 306 ae.e 4.lao a40 40.0 4.840 aeo 3e.a 4.ea

00 i3.4

80 la.ase 14.086 ls.ael ls.aee la.ee4 13.aes 10.7ae ~~.e81 Ia.s84 la.e

Be 13,ee3 14.aaa 14.6ee )7.a‘&g ::.:

ae 14:B87 Ia.oe4 18.897 11.7e7 16.7ee ]a.484 14.6ae 10.770 10.8am la.7eo 14;388 la.ae7 16.0ae 14.7ea Ie.oee 17.0ee le.oeo 115.888 17.7ea 16.ael te.7

81 la.1e9 i4.a9a lee8e Ia.eel ]a.e90 14.6eo la.88a la.eee 11.e93 la.4ee 14.106 18.384 13.0

TSH

1.3028.80

.90

1.90a.oo4.000.40a.303.eoa.801.701.40

1.00a.ooa.loa.40

.70

.70a.ool.eo3.104.10I.ao

1.108.ao4.101.401.10

.701.10a.eo1.TOa.ooa.oo1.60I.aol.eo1.70

1.80

.20

PI?L T4 FBS HBAIC

81.(I

22a.o 10.186.0 8.090.0 8.4

4.e

a.0174.0 10.1aa3.0

143.0 9.4

a44.0 Ii.a

380.0 Ia.a

o.a

100.00.0

172.0 10.3

179.0 8.8

06.0 12.8

k

PID

03383403003883e04 I843844048861807001alla88388880 I89e00D91191a914917OaoOaaeaoeat)03103a03403093904104a94406696090090s906000009070Q? tWo981993900

10011007103010001019I eaoI 8a4

WBC

SO(IO0700eaoo7100

1%%7aoo04007400eaoo08007700eaoo0800760074007100aloo600070009000

11s008000

laloo890047000100

%%7800

:%%48008100eaoo

10800li900

91008900?aoo8000740077008700

eaoo0700?aoo

e70010000

woosaw

10300

PUN

17803686a4to8834ae73:::7

aes 14ai8Woeae8a4eaoaeaeaeB480704a18ala48a40aeioaa4400007ole478a47104eaelaaaaaooaeaoaaso4ae804084a7eaaeea40aao8700707a788a7e6a40646160964144aea7a3a7

17ae4oaoeaaeaeeo17076aooOaaoeaae6871

COMPUTER LISTING OF 1987 RAW DATABAND LTMPE MOIIO EOB BA80 PLT ECT RBC UCV HGB

o000

14:000000000000

;o

1Ho00

1e:o00ao0

aioo0

7:0000

000000000

aeaoaa40a34eaeea0ss01eeaanooa6aBaaao1oaa4olaaloe1984ae7a8aa6aoeoaeoe3888ae]oaae8aa7ewaoaeo80171aaoaaaaea]4aalaoa37eaaoa1060a4161900340aa77a3a8eaeae3)06a8811601aaaaaoa4aooaaeo7

4030aa4aaaea17403303a700a4eaa7ata4017

80saaa48

eU87a;::

7401ae

elg434408aae

74:::

aaa480

07:ae4a4a

89

48:aao460390aee

00aaa010

eaala696

91ae7aleae4

16:171

aloao 1aa4180ela000178

a%

100I a4

a%

a%ae41eaaaa;:$

104~a4I 30

14:aee4ae174460

1040]Ia

a%ao Ieti1834aoa7Ba34aee

oaaa4ae3?804811964071a474aaa

3::aaa

1::

i::

lUo

a%

o aoo 44.2 0.a3,0 am 4a.o 4.00

1a4 aao 43.1 4.400 aaa 4e.a 4.700 alo 4a.a 4.aao a37 se.] 4.000 aae ae.a 3.030 alo 41,a 4.410 196 47,0 8.08

ea aoo aa.a a.a6o aoo 4a.a 4.09

184 100 44.4 4.a4o lae 4a.e 8.040 aoo 4a.a 4.a4

76 a48 30.7 4.aeo 408 aa.4 a.eoo 430 a7.a 4.ae

al 300 40.6 4.a9174 aao 4a.o 4.70

70 aeo 40.a 4.eao aee 30.7 4.10

1)0 a70 z+a.7 4.010 100 41.4 4.4Io 300 ae.s a.04

80 400 ae.3 4.7ao als ao.7 a.oe

01 afae 40.7 4.eaieo soa a4.j a.aa300 ae6 43,1 8!01

O 176 aa.a 4.al170 aao 40.9 a.ollae 3$6 30.s 4.14

0 aos ae.o a.7eo aa6 43.0 6.17

03 aao 38.0 a.@8o aae 30.8 4.04

119 aeo 34.3 a.alo a40 43.1 4.7Io 346 30.0 4.14

79 600 3e.v a.7eo 3111 ae.a 4.11

148 lao ae.e a.eo164 348 4S.4 4.9T

67 a4e 41.8 4.04

ea 31s 40.7 4.t14o ma 41.0 4.eao aoa 44.3 6.aeo aeo ae.e 4.000 sao 4a.7 sea

NM 370 41.7 4,070 aa6 46,8 4.00

aa 176 41.0 4.040 aaa 44.1 4.06

14.018.010.010.016.1Ia.ala,oIa.a14.311.914.113.0~4.a14.3

:& ::.:

a7 lane04 la.400 la.3a7 14.0as Ia.7aa 11.794 ]4.0oa la.aaa la.190 Io.a00 Isa97 11.8*e 14.6ae 13.0oa 10.003 la.e03 Ia,aa4 ]a.496 ]a.a91 la.490 11.89a 14.0B9 la.606 ta.400 IS.890 0.0a7 ~4.a90 Ia.o

sa 14.a80 14.3sa 10.100 ]a.e8010.809 13.193 16.706 14.aea 16.1

TSH

1.80

3.40

a.70

a.40

.00

PRL T4 FBS HBAIC

ale.o 8.’?80.0

114.0109.0

169.0 8.3187.0 I;:fIla.o108.0 7.1

162.0 8.0

139.0

0,0 91.o e.a

@.6

a}a.o 9.a

13.0 la4.o 7.6

lao.o I;.:

287.0 10:3

u-lC-J

D,-------

—

.%

N

4-W

PID

lsae16331641154016481062]083I 56010801s871s8918001681I 8041606160?I 8771678

6EI AGE

1 BO1 a4a 601 7sa 401 871 38a 44a 4a1 ma S4a 63a 00a se1 4aa 33a sea 5]

V BC Pull

13100 0943

7aoo 41870100 aeeollaoo 00480100 aeaomoo aeao8400 47080700 18700400 ao480000 40187aoo a71amoo 4eeo

Io600 4oaaa4m a94aeaoo a7ee

7400 a73a

COMPUTER LISTING OF 108’/NAV DATABAND LYMPH MONO EOS BASO PLT ECT RBC UCV lfGB TStl

o 4oel ea4

o 30s1 I ea

e::o0

8400

19000000

0

a15eaeoeae84aoao:;;:

aaao4704a3e7a3aoselaaelaaoaa

i 85aa4)aa7aoaaaeaeasa?8488a400eao

1::

1310

a~~

440I aa040lea

8::

?03aoala67aaoa

148

aea 266 41.9 4.66

]ee 190 38.3 4.aeo 130 44.0 4.710 300 34.0 a.73

]aa aao 41.0 4.6980 aeo 4a.7 4.a8

lee aeo 4a.e e.oee7 a3e 41.0 4.10

0 aae 38.7 a.eeo a7e 40.8 4.980 lee 4a.o 4.860 aao aO.4 a.7v

ala aao ae.7 4.4e84 aae 4e,a 4,e7

104 aee ae.a 4.04

140 aao 44.4 a.ie

90 14.3

60 13.3es 1s.001 ja.a00 14.097 14.479 14.098 la.e 4.40oa 13.a81 ta.49e 14.797 \3.o80 la.999 15.887 11.8

8e 18.4

PRL T4 FBs HBAIC

10{.O 8.8

207.0 11.0

10.0

06.0

ai7.o ia.e