Childhood asthma and indoor allergen exposure and sensitization in Buffalo, New York.

This nested case-control study examined the association between prevalent asthma and indoor allergen sensitization and/or exposure among children (aged 5-17 years) in Buffalo, New York. The study included a self-administered questionnaire, clinical interviews, skin allergen sensitivity tests and home dust sampling for house dust mites, cat, dog, cockroach and mouse allergens. After adjusting for multiple confounders, asthma cases had higher odds of being sensitized to Der p dust mites (odds ratio [OR]=1.94, 95% confidence interval (CI): 1.13-3.35), cat (OR=1.96, 95% CI: 1.13-3.39), or dog allergens (OR=1.89, 95% CI: 1.10-3.22) than the controls. A significantly positive association between asthma status presence of cat allergen in the child's mattress (ORs: 2.61, 95% CI: 1.09-6.28) was also found. Children with both sensitization and environmental exposure to cat allergens had higher odds of asthma (OR=7.08, 95% CI: 2.12-23.62) than those who were only sensitized to cat allergen (OR=2.31, 95% CI: 1.01-5.32) or had only home exposures (OR=1.47, 95% CI: 0.47-4.65). The association between allergen sensitization and asthma was more consistent than for home exposures. The findings help to confirm the role of allergen sensitization and home exposure in regard to asthma, and suggest that both, individually and jointly, are associated with asthma.

The association between local fish consumption and DDE, mirex, and HCB concentrations in the breast milk of Mohawk women at Akwesasne.

A study was conducted to assess the extent to which the consumption of local fish contaminated with p,p'-dichlorodiphenyl dichloroethylene (p,p'-DDE), mirex, and hexachlorobenzene (HCB) has impacted the concentrations of these compounds in the milk of nursing Mohawk women residing along the St. Lawrence River. From 1986 to 1992, 97 Mohawk women were interviewed, and each donated a one-time sample of at least 50 ml of breast milk. The comparison population consisted of 154 Caucasians from other rural areas in New York State. After adjustment for potential confounders, Mohawk mothers who gave birth from 1986 to 1990 had significantly higher geometric mean p,p'-DDE milk concentrations than did the control group, but no significant differences were observed from 1991 to 1992. In contrast, mirex was significantly elevated among the Mohawks throughout the study period, while HCB showed no difference at any point. Mohawk women with the greatest estimated cumulative lifetime exposure to p,p'-DDE from local fish consumption had a significantly higher geometric mean milk level of that compound relative to control women, but no differences in mirex or HCB concentrations in breast milk by local fish consumption were found. The reduction in breast milk p,p'-DDE concentrations among the Mohawk women from 1986 to 1990 parallels a corresponding decrease in local fish consumption, and may be the result of the advisories that have been issued over the past decade recommending against the consumption of local fish by pregnant and nursing Mohawk women. Elevations in the concentrations of mirex in the breast milk of the Mohawks are consistent with the fact that it is a common contaminant in the region and throughout the Lake Ontario-St. Lawrence River Basin.

Tandem mass spectrometric analysis for amino, organic, and fatty acid disorders in newborn dried blood spots: a two-year summary from the New England Newborn Screening Program.

BACKGROUND: Tandem mass spectrometry (MS/MS) is rapidly being adopted by newborn screening programs to screen dried blood spots for >20 markers of disease in a single assay. Limited information is available for setting the marker cutoffs and for the resulting positive predictive values. METHODS: We screened >160 000 newborns by MS/MS. The markers were extracted from blood spots into a methanol solution with deuterium-labeled internal standards and then were derivatized before analysis by MS/MS. Multiple reaction monitoring of each sample for the markers of interest was accomplished in approximately 1.9 min. Cutoffs for each marker were set at 6-13 SD above the population mean. RESULTS: We identified 22 babies with amino acid disorders (7 phenylketonuria, 11 hyperphenylalaninemia, 1 maple syrup urine disease, 1 hypermethioninemia, 1 arginosuccinate lyase deficiency, and 1 argininemia) and 20 infants with fatty and organic acid disorders (10 medium-chain acyl-CoA dehydrogenase deficiencies, 5 presumptive short-chain acyl-CoA dehydrogenase deficiencies, 2 propionic acidemias, 1 carnitine palmitoyltransferase II deficiency, 1 methylcrotonyl-CoA carboxylase deficiency, and 1 presumptive very-long chain acyl-CoA dehydrogenase deficiency). Approximately 0.3% of all newborns screened were flagged for either amino acid or acylcarnitine markers; approximately one-half of all the flagged infants were from the 5% of newborns who required neonatal intensive care or had birth weights <1500 g. CONCLUSIONS: In screening for 23 metabolic disorders by MS/MS, an mean positive predictive value of 8% can be achieved when using cutoffs for individual markers determined empirically on newborns.

Fingerprinting PCB patterns among Mohawk women.

This study examined the association of contaminated fish consumption and polychlorinated biphenyl (PCB) body burden by comparing the similarity of the congener pattern in yellow perch, caught near the point source of industrial pollution, and in other local fish to the pattern found in the breast milk of Mohawk women from Akwesasne, a Native American community located along the St. Lawrence River in New York, Ontario, and Quebec. The similarity is defined by the weighted Euclidean distance between two congener patterns. Ninety-seven Mohawk mothers participated and provided samples of breast milk. One hundred fifty-four nursing women from the Supplemental Nutrition Program for Women, Infants and Children (WIC) of Warren and Schoharie counties, New York, who gave birth during the same time period, were used as the comparison group. Results revealed that the breast milk of the Mohawk women, who ate the most local fish, had a congener pattern that more closely resembled that of perch caught near the waste site or average sampled fish caught in the Reserve than Mohawk women who ate less fish or the controls. The outcome demonstrates how PCBs may be "fingerprinted" as they migrate offsite from industrial sources and ultimately result in human exposure.

Local fish consumption and serum PCB concentrations among Mohawk men at Akwesasne.

A study was conducted to assess local fish consumption patterns and their relationship to concentrations of total polychlorinated biphenyls (PCBs) in the serum of Mohawk men residing near three hazardous waste sites. From 1992 to 1995, 139 men were interviewed and donated a 20-ml venous blood sample. The results indicated that the men ate a mean of 21.2 local fish meals during the past year, compared with annual means of 27.7 meals 1-2 years before and 88.6 meals more than 2 years before (P<0.001 for test of trend). This change is probably a consequence of advisories issued against the consumption of local fish, since 97% of the men were aware of the advisories and two-thirds had changed their behavior as a result. Multiple regression analysis revealed that serum PCB levels increased with age (beta=0.036, P<0.001) and local fish consumption (beta=0.088, P=0.006). The data suggest that local fish consumption has contributed to body burdens in this population and that the advisories have been effective in modifying local fish consumption habits.

Assessing environmental exposure to PCBs among Mohawks at Akwesasne through the use of geostatistical methods.

The Mohawk Nation at Akwesasne is a Native American community located along the St. Lawrence River in New York State, Ontario, and Quebec. One component of a multiphase human health study was to assess the impact of different pathways of human exposure resulting from the off-site migration of polychlorinated biphenyl (PCB) contamination in this area. This paper illustrates how mapped residential information and environmental sampling data can be united to assist in exposure assessment for epidemiologic studies using geographic information system (GIS) technology and statistical methods. A proportional sampling scheme was developed to collect 119 surface soils. Using a method of cross validation, the average estimated error can be computed and the best estimator can be selected. Seven spatial methods were examined to estimate surface soil PCB concentrations; the lowest relative mean error was 0.42% for Inverse 3 nearest neighbor weighted according to the inverse distance, and the highest relative mean error was 4.4% for Voronoi polygons. Residual plots indicated that all methods performed well except near some of the sampling points that formed the outer boundaries of the sampling distribution.

Fish consumption and breast milk PCB concentrations among Mohawk women at Akwesasne.

A study was conducted to determine the relation between the consumption of contaminated local fish and concentrations of total polychlorinated biphenyls (PCBs) and 68 PCB congeners in the milk of nursing Mohawk women residing near three hazardous waste sites. From 1986 to 1992, 97 Mohawk women were interviewed and donated at least 50 ml of breast milk. The comparison population consisted of 154 Caucasians. After adjustment for potential confounders, Mohawk mothers who gave birth in 1986-1989 had a geometric mean milk total PCB concentration of 0.602 ppm (fat basis) compared with 0.375 ppm for the control group (p = 0.009). These Mohawk women also had significantly higher geometric mean concentrations of nine congeners. Beginning in 1990, however, there were no significant differences between the Mohawk women and the comparison group. Estimated cumulative lifetime exposure from local fish consumption was significantly related to milk total PCB and to three congeners only among those Mohawks who gave birth from 1986 to 1989. The reduction in breast milk PCB concentrations parallels a corresponding decrease in local fish consumption and may be the result of the advisories that have been issued over the past decade recommending against the consumption of local fish by pregnant and nursing Mohawk women.

Environmental pollution and child health in central and Eastern Europe.

For the last 50 years, the economic and industrial development of the nations of Central and Eastern Europe has been achieved at the cost of environmental degradation. The health risks posed by this pollution to children and the steps necessary to ameliorate such risks are only beginning to be investigated. At a recent conference in Poland, sponsored in part by the National Institute of Environmental Health Sciences, participants from 11 countries in the region, together with scientists from Western Europe and the United States, met to share information regarding pediatric environmental health in Central and Eastern Europe, to consider methodologic issues in the design and conduct of such studies, and to discuss preventive strategies. This report summarizes the deliberations, outlines problem areas such as heavy metals and air pollution, delineates research and training needs to help Central and Eastern Europeans deal more effectively with such problems, and recommends specific future actions and collaborative efforts.

Growth and development and other risk factors for osteosarcoma in children and young adults.

BACKGROUND: Risk factors for osteosarcoma in young people were investigated in a population-based case-control study among residents of New York State, excluding New York City. METHODS: Cases (n = 130) were diagnosed between 1978 and 1988 at < or = 24 years of age. Controls were randomly selected from birth certificates and were pair matched to cases on year of birth and sex. Exposure information was obtained by telephone interview with a subject and/or parent, and from birth certificates and school and medical records. RESULTS AND CONCLUSIONS: A significant positive association was observed with height one year before diagnosis (P-value for trend = 0.02). No significant associations were observed between osteosarcoma and weight of body mass index one year before diagnosis, birth length, birthweight, gestational age, having reached puberty, having begun growth spurt, age at puberty, age growth spurt began, medical x-rays, antenatal exposures, family history of cancer, birth defects, or parental occupation.

Polychlorinated biphenyl (PCB) and dichlorodiphenyl dichloroethylene (DDE) exposure among Native American men from contaminated Great Lakes fish and wildlife.

The New York State Department of Health is performing an investigation of Mohawk men, women, and infants who live at the Akwesasne Reserve along the St. Lawrence River in New York, Ontario, and Quebec Three large industrial facilities bordering the Akwesasne Reserve have seriously contaminated the soil and the sediments and fish of the adjacent St. Lawrence River with polychlorinated biphenyls (PCBs). The main study goals are to investigate the associations among the consumption of locally caught fish, residential exposure, body burdens of PCBs, and liver enzyme induction. Contamination with PCBs, polychlorinated dibenzofurans, polychlorinated dibenzodioxins, polyaromatic hydrocarbons, dichlorodiphenyl dichloroethylene (DDE) and other chemicals has been documented in locally caught fish, ducks, and other wildlife. The contamination of fish and wildlife is a major concern of the Mohawk people, since their tradition and culture emphasize the interdependence of man and his environment and because many residents formerly depended heavily on local fish and waterfowl for food. The focus of this research from 1986-1992 was on nursing women and infants. The major purpose of the current project is to determine if there are associations between dietary, residential, and occupational exposures to PCBs and DDE and individual body burdens in Mohawk men, specifically the husbands, partners, fathers, brothers, or other male relatives of the women in our other studies. In other fish-eating populations, adult men have tended to demonstrate higher PCB and DDE body burdens than women and children. Exposure estimates based on the reported consumption of locally caught fish and wildlife and residential histories will be correlated with the specific pattern of PCB congeners found in serum, thereby establishing a direct relationship between two potential sources of exposure and body burdens. Liver function will be examined through the caffeine breath test (CBT), a sensitive, noninvasive method of assessment of enzyme induction, one of the earliest detectable biological responses to PCBs in laboratory animals. This test appears promising as a method to detect subtle subclinical effects before the onset of overt clinical symptoms. The project is among the first to explore differences in dietary and other exposures, body burdens, and potential adverse health effects due to specific PCB congeners in men and women from the same source population.

Fluoride exposure and childhood osteosarcoma: a case-control study.

OBJECTIVES: This study tests the hypothesis that fluoride exposure in a nonoccupational setting is a risk factor for childhood osteosarcoma. METHODS: A population-based case-control study was conducted among residents of New York State, excluding New York City. Case subjects (n = 130) were diagnosed with osteosarcoma between 1978 and 1988, at age 24 years or younger. Control subjects were matched to case subjects on year of birth and sex. Exposure information was obtained by a telephone interview with the subject, parent, or both. RESULTS: Based on the parents' responses, total lifetime fluoride exposure was not significantly associated with osteosarcoma among all subjects combined or among females. However, a significant protective trend was observed among males. Protective trends were observed for fluoridated toothpaste, fluoride tablets, and dental fluoride treatments among all subjects and among males. Based on the subjects' responses, no significant associations between fluoride exposure and osteosarcoma were observed. CONCLUSIONS: Fluoride exposure does not increase the risk of osteosarcoma and may be protective in males. The protective effect may not be directly due to fluoride exposure but to other factors associated with good dental hygiene. There is also biologic plausibility for a protective effect.

A prospective comparison of laparoscopy and imaging in the staging of esophagogastric cancer before surgery.

OBJECTIVE: To carry out a prospective comparison of laparoscopy and combined imaging (CT and ultrasound) in the preoperative staging of distal esophageal and gastric cancer in patients who were selected for surgery. METHODS: Patients with clinically overt metastases or a contraindication to major surgery were excluded. One hundred and forty-five patients underwent chest radiography, CT of mediastinum and abdomen, and ultrasonography of abdomen and laparoscopy. The primary diagnoses were adenocarcinoma of the esophagogastric region in 110 cases, squamous cell carcinoma of the distal esophagus in 30 patients, and five miscellaneous. RESULTS: Thirty nine (27%) patients had metastatic disease outside the potential field of resection. Metastases were detected preoperatively by laparoscopy in 30 patients (sensitivity 77%) and by combined imaging in 15 (sensitivity 38%) (p < 0.01). Twenty four patients with adenocarcinoma had metastases to the peritoneal cavity, which were detected preoperatively by laparoscopy in 23 (sensitivity 96%) and by combined imaging in five (sensitivity 21%) (p < 0.01). Peritoneal metastases were not seen in patients with squamous cell carcinoma. Fifteen patients had hepatic metastases, which were detected preoperatively by laparoscopy in nine (sensitivity 60%) and by combined imaging in seven (sensitivity 47%). Laparoscopy was more sensitive than combined imaging in detecting metastases in patients with adenocarcinoma [laparoscopy 28, combined imaging 10 (p < 0.01)]. CONCLUSION: Addition of laparoscopy to the staging protocol prevented unbeneficial thoraco-abdominal exploration in 20 patients with adenocarcinoma. Thus, laparoscopy should be used in the assessment of patients with adenocarcinoma of the esophagogastric region before performing excisional surgery.

Mortality among New York State highway maintenance workers: 1958-1980.

The mortality profile of 9585 male New York State Department of Transportation (NYSDOT) highway maintenance workers was examined by calculating age-era standard mortality ratios (SMRs), using the general male population of upstate New York as a reference group, for the period 1958-1980. The SMR for all workers was 1.14 (95% CI = 1.09, 1.18), with the greatest all-cause mortality among laborers (SMR = 1.23, 95% CI = 1.16, 1.29). The major contributors to this increase among laborers were circulatory system diseases (SMR = 1.18, 95% CI = 1.10, 1.27), diseases of the respiratory system (SMR = 1.34, 95% CI = 1.09, 1.64), digestive system diseases (SMR = 1.57, 95% CI = 1.26, 1.94), genitourinary system diseases (SMR = 1.61, 95% CI = 1.02, 2.41) and accidents, poison, and violence (SMR = 1.44, 95% CI = 1.19, 1.74). Some of the elevated risks observed may be attributed to cigarette smoking and other life-style factors that could not be assessed with the data available. However, the mortality risks for laborers increased with length of employment and latency, suggesting that occupational exposures may be contributing to the elevated risk in this cohort. Further studies should include information on life-style variables and other confounders as well as more detail on specific occupational exposures.

Fish PCB concentrations and consumption patterns among Mohawk women at Akwesasne.

A study was conducted to determine concentrations of polychlorinated biphenyls (PCBs) in local fish and to establish patterns of fish consumption of nursing Mohawk women residing near three industrial hazardous waste sites. From 1986 to 1992, 97 Mohawk women were interviewed within one month postpartum. A comparison group consisted of 154 nursing Caucasians. Samples of 348 local fish were analyzed for PCBs. The results indicated that fish in the Mohawk area, especially those collected offshore from the waste sites, had been contaminated with PCBs. The dietary data showed a greater past prevalence of local fish consumption among Mohawk mothers, with an overall annual mean of 23.5 local fish meals more than one year before the pregnancy compared with 14.1 for the control women (p < 0.001). The prevalence of consumption by the Mohawks, however, declined over time, resulting in overall mean rates of 9.2 local fish meals one year or less before pregnancy, and 3.9 meals per year during pregnancy (p < 0.001 for linear trend). Compared to the Mohawks, significantly fewer control women stopped eating local fish, and their rates declined less sharply. A secular trend was also observed in the overall rate of consumption during pregnancy for the Mohawks, with those who gave birth in 1986-1989 having a mean of 10.7 local fish meals per year during pregnancy, compared with means of 3.6 and 0.9 respectively for women who delivered in 1990 and 1991-1992 (p < 0.05 for linear trend). No such trend was apparent for the controls. No background variable was significantly related to the rate of local fish consumption among the Mohawks, but a decrease over time in the rate of local fish consumption was greater among those Mohawks who ate the most local fish initially (r = -0.76, p < 0.001), or who also reduced their alcohol intake during pregnancy (r = 0.35, p < 0.05). Mohawks were also more likely than the controls to trim the fat, remove the skin from, and fry and fish they ate during the past year. These dietary changes may be the result of advisories that have been issued over the past decade recommending against the consumption of local fish by pregnant and nursing Mohawk women. Such changes, if sustained, should reduce their exposure to PCBs and correspondingly the potential for adverse health effects.

Mono-ortho- and non-ortho-substituted polychlorinated biphenyls in human milk from Mohawk and control women: effects of maternal factors and previous lactation.

Fifty-four individual human milk samples from 50 mothers (20 Mohawks and 30 controls) were analyzed for four non-ortho- and eight mono-ortho-substituted polychlorinated biphenyls (PCBs). Mean total coplanar PCBs concentrations were 49 ng/g and 55 ng/g lipid for Mohawk and control women, respectively. A statistical evaluation of all analytical data reveals no significant difference of total coplanar PCB level between Mohawk and control women. The level of these contaminants is influenced by the age of the mother, number of breastfed children, and length of nursing period. Older women, primiparae, and cigarette smokers had higher levels of coplanar PCBs. In general, women had higher levels of coplanar PCBs in the first lactation and in the earlier samples of a given lactation, while levels declined both with duration of breast-feeding and with number of children nursed. The contribution of individual non-ortho- and mono-ortho-substituted PCB congeners to the total calculated toxic equivalent values (sigma TEQ) was assessed for the breast milk samples. The levels of polychlorinated dibenzo-p-dioxins (PCDDs) and polychlorinated dibenzofurans (PCDFs) in human milk of pooled specimens from Los Angeles, California and Binghamton, New York, widely separate cities in the United States (Schecter et al. 1989), were presented for reference purpose. The main contributions to the sigma TEQ were PCB congeners #118 (25.8 pg/g lipid), #126 (25 pg/g lipid), #105 (10.8 pg/g lipid), and #156 (7.4 pg/g lipid). Collectively, these compounds accounted for 70% of the sigma TEQ values.(ABSTRACT TRUNCATED AT 250 WORDS)

A case-control study of malignant melanoma of the trunk among white males in upstate New York.

To address the increase in the incidence of cutaneous melanoma in upstate New York in recent decades, a case-control study was conducted of the constitutional and environmental risk factors for malignant melanoma of the trunk among white males. Cases were identified from the New York Cancer Registry from 1977 through 1979 (the period of the greatest relative increase in incidence), and controls were selected using random digit dialing methods. A total of 324 cases or their next-of-kin and 415 controls were interviewed regarding physical and sociodemographic characteristics, lifestyle habits, and medical histories. The following variables were statistically significant in the final logistic regression analysis: birthmarks (O.R. = 3.87); sunburn easily (O.R. = 1.83); fair skin tone (O.R. = 1.63); northern European ancestry (O.R. = 1.51); blue eye color (O.R. = 1.46); and participation in water sports (O.R. = 2.02). Interaction terms between constitutional and environmental variables resulted in a significant relationship between the presence of freckles and bathing two or more times per day. Among freckled individuals, those who bathed more than once per day had a sixfold elevation in the risk compared to those who bathed less often. In comparison, the odds ratio for frequent bathing among men without freckles was only 1.24. The data suggest the following hypothesis for further study: the possibility that frequent bathing may be deleterious, especially among freckled individuals or those with pigmented nevi.

Exposure to asbestiform minerals and radiographic chest abnormalities in a talc mining region of upstate New York.

A radiologist in New York reported a high prevalence of pulmonary fibrosis in St. Lawrence and Jefferson counties. The New York State Department of Health responded by conducting a case history study of radiographic abnormalities found in the lung parenchyma and pleura of residents in Lawrence and Jefferson counties, where tremolitic talc has been mined for many years. During a 1-y period, all radiographs from 6 hospitals in the region were reviewed. A B-reader confirmed that 355 of 9,442 patients who were at least 40 y of age (3.8%) had a relevant abnormality; 60% of them reported occupational exposure to asbestiform minerals, and another 15% had a chest condition or injury that could have accounted for the abnormal radiograph. The results should be interpreted cautiously, but there was no evidence of widespread radiographic abnormalities resulting from ambient dust exposure. The data, however, support earlier studies that indicate that talc miners and millers experience excess parenchymal fibrosis and pleural changes. The data also suggest that individuals in the paper industry and construction trades may be at risk.

Familial clustering of neural tube defects and gastric cancer.

A retrospective cohort study was conducted to determine whether producing an offspring with a neural tube defect (NTD) is associated with the development of unusual patterns of cancer among the parents in subsequent years. Mothers and fathers who had a child with an NTD in Upstate New York from 1945 to 1955 were followed through 1979 and compared to a control group of parents with normal offspring. Overall mortality and site-specific cancer incidence were not significantly different for case parents versus control parents, with the exception of gastric cancer, which occurred significantly more frequently in case parents. The finding of a familial association between NTDs and gastric cancer, coupled with a parallel decline in rates of these two diseases, suggests a common aetiology, perhaps related to dietary factors.

A retrospective cohort study of cancer incidence among New York State Farm Bureau members.

Cancer incidence from 1973 through 1983 in 18,811 New York Farm Bureau members was examined using a retrospective cohort study design. The observed number of cancers for all age groups was 72% of the expected, and the major deficits in incidence occurred for lung (52% of expected), gastrointestinal (67% of expected), and bladder (78% of expected). Similar deficits have been reported by other researchers. Unlike other studies, we did not find a significant excess of cancer of any site. Given the healthy worker effect and the small numbers of incident tumors at some sites, the Standardized Cancer Incidence Ratios that were over 100 in value (i.e., lip, melanoma of the skin, prostate, multiple myeloma) merit further investigation. This study differs from previous research in population, setting, and method. Nonetheless, the general pattern of results is consistent with the findings of other investigations.

Health effects three years after potential exposure to the toxic contaminants of an electrical transformer fire.

A medical surveillance program has been established for 482 persons who were potentially exposed to polychlorinated biphenyls (PCBs), dibenzo-p-dioxins, and dibenzofurans from an electrical transformer fire in a Binghamton, NY office building in 1981. Vital Record and Cancer Registry data, medical records, and mail questionnaires were used to assess mortality, symptomatology, cancer incidence, and reproductive events through 1984. The numbers of deaths, cancers, fetal deaths, and infants with low birth weight or congenital malformations were similar to those expected on the basis of age- and sex-specific rates for upstate New York and other comparison populations. Two suicides were observed compared with 0.31 expected, but the difference was not statistically significant. After adjustment for possible confounders, persons with the greatest degree of potential exposure were significantly more likely than those with less exposure to report unexplained weight loss (relative risk [RR] = 12.80), muscle pain (RR = 5.07), frequent coughing (RR = 4.14), skin color changes (RR = 3.49), and nervousness or sleep problems (RR = 3.19). The possibility of recall bias and the intervening effects of stress, however, weaken the conclusion that toxic chemicals caused the symptomatology. Exposure-related systemic disorders, e.g., chloracne or peripheral neuropathy, were not diagnosed by personal physicians; however, some persons refused to release their medical records because of ongoing litigation. The findings are consistent with those of our earlier assessment.